BACKGROUND: People with spatial neglect after stroke or other brain injury have difficulty attending to one side of space. Various rehabilitation interventions have been used, but evidence of their benefit is unclear.
OBJECTIVES: The main objective was to determine the effects of non-pharmacological interventions for people with spatial neglect after stroke and other adult-acquired non-progressive brain injury.
SEARCH METHODS: We searched the Cochrane Stroke Group Trials Register (last searched October 2020), the Cochrane Central Register of Controlled Trials (CENTRAL; last searched October 2020), MEDLINE (1966 to October 2020), Embase (1980 to October 2020), the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1983 to October 2020), and PsycINFO (1974 to October 2020). We also searched ongoing trials registers and screened reference lists.
SELECTION CRITERIA: We included randomised controlled trials (RCTs) of any non-pharmacological intervention specifically aimed at spatial neglect. We excluded studies of general rehabilitation and studies with mixed participant groups, unless separate neglect data were available.
DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Review authors categorised the interventions into eight broad types deemed to be applicable to clinical practice through iterative discussion: visual interventions, prism adaptation, body awareness interventions, mental function interventions, movement interventions, non-invasive brain stimulation, electrical stimulation, and acupuncture. We assessed the quality of evidence for each outcome using the GRADE approach.
MAIN RESULTS: We included 65 RCTs with 1951 participants, all of which included people with spatial neglect following stroke. Most studies measured outcomes using standardised neglect assessments. Fifty-one studies measured effects on ADL immediately after completion of the intervention period; only 16 reported persisting effects on ADL (our primary outcome). One study (30 participants) reported discharge destination, and one (24 participants) reported depression. No studies reported falls, balance, or quality of life. Only two studies were judged to be entirely at low risk of bias, and all were small, with fewer than 50 participants per group. We found no definitive (phase 3) clinical trials. None of the studies reported any patient or public involvement. Visual interventions versus any control: evidence is very uncertain about the effects of visual interventions for spatial neglect based on measures of persisting functional ability in ADL (2 studies, 55 participants) (standardised mean difference (SMD) -0.04, 95% confidence interval (CI) -0.57 to 0.49); measures of immediate functional ability in ADL; persisting standardised neglect assessments; and immediate neglect assessments. Prism adaptation versus any control: evidence is very uncertain about the effects of prism adaptation for spatial neglect based on measures of persisting functional ability in ADL (2 studies, 39 participants) (SMD -0.29, 95% CI -0.93 to 0.35); measures of immediate functional ability in ADL; persisting standardised neglect assessments; and immediate neglect assessments. Body awareness interventions versus any control: evidence is very uncertain about the effects of body awareness interventions for spatial neglect based on measures of persisting functional ability in ADL (5 studies, 125 participants) (SMD 0.61, 95% CI 0.24 to 0.97); measures of immediate functional ability in ADL; persisting standardised neglect assessments; immediate neglect assessments; and adverse events. Mental function interventions versus any control: we found no trials of mental function interventions for spatial neglect reporting on measures of persisting functional ability in ADL. Evidence is very uncertain about the effects of mental function interventions on spatial neglect based on measures of immediate functional ability in ADL and immediate neglect assessments. Movement interventions versus any control: we found no trials of movement interventions for spatial neglect reporting on measures of persisting functional ability in ADL. Evidence is very uncertain about the effects of body awareness interventions on spatial neglect based on measures of immediate functional ability in ADL and immediate neglect assessments. Non-invasive brain stimulation (NIBS) versus any control: evidence is very uncertain about the effects of NIBS on spatial neglect based on measures of persisting functional ability in ADL (3 studies, 92 participants) (SMD 0.35, 95% CI -0.08 to 0.77); measures of immediate functional ability in ADL; persisting standardised neglect assessments; immediate neglect assessments; and adverse events. Electrical stimulation versus any control: we found no trials of electrical stimulation for spatial neglect reporting on measures of persisting functional ability in ADL. Evidence is very uncertain about the effects of electrical stimulation on spatial neglect based on immediate neglect assessments. Acupuncture versus any control: we found no trials of acupuncture for spatial neglect reporting on measures of persisting functional ability in ADL. Evidence is very uncertain about the effects of acupuncture on spatial neglect based on measures of immediate functional ability in ADL and immediate neglect assessments.
AUTHORS' CONCLUSIONS: The effectiveness of non-pharmacological interventions for spatial neglect in improving functional ability in ADL and increasing independence remains unproven. Many strategies have been proposed to aid rehabilitation of spatial neglect, but none has yet been sufficiently researched through high-quality fully powered randomised trials to establish potential or adverse effects. As a consequence, no rehabilitation approach can be supported or refuted based on current evidence from RCTs. As recommended by a number of national clinical guidelines, clinicians should continue to provide rehabilitation for neglect that enables people to meet their rehabilitation goals. Clinicians and stroke survivors should have the opportunity, and are strongly encouraged, to participate in research. Future studies need to have appropriate high-quality methodological design, delivery, and reporting to enable appraisal and interpretation of results. Future studies also must evaluate outcomes of importance to patients, such as persisting functional ability in ADL. One way to improve the quality of research is to involve people with experience with the condition in designing and running trials.
BACKGROUND: For people with physical, sensory and cognitive limitations due to stroke, the routine practice of oral health care (OHC) may become a challenge. Evidence-based supported oral care intervention is essential for this patient group.
OBJECTIVES: To compare the effectiveness of OHC interventions with usual care or other treatment options for ensuring oral health in people after a stroke.
SEARCH METHODS: We searched the Cochrane Stroke Group and Cochrane Oral Health Group trials registers, CENTRAL, MEDLINE, Embase, and six other databases in February 2019. We scanned reference lists from relevant papers and contacted authors and researchers in the field. We handsearched the reference lists of relevant articles and contacted other researchers. There were no language restrictions.
SELECTION CRITERIA: We included randomised controlled trials (RCTs) that evaluated one or more interventions designed to improve the cleanliness and health of the mouth, tongue and teeth in people with a stroke who received assisted OHC led by healthcare staff. We included trials with a mixed population provided we could extract the stroke-specific data. The primary outcomes were dental plaque or denture plaque. Secondary outcomes included presence of oral disease, presence of related infection and oral opportunistic pathogens related to OHC and pneumonia, stroke survivor and providers' knowledge and attitudes to OHC, and patient satisfaction and quality of life.
DATA COLLECTION AND ANALYSIS: Two review authors independently screened abstracts and full-text articles according to prespecified selection criteria, extracted data and assessed the methodological quality using the Cochrane 'Risk of bias' tool. We sought clarification from investigators when required. Where suitable statistical data were available, we combined the selected outcome data in pooled meta-analyses. We used GRADE to assess the quality of evidence for each outcome.
