Effectiveness of robotic-assisted gait training in stroke rehabilitation: A retrospective matched control study

This blog is a critical appraisal of the following randomized controlled trial: Effectiveness of robotic-assisted gait training in stroke rehabilitation: A retrospective matched control study

Background

Stroke occurs due to the disruption of oxygen transportation to the brain. An impairment associated with stroke is the loss of motor function resulting in decreased mobility. Physiotherapy intervention is required as a result and early rehabilitation is beneficial. Robotic-Assisted gait training (RAGT) is a new physiotherapy approach that incorporates repetitive task-specific practice to promote mobility and improved motor function.

What was the study?

This study aims to compare the RAGT approach compared to traditional physiotherapy intervention in promoting motor function recovery post stroke. 41 patients with subacute stroke (4-31 days post stroke) were selected in total. All patients were selected from the same ward and treatments were delivered by the same physiotherapy team 5 days per week.

14 participants received the robotic system device RAGT intervention which involved wearing a motor driven orthosis to assist in lower limb training. The patient’s whole body weight was supported over a treadmill throughout. The patients lower limbs were then guided by a speed controlled treadmill in order to induce the stance and swing phase of the gait pattern. These were selected due to the fact they had received four or more previous RAGT sessions.

The other 27 participants received traditional physiotherapy treatments for stroke rehabilitation to correspond with the Hong Kong Hospital Authority protocol. These approaches involved limb mobilisation, muscle tone normalisation, muscle strengthening, electrical muscle stimulation, transfer training, gait training and balance training.

The study used 4 functional outcome measures to assess the intervention, including the Modified Functional Ambulation Category (MFAC), Modified Rivermead Mobility Index (MRMI), Berg balance Scale (BBS) and Modified Barthel Index (MBI). Factors that were assessed included ambulation, mobility, balance and ADL’s of the participant. These measures were then used to compare the RAGT group with the control group in both pre- and post-intervention.

Results

According to the study, those in the RAGT group showed higher changes in all functional outcome measures than those in the control group. Greater improvements were identified in MFAC, MRMI, BBS and MBI scores for those receiving the RAGT intervention.

Strengths & Weaknesses of the study

To critically appraise this study, the CASP Case Control Study tool was used, with study aim and objectives, participant selection and results and outcomes all addressed during this study.

One striking weakness of this study was the small sample size. Due to the strict inclusion/exclusion criteria such as age, session participation, post stroke ability, the sample size was limited. Although the starting number of patients screened was 1,170, only 41 in total were suitable. An unequal sample size in each group was seen, as the control group consisted of a much larger sample. In order to develop a more significant data set a larger sample size would be required. The strict exclusion criteria made it difficult to maintain a larger number of participants. The time period that the study was conducted over (which was a year) was appropriate, however a larger sample size over this time could possibly have been more beneficial.

Aspects of the methods used noted that participant’s time in each session lasted 60-90 minutes, illustrating that not all participants received the same amount and it was judged on the tolerance of the patient. This means that some participants received more session time per week which could have affected the final results.

The allocation of the groups could have resulted in selection bias as the RAGT group had a specific criteria of four or more RAGT sessions. This familiarity with the treatment could ultimately lead to more favourable results. While blinding in this case could not be achieved it may lead to rater bias.

The study attempted to limit bias through a strict participation criteria, this meant that it resulted in a high drop-out level among patients. This approach strengthened the validity of the results as all participants were similar when starting the study with homogeneity being maintained in terms of age, duration of stroke and functional ability on admission. No significant differences (p<0.05 in all post recording), proving that higher gains were seen in the RAGT intervention group.

In addition, the implementers were all trained physiotherapists qualified to work both with the traditional physiotherapy group (control) as well as being certified to use the Lokomat Pro (robotic device) in the RAGT sessions.

Conclusion

The research indicates that the use of RAGT as a treatment method for stroke rehabilitation is beneficial and shows higher levels of improvement than just using traditional treatment methods. The findings need further research, and a larger sample size would also provide greater significance for future reference. Randomisation of participants may also be more beneficial as it may limit any possible selection bias.

References

• SALTER K, CAMPBELL N, RICHARDSON M, MEHTA S,JUTAI J, ZETTLER L, MOSES M, A & MAYS R. (2013). Outcome Measures in Stroke Rehabilitation. Evidence-Based Review of Stroke Rehabilitation.42-73.
• PING HO CHUNG B. (2017). Effectiveness of Robotic-Assisted Gait Training in Stroke Rehabilitation: A Retrospective Matched Control Study. Hong Kong Physiotherapy Journal. 36, 10-16.
• CRITICAL APPRAISAL SKILLS PROGRAM (CASP)- MAKING SENSE OF EVIDENCE. (2017). Case Control Checklist. Available: http://docs.wixstatic.com/ugd/dded87_63fb65dd4e0548e2bfd0a982295f839e.pdf. [Last accessed 20 Dec 2017.]
• KOPEC J & ESDAILE J. (1990). Bias in Case-Control Studies. A Review. Journal of Epidemiology and Community Health. 44(3): 179-186.

