Motor recovery after stroke: a systematic review
TL;DR: 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.
Abstract: 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.
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TL;DR: There is evidence to support rehabilitation in well coordinated multidisciplinary stroke units or through provision of early supported provision of discharge teams and promising interventions that could be beneficial to improve aspects of gait include fitness training, high-intensity therapy, and repetitive-task training.
1,691 citations
TL;DR: This guideline provides a synopsis of best clinical practices in the rehabilitative care of adults recovering from stroke to reduce the risk of downstream medical morbidity resulting from immobility, depression, loss of autonomy, and reduced functional independence.
Abstract: Purpose—The aim of this guideline is to provide a synopsis of best clinical practices in the rehabilitative care of adults recovering from stroke. Methods—Writing group members were nominated by th...
1,679 citations
TL;DR: Evidence that the use of virtual reality and interactive video gaming was not more beneficial than conventional therapy approaches in improving upper limb function is found and the evidence remains mostly low quality when rated using the GRADE system.
Abstract: Published version made available following 12 month embargo from the date of publication [12 Feb 2015] according to publisher policy. Accessed 10/03/2015. Published version available from 13 February 2016.
878 citations
TL;DR: This paper focuses on the prospect of improving the lives of countless disabled individuals through a combination of BCI technology with existing assistive technologies (AT) and identifies four application areas where disabled individuals could greatly benefit from advancements inBCI technology, namely, “Communication and Control”, ‘Motor Substitution’, ”Entertainment” and “Motor Recovery”.
Abstract: In recent years, new research has brought the field of electroencephalogram (EEG)-based brain–computer interfacing (BCI) out of its infancy and into a phase of relative maturity through many demonstrated prototypes such as brain-controlled wheelchairs, keyboards, and computer games. With this proof-of-concept phase in the past, the time is now ripe to focus on the development of practical BCI technologies that can be brought out of the lab and into real-world applications. In particular, we focus on the prospect of improving the lives of countless disabled individuals through a combination of BCI technology with existing assistive technologies (AT). In pursuit of more practical BCIs for use outside of the lab, in this paper, we identify four application areas where disabled individuals could greatly benefit from advancements in BCI technology, namely, “Communication and Control”, “Motor Substitution”, “Entertainment”, and “Motor Recovery”. We review the current state of the art and possible future developments, while discussing the main research issues in these four areas. In particular, we expect the most progress in the development of technologies such as hybrid BCI architectures, user–machine adaptation algorithms, the exploitation of users’ mental states for BCI reliability and confidence measures, the incorporation of principles in human–computer interaction (HCI) to improve BCI usability, and the development of novel BCI technology including better EEG devices.
792 citations
Cites background from "Motor recovery after stroke: a syst..."
...Recent clinical trials have provided new insights into the methods to assist motor recovery after stroke [40, 95, 179]....
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TL;DR: Evaluated efficacy of daily brain–machine interface (BMI) training to increase the hypothesized beneficial effects of physiotherapy alone in patients with severe paresis in a double‐blind sham‐controlled design proof of concept study.
Abstract: OBJECTIVE: Chronic stroke patients with severe hand weakness respond poorly to rehabilitation efforts. Here, we evaluated efficacy of daily brain-machine interface (BMI) training to increase the hypothesized beneficial effects of physiotherapy alone in patients with severe paresis in a double-blind sham-controlled design proof of concept study. METHODS: Thirty-two chronic stroke patients with severe hand weakness were randomly assigned to 2 matched groups and participated in 17.8 ± 1.4 days of training rewarding desynchronization of ipsilesional oscillatory sensorimotor rhythms with contingent online movements of hand and arm orthoses (experimental group, n = 16). In the control group (sham group, n = 16), movements of the orthoses occurred randomly. Both groups received identical behavioral physiotherapy immediately following BMI training or the control intervention. Upper limb motor function scores, electromyography from arm and hand muscles, placebo-expectancy effects, and functional magnetic resonance imaging (fMRI) blood oxygenation level-dependent activity were assessed before and after intervention. RESULTS: A significant group × time interaction in upper limb (combined hand and modified arm) Fugl-Meyer assessment (cFMA) motor scores was found. cFMA scores improved more in the experimental than in the control group, presenting a significant improvement of cFMA scores (3.41 ± 0.563-point difference, p = 0.018) reflecting a clinically meaningful change from no activity to some in paretic muscles. cFMA improvements in the experimental group correlated with changes in fMRI laterality index and with paretic hand electromyography activity. Placebo-expectancy scores were comparable for both groups. INTERPRETATION: The addition of BMI training to behaviorally oriented physiotherapy can be used to induce functional improvements in motor function in chronic stroke patients without residual finger movements and may open a new door in stroke neurorehabilitation.