MAIN RESULTS: Fifteen RCTs (22 randomised comparisons) involving 3631 participants with data for 1546 people with stroke met the selection criteria. OHC interventions compared with usual care Seven trials (2865 participants, with data for 903 participants with stroke, 1028 healthcare providers, 94 informal carers) investigated OHC interventions compared with usual care. Multi-component OHC interventions showed no evidence of a difference in the mean score (DMS) of dental plaque one month after the intervention was delivered (DMS -0.66, 95% CI -1.40 to 0.09; 2 trials, 83 participants; I2 = 83%; P = 0.08; very low-quality evidence). Stroke survivors had less plaque on their dentures when staff had access to the multi-component OHC intervention (DMS -1.31, 95% CI -1.96 to -0.66; 1 trial, 38 participants; P < 0.0001; low-quality evidence). There was no evidence of a difference in gingivitis (DMS -0.60, 95% CI -1.66 to 0.45; 2 trials, 83 participants; I2 = 93%; P = 0.26: very low-quality evidence) or denture-induced stomatitis (DMS -0.33, 95% CI -0.92 to 0.26; 1 trial, 38 participants; P = 0.69; low-quality evidence) among participants receiving the multi-component OHC protocol compared with usual care one month after the intervention. There was no difference in the incidence of pneumonia in participants receiving a multi-component OHC intervention (99 participants; 5 incidents of pneumonia) compared with those receiving usual care (105 participants; 1 incident of pneumonia) (OR 4.17, CI 95% 0.82 to 21.11; 1 trial, 204 participants; P = 0.08; low-quality evidence). OHC training for stroke survivors and healthcare providers significantly improved their OHC knowledge at one month after training (SMD 0.70, 95% CI 0.06 to 1.35; 3 trials, 728 participants; I2 = 94%; P = 0.03; very low-quality evidence). Pooled data one month after training also showed evidence of a difference between stroke survivor and providers' oral health attitudes (SMD 0.28, 95% CI 0.01 to 0.54; 3 trials, 728 participants; I2 = 65%; P = 0.06; very low-quality evidence). OHC interventions compared with placebo Three trials (394 participants, with data for 271 participants with stroke) compared an OHC intervention with placebo. There were no data for primary outcomes. There was no evidence of a difference in the incidence of pneumonia in participants receiving an OHC intervention compared with placebo (OR 0.39, CI 95% 0.14 to 1.09; 2 trials, 242 participants; I2 = 42%; P = 0.07; low-quality evidence). However, decontamination gel reduced the incidence of pneumonia among the intervention group compared with placebo gel group (OR 0.20, 95% CI 0.05 to 0.84; 1 trial, 203 participants; P = 0.028). There was no difference in the incidence of pneumonia in participants treated with povidone-iodine compared with a placebo (OR 0.81, 95% CI 0.18 to 3.51; 1 trial, 39 participants; P = 0.77). One OHC intervention compared with another OHC intervention Twelve trials (372 participants with stroke) compared one OHC intervention with another OHC intervention. There was no difference in dental plaque scores between those participants that received an enhanced multi-component OHC intervention compared with conventional OHC interventions at three months (MD -0.04, 95% CI -0.33 to 0.25; 1 trial, 61 participants; P = 0.78; low-quality evidence). There were no data for denture plaque.
AUTHORS' CONCLUSIONS: We found low- to very low-quality evidence suggesting that OHC interventions can improve the cleanliness of patient's dentures and stroke survivor and providers' knowledge and attitudes. There is limited low-quality evidence that selective decontamination gel may be more beneficial than placebo at reducing the incidence of pneumonia. Improvements in the cleanliness of a patient's own teeth was limited. We judged the quality of the evidence included within meta-analyses to be low or very low quality, and this limits our confidence in the results. We still lack high-quality evidence of the optimal approach to providing OHC to people after stroke.
BACKGROUND: Electromechanical- and robot-assisted gait-training devices are used in rehabilitation and might help to improve walking after stroke. This is an update of a Cochrane Review first published in 2007 and previously updated in 2017.
OBJECTIVES: Primary • To determine whether electromechanical- and robot-assisted gait training versus normal care improves walking after stroke Secondary • To determine whether electromechanical- and robot-assisted gait training versus normal care after stroke improves walking velocity, walking capacity, acceptability, and death from all causes until the end of the intervention phase SEARCH METHODS: We searched the Cochrane Stroke Group Trials Register (last searched 6 January 2020); the Cochrane Central Register of Controlled Trials (CENTRAL; 2020 Issue 1), in the Cochrane Library; MEDLINE in Ovid (1950 to 6 January 2020); Embase (1980 to 6 January 2020); the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 to 20 November 2019); the Allied and Complementary Medicine Database (AMED; 1985 to 6 January 2020); Web of Science (1899 to 7 January 2020); SPORTDiscus (1949 to 6 January 2020); the Physiotherapy Evidence Database (PEDro; searched 7 January 2020); and the engineering databases COMPENDEX (1972 to 16 January 2020) and Inspec (1969 to 6 January 2020). We handsearched relevant conference proceedings, searched trials and research registers, checked reference lists, and contacted trial authors in an effort to identify further published, unpublished, and ongoing trials.
SELECTION CRITERIA: We included all randomised controlled trials and randomised controlled cross-over trials in people over the age of 18 years diagnosed with stroke of any severity, at any stage, in any setting, evaluating electromechanical- and robot-assisted gait training versus normal care.
DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials for inclusion, assessed methodological quality and risk of bias, and extracted data. We assessed the quality of evidence using the GRADE approach. The primary outcome was the proportion of participants walking independently at follow-up.
MAIN RESULTS: We included in this review update 62 trials involving 2440 participants. Electromechanical-assisted gait training in combination with physiotherapy increased the odds of participants becoming independent in walking (odds ratio (random effects) 2.01, 95% confidence interval (CI) 1.51 to 2.69; 38 studies, 1567 participants; P < 0.00001; I² = 0%; high-quality evidence) and increased mean walking velocity (mean difference (MD) 0.06 m/s, 95% CI 0.02 to 0.10; 42 studies, 1600 participants; P = 0.004; I² = 60%; low-quality evidence) but did not improve mean walking capacity (MD 10.9 metres walked in 6 minutes, 95% CI -5.7 to 27.4; 24 studies, 983 participants; P = 0.2; I² = 42%; moderate-quality evidence). Electromechanical-assisted gait training did not increase the risk of loss to the study during intervention nor the risk of death from all causes. Results must be interpreted with caution because (1) some trials investigated people who were independent in walking at the start of the study, (2) we found variation between trials with respect to devices used and duration and frequency of treatment, and (3) some trials included devices with functional electrical stimulation. Post hoc analysis showed that people who are non-ambulatory at the start of the intervention may benefit but ambulatory people may not benefit from this type of training. Post hoc analysis showed no differences between the types of devices used in studies regarding ability to walk but revealed differences between devices in terms of walking velocity and capacity.
AUTHORS' CONCLUSIONS: People who receive electromechanical-assisted gait training in combination with physiotherapy after stroke are more likely to achieve independent walking than people who receive gait training without these devices. We concluded that eight patients need to be treated to prevent one dependency in walking. Specifically, people in the first three months after stroke and those who are not able to walk seem to benefit most from this type of intervention. The role of the type of device is still not clear. Further research should consist of large definitive pragmatic phase 3 trials undertaken to address specific questions about the most effective frequency and duration of electromechanical-assisted gait training, as well as how long any benefit may last. Future trials should consider time post stroke in their trial design.
