A systematic review of repetitive task training with modelling of resource use, costs and effectiveness

OBJECTIVES: To determine whether repetitive functional task practice (RFTP) after stroke improves limb-specific or global function or activities of daily living and whether treatment effects are dependent on the amount of practice, or the type or timing of the intervention. Also to provide estimates of the cost-effectiveness of RFTP. DATA SOURCES: The main electronic databases were searched from inception to week 4, September 2006. Searches were also carried out on non-English-language databases and for unpublished trials up to May 2006. REVIEW METHODS: Standard quantitative methods were used to conduct the systematic review. The measures of efficacy of RFTP from the data synthesis were used to inform an economic model. The model used a pre-existing data set and tested the potential impact of RFTP on cost. An incremental cost per quality-adjusted life-year (QALY) gained for RFTP was estimated from the model. Sensitivity analyses around the assumptions made for the model were used to test the robustness of the estimates. RESULTS: Thirty-one trials with 34 intervention-control pairs and 1078 participants were included. Overall, it was found that some forms of RFTP resulted in improvement in global function, and in both arm and lower limb function. Overall standardised mean difference in data suitable for pooling was 0.38 [95% confidence interval (CI) 0.09 to 0.68] for global motor function, 0.24 (95% CI 0.06 to 0.42) for arm function and 0.28 (95% CI 0.05 to 0.51) for functional ambulation. Results suggest that training may be sufficient to have an impact on activities of daily living. Retention effects of training persist for up to 6 months, but whether they persist beyond this is unclear. There was little or no evidence that treatment effects overall were modified by time since stroke or dosage of task practice, but results for upper limb function were modified by type of intervention. The economic modelling suggested that RFTP was cost-effective. Given a threshold for cost-effectiveness of 20,000 pounds per QALY gained, RFTP is cost-effective so long as the net cost per patient is less than 1963 pounds. This result showed some sensitivity to the assumptions made for the model. The cost-effectiveness of RFTP tends to stem from the relatively modest cost associated with this intervention. CONCLUSIONS: The evidence suggests that some form of RFTP can be effective in improving lower limb function at any time after stroke, but that the duration of intervention effect is unclear. There is as yet insufficient good-quality evidence to make any firm recommendations for upper limb interventions. If task-specific training is used, adverse effects should be monitored. While the effectiveness of RFTP is relatively modest, this sort of intervention appears to be cost-effective. Owing to the large number of ongoing trials, this review should be updated within 2 years and any future review should include a comparison against alternative treatments. Further research should evaluate RFTP upper limb interventions and in particular constraint-induced movement therapy, address practical ways of delivering RFTP interventions, be directed towards the evaluation of suitable methods to maintain functional gain, and be powered to detect whether RFTP interventions are cost-effective

Parallel-Serial Memoing: A Novel Approach to Analyzing Qualitative Data

The mechanisms by which talking therapies exert their beneficial effects are largely unknown. In exploring the process of a talking therapy, motivational interviewing (MI), when used to treat and prevent low mood in stroke survivors, we developed, what we believe to be, a novel approach to analyzing transcripts. We illustrate the method using qualitative data from MI sessions with 10 stroke survivors. The approach, drawing on grounded theory, incorporated processes of parallel and serial memoing among a team of researchers to allow a process of validation. This enabled us to describe session content and to develop theoretical interpretations of what was occurring in and across MI sessions. We found that this process can be used to integrate different perspectives in theory building, allowing for a richer description and more robust theoretical interpretation. Others can use and adapt this approach to develop insights into their own inquiry

The impact of educational interventions for health professionals on stroke patient care: an integrative review

Introduction: The National Stroke Strategy, and the development of the Stroke-Specific Education Framework, emphasised the need for a skilled and knowledgeable workforce. The Francis and Keogh reports highlighted the importance of on-going continuing professional development. However, key policies do not cite explicit evidence of the value of education and training. This study aimed to systematically review the literature exploring the impact of healthcare professional education and training on the process and outcome of stroke patient care. Methods: An integrative review approach was used to summarise the literature. A search strategy including the MeSH terms stroke, education and health personnel was developed and adapted to search bibliographic databases. The search strategy's quality was tested using backwards and forwards citation searches. Results were screened on title, abstract, and full paper. Systematic data extraction and synthesis were conducted. Results: Following screening, 23 studies met the inclusion criteria. Staff group varied: pre-hospital staff (n=4), healthcare assistants, student nurses and nurses (n=10), multi-disciplinary teams (n=8), pharmacists (n=1); as did settings; pre-hospital and hyperacute (n=7), acute and rehabilitation (n=15), and community (n=1). The majority, 17 studies, demonstrated that education and training had a positive impact on a range of patient and process outcomes, however, methodological quality was variable ranging from single centre observational studies to cluster RCTs. Conclusion: Robust studies are needed to explore the impact of stroke education and training of health care staff on patient care so that investment in education and training can be more clearly linked to optimum health outcome