Repetitive task training for improving functional ability after stroke: Cochrane systematic review
Assessed as up to date: 2016/09/22
Repetitive task training (RTT) involves the active practice of task-specific motor activities and is a component of current therapy approaches in stroke rehabilitation.Objectives
Primary objective: To determine if RTT improves upper limb function/reach and lower limb function/balance in adults after stroke.
Secondary objectives: 1) To determine the effect of RTT on secondary outcome measures including activities of daily living, global motor function, quality of life/health status and adverse events. 2) To determine the factors that could influence primary and secondary outcome measures, including the effect of 'dose' of task practice; type of task (whole therapy, mixed or single task); timing of the intervention and type of intervention.
We searched the Cochrane Stroke Group Trials Register (4 March 2016); the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library 2016, Issue 5: 1 October 2006 to 24 June 2016); MEDLINE (1 October 2006 to 8 March 2016); Embase (1 October 2006 to 8 March 2016); CINAHL (2006 to 23 June 2016); AMED (2006 to 21 June 2016) and SPORTSDiscus (2006 to 21 June 2016).Selection criteria
Randomised/quasi-randomised trials in adults after stroke, where the intervention was an active motor sequence performed repetitively within a single training session, aimed towards a clear functional goal.Data collection and analysis
Two review authors independently screened abstracts, extracted data and appraised trials. We determined the quality of evidence within each study and outcome group using the Cochrane 'Risk of bias' tool and GRADE (Grades of Recommendation, Assessment, Development and Evaluation) criteria. We did not assess follow-up outcome data using GRADE. We contacted trial authors for additional information.Main results
We included 33 trials with 36 intervention-control pairs and 1853 participants. The risk of bias present in many studies was unclear due to poor reporting; the evidence has therefore been rated 'moderate' or 'low' when using the GRADE system.
There is low-quality evidence that RTT improves arm function (standardised mean difference (SMD) 0.25, 95% confidence interval (CI) 0.01 to 0.49; 11 studies, number of participants analysed = 749), hand function (SMD 0.25, 95% CI 0.00 to 0.51; eight studies, number of participants analysed = 619), and lower limb functional measures (SMD 0.29, 95% CI 0.10 to 0.48; five trials, number of participants analysed = 419).
There is moderate-quality evidence that RTT improves walking distance (mean difference (MD) 34.80, 95% CI 18.19 to 51.41; nine studies, number of participants analysed = 610) and functional ambulation (SMD 0.35, 95% CI 0.04 to 0.66; eight studies, number of participants analysed = 525). We found significant differences between groups for both upper-limb (SMD 0.92, 95% CI 0.58 to 1.26; three studies, number of participants analysed = 153) and lower-limb (SMD 0.34, 95% CI 0.16 to 0.52; eight studies, number of participants analysed = 471) outcomes up to six months post treatment but not after six months. Effects were not modified by intervention type, dosage of task practice or time since stroke for upper or lower limb. There was insufficient evidence to be certain about the risk of adverse events.Authors' conclusions
There is low- to moderate-quality evidence that RTT improves upper and lower limb function; improvements were sustained up to six months post treatment. Further research should focus on the type and amount of training, including ways of measuring the number of repetitions actually performed by participants. The definition of RTT will need revisiting prior to further updates of this review in order to ensure it remains clinically meaningful and distinguishable from other interventions.
French Beverley, Thomas Lois H, Coupe Jacqueline, McMahon Naoimh E, Connell Louise, Harrison Joanna, Sutton Christopher J, Tishkovskaya Svetlana, Watkins Caroline L
Repetitive task training for improving functional ability after stroke
Review question: What are the effects of repeated practice of functional tasks on recovery after stroke when compared with usual care or placebo treatments?
Background: Stroke can cause problems with movement, often down one side of the body. While some recovery is common over time, about one third of people have continuing problems. Repeated practice of functional tasks (e.g. lifting a cup) is a treatment approach used to help with recovery of movement after stroke. This approach is based on the simple idea that in order to improve our ability to perform tasks we need to practice doing that particular task numerous times, like when we first learned to write. The types of practice that people do, and the time that they spend practicing, may affect how well this treatment works. To explore this further we also looked at different aspects of repetitive practice that may influence how well it works.
Study characteristics: We identified 33 studies with 1853 participants. Studies included a wide range of tasks to practice, including lifting a ball, walking, standing up from sitting and circuit training with a different task at each station. The evidence is current to June 2016.
Key results: In comparison with usual care (standard physiotherapy) or placebo groups, people who practiced functional tasks showed small improvements in arm function, hand function, walking distance and measures of walking ability. Improvements in arm and leg function were maintained up to six months later. There was not enough evidence to be certain about the risk of adverse events, for example falls. Further research is needed to determine the best type of task practice, and whether more sustained practice could show better results.
Quality of the evidence: We classified the quality of the evidence as low for arm function, hand function and lower limb functional measures, and as moderate for walking distance and functional ambulation. The quality of the evidence for each outcome was limited due poor reporting of study details (particularly in earlier studies), inconsistent results across studies and small numbers of study participants in some comparisons.
Implications for practice
The results of this review provide low- or moderate-quality evidence to validate the general principle that repetitive, task-specific training for lower limbs can result in functional gain when compared against other forms of usual care or attention control. There is low-quality evidence of improvement in arm and hand function following repetitive task training (RTT) of the upper limb. Effects for both upper and lower limb appear to be sustained up to six months post treatment. Some caution is needed in interpreting the lack of evidence of adverse effects, as few trials specifically monitored these as outcomes. If task-specific training is used in clinical practice, adverse effects should be monitored.
Implications for research
Further primary research should be directed towards exploration of the amount of lower limb task training actually performed, as opposed to the length of the therapy session, and include number of repetitions, and how to maintain functional gain after six months post treatment. It is unclear whether task training accelerates recovery or simply improves performance for a finite time interval. This review provided some evidence of a treatment effect for upper limb function, although, with the exception of two studies (Arya 2012; Winstein 2016), sample sizes were small. The conclusion of this review about evidence for efficacy of task training for arm function is therefore tentative. More intensive therapy (over 20 hours) does not appear to be more effective for either the upper or lower limb.
There were insufficient trials included in the review to evaluate the efficacy and cost-effectiveness of different intervention delivery methods for RTT, such as group training, or practice in the home environment. Further randomised controlled trials should evaluate practical ways of delivering RTT interventions. In particular, the acceptability of circuit type training interventions in community settings needs to be evaluated. Further research should also address practical ways of maintaining post-therapy functional gain beyond six months. Future trials should be powered to detect cost-effectiveness as well as clinical effect, and should include a quality of life measure as one of the outcomes.
We were unable to investigate the impact on people of different levels of pre-intervention disability, because of the wide range of baseline measures used. Analyses of this type would be facilitated by the inclusion in trials of baseline data using a common measure, such as the Barthel Index, which can be related to population norms dependent on time since stroke.
This review did not compare repetitive functional task training against other interventions not currently viewed as a component of usual care. Future updates of this review are likely to compare RTT against other interventions (for example, resistance training, constraint-induced movement therapy or robotics), or in combination with other interventions (e.g. strength training) rather than RTT against "usual care". The definition of RTT will need revisiting prior to further updates of this review in order to ensure it remains clinically meaningful and distinguishable from other interventions (for example, treadmill training, Mehrholz 2014).Get full text at The Cochrane Library
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