Stroke is a leading cause of death and disability in the UK and it can happen to anyone at any age. A stroke can cause loss of strength and feeling on one side of the body which can affect a stroke survivor’s function. The area of treatment for the upper limb affected by a stroke is called upper limb rehabilitation, and this brings us to the important work of the specialist neurological rehabilitation teams working within this field.

Did you know that between 50-80% of stroke survivors suffer from upper limb dysfunction after an acute stroke? In many cases patients struggle to use their upper limbs which contributes largely to long-term, continuous physical disability.

Stroke Recovery

It’s believed that most of the recovery from strokes occurs within the first 3-6 months but thereafter, improvement is less likely. While this is true for some, it can differ on a case-by-case basis and upper limb rehabilitation can be helpful for many stroke survivors in the longer term.

Clinical Research Into Upper Limb Rehabilitation

Thanks largely to the continued efforts from numerous dedicated experts both within and outside of the field of neurology, some more light has been shed on this topic. Among many other eminent clinicians and researchers is Consultant Neurologist Professor Nick Ward, a Professor of Clinical Neurology and Neurorehabilitation.

Professor Ward’s clinical and research interest is in stroke and neurorehabilitation with a particular focus on assessing and treating upper limb dysfunction. He uses structural and functional brain imaging techniques to investigate mechanisms of impairment and recovery after stroke. Let’s take a closer look at some of the information from his impressive keynote speech at the NNR Conference in 2019 .

How To Promote Upper Limb Rehabilitation After Stroke

It’s no easy feat increasing the activity of affected limbs but most studies of behavioural interventions have shown some promise. They focus on forms of constraint-induced movement therapy (CIMT), repetitive task training (RTT) or robotics.

Whilst there is some evidence to support the benefits of CIMT and RTT over ‘usual care’, it’s not as strong for ‘matched therapy’. In addition to that summation, the evidence suggesting that their benefits continue beyond the treatment period is not strong enough.

Using robotics can help increase the number of movement repetitions but trials are yet to produce meaningful clinical results. There have been several studies that tested more complex therapies while incorporating various elements and a good example of this is the ICARE Study.

The ICARE Study

In terms of upper limb treatment after  stroke, the Randomized Clinical Trialthe ICARE study went beyond simple repetitions. It was a more structured, collaborative, task-oriented and patient-centred motor training program that focused on impairment starting about 6 weeks after a stroke.

The results were not conclusive but upon further reflection, the number of hours in treatment over 10 weeks was too low, averaging 30 hours.

Many experts agree that stroke patients could, in fact, tolerate longer treatments and referred to one specific study which delivered 300 hours of upper limb rehabilitation.  (McCabe et al). It was aimed at chronic stroke patients over a 12-week period with some positive results showing marked improvement in impairment and activity. Since the initial study, the same group replicated the findings and showed that the effects were maintained after 3 months. (Daly, JJ et al).

The Queen Square Upper Limb (QSUL) Neurorehabilitation Programme

The QSUL Neurorehabilitation programme is a single centre clinical service providing 90 hours of treatment focusing on the upper limb rehabilitation after a stroke. Most of the patients in the programme were more than 6 months post-stroke and even though they showed signs of impairments and fatigue, they managed to complete 90 hours of the programme.

Despite the elapsed time since the stroke, the programme observed noticeable improvements in upper limb impairment and activity. Perhaps even more importantly, the improvements were maintained and even improved on in some cases up to 6 months after treatment.

Key Research Study Points

The first important point is that post-stroke rehabilitation programmes and clinical trials are almost always under-dosing patients. Considering the proven results, future clinical trials should investigate using higher doses than the current levels.

Secondly, it’s important to identify the core components of upper limb rehabilitation treatment. It may not be clear what the optimal approach should be for promoting upper limb rehabilitation but the simple approaches have not yet resulted in large or sustained effects which are both necessary to promote change in stroke recovery programmes.

It is very likely that successful post-stroke rehabilitation will require a combination of complementary approaches. If this is the case, determining the optimal combination by studying each approach separately is unlikely as the interactions between these elements must also be considered.

What Is The Best Solution For Upper Limb Rehabilitation?

The future of upper limb rehabilitation should focus on elements that have already demonstrated some success and then work out the key components from there. Instead of treatments producing small changes or improvements, the focus should be on interventions with a high chance of achieving minimum clinically important differences (MCID).

According to studies from McCabe et al, Daly et al and the QSUL programme, considerable improvements on both impairment and activity limitation have been shown. They involved more complex treatments which were not restricted to one element and should be considered in more detail.

A More Targeted Approach

The initial assessment of analysing the movement and performance of a stroke survivor’s  daily activities is crucial. The impact of the stroke can be varied and there are a range of impairments that need to be considered when assessing upper limb function. These include:  

• spasticity
• loss of joint and soft tissue range
• shoulder joint position changes
• patterns of weakness
• sensory loss and changes
• apraxia
• cognitive deficits
• fatigue and depression
• pain
• neglect and inattention

Because each impairment essentially becomes a therapeutic target, the correct treatment is only possible with informed clinical reasoning. The treatment, of course, will be based on the presence or absence of specific impairments and should be tailored where possible to meet collaborative patient centred goals.

How To Identify And Treat Barriers

It’s essential to avoid complications that will prevent a patient from participating in an active rehabilitation programme. One of the most common complications is a loss of passive joint range either from spasticity or non-neural shortening.

While this can happen in most joints, when it happens in the hand, a loss of flexion in the MCP joints makes it difficult to properly shape the hand so it can be used in functional activities. Treatment often involves splinting and optimal management of spasticity which provides patients with active voluntary movement that can be trained further.

Patients may also experience pain and restricted movement in the shoulder where restriction of external rotation could indicate adhesive capsulitis. Even though there is a lack of clear evidence for treating post-stroke adhesive capsulitis, capsular hydrodilatation followed by physiotherapy has shown some success.

Preparation, Education And Coaching

Manual techniques are often used to optimise and improve at an impairment level. With appropriate education, the therapist can encourage the stroke survivor and their family to undertake some of these techniques, some of which include:

• mobilizing joints to improve range
• lengthening and strengthening muscles to ensure they are at a biomechanical advantage to generate force
• training sensory discrimination and sensori-motor integration

Stroke patients can also reduce impairments through re-education of quality and control of movement within their daily activities, as well as improving postural control and balance. Patients will practice meaningful tasks repeatedly to master the task at hand, focusing on the quality of movement.

More On Coaching

Coaching involves instruction and supervision, as well as reinforcement which is important and is considered a key component of the QSUL programme. In fact, it was used throughout to introduce and implement new skills and knowledge into a patient’s individual daily routine. As a result, there was an increase in participation and a rise in confidence as they achieve their own desired goals. This promotes self-efficacy and motivation resulting in a sustained behavioural change long after the active treatment ends.

Final Thoughts

Upper limb rehabilitation should, where tolerated, aim to be a high dose treatment to enable the achievement of clinically meaningful improvement. Improved self-efficacy and behaviour change could result in further improvement which is not always seen with other upper limb interventions.

Evaluating different approaches and critically appraising its content helps to inform the key elements of successful treatment. While the activity and participation levels will vary depending on an individual’s specific goals, the overall treatment approach towards specific functional goals should be the same for all patients.

Conclusion

Even with all the progress, there is a long way to go before we truly identify optimum treatment options and the effects thereof on individuals. Success in this field will require careful assessment of behavioural intervention (input) and of the resulting behavioural change (output) at an appropriate level.

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