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Acapella vs. PEP mask therapy: A randomised trial in children with cystic fibrosis during respiratory exacerbation. A critical appraisal

This blog is a critical appraisal of the following randomized controlled trial: Acapella vs. PEP mask therapy: A randomised trial in children with cystic fibrosis during respiratory exacerbation

Background

Cystic fibrosis (CF) is an inherited genetic disease which is caused by a fault in the gene cystic fibrosis transmembrane conductance regulator (CFTR). When this gene becomes faulty it causes thick mucus to block the airways which makes it harder to breathe (Pelliccia 2017).

Physiotherapy for CF primarily consists of respiratory physiotherapy. Research which has previously been carried out has focused on positive expiratory pressure (PEP) therapy and postural drainage (Lannefors et al 1992, McIlwaine et al 1997 and Mortenson et al 1991).

What was the study?

The randomised trial recruited 23 participants, ranging from 7-18 years old. The trial participants were patients with CF who were admitted to hospital for a 10-day period with a respiratory exacerbation.  A power analysis was completed to determine how many participants were needed to give a statistically significant result. The eligibility criteria was set alongside an inclusion and exclusion criteria. The inclusion criteria was that the patient had to have previous experience with home PEP treatment, they could perform a lung function test reliably and were able to expectorate secretions successfully into a cup. Patients were excluded if they had a predicted FEV1 less than 30%; they required two or more physiotherapy sessions each day; they required supplementary oxygen; suffered from haemoptysis; were unable to complete standard PEP therapy; had surgery the previous month; and had a history of non-compliance with physiotherapy.

The purpose of the study was to investigate whether there were differences in lung function, exercise performance, weight of secretions and user satisfaction with the Acapella compared with PEP among children with CF admitted to hospital for ten days for intravenous antibiotics. Participants were given two treatment sessions each day. They were given the PEP mask or Acapella. Each session was standardised to ten sets of ten breaths followed by one or two huffs then a cough; this was carried out seated. The pressure of each device was also standardised to reflect normal clinical practice.

Groups were allocated by placing paper (18 PEP and 18 Acapella) into a double sealed envelope. A blinded researcher allocated groups by pulling paper from the envelope. They were not involved in the recruitment, assessment or treatment of the trial. Outcome measures used were a lung function test, 10m shuttle test, total of secretions expectorated and the chest physiotherapy patient satisfaction survey. All were measured at the beginning (baseline) and after ten days. The lung function test and 10m shuttle test were blinded.

Results

The study concluded that there was no statistically significant difference between the PEP group or Acapella group for any outcome measures.

What are the strengths and weaknesses of the study?

To critically appraise the article fully the Understanding Health Research tool was used.

The paper had many strengths throughout, one being that the research was carried out and funded by The Children’s Hospital Westmead Australia and there were no conflicts of interest. The trial was also reviewed and approved by an ethics committee. The authors provided clear research questions and aims which were all answered by the end of the paper. Both the sample size and withdrawal of one participant were explained and justified.  The paper only applied their findings to their population group. The trial was single-blinded, the allocation of groups was blinded and the lung function tests and 10m shuttle test. In the results, both the mean and standard deviation were given which implies the data was normally distributed. In regards to outcome measures, all four were clearly defined and explained. The modified 10 metre shuttle test has been found to be an appropriate outcome measure. It is both reliable, repeatable and sensitive (Bradley et al 2000). Although this relates to adults with CF it can be carried over to children as it is simple both to carry out and understand.

Although the paper was carried out to a high quality there were some weaknesses. One weakness of the trial was that it did not include a control group. By not including a control group, comparisons cannot be made to inform as to whether there were any changes in the health of participants caused fully by either the PEP or Acapella. The sample size of twenty-three children is a limitation as to the strength of this research as it is a small population. Although the trial was single-blinded it was not possible to double-blind the trial as those giving the treatment had to be aware of which intervention to give. The research found there was no clinically relevant findings to take into practice. The p values as stated in table two reiterates the fact that there is no difference between PEP and Acapella. In terms of outcome measures, the reliability of the chest physiotherapy patient satisfaction survey may be questioned as it is stated in the paper that parents were able to help participants. The researchers may have used a modified or diagram only outcome measure which the younger participants could complete independently.

Conclusion

To conclude, the study found no significant difference between PEP and Acapella in the treatment of children with CF and a respiratory exacerbation. Further research should be completed to decipher a conclusive answer with a larger sample size and control group.