Background: Organised inpatient (stroke unit) care is provided by multi-disciplinary teams that manage stroke patients. This can been provided in a ward dedicated to stroke patients (stroke ward), with a peripatetic stroke team (mobile stroke team), or within a generic disability service (mixed rehabilitation ward). Team members aim to provide co-ordinated multi-disciplinary care using standard approaches to manage common post-stroke problems. Objectives: • To assess the effects of organised inpatient (stroke unit) care compared with an alternative service. • To use a network meta-analysis (NMA) approach to assess different types of organised inpatient (stroke unit) care for people admitted to hospital after a stroke (the standard comparator was care in a general ward). Originally, we conducted this systematic review to clarify:. • The characteristic features of organised inpatient (stroke unit) care?. • Whether organised inpatient (stroke unit) care provide better patient outcomes than alternative forms of care?. • If benefits are apparent across a range of patient groups and across different approaches to delivering organised stroke unit care?. Within the current version, we wished to establish whether previous conclusions were altered by the inclusion of new outcome data from recent trials and further analysis via NMA. Search methods: We searched the Cochrane Stroke Group Trials Register (2 April 2019); the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 4), in the Cochrane Library (searched 2 April 2019); MEDLINE Ovid (1946 to 1 April 2019); Embase Ovid (1974 to 1 April 2019); and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 to 2 April 2019). In an effort to identify further published, unpublished, and ongoing trials, we searched seven trial registries (2 April 2019). We also performed citation tracking of included studies, checked reference lists of relevant articles, and contacted trialists. Selection criteria: Randomised controlled clinical trials comparing organised inpatient stroke unit care with an alternative service (typically contemporary conventional care), including comparing different types of organised inpatient (stroke unit) care for people with stroke who are admitted to hospital. Data collection and analysis: Two review authors assessed eligibility and trial quality. We checked descriptive details and trial data with co-ordinators of the original trials, assessed risk of bias, and applied GRADE. The primary outcome was poor outcome (death or dependency (Rankin score 3 to 5) or requiring institutional care) at the end of scheduled follow-up. Secondary outcomes included death, institutional care, dependency, subjective health status, satisfaction, and length of stay. We used direct (pairwise) comparisons to compare organised inpatient (stroke unit) care with an alternative service. We used an NMA to confirm the relative effects of different approaches. Main results: We included 29 trials (5902 participants) that compared organised inpatient (stroke unit) care with an alternative service: 20 trials (4127 participants) compared organised (stroke unit) care with a general ward, six trials (982 participants) compared different forms of organised (stroke unit) care, and three trials (793 participants) incorporated more than one comparison. Compared with the alternative service, organised inpatient (stroke unit) care was associated with improved outcomes at the end of scheduled follow-up (median one year): poor outcome (odds ratio (OR) 0.77, 95% confidence interval (CI) 0.69 to 0.87; moderate-quality evidence), death (OR 0.76, 95% CI 0.66 to 0.88; moderate-quality evidence), death or institutional care (OR 0.76, 95% CI 0.67 to 0.85; moderate-quality evidence), and death or dependency (OR 0.75, 95% CI 0.66 to 0.85; moderate-quality evidence). Evidence was of very low quality for subjective health status and was not available for patient satisfaction. Analysis of length of stay was complicated by variations in definition and measurement plus substantial statistical heterogeneity (I² = 85%). There was no indication that organised stroke unit care resulted in a longer hospital stay. Sensitivity analyses indicated that observed benefits remained when the analysis was restricted to securely randomised trials that used unequivocally blinded outcome assessment with a fixed period of follow-up. Outcomes appeared to be independent of patient age, sex, initial stroke severity, stroke type, and duration of follow-up. When calculated as the absolute risk difference for every 100 participants receiving stroke unit care, this equates to two extra survivors, six more living at home, and six more living independently. The analysis of different types of organised (stroke unit) care used both direct pairwise comparisons and NMA. Direct comparison of stroke ward versus general ward: 15 trials (3523 participants) compared care in a stroke ward with care in general wards. Stroke ward care showed a reduction in the odds of a poor outcome at the end of follow-up (OR 0.78, 95% CI 0.68 to 0.91; moderate-quality evidence). Direct comparison of mobile stroke team versus general ward: two trials (438 participants) compared care from a mobile stroke team with care in general wards. Stroke team care may result in little difference in the odds of a poor outcome at the end of follow-up (OR 0.80, 95% CI 0.52 to 1.22; low-quality evidence). Direct comparison of mixed rehabilitation ward versus general ward: six trials (630 participants) compared care in a mixed rehabilitation ward with care in general wards. Mixed rehabilitation ward care showed a reduction in the odds of a poor outcome at the end of follow-up (OR 0.65, 95% CI 0.47 to 0.90; moderate-quality evidence). In a NMA using care in a general ward as the comparator, the odds of a poor outcome were as follows: stroke ward - OR 0.74, 95% CI 0.62 to 0.89, moderate-quality evidence; mobile stroke team - OR 0.88, 95% CI 0.58 to 1.34, low-quality evidence; mixed rehabilitation ward - OR 0.70, 95% CI 0.52 to 0.95, low-quality evidence. Authors' conclusions: We found moderate-quality evidence that stroke patients who receive organised inpatient (stroke unit) care are more likely to be alive, independent, and living at home one year after the stroke. The apparent benefits were independent of patient age, sex, initial stroke severity, or stroke type, and were most obvious in units based in a discrete stroke ward. We observed no systematic increase in the length of inpatient stay, but these findings had considerable uncertainty.
BACKGROUND: Urinary incontinence can affect 40% to 60% of people admitted to hospital after a stroke, with 25% still having problems when discharged from hospital and 15% remaining incontinent after one year.This is an update of a review published in 2005 and updated in 2008.
OBJECTIVES: To assess the effects of interventions for treating urinary incontinence after stroke in adults at least one-month post-stroke.
SEARCH METHODS: We searched the Cochrane Incontinence and Cochrane Stroke Specialised Registers (searched 30 October 2017 and 1 November 2017 respectively), which contain trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov, WHO ICTRP and handsearched journals and conference proceedings.
SELECTION CRITERIA: We included randomised or quasi-randomised controlled trials.
DATA COLLECTION AND ANALYSIS: Two review authors independently undertook data extraction, risk of bias assessment and implemented GRADE.
