The effect of altering a single component of a rehabilitation programme on the functional recovery of stroke patients: a systematic review and meta-analysis

Considerations for developing complex post-stroke upper limb behavioural interventions: An international qualitative study

OBJECTIVE

To simultaneously explore the perspectives and opinions of different invested participant groups on the important considerations for development of upper limb behavioural interventions that drive optimal post-stroke upper limb motor recovery.

DESIGN

A qualitative descriptive study in a constructivist epistemology.

PARTICIPANTS

Purposively selected participant groups (preclinical research n = 9, clinical research n = 9, clinical experience n = 9 and lived experience n = 10).

SETTING

Research participants were selected from top internationally published authors. Experiential participants were recruited internationally, through networks.

RESULTS

Four themes were identified with embedded subthemes. Theme 1: 'Clinical relevance should be the core of a "good" research question' with two subthemes: 'Breaking down silos: forging interdisciplinary research teams', and 'Beyond the pipeline: bench to bedside and back'; theme 2: 'Balance restitution and compensation to maximise outcomes' with three subthemes: 'Good outcome: going beyond an outcome measure', 'Recovery is a puzzle: measure all the pieces', and 'Optimising capacity: knowing when and how'; theme 3: 'Stroke demands personalised solutions' with two subthemes: 'Condition-specific considerations', and 'Person-specific considerations'; theme 4: 'Upper limb recovery requires complex interventions' with four subthemes: 'Fuelling engagement', 'Content is crucial', 'Multidimensional dose', and 'Therapist sway'.

CONCLUSIONS

This study suggests that post-stroke upper limb motor interventions are the interactions of multiple intervention elements (e.g. dose and content) shaped by different contextual considerations (e.g. stroke and personal factors). Development of such interventions may need to consider both content and context of the intervention to drive optimal recovery.

Motor Learning Following Stroke: Mechanisms of Learning and Techniques to Augment Neuroplasticity

Sensorimotor impairments are common after stroke requiring stroke survivors to relearn lost motor skills or acquire new ones in order to engage in daily activities. Thus, motor skill learning is a cornerstone of stroke rehabilitation. This article provides an overview of motor control and learning theories that inform stroke rehabilitation interventions, discusses principles of neuroplasticity, and provides a summary of practice conditions and techniques that can be used to augment motor learning and neuroplasticity in stroke rehabilitation.

Sensorimotor integration within the primary motor cortex by selective nerve fascicle stimulation

KEY POINTS

Cortical integration of sensory inputs is crucial for dexterous movement. Short-latency somatosensory afferent inhibition of motor cortical output is typically produced by peripheral whole-nerve stimulation. We exploited intraneural multichannel electrodes used to provide sensory feedback for prosthesis control to assess whether and how selective intraneural sensory stimulation affects sensorimotor cortical circuits in humans. The activation of the primary somatosensory cortex (S1) was explored by recording scalp somatosensory evoked potentials. Sensorimotor integration was tested by measuring the inhibitory effect of the afferent stimulation on the output of the primary motor cortex (M1) generated by transcranial magnetic stimulation. We demonstrate in humans that selective intraneural sensory stimulation elicits a measurable activation of S1 and that it inhibits the output of M1 at the same time range of whole-nerve superficial stimulation.

ABSTRACT

The integration of sensory inputs in the motor cortex is crucial for dexterous movement. We recently demonstrated that a closed-loop control based on the feedback provided through intraneural multi-channel electrodes implanted in the median and ulnar nerves of a participant with upper limb amputation improved manipulation skills and increased prosthesis embodiment. Here we assessed, in the same participant, whether and how selective intraneural sensory stimulation also elicits a measurable cortical activation and affects sensorimotor cortical circuits. After estimating the activation of the primary somatosensory cortex evoked by intraneural stimulation, sensorimotor integration was investigated by testing the inhibition of primary motor cortex (M1) output to transcranial magnetic stimulation, after both intraneural and perineural stimulation. Selective sensory intraneural stimulation evoked a low-amplitude, 16 ms-latency, parietal response in the same area of the earliest component evoked by whole-nerve stimulation, compatible with fast-conducting afferent fiber activation. For the first time, we show that the same intraneural stimulation was also capable of decreasing M1 output, at the same time range of the short-latency afferent inhibition effect of whole-nerve superficial stimulation. The inhibition generated by the stimulation of channels activating only sensory fibers was stronger than the one due to intraneural or perineural stimulation of channels activating mixed fibers. We demonstrate in a human subject that the cortical sensorimotor integration inhibiting M1 output previously described after the experimental whole-nerve stimulation is present also with a more ecological selective sensory fiber stimulation. Abstract Figure: Double-sided filament electrodes (ds-FILE), bearing 16 active sites, and perineural Cuff electrodes were implanted in the median and ulnar nerve of the arm in a hand amputee (upper left panel, single nerve represented). Selectivity of stimulation (1), evoked activity in the somatosensory cortex (2), and sensorimotor integration (3) were investigated. TMS: transcranial magnetic stimulation. This article is protected by copyright. All rights reserved.

Effects of walking distance over robot-assisted training on walking ability in chronic stroke patients

An understanding of the dose-response during training is important to identify the rehabilitation programs to obtain the improvement in chronic stroke patients. The purpose of this study was to determine whether distance-dose (distance walked across all sessions) during robot-assisted training affects the change of walking speed and distance in chronic stroke patients after intervention. Fifteen chronic stroke patients were enrolled in this study. The patients performed 8 gait training sessions using the Hybrid Assistive Limb (HAL) for 3 weeks. Gait speed, stride length, cadence, and 2-minute walk test (2MWT) were measured before and post-intervention. Total walking distance (distance walked across all sessions) in individual patients were also measured. Gait speed, stride length, cadence, and 2-minute walk test (2MWT) improved significantly after training. The average of walking distance for 8 sessions in individual patients was 3793.3 ± 2105.3 m. Moreover, the change of gait speed (r = 0.53) and 2MWT (r = 0.70) were positively correlated with the walking distance during 8 sessions. This study of finding demonstrated that greater total distance walked over all sessions of training using the HAL is directly associated with the better walking outcomes in patients with chronic stroke. Further researches with a larger number of patients and a control group are needed to quantify the study results more precisely.

Principles of Neurorehabilitation After Stroke Based on Motor Learning and Brain Plasticity Mechanisms

What are the principles underlying effective neurorehabilitation? The aim of neurorehabilitation is to exploit interventions based on human and animal studies about learning and adaptation, as well as to show that the activation of experience-dependent neuronal plasticity augments functional recovery after stroke. Instead of teaching compensatory strategies that do not reduce impairment but allow the patient to return home as soon as possible, functional recovery might be more sustainable as it ensures a long-term reduction in impairment and an improvement in quality of life. At the same time, neurorehabilitation permits the scientific community to collect valuable data, which allows inferring about the principles of brain organization. Hence neuroscience sheds light on the mechanisms of learning new functions or relearning lost ones. However, current rehabilitation methods lack the exact operationalization of evidence gained from skill learning literature, leading to an urgent need to bridge motor learning theory and present clinical work in order to identify a set of ingredients and practical applications that could guide future interventions. This work aims to unify the neuroscientific literature relevant to the recovery process and rehabilitation practice in order to provide a synthesis of the principles that constitute an effective neurorehabilitation approach. Previous attempts to achieve this goal either focused on a subset of principles or did not link clinical application to the principles of motor learning and recovery. We identified 15 principles of motor learning based on existing literature: massed practice, spaced practice, dosage, task-specific practice, goal-oriented practice, variable practice, increasing difficulty, multisensory stimulation, rhythmic cueing, explicit feedback/knowledge of results, implicit feedback/knowledge of performance, modulate effector selection, action observation/embodied practice, motor imagery, and social interaction. We comment on trials that successfully implemented these principles and report evidence from experiments with healthy individuals as well as clinical work.

A Stroke Recovery Trial Development Framework: Consensus-Based Core Recommendations from the Second Stroke Recovery and Rehabilitation Roundtable

A major goal of the Stroke Recovery and Rehabilitation Roundtable (SRRR) is to accelerate development of effective treatments to enhance stroke recovery beyond that expected to occur spontaneously or with current approaches. In this paper, we describe key issues for the next generation of stroke recovery treatment trials and present the Stroke Recovery and Rehabilitation Roundtable Trials Development Framework (SRRR-TDF). An exemplar (an upper limb recovery trial) is presented to demonstrate the utility of this framework to guide the GO, NO-GO decision-making process in trial development.

A stroke recovery trial development framework: Consensus-based core recommendations from the Second Stroke Recovery and Rehabilitation Roundtable

A major goal of the Stroke Recovery and Rehabilitation Roundtable (SRRR) is to accelerate development of effective treatments to enhance stroke recovery beyond that expected to occur spontaneously or with current approaches. In this paper, we describe key issues for the next generation of stroke recovery treatment trials and present the Stroke Recovery and Rehabilitation Roundtable Trials Development Framework (SRRR-TDF). An exemplar (an upper limb recovery trial) is presented to demonstrate the utility of this framework to guide the GO, NO-GO decision-making process in trial development.

Is Environmental Enrichment Ready for Clinical Application in Human Post-stroke Rehabilitation?

