Interventions for improving upper limb function after stroke

Background: Improving upper limb function is a core element of stroke rehabilitation needed to maximise patient outcomes and reduce disability. Evidence about effects of individual treatment techniques and modalities is synthesised within many reviews. For selection of effective rehabilitation treatment, the relative effectiveness of interventions must be known. However, a comprehensive overview of systematic reviews in this area is currently lacking. Objectives: To carry out a Cochrane overview by synthesising systematic reviews of interventions provided to improve upper limb function after stroke. Methods: Search methods: We comprehensively searched the Cochrane Database of Systematic Reviews; the Database of Reviews of Effects; and PROSPERO (an international prospective register of systematic reviews) (June 2013). We also contacted review authors in an effort to identify further relevant reviews. Selection criteria: We included Cochrane and non‐Cochrane reviews of randomised controlled trials (RCTs) of patients with stroke comparing upper limb interventions with no treatment, usual care or alternative treatments. Our primary outcome of interest was upper limb function; secondary outcomes included motor impairment and performance of activities of daily living. When we identified overlapping reviews, we systematically identified the most up‐to‐date and comprehensive review and excluded reviews that overlapped with this. Data collection and analysis: Two overview authors independently applied the selection criteria, excluding reviews that were superseded by more up‐to‐date reviews including the same (or similar) studies. Two overview authors independently assessed the methodological quality of reviews (using a modified version of the AMSTAR tool) and extracted data. Quality of evidence within each comparison in each review was determined using objective criteria (based on numbers of participants, risk of bias, heterogeneity and review quality) to apply GRADE (Grades of Recommendation, Assessment, Development and Evaluation) levels of evidence. We resolved disagreements through discussion. We systematically tabulated the effects of interventions and used quality of evidence to determine implications for clinical practice and to make recommendations for future research. Main results: Our searches identified 1840 records, from which we included 40 completed reviews (19 Cochrane; 21 non‐Cochrane), covering 18 individual interventions and dose and setting of interventions. The 40 reviews contain 503 studies (18,078 participants). We extracted pooled data from 31 reviews related to 127 comparisons. We judged the quality of evidence to be high for 1/127 comparisons (transcranial direct current stimulation (tDCS) demonstrating no benefit for outcomes of activities of daily living (ADLs)); moderate for 49/127 comparisons (covering seven individual interventions) and low or very low for 77/127 comparisons. Moderate‐quality evidence showed a beneficial effect of constraint‐induced movement therapy (CIMT), mental practice, mirror therapy, interventions for sensory impairment, virtual reality and a relatively high dose of repetitive task practice, suggesting that these may be effective interventions; moderate‐quality evidence also indicated that unilateral arm training may be more effective than bilateral arm training. Information was insufficient to reveal the relative effectiveness of different interventions. Moderate‐quality evidence from subgroup analyses comparing greater and lesser doses of mental practice, repetitive task training and virtual reality demonstrates a beneficial effect for the group given the greater dose, although not for the group given the smaller dose; however tests for subgroup differences do not suggest a statistically significant difference between these groups. Future research related to dose is essential. Specific recommendations for future research are derived from current evidence. These recommendations include but are not limited to adequately powered, high‐quality RCTs to confirm the benefit of CIMT, mental practice, mirror therapy, virtual reality and a relatively high dose of repetitive task practice; high‐quality RCTs to explore the effects of repetitive transcranial magnetic stimulation (rTMS), tDCS, hands‐on therapy, music therapy, pharmacological interventions and interventions for sensory impairment; and up‐to‐date reviews related to biofeedback, Bobath therapy, electrical stimulation, reach‐to‐grasp exercise, repetitive task training, strength training and stretching and positioning. Authors' conclusions: Large numbers of overlapping reviews related to interventions to improve upper limb function following stroke have been identified, and this overview serves to signpost clinicians and policy makers toward relevant systematic reviews to support clinical decisions, providing one accessible, comprehensive document, which should support clinicians and policy makers in clinical decision making for stroke rehabilitation. Currently, no high‐quality evidence can be found for any interventions that are currently used as part of routine practice, and evidence is insufficient to enable comparison of the relative effectiveness of interventions. Effective collaboration is urgently needed to support large, robust RCTs of interventions currently used routinely within clinical practice. Evidence related to dose of interventions is particularly needed, as this information has widespread clinical and research implications