MAIN RESULTS: We included 20 trials (reporting 21 comparisons) with 1338 participants. Data for prespecified outcomes were not available except where reported below.Intervention versus no intervention/usual careBehavioural interventions: Low-quality evidence suggests behavioural interventions may reduce the mean number of incontinent episodes in 24 hours (mean difference (MD) -1.00, 95% confidence interval (CI) -2.74 to 0.74; 1 trial; 18 participants; P = 0.26). Further, low-quality evidence from two trials suggests that behavioural interventions may make little or no difference to quality of life (SMD -0.99, 95% CI -2.83 to 0.86; 55 participants).Specialised professional input interventions: One trial of moderate-quality suggested structured assessment and management by continence nurse practitioners probably made little or no difference to the number of people continent three months after treatment (risk ratio (RR) 1.28, 95% CI 0.81 to 2.02; 121 participants; equivalent to an increase from 354 to 453 per 1000, 95% CI 287 to 715).Complementary therapy: Five trials assessed complementary therapy using traditional acupuncture, electroacupuncture and ginger-salt-partitioned moxibustion plus routine acupuncture. Low-quality evidence from five trials suggested that complementary therapy may increase the number of participants continent after treatment; participants in the treatment group were three times more likely to be continent (RR 2.82, 95% CI 1.57 to 5.07; 524 participants; equivalent to an increase from 193 to 544 per 1000, 95% CI 303 to 978). Adverse events were reported narratively in one study of electroacupuncture, reporting on bruising and postacupuncture abdominal pain in the intervention group.Physical therapy: Two trials reporting three comparisons suggest that physical therapy using transcutaneous electrical nerve stimulation (TENS) may reduce the mean number of incontinent episodes in 24 hours (MD -4.76, 95% CI -8.10 to -1.41; 142 participants; low-quality evidence). One trial of TENS reporting two comparisons found that the intervention probably improves overall functional ability (MD 8.97, 95% CI 1.27 to 16.68; 81 participants; moderate-quality evidence).Intervention versus placeboPhysical therapy: One trial of physical therapy suggests TPTNS may make little or no difference to the number of participants continent after treatment (RR 0.75, 95% CI 0.19 to 3.04; 54 participants) or number of incontinent episodes (MD -1.10, 95% CI -3.99 to 1.79; 39 participants). One trial suggested improvement in the TPTNS group at 26-weeks (OR 0.04, 95% CI 0.004 to 0.41) but there was no evidence of a difference in perceived bladder condition at six weeks (OR 2.33, 95% CI 0.63 to 8.65) or 12 weeks (OR 1.22, 95% CI 0.29 to 5.17). Data from one trial provided no evidence that TPTNS made a difference to quality of life measured with the ICIQLUTSqol (MD 3.90, 95% CI -4.25 to 12.05; 30 participants). Minor adverse events, such as minor skin irritation and ankle cramping, were reported in one study.Pharmacotherapy interventions: There was no evidence from one study that oestrogen therapy made a difference to the mean number of incontinent episodes per week in mild incontinence (paired samples, MD -1.71, 95% CI -3.51 to 0.09) or severe incontinence (paired samples, MD -6.40, 95% CI -9.47 to -3.33). One study reported no adverse events.Specific intervention versus another interventionBehavioural interventions: One trial comparing a behavioural intervention (timed voiding) with a pharmacotherapy intervention (oxybutynin) contained no useable data.Complementary therapy: One trial comparing different acupuncture needles and depth of needle insertion to assess the effect on incontinence reported that, after four courses of treatment, 78.1% participants in the elongated needle group had no incontinent episodes versus 40% in the filiform needle group (57 participants). This trial was assessed as unclear or high for all types of bias apart from incomplete outcome data.Combined intervention versus single interventionOne trial compared a combined intervention (sensory motor biofeedback plus timed prompted voiding) against a single intervention (timed voiding). The combined intervention may make little or no difference to the number of participants continent after treatment (RR 0.55, 95% CI 0.06 to 5.21; 23 participants; equivalent to a decrease from 167 to 92 per 1000, 95% CI 10 to 868) or to the number of incontinent episodes (MD 2.20, 95% CI 0.12 to 4.28; 23 participants).Specific intervention versus attention controlPhysical therapy interventions: One study found TPTNS may make little or no difference to the number of participants continent after treatment compared to an attention control group undertaking stretching exercises (RR 1.33, 95% CI 0.38 to 4.72; 24 participants; equivalent to an increase from 250 to 333 per 1000, 95% CI 95 to 1000).
AUTHORS' CONCLUSIONS: There is insufficient evidence to guide continence care of adults in the rehabilitative phase after stroke. As few trials tested the same intervention, conclusions are drawn from few, usually small, trials. CIs were wide, making it difficult to ascertain if there were clinically important differences. Only four trials had adequate allocation concealment and many were limited by poor reporting, making it impossible to judge the extent to which they were prone to bias. More appropriately powered, multicentre trials of interventions are required to provide robust evidence for interventions to improve urinary incontinence after stroke.
BACKGROUND: Sensory stimulation via acupuncture has been reported to alter activities of numerous neural systems by activating multiple efferent pathways. Acupuncture, one of the main physical therapies in Traditional Chinese Medicine, has been widely used to treat patients with stroke for over hundreds of years. This is the first update of the Cochrane Review originally published in 2005.
OBJECTIVES: To assess whether acupuncture could reduce the proportion of people with death or dependency, while improving quality of life, after acute ischemic or hemorrhagic stroke.
SEARCH METHODS: We searched the Cochrane Stroke Group trials register (last searched on February 2, 2017), the Cochrane Central Register of Controlled Trials Ovid (CENTRAL Ovid; 2017, Issue 2) in the Cochrane Library, MEDLINE Ovid (1946 to February 2017), Embase Ovid (1974 to February 2017), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) EBSCO (1982 to February 2017), the Allied and Complementary Medicine Database (AMED; 1985 to February 2017), China Academic Journal Network Publishing Database (1998 to February 2017), and the VIP database (VIP Chinese Science Journal Evaluation Reports; 1989 to February 2017). We also identified relevant trials in the Chinese Clinical Trial Registry (last searched on Feburuary 20, 2017), the World Health Organization (WHO) International Clinical Trials Registry Platform (last searched on April 30, 2017), and Clinicaltrials.gov (last searched on April 30, 2017). In addition, we handsearched the reference lists of systematic reviews and relevant clinical trials.
SELECTION CRITERIA: We sought randomized clinical trials (RCTs) of acupuncture started within 30 days from stroke onset compared with placebo or sham acupuncture or open control (no placebo) in people with acute ischemic or hemorrhagic stroke, or both. Needling into the skin was required for acupuncture. Comparisons were made versus (1) all controls (open control or sham acupuncture), and (2) sham acupuncture controls.
DATA COLLECTION AND ANALYSIS: Two review authors applied the inclusion criteria, assessed trial quality and risk of bias, and extracted data independently. We contacted study authors to ask for missing data. We assessed the quality of the evidence by using the GRADE approach. We defined the primary outcome as death or dependency at the end of follow-up .
