Increasing the amount of usual rehabilitation improves activity after stroke

Article Reviews
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Read Full Text: Increasing the amount of usual rehabilitation improves activity after stroke: a systematic review
Journal: Journal of Physiotherapy
Year Published: 2016
Ranked 39th on our 2016-2021 list of the 100 Most Influential OT Research Articles

Advancements in stroke treatment truly represent the great frontier of OT practice. After all, stroke is the leading cause of disability worldwide—and, therefore, it is one of the most studied diagnoses.

This week’s article hits on a hot topic in stroke rehab: dosing. In other words, how much therapy is needed to yield worthwhile functional outcomes? At what point does the benefit of therapy start to plateau? (And, while we’re at it, what should all of this therapy even look like?)

You’ll discover how increasing dosage impacts recovery from stroke—and we’ll also discuss how this article sets the stage for additional topics we’ll discuss in the Club.

What we already know about stroke and motor learning.

The most common activity limitations reported by stroke survivors are walking and using the arm to complete self care tasks.

We already know that new motor learning needs to occur to remedy these difficulties. We also know that practice is essential, and it needs to be structured in a way that creates a progressive challenge for the patient.

That’s why the stroke guidelines below recommend large amounts of practice. Please note the below guidelines have both been updated since this week’s article was written.

What we kinda know about stroke and motor learning.

Research seems to indicate that a “large” amount of practice is important. But, what does “large” really mean—and what, exactly, should you be “practicing” with your clients?

Several systematic reviews have explored the effect of amount of practice on outcomes following a stroke.

All of the systematic reviews mentioned in this article found that extra rehab improved outcomes. But, the previous reviews had limitations. First, some of the trials compared an increased amount of rehab to no rehab! That doesn’t really answer if more rehab is helpful, does it? Secondly, they looked at trials that mixed the kind of rehab being used. For example, usual rehab was supplemented by some other rehab type, rather than simply adding additional dosage of the same type of rehab.

Which leads us to this current study…

What research questions did the authors explore?

The authors set out to build on existing dosage knowledge by exploring two questions:

  • When patients receive rehab aimed at reducing activity limitations of the lower and/or upper extremity after stroke, does adding extra rehab improve activity?
  • What is the amount of extra rehab that needs to be provided to achieve a beneficial effect?

What methods did they use?

The authors undertook a systematic review of randomized and quasi-randomized trials. (Please see the paper for full inclusion criteria.) But, basically, studies were included if:

  • The experimental group received extra rehab as compared to a control group receiving usual rehab
  • Such rehab was the same type as the baseline “usual” rehab
  • Such “usual” rehab was aimed at improving upper extremity (UE) or lower extremity (LE) activity

What kind of studies did they find?

14 studies were included in this review, involving 954 participants. The data they gathered from the study looked like some variation of this:

Usual upper limb rehab: 60 min, 5x/wk for 3 weeks
Extra upper limb rehab: Additional 60 min, 5x/wk for 3 weeks (a 100% increase in dosage)

What assessments were used to measure UE/LE activity?

Here are the outcome measures that they used to measure UE and LE activity:

What were the results?

The pooled data showed that additional rehab dosage improved activity immediately after the intervention period.

And, when they seperated the studies into those that provided “small” amounts of extra practice versus “large” amounts, they found that the effect size was greater in those studies with small amounts.

Here’s how they defined “small” versus “large” amounts of extra practice:

Small: extra practice was ≤ 100% of usual practice
Large: extra pratice was ＞100% of usual practice

Based on their calculations, the authors concluded that an extra 240% of rehab dosage was needed for there to be significant likelihood that additional rehab would improve activity. So, for example if usual rehab included 15 minutes of walking practice, a 240% increase would be an additional 36 minutes.

Authors’ conclusions

In their conclusion section, the authors dug into the numbers a little more. They pointed out that the studies that delivered “large” amounts of practice showed average numbers looking like this:

  • Control group rehab = 25 min/day ,
  • Extra rehab in the experimental group = 90 min/day (260% increase)

The authors felt their findings aligned with previous research that suggested a benefit from extra rehab after stroke.

They also felt that their findings indicated that the delivery of large amounts of rehab was feasible, and that “rehab programs need to provide a substantial amount of rehabilitation to guarantee an improvement in activity.”

Their final thoughts were that rehab therapy now faces the challenge of figuring out how to provide this increased rehab—and that a far-reaching change in clinical practice is needed.

Takeaways for OT practitioners

(Please note: these are my personal takeaways and were not mentioned specifically in the article.)

1. Neuroplasticity is amazing!

There is a lot to unpack in this topic, but I don’t want to lose sight of the big picture. Namely, that neuroplasticity is amazing, and we are so privileged to be practicing in an era where we understand that the brain is constantly changing—even after a major event like a stroke. (We’ve only come to fully appreciate this ability in the past few decades.)

