Loss of functional movement is a common consequence of stroke for which a wide range of interventions has been developed. In this Review, we aimed to provide an overview of the available evidence on interventions for motor recovery after stroke through the evaluation of systematic reviews, supplemented by recent randomised controlled trials. Most trials were small and had some design limitations. Improvements in recovery of arm function were seen for constraint-induced movement therapy, electromyographic biofeedback, mental practice with motor imagery, and robotics. Improvements in transfer ability or balance were seen with repetitive task training, biofeedback, and training with a moving platform. Physical fitness training, high-intensity therapy (usually physiotherapy), and repetitive task training improved walking speed. Although the existing evidence is limited by poor trial designs, some treatments do show promise for improving motor recovery, particularly those that have focused on high-intensity and repetitive task-specific practice.

https://www.thelancet.com/pdfs/journals/laneur/PIIS1474-4422(09)70150-4.pdf

Motor recovery after stroke: a systematic review

Background
Physical therapy (PT) is one of the key disciplines in interdisciplinary stroke rehabilitation. The aim of this systematic review was to provide an update of the evidence for stroke rehabilitation interventions in the domain of PT.

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What is the evidence for physical therapy poststroke? A systematic review and meta-analysis.

Summary Background Hemiplegia and hemiparesis are the most common deficits caused by stroke. A few small clinical trials suggest that fluoxetine enhances motor recovery but its clinical efficacy is unknown. We therefore aimed to investigate whether fluoxetine would enhance motor recovery if given soon after an ischaemic stroke to patients who have motor deficits. Methods In this double-blind, placebo-controlled trial, patients from nine stroke centres in France who had ischaemic stroke and hemiplegia or hemiparesis, had Fugl-Meyer motor scale (FMMS) scores of 55 or less, and were aged between 18 years and 85 years were eligible for inclusion. Patients were randomly assigned, using a computer random-number generator, in a 1:1 ratio to fluoxetine (20 mg once per day, orally) or placebo for 3 months starting 5–10 days after the onset of stroke. All patients had physiotherapy. The primary outcome measure was the change on the FMMS between day 0 and day 90 after the start of the study drug. Participants, carers, and physicians assessing the outcome were masked to group assignment. Analysis was of all patients for whom data were available (full analysis set). This trial is registered with ClinicalTrials.gov, number NCT00657163. Findings 118 patients were randomly assigned to fluoxetine (n=59) or placebo (n=59), and 113 were included in the analysis (57 in the fluoxetine group and 56 in the placebo group). Two patients died before day 90 and three withdrew from the study. FMMS improvement at day 90 was significantly greater in the fluoxetine group (adjusted mean 34·0 points [95% CI 29·7–38·4]) than in the placebo group (24·3 points [19·9–28·7]; p=0·003). The main adverse events in the fluoxetine and placebo groups were hyponatraemia (two [4%] vs two [4%]), transient digestive disorders including nausea, diarrhoea, and abdominal pain (14 [25%] vs six [11%]), hepatic enzyme disorders (five [9%] vs ten [18%]), psychiatric disorders (three [5%] vs four [7%]), insomnia (19 [33%] vs 20 [36%]), and partial seizure (one [ vs 0). Interpretation In patients with ischaemic stroke and moderate to severe motor deficit, the early prescription of fluoxetine with physiotherapy enhanced motor recovery after 3 months. Modulation of spontaneous brain plasticity by drugs is a promising pathway for treatment of patients with ischaemic stroke and moderate to severe motor deficit. Funding Public French National Programme for Clinical Research.

https://www.thelancet.com/pdfs/journals/laneur/PIIS1474-4422(10)70314-8.pdf

Fluoxetine for motor recovery after acute ischaemic stroke (FLAME): a randomised placebo-controlled trial

Stroke patients have impaired physical fitness and this may exacerbate their disability. It is not known whether improving physical fitness after stroke reduces disability. Objectives The primary aims were to establish whether physical fitness training reduces death, dependence and disability after stroke. The secondary aims included an investigation of the effects of fitness training on secondary outcome measures (including, physical fitness, mobility, physical function, health and quality of life, mood and the incidence of adverse events). Randomised controlled trials were included when an intervention represented a clear attempt to improve either muscle strength and/or cardiorespiratory fitness, and whose control groups comprised either usual care or a non-exercise intervention. A total of 12 trials were included in the review. No trials reported death and dependence data. Two small trials reporting disability showed no evidence of benefit. The remaining available secondary outcome data suggest that cardiorespiratory training improves walking ability (mobility). Observed benefits appear to be associated with specific or 'task-related' training.

