Introduction: A scoping review provides a means to synthesize and present a large body of literature on a broad topic, such as methods for various upper extremity activity-based therapy (ABT) interventions. Objectives: To describe our scoping review protocol to evaluate peer-reviewed articles focused on ABT interventions for individuals with neurologically impaired upper extremities. Methods: At Jefferson College of Health Professions and Sidney Kimmel Medical College at Jefferson, Philadelphia, the authors will follow this protocol to conduct a scoping review by establishing a research question and conducting a search of bibliographic databases to identify relevant studies. Using specific inclusion and exclusion criteria, abstracts will be screened and full-text articles will be reviewed for inclusion in charting, summarizing, and reporting results of appropriate studies. Conclusion: This protocol will guide the scoping review process to develop a framework for establishing a noninvasive ABT intervention informed by evidence for individuals with neurologically impaired upper extremities.
Activity-based rehabilitation, or activity-based therapy (ABT), interventions focus on functional and task-specific activities characterized by high intensity and high repetition with the goal to promote neuroplasticity and recovery following neurologic injury.1,2 Several studies have demonstrated that high intensity and repetitive practice interventions by themselves can minimize impairment and improve function.3–5 To further augment neuroplasticity, others have included additional strategies such as neuromuscular electrical stimulation (NMES), transcranial magnetic stimulation (TMS), and upper extremity (UE) robotic devices to the high-intensity–high-repetition ABT.3–4,6
ABT interventions are frequently offered in large rehabilitation programs specializing in neurologic care and are used across many neurological diagnoses.1,2 However, due to the high cost of equipment, high staff burden, and increased time commitment required of both therapy staff and patients, they are not widely available to individuals with neurological conditions. Moreover, emerging literature on ABT describes dosage recommendations (frequency per week, number of repetitions per session, etc) that may not always be achievable due to factors such as reimbursement and payment barriers and the need to attend to additional rehabilitation goals. Despite the literature2–6 on ABT interventions focusing on the UE, arm and hand function, there are wide variations in treatment specifications including type of orthosis or robotic, number of repetitions, frequency, duration, and intensity of treatment. Likewise, endpoints of treatment are evaluated using a variety of outcome measures, limiting our understanding about which ABT interventions work best, for whom, and to what endpoint.
Following a spinal cord injury (SCI), arm and hand control is often impaired resulting in significant functional limitations. Individuals with tetraplegia report their quality of life would be significantly impacted by improvements in arm and hand function.7 SCI results in difficulties in reaching and grasping that until recently were thought to be permanent, however ABT interventions demonstrate change and improvement.3–5 Although, recovery of UE function is a priority in rehabilitation following SCI, evidence in support of interventions to improve UE function need to be further understood. For example, individuals with UE impairment due to SCI would likely benefit from an ABT UE intervention program that they could perform in the home, using affordable, low-technology alternatives to the high-cost, high-technology ABT interventions often utilized in rehabilitation facilities. Given the wide variation in ABT interventions for the UE, we plan to conduct a formal scoping review of the literature with the goal of establishing a home-based ABT intervention for persons with cervical SCI that is informed by existing evidence.
A scoping review is a method to synthesize and present a large body of literature on a broad topic8 and to evaluate a wide variety of research studies.9 Scoping reviews use systematic methods10,11 and are becoming more prominent as a methodology.8 A scoping review works well to evaluate heterogeneous and complex literature.12 The literature surrounding ABT is diverse in focus, design, and research level, as it involves numerous interventions without a standard dose and varying clinical presentations between and within various neurological conditions. Evaluating ABT literature via scoping review will help us understand the diversity in approaches, populations studied, and outcomes assessed. Although the final outcome is to develop an intervention specific to individuals with incomplete SCI, by including a variety of neurological conditions such as stroke, cerebral palsy, traumatic brain injury, and multiple sclerosis in this scoping review, we will be able to evaluate existing ABT protocols for promoting neuroplasticity and potential devices. The impairments and functional limitations that result from a disorder and/or incident involving the nervous system may be similar in presentation and are often clinically addressed based on that presentation as opposed to a diagnosis-specific intervention. Persons with mobility limitations due to central neurological conditions such as stroke may have similar difficulties attending outpatient therapy programs. Information on intensity of outpatient ABT programs and success of home-based programs in these populations will inform our efforts to develop protocols for persons with incomplete cervical SCI. Differences exist among persons with these conditions as well; for example, stroke is typically unilateral while SCI is bilateral. We will exclude approaches such as mirror therapy that would not be applicable to cervical SCI. Therefore, the objective of this article is to describe a scoping review protocol to evaluate peer-reviewed literature focusing on ABT interventions for individuals with neurologically impaired UEs.
