Rehabilitation of motor function after stroke

Article Reviews
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Read Full Text for Free: Rehabilitation of motor function after stroke: A multiple systematic review focused on techniques to stimulate upper extremity recovery (Free)
Journal: Frontiers in Human Neuroscience
Year Published: 2016
Ranked 11th on our 2014-2019 list of the 50 most influential articles

Article overview for OT practitioners

This article is a systematic review, which is considered the top of the research hierarchy. What that means is as long as the review was conducted soundly, it provides some of the best, most complete evidence on the topic.

I would say this article is a must-read for anyone who works with stroke patients—and it would be a great article to incorporate into OT school curriculum, as it not only includes efficacy on rehab of motor function after stroke, but it also describes the hypothetical mechanisms behind each approach.

About the multiple systematic review

26 different treatment modalities were included in the search. Here is what was included:

  • Randomized Control Trials (RCTs)
  • Controlled Trials
  • Systematic Reviews
  • Meta-Analyes with a PEDro-scale of higher than or equal to 4

5712 articles were retrieved, but ultimately only 270 articles were included in this review.

Phases of stroke were defined as:

  • Acute—within the first month after stroke
  • Subacute—between 1 and 6 months after stroke
  • Chronic—longer than 6 months after stroke

A treatment modality was recommended as an adjuvant intervention if it has shown superior efficacy in combination with another rehabilitation intervention, compared to the intervention alone.

A treatment modality was recommended as a rehabilitation intervention if it showed superior efficacy, compared to another rehabilitation intervention.

Recommended interventions for rehab of motor function after stroke

It is important to note that a very conservative approach was adopted with regards to recommendations.

In acute stroke, the following interventions were studied and recommended:

Primary rehabilitation strategy

  • Muscle strengthening exercises
  • Constraint induced movement therapy (CIMT) - using a low dosage regimen
  • Mirror therapy

Adjuvant interventions

  • Passive neuromuscular stimulation
  • Repetitive transcranial magnetic stimulation
  • Transcranial direct current stimulation
  • SSRI and NARI antidepressants
  • Botulinum toxin

In subacute stroke, the following interventions were studied and recommended:

Primary rehabilitation strategy

  • Muscle strengthening exercises
  • Constraint induced movement therapy (CIMT)
  • Mirror therapy
  • Botulinum toxin

Adjuvant interventions

  • Mental practice with motor imagery
  • High-frequency transcutaneous electrical nerve stimulation (TENS)
  • Passive neuromuscular electrical stimulation (NES)
  • Repetitive transcranial magnetic stimulation
  • Transcranial direct current stimulation
  • SSRI and NARI antidepressants

In chronic stroke, the following interventions were studied and recommended:

Primary rehabilitation strategy

  • Muscle strengthening exercises
  • Constraint induced movement therapy (CIMT)
  • Mirror therapy
  • Botulinum toxin

Adjuvant interventions

  • Mental practice with motor imagery
  • High-frequency transcutaneous electrical nerve stimulation (TENS)
  • Repetitive transcranial magnetic stimulation
  • Transcranial direct current stimulation
  • Virtual reality

For a visual, and to help you factor in the amount of hand-movement and spasticity, here is a complete decision tree for you:

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Interventions that are not recommended

Here are some rehabilitation approaches that are not recommended, as current evidence does not show efficacy of UE motor outcomes:

  • Bobath concept
  • Manual passive stretching
  • Bilateral training (device or non-device assisted, task oriented)
  • Robot-assisted therapy for the paretic UE (task oriented)

And here are some rehabilitation approaches that are not recommended, due to lack of scientific data available. (Large randomized control trials are still needed to confirm preliminary data.)

