Peer Reviews on the Global Burden of Stroke
BMJ Open up. 2016; half dozen(6): e010866.
Tai Chi for stroke rehabilitation: protocol for a systematic review
Yong Zhang
1Department of Rehabilitation, Dongzhimen Hospital, The Beginning Affiliated Hospital of Beijing Academy of Chinese Medicine, Beijing, China
2National Constitute of Complementary Medicine, Western Sydney Academy, Sydney, New South Wales, Australia
3Section of Neurology and Stroke Eye, Dongzhimen Hospital, The First Affiliated Hospital of Beijing University of Chinese Medicine, Beijing, China
ivDepartment of International Communications, Beijing University of Chinese Medicine, Beijing, China
Shanshan Wang
iiNational Institute of Complementary Medicine, Western Sydney University, Sydney, New South Wales, Australia
4Section of International Communications, Beijing Academy of Chinese Medicine, Beijing, People's republic of china
Pei Chen
iiiDepartment of Neurology and Stroke Heart, Dongzhimen Hospital, The First Affiliated Hospital of Beijing University of Chinese Medicine, Beijing, China
Xiaoshu Zhu
2National Found of Complementary Medicine, Western Sydney University, Sydney, New South Wales, Australia
Zongheng Li
1Section of Rehabilitation, Dongzhimen Hospital, The First Affiliated Hospital of Beijing University of Chinese Medicine, Beijing, Cathay
Received 2015 Dec 14; Revised 2016 May 7; Accepted 2016 May 23.
Abstruse
Introduction
Stroke is a major crusade of decease and disability, and imposes a huge burden and significant workload for patients, their families and society. Every bit a special course of physical activity, Tai Chi is may be useful for stroke rehabilitation. The objective of this review is to systematically evaluate the efficacy and safety of Tai Chi for rehabilitation in stroke patients.
Methods and analysis
We will conduct a systematic search of the following electronic databases from their inception to 31 October 2015: MEDLINE, EMBASE, the Cochrane Library, the Chinese BioMedical Literature Database (CBM), the Chinese National Noesis Infrastructure (CNKI), the Chinese Scientific discipline and Applied science Periodical Database (VIP), Wanfang and the Chinese Dissertation Database. All relevant randomised controlled trials (RCTs) in English and Chinese volition be included. The main outcomes will be changes in the neurological function of patients and in independence in activities of daily living. Adverse events, adherence, costs and the cost effectiveness of Tai Chi volition also exist assessed. Two contained reviewers will select studies, excerpt data and appraise quality. Review Managing director five.iii will be used for assessment of risk of bias, information synthesis and subgroup analysis.
Ethics and broadcasting
This systematic review does non require formal ethical approval because all data will be analysed anonymously. Results will provide a general overview and evidence concerning the efficacy and safety of Tai Chi for stroke rehabilitation. Findings will be disseminated through peer-reviewed publications.
Trial registration number
CRD42015026999.
Keywords: tai chi, systematic review, protocol
Strengths and limitations of this study
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The current systematic review will reassess the efficacy and safety of Tai Chi for stroke rehabilitation and will provide further clinical show for both clinicians and patients.
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There may be language bias as only studies published in English and Chinese will be included, then relevant studies in other languages may exist missed.
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There may be pregnant heterogeneity due to the unlike types of Tai Chi and elapsing and frequency of practice.
Introduction
Description of the status
Stroke is the second virtually common cause of death and a major cause of disability worldwide.1 It greatly affects the quality of life of survivors and imposes a huge public health burden.2 As the population ages and lifestyles change, this burden is projected to increase markedly over the adjacent 20 years, especially in developing countries.3 A recent study indicated that stroke mortality rates have decreased worldwide merely that the absolute number of new stroke patients, stroke survivors with functional inability, stroke-related deaths, and the overall global burden of stroke have increased in the past two decades.ii An epidemiological written report showed that at that place were over 7 1000000 stroke survivors in China, approximately 70% of whom had functional disability.4 Stroke is the leading cause of disability and impacts greatly on patients' quality of life, resulting in a huge burden and pregnant workload for families and societies.v half dozen This situation demands effective modalities for stroke rehabilitation.
