背景:中风患者经常面临严重影响其日常生活的残疾。营养不良是这些患者的常见问题,营养不良会严重影响卒中后的功能恢复。因此,营养治疗对于管理卒中结局至关重要.然而,它对残疾的影响,日常生活活动(ADL),和其他关键成果尚未得到充分探索。
目的:评价营养治疗对脑卒中后患者减少残疾和改善ADL的作用。
方法:我们搜索了Cochrane卒中组的试验记录,中部,MEDLINE(自1946年起)Embase(自1974年起),CINAHL(自1982年起),和AMED(从1985年起)至2024年2月19日。我们还搜索了试验和研究登记处(ClinicalTrials.gov,世界卫生组织国际临床试验注册平台)和参考文章列表。
方法:我们纳入了随机对照试验(RCT),比较了营养治疗与安慰剂,日常护理,或中风后的一种营养疗法。营养治疗被定义为补充营养,包括能量,蛋白质,氨基酸,脂肪酸,维生素,矿物,通过口头,肠内,或肠胃外方法。作为一个比较器,一种营养疗法是指所有形式的营养疗法,排除定义用于干预组的特定营养疗法.
方法:我们使用Cochrane的Screen4Me工作流程来评估初始搜索结果。两位综述作者独立筛选了符合纳入标准的参考文献,提取的数据,并使用GRADE方法评估偏倚风险和证据的确定性。我们计算了连续数据的平均差(MD)或标准化平均差(SMD)和二分数据的比值比(OR),95%置信区间(CI)。我们使用I2统计量评估异质性。主要结果是残疾和ADL。我们还评估了步态,营养状况,全因死亡率,生活质量,手和腿的肌肉力量,认知功能,物理性能,中风复发,吞咽功能,神经损伤,和并发症(不良事件)的发展作为次要结局。
结果:我们确定了52个合格的RCT,涉及11,926名参与者。在急性期进行了36项研究,10在亚急性期,三个在急性期和亚急性期,还有三个在慢性期。23项研究包括缺血性中风患者,其中三名包括出血性中风患者,其中3例包括蛛网膜下腔出血(SAH)患者,23例包括缺血性或出血性卒中患者,包括SAH.有25种类型的营养补充剂用作干预措施。评估残疾和ADL作为结果的研究数量分别为9项和17项。对于使用口服能量和蛋白质补充剂的干预,这是这篇综述的主要干预措施,纳入了六项研究。七个结果的结果集中在(残疾,ADL,体重变化,全因死亡率,步态速度,生活质量,和并发症发生率(不良事件))如下:当“良好状态”定义为mRS评分为0至2时,没有证据表明减少残疾的差异(对于“良好状态”:OR0.97,95%CI0.86至1.10;1个RCT,4023名参与者;低确定性证据)。口服能量和蛋白质补充剂可以改善ADL,如FIM运动评分增加所示,但证据非常不确定(MD8.74,95%CI5.93至11.54;2项随机对照试验,165名参与者;非常低的确定性证据)。口服能量和蛋白质补充剂可能会增加体重,但证据非常不确定(MD0.90,95%CI0.23至1.58;3项RCT,205名参与者;非常低的确定性证据)。没有证据表明在降低全因死亡率方面存在差异(OR0.57,95%CI0.14至2.28;2项随机对照试验,4065名参与者;低确定性证据)。对于步态速度和生活质量,没有确定研究。关于并发症(不良事件)的发生率,没有证据表明感染的发生率有差异,包括肺炎,尿路感染,和败血症(OR0.68,95%CI0.20至2.30;1个RCT,42名参与者;非常低的确定性证据)。与常规治疗相比,干预措施与腹泻发生率增加相关(OR4.29,95%CI1.98至9.28;1RCT,4023名参与者;低确定性证据)和高血糖或低血糖的发生(OR15.6,95%CI4.84至50.23;1个RCT,4023名参与者;低确定性证据)。
结论:我们不确定营养治疗的效果,包括口服能量和蛋白质补充剂以及本综述中确定的其他补充剂,关于减少中风后患者的残疾和改善ADL。在纳入的研究中,评估了各种营养干预措施的结果。几乎所有研究的样本量都很小。这导致了进行荟萃分析的挑战,并降低了证据的准确性。此外,大多数研究都存在偏见风险,特别是在没有盲目性和不清楚的信息方面。关于不良事件,口服能量和蛋白质补充剂的干预与较高数量的不良事件相关,比如腹泻,高血糖症,和低血糖,与通常的护理相比。然而,证据质量很低。鉴于我们审查中大多数证据的确定性较低,需要进一步的研究。未来的研究应该集中在有针对性的营养干预,以减少残疾和改善ADL的理论基础上,中风后的人,有必要改进方法和报告。
BACKGROUND: Stroke patients often face disabilities that significantly interfere with their daily lives. Poor nutritional status is a common issue amongst these patients, and malnutrition can severely impact their functional recovery post-stroke. Therefore, nutritional therapy is crucial in managing stroke outcomes. However, its effects on disability, activities of daily living (ADL), and other critical outcomes have not been fully explored.
