The effect of upper-extremity aerobic exercise on complex regional pain syndrome type I: a randomized controlled study on subacute stroke

Complex Regional Pain Syndrome

Complex Regional Pain Syndrome is characterized by regional pain that is disproportionate to the triggering event, with no distribution to dermatomes, a tendency towards chronicity, and dysfunction. This narrative review proposes an update of criteria for diagnosis and management of the syndrome, providing information on epidemiology, etiology, and pathophysiology. We base our information on systematic and narrative reviews, as well as guidelines published in recent years, aiming to facilitate diagnostic suspicion and provide a broad overview of therapeutic possibilities.

Prevalence and predisposing factors of post-stroke complex regional pain syndrome: Retrospective case-control study

INTRODUCTION

Poststroke complex regional pain syndrome (CRPS) is an important complication in stroke survivors. The identification of factors associated with post-stroke CRPS is important for preventive measures and early diagnosis.

METHODS

A total of 141 first-ever stroke survivors in the subacute stage were retrospectively analyzed. Demographic data, diagnosis time, duration of hospitalization, location of brain lesion, etiology, comorbidities, and blood test findings were investigated. Clinical data included Medical Research Council (MRC) grade, Fugl-Meyer assessment (FMA), National Institute for Health Stroke Scale (NIHSS), Berg Balance Scale (BBS).

RESULTS

Among 141 patients with subacute stroke, 22 were diagnosed with CRPS, with a prevalence of 15.6 %. The mean time to diagnosis was 38.6 (±16.5) days. The prevalence according to the degree of paralysis was 33.3 % in MRC grades 0 and 1, 8.6 % in grade 2, and 0 % in grade 3 or higher. The incidence rates within 1 month after stroke were 1.42 % and 22.47 % between 1 and 3 months after stroke, respectively. The independent risk factors for CRPS were hospitalization duration and FMA, NIHSS, and BBS scores. The sensitivity and specificity of the NIHSS score for predicting post-stroke CRPS were 86.4 % and 59.7 %, respectively, with an optimal cutoff value of 7.5.

CONCLUSIONS

CRPS of the affected upper limb in stroke patients is associated with stroke severity, including paralysis, and the incidence increases over time during the subacute phase. Additionally, having sufficient strength to move through a full range of motion against gravity had a protective effect against CRPS.

Therapeutic management of the painful nerve: a narrative review of common rehabilitation interventions

There are many ways that rehabilitation therapists, including occupational and physical therapists, treat nerve-related pain. Commonly used interventions include neurodynamic treatment, pain neuroscience education, desensitization, exercise, physical agent modalities, mirror box therapy, and Kinesio taping. Despite common practice and anecdotal support, it can be challenging to determine the appropriate intervention for each patient. In this article, each of these treatment approaches is discussed, including indicated pain phenotypes and diagnoses, timing, efficacy, mechanism, contraindications, and limitations.

Effectiveness of acupuncture for pain relief in shoulder-hand syndrome after stroke: a systematic evaluation and Bayesian network meta-analysis

Background

Shoulder-hand syndrome (SHS) is a common complication after stroke, and SHS-induced pain significantly hampers patients' overall recovery. As an alternative therapy for pain relief, acupuncture has certain advantages in alleviating pain caused by SHS after stroke. However, choosing the best treatment plan from a variety of acupuncture options is still a serious challenge in clinical practice. Therefore, we conducted this Bayesian network meta-analysis to comprehensively compare the effectiveness of various acupuncture treatment methods.

Methods

We systematically searched for randomized controlled trials (RCTs) of acupuncture treatment in patients with post-stroke SHS published in PubMed, Embase, Cochrane, and Web of Science until 9 March 2023. We used the Cochrane bias risk assessment tool to assess the bias risk in the included original studies.

Results

A total of 50 RCTs involving 3,999 subjects were included, comprising 19 types of effective acupuncture interventions. Compared to single rehabilitation training, the top three interventions for VAS improvement were floating needle [VAS = -2.54 (95% CI: -4.37 to -0.69)], rehabilitation + catgut embedding [VAS = -2.51 (95% CI: -4.33 to -0.68)], and other multi-needle acupuncture combinations [VAS = -2.32 (95% CI: -3.68 to -0.94)]. The top three interventions for improving the Fugl-Meyer score were eye acupuncture [Meyer = 15.73 (95% CI: 3.4627.95)], other multi-needle acupuncture combinations [Meyer = 12.22 (95% CI: 5.1919.34)], and traditional western medicine + acupuncture + traditional Chinese medicine [Meyer = 11.96 (95% CI: -0.59 to 24.63)].