748 citations
Cites background from "Motor recovery after stroke: a syst..."
...Up to 30% of all stroke survivors experience very limited motor recovery and depend on assistance to manage their daily living activities.(1,2) Recent studies have provided evidence that techniques like constraint-induced movement therapy (CIMT) or bilateral arm training represent useful strategies to improve motor function in chronic stroke patients, but such options are not applicable for stroke patients with severe limb weakness, because...
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TL;DR: The World Health Organization’s (WHO) International Classification of Functioning, Disability and Health (ICF) has been revised to recognize that the concept of disability resides largely in the sociocultural domain of the authors' lives rather than being an attribute of the individual.
Abstract: One of the take-home messages from the III Step Conference held in July of 2005 was a suggestion that physical therapists adopt the World Health Organization’s (WHO) International Classification of Functioning, Disability and Health (ICF)1 as a framework for discussion of health and disabling conditions. For those less familiar with the ICF model and other contemporary models of disability, I refer the reader to Jette’s article in the III Step Series published in Physical Therapy.2 The ICF succeeds the WHO’s International Classification of Impairments, Disabilities, and Handicaps,3 known as the ICIDH, which was first introduced in 1980. The model of disablement most familiar to physical therapists in the United States is Nagi’s model of disablement4 that served as a foundation for the development of the Guide to Physical Therapy Practice. Nagi’s model comprises four categories: pathology, impairment, functional limitations, and disability. The new ICF model includes three domains of human function: body functions and structures, activities, and participation. which generally are analogous to the levels from the Nagi model of impairment, functional limitations, and disability, respectively. The utility of disablement models lies in the definitions of the levels and their subdomains which, if widely adopted, would facilitate communication among health professionals around the world. Campbell5 discussed the application of such models in her presentation at III Step and illustrated the use of the Nagi model in her research as a framework for her well known textbook.6 Every model has its strengths and limitations, but the ICF has been designed to address major criticisms of other models of disability. First, the model has been revised to recognize that the concept of disability resides largely in the sociocultural domain of our lives rather than being an attribute of the individual. Second, the disabling process is conceptualized as dynamic and bidirectional process rather than a linear consequence of pathology, impairments, and functional limitations. This change incorporates the possibility for secondary impairments that result from a disabling condition. In addition, a strength of the new ICF is that it is grounded in health rather than disease. Notably, the foundational domain of the model is termed health conditions rather than active pathologies that characterized the Nagi model. That change to focus on health condition makes the model more appropriate for the study, consideration, and discussion of health promotion. I urge our readers to familiarize themselves with the ICF and begin to frame discussion of clinical cases, research and professional discourse using its terminology.
3,713 citations
TL;DR: The Extremity Constraint Induced Therapy Evaluation (EXCITE) trial as mentioned in this paper showed that a 2-week program of constraint-induced movement therapy (CIMT) for patients more than 1 year after stroke who maintain some hand and wrist movement can improve upper extremity function that persists for at least 1 year.
