Kathryn S. Hayward

Interventions to promote upper limb recovery in stroke survivors with severe paresis: a systematic review

Purpose. To investigate the effect of interventions that promote upper limb (UL) recovery in stroke survivors with severe paresis. Methods. A systematic search of the scientific literature from January 1970 to March 2009 was conducted using CINAHL, Cochrane, PEDro, Pubmed and Web of Science. keywords used included stroke, severe, hemiplegia, UL, task-oriented, robot, non-robot and electrical stimulation. Methodological quality of the studies was assessed using the PEDro rating scale. Studies were grouped into one of three intervention categories: robotic therapy, electrical stimulation or ‘other’ therapy. Results. Seventeen randomised controlled trials met the inclusion criteria. A ‘best evidence synthesis’ indicated strong evidence that robotic therapy provides a large beneficial effect and limited evidence that electrical stimulation and ‘other’ interventions provide a large beneficial effect on function. There is no evidence that these interventions influence use of the arm in everyday tasks. Conclusion. There are a number of newly developed interventions that enable stroke survivors with severe paresis to actively participate in task-oriented practice to promote UL recovery. While these interventions offer some promise for stroke survivors with severe paresis, ultimately, the effectiveness of these interventions will be dependent on whether they lead to restoration of function to the point at which the stroke survivor can practice everyday tasks.

Biomarkers of stroke recovery: consensus-based core recommendations from the Stroke Recovery and Rehabilitation Roundtable

The most difficult clinical questions in stroke rehabilitation are “What is this patient’s potential for recovery?” and “What is the best rehabilitation strategy for this person, given her/his clinical profile?” Without answers to these questions, clinicians struggle to make decisions regarding the content and focus of therapy, and researchers design studies that inadvertently mix participants who have a high likelihood of responding with those who do not. Developing and implementing biomarkers that distinguish patient subgroups will help address these issues and unravel the factors important to the recovery process. The goal of the present paper is to provide a consensus statement regarding the current state of the evidence for stroke recovery biomarkers. Biomarkers of motor, somatosensory, cognitive and language domains across the recovery timeline post-stroke are considered; with focus on brain structure and function, and exclusion of blood markers and genetics. We provide evidence for biomarkers that are considered ready to be included in clinical trials, as well as others that are promising but not ready and so represent a developmental priority. We conclude with an example that illustrates the utility of biomarkers in recovery and rehabilitation research, demonstrating how the inclusion of a biomarker may enhance future clinical trials. In this way, we propose a way forward for when and where we can include biomarkers to advance the efficacy of the practice of, and research into, rehabilitation and recovery after stroke.

Factors Affecting the Ability of the Stroke Survivor to Drive Their Own Recovery outside of Therapy during Inpatient Stroke Rehabilitation

Aim. To explore factors affecting the ability of the stroke survivor to drive their own recovery outside of therapy during inpatient rehabilitation. Method. One-on-one, in-depth interviews with stroke survivors (n = 7) and their main carer (n = 6), along with two focus groups with clinical staff (n = 20). Data was thematically analysed according to group. Results. Stroke survivors perceived “dealing with loss,” whilst concurrently “building motivation and hope” for recovery affected their ability to drive their own recovery outside of therapy. In addition, they reported a “lack of opportunities” outside of therapy, with subsequent time described as “dead and wasted.” Main carers perceived stroke survivors felt “out of control … at everyones mercy” and lacked knowledge of “what to do and why” outside of therapy. Clinical staff perceived the stroke survivors ability to drive their own recovery was limited by the lack of “another place to go” and the “passive rehab culture and environment.” Discussion. To enable the stroke survivor to drive their own recovery outside of therapy, there is a need to increase opportunities for practice and promote active engagement. Suggested strategies include building the stroke survivors motivation and knowledge, creating an enriched environment, and developing daily routines to provide structure outside of therapy time.

Agreed definitions and a shared vision for new standards in stroke recovery research: The Stroke Recovery and Rehabilitation Roundtable taskforce

The first Stroke Recovery and Rehabilitation Roundtable established a game changing set of new standards for stroke recovery research. Common language and definitions were required to develop an agreed framework spanning the four working groups: translation of basic science, biomarkers of stroke recovery, measurement in clinical trials and intervention development and reporting. This paper outlines the working definitions established by our group and an agreed vision for accelerating progress in stroke recovery research.