Conclusion

Multiple acupuncture methods are significantly effective in improving pain and upper limb motor function in post-stroke SHS, with relatively few adverse events; thus, acupuncture can be promoted.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, CRD42023410957.

Rehabilitation Interventions for Complex Regional Pain Syndrome: An Overview of Systematic Reviews

OBJECTIVES

An increasing number of systematic reviews have been conducted on various conservative management of complex regional pain syndrome (CRPS) targeting different rehabilitation interventions and objectives. The intent of this article was to summarize and critically appraise the body of evidence on conservative management of the CRPS and to provide an overall picture of the current state of the literature.

METHODS

This study was an overview of systematic reviews on conservative treatments for CRPS. We conducted a literature search from inception to January 2023 in the following databases: Embase, Medline, CINAHL, Google Scholar, Cochrane Library, and Physiotherapy Evidence Database (PEDro). Two independent reviewers conducted study screening, data extraction, and methodological quality assessment (using AMSTAR-2). Qualitative synthesis was the preferred method for reporting the findings of our review. We calculated the corrected covered area index to account for the proportion of overlapping primary studies that were included in multiple reviews.

RESULT

We identified 214 articles, and a total of 9 systematic reviews of randomized controlled trials were eligible for inclusion. Pain and disability were the most common outcomes evaluated in the reviews. There were 6 (6/9; 66%) high-quality, 2 (2/9; 22%) moderate-quality, and 1 critically low-quality systematic review (1/9;11%), with the quality of the included trials ranging from very low to high. There was a large overlap across primary studies that were included in the systematic reviews (corrected covered area=23%). The findings of high-quality reviews support the effectiveness of mirror therapy (MT) and graded motor imagery (GMI) programs on pain and disability improvement in CRPS patients. The large effect size was reported for the effectiveness of MT on pain and disability (SMD:1.88 (95% CI: 0.73-3.02) and 1.30 (95% CI: 0.11-2.49), respectively) and the effectiveness of GMI program (GMIP) on pain and disability improvement (SMD: 1.36 (95% CI: 0.75-1.96) and 1.64 (95% CI: 0.53-2.74), respectively).

DISCUSSION

The evidence is in favor of adopting movement representation techniques, such as MT and GMI programs, for the treatment of pain and disability in patients with CRPS. However, this is based on a small body of primary evidence, and more research is required to generate conclusions. Overall, the evidence is not comprehensive or of sufficient quality to make definitive recommendations about the effectiveness of other rehabilitation interventions in improving pain and disability.

Interventions for treating pain and disability in adults with complex regional pain syndrome- an overview of systematic reviews

BACKGROUND

Complex regional pain syndrome (CRPS) is a chronic pain condition that usually occurs in a limb following trauma or surgery. It is characterised by persisting pain that is disproportionate in magnitude or duration to the typical course of pain after similar injury. There is currently no consensus regarding the optimal management of CRPS, although a broad range of interventions have been described and are commonly used. This is the first update of the original Cochrane review published in Issue 4, 2013.

OBJECTIVES

To summarise the evidence from Cochrane and non-Cochrane systematic reviews of the efficacy, effectiveness, and safety of any intervention used to reduce pain, disability, or both, in adults with CRPS.