OBJECTIVE: To evaluate the effects of nutritional therapy on reducing disability and improving ADL in patients after stroke.
METHODS: We searched the trial registers of the Cochrane Stroke Group, CENTRAL, MEDLINE (from 1946), Embase (from 1974), CINAHL (from 1982), and AMED (from 1985) to 19 February 2024. We also searched trials and research registries (ClinicalTrials.gov, World Health Organization International Clinical Trials Registry Platform) and reference lists of articles.
METHODS: We included randomised controlled trials (RCTs) that compared nutritional therapy with placebo, usual care, or one type of nutritional therapy in people after stroke. Nutritional therapy was defined as the administration of supplemental nutrients, including energy, protein, amino acids, fatty acids, vitamins, and minerals, through oral, enteral, or parenteral methods. As a comparator, one type of nutritional therapy refers to all forms of nutritional therapies, excluding the specific nutritional therapy defined for use in the intervention group.
METHODS: We used Cochrane\'s Screen4Me workflow to assess the initial search results. Two review authors independently screened references that met the inclusion criteria, extracted data, and assessed the risk of
bias and the certainty of the evidence using the GRADE approach. We calculated the mean difference (MD) or standardised mean difference (SMD) for continuous data and the odds ratio (OR) for dichotomous data, with 95% confidence intervals (CIs). We assessed heterogeneity using the I2 statistic. The primary outcomes were disability and ADL. We also assessed gait, nutritional status, all-cause mortality, quality of life, hand and leg muscle strength, cognitive function, physical performance, stroke recurrence, swallowing function, neurological impairment, and the development of complications (adverse events) as secondary outcomes.
RESULTS: We identified 52 eligible RCTs involving 11,926 participants. Thirty-six studies were conducted in the acute phase, 10 in the subacute phase, three in the acute and subacute phases, and three in the chronic phase. Twenty-three studies included patients with ischaemic stroke, three included patients with haemorrhagic stroke, three included patients with subarachnoid haemorrhage (SAH), and 23 included patients with ischaemic or haemorrhagic stroke including SAH. There were 25 types of nutritional supplements used as an intervention. The number of studies that assessed disability and ADL as outcomes were nine and 17, respectively. For the intervention using oral energy and protein supplements, which was a primary intervention in this review, six studies were included. The results for the seven outcomes focused on (disability, ADL, body weight change, all-cause mortality, gait speed, quality of life, and incidence of complications (adverse events)) were as follows: There was no evidence of a difference in reducing disability when \'good status\' was defined as an mRS score of 0 to 2 (for \'good status\': OR 0.97, 95% CI 0.86 to 1.10; 1 RCT, 4023 participants; low-certainty evidence). Oral energy and protein supplements may improve ADL as indicated by an increase in the FIM motor score, but the evidence is very uncertain (MD 8.74, 95% CI 5.93 to 11.54; 2 RCTs, 165 participants; very low-certainty evidence). Oral energy and protein supplements may increase body weight, but the evidence is very uncertain (MD 0.90, 95% CI 0.23 to 1.58; 3 RCTs, 205 participants; very low-certainty evidence). There was no evidence of a difference in reducing all-cause mortality (OR 0.57, 95% CI 0.14 to 2.28; 2 RCTs, 4065 participants; low-certainty evidence). For gait speed and quality of life, no study was identified. With regard to incidence of complications (adverse events), there was no evidence of a difference in the incidence of infections, including pneumonia, urinary tract infections, and septicaemia (OR 0.68, 95% CI 0.20 to 2.30; 1 RCT, 42 participants; very low-certainty evidence). The intervention was associated with an increased incidence of diarrhoea compared to usual care (OR 4.29, 95% CI 1.98 to 9.28; 1 RCT, 4023 participants; low-certainty evidence) and the occurrence of hyperglycaemia or hypoglycaemia (OR 15.6, 95% CI 4.84 to 50.23; 1 RCT, 4023 participants; low-certainty evidence).
CONCLUSIONS: We are uncertain about the effect of nutritional therapy, including oral energy and protein supplements and other supplements identified in this review, on reducing disability and improving ADL in people after stroke. Various nutritional interventions were assessed for the outcomes in the included studies, and almost all studies had small sample sizes. This led to challenges in conducting meta-analyses and reduced the precision of the evidence. Moreover, most of the studies had issues with the risk of
bias, especially in terms of the absence of blinding and unclear information. Regarding adverse events, the intervention with oral energy and protein supplements was associated with a higher number of adverse events, such as diarrhoea, hyperglycaemia, and hypoglycaemia, compared to usual care. However, the quality of the evidence was low. Given the low certainty of most of the evidence in our review, further research is needed. Future research should focus on targeted nutritional interventions to reduce disability and improve ADL based on a theoretical rationale in people after stroke and there is a need for improved methodology and reporting.