Methods
This scoping review protocol is based on the methodological framework of Arksey and O'Malley10 with further refinement by Levac11 (Figure 1). There are five required steps when conducting a scoping review: (1) identifying the research question, (2) identifying relevant studies, (3) study selection, (4) charting the data, and (5) collating, summarizing, and reporting results. The sixth step, consultation, is optional.
Scoping review protocol schematic. ABT = activity-based rehabilitation; UE = upper extremity.
Scoping review protocol schematic. ABT = activity-based rehabilitation; UE = upper extremity.
Step one: Identifying the research question
As described in Figure 1, step one of a scoping review involves articulating the research question, including defining the concept, the population, and the outcomes of interest.5 The primary research question of this scoping review is “What activity-based therapy interventions are being implemented for upper extremity neurorehabilitation?” Objectives underlying this research question include (a) identifying noninvasive ABT interventions to augment and facilitate neuroplasticity of the UE (b) to understand which noninvasive methods appear to be effective, for what aspect of the UE, and for whom; (c) identifying how endpoints of UE ABT interventions are being evaluated; (d) identifying the facilitators and barriers to implementing UE ABT interventions in the clinic and in the home; and (e) identifying low-cost, low-burden, and low-tech ABT interventions that appear to be effective, can be transferred to the home, and are acceptable to end users.
Steps two and three: Identifying relevant studies and study selection
Search terms and search strategy
An experienced librarian (G.K.) will develop and execute a search strategy to identify relevant literature; no repeat searches will be conducted. The search will include the following limits: humans only, English only, and the year 2000 to current. As shown in Figure 2, we will search for the intersection of terms for three concepts: activity-based rehabilitation, upper extremity, and neurological diagnoses. Terms for activity-based rehabilitation will include activity based, repetitive task training, task specific training, neurological rehabilitation, neurorehabilitation, rehabilitation, prehensile, reach, or grasp. Upper extremity terms will include upper extremity, upper limb, arm, shoulder, elbow, forearm, hand, wrist, or finger. Neurological diagnosis terms will include spinal cord injuries, stroke, cerebral palsy, brain injuries, multiple sclerosis, amyotrophic lateral sclerosis, or quadriplegia. Controlled vocabulary terms will be identified for each database. See Table 1 for the MEDLINE strategy. The search terms may be modified once the search has commenced. The following bibliographic databases will be searched with limits described above in this scoping review: Ovid MEDLINE including Epub Ahead of Print and In-Process & other Non-Indexed Citations, EBSCOhost Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Cochrane Central Register of Controlled Trials (CENTRAL), and OTseeker. The abstracts from literature included will be uploaded into Covidence, an online tool developed for systematic reviews, to remove duplicates and manage the screening and data extraction process. Additionally, we will search for dissertations, theses, and book chapters using ProQuest Dissertation Express, Scopus, and various academic institutional repositories such as the University of Southern California Digital Library, Indiana University ScholarWorks, and MIT DSpace.
Inclusion and exclusion criteria
Inclusion and exclusion criteria for the abstract screen and full-text review phases of study selection are included in Table 2. Keeping with scoping review methodologies, inclusion and exclusion criteria may be modified during the scoping review process as determined by the research team.
Study eligibility
Screening for study eligibility will be conducted in a two-step process. First, using the abstract screen criteria (Table 2), content of the abstract, title, and year of publication will be screened, independently, by one study team member (C.C.T., R.J.M., S.D., MJ.M.) and one trained occupational or physical therapy graduate student to determine whether the study appears to meet the selection criteria. Abstracts meeting selection criteria will advance to full-text review. If conflicts arise, a senior investigator (R.J.M., MJ.M.) will resolve them.