METHODS

We identified Cochrane reviews and non-Cochrane reviews through a systematic search of Ovid MEDLINE, Ovid Embase, Cochrane Database of Systematic Reviews, CINAHL, PEDro, LILACS and Epistemonikos from inception to October 2022, with no language restrictions. We included systematic reviews of randomised controlled trials that included adults (≥18 years) diagnosed with CRPS, using any diagnostic criteria.  Two overview authors independently assessed eligibility, extracted data, and assessed the quality of the reviews and certainty of the evidence using the AMSTAR 2 and GRADE tools respectively. We extracted data for the primary outcomes pain, disability and adverse events, and the secondary outcomes quality of life, emotional well-being, and participants' ratings of satisfaction or improvement with treatment.  MAIN RESULTS: We included six Cochrane and 13 non-Cochrane systematic reviews in the previous version of this overview and five Cochrane and 12 non-Cochrane reviews in the current version. Using the AMSTAR 2 tool, we judged Cochrane reviews to have higher methodological quality than non-Cochrane reviews. The studies in the included reviews were typically small and mostly at high risk of bias or of low methodological quality. We found no high-certainty evidence for any comparison.  There was low-certainty evidence that bisphosphonates may reduce pain intensity post-intervention (standardised mean difference (SMD) -2.6, 95% confidence interval (CI) -1.8 to -3.4, P = 0.001; I2 = 81%; 4 trials, n = 181) and moderate-certainty evidence that they are probably associated with increased adverse events of any nature (risk ratio (RR) 2.10, 95% CI 1.27 to 3.47; number needed to treat for an additional harmful outcome (NNTH) 4.6, 95% CI 2.4 to 168.0; 4 trials, n = 181).  There was moderate-certainty evidence that lidocaine local anaesthetic sympathetic blockade probably does not reduce pain intensity compared with placebo, and low-certainty evidence that it may not reduce pain intensity compared with ultrasound of the stellate ganglion. No effect size was reported for either comparison. There was low-certainty evidence that topical dimethyl sulfoxide may not reduce pain intensity compared with oral N-acetylcysteine, but no effect size was reported. There was low-certainty evidence that continuous bupivacaine brachial plexus block may reduce pain intensity compared with continuous bupivacaine stellate ganglion block, but no effect size was reported. For a wide range of other commonly used interventions, the certainty in the evidence was very low and provides insufficient evidence to either support or refute their use. Comparisons with low- and very low-certainty evidence should be treated with substantial caution. We did not identify any RCT evidence for routinely used pharmacological interventions for CRPS such as tricyclic antidepressants or opioids.

AUTHORS' CONCLUSIONS

Despite a considerable increase in included evidence compared with the previous version of this overview, we identified no high-certainty evidence for the effectiveness of any therapy for CRPS. Until larger, high-quality trials are undertaken, formulating an evidence-based approach to managing CRPS will remain difficult. Current non-Cochrane systematic reviews of interventions for CRPS are of low methodological quality and should not be relied upon to provide an accurate and comprehensive summary of the evidence.

The Effectiveness of Rehabilitation Interventions on Pain and Disability for Complex Regional Pain Syndrome: A Systematic Review and Meta-analysis

OBJECTIVES

To summarize and critically appraise the body of evidence on conservative management of complex regional pain syndrome (CRPS), we conducted a systematic review and meta-analysis of randomized controlled trials (RCTs).

METHODS

We conducted a literature search from inception to November 2021 in the following databases: Embase, Medline, CINAHL, Google Scholar, PEDRO, and Psychinfo. Two independent reviewers conducted risk of bias and quality assessment. Qualitative synthesis and meta-analysis were the methods for summarizing the findings of the RCTs. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to rate the overall quality and certainty of the evidence on each treatment outcome.

RESULT

Through a database search, 751 records were found, and 33 RCTs were eligible for inclusion. Studies were published between 1995 and 2021. The overall risk of bias for 2 studies was low, 8 studies were unclear, and 23 studies were high.Low-quality evidence suggests that mirror therapy (as an addition to conventional stroke rehabilitation interventions) and graded motor imagery program (compared with routine rehabilitation interventions) may result in a large improvement in pain and disability up to 6-month follow-up in poststroke CRPS-1 patients. Low-quality evidence suggests that pain exposure therapy and aerobic exercises as an additive treatment to physical therapy interventions may result in a large improvement in pain up to a 6-month follow-up. The evidence is very uncertain about the effect of all other targeted interventions over conventional physical therapy or sham treatments on pain and disability.

DISCUSSION

There is an ongoing need for high-quality studies to inform conservative management choices in CRPS.

