Dose, Content, and Context of Usual Care in Stroke Upper Limb Motor Interventions: A Systematic Review

High-Dose, High-Intensity Stroke Rehabilitation: Why Aren't We Giving It?

Current doses and intensities of post-stroke rehabilitation therapy provided as “usual care” are paltry compared to the magnitudes needed to drive large behaviorally-relevant reductions in neurologic impairments. There is convergent evidence indicating that high dose, high intensity rehabilitation is effective for improving outcomes after stroke with large effect sizes compared to usual care. Here we highlight some of this evidence (focusing on studies of upper extremity motor rehabilitation) and then ask the simple question— why are we not delivering high doses and intensities of rehabilitation in clinical practice? We contend that reasons for lack of implementation of high dose, high intensity rehabilitation have to do with questionable conceptual, ideological, and economic assumptions. In addition, there are practical challenges, which we argue can be overcome with technology. Current practice (we refer primarily to the context of US healthcare) in stroke rehabilitation is itself built on very little evidence, indeed considerably less than the cumulative evidence indicating that high dose, high intensity rehabilitation would be more effective. Our hope is that this Perspective will help persuade multiple stake holders (neurologists, physiatrists, therapists, researchers, patients, policy makers, and insurance companies) to advocate for higher doses and intensities of rehabilitation. There is certainly more research to be done on new ways to deliver high-dose, high-intensity neurorehabilitation, as well as zeroing in on its best timing and dosing, and how to best combine it with drugs and physiological stimulation. In the meantime, our view is that a large body of convergent evidence already justifies seeking to incorporate higher doses and intensities of therapy into current clinical practice as the new standard of care.

MGH Laboratory for Translational Neurorecovery: @LTNeurorecovery (X), @ltneuro (Instagram)

MGH Center for Neurotechnology and Neurorecovery: @MGH_CNTR (X)

Motor Rehabilitation Provides Modest Functional Benefits After Intracerebral Hemorrhage: a Systematic Review and Meta-Analysis of Translational Rehabilitation Studies

Few certainties exist regarding the optimal type, timing, or dosage of rehabilitation after stroke. Despite differing injury mechanisms and recovery patterns following ischemic and hemorrhagic stroke, most translational stroke research is conducted after ischemia. As we enter the era of personalized medicine, exploring subtype-specific treatment efficacy is essential to optimizing recovery. Our objective was to characterize common rehabilitation interventions used after in vivo preclinical intracerebral hemorrhage (ICH) and assess the impact of post-ICH rehabilitation (vs. no-rehabilitation) on recovery of motor function. Following PRISMA guidelines, a systematic review (Academic Search Complete, CINAHL, EMBASE, Medline, PubMed Central) identified eligible articles published up to December 2022. Risk of bias (SYRCLE) and study quality (CAMARADES) were evaluated, and random-effects meta-analysis was used to assess treatment efficacy in recovery of forelimb and locomotor functions. Thirty articles met inclusion criteria, and 48 rehabilitation intervention groups were identified. Most used collagenase to model striatal ICH in young, male rodents. Aerobic exercise, enriched rehabilitation, and constraint-induced movement therapy represented ~ 70% of interventions. Study quality was low (median 4/10, range 2-8), and risk of bias was unclear. Rehabilitation provided modest benefits in skilled reaching, spontaneous impaired forelimb use, and locomotor function; however, effects varied substantially by endpoint, treatment type, and study quality. Rehabilitation statistically improves motor function after preclinical ICH, but whether these effects are functionally meaningful is unclear. Incomplete reporting and variable research quality hinder our capacity to analyze and interpret how treatment factors influence rehabilitation efficacy and recovery after ICH.

