https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(13)62229-1.pdf

How to increase value and reduce waste when research priorities are set

Background
Physical therapy (PT) is one of the key disciplines in interdisciplinary stroke rehabilitation. The aim of this systematic review was to provide an update of the evidence for stroke rehabilitation interventions in the domain of PT.

/pdf/what-is-the-evidence-for-physical-therapy-poststroke-a-9oycnv3dy7.pdf

What is the evidence for physical therapy poststroke? A systematic review and meta-analysis.

Stroke patients have impaired physical fitness and this may exacerbate their disability. It is not known whether improving physical fitness after stroke reduces disability. Objectives The primary aims were to establish whether physical fitness training reduces death, dependence and disability after stroke. The secondary aims included an investigation of the effects of fitness training on secondary outcome measures (including, physical fitness, mobility, physical function, health and quality of life, mood and the incidence of adverse events). Randomised controlled trials were included when an intervention represented a clear attempt to improve either muscle strength and/or cardiorespiratory fitness, and whose control groups comprised either usual care or a non-exercise intervention. A total of 12 trials were included in the review. No trials reported death and dependence data. Two small trials reporting disability showed no evidence of benefit. The remaining available secondary outcome data suggest that cardiorespiratory training improves walking ability (mobility). Observed benefits appear to be associated with specific or 'task-related' training.

/pdf/physical-fitness-training-for-stroke-patients-29s61ki4l4.pdf

Physical fitness training for stroke patients

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

Post-stroke dementia (PSD) or post-stroke cognitive impairment (PSCI) may affect up to one third of stroke survivors. Various definitions of PSCI and PSD have been described. We propose PSD as a label for any dementia following stroke in temporal relation. Various tools are available to screen and assess cognition, with few PSD-specific instruments. Choice will depend on purpose of assessment, with differing instruments needed for brief screening (e.g., Montreal Cognitive Assessment) or diagnostic formulation (e.g., NINDS VCI battery). A comprehensive evaluation should include assessment of pre-stroke cognition (e.g., using Informant Questionnaire for Cognitive Decline in the Elderly), mood (e.g., using Hospital Anxiety and Depression Scale), and functional consequences of cognitive impairments (e.g., using modified Rankin Scale). A large number of biomarkers for PSD, including indicators for genetic polymorphisms, biomarkers in the cerebrospinal fluid and in the serum, inflammatory mediators, and peripheral microRNA profiles have been proposed. Currently, no specific biomarkers have been proven to robustly discriminate vulnerable patients (‘at risk brains’) from those with better prognosis or to discriminate Alzheimer’s disease dementia from PSD. Further, neuroimaging is an important diagnostic tool in PSD. The role of computerized tomography is limited to demonstrating type and location of the underlying primary lesion and indicating atrophy and severe white matter changes. Magnetic resonance imaging is the key neuroimaging modality and has high sensitivity and specificity for detecting pathological changes, including small vessel disease. Advanced multi-modal imaging includes diffusion tensor imaging for fiber tracking, by which changes in networks can be detected. Quantitative imaging of cerebral blood flow and metabolism by positron emission tomography can differentiate between vascular dementia and degenerative dementia and show the interaction between vascular and metabolic changes. Additionally, inflammatory changes after ischemia in the brain can be detected, which may play a role together with amyloid deposition in the development of PSD. Prevention of PSD can be achieved by prevention of stroke. As treatment strategies to inhibit the development and mitigate the course of PSD, lowering of blood pressure, statins, neuroprotective drugs, and anti-inflammatory agents have all been studied without convincing evidence of efficacy. Lifestyle interventions, physical activity, and cognitive training have been recently tested, but large controlled trials are still missing.

/pdf/post-stroke-dementia-a-comprehensive-review-t3gmks69ep.pdf

Post-stroke dementia - a comprehensive review

BackgroundResearch resources should address the issues that are most important to people affected by a particular healthcare problem. Systematic identification of stroke survivor, caregiver, and he...

Top 10 research priorities relating to life after stroke--consensus from stroke survivors, caregivers, and health professionals.

Top ten research priorities relating to life after stroke.