Effect and mechanisms of exercise for complex regional pain syndrome

Complex regional pain syndrome characterized by severe pain and dysfunction seriously affects patients' quality of life. Exercise therapy is gaining attention because it can effectively relieve pain and improve physical function. Based on the previous studies, this article summarized the effectiveness and underlying mechanisms of exercise interventions for complex regional pain syndrome, and described the gradual multistage exercise program. Exercises suitable for patients with complex regional pain syndrome mainly include graded motor imagery, mirror therapy, progressive stress loading training, and progressive aerobic training. In general, exercise training for patients with complex regional pain syndrome not only alleviates pain but also improves physical function and positive mental status. The underlying mechanisms of exercise interventions for complex regional pain syndrome include the remodeling of abnormal central and peripheral nervous system, the regulation of vasodilation and adrenaline levels, the release of endogenous opioids, and the increased anti-inflammatory cytokines. This article provided a clear explanation and summary of the research on exercise for complex regional pain syndrome. In the future, more high-quality studies with sufficient sample sizes may provide more exercise regimens and better evidence of efficacy.

The effect and mechanism of exercise for post-stroke pain

One of the common negative effects of a stroke that seriously lowers patients' quality of life is post-stroke pain (PSP). Thus, exercise in PSP management has become a hot research topic. The main advantages of exercise therapy are affordability and ease of acceptance by patients compared to other treatment methods. Therefore, this article reviews the effectiveness and possible mechanisms of exercise interventions for PSP. Exercise training for patients with PSP not only improves physical function but also effectively reduces pain intensity and attenuates the behavioral response to pain. In addition, exercise therapy can improve brain function and modulate levels of pro-inflammatory and neurotrophic factors to exert specific analgesic effects. Potential mechanisms for exercise intervention include modulation of synaptic plasticity in the anterior cingulate gyrus, modulation of endogenous opioids in vivo, reversal of brain-derived neurotrophic factor overexpression, inhibition of purinergic receptor (P2X4R, P2X7R) expression, and inhibition of microglia activation. However, current research on exercise for PSP remains limited, and the sustainable benefits of exercise interventions for PSP need to be further investigated.

Effectiveness of Rehabilitation Exercise in Improving Physical Function of Stroke Patients: A Systematic Review

Rehabilitation is a crucial part of recovery for stroke survivors, and numerous studies have examined various exercises and treatments of stroke. In addition, it is very important for patients to choose the timing of rehabilitation and what kind of rehabilitation they will proceed with. The purpose of the current study is to examine research investigating the effects of rehabilitation exercise programs in recovery of physical function in patients with stroke, based on aspects of their physical function, physical strength, and daily activities, and systematically examine their effects. Therefore, through systematic review, we have investigated the effects of interventions in rehabilitation exercise programs for recovery of physical function in patients with stroke. We collected relevant publications through the databases MEDLINE/PubMed and Google scholar. Twenty-one articles were ultimately selected for the analysis. We classified the rehabilitation programs and identified the trends of treatment for stroke survivors. Our review indicated that task-oriented therapy is still dominant, but various types of combined rehabilitations have been attempted. In addition, it was identified that physical and active rehabilitation were required rather than unconditional rest, even at an early stage. Home-based treatment was used for rapid recovery and adaptation to daily life during the mid-term period.

Active Videogaming Interventions in Adults with Neuromuscular Conditions: A Scoping Review

This review synthesized active videogaming (AVG) intervention literature over a 10-year period (2010-2020) for people with neuromuscular conditions (18-64 years of age), examining interventions that aimed to improve health and secondary conditions, physical activity, and outcomes quality of life (QOL). Systematic searches yielded 40 eligible studies. The major groups were multiple sclerosis (40%) and stroke (33%), and the study participants had mostly mild-to-moderate disability who were able to play games in a standing position. Research designs primarily involved randomized controlled trials (65%) and pre/post-trial design without a control group (28%). The majority of interventions used commercial off-the-shelf gaming systems, such as Nintendo Wii and Microsoft Kinect. Studies reported significant improvements in health outcomes, specifically in balance (n = 30/36), mobility (n = 24/27), and cardiorespiratory fitness (n = 6/8). Positive changes were also seen in secondary conditions (n = 8/12), physical activity (n = 3/4), and QOL outcomes (n = 8/16). AVG research for people with neuromuscular conditions has grown in both quantity and quality but several gaps remain. Study findings provide a roadmap for future AVG trials on understudied populations, and highlight technology and targeted outcomes as drivers of future intervention research.