My favorite stroke rehab phase to describe this plasticity is: “you gain what you train.” We first learned this phrase in the amazing article “Rehabilitation of motor function after stroke.” And, to me, this week’s article really reinforced that principle: namely, if you focus on upper limb training, you’ll make gains in the upper limb activity you are practicing.

2. I have a lot more questions I want answered before overhauling therapy for every patient.

While it is amazing that the patients continued to make gains in UE and LE activity as a result of a higher dosage of rehab, I really wanted to know:

  • Did it make a difference in their quality of life?
  • Did all of the extra rehab feel worth it to them?
  • And, is there an easier way to make these gains?

In the beginning of this article, the authors highlighted the fact that rehabilitation is resource-intensive, both for the healthcare system and the patients themselves. So, I would want to know that the gains from all the extra time, money, and effort are translating to benefits beyond a standardized test.

This current article, and ones like it, do make me feel confident that an increase in therapy may be appropriate for some people we see, but I’m not yet convinced it is right for everyone. I think we still really need to listen to the priorities of our patients, and collaboratively build a plan with them.

3. More “usual rehab” is not the only option for getting the extra needed practice.

The authors seemed to see a future where we just increase the usual rehab we’ve been doing. But, I don’t think they are taking into account the tremendous technology gains, like virtual reality, robotic therapy, and even brain-computer interface.

All of these tech advancements are meant to increase practice and repetitions beyond what can take place in a standard therapy session. As research emerges on these technologies, we’ll make sure to follow it and discuss its findings in the Club :slight_smile:

I’m also particularly excited about the opportunities telehealth is opening, as well as the new information we are learning about various coaching models. I personally see a future where we are way more focused on incorporating more functional sessions in the home, which would be supported by new models of therapy, rather than piling on additional "in-clinic time, which is supported by new models of therapy, versus piling on “in-clinic time.”

Here’s the full APA citation for this article:
Schneider EJ, Lannin NA, Ada L, Schmidt J. Increasing the amount of usual rehabilitation improves activity after stroke: a systematic review. J Physiother. 2016 Oct;62(4):182-7. doi: 10.1016/j.jphys.2016.08.006. Epub 2016 Aug 24. PMID: 27637769.

What questions/thoughts does this article raise for you?

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Sarah,
I get very excited when you choose articles on stroke intervention. This topic is very close to my heart for more reasons than one and this article has validated my practice in this area.
When I finished OT school, there was no concept of 'neuroplasticity". We were taught to do PROM to the affected UE and change the patient’s hand dominance ASAP so they could complete their ADLs with their unaffected hand. We actually facilitated the “learned non-use” of the affected extremity (Some of our newer OT practitioners may have never heard of this). So you can imagine how excited I was when this whole idea of the brain forming new connections and have the ability to remold itself with repeated practice (neuroplasticity) was discovered. (I never fail to mention this to my OT students during my “stroke lecture”).
I agree with you that the therapy we provide has to be meaningful and improve the quality of life of our patients rather than be mere numbers on a test. A higher dosage of therapy is beneficial but it does not have to be more repetitions of exercises for every patient in the clinic. One way I try to get the patient and family buy-in for extra work outside of therapy time by utilizing CIMT techniques is by explaining the concept of “neuroplasticity” in layman’s terms. When people understand why they are doing what they are asked to do, they are more likely to be motivated to continue that on their own. I am also excited about the various adjunct technologies available now for stroke intervention but firmly believe that functional use of the UE in everyday tasks is of utmost value. Thank you.

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Very interesting article Sarah! The concept of neuroplasticity and rehabilitation from CVA is fascinating! I am a neuro geek and wanted to share some really interesting research that applies to rehab success after CVA. Dr. Jeffrey Kleim has been researching genetic factors that may be able to predict who will respond better to rehabilitation following CVA - based on if an individual has the genetic polymorphism that supports optimal neuroplasticity. I cited one of his articles below, you can find many of his just by doing a Google scholar search for Dr.Jeffrey Kleim. During one of his lectures. Dr. Kleim suggested that being able to predict who is more likely to have good rehab outcomes post CVA by a simple DNA test, may be used in the future by insurance companies to limit reimbursement for rehab for the patients who do not have the polymorphism that supports optimal neuroplasticity. Individuals who have the polymorphism would respond much better to our treatment interventions than individuals who do not have the genetic trait.
If you are interested in the article below I highly encourage you to read other work by Dr. Kleim and catch a lecture if possible- the future implications for how we deliver therapy services are really interesting!
Great topic for the week Sarah! I look forward to reading everyone’s input!
Article summary below:

Brain plasticity and genetic factors

Kristin M Pearson-Fuhrhop, Jeffrey A Kleim, Steven C Cramer

Topics in stroke rehabilitation 16 (4), 282-299, 2009

Brain plasticity refers to changes in brain function and structure that arise in a number of contexts. One area in which brain plasticity is of considerable interest is recovery from stroke, both spontaneous and treatment-induced. A number of factors influence these poststroke brain events. The current review considers the impact of genetic factors. Polymorphisms in the human genes coding for brain-derived neurotrophic factor (BDNF) and apolipoprotein E (ApoE) have been studied in the context of plasticity and/or stroke recovery and are discussed here in detail. Several other genetic polymorphisms are indirectly involved in stroke recovery through their modulating influences on processes such as depression and pharmacotherapy effects. Finally, new genetic polymorphisms that have not been studied in the context of stroke are proposed as new directions for study. A better understanding of genetic influences on recovery and response to therapy might allow improved treatment after stroke.

