国際生活機能分類(International Classification of Functioning, Disability and Health: ICF)にみた福祉・保健・医療の専門職協働における連携に関する貢献と課題

Background
Improving upper limb function is a core element of stroke rehabilitation needed to maximise patient outcomes and reduce disability. Evidence about effects of individual treatment techniques and modalities is synthesised within many reviews. For selection of effective rehabilitation treatment, the relative effectiveness of interventions must be known. However, a comprehensive overview of systematic reviews in this area is currently lacking.

Objectives
To carry out a Cochrane overview by synthesising systematic reviews of interventions provided to improve upper limb function after stroke.

Methods
Search methods: We comprehensively searched the Cochrane Database of Systematic Reviews; the Database of Reviews of Effects; and PROSPERO (an international prospective register of systematic reviews) (June 2013). We also contacted review authors in an effort to identify further relevant reviews.

Selection criteria: We included Cochrane and non-Cochrane reviews of randomised controlled trials (RCTs) of patients with stroke comparing upper limb interventions with no treatment, usual care or alternative treatments. Our primary outcome of interest was upper limb function; secondary outcomes included motor impairment and performance of activities of daily living. When we identified overlapping reviews, we systematically identified the most up-to-date and comprehensive review and excluded reviews that overlapped with this.

Data collection and analysis: Two overview authors independently applied the selection criteria, excluding reviews that were superseded by more up-to-date reviews including the same (or similar) studies. Two overview authors independently assessed the methodological quality of reviews (using a modified version of the AMSTAR tool) and extracted data. Quality of evidence within each comparison in each review was determined using objective criteria (based on numbers of participants, risk of bias, heterogeneity and review quality) to apply GRADE (Grades of Recommendation, Assessment, Development and Evaluation) levels of evidence. We resolved disagreements through discussion. We systematically tabulated the effects of interventions and used quality of evidence to determine implications for clinical practice and to make recommendations for future research.

Main results
Our searches identified 1840 records, from which we included 40 completed reviews (19 Cochrane; 21 non-Cochrane), covering 18 individual interventions and dose and setting of interventions. The 40 reviews contain 503 studies (18,078 participants). We extracted pooled data from 31 reviews related to 127 comparisons. We judged the quality of evidence to be high for 1/127 comparisons (transcranial direct current stimulation (tDCS) demonstrating no benefit for outcomes of activities of daily living (ADLs)); moderate for 49/127 comparisons (covering seven individual interventions) and low or very low for 77/127 comparisons.

Moderate-quality evidence showed a beneficial effect of constraint-induced movement therapy (CIMT), mental practice, mirror therapy, interventions for sensory impairment, virtual reality and a relatively high dose of repetitive task practice, suggesting that these may be effective interventions; moderate-quality evidence also indicated that unilateral arm training may be more effective than bilateral arm training. Information was insufficient to reveal the relative effectiveness of different interventions.

Moderate-quality evidence from subgroup analyses comparing greater and lesser doses of mental practice, repetitive task training and virtual reality demonstrates a beneficial effect for the group given the greater dose, although not for the group given the smaller dose; however tests for subgroup differences do not suggest a statistically significant difference between these groups. Future research related to dose is essential.

Specific recommendations for future research are derived from current evidence. These recommendations include but are not limited to adequately powered, high-quality RCTs to confirm the benefit of CIMT, mental practice, mirror therapy, virtual reality and a relatively high dose of repetitive task practice; high-quality RCTs to explore the effects of repetitive transcranial magnetic stimulation (rTMS), tDCS, hands-on therapy, music therapy, pharmacological interventions and interventions for sensory impairment; and up-to-date reviews related to biofeedback, Bobath therapy, electrical stimulation, reach-to-grasp exercise, repetitive task training, strength training and stretching and positioning.

Authors' conclusions
Large numbers of overlapping reviews related to interventions to improve upper limb function following stroke have been identified, and this overview serves to signpost clinicians and policy makers toward relevant systematic reviews to support clinical decisions, providing one accessible, comprehensive document, which should support clinicians and policy makers in clinical decision making for stroke rehabilitation.

