ReJoycetherapy

Here’s a great scientific literature review of Arm Function Rehabilitation After Stroke. Unfortunately, it isn’t hugely accessible to non-technical readers (not many people know what “ipsilesional corticospinal excitability” means). Here’s my review of the main points of the article, in plain terms:

• This study examined 66 other studies published between 2004 and 2008 from Medline using the keywords “stroke”, “upper limb”, and “rehabilitation”.
• Only randomized control studies were included in the review.
• High intensity rehabilitation training programs during subacute stroke rehabilitaiton (less than 6-months post-stroke) resulted in significant improvements in arm function.
• Learned non-use (gradually giving up trying to use a partially paralyzed arm) is the result of brain re-organization that starts within hours of a stroke.
• Rehabilitation that concentrates on compensation using the healthy limb can accelerate and perpetuate learned non-use. Some of the studies examined inhibition of the healthy part of the brain’s motor cortex using TMS.
• Natural plasticity of the brain after stroke, which is associated with a re-allocation of brain networks from one function to another, leads to a certain amount of natural upper extremity neurological recovery
• Training by repeating tasks directly linked to daily life activities promotes recovery. An “enriched” sensory environment (proprioceptive, visual, etc.) while performing these tasks is beneficial.
• Residual voluntary motor ability at 1-month post stroke is the best predictor of how much hand dexterity will be regained.
• In people whose stroke occurred 6 months or more previously (referred to as ”chronic”), 2 hours of transcutaneous neurostimulation (with an FES stimulator, for example) delivered just prior to rehabilitation training sessions, improves function of the weak hand
• The impact of acupuncture on upper limb motor recovery is not conclusive.
• Thermal stimulation, where patients are encouraged to take their paretic arm away when they feel an uncomfortable sensation, could promote recovery.
• Constraint-induced movement therapy is effective in reversing learned non-use of a paretic arm. It is believed that CIMT encourages the brain re-allocation referred to above.
• For higher-functioning chronic stroke survivors, mental imagery:   imagining moving the paretic limb, or imagining movements performed by another person, are beneficial to recovery of motor function. No benefit has been demonstrated in lower-functioning stroke survivors and those with cognitive impairments. Mental imagery hasn’t been the subject of many randomly controlled studies.
• Unilateral task practice using the paretic limb yields improvements superior to those of bimanual task practice.
• Both transcranial magnetic stimulation (TMS) and transcranial electrical stimulation (TES) have been shown to facilitate some motor recovery, but the cost/benefit and risk/benfit ratios have yet to be evaluated.
• TMS inhibition of the healthy part of the motor cortex can temporarily improve dexterity of the paretic limb, but at this stage this is not a clinically relevant treatment. In some cases, the inhibition procedure may actually be harmful.
• Constraint of the healthy limb in CIMT doesn’t yield more functional improvements than intensive movement therapy without a constraint.
• More intensive training very soon after a stroke doesn’t yield functional improvement beyond that of standard treatment.
• One year after a stroke, 9 hours of movement therapy isn’t sufficient to yield clinically significant results, whereas 57 hours of rehabilitation training does yield results for people with moderate motor impairment.
• EMG-triggered electrical stimulation eliciting hand opening, (i.e. bursts of electrical stimulation of a muscle initiated by weak voluntary activation of the muscle), has been claimed to be more efficacious than electrical stimulation triggered by other means, but there is insufficient evidence to fully validate this conclusion.
• Electrical stimulation to open the hand during repetitive grasp and release tasks is an integral part of a functional strategy, and promotes motor relearning.
• Several studies have concluded that CIMT is better than conventional therapy, including one study of 43 patients at less than 16 weeks poststroke.
• In a very broad study of 222 patients, CIMT improved pinch grip and several fine motor tasks, but failed to show significant improvement in a patient’s ability to open his or her hand.
• The following details results for various robotics systems:
  - NeReBot: A group of acute poststroke subjects (some as early as 7-days poststroke) had better voluntary hand control compared to a group who received no therapy. The results were still evident 8 months later.
  - InMotion2: “The motor improvements observed after 18 hours of therapy are not clinically significant and do not spread to distal motor capacities.”
  - Bi-Manu-Track: Bimanual and uni-manual rehabilitation yielded similar improvements with the use of this robot.
  - MIME and BACTRAC: “The functional improvements on manual dexterous ability are limited to the execution speed of tasks that the patient had already mastered before treatment.”
• Author’s therapy recommendations: