Effects of virtual reality-based telerehabilitation for stroke patients: A systematic review and meta-analysis of randomized controlled trials

BackgroundTelerehabilitation provides an essential opportunity to deliver continuous rehabilitation services for stroke patients at home, especially amid a global pandemic. Virtual reality is a simulation technology that has shown promising outcomes in stroke rehabilitation. Combining telerehabilitation and virtual reality is an emerging and innovative approach that enriches the rehabilitation experience and potentially enhances functional recovery outcomes. This review synthesized current evidence of using virtual reality-based telerehabilitation for patients after stroke and compared it with conventional in-person rehabilitation.MethodsRandomized controlled trials were searched across six databases published after 2000. Two independent reviewers conducted study selection, data extraction and quality assessment. The Physiotherapy Evidence Databases scale was used to evaluate the methodological quality. Qualitative synthesis and meta-analysis were conducted to compare functional outcomes after Virtual reality-based telerehabilitation with conventional in-person rehabilitation.ResultsNine studies including 260 participants were selected from 933 relevant records. Seven studies met the criteria for good quality based on the Physiotherapy Evidence Databases scale, two studies were fair quality. Compared with conventional in-person rehabilitation, the meta-analysis indicated that virtual reality-based telerehabilitation had comparable outcomes of upper extremity function and balance function. Both groups demonstrated similar effects on outcomes in mobility, cognition, activities of daily life, and quality of life.ConclusionsVirtual reality-based telerehabilitation is an effective alternative approach for patients with stroke, given the barriers and restrictions of traditional in-person rehabilitation.     

Mental practice for upper limb motor restoration after stroke: an updated meta-analysis of randomized controlled trials

Objectives: Stroke is a common refractory disease that may cause dysfunctions in the motor system. The study aimed to evaluate the effects of mental practice (MP) compared with other methods on upper limb motor restoration after stroke.

Methods: Eligible studies were identified from Pubmed, Embase, and The Cochrane Library. The study quality was assessed with the Cochrane risk assessment tool and heterogeneity test was performed using I² statistic and Q test. Random- and fixed-effects models were used and data were reported as weighted mean difference (WMD) and 95% confidence intervals (CIs). The publication bias was examined by Egger’s test and the sensitivity analysis was conducted by ignoring one literature at a time to observe whether this document could reverse the merged results.

Results: Total of 12 randomized controlled trials were identified. No evidence of publication bias was found. In a fixed-effect model, MP (experimental group) resulted in a significantly larger increase in Fugl-Meyer assessment (FMA) compared with other exercise methods (control group) (WMD = 2.0702, 95% CI: 1.2354–2.905, Z = 4.8606, P < 0.001). In a random-effect model, a significant pooled outcome was obtained for action research arm test (ARAT) (WMD = 4.0936, 95% CI: 1.9900–6.1971, Z = 3.8141, P < 0.001). Sensitivity analysis revealed that the merged WMDs of FMA and ARAT were not reversed.

Conclusions: Mental practice is effective on upper limb motor restoration after stroke. It is recommended to treat with MP to improve the outcome of stroke.     

The cognitive rehabilitation of limb apraxia in patients with stroke

Apraxia is a higher level motor deficit that occurs when processing a goal-directed action. The apraxic deficit can manifest itself in absence of sensory input deficits or motor output deficits, neglect, frontal inertia or dementia. According to a clinical classification still largely in use, there are two main forms of limb apraxia: ideomotor (IMA) and ideational (IA), observed when a patient is required to imitate a gesture or use an object, respectively. In the present review, we examined only the cognitive treatments of both types of limb apraxia of a vascular aetiology. Despite the high prevalence of limb apraxia caused by left brain damage, and the fact that apraxia has been known for over a century, the literature regarding its rehabilitation is still very limited. This is partly due to the nature of the recovery from the deficit, and in part to the automatic-voluntary dissociation. Here we review those treatments that have proved most successful in helping patients to recover from limb apraxia.     

Low-molecular-weight heparins and heparinoids in acute ischemic stroke : a meta-analysis of randomized controlled trials

BACKGROUND AND PURPOSE: Low-molecular-weight heparins and heparinoids (LMWHs) are superior to unfractionated heparin in the prevention and treatment of venous thromboembolism and acute coronary syndromes. We performed a systematic review of randomized controlled trials (RCTs) to examine the safety and efficacy of LMWH in acute ischemic stroke. METHODS: Randomized, controlled, and nonconfounded trials of LMWH in acute ischemic stroke were identified from the Cochrane Library (version 2, 1999), previous systematic reviews, and a review of publication quality relating to acute stroke trials. The authors each independently extracted data by treatment group and assessed trial quality using Cochrane Collaboration criteria. RESULTS: Eleven completed RCTs involving 3048 patients were identified; data were available from 10 of these. Four trials explicitly excluded patients with presumed cardioembolic stroke. Treatment with LMWH was associated with significant reductions in prospectively identified deep vein thrombosis (OR 0.27, 95% CI 0.08 to 0.96) and symptomatic pulmonary embolism (OR 0.34, 95% CI 0.17 to 0.69) and with increased major extracranial hemorrhage (OR 2.17, 95% 1.10 to 4.28). Nonsignificant increases in end-of-treatment (OR 1.20, 95% CI 0.86 to 1.69) and end-of-trial (OR 1.05, 95% CI 0.83 to 1.32) case fatality and symptomatic intracranial hemorrhage (OR 1.77, 95% CI 0. 95 to 3.31) were observed. End-of-trial death and disability was nonsignificantly reduced (OR 0.87, 95% CI 0.72 to 1.06). CONCLUSIONS: ++LMWHs reduce venous thromboembolic events in patients with acute ischemic stroke and increase the risk of extracranial bleeding. A nonsignificant reduction in combined death and disability and nonsignificant increases in case fatality and symptomatic intracranial hemorrhage were also observed. On the basis of the current evidence, LMWH should not be used in the routine management of patients with ischemic stroke.     

Mindfulness meditation for insomnia: A meta-analysis of randomized controlled trials

BackgroundInsomnia is a widespread and debilitating condition that affects sleep quality and daily productivity. Although mindfulness meditation (MM) has been suggested as a potentially effective supplement to medical treatment for insomnia, no comprehensively quantitative research has been conducted in this field. Therefore, we performed a meta-analysis on the findings of related randomized controlled trials (RCTs) to evaluate the effects of MM on insomnia.MethodsRelated publications in PubMed, EMBASE, the Cochrane Library and PsycINFO were searched up to July 2015. To calculate the standardized mean differences (SMDs) and 95% confidence intervals (CIs), we used a fixed effect model when heterogeneity was negligible and a random effect model when heterogeneity was significant.ResultsA total of 330 participants in 6 RCTs that met the selection criteria were included in this meta-analysis. Analysis of overall effect revealed that MM significantly improved total wake time and sleep quality, but had no significant effects on sleep onset latency, total sleep time, wake after sleep onset, sleep efficiency, total wake time, ISI, PSQI and DBAS. Subgroup analyses showed that although there were no significant differences between MM and control groups in terms of total sleep time, significant effects were found in total wake time, sleep onset latency, sleep quality, sleep efficiency, and PSQI global score (absolute value of SMD range: 0.44–1.09, all p < 0.05).ConclusionsThe results suggest that MM may mildly improve some sleep parameters in patients with insomnia. MM can serve as an auxiliary treatment to medication for sleep complaints.     

Rehabilitation of limb apraxia improves daily life activities in patients with stroke

We randomly assigned 33 patients with left hemisphere stroke, limb apraxia, and aphasia to an apraxia or a control (aphasia) treatment group. Before and after each treatment, patients underwent a comprehensive neuropsychological testing battery and a caregiver evaluation of patient's activities of daily life (ADL) independence. Apraxia severity was related with ADL independence. Control (aphasia) treatment improved patients' language and intelligence performance. Apraxia treatment specifically improved praxic function and ADL.     

Intramuscular olanzapine for agitated patients: A systematic review and meta-analysis of randomized controlled trials

We performed an updated systematic review and meta-analysis of randomized controlled trials (RCTs) of intramuscular (IM)-olanzapine (OLA-IM) versus controls in agitated patients. The risk ratio, number-needed-to-treat/harm, and standardized mean difference based on a random effects model were calculated. We identified 13 RCTs (19 comparisons) as follows: 7 comparisons with 1059 patients for OLA-IM versus placebo; 5 comparisons with 613 patients for OLA-IM versus haloperidol (HAL)-IM; 2 comparisons with 108 patients for OLA-IM versus ziprasidone (ZIP)-IM; 2 comparisons with 110 patients for OLA-IM versus HAL-IM plus midazolam; and 3 comparisons with 412 patients for OLA-IM versus HAL-IM plus promethazine, 2 comparisons with 355 patients for OLA-IM versus lorazepam-IM (LOR-IM); and 1 comparison with 67 patients for OLA-IM versus HAL-IM plus LOR-IM. OLA-IM was superior to placebo in both Positive and Negative Syndrome Scale-Excited Component (PANSS-EC) and Agitation–Calmness Evaluation Scale (ACES) scores 2 h after first injection, and had a comparable side effect profile, including over sedation, extrapyramidal symptoms, akathisia, and anticholinergic use. While there was no significant difference in PANSS-EC scores after 2 h between OLA-IM and HAL-IM, OLA-IM outperformed HAL-IM in ACES after 2 h. Compared with HAL-IM, OLA-IM was associated with fewer side effects, including anticholinergic use, akathisia, extrapyramidal symptoms, and dystonia, and marginally less QT prolongation compared with HAL-IM. Based on our findings, OLA-IM is preferable to HAL-IM for the treatment of agitated patients. However, comparator data for ZIP-IM, LOR-IM and HAL-IM combination therapy were insufficient.     

Effectiveness of digital psychotherapeutic intervention among perinatal women: A systematic review and meta-analysis of randomized controlled trials

BACKGROUNDThe perinatal period is a challenging time of substantial emotional, physiological, social, and relational changes. Depression, anxiety, and stress symptoms are common, and co-exist in the perinatal period. Digital technology continues to grow at an unprecedented pace with wide application, including psychotherapeutic intervention. A growing number of meta-analyses supported the application of digital psychotherapeutic intervention across different populations, but relatively few meta- and meta-regression analyses have concentrated on perinatal women.AIMTo evaluate the effectiveness of digital psychotherapeutic intervention on improving psychological outcomes among perinatal women and identify its essential features.METHODSRandomized controlled trials (RCTs) were obtained from eight databases, including Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, Embase, Scopus, PsycINFO, PubMed, Web of Science, and ProQuest Dissertation and Theses from inception up until November 24, 2020. Comprehensive Meta-analysis 3.0 software was used to conduct meta- and meta-regression analyses. The Cochrane risk-of-bias tool and the Grading of the Recommendation, Assessment, Development, and Evaluation system were adopted to assess the individual and overall qualities of the evidence, respectively.RESULTSA total of 25 RCTs that included 3239 women were identified. Meta-analyses revealed that intervention significantly improved depression (Hedges’s g = 0.49), anxiety (g = 0.25), and stress (g = 0.47) symptoms compared to the control. Subgroup analyses demonstrated that a website platform with ≥ eight therapist-guided sessions using the theoretical principle of cognitive behavioral therapy was more effective than other treatments in improving depression symptoms in postnatal women. Meta-regression analyses observed that the age of perinatal women and the type of psychotherapy also had statistically significant effects on depression symptoms. Egger’s regression asymmetry tests suggested that no publication biases occurred, but the overall quality of the evidence was very low.CONCLUSIONThis review suggests that digital psychotherapeutic intervention may be a potential solution to reduce psychological problems in perinatal women. Further high-quality RCTs with large sample sizes are needed.     

Cilostazol administration for subarachnoid hemorrhage: A meta-analysis of randomized controlled trials

IntroductionThe efficacy of cilostazol administration to treat subarachnoid hemorrhage remains controversial. We conduct a systematic review and meta-analysis to explore the influence of cilostazol administration on treatment efficacy for subarachnoid hemorrhage.MethodsWe have searched PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases through July 2020 for randomized controlled trials (RCTs) assessing the effect of cilostazol administration in patients with subarachnoid hemorrhage. This meta-analysis is performed using the random-effect model.ResultsFour RCTs involving 405 patients were included in the meta-analysis. Overall, compared with control group for subarachnoid hemorrhage, cilostazol intervention can significantly reduce symptomatic vasospasm (OR = 0.35; 95% CI = 0.21 to 0.60; P = 0.0001) and cerebral infarction (OR = 0.40; 95% CI = 0.22 to 0.73; P = 0.003), as well as improve no or mild angiographic vasospasm (OR = 2.01; 95% CI = 1.19 to 3.42; P = 0.01) and mRS score ≤ 2 (OR = 2.70; 95% CI = 1.09 to 6.71; P = 0.03), but revealed no obvious influence on severe angiographic vasospasm (OR = 0.53; 95% CI = 0.27 to 1.02; P = 0.06). There were no increase in adverse events (OR = 1.17; 95% CI = 0.54 to 2.52; P = 0.69), hemorrhagic events (OR = 0.62; 95% CI = 0.06 to 6.27; P = 0.69) and cardiac events (OR = 2.14; 95% CI = 0.44 to 10.27; P = 0.34) after the cilostazol intervention than control intervention.ConclusionsCilostazol treatment may be effective to treat subarachnoid hemorrhage in the terms of symptomatic vasospasm, cerebral infarction, no or mild angiographic vasospasm and mRS score ≤ 2.     

Effects of robot-assisted upper limb rehabilitation in stroke patients: a systematic review with meta-analysis

Neurological Sciences - Technology-supported training is emerging as a solution to support therapists in their efforts providing high-intensity, repetitive, and task-specific treatment, in order to...     

Effects of capsaicin on swallowing function in stroke patients with dysphagia: A randomized controlled trial

Background/AimsDysphagia is a common complication after acute stroke. While there are several innovative treatments being tested to improve the swallowing function of stroke patients with dysphagia, our aim is to explore the use of readily available natural capsaicin in stroke patients with dysphagia.Study designA randomized, double-blind study.MethodsSixty-nine hospitalized stroke patients were enrolled in this study. The capsaicin intervention group received thermal tactile stimulation with supplementation of natural capsaicin and additional nectar viscosity boluses. The control group received stimulation and boluses with placebo. Swallowing function was evaluated before and after the 3-week treatment, using Volume-Viscosity Swallow Test, Eating Assessment Tool, Standardized Swallowing Assessment, and Water Swallow Test.ResultsThe score decreases in the Eating Assessment Tool and Standardized Swallowing Assessment of the capsaicin intervention group were significantly greater than that of the placebo control group (P < .01). Among the 60 patients, the capsaicin intervention group exhibited effectiveness in a higher number of patients (n = 27, 90%) than the placebo group (n = 9, 30%, P < .001).ConclusionsRegular use of natural capsaicin could promote the recovery of swallow function in stroke patients with dysphagia. The ample availability of natural capsaicin could provide a low cost, easily accessible, and safe alternative method to address dysphagia in stoke patients.     

Efficacy and safety of remote ischemic conditioning for acute ischemic stroke: A comprehensive meta-analysis from randomized controlled trials

Background and Purpose

Remote ischemic conditioning (RIC) is a remote, transient, and noninvasive procedure providing temporary ischemia and reperfusion. However, there is no comprehensive literature investigating the efficacy and safety of RIC for the treatment of acute ischemic stroke. In the present study, we performed a comprehensive meta-analysis of the available studies.

Methods

MEDLINE, Embase, the Cochrane Library database (CENTRAL), and ClinicalTrials.gov were searched before Sep 7, 2022. The data were analyzed using Review Manager 5.4.1 software, Stata version 16.0 software, and R 4.2.0 software. Odds ratio (OR), mean difference (MD), and corresponding 95% CIs were pooled using fixed-effects meta-analysis.

Results

We pooled 6392 patients from 17 randomized controlled trials. Chronic RIC could reduce the recurrence of ischemic stroke at the endpoints (OR 0.67, 95% CI [0.51, 0.87]). RIC could also improve the prognosis of patients at 90 days as assessed by mRS score (mRS 0–1: OR 1.29, 95% CI [1.09, 1.52]; mRS 0–2: OR 1.22, 95% CI [1.01, 1.48]) and at the endpoints assessed by NIHSS score (MD −0.99, 95% CI [−1.45, −0.53]). RIC would not cause additional adverse events such as death (p = 0.72), intracerebral hemorrhage events (p = 0.69), pneumonia (p = 0.75), and TIA (p = 0.24) but would inevitably cause RIC-related adverse events (OR 26.79, 95% CI [12.08, 59.38]).

Conclusions

RIC could reduce the stroke recurrence and improve patients' prognosis. Intervention on bilateral upper limbs, 5 cycles, and a length of 50 min in each intervention might be an optimal protocol for RIC at present. RIC could be an effective therapy for patients not eligible for reperfusion therapy. RIC would not cause other adverse events except for relatively benign RIC-related adverse events.     

Selective dorsal rhizotomy: meta-analysis of three randomized controlled trials

This study is a comparative analysis and meta-analysis of three randomized clinical trials. Children with spastic diplegia received either 'selective' dorsal rhizotomy (SDR) plus physiotherapy (SDR+PT) or PT without SDR (PT-only). Common outcome measures were used for spasticity (Ashworth scale) and function (Gross Motor Function Measure [GMFM]). Baseline and 9- to 12-month outcome data were pooled (n=90). At baseline, 82 children were under 8 years old and 65 had Gross Motor Function Classification System level II or III disability. Pooled Ashworth data analysis confirmed a reduction of spasticity with SDR+PT (mean change score difference -1.2; Wilcoxonp<0.001). Pooled GMFM data revealed greater functional improvement with SDR+PT (difference in change score +4.0, p=0.008). Multivariate analysis in the SDR+PT group revealed a direct relationship between percentage of dorsal root tissue transected and functional improvement. SDR+PT is efficacious in reducing spasticity in children with spastic diplegia and has a small positive effect on gross motor function.     

Patent foramen ovale closure versus medical therapy in cases with cryptogenic stroke,meta-analysis of randomized controlled trials

Background

PFO is more common in cases with cryptogenic stroke compared to cases with no stroke or stroke of identified etiology. Several randomized controlled trials (RCTs) comparing PFO closure with medical therapy have been published with controversial findings.

Methods

PubMed, Embase and Cochrane library databases were searched for RCT comparing PFO closure with medical therapy including antiplatelet therapy (aspirin or clopidogrel or combination) or anticoagulation. We identified 5 trials, including 3627 cases. The mean duration of follow-up was 4 years. Relative risk (RR) and 95% confidence intervals (CI) were calculated using fixed and random-effects models.

Results

There was a significant reduction in the incidence of stroke among the PFO closure group compared to medical therapy group, 2.0 versus 4.2%, RR 0.48; 95% CI (0.3, 0.7), p < 0.001. The incidence of AF was higher in the PFO closure group compared to medical therapy group, 4.2 versus 0.7%, respectively, RR 5.9, 95% CI (3, 11), p < 0.001. After exclusion of oral anticoagulants cases (19%), analysis showed a lower incidence of stroke in the PFO closure group (2%) compared to antiplatelet therapy (5.2%), RR 0.4; 95% CI (0.3, 0.6), p < 0.001. There was no significant difference between both groups in the incidence of transient ischemic attacks or all-cause deaths.