Abstract: ContextSingle-site studies suggest that a 2-week program of constraint-induced movement therapy (CIMT) for patients more than 1 year after stroke who maintain some hand and wrist movement can improve upper extremity function that persists for at least 1 year.ObjectiveTo compare the effects of a 2-week multisite program of CIMT vs usual and customary care on improvement in upper extremity function among patients who had a first stroke within the previous 3 to 9 months.Design and SettingThe Extremity Constraint Induced Therapy Evaluation (EXCITE) trial, a prospective, single-blind, randomized, multisite clinical trial conducted at 7 US academic institutions between January 2001 and January 2003.ParticipantsTwo hundred twenty-two individuals with predominantly ischemic stroke.InterventionsParticipants were assigned to receive either CIMT (n = 106; wearing a restraining mitt on the less-affected hand while engaging in repetitive task practice and behavioral shaping with the hemiplegic hand) or usual and customary care (n = 116; ranging from no treatment after concluding formal rehabilitation to pharmacologic or physiotherapeutic interventions); patients were stratified by sex, prestroke dominant side, side of stroke, and level of paretic arm function.Main Outcome MeasuresThe Wolf Motor Function Test (WMFT), a measure of laboratory time and strength-based ability and quality of movement (functional ability), and the Motor Activity Log (MAL), a measure of how well and how often 30 common daily activities are performed.ResultsFrom baseline to 12 months, the CIMT group showed greater improvements than the control group in both the WMFT Performance Time (decrease in mean time from 19.3 seconds to 9.3 seconds [52% reduction] vs from 24.0 seconds to 17.7 seconds [26% reduction]; between-group difference, 34% [95% confidence interval {CI}, 12%-51%]; P<.001) and in the MAL Amount of Use (on a 0-5 scale, increase from 1.21 to 2.13 vs from 1.15 to 1.65; between-group difference, 0.43 [95% CI, 0.05-0.80]; P<.001) and MAL Quality of Movement (on a 0-5 scale, increase from 1.26 to 2.23 vs 1.18 to 1.66; between-group difference, 0.48 [95% CI, 0.13-0.84]; P<.001). The CIMT group achieved a decrease of 19.5 in self-perceived hand function difficulty (Stroke Impact Scale hand domain) vs a decrease of 10.1 for the control group (between-group difference, 9.42 [95% CI, 0.27-18.57]; P=.05).ConclusionAmong patients who had a stroke within the previous 3 to 9 months, CIMT produced statistically significant and clinically relevant improvements in arm motor function that persisted for at least 1 year.Trial Registrationclinicaltrials.gov Identifier: NCT00057018
1,662 citations
Journal Article•
TL;DR: Extensive restraint of an unaffected upper extremity and practice of functional movements with the impaired limb proved to be an effective means of restoring substantial motor function in stroke patients with chronic motor impairment identified by the inclusion criteria of this project.
1,566 citations
01 Jan 2006
TL;DR: The Extremity Constraint Induced Therapy Evaluation (EXCITE) trial as discussed by the authors was designed to compare the effects of a 2-week multisite program of CIMT vs usual andcustomary care.
Abstract: Context Single-sitestudiessuggestthata2-weekprogramofconstraint-inducedmove-ment therapy (CIMT) for patients more than 1 year after stroke who maintain somehand and wrist movement can improve upper extremity function that persists for atleast 1 year.Objective To compare the effects of a 2-week multisite program of CIMT vs usualandcustomarycareonimprovementinupperextremityfunctionamongpatientswhohad a first stroke within the previous 3 to 9 months.Design and Setting The Extremity Constraint Induced Therapy Evaluation(EXCITE) trial, a prospective, single-blind, randomized, multisite clinical trial con-ducted at 7 US academic institutions between January 2001 and January 2003.Participants Twohundredtwenty-twoindividualswithpredominantlyischemicstroke.Interventions Participants were assigned to receive either CIMT (n=106; wearinga restraining mitt on the less-affected hand while engaging in repetitive task practiceandbehavioralshapingwiththehemiplegichand)orusualandcustomarycare(n=116;rangingfromnotreatmentafterconcludingformalrehabilitationtopharmacologicorphysiotherapeutic interventions); patients were stratified by sex, prestroke dominantside, side of stroke, and level of paretic arm function.Main Outcome Measures The Wolf Motor Function Test (WMFT), a measure oflaboratory time and strength-based ability and quality of movement (functional abil-ity),andtheMotorActivityLog(MAL),ameasureofhowwellandhowoften30com-mon daily activities are performed.Results From baseline to 12 months, the CIMT group showed greater improve-ments than the control group in both the WMFT Performance Time (decrease inmean time from 19.3 seconds to 9.3 seconds [52% reduction] vs from 24.0 sec-onds to 17.7 seconds [26% reduction]; between-group difference, 34% [95% con-fidence interval {CI}, 12%-51%];
1,494 citations