MAIN RESULTS: We included in this updated review 33 RCTs with 3946 participants. Twenty new trials with 2780 participants had been completed since the previous review. Outcome data were available for up to 22 trials (2865 participants) that compared acupuncture with any control (open control or sham acupuncture) but for only six trials (668 participants) that compared acupuncture with sham acupuncture control. We downgraded the evidence to low or very low quality because of risk of bias in included studies, inconsistency in the acupuncture intervention and outcome measures, and imprecision in effect estimates.When compared with any control (11 trials with 1582 participants), findings of lower odds of death or dependency at the end of follow-up and over the long term (≥ three months) in the acupuncture group were uncertain (odds ratio [OR] 0.61, 95% confidence interval [CI] 0.46 to 0.79; very low-quality evidence; and OR 0.67, 95% CI 0.53 to 0.85; eight trials with 1436 participants; very low-quality evidence, respectively) and were not confirmed by trials comparing acupuncture with sham acupuncture (OR 0.71, 95% CI 0.43 to 1.18; low-quality evidence; and OR 0.67, 95% CI 0.40 to 1.12; low-quality evidence, respectively).In trials comparing acupuncture with any control, findings that acupuncture was associated with increases in the global neurological deficit score and in the motor function score were uncertain (standardized mean difference [SMD] 0.84, 95% CI 0.36 to 1.32; 12 trials with 1086 participants; very low-quality evidence; and SMD 1.08, 95% CI 0.45 to 1.71; 11 trials with 895 participants; very low-quality evidence). These findings were not confirmed in trials comparing acupuncture with sham acupuncture (SMD 0.01, 95% CI -0.55 to 0.57; low-quality evidence; and SMD 0.10, 95% CI -0.38 to 0.17; low-quality evidence, respectively).Trials comparing acupuncture with any control have reported little or no difference in death or institutional care at the end of follow-up (OR 0.78, 95% CI 0.54 to 1.12; five trials with 1120 participants; low-quality evidence), death within the first two weeks (OR 0.91, 95% CI 0.33 to 2.55; 18 trials with 1612 participants; low-quality evidence), or death at the end of follow-up (OR 1.08, 95% CI 0.74 to 1.58; 22 trials with 2865 participants; low-quality evidence).The incidence of adverse events (eg, pain, dizziness, faint) in the acupuncture arms of open and sham control trials was 6.2% (64/1037 participants), and 1.4% of these (14/1037 participants) discontinued acupuncture. When acupuncture was compared with sham acupuncture, findings for adverse events were uncertain (OR 0.58, 95% CI 0.29 to 1.16; five trials with 576 participants; low-quality evidence).
AUTHORS' CONCLUSIONS: This updated review indicates that apparently improved outcomes with acupuncture in acute stroke are confounded by the risk of bias related to use of open controls. Adverse events related to acupuncture were reported to be minor and usually did not result in stopping treatment. Future studies are needed to confirm or refute any effects of acupuncture in acute stroke. Trials should clearly report the method of randomization, concealment of allocation, and whether blinding of participants, personnel, and outcome assessors was achieved, while paying close attention to the effects of acupuncture on long-term functional outcomes.
Antecedentes: Un accidente cerebrovascular ocurre cuando el suministro de sangre a parte del cerebro se corta. Las actividades de la vida diaria (AVD) son actividades diarias en el hogar que las personas llevan a cabo para mantener la salud y el bienestar. ADLs incluyen la capacidad de: comer y beber sin ayuda, moverse, ir al baño, llevar a cabo tareas de higiene personal, vestir sin ayuda, y el novio. La apoplejía causa limitaciones funcionales relacionadas con el deterioro que pueden resultar en dificultades para participar en ADLs independientemente de la supervisión, dirección o asistencia física. Para adultos con accidente cerebrovascular, el objetivo de la terapia ocupacional es mejorar su capacidad para llevar a cabo actividades de la vida diaria. Las estrategias utilizadas por los terapeutas ocupacionales incluyen la evaluación, el tratamiento, las técnicas de adaptación, la tecnología de asistencia y las adaptaciones ambientales. OBJETIVOS: Evaluar los efectos de las intervenciones de terapia ocupacional sobre la capacidad funcional de adultos con ictus en el ámbito de las actividades de la vida diaria, en comparación con ninguna intervención o atención / práctica estándar. MÉTODOS DE BÚSQUEDA: Para esta actualización, se realizaron búsquedas en el Registro de Ensayos del Grupo Cochrane de Accidentes Cerebrales (Cochrane Stroke Group) (última búsqueda el 30 de enero de 2017), en el Registro Cochrane de Ensayos Controlados (Cochrane Controlled Trials Register) (The Cochrane Library, enero de 2017), MEDLINE (1946 a 5 January 2017) 5 de enero de 2017), CINAHL (1937 a enero de 2017), PsycINFO (1806 a 2 de noviembre de 2016), AMED (1985 a 1 de noviembre de 2016) y Web of Science (1900 a 6 de enero de 2017). También se realizaron búsquedas en registros de literatura gris y ensayos clínicos. Criterios de selección: Se identificaron ensayos controlados aleatorios de una intervención de terapia ocupacional (en comparación con ninguna intervención o atención estándar / práctica) donde las personas con accidente cerebrovascular practicaban actividades de la vida diaria o donde el desempeño en las actividades de la vida diaria era el foco de la terapia ocupacional . Dos revisores seleccionaron de forma independiente los ensayos, evaluaron el riesgo de sesgo y extrajeron los datos para los resultados preespecificados. Los resultados primarios fueron la proporción de participantes que se habían deteriorado o eran dependientes en las actividades personales de la vida diaria y el desempeño en las actividades de la vida diaria al final del seguimiento. PRINCIPALES RESULTADOS: Se incluyeron nueve estudios con 994 participantes en esta actualización. La terapia ocupacional dirigida a las actividades de la vida diaria después del accidente cerebrovascular aumentó las puntuaciones de rendimiento (diferencia de medias estandarizada 0,17, intervalo de confianza del 95% (IC) 0,03 a 0,31, P = 0,02, 7 estudios, 749 participantes, pruebas de baja calidad) Riesgo de mal resultado (muerte, deterioro o dependencia en las actividades personales de la vida diaria) (odds ratio (OR) 0,71, IC del 95%: 0,52 a 0,96, P = 0,03, 5 estudios, 771 participantes). También se encontró que aquellos que recibieron terapia ocupacional fueron más independientes en actividades extendidas de la vida diaria (OR 0,22 (IC del 95%: 0,07 a 0,37), P = 0,005, 5 estudios, 665 participantes, evidencia de baja calidad). La terapia ocupacional no influyó en la mortalidad (OR: 1,02 (IC 95% 0,65 a 1,61), P = 0,93, 8 estudios, 950 participantes), o reducir las probabilidades combinadas de muerte e institucionalización (OR 0,89 (IC del 95%: 0,60 a 1,32) , P = 0,55, 4 estudios, 671 participantes), o muerte y dependencia (OR 0,89 (IC del 95%: 0,64 a 1,23), P = 0,47, 4 ensayos, 659 participantes). La terapia ocupacional no mejoró el estado de ánimo ni las puntuaciones de angustia (OR 0,08 (IC del 95%: -0,09 a 0,26), P = 0,35, 4 estudios, 519 participantes, evidencia de baja calidad). No hubo datos suficientes para determinar los efectos de la terapia ocupacional sobre la calidad de vida relacionada con la salud. No se encontraron estudios de cuidadores con consentimiento previo a la participación en el estudio y, por lo tanto, no hubo resultados relacionados con el cuidador en nuestra revisión. No hubo datos suficientes para determinar la satisfacción de los participantes y cuidadores con los servicios. Usando GRADE, la calidad de la evidencia fue baja. La principal limitación fue el número de estudios con un riesgo poco claro de sesgo de selección y un riesgo inevitable alto de sesgo de rendimiento y detección, ya que tanto los participantes como los terapeutas ocupacionales no podían cegarse a la intervención. Además, hubo una escasez de datos para nuestros resultados de interés y degradamos la calidad de nuestra evidencia por estas razones. Se encontró evidencia de baja calidad que la terapia ocupacional dirigida hacia actividades de la vida diaria después del accidente cerebrovascular puede mejorar el desempeño en las actividades de la vida diaria y reducir el riesgo de deterioro en estas habilidades. Debido a que los estudios incluidos tenían defectos metodológicos, esta investigación no proporciona una indicación fiable de los efectos probables de la terapia ocupacional para adultos con accidente cerebrovascular.