Conclusion

PFO closure results in a significant reduction in the recurrence of ischemic stroke compared to medical therapy alone, primarily antiplatelet, among cases with PFO and cryptogenic stroke.

     

Constraint-induced movement therapy in treatment of acute and sub-acute stroke: a meta-analysis of 16 randomized controlled trials

OBJECTIVE: The aim of this meta-analysis was to evaluate the clinical efficacy of constraint-induced movement therapy in acute and sub-acute stroke.DATA SOURCES: The key words were stroke, cerebrovascular accident, constraint-induced therapy, forced use, and randomized controlled trial. The databases, including China National Knowledge Infrastructure, Wan Fang, Weipu Information Resources System, Chinese Biomedical Literature Database, Pub Med, Medline, Embase, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews, were searched for studies on randomized controlled trials for treating acute or sub-acute stroke published before March 2016. DATA SELECTION: We retrieved relevant randomized controlled trials that compared constraint-induced movement therapy in treatment of acute or sub-acute stroke with traditional rehabilitation therapy(traditional occupational therapy). Patients were older than 18 years, had disease courses less than 6 months, and were evaluated with at least one upper extremity function scale. Study quality was evaluated, and data that met the criteria were extracted. Stata 11.0 software was used for the meta-analysis. OUTCOME MEASURES: Fugl-Meyer motor assessment of the arm, the action research-arm test, a motor activity log for amount of use and quality of movement, the Wolf motor function test, and a modified Barthel index.RESULTS: A total of 16 prospective randomized controlled trials(379 patients in the constraint-induced movement-therapy group and 359 in the control group) met inclusion criteria. Analysis showed significant mean differences in favor of constraint-induced movement therapy for the Fugl–Meyer motor assessment of the arm(weighted mean difference(WMD) = 10.822; 95% confidence intervals(95% CI): 7.419–14.226), the action research-arm test(WMD = 10.718; 95% CI: 5.704–15.733), the motor activity log for amount of use and quality of movement(WMD = 0.812; 95% CI: 0.331–1.293) and the modified Barthel index(WMD = 10.706; 95% CI: 4.417–16.966). CONCLUSION: Constraint-induced movement therapy may be more beneficial than traditional rehabilitation therapy for improving upper limb function after acute or sub-acute stroke.     

Yoga for anxiety: A systematic review and meta-analysis of randomized controlled trials

Yoga has become a popular approach to improve emotional health. The aim of this review was to systematically assess and meta-analyze the effectiveness and safety of yoga for anxiety. Medline/PubMed, Scopus, the Cochrane Library, PsycINFO, and IndMED were searched through October 2016 for randomized controlled trials (RCTs) of yoga for individuals with anxiety disorders or elevated levels of anxiety. The primary outcomes were anxiety and remission rates, and secondary outcomes were depression, quality of life, and safety. Risk of bias was assessed using the Cochrane tool. Eight RCTs with 319 participants (mean age: 30.0–38.5 years) were included. Risk of selection bias was unclear for most RCTs. Meta-analyses revealed evidence for small short-term effects of yoga on anxiety compared to no treatment (standardized mean difference [SMD] = −0.43; 95% confidence interval [CI] = −0.74, −0.11; P = .008), and large effects compared to active comparators (SMD = −0.86; 95% CI = −1.56, −0.15; P = .02). Small effects on depression were found compared to no treatment (SMD = −0.35; 95% CI = −0.66, −0.04; P = .03). Effects were robust against potential methodological bias. No effects were found for patients with anxiety disorders diagnosed by Diagnostic and Statistical Manual criteria, only for patients diagnosed by other methods, and for individuals with elevated levels of anxiety without a formal diagnosis. Only three RCTs reported safety-related data but these indicated that yoga was not associated with increased injuries. In conclusion, yoga might be an effective and safe intervention for individuals with elevated levels of anxiety. There was inconclusive evidence for effects of yoga in anxiety disorders. More high-quality studies are needed and are warranted given these preliminary findings and plausible mechanisms of action.