Currently, no high-quality evidence can be found for any interventions that are currently used as part of routine practice, and evidence is insufficient to enable comparison of the relative effectiveness of interventions. Effective collaboration is urgently needed to support large, robust RCTs of interventions currently used routinely within clinical practice. Evidence related to dose of interventions is particularly needed, as this information has widespread clinical and research implications.

Interventions for improving upper limb function after stroke

The Assessment of Motor and Process Skills (AMPS) is an innovative observational assessment that is used to measure the quality of a person’s performance of domestic (instrumental) or basic (personal) activities of daily living (ADL). The quality of the person’s ADL performance is assessed by rating the effort, efficiency, safety, and independence of 16 ADL motor and 20 ADL process skill items. The ADL motor and ADL process skill are analogous to the goal-directed actions defined under the Activities and Participation domains of the International Classification of Functioning, Disability and Health (World Health Organization [WHO], 2001), and are thus the small units of performance that when carried out, one by one, result in the overall task being completed.

呼吸器疾患におけるAssessment of Motor and Process Skillsの応用

Post-traumatic growth (PTG) is the phenomenon of positive change through the experience of trauma and adversity (O'Leary & Ickovics, 1995). Research suggests that the type of trauma sustained could have differing processes and outcomes from each other (Demark-wahnefried et al., 2000; Sabiston, McDonough, and Crocker, 2007). The aim of this study was to synthesize qualitative data on PTG and illness related trauma. Fifty-seven published journal articles dating from before November 1st, 2007 in PsychINFO, MEDLINE, EMBASE, Web of Knowledge and from the authors own knowledge of the area were reviewed. Key words included PTG; benefit finding; thriving and positive changes. Key themes included: 'reappraisal of life and priorities'; 'trauma equals development of self'; 'existential re-evaluation'; and 'a new awareness of the body'. Findings suggest that there are unique elements to illness related PTG and a need for additional research into the processes and outcomes of physical illness related trauma.

http://www.katehefferon.com/wp-content/uploads/2010/07/Hefferon-Grealy-Mutrie-BJHP.pdf

Post-traumatic growth and life threatening physical illness: a systematic review of the qualitative literature

Robot-mediated post-stroke therapy for the upper-extremity dates back to the 1990s. Since then, a number of robotic devices have become commercially available. There is clear evidence that robotic interventions improve upper limb motor scores and strength, but these improvements are often not transferred to performance of activities of daily living. We wish to better understand why. Our systematic review of 74 papers focuses on the targeted stage of recovery, the part of the limb trained, the different modalities used, and the effectiveness of each. The review shows that most of the studies so far focus on training of the proximal arm for chronic stroke patients. About the training modalities, studies typically refer to active, active-assisted and passive interaction. Robot-therapy in active assisted mode was associated with consistent improvements in arm function. More specifically, the use of HRI features stressing active contribution by the patient, such as EMG-modulated forces or a pushing force in combination with spring-damper guidance, may be beneficial. Our work also highlights that current literature frequently lacks information regarding the mechanism about the physical human-robot interaction (HRI). It is often unclear how the different modalities are implemented by different research groups (using different robots and platforms). In order to have a better and more reliable evidence of usefulness for these technologies, it is recommended that the HRI is better described and documented so that work of various teams can be considered in the same group and categories, allowing to infer for more suitable approaches. We propose a framework for categorisation of HRI modalities and features that will allow comparing their therapeutic benefits.

