Critical Review Form – Quantitative Studies

Law, M., Stewart, D., Pollock, N., Letts, L. Bosch, J., & Westmorland, M.
McMaster University
- Adapted Word Version Used with Permission –

The EB Group would like to thank Dr. Craig Scanlan, University of Medicine and Dentistry of NJ, for
providing this Word version of the quantitative review form.

Instructions: Use tab or arrow keys to move between fields, mouse or spacebar to check/uncheck boxes.

CITATION Provide the full citation for this article in APA format:

STUDY PURPOSE Outline the purpose of the study. How does the study apply to your research
question?
Was the purpose
stated clearly? • To determine whether the addition of deep or superficial heating to
stretching produces better clinical outcomes than stretching alone in the
Yes management of frozen shoulder.
No

LITERATURE Describe the justification of the need for this study:

Was relevant • Frozen shoulder or adhesive capsulitis is a common insidious condition

background that is associated with pain and with a restricted range of motion (ROM)
literature reviewed? around the shoulder joint.
Yes
No • It can arise from idiopathic or post-traumatic causes. Frozen shoulder
usually involves 3 phases: (i) the painful phase, which usually lasts for
2–9 months and leads to progressive stiffness; (ii) the stiffness phase,
which usually lasts for 3–9 months, during which the pain gradually
subsides but marked © 2007 The Authors. doi: 10.2340/16501977-0146
stiffness develops in all planes of the shoulder joint; (iii) the thawing
phase, which usually persists for 12–42 months, during which there is a
slow gain in motion and comfort.

• Heat modalities are commonly classified as superficial or deep heating

agents. Examples of deep heating agents are ultrasound or shortwave
diathermy (SWD)

• It has been suggested that a deep heating agent could produce a greater
increase in tissue extensibility than superficial heating

DESIGN Describe the study design. Was the design appropriate for the study question?
(e.g., for knowledge level about this issue, outcomes, ethical issues, etc.):
Randomized
(RCT) • Randomized Controlled study
cohort

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 single case Specify any biases that may have been operating and the direction of their
design influence on the results:
before and after
case-control • There are no biases
cross-sectional
case study

SAMPLE Sampling (who; characteristics; how many; how was sampling done?) If more
than one group, was there similarity between the groups?:
N=
Was the sample • Thirty subjects (9 men and 21 women, age range 37–79 years, with
described in detail? idiopathic frozen shoulder in the stiffness phase participated in this study.
Yes
No • Inclusion criteria:
1. If they had experienced shoulder pain and limited shoulder
Was sample size movement for at least 8 weeks.
justified? • Exclusion criteria:
Yes 1. If they had a history of trauma to the shoulder, acute signs of
No inflammation over the shoulder, intrinsic shoulder pathology
N/A 2. If they were taking analgesic or anti-inflammatory drugs
3. If they had metal implants
4. Impaired sensation of hot and cold, were pregnant, or had a
cardiac pacemaker

• Subjects were  randomly  allocated  into  one  of  the  following  3  groups: 
(i)  SWD plus  stretching  (n = 10);  (ii)  HP plus  stretching  (n =10);  or  (iii) 
stretching exercises  alone  (n = 10)

• Randomization was performed using an on-line randomization plane

(http://www.randomization.com)

Describe ethics procedures. Was informed consent obtained?:

• The study was approved by a local ethics committee

• An informed consent has been obtained

OUTCOMES Specify the frequency of outcome measurement (i.e., pre, post, follow-up):
• Each treatment session lasted for 20 min. 3 times per week for 4 weeks.
Were the outcome • Assessments were made prior to treatment at the baseline, at sessions
measures reliable? 6 and 12, and at the 4-week follow-up session.
Yes List measures used: Outcome areas:
No • American Shoulder and Elbow • To measure the treatment
Not addressed Surgeons (ASES) assessment form outcomes in the present study
• 10-cm horizontal visual analogue
Were the outcome scale (VAS) line • Pain

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measures valid?
Yes • Goniometer
No • ROM
Not addressed

INTERVENTION Provide a short description of the intervention (focus, who delivered it, how
often, setting). Could the intervention be replicated in practice?
Intervention was
described in detail? • A shortwave diathermy machine (Curapuls 419, Enraf Nonius, the
Yes Netherlands) with an operating frequency of 27.12 MHz was used to
No deliver the deep heating treatment. The subjects were positioned
Not addressed comfortably sitting on a wooden chair with their back and affected
arm supported.
Contamination was • A pair of disc electrodes was placed on the anteriorposterior aspects
avoided? of the affected glenohumeral joint, separated by a hand’s-breadth from
Yes the surface of the body.
No • If the level of perceived heating changed during the application, the
Not addressed machine’s output was adjusted to maintain the sensation of comfortable
N/A warmth throughout the treatment.
• For the HP group, an electrical hot pack sized 35.5 × 68.5 cm was
Cointervention was used to deliver superficial heating. the temperature was set at 63°C.
avoided? • Immediately after the heat treatment, subjects were asked to perform
Yes 4 stretching exercises in the following fixed sequence: stretching in
No external rotation, in flexion, followed by stretching in hand-behindthe-
Not addressed back and cross-body adduction. They were asked to repeat the
N/A stretches 4 times. Each stretch was sustained for 30 sec, with 10 sec
rest between each stretch.
• The subjects were asked to perform the stretching exercises at home
every day

