Endovascular treatment of cervical myelopathy from brachiocephalic venous stenosis.

Central venous stenosis is a rare cause of neurologic pathology. Here we present a case of brachiocephalic vein stenosis causing cervical myelopathy through venous engorgement. Our patient was a 51-y/o male who presented with ambulatory dysfunction so he was evaluated for cervical myelopathy. Imaging revealed cord compression from venous engorgement and brachiocephalic vein stenosis. He was treated with angioplasty and vessel stenting which significantly improved flow on postintervention imaging. In conclusion, preoperative vascular imaging should be considered in myelopathic patients as it can detect this rare but dangerous etiology

Interventions for improving upper limb function after stroke

Background: Improving upper limb function is a core element of stroke rehabilitation needed to maximise patient outcomes and reduce disability. Evidence about effects of individual treatment techniques and modalities is synthesised within many reviews. For selection of effective rehabilitation treatment, the relative effectiveness of interventions must be known. However, a comprehensive overview of systematic reviews in this area is currently lacking. Objectives: To carry out a Cochrane overview by synthesising systematic reviews of interventions provided to improve upper limb function after stroke. Methods: Search methods: We comprehensively searched the Cochrane Database of Systematic Reviews; the Database of Reviews of Effects; and PROSPERO (an international prospective register of systematic reviews) (June 2013). We also contacted review authors in an effort to identify further relevant reviews. Selection criteria: We included Cochrane and non‐Cochrane reviews of randomised controlled trials (RCTs) of patients with stroke comparing upper limb interventions with no treatment, usual care or alternative treatments. Our primary outcome of interest was upper limb function; secondary outcomes included motor impairment and performance of activities of daily living. When we identified overlapping reviews, we systematically identified the most up‐to‐date and comprehensive review and excluded reviews that overlapped with this. Data collection and analysis: Two overview authors independently applied the selection criteria, excluding reviews that were superseded by more up‐to‐date reviews including the same (or similar) studies. Two overview authors independently assessed the methodological quality of reviews (using a modified version of the AMSTAR tool) and extracted data. Quality of evidence within each comparison in each review was determined using objective criteria (based on numbers of participants, risk of bias, heterogeneity and review quality) to apply GRADE (Grades of Recommendation, Assessment, Development and Evaluation) levels of evidence. We resolved disagreements through discussion. We systematically tabulated the effects of interventions and used quality of evidence to determine implications for clinical practice and to make recommendations for future research. Main results: Our searches identified 1840 records, from which we included 40 completed reviews (19 Cochrane; 21 non‐Cochrane), covering 18 individual interventions and dose and setting of interventions. The 40 reviews contain 503 studies (18,078 participants). We extracted pooled data from 31 reviews related to 127 comparisons. We judged the quality of evidence to be high for 1/127 comparisons (transcranial direct current stimulation (tDCS) demonstrating no benefit for outcomes of activities of daily living (ADLs)); moderate for 49/127 comparisons (covering seven individual interventions) and low or very low for 77/127 comparisons. Moderate‐quality evidence showed a beneficial effect of constraint‐induced movement therapy (CIMT), mental practice, mirror therapy, interventions for sensory impairment, virtual reality and a relatively high dose of repetitive task practice, suggesting that these may be effective interventions; moderate‐quality evidence also indicated that unilateral arm training may be more effective than bilateral arm training. Information was insufficient to reveal the relative effectiveness of different interventions. Moderate‐quality evidence from subgroup analyses comparing greater and lesser doses of mental practice, repetitive task training and virtual reality demonstrates a beneficial effect for the group given the greater dose, although not for the group given the smaller dose; however tests for subgroup differences do not suggest a statistically significant difference between these groups. Future research related to dose is essential. Specific recommendations for future research are derived from current evidence. These recommendations include but are not limited to adequately powered, high‐quality RCTs to confirm the benefit of CIMT, mental practice, mirror therapy, virtual reality and a relatively high dose of repetitive task practice; high‐quality RCTs to explore the effects of repetitive transcranial magnetic stimulation (rTMS), tDCS, hands‐on therapy, music therapy, pharmacological interventions and interventions for sensory impairment; and up‐to‐date reviews related to biofeedback, Bobath therapy, electrical stimulation, reach‐to‐grasp exercise, repetitive task training, strength training and stretching and positioning. Authors' conclusions: Large numbers of overlapping reviews related to interventions to improve upper limb function following stroke have been identified, and this overview serves to signpost clinicians and policy makers toward relevant systematic reviews to support clinical decisions, providing one accessible, comprehensive document, which should support clinicians and policy makers in clinical decision making for stroke rehabilitation. Currently, no high‐quality evidence can be found for any interventions that are currently used as part of routine practice, and evidence is insufficient to enable comparison of the relative effectiveness of interventions. Effective collaboration is urgently needed to support large, robust RCTs of interventions currently used routinely within clinical practice. Evidence related to dose of interventions is particularly needed, as this information has widespread clinical and research implications