Home-based therapy programmes for upper limb functional recovery following stroke

Background: With an increased focus on home-based stroke services and the undertaking of programmes, targeted at upper limb recovery within clinical practice, a systematic review of home-based therapy programmes for individuals with upper limb impairment following stroke was required. Objectives: To determine the effects of home-based therapy programmes for upper limb recovery in patients with upper limb impairment following stroke. Search methods: We searched the Cochrane Stroke Group's Specialised Trials Register (May 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 2), MEDLINE (1950 to May 2011), EMBASE (1980 to May 2011), AMED (1985 to May 2011) and six additional databases. We also searched reference lists and trials registers. Selection criteria: Randomised controlled trials (RCTs) in adults after stroke, where the intervention was a home-based therapy programme targeted at the upper limb, compared with placebo, or no intervention or usual care. Primary outcomes were performance in activities of daily living (ADL) and functional movement of the upper limb. Secondary outcomes were performance in extended ADL and motor impairment of the arm. Data collection and analysis: Two review authors independently screened abstracts, extracted data and appraised trials. We undertook assessment of risk of bias in terms of method of randomisation and allocation concealment (selection bias), blinding of outcome assessment (detection bias), whether all the randomised patients were accounted for in the analysis (attrition bias) and the presence of selective outcome reporting. Main results: We included four studies with 166 participants. No studies compared the effects of home-based upper limb therapy programmes with placebo or no intervention. Three studies compared the effects of home-based upper limb therapy programmes with usual care. Primary outcomes: we found no statistically significant result for performance of ADL (mean difference (MD) 2.85; 95% confidence interval (CI) -1.43 to 7.14) or functional movement of the upper limb (MD 2.25; 95% CI -0.24 to 4.73)). Secondary outcomes: no statistically significant results for extended ADL (MD 0.83; 95% CI -0.51 to 2.17)) or upper limb motor impairment (MD 1.46; 95% CI -0.58 to 3.51). One study compared the effects of a home-based upper limb programme with the same upper limb programme based in hospital, measuring upper limb motor impairment only; we found no statistically significant difference between groups (MD 0.60; 95% CI -8.94 to 10.14). Authors' conclusions: There is insufficient good quality evidence to make recommendations about the relative effect of home-based therapy programmes compared with placebo, no intervention or usual care

Poststroke Fatigue: Who Is at Risk for an Increase in Fatigue?

Background. Several studies have examined determinants related to post-stroke fatigue. However, it is unclear which determinants can predict an increase in poststroke fatigue over time. Aim. This prospective cohort study aimed to identify determinants which predict an increase in post-stroke fatigue. Methods. A total of 250 patients with stroke were examined at inpatient rehabilitation discharge (T0) and 24 weeks later (T1). Fatigue was measured using the Fatigue Severity Scale (FSS). An increase in post-stroke fatigue was defined as an increase in the FSS score beyond the 95% limits of the standard error of measurement of the FSS (i.e., 1.41 points) between T0 and T1. Candidate determinants included personal factors, stroke characteristics, physical, cognitive, and emotional functions, and activities and participation and were assessed at T0. Factors predicting an increase in fatigue were identified using forward multivariate logistic regression analysis. Results. The only independent predictor of an increase in post-stroke fatigue was FSS (OR 0.50; 0.38–0.64, P < 0.001). The model including FSS at baseline correctly predicted 7.9% of the patients who showed increased fatigue at T1. Conclusion. The prognostic model to predict an increase in fatigue after stroke has limited predictive value, but baseline fatigue is the most important independent predictor. Overall, fatigue levels remained stable over time

Characterization of upper limbs movements of healthy and poststroke adults.

