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collection and analysis: Two overview authors independently applied the selection criteria, excluding reviews that were superseded by more up-to-date reviews including the same (or similar) studies.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.

Interventions for improving upper limb function after stroke

Background
Electromechanical and robot-assisted arm training devices are used in rehabilitation, and may help to improve arm function after stroke.

Objectives
To assess the effectiveness of electromechanical and robot-assisted arm training for improving activities of daily living, arm function, and arm muscle strength in people after stroke. We also assessed the acceptability and safety of the therapy.

Search methods
We searched the Cochrane Stroke Group's Trials Register (last searched February 2015), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library 2015, Issue 3), MEDLINE (1950 to March 2015), EMBASE (1980 to March 2015), CINAHL (1982 to March 2015), AMED (1985 to March 2015), SPORTDiscus (1949 to March 2015), PEDro (searched April 2015), Compendex (1972 to March 2015), and Inspec (1969 to March 2015). We also handsearched relevant conference proceedings, searched trials and research registers, checked reference lists, and contacted trialists, experts, and researchers in our field, as well as manufacturers of commercial devices.

Selection criteria
Randomised controlled trials comparing electromechanical and robot-assisted arm training for recovery of arm function with other rehabilitation or placebo interventions, or no treatment, for people after stroke.

Data collection and analysis
Two review authors independently selected trials for inclusion, assessed trial quality and risk of bias, and extracted data. We contacted trialists for additional information. We analysed the results as standardised mean differences (SMDs) for continuous variables and risk differences (RDs) for dichotomous variables.

Main results
We included 34 trials (involving 1160 participants) in this update of our review. Electromechanical and robot-assisted arm training improved activities of daily living scores (SMD 0.37, 95% confidence interval (CI) 0.11 to 0.64, P = 0.005, I² = 62%), arm function (SMD 0.35, 95% CI 0.18 to 0.51, P < 0.0001, I² = 36%), and arm muscle strength (SMD 0.36, 95% CI 0.01 to 0.70, P = 0.04, I² = 72%), but the quality of the evidence was low to very low. Electromechanical and robot-assisted arm training did not increase the risk of participant drop-out (RD 0.00, 95% CI -0.02 to 0.03, P = 0.84, I² = 0%) with moderate-quality evidence, and adverse events were rare.

Authors' conclusions
People who receive electromechanical and robot-assisted arm and hand training after stroke might improve their activities of daily living, arm and hand function, and arm and hand muscle strength. However, the results must be interpreted with caution because the quality of the evidence was low to very low, and there were variations between the trials in the intensity, duration, and amount of training; type of treatment; and participant characteristics.

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Electromechanical and robot‐assisted arm training for improving activities of daily living, arm function, and arm muscle strength after stroke

The study of stroke and its treatment in human subjects requires accurate measurement of behavioral status. Arm motor deficits are among the most common sequelae after stroke. The Action Research Arm Test (ARAT) is a reliable, valid measure of arm motor status after stroke. This test has established value for characterizing clinical state and for measuring spontaneous and therapy-induced recovery; however, sufficient details have not been previously published to allow for performance of this scale in a standardized manner over time and across sites. Such an approach to ARAT scoring would likely reduce variance between investigators and sites. This report therefore includes a manual that provides a highly detailed and standardized approach for assigning ARAT scores. Intrarater reliability and interrater reliability, as well as validity, with this approach were measured and are excellent. The ARAT, when performed in a standardized manner, is a useful tool for assessment of arm motor deficits after stroke.

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A standardized approach to performing the action research arm test.

Background and Purpose— Mental practice (MP) of a particular motor skill has repeatedly been shown to activate the same musculature and neural areas as physical practice of the skill. Pilot study results suggest that a rehabilitation program incorporating MP of valued motor skills in chronic stroke patients provides sufficient repetitive practice to increase affected arm use and function. This Phase 2 study compared efficacy of a rehabilitation program incorporating MP of specific arm movements to a placebo condition using randomized controlled methods and an appropriate sample size.

Method— Thirty-two chronic stroke patients (mean=3.6 years) with moderate motor deficits received 30-minute therapy sessions occurring 2 days/week for 6 weeks, and emphasizing activities of daily living. Subjects randomly assigned to the experimental condition also received 30-minute MP sessions provided directly after therapy requiring daily MP of the activities of daily living; subjects assigned to the control group received the same amount of therapist interaction as the experimental group, and a sham intervention directly after therapy, consisting of relaxation. Outcomes were evaluated by a blinded rater using the Action Research Arm test and the upper extremity section of the Fugl-Meyer Assessment.

Results— No pre-existing group differences were found on any demographic variable or movement scale. Subjects receiving MP showed significant reductions in affected arm impairment and significant increases in daily arm function (both at the P <0.0001 level). Only patients in the group receiving MP exhibited new ability to perform valued activities.

Conclusions— The results support the efficacy of programs incorporating mental practice for rehabilitating affected arm motor function in patients with chronic stroke. These changes are clinically significant.

Mental Practice in Chronic Stroke: Results of a Randomized, Placebo-Controlled Trial

Conventional neurorehabilitation appears to have little impact on impairment over and above that of spontaneous biological recovery Robotic neurorehabilitation has the potential for a greater impact on impairment due to easy deployment, its applicability across of a wide range of motor impairment, its high measurement reliability, and the capacity to deliver high dosage and high intensity training protocols We first describe current knowledge of the natural history of arm recovery after stroke and of outcome prediction in individual patients Rehabilitation strategies and outcome measures for impairment versus function are compared The topics of dosage, intensity, and time of rehabilitation are then discussed Robots are particularly suitable for both rigorous testing and application of motor learning principles to neurorehabilitation Computational motor control and learning principles derived from studies in healthy subjects are introduced in the context of robotic neurorehabilitation Particular attention is paid to the idea of context, task generalization and training schedule The assumptions that underlie the choice of both movement trajectory programmed into the robot and the degree of active participation required by subjects are examined We consider rehabilitation as a general learning problem, and examine it from the perspective of theoretical learning frameworks such as supervised and unsupervised learning We discuss the limitations of current robotic neurorehabilitation paradigms and suggest new research directions from the perspective of computational motor learning

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Robotic neurorehabilitation: a computational motor learning perspective

Objectives: To establish: (1) inter-rater and test–retest reliability of standardized guidelines for the Fugl-Meyer upper limb section, Action Research Arm Test and Box and Block Test in patients with paresis secondary to stroke, multiple sclerosis or traumatic brain injury and (2) correlation between these arm motor scales and more general measures of impairment and activity limitationDesign: Multicentre cohort studySetting: Three European referral centres for neurorehabilitationSubjects: Thirty-seven stroke, 14 multiple sclerosis and five traumatic brain injury patientsMain measures: Scores of the Fugl-Meyer Test (arm section), Action Research Arm Test, and Box and Block Test derived from video informationResults: All three motor tests showed very high inter-rater and test–retest reliability (ICC and rho for main variables>095) Correlation between the motor scales was very high (rho>092) Motor scales correlated moderately highly with the Hemispheric Stroke Scale, a measure of impairment (rho=0

Reliability and validity of arm function assessment with standardized guidelines for the Fugl-Meyer Test, Action Research Arm Test and Box and Block Test: a multicentre study

Paolo di Bella

Papers

Reliability and validity of arm function assessment with standardized guidelines for the Fugl-Meyer Test, Action Research Arm Test and Box and Block Test: a multicentre study