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Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

What is the probability of patients who are nonambulatory after stroke regaining independent walking? A systematic review

E Preston, L Ada, CM Dean, R Stanton, and G Waddington.

Review published: 2011.

CRD summary

This review concluded that the probability of people who were non-ambulatory up to one month after stroke regaining independent walking at three months was 60% in rehabilitation units, and 39% in acute units. The methods of synthesis were questionable and there were no direct comparisons and no mention of interventions used. Therefore, the findings may not be reliable.

Authors' objectives

To determine the probability of walking for people who were non-ambulatory in the first month after a stroke, who were managed in acute and rehabilitation units.

Searching

MEDLINE, CINAHL, EMBASE, Web of Science and Scopus were searched to September 2010. Search terms were reported. No language restrictions were applied. The reference lists of identified papers were checked for additional studies.

Study selection

Prospective studies, with consecutive sampling, non-ambulatory adults with hemiplegic stroke were eligible for inclusion. Participants had to be in-patients in acute or rehabilitation units. Studies had to report measures of walking, with initial measurement undertaken within one month of stroke and final measurement at discharge or more than three months after stroke. Acute units included stroke units or general medical units. Rehabilitation units were any in-patient units where people had been selected and transferred after acute care. Where several measures of walking were presented, independent walking was defined as being able to walk without human assistance.

Men and women were in the included studies and mean ages ranged from 57 to 80 years. Definitions of non-ambulatory included being able to walk but with human assistance. Initial assessments were undertaken between two and 31 days. Follow-up assessments were at discharge and/or from two to 12 months. Measurements included validated and custom made scales, or ability to walk without assistance.

One reviewer did the initial assessment. Two reviewers then independently selected studies from full papers. Conflicts were resolved by discussion with a third author.

Assessment of study quality

Quality was assessed using Hayden's tool. This was based on representativeness of study population, study attrition, measures of outcomes, measures of confounders. Good quality was defined as having met three categories, or two categories and partly met for other two.

Quality was assessed by two reviewers independently. Disagreements were resolved by a third reviewer.

Data extraction

Data were extracted to calculate probability and 95% confidence intervals (CI) of independent walking, according to the proportion of participants who achieved walking.

Data were extracted by one reviewer and checked by a second. Where necessary authors were contacted to clarify data.

Methods of synthesis

Probabilities and 95% confidence interval were pooled using a fixed-effect method. Heterogeneity was assessed using Ι². Where Ι² greater than 50% sensitivity analyses were undertaken using a random-effects model. Results were reported at three, six and 12 months after stroke. Post-hoc regression analysis was undertaken taking into account the number of days after stroke that the measurement of nonambulatory status occurred.

Results of the review

Twenty six studies were included, but only 17 (2,156 participants) contributed to results. Study size ranged from 13 to 510.

According to overall scoring, thirteen of the 17 studies were considered of good quality. Four did not meet the criteria for accounting for confounders, and 13 only partly met this criteria, 10 met criteria for representativeness of study population, but seven only partly met this criteria.

For rehabilitation units, the probability of regaining independent walking was 0.6 (95% CI 0.47 to 0.72; nine studies) at three months, 0.65 (95% CI 0.53 to 0.77; three studies) at six months, and 0.91 (95% CI 0.81 to 1.00; one study) at 12 months.

For acute units, the probability of regaining independent walking was 0.39 (95% CI 0.27 to 0.52, five studies) at three months, 0.69 (95% CI 0.46 to 0.92, two studies) at six months, and 0.74 (95% CI 0.59 to 0.88, one study) at 12 months.

Results for post hoc regression analysis were reported in the paper.

Authors' conclusions

The probability of people non-ambulatory within the first month of a stroke regaining independent walking at three months was 60% in rehabilitation units, and 39% in acute units.

CRD commentary

The aims of this review were clearly stated in terms of inclusion criteria. The search was not restricted by language so language bias was unlikely. It wasn't clear whether unpublished studies were eligible, or whether publication bias may have affected the review. The methods of the review were those aimed at reducing reviewer error or bias. Quality was assessed using a scoring system, but details of result for each item were presented.

It wasn't entirely clear whether the methods of synthesis were appropriate. The authors undertook tests for heterogeneity, but results were not reported. Data in some figures presented suggested considerable heterogeneity. Little information was presented about included participants and this could affect the generalisability of the review. The authors looked at differences between rehabilitation and acute settings, but there was no mention of what interventions were given to people to help them regain their walking abilities. All data came from observational studies, many of which were small, and which were generally considered of lower quality as other factors may have influenced results. In particular, as the authors acknowledge, there may have been clinical differences between participants treated in the different settings, with those in the rehabilitation units being a specially selected group. It wasn't clear why the authors considered, and described, 26 studies in the review, but only presented outcomes for 17 of these.

As there were questions about the possibility of missed data, the methods of synthesis and lower quality of included data, from generally small observational studies, with no direct comparison between the different service units, conclusions should be treated with caution as the findings may not be reliable.

Implications of the review for practice and research

Practice: The authors state that this information could be used to make decisions about allocation of rehabilitation resources, education of patients and carers and for discharge planning.

Research: The authors did not state any implications for research.

Funding

No funding.

Bibliographic details

Preston E, Ada L, Dean CM, Stanton R, Waddington G. What is the probability of patients who are nonambulatory after stroke regaining independent walking? A systematic review International Journal of Stroke 2011; 6(6): 531-540. [PubMed: 22111798]

PubMedID

22111798

Indexing Status

Subject indexing assigned by NLM

MeSH

Activities of Daily Living; Aged; Aged, 80 and over; Caregivers; Data Interpretation, Statistical; Female; Humans; Male; Middle Aged; Probability; Recovery of Function; Stroke /epidemiology /rehabilitation; Time Factors; Treatment Outcome; Walking /physiology

AccessionNumber

12011007591

Date bibliographic record published

11/07/2012

Date abstract record published

19/10/2012

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.

CRD has determined that this article meets the DARE scientific quality criteria for a systematic review.

Copyright © 2014 University of York.

PMID: 22111798

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