Physiotherapy for pain and disability in adults with complex regional pain syndrome (CRPS) types I and II

BACKGROUND

Complex regional pain syndrome (CRPS) is a painful and disabling condition that usually manifests in response to trauma or surgery and is associated with significant pain and disability. CRPS can be classified into two types: type I (CRPS I) in which a specific nerve lesion has not been identified and type II (CRPS II) where there is an identifiable nerve lesion. Guidelines recommend the inclusion of a variety of physiotherapy interventions as part of the multimodal treatment of people with CRPS. This is the first update of the review originally published in Issue 2, 2016.

OBJECTIVES

To determine the effectiveness of physiotherapy interventions for treating pain and disability associated with CRPS types I and II in adults.

SEARCH METHODS

For this update we searched CENTRAL (the Cochrane Library), MEDLINE, Embase, CINAHL, PsycINFO, LILACS, PEDro, Web of Science, DARE and Health Technology Assessments from February 2015 to July 2021 without language restrictions, we searched the reference lists of included studies and we contacted an expert in the field. We also searched additional online sources for unpublished trials and trials in progress.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of physiotherapy interventions compared with placebo, no treatment, another intervention or usual care, or other physiotherapy interventions in adults with CRPS I and II. Primary outcomes were pain intensity and disability. Secondary outcomes were composite scores for CRPS symptoms, health-related quality of life (HRQoL), patient global impression of change (PGIC) scales and adverse effects.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened database searches for eligibility, extracted data, evaluated risk of bias and assessed the certainty of evidence using the GRADE system.

MAIN RESULTS

We included 16 new trials (600 participants) along with the 18 trials from the original review totalling 34 RCTs (1339 participants). Thirty-three trials included participants with CRPS I and one trial included participants with CRPS II. Included trials compared a diverse range of interventions including physical rehabilitation, electrotherapy modalities, cortically directed rehabilitation, electroacupuncture and exposure-based approaches. Most interventions were tested in small, single trials. Most were at high risk of bias overall (27 trials) and the remainder were at 'unclear' risk of bias (seven trials). For all comparisons and outcomes where we found evidence, we graded the certainty of the evidence as very low, downgraded due to serious study limitations, imprecision and inconsistency. Included trials rarely reported adverse effects. Physiotherapy compared with minimal care for adults with CRPS I One trial (135 participants) of multimodal physiotherapy, for which pain data were unavailable, found no between-group differences in pain intensity at 12-month follow-up. Multimodal physiotherapy demonstrated a small between-group improvement in disability at 12 months follow-up compared to an attention control (Impairment Level Sum score, 5 to 50 scale; mean difference (MD) -3.7, 95% confidence interval (CI) -7.13 to -0.27) (very low-certainty evidence). Equivalent data for pain were not available. Details regarding adverse events were not reported. Physiotherapy compared with minimal care for adults with CRPS II We did not find any trials of physiotherapy compared with minimal care for adults with CRPS II.

AUTHORS' CONCLUSIONS

The evidence is very uncertain about the effects of physiotherapy interventions on pain and disability in CRPS. This conclusion is similar to our 2016 review. Large-scale, high-quality RCTs with longer-term follow-up are required to test the effectiveness of physiotherapy-based interventions for treating pain and disability in adults with CRPS I and II.

Muscle-brain communication in pain: The key role of myokines

Pain is the most common reason for a physician visit, which accounts for a considerable proportion of the global burden of disease and greatly affects patients' quality of life. Therefore, there is an urgent need to identify new therapeutic targets involved in pain. Exercise-induced hypoalgesia (EIH) is a well known phenomenon observed worldwide. However, the available evidence demonstrates that the mechanisms of EIH remain unclear. One of the most accepted hypotheses has been the activation of several endogenous systems in the brain. Recently, the concept that the muscle acts as a secretory organ has attracted increasing attention. Proteins secreted by the muscle are called myokines, playing a critical role in communicating with other organs, such as the brain. This review will focus on several myokines and discuss their roles in EIH.

Prevalence and Related Factors for Poststroke Complex Regional Pain Syndrome: A Retrospective Cross-Sectional Cohort Study

OBJECTIVE

The objective of this study was to evaluate the prevalence of poststroke complex regional pain syndrome (CRPS) to estimate related factors for poststroke CRPS in patients with first-ever stroke.

DESIGN

This was a retrospective cross-sectional cohort study of adult patients (age >18y) with stroke who were admitted to rehabilitation unit from December 2014 to May 2018 in Korea.