References

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Hydrotherapy Versus Conventional Land-Based Exercise for the Management of Patients With Osteoarthritis of the Knee: A critical appraisal

This blog is a critical appraisal of the following randomized controlled trial:  Hydrotherapy versus conventional land-based exercise for the management of patients with osteoarthritis of the knee

Background

Osteoarthritis (OA) is highly prevalent and it is the leading cause of disability worldwide (Vina and Kwoh 2017). Knee OA patients are likely to have complex and multifactorial joint degeneration which negatively affects their physical and mental well-being. Despite being highly used in physiotherapy, the clinical evidence of knee OA hydrotherapy is poor. Therefore, this clinical trial evaluated the effectiveness of knee OA hydrotherapy and compared the outcomes with conventional land-based exercise users.

What was the study?

64 participants with knee OA were selected with inclusive criteria from one local hospital in Brazil. Researchers allocated all the participants to either the water-based or land-based exercise group randomly. Then, exercises such as strengthening and stretching of lower extremity muscles and gait training were instructed by 2 physiotherapists, who crossover between groups every week. The duration of the study was 18 weeks.

The primary outcome was pain which was measured by the visual analog scale (VAS). The secondary outcome consisted of Lequesne Index for knee OA, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), VAS for pain and time during the 50-foot walk test (50FWT), and the amount of non-steroidal anti-inflammatory drugs taken. All outcomes were measured by an independent investigator at baseline, 9 weeks and 18 weeks from the start of the program.

Results

The two groups had similar pain reduction and improvements in WOMAC, Lequesne index and the 50FWT throughout. The water-based group had resulted in a greater reduction of pain than the land-based group before and after the 50FWT test at the end of the study.

The weaknesses and strengths of the study

First of all, the sample size of the study was significantly small, consisting of 64 participants from the same hospital in Brazil. Highlighted by an observational study, the burden of knee OA in Latin American countries is highly related to demographic, ethical, methodological, and health care accessibility factors (Burgos-Vargas et al. 2014). These factors can lead to various results over different patient cultures. Therefore, a larger sample size should be implemented to get a more clinically significant result.

Although the two groups were similar in terms of demographic background, the male to female ratio in both groups differed significantly (water-based group: 2 male, 30 female and land-based group: 3 male, 29 female). Researchers suggested that women are more sensitive to pain than men (Stanford medicine 2012), thus increasing the risk of bias in the outcome: VAS for pain. According to a study, women have a significantly larger amount of cartilage loss and a greater OA heritability than men (Price and Herndon 2009). This may lead to a gap between genders in the development of OA. Moreover, it is suggested that there were more men with knee OA onset than women among Brazilians (Burgos-Vargas et al. 2014). Therefore, since the gender ratio in this study is significantly unequal when compared to the total knee OA population in Brazil, it may threaten the external validity of the study.

Moreover, the lack of control group is an obvious weakness of this study. Regarding the gold standard of a clinical trial, a control group is fundamental to show the effects of an intervention when comparing the intervention group and the control group (DeMets 1985). Although researchers had highly considered the previous positive evidence of conventional land-based exercises, they were still unable to rule out that improvements from both groups could be contributed by factors other than the intervention (e.g. duration of physiotherapy, degree of patients’ motivation and attention).

Regarding the strengths of the study, the participants were randomly allocated to groups by block randomisation and all results were measured by a blinded investigator to enhance internal validity. In the exercise program, modifications of land-based exercise were made to be performed in an aquatic setting. Therefore, the same types of exercises were used among participants, thus reducing the risk of bias. Although it was impossible for the instructors to be blinded, they crossed over between groups every week throughout the protocol to minimise factors which may alter the result. For example, the instructors skill level, amount of intervention time from each instructor and the degree of motivation from participants could cause bias in this study.

In fact, the participation rate from the water-based group (96%) is greater than the land-based group (81%), which implies a higher adherence to the intervention. It is known that adherence of the patient is essential to enhance functional ability, well-being and quality of life (Belza et al. 2002). Therefore, patients in the water-based group may be relatively more willing to follow the protocol, which could be a significant factor that alters the outcome. Although there were 7 drop-outs throughout the study due to various reasons, all data were analysed according to the intention-to-treat principle, which gives an unbiased estimation of the treatment effect (Sedgwick 2013). This study was superior to previous studies regarding the duration of intervention, lower mean age of participants and functional outcome measures.

Conclusion

Hydrotherapy was superior to conventional land-based exercise in terms of pain relief before and after walking. It showed that hydrotherapy is effective and should be included in the therapeutic approaches recommended for knee OA patients. Future research should investigate the improvement of strength and long-term effects of hydrotherapy.

References

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A esperança pode levar a expectativas não realistas

Moving for a Job? Here’s What to Consider

Using the tips here, you can also make a smooth move for a job.