Description of the intervention
Tai Chi (also known as Tai Ji or Tai Chi Chuan) is a form of physical activity that has been widely expert in China and elsewhere. Tai Chi originated in China equally a martial fine art hundreds of years agone. Combining concrete move, meditation and controlled animate to attain a listen-body connection, Tai Chi induces relaxation and mental tranquility and improves balance, postural control, movement coordination, strength and flexibility.7–9 Information technology has become a popular exercise worldwide in recent years.10 Numerous studies accept been conducted on the clinical awarding of Tai Chi and accept validated its effects in improving various symptoms.ten Previous studies indicated that Tai Chi can be prescribed equally a beneficial and rubber practice for neurological illness,11 12 cardiovascular disease,thirteen xiv orthopaedic affliction,nine fifteen rheumatological illness,16 cancer17 and some other conditions.
Tai Chi has also been incorporated into stroke rehabilitation programmes.18 19 Previous studies and reviews suggested that Tai Chi is safe and feasible for stroke patients with functional disability and may serve as an additional do modality in stroke rehabilitation. It has been demonstrated that Tai Chi is benign in improving motor office,20 standing balance21 22 and quality of life,20 21 and in reducing fall rates20 in stroke patients. In add-on, some ongoing studies are investigating the effects of Tai Chi for stroke rehabilitation.23 24 Thus, it is necessary to systematically review the efficacy and safety of Tai Chi for stroke rehabilitation and provide further clinical bear witness for the benefit of both clinicians and patients.
How the intervention might work
Tai Chi may be helpful for stroke patients as its exercise involves mechanisms similar those of conventional stroke rehabilitation techniques, like the Bobath programme and proprioceptive neuromuscular facilitation.xviii Most Tai Chi movements are helical and aimed at strengthening the limbs and core muscles of the abdomen and back.25 This correlates with conventional stroke rehabilitation techniques which also focus on strength exercises for the limbs and the trunk. Since Tai Chi is practiced generally on one foot, information technology is also a weight-begetting exercise that improves residual similar to conventional rehabilitation exercises.xix The requirement for deep animate and relaxation of the torso and mind when practicing Tai Chi is consequent with stroke rehabilitation therapies that encourage patients to relax and stay calm to reach better recovery. One of the most important principles of Tai Chi is 'conquering the unyielding with the yielding', which correlates with physiotherapy in treating spasticity with gentle manipulation.
Objectives
The objective of this review is to systematically evaluate the efficacy and safety of Tai Chi for rehabilitation in stroke patients.
Methods and analysis
Types of studies
We will simply include clinical randomised controlled trials (RCTs) in English and Chinese without whatsoever restrictions on publication status. Non-RCTs, quasi-RCTs and uncontrolled clinical trials such every bit case studies will exist excluded.
Types of participants
Trials involving patients of whatever age with ischaemic or haemorrhagic stroke will exist included. Stroke must be diagnosed according to the WHO definition (apace developing clinical signs of focal (or global) disturbance of cognitive role, lasting more than 24 hours or leading to death, with no apparent cause other than that of vascular origin)26 or confirmed past CT or MRI. There will be no limitation in relation to time from the onset of stroke. Patients with subarachnoid haemorrhage or subdural haematoma volition be excluded.
Types of interventions
Similarly to other listen-body interventions similar yoga and Qigong, Tai Chi is also inherently varied and heterogeneous which makes standardisation difficult. Thus, we volition accept all types of Tai Chi interventions regardless of their class, style, elapsing and frequency. Still, stratified analysis according to these variables will be performed if sufficient studies are included. The intervention in the treatment grouping should exist Tai Chi exercises with or without conventional rehabilitative treatment. The control intervention will include conventional rehabilitative handling, other forms of exercises, or no treatment. Some other co-interventions, such as basic medication for stroke, lifestyle modifications for stroke, stroke diets and stroke instruction programmes, are adequate on condition that the same co-interventions are simultaneously applied in all arms of a study.
Types of outcome assessments
Primary outcomes
The primary outcomes of this review will focus on changes in patients' neurological function, balance and independence in activities of daily living. This will encompass assessment tools based on the National Institutes of Health Stroke Scale (NIHSS), Fugl-Meyer Assessment (FMA), Berg Balance Scale (BBS), modified Rankin Scale (mRS), Barthel Index (BI), Stroke Specific Quality of Life Scale (SSQOL) or the researchers' own definition.
Secondary outcomes
Secondary upshot measures will include possible mental wellness improvements related to the practice of Tai Chi, adverse events associated with Tai Chi, all-cause death during the entire treatment and follow-up period, adherence to Tai Chi, and the costs and cost effectiveness of Tai Chi.