SETTING

Single acute rehabilitation unit of university hospital.

PARTICIPANTS

Participants (N=313) diagnosed with first-ever stroke were identified from the stroke rehabilitation registry of our institute.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Prevalence of poststroke CRPS based on clinical features and 3-phase bone scintigraphy and the related factors of poststroke CRPS.

RESULTS

A total of 313 records were analyzed, including demographic, clinical characteristics, and functional variables. Poststroke CRPS was found in 8.94% (28 of 313) patients with first-ever stroke. Logistic regression analysis showed that Fugl Meyer Assessment of Upper Extremity (FMA-UE) score was a significant associated factor for the presence of CRPS (odds ratio, 0.96; 95% confidence interval, 0.94-0.98; P=.003). The cutoff value of 76 points for FMA-UE score yielded moderate accuracy in identifying of poststroke CRPS (92.6% sensitivity, 65.8% specificity, and 0.85 area under the curve).

CONCLUSIONS

The prevalence of poststroke CRPS was 8.94% in patients with first-ever stroke. The FMA-UE score was associated with the poststroke CRPS. Therefore, in patients with low FMA-UE score, prevention and high suspicion of post-stroke CRPS is necessary.

Effectiveness of non-pharmacological interventions for treating post-stroke depressive symptoms: Systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To compare the effectiveness of non-pharmacological interventions on depressive symptoms in people after stroke.

DATA SOURCES

A literature search was performed through databases from January 2000 to August 2018: MEDLINE; CINAHL Plus; Scopus; Academic Search Complete; Cochrane Central Register of Controlled Trials; Scopus; and Library, Information Science and Technology Abstracts. Search terms included depression, stroke, non-pharmacologic, and intervention.

STUDY SELECTION

We included randomized controlled trials comparing non-pharmacological interventions to controls for depressive symptoms in people after stroke. Of 1703 identified articles, 22 trials were included in narrative synthesis, of which 13 were eligible for meta-analysis.

DATA EXTRACTION

Two reviewers extracted characteristics of participants, interventions, and results from all included trials.

DATA SYNTHESIS

Thirteen interventions were categorized into four types: complementary and alternative therapy (five trials, n=228), exercise (four trials, n=263), psychosocial therapy (two trials, n=216), and multifactorial therapy (two trials, n=358). Overall beneficial effects of non-pharmacological interventions on depressive symptoms were found both post-intervention (effect size [ES] = -0.24, 95% confidence Interval [CI]: -0.37 to -0.11, p < 0.05) and at follow-up (ES = -0.22, CI: -0.36 to -0.07, p< 0.05). We found individual beneficial effects for complementary and alternative therapy (ES = -0.29, CI: -0.55 to -0.02, p < 0.05) and psychosocial therapy (ES = - 0.33, CI: -0.60 to -0.06, p < 0.05) post-intervention.

CONCLUSIONS

Complementary and alternative therapy and psychosocial therapy appear to be promising strategies for improving post-stroke depression. Future studies target  a personalized approach for people with specific conditions such as cognitive impairment.

Generalizability of Results from Randomized Controlled Trials in Post-Stroke Physiotherapy

Purpose: The randomized controlled trial (RCT) is considered a reliable experimental design, able to detect the effect of an intervention. However, a criticism frequently levelled at RCTs by clinicians is their lack of generalizability. This study aimed to evaluate the generalizability of findings from RCTs of physiotherapy interventions for individuals with stroke. Method: A sample of RCTs of physiotherapy interventions after stroke indexed in the PEDro database was selected, and the reported inclusion and exclusion criteria were analyzed. Results: We reviewed 100 articles, which included 7,366 participants (41.6% women, with a mean weighted age of 65.5 years). The most frequent criteria for exclusion were comorbidity (83%), cognitive impairments (69%), communication skills (55%), recurrent stroke (53%), low functional level (47%) and being elderly (25%). Conclusions: A variety of cohorts of individuals who have had a stroke are excluded from RCTs published in the field of physiotherapy. Because they represent a substantial proportion of the real-world population with stroke, and consequently treated in clinical practice, more vulnerable cohorts of participants should be included in RCTs.

Physical fitness training for stroke patients

BACKGROUND

Levels of physical activity and physical fitness are low after stroke. Interventions to increase physical fitness could reduce mortality and reduce disability through increased function.

