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Critically appraised topic with a context
- 1. Rawan Alyemani Critically AppraisedTopic (CAT)
- 2. Faculty of Health,Medicine and Life Sciences Clinical Case 78-years-old male patient brought by an ambulance to the emergency department of university hospital of limerick, complaining of left sided weakness of upper and lower limb, left side facial droop and slurred speech. Plus, the symptoms were associated with confusion, headache and nausea. Further investigations including Lab investigation and CT scan were done, resulting in the diagnosis of Stroke which matches his clinical presentation. Moreover, patient has shown an improvement regarding muscle weakness of upper and lower limb of the left side from no power into two – three muscle straight. Regarding his past medical history, he has a history of temporal arteritis, TIA, rheumatoid arthritis and hypercholesterolemia. No previous surgery. No family history of stroke. He is ex-smoker and does drink 4 unit per day of alcohol. In term of his social life, he lives his wife in a bungalow. He used to do all his daily activities independently; For that reason patient would like to know if rehabilitation might help him with regaining his strength again?
- 3. Faculty of Health,Medicine and Life Sciences Disease/ Disorder Stroke Body functions and structures: (Impairments) - L leg weakness - L arm weakness - L arm spasticity - Loss of balance Activities: (Limitations) Mobility - Need help with positing Sitting Balance - Able to maintain siting position. Standing Balance - Not able to stand, wheel chair is required. - Require assistance for eating Participation: (Restrictions) Mobility activities - Unable to move within the room, chair is needed to move and assistance. Community activities - Not able to participate in e.g. grocery shopping or sport Environmental Factors: (barriers/facilitators) - Lives with wife in bungalow - Family support - Watching TV Personal Factors: (barriers/facilitators) - 78 year old - Male - Married - Retired - Coping with his disease - Fear of not getting better ICF plot -----------------Client……………………………………………..Date.………………………………………Generated by……………………………
- 4. Faculty of Health,Medicine and Life Sciences Question To what extent can rehabilitation be helpful in regaining motor recovery in a 78-years-old male patient who is newly diagnosed with a stroke, ex-smoker and has other comorbidities? Can rehabilitation help with regaining his strength after stroke diagnosis?
- 5. Faculty of Health,Medicine and Life Sciences P: 78 year old male, weakness I: Rehabilitation C: Conventional training program O: Motor recovery T: 6 months
- 6. Faculty of Health,Medicine and Life Sciences Search • Irish Heart Foundation • Stroke Association • Stroke support Basic search with Google, usi ng simple words and questio ns from patient's perspective regarding the outcome of reh abilitation
- 7. Faculty of Health,Medicine and Life Sciences Clinical search
- 8. Faculty of Health,Medicine and Life Sciences Article and motivation • The search resulted in 172 articles, th erefore I limited the search to new pu blication study that resulted in “ 66 art icles”. • Other articles were excluded due to ou tcomes differences like exercise for pr eventing falls, focus on one part of the body... ect. • This article was chosen because it has a larger number of studies included (1 29)
- 9. Faculty of Health,Medicine and Life Sciences Internal validity Criteria Clearly focused question Right choice of papers included Inclusion of all relevant studies Assessment of quality of included studies Results combination
- 10. Faculty of Health,Medicine and Life Sciences Evidence table
- 11. Faculty of Health,Medicine and Life Sciences Comments & Discussion Motor impairment is a common feature of stroke and evidence suggest that an early rehabilitation may have recovery benefits. • The trial has shown that ETP is effect for motor recovery within 6 months period, but it did not show to be superior to CTPs. • There are few issues with the study including; the baseline performance of participants, influencing factors and frequency of rehabilitation received.
- 12. Faculty of Health,Medicine and Life Sciences Compared to the grey sources? • There seems to be a consensus that rehabilitation do have a benefit for patients recovery.
- 13. Faculty of Health,Medicine and Life Sciences Bottom line Reading both grey sources and articles gives the indication that rehabilitation has a direct significant for motor recovery. Moreover patients seem to benefit from rehabilitation even when recovery time is different as it could takes a longer period to get a full recovery or a minimal recovery. Therefore, I would advise that the patient attend rehabilitation session, in order to gain his motor function back, as later on it is going to help with daily activity and participation in society.
- 14. Faculty of Health,Medicine and Life Sciences Questions?
Editor's Notes
- #3 Moreover, patient had experienced three episodes of seizure following the onset of symptoms.