Technology-Enabled Upper Limb Rehabilitation for Neurological Impairment: A Feasibility Randomized-Controlled Trial Protocol

Background. Technology-enabled upper limb (UL) rehabilitation improves therapy intensity and impairment outcomes, however clinical usage remains low and evidence for functional outcomes is limited. While benefits of single-mode technologies have been demonstrated, a combination of technology modes or "hybrid" approach is an emerging option with shoulder to fingertip capability. Investigation of this approach within a hospital setting is warranted to inform occupational therapy practice with neurological patients. Purpose. This study examines feasibility of hybrid technology-enabled UL rehabilitation for in-patients with neurological impairments. Method and Analyses. A Phase II feasibility randomized controlled trial (RCT) will compare usual care versus hybrid technology intervention using three technology modes (robotics, virtual reality, sensor-based therapy) plus usual care. Pre-post outcomes for UL impairment, activity, participation and self-reported function will be analyzed using 2 × 2 repeated measures ANOVA. Effect sizes will inform a power analysis for a full-scale RCT. Field observations and participant surveys will capture feasibility factors. It is anticipated hybrid technology for UL neurorehabilitation will be feasible in a hospital setting and show preliminary effectiveness for improving UL use in daily activities. Ethics and Dissemination. Ethics granted from RBWH Human Research Ethics Committee (HREC/2020/QRBW/67076) and The University of Queensland (2021/HE002211).

Upper-extremity motor recovery after stroke: A systematic review and meta-analysis of usual care in trials and observational studies

BACKGROUND

A better knowledge of upper-extremity (UE) recovery in patients with stroke receiving usual care (UC) is crucial for informing clinicians on expected recovery and serves as reference for future studies.

OBJECTIVES

This systematic review and meta-analysis aimed to assess rate and amount of recovery of UE with UC in the subacute phase of stroke and identify covariates of UE recovery.

METHODS

PRISMA-guidelines were used for search in PubMed, Cinahl and PEDro. Observational studies (OS) and UC groups of randomized control trials (RCT) of adults with subacute stroke and UE paresis were included, each reporting UE function at least at two time points. Placebo-, sham-controlled, dose-matched trials and trials with <10 participants were excluded.

RESULTS

From 1220 records, 54 papers (19 OS and 35 RCTs) involving 2774 subacute stroke patients were included. Fugl-Meyer Assessment of Upper Extremity (FMA-UE) and Action Research Arm Test (ARAT) were most frequently reported UE outcomes. Across RCTs, FMA-UE and ARAT improved 10 and 8 points, respectively, on average at 4-weeks from baseline. In OS, FMA-UE, improved 12 points at 12 weeks and 16 points at 24 weeks from baseline. Stroke severity, UE function, and lesion load of the cortico-spinal tract at baseline were associated with UE recovery.

CONCLUSIONS

UE function in subacute stroke showed improvements that exceeded the threshold for clinically important change across RCTs and OS. This review provides estimates of expected change in UC groups for sample size calculations and planning of future trials, thereby enhancing statistical power and comparability of findings.

Bimanual Arm Trainer Versus Traditional Occupational Therapy Services in Upper Extremity Function

IMPORTANCE

Upper extremity (UE) dysfunction resulting from stroke significantly affects a person's ability to complete self-care activities, consequently diminishing functional independence. Effective interventions that improve UE function in persons with stroke are needed.

OBJECTIVE

To explore the effectiveness of the Bimanual Arm Trainer (BAT) compared with traditional occupational therapy treatment sessions (i.e., a control group) on improving UE function after acute ischemic stroke.

DESIGN

Clinical trial, two-group, nonrandomized repeated-measures design.

SETTING

Inpatient rehabilitation facility.

PARTICIPANTS

Twenty-seven persons with ischemic stroke and an Action Research Arm Test (ARAT) score ≤17.

INTERVENTION

Minimum of three 10-min sessions on the BAT.

OUTCOMES AND MEASURES

ARAT, Upper Extremity Fugl-Meyer Assessment of Motor Recovery after Stroke (FMA-UE).

RESULTS

Both the intervention and control groups showed significant improvement on the ARAT from evaluation to discharge (main effect of time: p = .02). There was no statistically significant main effect of group and no significant Time × Group interaction (p = .63). FMA-UE scores also improved significantly in the intervention group from evaluation to discharge (p < .001). FMA-UE scores were not available for the control group.

