INTERNATIONAL CONFERENCE OF OCCUPATIONAL THERAPY 2012 To study the effectiveness of repetitive task oriented training as Occupational Therapy intervention in upper limb weakness in adult stroke: Systematic Review. Hamad Medical Corporation, Occupational Therapy Department, Doha Qatar. Priya Vitthal Gawhale Repetitive Task Training is a treatment in which client repeat a series of specific movements over and over again. A stroke often leaves a person with problems using their arms and legs. The goal is to improve functional use of your arms and legs. 1
2012/4/2 1.Introduction 2.Methods 2 Methods 3.Results 4.Discussion 5.Limitations 6.Conclusion and Implications 6.Conclusion and Implications 7.Acknowledgements 2
2012/4/2 stroke leads to interference in Performance areas such as ADL, Work and in context including all physical, social, psychological areas. 3
Primary specific objectives: To determine the effectiveness of repetitive task oriented training in upper limb weakness in stroke. Secondary Objective: To study the effect of repetitive task oriented training as occupational Therapy intervention in stroke in upper limb function and activities of daily living. Search strategy: Search strategy used for database MEDLINE, EMBASE, CINAHL, Cochrane controlled trials searched for articles in repetitive task oriented Training in stroke. 4
1. computer aided search in bibliographic databases was done of follows 2. longitudinal cohort studies, 3 original prognostic studies, and 4. randomized controlled trials, 5. papers addressing task oriented training in stroke published in the period from 1996 to October 2011, were included. DESIGN: Systematic Literature Review 5
Inclusion criteria 1) Studies randomized controlled clinical trials, cohort studies, case studies, overviewed. 2) Participants Adults with age group of 30 70 diagnosis of stroke Ischemic and hemorrhagic stroke. 3) Articles studies with Interventions as repetitive, task and function based upper limb strengthening activities used to improve upper limb function 4) Types of outcome measures Interventions focused On functional performance using repetitive training in arm. 6
Client with perceptual deficits & severe cognitive impairment excluded. Motor recovery stage 1 to 3 were excluded. Level1 A Systematic review of RCT Level 1B = RCT with narrow Confidence interval Level 1c= All or None case Series Level 2A = Systematic review cohort studies Level 2B= cohort study/ low quality RCT Level2c=Outcomes research Level 3A=Systematic review of case controlled Level 3B=Case controlled study Level 4=Case series. LEVEL 5 Experts opinion 7
1) We found total 30 RCT on repetitive task training in stroke in upper limb. Study selected the comparison done control group with usual care and experimental group with repetitive task training. 2) Primary Outcome measures tool for upper limb function measured by Arm function test, hand function test and sitting balance/ reach. Specific outcome measures UE/reach were motor assessment Scale,Action research arm test, the functional test of Hemi paretic UE. 4) Studies with Hand function measured used nine hole test, box and block test. 5) Sitting balance and reach using sitting equilibrium index and motor assessment scale. 6) SECONDARY OUTCOME MEASURES: Using Activity of daily living impairment level measured by the Functional Independence Measure( FIM). 8
Study design Sacketts level of evidence Outcome measures used Intervention used Results Rf References Potentially relevant citations retrieved from electronic literature search (n = 478) Citations excluded based on inclusion and exclusion criteria (n = 248) Abstracts put forward to review (n = 554) Abstracts excluded based on inclusion and exclusion criteria (n = 633) Additional abstracts were excluded because publication dates prior to the year 1996. FOR CURRENT Updates Full-text articles put forward to review (n = 378) Studies excluded after full-text review (n = 199) Additional studies were excluded as the participants were not DCD diagnosed using the sacketts level criteria (n = 52) Studies included in systematic review (n = 30 9
Study methodology Study Design/ of articles retrieved Randomized controlled trial Systematic Review Randomized controlled trial Randomized controlled trial Study Design/ methodology of articles retrieve Randomized controlled trial Randomized controlled trial Randomized controlled trial Randomized controlled trial Randomized controlled trial Sacketts level of evidence Outcome measure used Level 1 Arm function, Hand function, sitting balance, ADL, upper limb impairment Level 1 Level 1 Sacketts level of evidence Level 1 Level 1 Level 1 Level 1 Level 1 Block & Box test & Nine hole peg test. Arm function test,hand function test. Outcome measure used Arm function test,berge balance test Jebson hand function test, Arm function test, box and block test Arm function test, hand function tests Wolf motor function test, fugl Meyer arm test Intervention used Results Author Repetitive task Studies shows French et.al.2007 oriented training modest in upper limb such as reaching, improv holding drinking glass,etc. ement in ADL But slight improvement in upper limb impairment. Repetitive task Review of study Higgins,Woodoriented training shows significant Dauphinees. in upper limb. improvement