RESULTS What were the results? Were they statistically significant (i.e., p < 0.05)? If
not statistically significant, was study big enough to show an important
Results were reported in difference if it should occur? If there were multiple
terms of statistical outcomes, was that taken into account for the statistical analysis?
significance?
Yes • A significant improvement was seen in all groups in all outcome
No measures except for that of shoulder flexion range. The improvement
N/A in the shoulder score index and in the range of motion was
Not addressed significantly better in the deep heating group than in the superficial
heating group.
Were the analysis • No significant differ-ence (p > 0.05) was found among all of the outcome
method(s) appropriate? measures at the baseline.
Yes • By session 12, the shoulder score index in the SWD group had increased
No by 63.4%, compared with 45.2% in the HP group and 38.4% in the
Not addressed stretching alone group

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Clinical importance was What was the clinical importance of the results? Were differences between
reported? groups clinically meaningful? (if applicable)
Yes
No • The addition of deep heating to stretching exercises produced a
Not addressed greater improvement in pain relief, and resulted in better performance
in the activities of daily living and in range of motion than did superficial
heating.
Drop-outs were Did any participants drop out from the study? Why? (Were reasons given
reported? and were drop-outs handled appropriately?)
Yes
No •None of the participants in any of the treatment groups dropped out
throughout the study period
CONCLUSIONS AND What did the study conclude? What are the implications of these results for
IMPLICATIONS practice? What were the main limitations or biases in the study?

Conclusions were • In conclusion, our findings suggest that the addition of deep heating
appropriate given study (using SWD) to stretching exercises is more effective than superficial
methods and results heating (using Hp) or stretching alone in improving shoulder pain and
Yes function.
No
• Also, the addition of deep heating to stretching produces a
significantly greater gain in shoulder ROM (flexion, external rotation
with the arm by one’s side, external rotation with the arm in
abduction and in the hand-behind-back position) than does the use of a
superficial heating plus stretching.

• However, the addition of superficial heating to stretching will not

produce a further enhancement of the shoulder score index or a gain
in shoulder ROM for patients with frozen shoulder.

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 Critical Review Form – Quantitative Studies
Law, M., Stewart, D., Pollock, N., Letts, L. Bosch, J., & Westmorland, M.
McMaster University
- Adapted Word Version Used with Permission –

The EB Group would like to thank Dr. Craig Scanlan, University of Medicine and Dentistry of NJ, for
providing this Word version of the quantitative review form.

Instructions: Use tab or arrow keys to move between fields, mouse or spacebar to check/uncheck boxes.

CITATION Provide the full citation for this article in APA format:

Yan, T., & Lin, Z. (2011). Long-term effectiveness of neuromuscular

electrical stimulation for promoting motor recovery of the upper
extremity after stroke. Journal of Rehabilitation Medicine, 43(6),
506–510. doi:10.2340/16501977-0807

STUDY PURPOSE Outline the purpose of the study. How does the study apply to your research
question?
Was the purpose
stated clearly?  To investigate the long-term efficacy of neuromuscular electrical
stimulation in enhancing motor recovery in the upper extremities of
Yes stroke patients.
No

LITERATURE Describe the justification of the need for this study:

 Stroke is the third largest cause of death and one of the main causes
Was relevant of disability in China and worldwide.
background literature  Approximately 75% of survivors have some sort of impairment, the
reviewed? UE being one of the most frequently affected areas.
Yes  Many clinical studies have demonstrated that electrical stimulation
No after stroke greatly improves motor function and performance in
activities of daily living and reduces long-term disability
 Intense and task-oriented training has been found to yield better UE
control, particularly in patients who demonstrate at least modest
motor control prior to treatment.
 Several researchers have reported that task-specific, repetitive
training with or without restraining the non-paretic extremity results
in significantly faster improvement in upper extremity function
among both chronic and subacute stroke survivors

DESIGN Describe the study design. Was the design appropriate for the study
question? (e.g., for knowledge level about this issue, outcomes, ethical
Randomized (RCT) issues, etc.):
cohort
single case design  The research design used was a randomized controlled trial wherein
before and after subjects were divided into control and experimental group, both
case-control receiving PT and OT services but experimental group received NES.

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 cross-sectional
case study Specify any biases that may have been operating and the direction of their
influence on the results:
 Single blind-outcome measurements were assessed by the
physiotherapists, who did not know to which group each patient
belonged.