Search methods for identification of studies
Electronic searches
We will conduct a systematic search of the following electronic databases from inception to 31 October 2015: MEDLINE, EMBASE, the Cochrane Library, the Chinese BioMedical Literature Database (CBM), the Chinese National Noesis Infrastructure (CNKI), the Chinese Scientific discipline and Applied science Periodical Database (VIP), Wanfang and the Chinese Dissertation Database (CDD).
We have adult the MEDLINE search strategy (see table ane) based on guidance from the Cochrane handbook and will employ similar strategies for other electronic databases.
Tabular array one
Search strategy for MEDLINE
| Number | Search items |
|---|---|
| 1 | exp tai chi/ or tai ji/ |
| 2 | (tai chi or tai ji or taichi or tai chi chuan or taichi chuan or taiji or tai ji quan or taiji quan or martial arts or shadowbox$).tw. |
| 3 | or/ ane–2 |
| 4 | cerebrovascular disorders/ or exp basal ganglia cerebrovascular illness/ or exp brain ischemia/ or exp carotid avenue diseases/ or exp intracranial arterial diseases/ or exp "intracranial embolism and thrombosis"/ or exp intracranial hemorrhages/ or stroke/ or exp brain infarction/ or vasospasm, intracranial/ or vertebral avenue dissection/ |
| 5 | (stroke or poststroke or mail service-stroke or cerebrovasc$ or brain vasc$ or cerebral vasc$ or cva$ or apoplex$).tw. |
| 6 | ((encephalon$ or cerebr$ or cerebell$ or intracran$ or intracerebral) adj5 (isch?emi$ or infarct$ or thrombo$ or emboli$ or occlus$)).tw. |
| 7 | ((brain$ or cerebr$ or cerebell$ or intracerebral or intracranial or subarachnoid) adj5 (haemorrhage$ or hemorrhage$ or haematoma$ or hematoma$ or drain$)).tw. |
| 8 | hemiplegia/ or exp paresis/ |
| 9 | (hemipleg$ or hemipar$ or paresis or paretic).tw. |
| 10 | or/ four–9 |
| 11 | 3 and x |
Other resources
The WHO International Clinical Trials Registry Platform (ICTRP) and its Registry Network and the reference lists of related reviews and retrieved articles will be checked for additional studies. We volition also scan the abstracts of non-English language studies if they are available in English. Nosotros will also search relevant conference papers on this topic.
Data collection and analysis
Selection of studies
Two review authors (YZ and SW) will independently bank check the titles and abstracts of retrieved results and select all potentially relevant references. All records will be managed with Endnote X7 in a carve up database. The two reviewers will and then independently read the total texts and select studies to exist included based on our predetermined inclusion criteria. In case of unclear data or missing data, we will contact the original authors for clarification. Disagreements regarding inclusion will be resolved by discussion and consultation with an experienced reviewer (XZ). Details of the entire selection procedure will be shown in a PRISMA catamenia chart (see effigy 1).
Flow diagram of the study choice process. CBM, Chinese BioMedical Literature Database; CDD, Chinese Dissertation Database; CNKI, Chinese National Cognition Infrastructure; RCT, randomised controlled trial; VIP, Chinese Science and Engineering science Periodical Database.
Data extraction and management
Two review authors (YZ and SW) volition independently carry out data extraction using a piloted data extraction course which volition be developed past all authors with reference to previously published systematic review papers on Tai Chi and stroke. Data volition include general information on the publications (reference identification, authors, country, journal name, year of publication, etc), details of report design (sample size, randomisation, blinding, etc), participants (inclusion and exclusion criteria, age, gender, illness duration, etc), interventions (types of Tai Chi, types of control, duration, frequency, etc) and outcomes (observation time points, measurement tools, follow-up, adherence, agin events, costs and price effectiveness, etc). The original authors will exist contacted in case of missing data. Where there is disagreement regarding data extraction, a third experienced reviewer (XZ) volition be consulted for consensus.
Cess of risk of bias in included studies
Take a chance of bias volition be assessed past 2 independent authors (YZ and SW) using the Cochrane risk of bias tool recommended by the Cochrane reviewer's handbook. Whatsoever disagreements will be resolved through consultation with a third experienced reviewer (XZ). The following volition be assessed for take a chance of bias: selection, performance, detection, attrition, reporting and other factors. We will non consider bias among participants and personnel considering the practice of Tai Chi makes blinding impossible. All included studies will be categorised into iii categories: high, unclear and depression run a risk of bias.
Measure of treatment outcome
We will summate risk ratios (RRs) with 95% CIs for dichotomous outcomes and mean differences (MDs) or standard mean differences (SMDs) with 95% CIs for continuous outcomes.