For studies moving to full-text review, a trained occupational therapy graduate student will obtain the full-text article and upload it into Covidence. Each full-text article will be reviewed using the full-text review for eligibility criteria (Table 2) independently, by trained occupational or physical therapy graduate students and one research team member (C.C.T., R.J.M., S.D., MJ.M.).
Conflicts will be resolved by senior research team members. Reasons for excluding full-text articles will be recorded in Covidence, and studies that meet eligibility will move to step four.
Steps four and five: Charting the data and collating, summarizing, and reporting results
Full-text data extraction team
The data extraction team will consist of the principal (R.J.M.) and senior (MJ.M.) investigators, one physical therapist (C.C.T.), one certified hand therapist who is licensed as both an occupational and physical therapist (S.D.), and two doctoral-level occupational therapists, with at least 10 years of experience in clinical practice and/or research in neurorehabilitation. The data extraction team will meet to customize a data collection template in Covidence, based on variables described in Table 3. Using this template, each team member will extract data from an initial 10 studies – five studies as the primary extractor and five studies as the secondary extractor. The data extracted from the 10 studies will be reviewed for consistency, and the team will discuss reasons for discrepancy between extractors and refine definitions and processes as needed for clarity. This process may occur more than once if necessary. Once the agreement for processes and consistency in data extraction are demonstrated, data from each study will be extracted and charted in Covidence by two members of the data extraction team. The secondary extractor will establish final consensus for each data variable. Team meetings will occur bi-weekly throughout the data extraction phase to monitor progress.
Once data extraction from every study is complete, results will be exported from Covidence to Excel. Summary and descriptive statistics will be used to examine and quantify types of interventions, frequency, intensity and duration parameters, intervention endpoints, clinical populations, and methods of assessment. Conceptual mapping13,14 will be used to identify relationships among interventions, outcomes, and samples. It will also be used to thematically describe low-tech and high-tech approaches to ABT, gaps in outcomes, and barriers and facilitators to feasibility of and satisfaction with ABT. Data will be used to answer the scoping review questions and objectives. The findings will be presented to an external advisory panel to inform development, implementation, and evaluation of lab- and home-based ABT. The final results will be published in a peer-reviewed journal.
Implication of Scoping Review
This scoping review protocol will guide a formal review of the literature on UE ABT in clinical samples with neurological conditions from which specificities about interventions such as dosage, equipment, set-up requirements, and outcomes will be examined. Although our intent is to use the results of the scoping review to inform UE ABT protocols for home use by persons with SCI, studies with clinical samples other than SCI will also be reviewed owing to the likelihood that many interventions used with persons with stroke, cerebral palsy, traumatic brain injury, and multiple sclerosis can inform protocol development for persons with SCI. The results of this scoping review have the potential to impact care of the impaired UE due to SCI and current neurorehabilitative practice and will be of interest to rehabilitation professionals seeking to implement economic yet effective UE ABT interventions in the home setting.
REFERENCES
Funding and Conflicts of Interest
Christina Calhoun Thielen reports a portion of her salary was paid by grants issued to Sidney Kimmel Medical College at Jefferson by the National Institute on Disability, Independent Living and Rehabilitation Research (grant 90SI5024). Ralph Marino reports grants from the National Institute on Disability, Independent Living and Rehabilitation Research during the conduct of the study. Gary Kaplan reports his participation on this project was supported by a grant issued to Sidney Kimmel Medical College at Jefferson by the National Institute on Disability, Independent Living and Rehabilitation Research (grant 90SI5024). MJ Mulcahey reports grants from Shriners Hospitals for Children, grants from National Institute for Neurological Diseases and Stroke, grants from Craig H. Neilsen Foundation, and grants from The Rick Hansen Institute during the conduct of the study; personal fees from TSCIR, the textbook The Child and Young Adult with Spinal Cord Injury, from Department of Defense, and from Craig H. Neilsen Foundation outside the submitted work. Susan Duff has nothing to disclose.