Environmental enrichment (EE) has been widely used as a means to enhance brain plasticity mechanisms (e.g., increased dendritic branching, synaptogenesis, etc.) and improve behavioral function in both normal and brain-damaged animals. In spite of the demonstrated efficacy of EE for enhancing brain plasticity, it has largely remained a laboratory phenomenon with little translation to the clinical setting. Impediments to the implementation of enrichment as an intervention for human stroke rehabilitation and a lack of clinical translation can be attributed to a number of factors not limited to: (i) concerns that EE is actually the "normal state" for animals, whereas standard housing is a form of impoverishment; (ii) difficulty in standardizing EE conditions across clinical sites; (iii) the exact mechanisms underlying the beneficial actions of enrichment are largely correlative in nature; (iv) a lack of knowledge concerning what aspects of enrichment (e.g., exercise, socialization, cognitive stimulation) represent the critical or active ingredients for enhancing brain plasticity; and (v) the required "dose" of enrichment is unknown, since most laboratory studies employ continuous periods of enrichment, a condition that most clinicians view as impractical. In this review article, we summarize preclinical stroke recovery studies that have successfully utilized EE to promote functional recovery and highlight the potential underlying mechanisms. Subsequently, we discuss how EE is being applied in a clinical setting and address differences in preclinical and clinical EE work to date. It is argued that the best way forward is through the careful alignment of preclinical and clinical rehabilitation research. A combination of both approaches will allow research to fully address gaps in knowledge and facilitate the implementation of EE to the clinical setting.

Interventions to Improve Movement and Functional Outcomes in Adult Stroke Rehabilitation: Review and Evidence Summary

Background

Patients who have had a stroke may not be familiar with the terminology nor have the resources to efficiently search for evidence-based rehabilitation therapies to restore movement and functional outcomes. Recognizing that a thorough systematic review on this topic is beyond the scope of this article, we conducted a rapid review evidence summary to determine the level of evidence for common rehabilitation interventions to improve movement/motor and functional outcomes in adults who have had a stroke.

Objective

The objective of this study was to find evidence for common rehabilitation interventions to improve movement/motor and functional outcomes in adults who have had a stroke.

Methods

Medline Complete, PubMed, CINAHL Complete, Cochrane Database, Rehabilitation and Sports Medicine Source, Dissertation Abstracts International, and National Guideline Clearinghouse, from 1996 to April of 2016, were searched. From 348 articles, 173 met the following inclusion criteria: (1) published systematic reviews or meta-analyses, (2) outcomes target functional movement or motor skills of the upper and lower limbs, (3) non-pharmacological interventions that are commonly delivered to post-stroke population (acute and chronic), (4) human studies, and (5) English. Evidence tables were created to analyze the findings of systematic reviews and meta-analyses by category of interventions and outcomes.

Results

This rapid review found that the following interventions possess credible evidence to improve functional movement of persons with stroke: cardiorespiratory training, therapeutic exercise (ie, strengthening), task-oriented training (task-specific training), constraint-induced movement therapy (CIMT), mental practice, and mirror therapy. Neuromuscular electrical stimulation (NMES) (ie, functional electrical stimulation) shows promise as an intervention for stroke survivors.

Conclusions

Most commonly delivered therapeutic interventions to improve motor recovery after a stroke possess moderate quality evidence and are effective. Future research recommendations, such as optimal timing and dosage, would help rehabilitation professionals tailor interventions to achieve the best outcomes for stroke survivors.

Health-related quality of life in stroke patients questionnaire, short version (HRQOLISP-40): validation for its use in Colombia

Background

The health-related quality of life in stroke patients (HRQOLISP-40, short version) survey was developed in Nigeria and constitutes a 40-item, multidimensional, self-administrated questionnaire. We assessed the validity and reliability of the HRQOLISP-40 Spanish version for stroke patients in Colombia.

Methods

The analysis included factor analysis, confirmatory factor analysis, Rasch analysis, convergent validity, internal consistency (261 stroke patients), test-retest reliability (73 patients assessed at two different times) and sensitivity to change (46 patients assessed before and after a rehabilitation intervention).

Results

We found an 8-domain structure. None of the items had a significant impact on the global alpha value in order to be removed. Lin’s concordance correlation coefficient indicated test-retest reliability (Rho IC: 0.76 to 0.95), suggesting an adequate stability of the instrument. Regarding sensitivity to change differences, they were only significant in the psychological and eco-social domains (p <0.05). When comparing SF-36 with HRQOLISP-40, all the correlation coefficients values were significantly different from zero, except those related to vitality. The highest scores were found in the physical and physical functioning domains, with a value of 0.722.

Conclusions

The HRQOLISP-40 scale is valid and reliable for assessing patients’ quality of life after a stroke. Validating quality of life assessment instruments is necessary in order to improve the effectiveness of rehabilitation programs for Colombian stroke patients.

Electronic supplementary material

The online version of this article (doi:10.1186/s12883-016-0770-5) contains supplementary material, which is available to authorized users.