SAMPLE Sampling (who; characteristics; how many; how was sampling done?) If
more than one group, was there similarity between the groups?:
N =46
Was the sample  Sample size was calculated prior to recruiting the participants.
described in detail?  Non probability purposive sampling
Yes  Inclusion Criteria:
No
1. Stroke; within 3 months post-onset admitted to the Neurology or
Was sample size Rehabilitation Department of the 5th Affiliated Hospital of Sun Yat-
justified? sen University between January and August 2008
Yes 2. Diagnosed with either cerebral infarction or cerebral haemorrhage
No using either CT scan or MRI;
N/A 3. Fulfilling the diagnostic and classification criteria for stroke
established by the Chinese Neuroscience and Neurosurgery Institute.
4. All the subjects were in the age range 44–80 years, with hemiplegia
of one upper limb.
5. Their shoulder flexor strength before treatment was grade 3 or less
(out of 5).
6. They were also required to have no severe cognitive dysfunction
(with a score of 7 or better on the abbreviated mental test (19)) and to
be willing to sign an informed consent form.
 Exclusion Criteria

1. Subarachnoid haemorrhage
2. Shoulder muscle strength ≥ grade 3
3. Severe heart, liver, kidney or infectious disease; head injury; tumour
4. A score < 7 on the abbreviated mental test
5. If they were younger than 44 years, older than 80 years, or were not
willing to sign the consent form.

Describe ethics procedures. Was informed consent obtained?:

 Informed consent was given.

 The study was approved by the ethics committee of Sun Yat-sen
Memorial Hospital.

OUTCOMES Specify the frequency of outcome measurement (i.e., pre, post, follow-up):
 Treatment lasted for 30 min, 5 days per week for 3 weeks.
Were the outcome  Assessments were repeated 1, 3 and 6 months later.

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measures reliable?
Yes
No
Not addressed List measures used: Outcome areas:

Were the outcome  Modified Ashworth Scale  Spasticity

measures valid? (MAS)
Yes  Fugl-Meyer Assessment  Evaluate the UE
No (FMA-U)
Not addressed  Modified Barthel Index  Activities of daily living
(MBI)

INTERVENTION Provide a short description of the intervention (focus, who delivered it, how
often, setting). Could the intervention be replicated in practice?
Intervention was
described in detail? • Both groups received physical and occupational therapy, for 30 mins
Yes on 5 days each week for 3 wks.
No • NES groupà 2-channel Respond Select II stimulator (30Hz, with a
Not addressed pulse width of 300 μs, and ramp up and down times of 1 s each)
• The surface electrodes were applied over the motor points near the
Contamination was middle of the supraspinatus muscle and the deltoid muscle on the
avoided? paretic side, as well as over the wrist extensor (between one-third
Yes and half-way from the proximal end of the dorsal forearm)
No • Control grp didn’t receive any ES
Not addressed
N/A

Cointervention was
avoided?
Yes
No
Not addressed
N/A

RESULTS What were the results? Were they statistically significant (i.e., p < 0.05)? If
not statistically significant, was study big enough to show an important
Results were reported in difference if it should occur? If there were multiple outcomes, was that taken
terms of statistical into account for the statistical analysis?
significance?  After 2 weeks of treatment, all patients showed significant
Yes improvement in upper limb function (p < 0.05), and at least some of
No the improvement persisted for the entire 6 months in every case.
N/A  The patients in the NES group, on average, showed significant
Not addressed enhancement in shoulder retrusion, put-up, outreach, external
rotation and flexion, as well as improved flexion and extension of the
Were the analysis wrist and fingers.
method(s) appropriate?  The NES group showed significantly better progress of MAS scores
Yes at the 3rd week and 1 month later (p < 0.05), but at the 3- and 6-
No month evaluations their advantage had disappeared.

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 Not addressed
 The patients in the NES group showed greater improvement in their
ability in activities of daily living than the control group.

Clinical importance was What was the clinical importance of the results? Were differences between
reported? groups clinically meaningful? (if applicable)
Yes
No  The study found that NES treatment during early rehabilitation not
Not addressed only significantly improved motor function in the hemiplegic upper
extremities of stroke patients and then indirectly enhanced their
ability in activities of daily living due to their improvement in motor
function in the affected upper extremity, but also that its effects
persist for at least 6 months after the treatment has been
discontinued.

Drop-outs were Did any participants drop out from the study? Why? (Were reasons given
reported? and were drop-outs handled appropriately?)
Yes
No  7 pts were dropped due to early discharge, including 3 in the NES
group, and 4 in the CG. 2 subjects could not finish the study due to
illness.

CONCLUSIONS AND What did the study conclude? What are the implications of these results for
IMPLICATIONS practice? What were the main limitations or biases in the study?
 NES combined with standard rehabilitation treatment promotes
Conclusions were muscle strength and motor function in the upper extremities, and thus
appropriate given study improves ability in activities of daily living of patients after a first
methods and results stroke. Its effects persist for at least 6 months.
Yes  Absence of a sham stimulation group
No  Future studies, using similar stimulation protocols with a larger
sample, are needed to gain further insight into the potential to induce
functionally beneficial neuroplasticity in stroke patients.

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