ANTECEDENTES: Las personas con accidente cerebrovascular reciben convencionalmente una parte sustancial de su rehabilitación en el hospital. Se han desarrollado servicios que ofrecen a las personas en el hospital un alta temprana con rehabilitación en el hogar (descarga temprana apoyada: ESD). OBJETIVOS: Establecer si, en comparación con la atención convencional, los servicios que ofrecen a las personas hospitalizadas con ictus una política de alta temprana con rehabilitación proporcionada en la comunidad (EDS) pueden: 1) acelerar el regreso a casa; Resultados del cuidador, 3) ser aceptable satisfactorio para los pacientes y cuidadores, y 4) tener uso justificado de las implicaciones de recursos. Métodos de búsqueda Se realizaron búsquedas en el Registro de Ensayos Controlados del Grupo Cochrane de Accidentes Cerebrovasculares (Cochrane Stroke Group) (enero de 2017), en el Registro Cochrane Central de Ensayos Controlados (CENTRAL 2017, Número 1) en la Biblioteca Cochrane (en enero de 2017), en MEDLINE en Ovid Ovid (buscado en enero de 2017), CINAHL en EBSCO (Índice acumulativo de enfermería y literatura afines de salud, 1937 a diciembre de 2016) y Web of Science (hasta enero de 2017). En un esfuerzo por identificar ensayos publicados, no publicados y en curso, se realizaron búsquedas en seis registros de ensayos (marzo de 2017). También realizamos el seguimiento de citas de los estudios incluidos, verificamos las listas de referencias de artículos relevantes y contactamos con los investigadores. Ensayos controlados aleatorios (ECAs) que reclutan pacientes con ictus en el hospital para recibir atención convencional o cualquier intervención de servicio que haya proporcionado rehabilitación y apoyo en un entorno comunitario con el objetivo de reducir la duración de la atención hospitalaria. Recopilación y análisis de datos: El resultado primario del paciente fue el punto final compuesto de muerte o dependencia a largo plazo registrada al final del seguimiento programado. Dos revisores examinaron los ensayos, los clasificaron sobre su elegibilidad y extrajeron los datos. Siempre que fue posible, buscamos datos estandarizados de los ensayos primarios. Se analizaron los resultados de todos los ensayos y subgrupos de pacientes y servicios, en particular si la intervención fue proporcionada por un equipo multidisciplinario coordinado (equipo coordinado de ESD) o no. Se evaluó el riesgo de sesgo para los ensayos incluidos y se utilizó GRADE para evaluar la calidad del cuerpo de pruebas. Se incluyeron 17 ensayos, en los que se reclutaron 2422 participantes, para los que se dispone actualmente de datos sobre los resultados. Los participantes tendieron a ser un grupo de ancianos seleccionados de sobrevivientes de accidente cerebrovascular con discapacidad moderada. El grupo de ESD mostró reducciones en la duración de la estancia hospitalaria equivalente a aproximadamente seis días (diferencia de medias) -5,5, intervalo de confianza del 95% (IC) -3 a -8 días, p <0,0001, evidencia de grado moderado). El resultado primario estuvo disponible para 16 ensayos (2359 participantes). En general, las odds ratios (OR) para el resultado de la muerte o la dependencia al final del seguimiento programado (mediana 6 meses, rango 3 a 12) fue OR 0,80 (IC del 95%: 0,67 a 0,95; P = 0,01; Grado de evidencia) que equivale a cinco menos resultados adversos por cada 100 pacientes que reciben ESD. Los resultados de la muerte (16 ensayos, 2116 participantes) y la muerte o que requirieron atención institucional (12 ensayos, 1664 participantes) fueron OR 1,04 (IC del 95%: 0,77 a 1,40; P = 0,81; IC 0,59 a 0,96, P = 0,02, pruebas de grado moderado), respectivamente. También se observaron pequeñas mejoras en las actividades extendidas de los participantes en las puntuaciones de la vida diaria (diferencia de medias estandarizada 0,14, IC del 95%: 0,03 a 0,25, P = 0,01, evidencia de bajo grado) y satisfacción con los servicios (OR 1,60, IC del 95% 1,08 a 2,38, P = 0,02, evidencia de bajo grado). No se observaron diferencias claras en las actividades de los participantes en las puntuaciones de la vida diaria, estado de salud subjetivo del paciente o estado de ánimo, estado de salud subjetivo, estado de ánimo o satisfacción con los servicios de los cuidadores. Encontramos evidencia de baja calidad de que el riesgo de reingreso hospitalario fue similar en el grupo de atención ESD y atención convencional (OR 1,09, IC del 95%: 0,79 a 1,51, P = 0,59, evidencia de bajo grado). La evidencia de los beneficios aparentes fue más débil en el seguimiento de uno y cinco años. Los costos estimados de seis ensayos individuales variaron entre un 23% menor y un 15% mayor para el grupo ESD en comparación con la atención habitual. En una serie de análisis pre-planificados, las mayores reducciones en la muerte o la dependencia fueron vistas en los ensayos que evaluaron un co- Con una sugerencia de resultados más pobres en aquellos servicios sin un equipo coordinado (interacción de subgrupos a P = 0,06). Los pacientes con apoplejía con discapacidad de leve a moderada en la línea de base mostraron mayores reducciones en la muerte o la dependencia que aquellos con un accidente cerebrovascular más grave (interacción de subgrupos a P = 0,04). Conclusiones de los autores: Los servicios de ESD adecuadamente dotados con un equipo coordinado multidisciplinario para un grupo seleccionado de pacientes con ictus pueden reducir la dependencia a largo plazo y la admisión a cuidados institucionales, así como reducir la duración de la estancia hospitalaria. Los resultados no son concluyentes para los servicios sin la participación coordinada del equipo multidisciplinario. No se observó ningún impacto adverso en el estado de ánimo o estado de salud subjetivo de los pacientes o cuidadores, ni en la readmisión al hospital.
BACKGROUND: Treadmill training, with or without body weight support using a harness, is used in rehabilitation and might help to improve walking after stroke. This is an update of the Cochrane review first published in 2003 and updated in 2005 and 2014.
OBJECTIVES: To determine if treadmill training and body weight support, individually or in combination, improve walking ability, quality of life, activities of daily living, dependency or death, and institutionalisation or death, compared with other physiotherapy gait-training interventions after stroke. The secondary objective was to determine the safety and acceptability of this method of gait training.