Commercial gaming devices for stroke upper limb rehabilitation: the stroke survivor experience

Introduction Approximately 30% of stroke survivors experience an upper limb impairment, which impacts on participation and quality of life. Gaming devices (Nintendo Wii) are being incorporated into rehabilitation to improve function. We explored the stroke survivor experience of gaming as an upper limb intervention. Methods Semi-structured, individual interviews with stroke survivors living within the UK were completed. Interviews were audio-recorded, transcribed verbatim and analysed using Framework methods. Transcripts were coded and summarised into thematic charts. Thematic charts were refined during analysis until the final framework emerged. Results We captured experiences of 12 stroke survivors who used Nintendo Wii. Gaming devices were found to be acceptable for all ages but varying levels of enthusiasm existed. Enthusiastic players described gaming as having a positive impact on their motivation to engage in rehabilitation. For some, this became a leisure activity, encouraging self-practice. Non-enthusiastic players preferred sports to gaming. Conclusion An in-depth account of stroke survivor experiences of gaming within upper limb rehabilitation has been captured. Suitability of gaming should be assessed individually and stroke survivor abilities and preference for interventions should be taken into consideration. There was no indication that older stroke survivors or those with no previous experience of gaming were less likely to enjoy the activity

The purpose of rating quality of evidence differs in an overview, as compared to guidelines or recommendations

No abstract available

An algorithm was developed to assign GRADE levels of evidence to comparisons within systematic reviews

Objectives: One recommended use of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach is supporting quality assessment of evidence of comparisons included within a Cochrane overview of reviews. Within our overview, reviewers found that current GRADE guidance was insufficient to make reliable and consistent judgments. To support our ratings, we developed an algorithm to grade quality of evidence using concrete rules. Methods: Using a pragmatic, exploratory approach, we explored the challenges of applying GRADE levels of evidence and developed an algorithm to applying GRADE levels of evidence in a consistent and transparent approach. Our methods involved application of algorithms and formulas to samples of reviews, expert panel discussion, and iterative refinement and revision. Results: The developed algorithm incorporated four key criteria: number of participants, risk of bias of trials, heterogeneity, and methodological quality of the review. A formula for applying GRADE level of evidence from the number of downgrades assigned by the algorithm was agreed. Conclusion: Our algorithm which assigns GRADE levels of evidence using a set of concrete rules was successfully applied within our Cochrane overview. We propose that this methodological approach has implications for assessment of quality of evidence within future evidence syntheses

The feasibility and effects of eye movement training for visual field loss after stroke: a mixed methods study

Acknowledgements The author(s) would like to thank the designers of all included scanning training tools for providing free access during this study. They wish to note that MyHappyNeuron is designed for a general population, and a version specifically for healthcare use (HappyNeuron Pro) is also available. We would also like to thank the low vision centres and rehabilitation officers involved in this study Funding This study was funded by the Stroke Association (UK) by way of a Junior Research and Training Fellowship held by the lead author (TSA JRTF 2011/02). MCB, AP and the NMAHP Research Unit are funded by the Scottish Government Health and Social Care Directorates. The views expressed here are those of the authors and not necessarily those of the funders.Peer reviewedPublisher PD