We are keen to regularly profile rehabilitation-related research conducted within NZ.  Please contact us if you would like us to profile a published paper, poster or conference presentation

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  • 10 Feb 2015 10:31 AM | William Levack (Administrator)

    Systematic reviews, which once upon a time were new and unfamiliar, have now proliferated and are commonplace.  Where once it was difficult to read all the clinical trials published on a given topic, it is now a challenge to just get through all the systematic reviews that have been written!  In response to this, the Cochrane Collaboration (which all New Zealanders can access for free via the Ministry of Health website) has begun publishing Cochrane Overviews.  These are, in essence, systematic reviews of systematic reviews.

    One excellent example of a Cochrane Overview is a recent publication by Pollock and colleagues (2014) entitled “Interventions for improving upper limb function after stroke.”  For this overview, Pollock et al. collected, critically appraised, and combined the findings from 40 complete systematic reviews on various interventions for hemiplegic arms and hands after stroke.  This includes 19 Cochrane reviews and 21 published non-Cochrane reviews.  The review covers 18 individual interventions, including investigation of dosages (e.g. frequency and intensity of exercise) and the setting for intervention.


    So how useful are these new types of reviews?  What can a Cochrane Overview actually tell us about therapies for people with upper limb hemiplegia after stroke?  In fact it would appear quiet a bit!  Here is summary of some of the key findings from Pollack et al.'s (2014) review:

    • We can say there is moderate quality evidence that the following interventions for hemiplegic upper limbs after stroke may be effective: constraint-induced movement therapy (CIMT), mental practice, mirror therapy, interventions for sensory impairment, virtual reality, and a relatively high dose of repetitive task practice.
    • There is now moderate quality evidence that unilateral arm training (exercise of the weak arm) is probably more effective that bilateral arm training (exercise involving both arms at the same time).  This has been a bit of an on-going debate for the last couple of decades, so it is interesting to see the weight of evidence slowly coming out in favour of one side of the debate over the other.
    • While there is still need for further research to determine the right dose of rehabilitation for hemiplegic arms, there is growing evidence that more is indeed better - more intensive exercise increases the opportunities for people to regain arm and hand function after stroke.
    • The highest quality evidence was in relation to transcranial direct current stimulation, which (interesting, given that this seems to be all the rage at the moment) showed that this type of therapy is NOT effective for improving people's upper limb functional ability after stroke.

    The review concluded that there was still considerable room for improving the quality of research trials into upper limb therapies, and in particular into determining the optimal intervention dose for arm rehabilitation.

    William Levack is an Associate Professor of Rehabilitation at the Rehabilitation Teaching & Research Unit, University of Otago, Wellington, New Zealand. Twitter: @DrLevack


    Pollock et al. (2014) Interventions for improving upper limb function after stroke. Cochrane Database of Systematic Reviews. Issue 11. Art. No.: CD010820. DOI:10.1002/14651858.CD010820.pub2.

  • 10 Feb 2015 8:44 AM | William Levack (Administrator)

    Popular culture plays a significant role in how the general public views disability.  Representations in the media influence how people think about impairments, and therefore how they act towards people with differences in body structure and function.  If impairments are presented in movies as something to be feared or despised, then people will learnt to fear and despise them, with these attitudes (and subsequent behaviour) contributing to everyday disabling experiences for others.

    Recently, I was playing a free online game, Facility Z, in which the ‘twist’ at the end involved discovering some guy in a wheelchair as the villain of the story (i.e. the evil scientist in a wheelchair cliché).  This got me thinking about all the times that people with disabilities have been villains in movies, books, and games. (Of course, people with impairments are frequently the heroes in these stories too, raising other questions about the role of the ‘super crip’ in popular media, but I’ll save that discussion for another day.)

    Disability is often presented in these stories as representing ‘otherness’, with authors of these games, books, and movies using disability in an attempt to make their hero’s nemesis more scary.  This presents people with impairments as being ‘not like us’ and therefore objects of uncertainly and a potential threat.  Negative stereotypes, discriminatory views of disability, and able-bodied people’s fear of the unknown are used as tools of convenience by the author to drive the story’s narrative.  Examples of this include Dr Strangelove (in a wheelchair) and Dr No (with mechanical hands) from the James Bond franchise, and Davros, creator of the Daleks, from Doctor Who.

    Other times authors use disability as a justification for why the villain in a story turned bad.  The disability becomes a plot point. Perhaps the villain has been seeking a cure for their impairment and as a result of an experiment going ‘horribly wrong’ the otherwise well-intentioned antagonist turns ‘bad’.  Inevitably the usually able-bodied hero has to rescue the villain from themselves, or save other people from them, perhaps unwillingly destroying the villain in the process.  Here, disability is presented as the origin of evil; an explanation why people with good intentions might go bad.  An example of this type of villain is Spiderman’s nemesis, the Lizard, who turned into a superhuman monster after daring to dabble with reptilian DNA in an attempt to grow back his amputated arm.  Another example is the character Blizzard in the 1920's silent film classic, The Penalty, the plot of which, according to Wikipedia, is as follows: "Driven insane by the social pressures of being forced to walk on crutches, (bilateral amputee) Blizzard becomes a crime lord. He tracks down the doctor who performed his operation, and plots a twisted revenge: kidnap the doctor's daughter's fiance, and graft his legs onto Blizzard's stumps."

    But in an inclusive world, people with disabilities should have every chance of being the villain as they do of being the hero in these stories.  Is it possible then for a person with impairments to be the villain of a story, but where their impairment is incidental to the plot?  I've wondered whether one movie character has recently achieved this – Bolivar Trask from “X-men: Days of Future Past”.  Played by Peter Dinklage (fresh from massive popular acclaim as the anti-hero, Tyrion Lannister, in Game of Thrones) Trask is the evil scientist who takes it upon himself to defend humanity by creating giant robots designed to hunt down and kill the growing mutant superhuman population (the X-men and their community; i.e. the heroes of the story).  Interestingly, Bolivar Trask in the original X-men comic book on which the movie is based, did not have a height restricted disorder.  But because Dinklage (the actor) has achondroplasia, Trask (the character) is also restricted in height.  Sure, the introduction of a Trask with dwarfism in the movies adds an interesting element to his character, but this is utterly incidental to Dinklage’s massive onscreen presence, which is what brings Trask to life for the audience.  With a recent resurgence of criticism of able-bodied actors playing disabled characters, it is very refreshing for the movie casting to head in the other direction for a change. 

    William Levack is an Associate Professor of Rehabilitation at the Rehabilitation Teaching & Research Unit, University of Otago, Wellington, New Zealand. Twitter: @DrLevack

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