Dose of arm activity training during acute and subacute rehabilitation post stroke: a systematic review of the literature

Aim: To determine the dose of activity-related arm training undertaken by stroke survivors during acute and subacute rehabilitation. Methods: A systematic review of PubMed, CINAHL and EMBASE up to December 2014 was completed. Studies were eligible if they defined the dose (time or repetitions) of activity-related arm training using observational methods for a cohort of adult stroke survivors receiving acute or subacute rehabilitation. All studies were quality appraised using an evidence-based learning critical appraisal checklist. Data was analysed by method of documented dose per session (minutes, repetitions), environment (acute or subacute rehabilitation) and therapy discipline (physiotherapy, occupational therapy). Results: Ten studies were included: two observed stroke survivors during acute rehabilitation and eight during subacute rehabilitation. During acute rehabilitation, one study reported 4.1 minutes per session during physiotherapy and 11.2 minutes during occupational therapy, while another study reported 5.7 minutes per session during physiotherapy only. During inpatient rehabilitation, activity-related arm training was on average undertaken for 4 minutes per session (range 0.9 to 7.9, n = 4 studies) during physiotherapy and 17 minutes per session (range 9.3 to 28.9, n = 3 studies) during occupational therapy. Repetitions per session were reported by two studies only during subacute rehabilitation. One study reported 23 repetitions per session during physiotherapy and occupational therapy, while another reported 32 repetitions per session across both disciplines. Conclusion: The dose of activity-related arm training during acute and subacute rehabilitation after stroke is limited.

SMART Arm with Outcome-Triggered Electrical Stimulation: A Pilot Randomized Clinical Trial

Abstract Background: The SMART (SensoriMotor Active Rehabilitation Training) Arm is a nonrobotic device designed to allow stroke survivors with severe paresis to practice reaching. It can be used with or without outcome-triggered electrical stimulation (OT-stim) to augment movement. The aim of this study was to evaluate the efficacy of SMART Arm training when used with or without OT-stim, in addition to usual care, as compared with usual care alone during inpatient rehabilitation. Methods: Eight stroke survivors received 20 hours of SMART Arm training over 4 weeks; they were randomly assigned to either (1) SMART Arm training with OT-stim or (2) SMART Arm training alone. Usual therapy was also provided. A historical cohort of 20 stroke survivors formed the control group and received only usual therapy. The primary outcome was Motor Assessment Scale Item 6, Upper Arm Function. Results: Findings for all participants were comparable at baseline. SMART Arm training, with or without OT-stim, led to a significantly greater improvement in upper arm function than usual therapy alone (P = .024). There was no difference in improvement between training with or without OT-stim. Initial motor severity and presence of OT-stim influenced the number of repetitions performed and the progression of SMART Arm training practice conditions. Conclusion: Usual therapy in combination with SMART Arm training, with or without OT-stim, appears to be more effective than usual therapy alone for stroke survivors with severe paresis. These findings warrant further investigation into the benefits of SMART Arm training for stroke survivors with severe paresis undergoing inpatient rehabilitation during the subacute phase of recovery.

Embedding an enriched environment in an acute stroke unit increases activity in people with stroke: a controlled before–after pilot study:

Objectives: To determine whether an enriched environment embedded in an acute stroke unit could increase activity levels in acute stroke patients and reduce adverse events. Design: Controlled before–after pilot study. Setting: An acute stroke unit in a regional Australian hospital. Participants: Acute stroke patients admitted during (a) initial usual care control period, (b) an enriched environment period and (c) a sustainability period. Intervention: Usual care participants received usual one-on-one allied health intervention and nursing care. The enriched environment participants were provided stimulating resources, communal areas for eating and socializing and daily group activities. Change management strategies were used to implement an enriched environment within existing staffing levels. Main Measures: Behavioural mapping was used to estimate patient activity levels across groups. Participants were observed every 10 minutes between 7.30 am and 7.30 pm within the first 10 days after stroke. Adverse and serious adverse events were recorded using a clinical registry. Results: The enriched environment group (n = 30, mean age 76.7 ± 12.1) spent a significantly higher proportion of their day engaged in ‘any’ activity (71% vs. 58%, P = 0.005) compared to the usual care group (n = 30, mean age 76.0 ± 12.8). They were more active in physical (33% vs. 22%, P < 0.001), social (40% vs. 29%, P = 0.007) and cognitive domains (59% vs. 45%, P = 0.002) and changes were sustained six months post implementation. The enriched group experienced significantly fewer adverse events (0.4 ± 0.7 vs.1.3 ± 1.6, P = 0.001), with no differences found in serious adverse events (0.5 ± 1.6 vs.1.0 ± 2.0, P = 0.309). Conclusions: Embedding an enriched environment in an acute stroke unit increased activity in stroke patients.