Introdução: O comprometimento motor do membro superior afeta muitos sobreviventes pós-AVC em todo o mundo e a sua recuperação é lenta e complexa. A evidência de comprometimento bilateral após AVC está a crescer, levando à necessidade de desenvolver uma referência saudável para a qualidade do desempenho motor, em vez dos dados do membro superior ipsilesional. Objetivos: Caracterizar o movimento dos membros superiores de adultos saudáveis e pós-AVC, através da análise cinemática, durante o desempenho das tarefas "beber" e "acender a luz". Métodos: 63 adultos saudáveis e 5 pacientes pós-AVC foram elegíveis para desempenhar as tarefas "beber" e "acender a luz" com os dois membros superiores. Os pacientes pós-AVC foram avaliados no início da fase sub-aguda e no início da fase crónica. Os movimentos das tarefas foram captados por um sistema de captura de movimento 3D, variáveis cinemáticas da mão e articulares foram analisadas e foram feitas comparações entre tarefas e entre adultos saudáveis e pós-AVC. Resultados: A tarefa beber teve cinco fases com diferentes habilidades motoras e estratégias cinemáticas que foram influenciadas principalmente pela idade e pelo sexo. Acender a luz tem menor exigência manual, quando comparada com o beber. Os formatos diferentes dos alvos e a interação diferente parecem ser responsáveis por diferenças nas estratégias cinemáticas entre as duas tarefas executadas pelos adultos saudáveis. Foram encontradas diferenças entre as estratégias cinemáticas usadas pelos adultos pós-AVC e as usadas pelos adultos saudáveis. Todos os pacientes pós-AVC apresentaram alterações cinemáticas bilaterais em ambas as tarefas. Conclusão: Foi feita uma análise abrangente das estratégias cinemáticas das tarefas beber e acender a luz, de modo a obter uma referência do desempenho de atividades da vida diária com diferentes exigências de manualidade para adultos pós-AVC. Todos os pacientes estudados apresentaram alterações cinemáticas bilaterais, o que suporta a implementação de uma avaliação bilateral e a necessidade de ter uma referência saudável para a qualidade do desempenho motor. A severidade inicial do AVC e a idade dos pacientes parecem ter sido as informações mais importantes para explicar a extensão das alterações cinemáticas, mas a localização do AVC parece ter condicionado a especificidade dos défices, bem como a recuperação.PALAVRAS-CHAVE: ACIDENTE VASCULAR CEREBRAL; MEMBROS SUPERIORES; RECUPERAÇÃO MOTORA; AVALIAÇÃO DA QUALIDADE DA PERFORMANCE MOTORA; ANÁLISE CINEMÁTICA.Introduction: Upper limb (UL) motor impairment affects numerous poststroke survivors worldwide and its recovery is slow and complex. Evidence of bilateral impairment after stroke is growing, which creates the need to have a healthy reference for the quality of motor performance instead of ipsilesional UL data. Currently, kinematic analysis is considered one of the best ways to improve the understanding about the mechanisms that drive motor recovery, but a set of methodological flaws is hampering this knowledge. Aims: To characterize the ULs movement of healthy and poststroke adults, through kinematic analysis, during the performance of drinking and turning on the light tasks. Methods: 63 healthy adults and 5 poststroke patients were eligible to perform drinking and turning on the light tasks with both ULs. Poststroke patients were assessed in early sub-acute phase and in the beginning of chronic phase. Tasks movements were captured by a 3D motion capture system, end-point and joint kinematics were analysed and comparisons between tasks and healthy and poststroke adults were made. Results: Drinking task has five phases with different motor skills and kinematic strategies that were mainly influenced by age and sex. Turning on the light has a lower handling requirement, when compared to drinking. The different target formats and the different interaction with them seemed to be responsible for differences in kinematic strategies between both tasks performed by healthy adults. Differences were found between the kinematic strategies used by poststroke adults and those of healthy adults. All poststroke patients presented bilateral kinematic alterations in both tasks. Conclusion: A comprehensive analysis of kinematic strategies of drinking and turning on the light were made, in order to obtain a reference of the performance of activities of daily living with different handling requirement for poststroke adults. All studied patients showed bilateral kinematic alterations, which supports the implementation of a bilateral assessment and the need to have a healthy reference for the quality of motor performance. Initial severity of stroke and patients' age appear to have been the most important information to explain the extent of kinematic alterations, but stroke location seemed to have conditioned the specificity of deficits as well as the recovery