  • Perfetti method
  • Picard method
  • Isokinetic muscle strengthening
  • Device-assisted stretching (contention, splint, cast, taping)
  • Motor skill learning techniques (other than CIMT)
  • Movement observation
  • Motor imitation
  • Electroacupuncture
  • Low-frequency TENS
  • Electromyography-triggered neuromuscular stimulation
  • Theta-burst stimulation
  • Paired associative stimulation
  • Deep brain stimulation
  • Virtual immersion
  • Serious gaming
  • Passive, music supported therapy

Recent technological advances not included in this review

  • Brain-computer interface technologies
  • Functional electrical stimulation (FES)

Key takeaways for therapists

I’m lifting the takeaways right from the discussion section of the article, as they are just too good not to share:

1. UE motor rehab after stroke can work! This review indicates that functional recovery from stroke is positively influenced by goal-specific sensorimotor input through training or everyday use of the affected arm and hand.
2. Task-oriented approaches may not translate to broader functional improvements. As the article says “you gain what you train.” While task-oriented training may improve performance in that specific task, subsequent improvements do not transfer to improving participation in activities of daily living.
3. We need to stay focused on “real-world,” activity-related input. Here’s a direct quote from the article: “It also seems that the impact of rehabilitation technology of functional outcome could be optimized by offering more chances to the nervous system to experience “real” and repetitive activity related, adequate sensory-motor input during the training on upper limb movement, instead of task-specific exercises.” (page 16)

Documentation ideas from this article:

For your assessment section:

This patient presents with UE motor deficits that are negatively impacting her ability to participate in daily activities. Occupational therapy is required to provide goal-specific sensorimotor input through training on everyday use of the affected arm and hand—which robust research indicates positively influences functional recovery. (Rehabilitation of motor function after stroke: A multiple systematic review focused on techniques to stimulate upper extremity recovery, 2016)

Listen to a summary in podcast form

Find other platforms for listening to the OT Potential Podcast here.

What questions/thoughts does this article raise for you?

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Wow Sarah this is such a great summary! You’ve done a fabulous job outlining the findings and important bits. If I’m allowed to generalize for a minute: it seems the more of these reviews we read and digest, the more it becomes clear that DOING REAL STUFF is the best therapy. And that is so OT. Technology has not been able to replicate what naturally happens when we engage in meaningful goal directed activity - and probably never will. Same thing goes for any particular theoretical approach or branded intervention. It’s tough that the"fancier" interventions tend to get the research and funding and then are not shown to be terribly effective. We need more courageous OTs who are willing to study the mundane use of everyday activity in stroke so that eventually or approaches are better represented in these kinds of meta analyses.

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I am a new OT, and I work in homecare, so have not had any mentoring other then what I received in Field Work. What I have on my side is age, I am 59 and have life experience. Presently I have a number of stroke patients in my caseload and this article was helpful in giving me confidence that I am doing what is best evidence wise for them. I always ask what their leisure life activities are/were prior and move forward from there.

Whether we garden, cook, knit, color, or groom the dog. I find ways to incorporate the use of their limb in a skill that is familiar and wanted to rehabilitate.

I am seeing good results, but most of all smiles and thanks for a return to some form of normal in their life.

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Hey @DevonCochrane! Yes, I would agree with you! OTs everywhere should feel confident that focusing on function continues to be one of the best approaches they can take.

I was reminded of this recently when I was seeing a PT for a foot issue. Even though I was really motivated and educated about my issue, I was still terrible at getting the exercise repetitions in that they wanted me to. At the end of the day it very difficult to build new habits! But when we tie our treatments into activities the patients is already doing during the day, it is so much easier to repetitively and consistently practice the skills they are learning.

That being said, I think that as OTs we do need to stay open to the new technologies that are coming to the market, because they are so much more advanced than anything we have seen before. And we may find certain patients on our caseload who are really motivated to try the cutting edge technologies.

I would be really curious to know what @lauren2 or @lauren1’s take on this article was (they both work with stroke technology).

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Hi @lisa! Welcome to the profession and to the OT Potential Club!

I’m so glad you are here! I started my career in a small rural hospital as the only OT, and it was that desire for mentoring that led me to create this club!

I agree that you can feel confident that your function-based approach is what your patients need. It warms my heart to think of them returning to these valued activities. And, the consistent opportunities for engaging their active side is exactly the repetition that their recovering brain needs!

Keep up the great work and let us know if you we can support you in anyway!

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@lisa how inspiring of an attitude and practice that you already have. I love and am inspired by your chosen incorporations already (as a fellow home health OT).

It’s also striking to me how EASY it is to absolutely TAKE FOR GRANTED the power of occupation, especially “mundane” or daily tasks that are woven almost blindly into our daily lives. I wish I would have seen this article one month ago (actually about 5 years ago, lol).

@SarahLyon thank you for helping to bring the potent research to bite size. It’s profound.

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