The efficacy of SMART Arm training early after stroke for stroke survivors with severe upper limb disability: a protocol for a randomised controlled trial

BackgroundRecovery of upper limb function after stroke is poor. The acute to subacutephase after stroke is the optimal time window to promote the recovery ofupper limb function. The dose and content of training providedconventionally during this phase is however, unlikely to be adequate todrive functional recovery, especially in the presence of severe motordisability. The current study concerns an approach to address thisshortcoming, through evaluation of the SMART Arm, a non-robotic device thatenables intensive and repetitive practice of reaching by stroke survivorswith severe upper limb disability, with the aim of improving upper limbfunction. The outcomes of SMART Arm training with or withoutoutcome-triggered electrical stimulation (OT-stim) to augment movement andusual therapy will be compared to usual therapy alone.Methods/DesignA prospective, assessor-blinded parallel, three-group randomised controlledtrial is being conducted. Seventy-five participants with a first-everunilateral stroke less than 4 months previously, who present with severe armdisability (three or fewer out of a possible six points on the MotorAssessment Scale [MAS] Item 6), will be recruited from inpatientrehabilitation facilities. Participants will be randomly allocated to one ofthree dose-matched groups: SMART Arm training with OT-stim andusual therapy; SMART Arm training without OT-stim and usualtherapy; or usual therapy alone. All participants will receive 20 hours ofupper limb training over four weeks. Blinded assessors will conduct fourassessments: pre intervention (0-weeks), post intervention (4-weeks), 26weeks and 52 weeks follow-up. The primary outcome measure is MAS item 6. Allanalyses will be based on an intention-to-treat principle.DiscussionBy enabling intensive and repetitive practice of a functional upper limb taskduring inpatient rehabilitation, SMART Arm training with or without OT-stimin combination with usual therapy, has the potential to improve recovery ofupper limb function in those with severe motor disability. The immediate andlong-term effects of SMART Arm training on upper limb impairment, activityand participation will be explored, in addition to the benefit of trainingwith or without OT-stim to augment movement when compared to usual therapyalone.Trial registrationACTRN12608000457347

Are we armed with the right data? Pooled individual data review of biomarkers in people with severe upper limb impairment after stroke

To build an understanding of the neurobiology underpinning arm recovery in people with severe arm impairment due to stroke, we conducted a pooled individual data systematic review to: 1) characterize brain biomarkers; 2) determine relationship(s) between biomarkers and motor outcome; and 3) establish relationship(s) between biomarkers and motor recovery. Three electronic databases were searched up to October 2, 2015. Eligible studies included adults with severe arm impairment after stroke. Descriptive statistics were calculated to characterize brain biomarkers, and pooling of individual patient data was performed using mixed-effects linear regression to examine relationships between brain biomarkers and motor outcome and recovery. Thirty-eight articles including individual data from 372 people with severe arm impairment were analysed. The majority of individuals were in the chronic (> 6 months) phase post stroke (51%) and had a subcortical stroke (49%). The presence of a motor evoked potential (indexed by transcranial magnetic stimulation) was the only biomarker related to better motor outcome (p = 0.02). There was no relationship between motor outcome and stroke volume (cm3), location (cortical, subcortical, mixed) or side (left vs. right), and corticospinal tract asymmetry index (extracted from diffusion weighted imaging). Only one study had longitudinal data, thus no data pooling was possible to address change over time (preventing our third objective). Based on the available evidence, motor evoked potentials at rest were the only biomarker that predicted motor outcome in individuals with severe arm impairment following stroke. Given that few biomarkers emerged, this review highlights the need to move beyond currently known biomarkers and identify new indices with sufficient variability and sensitivity to guide recovery models in individuals with severe motor impairments following stroke. PROSPERO: CRD42015026107.

The effect of altering a single component of a rehabilitation programme on the functional recovery of stroke patients: a systematic review and meta-analysis

Objective: To evaluate the effect of altering a single component of a rehabilitation programme (e.g. adding bilateral practice alone) on functional recovery after stroke, defined using a measure of activity. Data sources: A search was conducted of Medline/Pubmed, CINAHL and Web of Science. Review methods: Two reviewers independently assessed eligibility. Randomized controlled trials were included if all participants received the same base intervention, and the experimental group experienced alteration of a single component of the training programme. This could be manipulation of an intrinsic component of training (e.g. intensity) or the addition of a discretionary component (e.g. augmented feedback). One reviewer extracted the data and another independently checked a subsample (20%). Quality was appraised according to the PEDro scale. Results: Thirty-six studies (n = 1724 participants) were included. These evaluated nine training components: mechanical degrees of freedom, intensity of practice, load, practice schedule, augmented feedback, bilateral movements, constraint of the unimpaired limb, mental practice and mirrored-visual feedback. Manipulation of the mechanical degrees of freedom of the trunk during reaching and the addition of mental practice during upper limb training were the only single components found to independently enhance recovery of function after stroke. Conclusion: This review provides limited evidence to support the supposition that altering a single component of a rehabilitation programme realises greater functional recovery for stroke survivors. Further investigations are required to determine the most effective single components of rehabilitation programmes, and the combinations that may enhance functional recovery.