/pdf/physical-fitness-training-for-stroke-patients-29s61ki4l4.pdf

Physical fitness training for stroke patients

Longitudinal studies show that almost all stroke patients experience at least some predictable degree of functional recovery in the first six months post stroke. However, the non-linear pattern as a function of time is not well understood. Several mechanisms are presumed to be involved, such as recovery of penumbral tissues, neural plasticity, resolution of diaschisis and behavioural compensation strategies. Rehabilitation is believed to modulate this logistic pattern of recovery, probably by interacting with these underlying processes. However, prediction models that are adjusted for the effects of time after stroke onset suggest that outcome is largely defined within the first weeks post stroke, although functional improvement has been found to extend beyond six months post stroke. In addition, kinematic studies show that functional improvement is more than recovery from impairments alone, suggesting that patients are able to improve in terms of gait or dexterity deficits using behavioural compensation strategies. Therefore, understanding the impact of task-dependent cortical activation patterns in non-invasive methods requires not only information derived from longitudinal studies pertaining to functional outcomes, but also a better understanding of what is kinematically learned during the acquisition of new skills.

Understanding the pattern of functional recovery after stroke: facts and theories.

Objective: To study the effects of augmented exercise therapy time for arm rehabilitation as either Bobath therapy or the impairment-oriented training (Arm BASIS training) in stroke patients with arm severe paresis.Design: Single blind, multicentre randomized control trial.Setting: Three inpatient neurorehabilitation centres.Subjects: Sixty-two anterior circulation ischaemic stroke patients.Interventions: Random assignment to three group: (A) no augmented exercise therapy time, (B) augmented exercise therapy time as Bobath therapy and (C) augmented exercise therapy time as Arm BASIS training.Main measures: Main outcome measure: Fugl-Meyer arm motor score. Secondary measure: Action Research Arm Test (ARA). Ancillary measures: Fugl-Meyer arm sensation and joint motion/pain scores and the Ashworth Scale (elbow flexors).Results: An overall effect of augmented exercise therapy time on Fugl-Meyer scores after four weeks was not corroborated (mean and 95% confidence interval (CI) of change scores: no augmented e...

Impairment-oriented training or Bobath therapy for severe arm paresis after stroke: a single-blind, multicentre randomized controlled trial

Purpose. To assess the effects of d-amphetamine on motor facilitation and recovery in stroke patients with mild arm paresis receiving the Arm Ability training. Methods. Thirty-one stroke patients with mild arm paresis were randomly assigned to either (a.) receiving placebo or (b.) d-amphetamine twice a week 2 hours before Arm Ability training sessions for three weeks. Main outcome measure: time needed to perform TEMPA tasks, a measure of upper extremity performance reflecting everyday life tasks. Secondary measures: aimed movements, tapping, and a 10 m walkway as well as motor performance during training sessions. Results. The interim efficacy analysis of 26 stroke patients who completed the study intervention showed overall arm motor recovery both from pre to post test after 3 weeks of training and from pre test to follow-up 1 year later. No superior effect of d-amphetamine over placebo could be substantiated for either motor facilitation during training or motor recovery (post training or long-term). D-amphetamine exerted mild effects on blood pressure. Serious adverse events were not observed. Conclusions. d-Amphetamine failed to facilitate motor performance during training sessions, to promote skill acquisition with training tasks, and most importantly to enhance motor recovery among patients with mild arm paresis after stroke.

Amphetamine fails to facilitate motor performance and to enhance motor recovery among stroke patients with mild arm paresis: interim analysis and termination of a double blind, randomised, placebo-controlled trial.

Purpose: Receiving the Arm Ability Training for three weeks improves motor function among stroke patients with mild arm paresis. There is, however, a considerable variability in recovery among patients receiving the Arm Ability Training. The study investigated whether intersubject differences in movement-related electric brain activity explain the variability in motor recovery. Methods: In a sample of 9 patients receiving the Arm Ability Training both motor performance using a standardised arm function test (TEMPA) and movement-related electric brain activity, i.e. slow cortical potentials (DC) as well as event-related desynchronisation of alpha (alpha-ERD) and beta activity (beta-ERD), were assessed before the Arm Ability Training was started. Stepwise multiple regression was used to establish the best predictive model for motor improvement scores (TEMPA difference from pre to post test three weeks later). Results: Stepwise multiple regression indicated that electric brain activity during movement preparation explained the variance of motor improvement scores completely. Further, electric brain activity during movement as well as baseline motor performance accounted each for 50% of the variance of motor improvement scores. Conclusions: Activation of sensorimotor areas during movement preparation and deactivation of other cortical areas during movement execution seem to be factors that predict a favourable outcome after training.

Brain activation pattern as assessed with multi-modal EEG analysis predict motor recovery among stroke patients with mild arm paresis who receive the Arm Ability Training.

U. Engel

Papers

Impairment-oriented training or Bobath therapy for severe arm paresis after stroke: a single-blind, multicentre randomized controlled trial

Amphetamine fails to facilitate motor performance and to enhance motor recovery among stroke patients with mild arm paresis: interim analysis and termination of a double blind, randomised, placebo-controlled trial.

Brain activation pattern as assessed with multi-modal EEG analysis predict motor recovery among stroke patients with mild arm paresis who receive the Arm Ability Training.