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Cochrane Crowd for students: what’s in it for you?

Cochrane Crowd’s Community Engagement and Partnerships Manager Emily Steele, and Co-Leader Anna Noel-Storr blog about the benefits for students of getting involved with Cochrane Crowd, Cochrane’s citizen science platform.

Student readers, do you realise that Cochrane’s citizen science platform Cochrane Crowd offers some wonderful and tangible benefits for students? By getting involved with Cochrane Crowd, you contribute to Cochrane’s mission of improving health evidence while at the same time adding to your student portfolio, improving your CV, earning Cochrane Crowd badges, working towards full Cochrane Membership, upskilling in health evidence and keeping abreast of the latest literature. Talk about an all-out win for everyone involved!

Take a look at this 2-minute introduction to Cochrane Crowd and then read on for five benefits of joining Cochrane Crowd as a student.

1. Earn a Certificate of Achievement for your student portfolio or CV

We know it’s important to build up your portfolio and CV, so once you’ve contributed 200 or more classifications to Cochrane Crowd you become eligible for a Certificate of Achievement. Since Cochrane is the global leader in health evidence synthesis, this is bound to impress, right!? Just email us at crowd@cochrane.org once you’ve reached 200 and let us know you’d like a certificate.

2. Become eligible for Cochrane Membership

If you’re a die-hard Cochranite, you might know it’s possible to earn Cochrane Membership. While everyone is invited to join Cochrane as a Cochrane supporter, once you’ve contributed in a substantive way you are offered membership, which allows you to vote in Cochrane elections, stand for internal governance positions – and let’s face it , would be another great addition to your student portfolio and CV.

By completing 1,000 classifications across Cochrane Crowd’s key tasks, you’ll receive an invitation to become a Cochrane Member. You can read more about the Cochrane Membership scheme here and here.

3. Build a collection of Cochrane Crowd badges

Anyone other than me enjoy prize incentives? Good. You’ll earn badges for every task within Cochrane Crowd: a green badge once you finish task training, bronze once you classify 100 studies, through to silver and finally a gold badge once you’ve completed 1,000 classifications. Exceptional members who are highly accurate will become tasks experts and receive purple badges. Full flush of purple, anyone?

4. Build expertise in health evidence

There are learning pathways built into Cochrane Crowd, so you’ll build health evidence skills within our supportive environment. Some of the opportunities we offer include the following:

• When you first join Crowd you have access to our beginner-level tasks. As you progress, more challenging tasks become available.
• We provide interactive training modules for each Cochrane Crowd task: you get immediate feedback as you progress through the exercises.
• You can monitor your accuracy on each Crowd task through the History and Settings buttons, accessible on your dashboard. Celebrate your accurate classifications, and learn from your mistakes.

5. Keep up with the literature

If you’re passionate about a particular health topic, you can focus on that topic in Cochrane Crowd. For each task simply go to the History and Settings button/Settings tab, and enter the topic under Prioritise Records I Receive. Et voila! You’ll be reading up on your favourite topic while screening for Cochrane Crowd.

And, coming soon…

 As if all that wasn’t enough, two further developments in Cochrane Crowd that we hope will appeal to students are coming soon. The first is called Screen4Me. This is where Crowd contributors can get involved in helping screen search results for specific Cochrane reviews. We hope to launch Screen4Me by the end of the year! The second is a student pathway designed especially for studentsmade up of Crowd tasks in combination with more traditional learning modules, guiding students through a range of topics and activities from understanding study designs and PICO, through to critical appraisal and nitty gritty statistical issues.

So, what are you waiting for? Hop over and join Cochrane Crowd here.

Anna Noel-Storr is the Information Specialist for the Cochrane Dementia and Cognitive Improvement Group and also works on a number of projects including Cochrane Crowd.

If you love Crowd and think it would work for your course why not tell your lecturer about Cochrane Classmate? In Classmate, they’ll be able to set up Crowd challenges where you and your classmates collectively screen as much as possible in a set period of time. Believe us, it’s lots of fun!

And if you’re interested in contributing directly to Cochrane systematic reviews, you might also like to take a look at Cochrane’s TaskExchange platform: look out for the green leaf tasks specifically aimed at evidence newcomers!

Sign up to Cochrane Crowd, follow us on Twitter and contact us at crowd@cochrane.org.

Support for Project Transform was provided by Cochrane and the National Health and Medical Research Council of Australia (APP1114605). The contents of the published material are solely the responsibility of the Administering Institution, a Participating Institution or individual authors and do not reflect the views of the NHMRC.

 

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4 Student Loan Forgiveness Options for Lawyers

Are you looking for support paying back your law school debt while working in the public sector?

The post 4 Student Loan Forgiveness Options for Lawyers appeared first on Earnest Blog | Money Advice for Young Professionals.