Background To arrive at an agreed, prioritized ranking of treatment uncertainties in
asthma that need further research, by developing a collaboration of patients, carers and
clinicians, facilitated by the James Lind AllianceWorking Partnership between Asthma UK
and the British Thoracic Society.
Methods A four-step procedure: (1) establish a collaborative Working Partnership; (2)
identify and collect treatment uncertainties by using a patient survey and analysing existing
systematic reviews, clinical guidelines and query-answering services; (3) categorize uncertainties;
and (4) convene a workshop using a nominal group process to establish a ranked
prioritization of treatment uncertainties in asthma.
Findings Agreement and rankings were reached for 10 treatment uncertainties. The
highest was given to the uncertainty surrounding the adverse effects of inhaled and oral
steroids. The top three priorities dealt with clinical management issues, where uncertainties
still exist, namely concerns about the side effects of inhaled and oral steroids, how to
manage asthma when other illnesses exist or how to rely on personal decisions in an
ever-changing illness (self-management).
Interpretation The key outcome is the generation of a prioritized list of treatment uncertainties
in asthma, agreed by a collaboration of patients and health professionals, to inform
the commissioning of new research. Such a large number of patient-identified treatment
uncertainties had not previously been identified in the literature, an indication perhaps that
asthma self-management is a neglected research area. Whether the results have an influence
of research funding decisions is not yet known.

Identifying and prioritizing uncertainties: patient and clinician engagement in the identification of research questions

Summary The James Lind Initiative (JLI) was established in 2003 in response to a call by the Medical Research Council, endorsed by the Department of Health (DH), for the creation of 'a communications and discussion forum on randomized controlled trials, involving patients, practitioners, research- ers, and others'. This brief was approached indirectly by encouraging more explicit acknowledgement of uncertainties about the effects of treatments. Between 2003 and 2013, the JLI developed the UK Database of Uncertainties about the Effects of Treatments (UK DUETs) to assemble and publish uncertainties (www.library.nhs.uk/duets/), and the James Lind Alliance (JLA) to provide a formal structure within which patients and clinicians could identify uncertainties and agree priorities for research (www.lindalliance.org). UK DUETs and the JLA have both now been mainstreamed, UK DUETs by incorporation within the National Institute for Health and Clinical Excellence (NICE), the JLA by designation as a partner organization of NIHR, managed by the NIHR Evaluation, Trials and Studies Coordinating Centre (NETSCC). Parallel to its development of methods for research prioritization, the Initiative has worked with others to produce printed and digital resources (www.jameslindlibrary.org; www.testingtreatments.org) to help enhance general knowledge about why it is important to address uncertainties about the effects of treat- ments; how to recognize rigorous tests of treatments; and how to reduce avoidable waste in research. The JLI will continue to work on these resources and themes over coming years.

https://journals.sagepub.com/doi/pdf/10.1177/0141076813493063

Tackling treatment uncertainties together: the evolution of the James Lind Initiative, 2003–2013:

Aims

Research often neglects important gaps in existing evidence. Throughout healthcare, clinicians and patients face avoidable “clinical uncertainties” daily, making decisions about treatments without reliable evidence about their effects. This partnership of patients and clinicians aimed to identify and prioritize “clinical uncertainties” relating to treatment of urinary incontinence (UI).



Methods

UK clinician and patient organizations whose remit includes UI were invited to participate. Participating organizations consulted memberships to identify “uncertainties” affecting treatment decisions. “Uncertainties” were also identified in published research recommendations. Prioritization involved two phases: shortlisting of “uncertainties” by organizations; patient-clinician prioritization using established consensus methods. Prioritized “uncertainties” were verified by checking any available relevant up-to-date published systematic reviews.



Results

Thirty organizations were invited; 8 patient and 13 clinician organizations participated. Consultation generated 417 perceived “uncertainties,” research recommendations 131. Refining, excluding and combining produced a list of 226. Prioritization shortlisted 29 “uncertainties,” then a “top ten” (5 submitted by clinicians, 4 by patients, 1 from research recommendations).



Conclusions

The partnership successfully developed and tested a systematic and transparent methodology for patient–clinician consultation and consensus. Through consensus, unanswered research questions of importance to patients and clinicians were identified and prioritized. The final list reflects the heterogeneity of populations, treatments and evidence needs associated with UI. Some prioritized “uncertainties” relate to treatments that are widely used yet whose effects are not thoroughly understood, some to access to care, some to precise surgical questions. Research needs to address the uncertainties range from systematic reviewing to primary research. Neurourol. Urodynam. 29:708–714, 2010. © 2010 Wiley-Liss, Inc.

Prioritizing research: Patients, carers, and clinicians working together to identify and prioritize important clinical uncertainties in urinary incontinence.

Lester Firkins

Papers

Top 10 research priorities relating to life after stroke--consensus from stroke survivors, caregivers, and health professionals.

Top ten research priorities relating to life after stroke.

Identifying and prioritizing uncertainties: patient and clinician engagement in the identification of research questions

Tackling treatment uncertainties together: the evolution of the James Lind Initiative, 2003–2013:

Prioritizing research: Patients, carers, and clinicians working together to identify and prioritize important clinical uncertainties in urinary incontinence.