Increasing the amount of usual rehabilitation improves activity after stroke: a systematic review

QUESTIONS

In people receiving rehabilitation aimed at reducing activity limitations of the lower and/or upper limb after stroke, does adding extra rehabilitation (of the same content as the usual rehabilitation) improve activity? What is the amount of extra rehabilitation that needs to be provided to achieve a beneficial effect?

DESIGN

Systematic review with meta-analysis of randomised trials.

PARTICIPANTS

Adults aged 18 years or older that had a diagnosis of stroke.

INTERVENTION

Extra rehabilitation with the same content as usual rehabilitation aimed at reducing activity limitations of the lower and/or upper limb.

OUTCOME MEASURES

Activity measured as lower or upper limb ability.

RESULTS

A total of 14 studies, comprising 15 comparisons, met the inclusion criteria. Pooling data from all the included studies showed that extra rehabilitation improved activity immediately after the intervention period (SMD=0.39, 95% CI 0.07 to 0.71, I(2)=66%). When only studies with a large increase in rehabilitation (> 100%) were included, the effect was greater (SMD 0.59, 95% CI 0.23 to 0.94, I(2)=44%). There was a trend towards a positive relationship (r=0.53, p=0.09) between extra rehabilitation and improved activity. The turning point on the ROC curve of false versus true benefit (AUC=0.88, p=0.04) indicated that at least an extra 240% of rehabilitation was needed for significant likelihood that extra rehabilitation would improve activity.

CONCLUSION

Increasing the amount of usual rehabilitation aimed at reducing activity limitations improves activity in people after stroke. The amount of extra rehabilitation that needs to be provided to achieve a beneficial effect is large.

TRIAL REGISTRATION

PROSPERO CRD42012003221. [Schneider EJ, Lannin NA, Ada L, Schmidt J (2016) Increasing the amount of usual rehabilitation improves activity after stroke: a systematic review.Journal of Physiotherapy62: 182-187].

Effect of Trunk Support on Upper Extremity Function in People With Chronic Stroke and People Who Are Healthy

BACKGROUND

Trunk control is thought to contribute to upper extremity (UE) function. However, this common assumption in neurorehabilitation has not been validated in clinical trials.

OBJECTIVE

The study objectives were to investigate the effect of providing external trunk support on trunk control and UE function and to examine the relationship between trunk control and UE function in people with chronic stroke and people who were healthy.

DESIGN

A cross-sectional study was conducted.

METHODS

Twenty-five people with chronic stroke and 34 people who were healthy and matched for age and sex were recruited. Trunk control was assessed with the Trunk Impairment Scale (TIS), and UE impairment and UE function were assessed with the UE subsection of the Fugl-Meyer Assessment (FMA-UE) and the Streamlined Wolf Motor Function Test (SWMFT), respectively. The TIS and SWMFT were evaluated, with and without external trunk support; the FMA-UE was evaluated without trunk support.

RESULTS

With trunk support, people with stroke showed improvement from 18 to 20 points on the TIS, a reduction in SWMFT performance times from 37.20 seconds to 35.37 seconds for the affected UE, and improvement from 3.3 points to 3.4 points on the SWMFT Functional Ability Scale for the function of the affected UE. With trunk support, the SWMFT performance time for people who were healthy was reduced from 1.61 seconds to 1.48 seconds for the dominant UE and from 1.71 seconds to 1.59 seconds for the nondominant UE. A significant moderate correlation was found between the TIS and the FMA-UE (r=.53) for people with stroke.

LIMITATIONS

The limitations included a nonmasked assessor and a standardized height of the external trunk support.

CONCLUSIONS

External trunk support improved trunk control in people with chronic stroke and had a statistically significant effect on UE function in both people with chronic stroke and people who were healthy. The findings suggest an association between trunk control and the UE when external trunk support was provided and support the hypothesis that lower trunk and lumbar stabilization provided by external support enables an improvement in the ability to use the UE for functional activities.

Proprioceptive rehabilitation of upper limb dysfunction in movement disorders: a clinical perspective

Movement disorders (MDs) are frequently associated with sensory abnormalities. In particular, proprioceptive deficits have been largely documented in both hypokinetic (Parkinson’s disease) and hyperkinetic conditions (dystonia), suggesting a possible role in their pathophysiology. Proprioceptive feedback is a fundamental component of sensorimotor integration allowing effective planning and execution of voluntary movements. Rehabilitation has become an essential element in the management of patients with MDs, and there is a strong rationale to include proprioceptive training in rehabilitation protocols focused on mobility problems of the upper limbs. Proprioceptive training is aimed at improving the integration of proprioceptive signals using “task-intrinsic” or “augmented feedback.” This perspective article reviews the available evidence on the effects of proprioceptive stimulation in improving upper limb mobility in patients with MDs and highlights the emerging innovative approaches targeted to maximizing the benefits of exercise by means of enhanced proprioception.