Keep it real: Stroke rehab of the upper extremity

Hatem, S. M., Saussez, G., della Faille, M., Prist, V., Zhang, X., Dispa, D., & Bleyenheuft, Y. (2016). Rehabilitation of motor function after stroke: a multiple systematic review focused on techniques to stimulate upper extremity recovery. Frontiers in human neuroscience, 10, 442.

Bottom Line:

Patients working to restore upper extremity function post stroke deserve intervention that is meaningful and effective.

The good news is that review after review demonstrates that real, functional activities are the best way to restore upper extremity function after stroke.

Current evidence suggests not to fuss too much with static splinting and stretching or “neurofacilitation” (i.e. branded interventions like Bobath). Passive repetitive-task based activities don’t work and have less meaning for patients. OTs can also relax about expensive technology like robotics and virtual reality, because they generally perform as well or worse than real-life, meaningful functional activity.

More:

  • Constraint therapy seems to work well, but the tasks need to be specific and structured (forced use without direction or feedback isn’t helpful)

  • Mirror therapy can be a helpful adjunct, along with motor imagery and metal practice seems to work

  • Basic strengthening helps improve function with no need to do “isokinetic training” or special exercises. Keep it simple.

  • Non-invasive stimulation (peripheral and brain based) shows some promise, but should be seen as a adjunct

  • Bobath therapy (and related practices like Perfetti or Picard therapy) is similar or inferior to other rehabilitation approaches

  • Stretching is probably a waste of time (if you’re not using botox)

  • Bilateral training (using the unaffected limb with hopes of transfer to the affected) has not really panned out in the research

  • Robot assisted therapy doesn’t perform better than human-facilitated therapy

  • Virtual reality therapy doesn’t perform any better than real life therapy

Quote:

“Overall, evidence of this ‘multiple’ systematic review indicated that the functional recovery from stroke is positively influenced by goal-specific sensorimotor input through training or everyday use of the arm and hand. Task-oriented training optimizes the Upper Extremity motor function related to the targeted motor task (“you gain what you train”), but subsequent improvements of motor impairment do not transfer to improving motor disabilities in activities of daily living... It also seems that the impact of rehabilitation technology on functional outcome could be optimized by offering more chances to the nervous system to experience “real” and repetitive activity-related adequate sensory-motor input during training of upper limb movement, instead of task-specific exercises”.

So what’s the deal?

Keep it real.