OBJECTIVES

The primary objectives of this updated review were to determine whether fitness training after stroke reduces death, death or dependence, and disability. The secondary objectives were to determine the effects of training on adverse events, risk factors, physical fitness, mobility, physical function, health status and quality of life, mood, and cognitive function.

SEARCH METHODS

In July 2018 we searched the Cochrane Stroke Trials Register, CENTRAL, MEDLINE, Embase, CINAHL, SPORTDiscus, PsycINFO, and four additional databases. We also searched ongoing trials registers and conference proceedings, screened reference lists, and contacted experts in the field.

SELECTION CRITERIA

Randomised trials comparing either cardiorespiratory training or resistance training, or both (mixed training), with usual care, no intervention, or a non-exercise intervention in stroke survivors.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed quality and risk of bias, and extracted data. We analysed data using random-effects meta-analyses and assessed the quality of the evidence using the GRADE approach. Diverse outcome measures limited the intended analyses.

MAIN RESULTS

We included 75 studies, involving 3017 mostly ambulatory participants, which comprised cardiorespiratory (32 studies, 1631 participants), resistance (20 studies, 779 participants), and mixed training interventions (23 studies, 1207 participants). Death was not influenced by any intervention; risk differences were all 0.00 (low-certainty evidence). There were few deaths overall (19/3017 at end of intervention and 19/1469 at end of follow-up). None of the studies assessed death or dependence as a composite outcome. Disability scores were improved at end of intervention by cardiorespiratory training (standardised mean difference (SMD) 0.52, 95% CI 0.19 to 0.84; 8 studies, 462 participants; P = 0.002; moderate-certainty evidence) and mixed training (SMD 0.23, 95% CI 0.03 to 0.42; 9 studies, 604 participants; P = 0.02; low-certainty evidence). There were too few data to assess the effects of resistance training on disability. Secondary outcomes showed multiple benefits for physical fitness (VO2 peak and strength), mobility (walking speed) and physical function (balance). These physical effects tended to be intervention-specific with the evidence mostly low or moderate certainty. Risk factor data were limited or showed no effects apart from cardiorespiratory fitness (VO2 peak), which increased after cardiorespiratory training (mean difference (MD) 3.40 mL/kg/min, 95% CI 2.98 to 3.83; 9 studies, 438 participants; moderate-certainty evidence). There was no evidence of any serious adverse events. Lack of data prevents conclusions about effects of training on mood, quality of life, and cognition. Lack of data also meant benefits at follow-up (i.e. after training had stopped) were unclear but some mobility benefits did persist. Risk of bias varied across studies but imbalanced amounts of exposure in control and intervention groups was a common issue affecting many comparisons.

AUTHORS' CONCLUSIONS

Few deaths overall suggest exercise is a safe intervention but means we cannot determine whether exercise reduces mortality or the chance of death or dependency. Cardiorespiratory training and, to a lesser extent mixed training, reduce disability during or after usual stroke care; this could be mediated by improved mobility and balance. There is sufficient evidence to incorporate cardiorespiratory and mixed training, involving walking, within post-stroke rehabilitation programmes to improve fitness, balance and the speed and capacity of walking. The magnitude of VO2 peak increase after cardiorespiratory training has been suggested to reduce risk of stroke hospitalisation by ˜7%. Cognitive function is under-investigated despite being a key outcome of interest for patients. Further well-designed randomised trials are needed to determine the optimal exercise prescription, the range of benefits and any long-term benefits.

Sphingosine 1-phosphate receptor modulation attenuate mechanical allodynia in mouse model of chronic complex regional pain syndrome by suppressing pathogenic astrocyte activation

Background and objectives

FTY720 ((2-amino-2-)2-[4-octylphenyl]ethyl)-1,3-propanediol) is an Food and Drug Administration (FDA)-approved immunomodulatory drug for treating multiple sclerosis. It inhibits lymphocyte egression from lymphoid tissues by downregulating sphingosine-1 phosphate receptor (S1PR). To date, there has been no study on the effects of FTY720 on the chronic stage of the complex regional pain syndrome (CRPS) rodent model, despite its antiallodynic effect in previous studies. Thus, the aim of this study is to investigate the effect of FTY720 in a chronic stage of the CRPS mouse model.

