Scoping Reviews: Rehabilitation Services and

Assistive Technology in Less Resourced Settings

Rebecca Matter & Mark Harniss Department of Rehabilitation Medicine

University of Washington

November 2014

Purpose of the WHO Health-Related Rehabilitation Guidelines

To support implementation of health-related rehabilitation aspects of the CRPD and World Disability Report.

To provide guidance to governments and other relevant actors on how to strengthen health-related rehabilitation in less resourced settings.

Evidence Reviews to Inform Guidelines

Seven evidence reviews commissioned by WHO:– Service Delivery– Assistive Technology – Background– Leadership & Governance– Rehabilitation Workforce– Financing– Information Systems

What is a Scoping Review?

A review to increase understanding of the research landscape by examining the extent, range and nature of existing evidence.

– provide an overview of key themes,– does not include grading or assessing the

quality of evidence.

Scoping Review Steps

1. Search for peer-reviewed research publications on scoping review topics

2. Screen to exclude irrelevant research publications

3. Summarize characteristics of relevant research publications

Search Strategy• Four academic databases searched

• PubMed• EMBASE• CINAHL• Cochrane

• Publication date range 2000-2013• Searches combine key Concepts • Search strings adapted for each

database

Developing Search Strings

Expert panel feedback• Added and deleted terms (e.g., pressure cushion)

• Modified concept (e.g., expanded Disability concept to include select chronic conditions)

Health science librarian• Design search to yield highest relevant/least

irrelevant results

Search StringExample: Service Delivery – PubMed, Search 1

CONCEPT A – Rehabilitation

(((((("Physical and Rehabilitation Medicine"[Majr] OR "Rehabilitation Nursing"[Majr] OR "Rehabilitation of Speech and Language Disorders"[Majr] OR "rehabilitation centers"[Majr] OR "Rehabilitation"[Majr] OR "occupational therapy"[Majr] OR "recreation therapy"[Majr] OR "Physical Therapy Modalities"[Majr] OR "Physical Therapists"[Majr] OR "Physical Therapy Specialty"[Majr] OR "orthopedics"[Majr] OR "correction of hearing impairment"[Majr] OR "exercise therapy"[Majr] OR "Audiology"[Majr] OR "Speech-Language Pathology"[Majr] OR (biokinetics[tiab] OR biokineticist[tiab] OR "rehabilitation medicine"[tiab] OR "rehabilitation services"[tiab] OR telerehab[tiab] OR tele-rehabilitation[tiab] OR "community-based rehabilitation"[tiab] OR "community based rehabilitation"[tiab] OR "rehabilitation worker*"[tiab] OR "rehabilitation assistant*"[tiab] OR "rehabilitation centre"[tiab])) OR (physiotheraphy[tiab] OR physiatry[tiab]))) OR Neurorehabilitation[tiab])))

CONCEPT B – Less Resourced Setting(((("developing country"[tiab] OR "developing countries"[tiab] OR "developing nation"[tiab] OR "developing nations"[tiab] ….OR ("developing countries"[MeSH Terms] OR "poverty areas"[MeSH Terms] OR "poverty"[MeSH Terms] OR "vulnerable populations"[MeSH Terms] OR "medically underserved area"[MeSH Terms])) OR … (All LMICS by the World Bank Country Classification)…

Combined ConceptsExample: Service Delivery – PubMed, Search 1

Rehabilitation Less Resourced Setting

% of results applicable toless resourced settings

Example: Service Delivery - Search 1

3.7% 2.1% 2.2% 3.1%

Publ

icati

ons

for C

once

pt A

(r

ehab

ilita

tion

serv

ices

)

Search Results

PubMed EMBASE CINAHL Cochrane Total Duplicates deleted

Final Results

0500

100015002000250030003500400045005000

1936

1154 1219

341

4650

833

3817

643

1562

773

103

3081

423

2658

Service Delivery Assistive Technology

Num

ber o

f pub

licati

ons

zzz

Screening Process1. Initial screening – Is this publication relevant?

– abstracts of each publication reviewed

2. Secondary screening – Is the evidence of high quality (RCT, SR)?

– Abstracts or full article reviewed if needed

Initial Screening Questions1. Does the publication address (AT/rehabilitation) as a primary research

topic? YES = INCLUDE

2. Does the publication focus on a resource limited setting or resource limited population? YES = INCLUDE

3. Does the publication primarily inform clinical practice? YES = EXCLUDE

4. Does the publication provide adequate research evidence? YES = INCLUDE

Secondary Screening Question1. Is the study an RCT or systematic review? YES = INCLUDE

Screening ResultsSearch results of potentially relevant

unique records screened = 100% (3817)100% (2658)

Does the record address all criteria questions?

Yes Total records included for rapid extraction

10% (398 ) 10% (253)

NoTotal excluded records =

90% (3453) 92% (2434)

Does the record have a high quality research design (RCTs, SRs)?