SEARCH METHODS: We searched the Cochrane Stroke Group Trials Register (last searched 14 February 2017), the Cochrane Central Register of Controlled Trials (CENTRAL) and the Database of Reviews of Effects (DARE) (the Cochrane Library 2017, Issue 2), MEDLINE (1966 to 14 February 2017), Embase (1980 to 14 February 2017), CINAHL (1982 to 14 February 2017), AMED (1985 to 14 February 2017) and SPORTDiscus (1949 to 14 February 2017). We also handsearched relevant conference proceedings and ongoing trials and research registers, screened reference lists, and contacted trialists to identify further trials.
SELECTION CRITERIA: Randomised or quasi-randomised controlled and cross-over trials of treadmill training and body weight support, individually or in combination, for the treatment of walking after stroke.
DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials, extracted data, and assessed risk of bias and methodological quality. The primary outcomes investigated were walking speed, endurance, and dependency.
MAIN RESULTS: We included 56 trials with 3105 participants in this updated review. The average age of the participants was 60 years, and the studies were carried out in both inpatient and outpatient settings. All participants had at least some walking difficulties and many could not walk without assistance. Overall, the use of treadmill training did not increase the chances of walking independently compared with other physiotherapy interventions (risk difference (RD) -0.00, 95% confidence interval (CI) -0.02 to 0.02; 18 trials, 1210 participants; P = 0.94; I² = 0%; low-quality evidence). Overall, the use of treadmill training in walking rehabilitation for people after stroke increased the walking velocity and walking endurance significantly. The pooled mean difference (MD) (random-effects model) for walking velocity was 0.06 m/s (95% CI 0.03 to 0.09; 47 trials, 2323 participants; P < 0.0001; I² = 44%; moderate-quality evidence) and the pooled MD for walking endurance was 14.19 metres (95% CI 2.92 to 25.46; 28 trials, 1680 participants; P = 0.01; I² = 27%; moderate-quality evidence). Overall, the use of treadmill training with body weight support in walking rehabilitation for people after stroke did not increase the walking velocity and walking endurance at the end of scheduled follow-up. The pooled MD (random-effects model) for walking velocity was 0.03 m/s (95% CI -0.05 to 0.10; 12 trials, 954 participants; P = 0.50; I² = 55%; low-quality evidence) and the pooled MD for walking endurance was 21.64 metres (95% CI -4.70 to 47.98; 10 trials, 882 participants; P = 0.11; I² = 47%; low-quality evidence). In 38 studies with a total of 1571 participants who were independent in walking at study onset, the use of treadmill training increased the walking velocity significantly. The pooled MD (random-effects model) for walking velocity was 0.08 m/s (95% CI 0.05 to 0.12; P < 0.00001; I2 = 49%). There were insufficient data to comment on any effects on quality of life or activities of daily living. Adverse events and dropouts did not occur more frequently in people receiving treadmill training and these were not judged to be clinically serious events.
AUTHORS' CONCLUSIONS: Overall, people after stroke who receive treadmill training, with or without body weight support, are not more likely to improve their ability to walk independently compared with people after stroke not receiving treadmill training, but walking speed and walking endurance may improve slightly in the short term. Specifically, people with stroke who are able to walk (but not people who are dependent in walking at start of treatment) appear to benefit most from this type of intervention with regard to walking speed and walking endurance. This review did not find, however, that improvements in walking speed and endurance may have persisting beneficial effects. Further research should specifically investigate the effects of different frequencies, durations, or intensities (in terms of speed increments and inclination) of treadmill training, as well as the use of handrails, in ambulatory participants, but not in dependent walkers.
Antecedentes: El accidente cerebrovascular es la segunda causa más común de muerte en el mundo y en China se ha convertido en la principal causa de muerte. También es una causa principal de discapacidad y dependencia de adultos. La acupuntura para el accidente cerebrovascular se ha utilizado en China durante cientos de años y se practica cada vez más en algunos países occidentales. Esta es una actualización de la revisión Cochrane publicada originalmente en 2006. OBJETIVOS: Determinar la eficacia y seguridad de la terapia de acupuntura en personas con ictus subagudo y crónico. Tenemos la intención de probar las siguientes hipótesis: 1) la acupuntura puede reducir el riesgo de muerte o la dependencia en las personas con accidente cerebrovascular subagudo y crónica al final del tratamiento y en el seguimiento; 2) la acupuntura puede mejorar el déficit neurológico y la calidad de vida después del tratamiento y al final del seguimiento; 3) la acupuntura puede reducir el número de personas que requieren atención institucional; Y 4) la acupuntura no está asociada con ningún efecto adverso intolerable. Métodos de búsqueda Se realizaron búsquedas en el Registro de ensayos del Grupo Cochrane de Accidentes Cerebrovasculares (Cochrane Stroke Group) (junio de 2015), en el Registro Cochrane Central de Ensayos Controlados (CENTRAL, Cochrane Library 2015, Número 7), MEDLINE (1966 a julio 2015, Ovid) , Ovid), CINAHL (1982 a julio de 2015, EBSCO) y AMED (1985 a julio de 2015, Ovid). También se realizaron búsquedas en las siguientes cuatro bases de datos médicas chinas: Base de Datos de Medicina Biológica de China (julio de 2015); Base de datos de revistas científicas y técnicas de China (julio de 2015); China National Infrastructure (julio de 2015) y la base de datos Wan Fang (julio de 2015). CRITERIOS DE SELECCIÓN: Ensayos clínicos no confinados verdaderamente aleatorizados entre personas con accidente cerebrovascular isquémico o hemorrágico, en estadio subagudo o crónico, que comparan la acupuntura con aguja con acupuntura placebo, acupuntura falsa o ausencia de acupuntura. Dos revisores seleccionaron de forma independiente los ensayos para su inclusión, evaluaron la calidad, extrajeron y revisaron los datos. Se incluyeron 31 ensayos con un total de 2257 participantes en los estadios subagudo o crónico del accidente cerebrovascular. La calidad metodológica de la mayoría de los ensayos incluidos no fue alta. La calidad de la evidencia de los principales resultados fue baja o muy baja basada en la evaluación por el sistema de Grados de Recomendación, Evaluación, Desarrollo y Evaluación (GRADE). Dos ensayos compararon la acupuntura real más el tratamiento basal con la acupuntura simulada más el tratamiento inicial. No hubo evidencia de diferencias en los cambios de la función motora y la calidad de vida entre la acupuntura real y la acupuntura simulada para las personas con accidente cerebrovascular en la fase de convalecencia. Veintinueve ensayos compararon la acupuntura más el tratamiento basal versus el tratamiento basal solo. En comparación con la ausencia de acupuntura, la acupuntura tuvo efectos benéficos en la mejora de la dependencia (actividad de la vida diaria) medida por el Índice de Barthel (nueve ensayos, 616 participantes, diferencia de medias (MD) 9,19, 95% de confianza (IC) 4,34 a 14,05, GRADO muy bajo), deficiencia neurológica global (siete ensayos, 543 participantes, odds ratio (OR) 3,89, IC del 95% 1,78 a 8,49, GRADE bajo) y deficiencias neurológicas específicas, Evaluación de Fugl-Meyer (cuatro ensayos, 245 participantes, MD 6,16, IC del 95% 4,20 a 8,11, GRADE bajo), función cognitiva medida por el Mini-Mental State Examination (cinco ensayos, 278 participantes; 5,05; Grado muy bajo), depresión medida por la Escala de Depresión de Hamilton (seis ensayos, 552 participantes, MD -2,58; IC del 95%: -3,28 a -1,87; GRADO muy bajo) MD -1,11, IC del 95%: -2,08 a -0,14; G RADE muy bajo), y el dolor medido por la escala analógica visual (dos ensayos, 118 participantes; MD -2,88, IC del 95%: -3,68 a -2,09; GRADE bajo). La enfermedad causada por la acupuntura y la intolerancia al dolor en los puntos de acupuntura se informó en algunos participantes con accidente cerebrovascular en los grupos de acupuntura. En todos los ensayos incluidos no se dispone de datos sobre la mortalidad, la proporción de personas que requieren atención institucional o que requieren un amplio apoyo familiar y la mortalidad por todas las causas. CONCLUSIONES De los datos disponibles, la acupuntura puede tener efectos beneficiosos sobre la mejora de la dependencia, la deficiencia neurológica global y algunos trastornos neurológicos específicos para las personas con accidente cerebrovascular en la fase de convalecencia, sin eventos adversos graves evidentes. Sin embargo, la mayoría de los ensayos incluidos fueron de calidad y tamaño inadecuados. Por lo tanto, hay pruebas inadecuadas para sacar conclusiones sobre su uso rutinario. Para evaluar más a fondo los ensayos de acupuntura para el accidente cerebrovascular, se necesitan ensayos de gran tamaño, aleatorizados, multicéntricos y de gran tamaño.