Unit of measurement of analysis issues
The primary unit of analysis volition be all individuals participating in the trials. In case of 3 or more dissimilar intervention groups within a trial, we will present pairwise comparison results through different subgroups of interventions. If bachelor, we will combine relevant groups to provide a single pairwise comparing with the Tai Chi group.
Dealing with missing data
We volition contact the original authors in case of missing information. If this fails to elicit the required information, nosotros will just analyse the available data and address the potential impact of these missing data on the results of the review in the give-and-take section.
Assessment of heterogeneity
We will check the results of the χ2 exam (significance level: 0.one) to assess the heterogeneity of included studies and the Iii statistic to quantify inconsistency. An I2 value of 50% or higher will indicate the presence of substantial heterogeneity. If in that location is a low level of heterogeneity among included studies, we volition synthesise the results in a meta-analysis. In case of substantial heterogeneity, we will perform a systematic synthesis instead.
Cess of reporting biases
We will assess reporting bias according to the Espoused criteria and will generate funnel plots to assess reporting bias if sufficient studies are included. We will try to explore possible interpretations other than publication bias and linguistic communication bias if funnel plots are disproportionate.
Data synthesis
Data synthesis volition be performed with Cochrane Review Manager (V.five.3). Nosotros will adopt the fixed furnishings model or random effects model depending on the results of heterogeneity assessment.
Subgroup analysis
Nosotros plan to carry out subgroup analysis if sufficient comparable studies are identified. We intend to stratify the results by duration, fashion and frequency of Tai Chi. Nosotros volition too focus on subgroup analyses of comparing between Tai Chi and unlike stroke rehabilitation treatments. The incidence rates of unlike types of adverse events volition too be calculated.
Sensitivity analysis
To ensure the robustness of show, we volition perform sensitivity analysis to assess the impact of studies with a high gamble of bias. We will compare the results to determine whether lower quality studies should be excluded on the basis of sample size, forcefulness of evidence and influence on pooled effective size.
Grading the quality of evidence
To help health professional brand decisions regarding individual patients, nosotros volition further evaluate the quality of evidence for outcomes by using the GRADE organisation. We will likewise consider the quality of evidence, potential benefits and harms, study context and patients' value when interpreting the results.
Ethics and dissemination
This systematic review does not require formal ethical approval considering all information used volition be anonymous with no concerns regarding privacy. Results will provide a general overview and bear witness concerning the effectiveness and safe of Tai Chi for stroke rehabilitation. Findings volition exist disseminated through peer-reviewed publications.
Discussion
The previous review published 3 years ago failed to determine a beneficial outcome of Tai Chi for stroke rehabilitation.27 Another Cochrane review aimed at evaluating the effectiveness of Tai Chi on dependency and motor part for the recovery of stroke patients was registered in Dec 2012.28 However, the authors take failed to provide any results of their review. About 10 new RCTs of Tai Chi applied for stoke rehabilitation have been published in the by 3 years. Thus, it is necessary to conduct a systematic review to reassess the efficacy and safety of Tai Chi for stroke rehabilitation. In the current paper, we have described the protocol for a systematic review designed to assess the efficacy and safety of Tai Chi for stroke rehabilitation. We hope that our results may be of do good to patients and provide farther clinical show for both clinicians and patients making decisions regarding the do of Tai Chi for stroke rehabilitation.
However, the proposed systematic review has some potential limitations. In that location may exist a language bias as we will only include studies published in English and Chinese, which hateful some relevant studies in other languages (eg, Korean and Japanese) may be missed. Some other limitation is that there may exist meaning heterogeneity due to the various dissimilar types of Tai Chi, styles, duration and frequency.
Footnotes
Contributors: YZ, XZ and ZL conceived the written report. The protocol was drafted by YZ, and revised by XZ and ZL. YZ, SW, PC and XZ adult the search strategy. YZ and SW will independently work on data extraction and synthesis.
Funding: This work is supported by the following: the Middle-aged Teachers Inquiry Funds of Beijing University of Chinese Medicine (grant no. 2015-JYB-JSMS082), the Second Round of Special Project for Chinese Medicine Clinical Enquiry Base of operations of the Communist china State Administration of Traditional Chinese Medicine (grant no. JDZX2015312) and the Oversea Teachers Program of Prc Confucius Institute Headquarters (Hanban).
Competing interests: None declared.
Provenance and peer review: Not commissioned; externally peer reviewed.
Information sharing statement: The results of the review will be disseminated through peer-reviewed publications.
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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4916580/
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