NoTotal excluded records =

9% (348) 9% (242)

Yes1% (50) 0.4 % (11)S

econ

dary

S

cree

ning

Initi

al S

cree

ning

Records added = 1% (29)

Initial Screening: Reasons for Excluding Publications

Criteria Examples

Service Delivery

Not rehabilitation

• Orthopedic surgery or neurosurgery• Drug and alcohol rehab

Not services • Prevalence/needs assessment studies• Addressed other reviews (workforce, policy, financing)

Assistive Technology

Not assistive technology

• Endoprosthesis (hip replacement)• Contact lenses hygiene

Applied to both reviews

Not health-related

• Education-based• Employment-based (vocational rehab)

Not systems-level

• Primarily informed clinical decision making (screening, diagnosis, treatment)

Not resource limited setting • US veterans returning from LMIC

Not adequate research • Opinion/commentary

Number of Publications by Year20

00

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

0

10

20

30

40

50

60

7

13

7

13

2021

18

28

3432

44

5256

53

85

710

21

8

15 14

2124

28

23

37

31

Service Delivery Assistive Technology

Num

ber o

f pub

licati

ons

Percentage of Publications by Region

0%

5%

10%

15%

20%

25%

30%

15%

19%

15%

9%

15%

18%

26%

21%

16%

20%

9%

28%

21%

18%

Service Delivery Assistive Technology

Assistive Technology:Number of Publications by AT Category

OtherPressure Cushions

ICTsACC/Communication

OrthoticsOther Visual Aids

Other Mobility DevicesContact Lenses

AT General/Multiple Types of ATHearing AidsWheelchairs

ProstheticsSpectacles

0 10 20 30 40 50 60 70 80

1

4

6

8

8

10

11

13

13

30

34

61

67

Number of publications

Assistive Technology:Sample Size by Type of AT

Assistive Technology N AverageContact Lenses 13 48,476Spectacles 67 2,753Hearing Aids 30 1,404Other Visual Aids 10 195Wheelchairs 34 162Prosthetics 61 128Orthotics 8 99ACC/Communication 8 96Other Mobility Devices 11 74ICTs 6 59Pressure Cushions 4 40

Service Delivery: Population

Not specified7%

Communicable diseases

6%

Non-communicable diseases/ conditions

55%

Trauma11%

Impairment/ disabil-ity

21%

EarthquakesCar accidents

LeprosyHIV/AIDs

DisabilitiesHearing

DiabetesMental healthHeart diseaseStroke

Service Delivery: Type of Rehabilitation

Prosthetic and orthotic servicesPulmonary rehabilitation

Speech and language therapyOccupational therapy

AudiologyOrthopedics

Other*Cardiac rehabilitation

Physical therapyMultiple disciplines

Psychosocial rehabilitationDisease mgmt support

Rehabilitation general/not specified

0 20 40 60 80 100 120

4

9

10

11

12

17

22

26

30

31

36

78

112

Number of publications

Service Delivery: Systems-level themes

Group-based/peer-led

Multidisciplinary services

Post-acute services

Caregiving

Multiple primary themes

Quality of services

Rehabilitation in emergency settings

Telerehabilitation

Self-management

CBR

Availability of services

Access and barriers

0 10 20 30 40 50 60

10

10

11

12

15

15

21

21

29

33

44

50

3

1

1

2

5

1

1

1

12

1

1

0

Lower level evidence RCTs/SRs

Summary of Scoping Review Findings• Rehabilitation and AT evidence is sparse from less

resource settings.• Majority of relevant studies have lower level

evidence.• Evidence and levels of evidence are not evenly

distributed across topics, themes or populations.

Select Findings by ReviewService delivery Assistive technology• Majority of studies address

rehabilitation generally, psychosocial rehab, self-management, physical therapy

• Fewest studies address P & O services, Pulmonary rehab, SLP, OT

• Majority of evidence address chronic conditions (diabetes, mental health)

• Majority of studies address Spectacles, Prosthetics, Wheelchairs, Hearing Aids

• Fewest studies address AAC, ICTs, Orthotics, Pressure Cushions

• Average sample size on visual AT (spectacles, contact lenses) greatly exceeds other types of AT

Challenges• Lack of agreed upon definitions of key

concepts– Rehabilitation (self-management, substance abuse,

psychiatry, orthopedic surgery)– Assistive technology vs. medical device (cochlear,

accessible website)– Health systems vs. clinical evidence

• Difficulty in applying the ICF framework when studies are disability or disorder specific

• Limited time and resources

Who will use these findings?• Guideline developers

– Use suitable evidence review and synthesis methods (not GRADE)

– Search additional sources (grey literature)• Researchers/academics

– Need for common language/definitions– Address research gaps – Synthesize and translate evidence on specific

topics/themes where evidence exists– Improve methods for evidence synthesis of

observational research

How can this these findings help strengthen systems?

Decision makers responsible for strengthening rehab/AT systems need evidence on system-level solutions that apply to multiple populations.

– Example: Synthesize Evidence on home-based services

• Psychosocial support for parents of child with CP• Training for caregivers of adults with dementia• Transition services for people with SCI or stroke

What is Next?

• Status of WHO health–related rehabilitation guidelines

• Publishing scoping reviews• PHD research project

– Strengthening provision of rehabilitation services/AT for people with mobility limitations.

• Further synthesis of scoping review publications• Qualitative research on example of a successful model

Research Team and Expert Panel• Mark Harniss, UW• Becky Matter, UW• Tone Øderud, SINTEF• Arne Eide, SINTEF• Johan Borg, Abilia• Antony Duttine, HI • Kurt Johnson, UW• Pat Brown, UW• Sharon Brown, UW• Terry Ann Jankowski, UW

• Deepti Samant• Sarah Parker Harris• Catherine Sykes• Elsje Scheffler• Kim Reisinger• Shona McDonald• Gubela Mji• Stephanie Nixon• Jon Pearlman• Hasheem Mannan• Cecilia Nleya• Bolajoko Olusanya

• Malcolm Maclachlan

• A.K. Mukerjee• Federico Montero• Jan Monsbakken• Chiara Retis• Barbara Lawrence• Tomas Lagerwell• Alex Galvez• Pierre Brantus

Questions?

Contact Info

Rebecca Matter bmatter@uw.edu Mark Harniss mharniss@uw.edu

Department of Rehabilitation MedicineUniversity of WashingtonBox 357920Seattle, WA 98195