/pdf/training-modalities-in-robot-mediated-upper-limb-4qhvjoaziu.pdf

Training modalities in robot-mediated upper limb rehabilitation in stroke: a framework for classification based on a systematic review

1. Pathophysiology and Medical Management of Stroke 2. Application of Learning and Environmental Strategies to Activity Based Treatment 3. Psychosocial Aspects of Stroke Rehabilitation 4. Trunk Control: A Prerequisite for Functional Independence 5. Balance Impairments: Functional Implications 6. Upper Extremity Function and Management Post Stroke 7. Edema Control in the Person Surviving Stroke 8. Splinting Applications Post Stroke 9. Casting Applications Post Stroke 10. Functional Mobility 11. Gait Awareness 12. Understanding Vision and the Effects of Stroke on the Visual System 13. Impact of Neurobehavioral Deficits on Activities of Daily Living 14. Treatment of Neurobehavioral Deficits: A Function-Based Approach 15. Enhancing Performance of Instrumental Activities of Daily Living 16. Driving After a Stroke 17. Dysphagia Management After a Stroke 18. Sexual Function and Intimacy After a Stroke 19. Seating and Wheeled Mobility Prescription 20. Home Evaluation and Modifications 21. Assistive Technology 22. Activities of Daily Living Adaptations: Managing the Environment with One-Handed Techniques 23. Leisure Following a Stroke: Methods to Improve Skills 24. A Survivor's Perspective 25. Helping the Family to Support the Patient After a Stroke 26. Total Quality Management of the Adult Stroke Population 27. COTA/OTR Partnerships: Teamwork to Enhance Living Skills After a Stroke

Stroke Rehabilitation: A Function-Based Approach

OBJECTIVE. We sought to determine whether mental practice is an effective intervention to improve upper-limb recovery after stroke. 

METHOD. We conducted a systematic review of the literature, searching electronic databases for the years 1985 to February 2009. We selected studies according to specified criteria, rated each study for level of evidence, and summarized study elements. 

RESULTS. Studies differed with respect to design, patient characteristics, intervention protocols, and outcome measures. All studies used imagery of tasks involving movement of the impaired limb. The length of the interventions and number of practice hours varied. Results suggest that mental practice combined with physical practice improves upper-limb recovery. 

CONCLUSION. When added to physical practice, mental practice is an effective intervention. However, generalizations are difficult to make. Further research is warranted to determine who will benefit from training, the dosing needed, the most effective protocols, whether improvements are retained, and whether mental practice affects perceived occupational performance

Use of Mental Practice to Improve Upper-Limb Recovery After Stroke: A Systematic Review

We conducted a review to determine the effectiveness of interventions to improve occupational performance in people with motor impairments after stroke as part of the American Occupational Therapy Association's Evidence-Based Practice Project. One hundred forty-nine studies met inclusion criteria. Findings related to key outcomes from select interventions are presented. Results suggest that a variety of effective interventions are available to improve occupational performance after stroke. Evidence suggests that repetitive task practice, constraint-induced or modified constraint-induced movement therapy, strengthening and exercise, mental practice, virtual reality, mirror therapy, and action observation can improve upper-extremity function, balance and mobility, and/or activity and participation. Commonalities among several of the effective interventions include the use of goal-directed, individualized tasks that promote frequent repetitions of task-related or task-specific movements.

Effectiveness of interventions to improve occupational performance of people with cognitive impairments after stroke: an evidence-based review.

Chapter 1 – Overview of Cognitive and Perceptual Rehabilitation

Glen Gillen, EdD, OTR, FAOTA, is Associate Professor, Programs in Occupational Therapy, Department of Rehabilitation and Regenerative Medicine, Columbia University, 710 West 168th Street, 8th Floor, New York, NY 10032; GG50@Columbia.edu Gillen, G. (2013). A fork in the road: An occupational hazard? (Eleanor Clarke Slagle Lecture). American Journal of Occupational Therapy, 67, 641–652. http://dx.doi.org/10.5014/ajot.2013.676002

Glen Gillen

Papers

Stroke Rehabilitation: A Function-Based Approach

Use of Mental Practice to Improve Upper-Limb Recovery After Stroke: A Systematic Review

Effectiveness of interventions to improve occupational performance of people with cognitive impairments after stroke: an evidence-based review.

Chapter 1 – Overview of Cognitive and Perceptual Rehabilitation

A Fork in the Road: An Occupational Hazard?