Hand Open Exercises as a Hand Rehabilitation on Poststroke Muscle Strength by Modified Sphygmomanometer Test

Stroke is a disease that affects of arteries leading to and within the brain. Poststroke patients have may experiences like a loss of motor function and may cause impaired mobility. Hand open exercises could increasing the strengthening muscles and the recovery of hand function is one of the most challenging topics in stroke rehabilitation. This research aims to determine the effectiveness of Hand Open exercises on muscle strength by modified sphygmomanometer test (MST) as a measurement method. This research design used quasi experimental design. Number of samples 90 respondents with sampling technique used purposive sampling. Most respondent of this study has age (55-65 years) that 38.9% and female is 56.7%. Different paired test results showed a significant increase in muscle strength before and after intervention p=0.000 (<0,05). The result of independent different test have a significant increase in muscle strength between the hand open intervention group and the control group with p=0,000 (<0,05). Hand open intervention gives an effect to increasing of muscle strength by modified sphygmomanometer test (MST) method as many 45,1%. It means that hand open can be increased muscle strength of poststroke patients and this research recommends for further research as nursing self-care interventions in nursing care

Influence of motor imagery training on gait rehabilitation in sub-acute stroke: a randomized controlled trial

Objective: To evaluate the effect of mental practice on motor imagery ability and assess the influence of motor imagery on gait rehabilitation in sub-acute stroke. Design: Randomized controlled trial. Subjects: A total of 44 patients with gait dysfunction after first-ever stroke were randomly allocated to a motor imagery training group and a muscle relaxation group. Methods: The motor imagery group received 6 weeks of daily mental practice. The relaxation group received a muscle relaxation programme of equal duration. Motor imagery ability and lower limb function were assessed at baseline and after 6 weeks of treatment. Motor imagery ability was tested using a questionnaire and mental chronometry test. Gait outcome was evaluated using a 10-m walk test (near transfer) and the Fugl-Meyer assessment (far transfer). Results: Significant between-group differences were found, with the vividness of kinesthetic imagery and the walking test results improving more in the motor imagery group than in the muscle relaxation group. There was no group interaction effect for the far transfer outcome score. Conclusion: Motor imagery training may have a beneficial task-specific effect on gait function in sub-acute stroke; however, longer term confirmation is required

The Effectiveness of Lower-Limb Wearable Technology for Improving Activity and Participation in Adult Stroke Survivors: A Systematic Review

Background: With advances in technology, the adoption of wearable devices has become a viable adjunct in poststroke rehabilitation. Regaining ambulation is a top priority for an increasing number of stroke survivors. However, despite an increase in research exploring these devices for lower limb rehabilitation, little is known of the effectiveness. Objective: This review aims to assess the effectiveness of lower limb wearable technology for improving activity and participation in adult stroke survivors. Methods: Randomized controlled trials (RCTs) of lower limb wearable technology for poststroke rehabilitation were included. Primary outcome measures were validated measures of activity and participation as defined by the International Classification of Functioning, Disability and Health. Databases searched were MEDLINE, Web of Science (Core collection), CINAHL, and the Cochrane Library. The Cochrane Risk of Bias Tool was used to assess the methodological quality of the RCTs. Results: In the review, we included 11 RCTs with collectively 550 participants at baseline and 474 participants at final follow-up including control groups and participants post stroke. Participants' stroke type and severity varied. Only one study found significant between-group differences for systems functioning and activity. Across the included RCTs, the lowest number of participants was 12 and the highest was 151 with a mean of 49 participants. The lowest number of participants to drop out of an RCT was zero in two of the studies and 19 in one study. Significant between-group differences were found across three of the 11 included trials. Out of the activity and participation measures alone, P values ranged from P=.87 to P≤.001. Conclusions: This review has highlighted a number of reasons for insignificant findings in this area including low sample sizes, appropriateness of the RCT methodology for complex interventions, a lack of appropriate analysis of outcome data, and participant stroke severity