Method

The authors used a mouse model of CRPS, involving tibia fracture/cast immobilization, to test the efficacy of intrathecal FTY720 (2.5 or 25 ng daily; 6 days) or vehicle during the chronic (7 weeks after fracture) stage of CRPS.

Results

Intrathecal recombinant FTY720 administration was antiallodynic in the chronic stage of the CRPS mouse model, and such an effect of FTY720 developed by modulating astrocyte activation in the spinal cord. Additionally, according to the in vitro data, the FTY720 treatment inhibited S1P-induced increase in the nitric oxide production and suppression of the NF-κB pathway, by inhibiting the phosphorylation of NF-κB/p65 in astrocytes without toxic effect on astrocytes.

Conclusion

Collectively, these results demonstrate that intrathecally administered FTY720 attenuates mechanical allodynia in the chronic stage of the CRPS mouse model.

Aerobic exercise alleviates depressive symptoms in patients with a major non-communicable chronic disease: a systematic review and meta-analysis

OBJECTIVE

To assess whether aerobic exercise was superior to usual care in alleviating depressive symptoms in patients living with a major non-communicable disease.

DATA SOURCES

Data were obtained from online databases (PubMed, PsycINFO and SPORTDiscus) as well as from reference lists. The search and collection of eligible studies was conducted up to 18 October 2018 (PROSPERO registration number CRD42017069089).

STUDY SELECTION

We included interventions that compared aerobic exercise with usual care in adults who reported depressive symptoms (ie, not necessarily the clinical diagnosis of depression) and were living with a major non-communicable disease.

RESULTS

Twenty-four studies were included in the meta-analysis (4111 patients). Aerobic exercise alleviated depressive symptoms better than did usual care (standardised mean difference (SMD)=0.50; 95% CI 0.25 to 0.76; Grading of Recommendations Assessment, Development and Evaluation: low quality). Aerobic exercise was particularly effective in alleviating depressive symptoms in cardiac patients (SMD=0.67; 95% CI 0.35 to 0.99).

CONCLUSION

Aerobic exercise alleviated depressive symptoms in patients living with a major non-communicable disease, particularly in cardiac populations. Whether aerobic exercise treats clinically diagnosed depression was outside the scope of this study.

Treatment of complex regional pain syndrome: an updated systematic review and narrative synthesis

PURPOSE

Although multiple treatments have been advocated for complex regional pain syndrome (CRPS), the levels of supportive evidence are variable and sometimes limited. The purpose of this updated review is to provide a critical analysis of the evidence pertaining to the treatment of CRPS derived from recent randomized-controlled trials (RCTs).

SOURCE

The MEDLINE, EMBASE, Psychinfo, and CINAHL databases were searched to identify relevant RCTs conducted on human subjects and published in English between 1 May 2009 and 24 August 2017.

PRINCIPAL FINDINGS

The search yielded 35 RCTs of variable quality pertaining to the treatment of CRPS. Published trials continue to support the use of bisphosphonates and short courses of oral steroids in the setting of CRPS. Although emerging evidence suggests a therapeutic role for ketamine, memantine, intravenous immunoglobulin, epidural clonidine, intrathecal clonidine/baclofen/adenosine, aerobic exercise, mirror therapy, virtual body swapping, and dorsal root ganglion stimulation, further confirmatory RCTs are warranted. Similarly, trials also suggest an expanding role for peripheral sympathetic blockade (i.e., lumbar/thoracic sympathetic, stellate ganglion, and brachial plexus blocks).

CONCLUSIONS

Since our prior systematic review article (published in 2010), 35 RCTs related to CRPS have been reported. Nevertheless, the quality of trials remains variable. Therefore, further research is required to continue investigating possible treatments for CRPS.

Demystifying Poststroke Pain: From Etiology to Treatment

Pain after stroke is commonly reported but often incompletely managed, which prevents optimal recovery. This situation occurs in part because of the esoteric nature of poststroke pain and its limited presence in current discussions of stroke management. The major specific afflictions that affect patients with stroke who experience pain include central poststroke pain, complex regional pain syndrome, and pain associated with spasticity and shoulder subluxation. Each disorder carries its own intricacies that require specific approaches to treatment and understanding. This review aims to present and clarify the major pain syndromes that affect patients who have experienced a stroke in order to aid in their diagnosis and treatment.