- #4 bungalow
- #7 Stroke association the website has a good explanation regarding the most common questions from patient and explain the steps of rehab. Gave a guidance regarding patient issue. As well, patient stories are available online as well and most of them have explain there experience with rehab. Like “ my confidence is probably the hardest part to even gain back. I am still not fully confident but the rehab is definitely helping this. As my leg get stronger my confidence grows’ So, it is quite a good website for patient who what to know more regarding there progress of rehab by looking into other patient stories how it has improved there quality of life for good. Moreover, it dose provide guidance, stroke help line (call or email) and peer support by providing the closet clubs and groups near the patient area. https://irishheart.ie/get-support/support-groups/stroke-support-groups/ This is an Irish organization that provide a number of stoke support groups in Dublin, Galway, Sligo and Waterford ect, as well, patient can benefit from Facebook group that was created early this year. it help to discuss and share their experiences. Also, patient can look at tweeter and instgram if interested in. https://www.facebook.com/groups/446637476084272/ Stroke support The stroke support club is a voluntary group which was set up in 2005 to support people who have had a stroke. The club also offers support to their families, carers and friends. The organization located in limerick.
- #8 Search (((((((stroke) OR "Stroke"[Mesh]) OR ((Therapy/Broad[filter]) AND (stroke)))) AND (((rehabilitation) OR rehabilitative) OR "Rehabilitation"[Mesh]))) AND ((meta analysis) OR "Meta-Analysis" [Publication Type])) AND (((((motor recovery) OR "Muscle Strength Dynamometer"[Mesh]) OR muscle strength)) OR functional level)
- #9 https://www.ncbi.nlm.nih.gov/pubmed/30686327 Search (((((((stroke) OR "Stroke"[Mesh]) OR ((Therapy/Broad[filter]) AND (stroke)))) AND (((rehabilitation) OR rehabilitative) OR "Rehabilitation"[Mesh]))) AND ((meta analysis) OR "Meta-Analysis" [Publication Type])) AND (((((motor recovery) OR "Muscle Strength Dynamometer"[Mesh]) OR muscle strength)) OR functional level) Filters: Publication date from 2016/01/01 to 2019/12/31; Humans
- #10 https://casp-uk.net/wp-content/uploads/2018/01/CASP-Systematic-Review-Checklist_2018.pdf Section A: Are the results of the review valid? Did the review address a clearly focused question? Yes, clearly focused questions, and study included a 178 studies to review. Intervention was clearly given in the article, experimented training program (ETP). Outcome aimed to enhance motor recovery at impairment and functional levels. 2. Did the authors look for the right type of papers? The study has included the right RCT control trial as it has included 18 RCT associated with EPT, that show the effect of the program. 3. Do you think all the important, relevant studies were included? Yes, as database were collected from pubmed search, cocharne review and follow up from references lists. Moreover, looking at the eligibility of inclusion, the study enrolled RCT that has patient who were diagnosed within 6 months and had an intervention duration od > 2 weeks and studied compare ETP with or with CTPs. And articles were published in English. 4. Did the review’s authors do enough to assess quality of the included studies? Yes, the study has assess the quality by using PEDro scale (0-10), this study has included trial with score of > 4 and higher. 5. If the results of the review have been combined, was it reasonable to do so? There were quite different in the result of included studied as p value were rejected in some of the study and result were clearly displaced on table 2 and 3. Section B: What are the results? 6. What are the overall results of the review? It shown that ETPs is an effective method to enhance poststroke motor recovery. It has confirm that CIMT and task oriented training are effective. Looking at the p value few tests has shown to be significant with improving motor function. 7. How precise are the results? Standard mean difference has been used.
- #11 By looking at P value in some of the following tests has shown to be effective with a significant p value of <0.05 CIMT has shown to be the superior for motor recovery function based on the p value.
- #12 CTPs, mean conventional training program, it was consider as a control group in the study. These group has a rehab without electrical or mechanical devices ( physiotherapy and occupational therapy).. As it is a meta analysis it is difficult to know the exact T0 of the participate included in the trial. As it has included a participate who were diagnosed with 6 months but clear when rehab program started. As this might has an affect on the study result. Moreover, when it comes to the prognostic factors it was one of the limited factor of the study and I believe it would has some affect on the result of the study.
- #13 As, it has shown the result in patient website (grey sources) and scientifically (trial)