People with spatial neglect after stroke or other brain injury have difficulty attending to one side of space. Various rehabilitation interventions have been used, but evidence of their benefit is unclear.
OBJECTIVES:
The main objective was to determine the effects of non-pharmacological interventions for people with spatial neglect after stroke and other adult-acquired non-progressive brain injury.
SEARCH METHODS:
We searched the Cochrane Stroke Group Trials Register (last searched October 2020), the Cochrane Central Register of Controlled Trials (CENTRAL; last searched October 2020), MEDLINE (1966 to October 2020), Embase (1980 to October 2020), the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1983 to October 2020), and PsycINFO (1974 to October 2020). We also searched ongoing trials registers and screened reference lists.
SELECTION CRITERIA:
We included randomised controlled trials (RCTs) of any non-pharmacological intervention specifically aimed at spatial neglect. We excluded studies of general rehabilitation and studies with mixed participant groups, unless separate neglect data were available.
DATA COLLECTION AND ANALYSIS:
We used standard Cochrane methods. Review authors categorised the interventions into eight broad types deemed to be applicable to clinical practice through iterative discussion: visual interventions, prism adaptation, body awareness interventions, mental function interventions, movement interventions, non-invasive brain stimulation, electrical stimulation, and acupuncture. We assessed the quality of evidence for each outcome using the GRADE approach.
MAIN RESULTS:
We included 65 RCTs with 1951 participants, all of which included people with spatial neglect following stroke. Most studies measured outcomes using standardised neglect assessments. Fifty-one studies measured effects on ADL immediately after completion of the intervention period; only 16 reported persisting effects on ADL (our primary outcome). One study (30 participants) reported discharge destination, and one (24 participants) reported depression. No studies reported falls, balance, or quality of life. Only two studies were judged to be entirely at low risk of bias, and all were small, with fewer than 50 participants per group. We found no definitive (phase 3) clinical trials. None of the studies reported any patient or public involvement. Visual interventions versus any control: evidence is very uncertain about the effects of visual interventions for spatial neglect based on measures of persisting functional ability in ADL (2 studies, 55 participants) (standardised mean difference (SMD) -0.04, 95% confidence interval (CI) -0.57 to 0.49); measures of immediate functional ability in ADL; persisting standardised neglect assessments; and immediate neglect assessments. Prism adaptation versus any control: evidence is very uncertain about the effects of prism adaptation for spatial neglect based on measures of persisting functional ability in ADL (2 studies, 39 participants) (SMD -0.29, 95% CI -0.93 to 0.35); measures of immediate functional ability in ADL; persisting standardised neglect assessments; and immediate neglect assessments. Body awareness interventions versus any control: evidence is very uncertain about the effects of body awareness interventions for spatial neglect based on measures of persisting functional ability in ADL (5 studies, 125 participants) (SMD 0.61, 95% CI 0.24 to 0.97); measures of immediate functional ability in ADL; persisting standardised neglect assessments; immediate neglect assessments; and adverse events. Mental function interventions versus any control: we found no trials of mental function interventions for spatial neglect reporting on measures of persisting functional ability in ADL. Evidence is very uncertain about the effects of mental function interventions on spatial neglect based on measures of immediate functional ability in ADL and immediate neglect assessments. Movement interventions versus any control: we found no trials of movement interventions for spatial neglect reporting on measures of persisting functional ability in ADL. Evidence is very uncertain about the effects of body awareness interventions on spatial neglect based on measures of immediate functional ability in ADL and immediate neglect assessments. Non-invasive brain stimulation (NIBS) versus any control: evidence is very uncertain about the effects of NIBS on spatial neglect based on measures of persisting functional ability in ADL (3 studies, 92 participants) (SMD 0.35, 95% CI -0.08 to 0.77); measures of immediate functional ability in ADL; persisting standardised neglect assessments; immediate neglect assessments; and adverse events. Electrical stimulation versus any control: we found no trials of electrical stimulation for spatial neglect reporting on measures of persisting functional ability in ADL. Evidence is very uncertain about the effects of electrical stimulation on spatial neglect based on immediate neglect assessments. Acupuncture versus any control: we found no trials of acupuncture for spatial neglect reporting on measures of persisting functional ability in ADL. Evidence is very uncertain about the effects of acupuncture on spatial neglect based on measures of immediate functional ability in ADL and immediate neglect assessments.
AUTHORS' CONCLUSIONS:
The effectiveness of non-pharmacological interventions for spatial neglect in improving functional ability in ADL and increasing independence remains unproven. Many strategies have been proposed to aid rehabilitation of spatial neglect, but none has yet been sufficiently researched through high-quality fully powered randomised trials to establish potential or adverse effects. As a consequence, no rehabilitation approach can be supported or refuted based on current evidence from RCTs. As recommended by a number of national clinical guidelines, clinicians should continue to provide rehabilitation for neglect that enables people to meet their rehabilitation goals. Clinicians and stroke survivors should have the opportunity, and are strongly encouraged, to participate in research. Future studies need to have appropriate high-quality methodological design, delivery, and reporting to enable appraisal and interpretation of results. Future studies also must evaluate outcomes of importance to patients, such as persisting functional ability in ADL. One way to improve the quality of research is to involve people with experience with the condition in designing and running trials.