CONCLUSIONS AND RELEVANCE

Both the intervention and control groups demonstrated significant improvements in UE function from evaluation to discharge. There were no statistically significant differences between groups, indicating that the BAT results in similar improvements in UE function, as would be expected in traditional occupational therapy. Further research is warranted to examine additional BAT programs, use different outcome measures, and assess participants over a longer time span. Plain-Language Summary: The Bimanual Arm Trainer (BAT) is a novel device that can be used in occupational therapy to improve arm function among stroke patients. There is limited research on BAT's effectiveness in improving arm function among stroke patients. In an acute inpatient rehabilitation setting, we compared outcome scores of patients who received traditional occupational therapy services with those who also used the BAT. Both groups achieved significant improvements in arm function from evaluation to discharge. We found that the addition of the BAT interventions did not significantly affect the outcome measure scores for either group. We conclude that more research is needed to examine additional BAT programs, use different outcome measures, and assess participants over a longer period of time.

Considerations for developing complex post-stroke upper limb behavioural interventions: An international qualitative study

OBJECTIVE

To simultaneously explore the perspectives and opinions of different invested participant groups on the important considerations for development of upper limb behavioural interventions that drive optimal post-stroke upper limb motor recovery.

DESIGN

A qualitative descriptive study in a constructivist epistemology.

PARTICIPANTS

Purposively selected participant groups (preclinical research n = 9, clinical research n = 9, clinical experience n = 9 and lived experience n = 10).

SETTING

Research participants were selected from top internationally published authors. Experiential participants were recruited internationally, through networks.

RESULTS

Four themes were identified with embedded subthemes. Theme 1: 'Clinical relevance should be the core of a "good" research question' with two subthemes: 'Breaking down silos: forging interdisciplinary research teams', and 'Beyond the pipeline: bench to bedside and back'; theme 2: 'Balance restitution and compensation to maximise outcomes' with three subthemes: 'Good outcome: going beyond an outcome measure', 'Recovery is a puzzle: measure all the pieces', and 'Optimising capacity: knowing when and how'; theme 3: 'Stroke demands personalised solutions' with two subthemes: 'Condition-specific considerations', and 'Person-specific considerations'; theme 4: 'Upper limb recovery requires complex interventions' with four subthemes: 'Fuelling engagement', 'Content is crucial', 'Multidimensional dose', and 'Therapist sway'.

CONCLUSIONS

This study suggests that post-stroke upper limb motor interventions are the interactions of multiple intervention elements (e.g. dose and content) shaped by different contextual considerations (e.g. stroke and personal factors). Development of such interventions may need to consider both content and context of the intervention to drive optimal recovery.

Unsupervised robot-assisted rehabilitation after stroke: feasibility, effect on therapy dose, and user experience

BACKGROUND

Unsupervised robot-assisted rehabilitation is a promising approach to increase the dose of therapy after stroke, which may help promote sensorimotor recovery without requiring significant additional resources and manpower. However, the unsupervised use of robotic technologies is not yet a standard, as rehabilitation robots often show low usability or are considered unsafe to be used by patients independently. In this paper we explore the feasibility of unsupervised therapy with an upper limb rehabilitation robot in a clinical setting, evaluate the effect on the overall therapy dose, and assess user experience during unsupervised use of the robot and its usability.

METHODS

Subacute stroke patients underwent a four-week protocol composed of daily 45 min-sessions of robot-assisted therapy. The first week consisted of supervised therapy, where a therapist explained how to interact with the device. The second week was minimally supervised, i.e., the therapist was present but intervened only if needed. After this phase, if participants learnt how to use the device, they proceeded to two weeks of fully unsupervised training. Feasibility, dose of robot-assisted therapy achieved during unsupervised use, user experience, and usability of the device were evaluated. Questionnaires to evaluate usability and user experience were performed after the minimally supervised week and at the end of the study, to evaluate the impact of therapists' absence.

RESULTS

Unsupervised robot-assisted therapy was found to be feasible, as 12 out of the 13 recruited participants could progress to unsupervised training. During the two weeks of unsupervised therapy participants on average performed an additional 360 min of robot-assisted rehabilitation. Participants were satisfied with the device usability (mean System Usability Scale scores > 79), and no adverse events or device deficiencies occurred.

CONCLUSIONS

We demonstrated that unsupervised robot-assisted therapy in a clinical setting with an actuated device for the upper limb was feasible and can lead to a meaningful increase in therapy dose. These results support the application of unsupervised robot-assisted therapy as a complement to usual care in clinical settings and pave the way to its application in home settings.

TRIAL REGISTRATION

Registered on 13.05.2020 on clinicaltrials.gov (NCT04388891).