The Effect of Dry Needling on Lower Limb Dysfunction in Poststroke Survivors

Background: Spasticity is one of the main complications in poststroke survivors leading to difficulties in walking and standing resulting in high levels of disability. Objective: The aim of the study was to investigate the effects of deep dry needling on lower limb dysfunction in poststroke spastic patients. Methods: A randomized clinical trial conducted in poststroke survivors who were assigned to one of 2 groups: Deep dry needling (intervention group) and sham dry needling (control group). The primary outcome measures were Modified Modified Ashworth Scale (MMAS) and functional tests (timed up and go test, 10-meter walk test). Secondary outcome measures were active ankle dorsiflexion range of motion (AROM), passive ankle dorsiflexion range of motion (PROM), single leg stance test, and Barthel index. All measurements were assessed at baseline (T0), immediately after the third session 1 week later (T1), and 1 month after the end of the intervention (T2). Results: We recruited 24 patients (71% male; mean age 57 ± 10 years; 26.4 ± 1.8 kg•m−2; time since event: 25.2 ± 12.5 months). There were significant improvements in MMAS, timed up and go test, 10-meter walk test, Barthel scale, and PROM (P . 05). Conclusions: Deep dry needling decreases muscle spasticity and improves lower limb function and gait speed in poststroke survivors

Evidence for early physiotherapy after acute stroke: a scoping review

Neuroscience evidence indicates that early rehabilitation can guarantee better outcomes and quicker cortical re-organization after lesion. Although there are some studies related to the acute stroke physiotherapy intervention, it seems that few consider the evidence that link neuroplasticity and neurorehabilitation. Therefore, understanding the current state of the art of physiotherapy intervention is vital to potentialize the intervention so the enhance neuroplastic window is properly explored. To analyze the physiotherapy's intervention on acute stroke patients, so it reveals the underlined evidence for the selection of the approach and if the neurophysiological mechanisms are associated. This scoping review's methodology follows the Joanna Briggs Institue. A main search was conducted across Pubmed, PEdro and Web of science in December 2020, including only studies in Portuguese or English. Studies included focused on the concept of physiotherapy's intervention in a population of adult acute stroke patients, in an acute care context. Were identified 14 categories of interventions in 37 studies. 62% of studies didn't give any justification for the choic of method and the ones who did, weren't focused on neurophysiological knowledge. A wide range of interventions was found in which only 38% showed justifications that were considered insufficient and imprecise

Low-Cost Wearable Data Acquisition for Stroke Rehabilitation: A Proof-of-Concept Study on Accelerometry for Functional Task Assessment

Background: An increasingly aging society and consequently rising number of patients with poststroke-related neurological dysfunctions are forcing the rehabilitation field to adapt to ever-growing demands. Although clinical reasoning within rehabilitation is dependent on patient movement performance analysis, current strategies for monitoring rehabilitation progress are based on subjective time-consuming assessment scales, not often applied. Therefore, a need exists for efficient nonsubjective monitoring methods. Wearable monitoring devices are rapidly becoming a recognized option in rehabilitation for quantitative measures. Developments in sensors, embedded technology, and smart textile are driving rehabilitation to adopt an objective, seamless, efficient, and cost-effective delivery system. This study aims to assist physiotherapists’ clinical reasoning process through the incorporation of accelerometers as part of an electronic data acquisition system. Methods: A simple, low-cost, wearable device for poststroke rehabilitation progress monitoring was developed based on commercially available inertial sensors. Accelerometry data acquisition was performed for 4 first-time poststroke patients during a reach-press-return task. Results: Preliminary studies revealed acceleration profiles of stroke patients through which it is possible to quantitatively assess the functional movement, identify compensatory strategies, and help define proper movement. Conclusion: An inertial data acquisition system was designed and developed as a low-cost option for monitoring rehabilitation. The device seeks to ease the data-gathering process by physiotherapists to complement current practices with accelerometry profiles and aid the development of quantifiable methodologies and protocols.info:eu-repo/semantics/publishedVersio