in arm functions. Repetitive task Study shows task Resink oriented training. oriented training M.Schurmans effective In M.,Hafsteinsdottir. improving T. participation ADL. Intervention used Results Author Task oriented training, functional task training in upper limb. Repetitive task oriented retraining in upper limb Task oriented strength training in upper limb. Repetitive functional task oriented training with practice Task oriented training. Results shows significant improvement in activities of daily living,no difference in hand strength improvement. Results shows task oriented training is effective in upper limb function. All the results shows significant improvement in participation of daily living. Results shows the significant improvement in self care. Results shows some improvement in activities of daily living. Salbach et,al Blennerhassett and dite Yange et,al (2006) Winstein et.al Pang et.al Study design Sacketts evidence level ( /6) Outcome measure used Intervention/ Author Sample Size EXPRIM(n) Control (N) Result Ramdomised control Trial 1 Arm function test, sitting balance, ADL, Repetitive task training such as reaching, holding, drinking glass of water French et.al (2007) 60 60 Studies shows m improvement in A But not in upper impairment Block and RCT 1 box test, t nine hole. ADL Repetitive e Haggins task training in UE 80 80 Review of study shows signif improvement in ac of daily living. A f ti R titi Study shows task i t d t i i 10
Study design SACKETS Evidence Level author Results Sample Size Exp. (N) Control (N) Outcome Measure RCT 1 Thielman ADL IMPROVE MENT SIGNIFICA NT 80 80 MAS, FIM RCT 1 dean & shephard Improvement in ADL 40 40 MAS. Sitting index RCT 1 Yang et.al significant improvement in ADL 60 60 Improvement in functional task. RCT 1 Beverly french shows modest improvem ent in self care activities 90 90 Arm function test, hand function tests This systematic review explored the efficacy of repetitive task oriented as OT intervention for stroke.using Ui the primary outcome measures arm function test, hand function test and secondary outcome measure FIM in ADL. This review shows significant effect in ADL participation. we applied a qualitative best evidence synthesis. We found limited evidence for improving sitting balance & hand functions and upper limb functions. 11
BLUE LINE- Shows significant improvement in Arm functions YELLOW LINE- Shows slight improvement in ADL functions RED LINE Shows no statically improvement in hand functions. Data analyzed in systematic review shows task orientedretraining retraining more effective in acute and sub acute stroke clients than chronic clients. Repetitive task training shows early recovery in activities of daily living But shows not significant improvement in hand strength. 12
Limitation of study only English articles reviewed Review focused on intervention in ADL but could not able to focused on Quality of life domain. 13
2012/4/2 The above analysis data regarding systematic review of repetitive task oriented training review of repetitive task oriented training shows significant improvement in ADL activities. Task should be more goal oriented. Further research in repetitive task training should be using more specific and meaning task which can be used as functional outcome for which can be used as functional outcome for early recovery. 14
I want to say special words of thanks to International scientific organizing committee of Honk kong and chairman Dr. simon and secretary mam Ceilina cum for helping me each step. very special heartly thank to my Occupational Therapy Department Head Mr. sultan sir and shobha mam. Thank you to MEDICAL RESEARCH for approval & assistance. Special lthank to my dear respected tdsir Alaa sheikh acting supervisor of HGH for supporting to me. Thank my colleagues, Library of HAMAD Medical Corporation for availing books journals. 1) Upper limb recovery after stroke: the stroke survivors' perspective Disability Rehab. 2005;27: 1213 1223.CrossRefMedline 2). Probability of regaining dexterity in the flaccid upper limb: impact of severity of paresis and time since onset in acute stroke. Stroke. 2003;34:2181 2186. 3) Predicting motor recovery of the upper limb after stroke rehabilitation: value of a clinical examination. 2000.CrossRefMedline 4) Paretic upper limb strength best explains arm activity in people with stroke. Phys Ther2007 15
REFERENCE 4) Review: Task oriented training in rehabilitation after stroke systematic review.(journal of adv Nurs 2009) 5)Repetitive task training for improving functional ability after stroke(the Cochrane Database of systematic review 2007) 6) Giban, J.W. &schkade,j. K.(1997) Occupational adaptation intervention with patients cerebro vascular accident. American Journal Of Occupational Therapy) 7) The Effect of task oriented intervention on arm function in people with in stroke : a Randomised controlled trial.( School of physical & occupational Therapy, faculty of medicine) 8) Upper limb recovery after stroke: the stroke survivors' perspective Disability Rehah.2005;27:1213 1223.CrossRefMedline 9) Probability of regaining dexterity in the flaccid upper limb: impact of severity of paresis and time since onset in acute stroke. Stroke. 2003;34:2181 2186. 16
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