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I totally agree with this!! And, personally, havent seen anything in research to suggest otherwise! To my this goes back to the concept of you “Gain what you train.” It seems like if you practice specific skill, like with robotics, you’ll get good at THAT skill in that context, but you can’t assume it will translate to improved quality of life. From my vantage point it seems like the best way to improve at functional tasks in your day to day life is to practice them! If you are ever looking for an article to read in your class about this, I LOVE this journal article on this topic:

Rehabilitation of motor function after stroke

I also love your emphasis on education! The more the client can understand the goal of rehab and take ownership of it the better.

And, finally, it is incredible to me the changes in stroke rehab you have experienced in your career! We are SO LUCKY to be practicing in this age! To me, so many of the scientific advances of the past decades have been good news for rehab therapists, and OTs in particular!

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@Pollywallace, I’m SO GLAD you brought this up!! I think it is incredibly important for OTs to realize that it is not long before we have biomarkers to tell us who is a good candidate for therapy AND if the therapy is working!

I’m excited to read over the info you sent! Here’s an article in a similar vein that we looked at last year!

Connectivity measures are robust biomarkers of cortical function and plasticity after stroke

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Thanks Sarah :smiley: I remember reading that article- I am really interested in research into biomarkers and research tools like imaging/ functional mri’s. I agree that access to neuroscience work is so much easier now, and I look forward to even closer relationships between OT practioners and researchers- to blend the art and the science behind what we do! Exciting times!

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Thanks so much. I will definitely include this article in my stroke module. I did read it last night before commenting on the club. Very exciting indeed.

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Thanks Sarah for bringing up this article. Like Sanchala stated, I get very excited about anything related to Neuro rehab. All the comments are so important with different perspective.
Just adding- We all as OT’s strongly believe in asking our patients what do they really want to achieve from their rehab process, involving family if possible in setting their goals. However, at times they have gone through multiple rounds of intense/extra therapy , and not achieving functional independence as the focus has been only on UE recovery .
In those situations we as therapist have a huge responsibility in redirecting them and providing education and rehabilitation that has functional outcome (as we all understand the long term effects of caregiver burnouts) incorporating their affected side so they see the progress in their rehab process . For me, it has been an emotional struggle on how these patients come with so much hope on getting back their hand back to be able to type , where they are depending on caregivers to assist them with clothing management or dressing etc . How we communicate and provide the realistic opportunities that they see as progress is the key.

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How to insure more rehab with this crazy change in health insurance?

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Yes, insurance is such a good point. What setting are you working in (or thinking of in particular?) It does feel like overall that many of the advances in stroke care are only fully accessible to those who can self-pay. This is why we need to keep inching toward value-based care. And, using research like this to showcase how important OT is in value-based care models.

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Sanchala,
Like you neuroplasticity was not a concept in research when I started to practice and everything that comes out regarding neuroplasticity excites me because the brain’s neuroplasticity crosses most therapy settings and populations. Most of us will have clients that will benefit from this principle combined with other evidence-based models like CIMT and Mirror therapy while understanding the principles of motor learning. It is interesting that the clients gain abilities in what they practice…practice makes perfect or you gain what you train supporting motor learning theory. I see the uniqueness of OT practice as making sure the sessions include the practice of what the client wants to do. The client’s desires and needs have to stay in the front of the picture.
The measures used measure arm function, in terms of performance skills related to grip, pinch, strength, and functionality related to use of a limb in designated tasks but I agree with you Sarah that I would like to see more implementation of the client’s perception of gains made by the increased dosing of therapy in terms of perceived gains or perceptions of quality of life changes based on time put in and therapy dosage. Another measure could include caregiver perceived burden and the changes in caregiver perceived burden after the increased dosage and client gains as mentioned by Karia.

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Yes!! I agree with everything you said, and especially love this line! We are so fortunate in OT to have the research backing up our function-based approach! I worry about other professionals who are too stuck solely in the bio-mechanical approach—I just don’t see that being the future of therapy!

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Thank you for the article and yes I agree that stroke patients need focus treatment in the beginning. The issue I feel is that kind of insurance patients has limit the amount of treatment they got, which make it difficult for some patients to get treatment they need.

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