Motor Recovery After Stroke: a Systematic Review

But none of the interventions has an efficacy rating or any indication as to the damage diagnosis it is to be used for.

Motor Recovery After Stroke: a Systematic Review

Peter Langhorne, Fiona Coupar, Alex Pollock
Loss of functional movement is a common consequence of stroke for which a wide range of interventions has been developed. In this Review, we aimed to provide an overview of the available evidence on interventions for motor recovery after stroke through the evaluation of systematic reviews, supplemented by recent randomised controlled trials. Most trials were small and had some design limitations. Improvements in recovery of arm function were seen for constraint-induced movement therapy, electromyographic biofeedback, mental practice with motor imagery, and robotics. Improvements in transfer ability or balance were seen with repetitive task training, biofeedback, and training with a moving platform. Physical fitness training, high-intensity therapy (usually physiotherapy), and repetitive task training improved walking speed. Although the existing evidence is limited by poor trial designs, some treatments do show promise for improving motor recovery, particularly those that have focused on high-intensity and repetitive task-specific practice. Introduction Stroke is a common global health-care problem that is serious and disabling.1 In high-income countries, stroke is the third most common cause of death and is the main cause of acquired adult disability.1,2 However, as most patients with stroke survive the initial injury, the biggest effect on patients and families is usually through long-term impairment, limitation of activities (disability), and reduced participation (handicap). The most common and widely recognised impairment caused by stroke is motor impairment, which can be regarded as a loss or limitation of function in muscle control or movement or a limitation in mobility.3 Motor impairment after stroke typically affects the control of movement of the face, arm, and leg of one side of the body1 and affects about 80% of patients. Therefore, much of the focus of stroke rehabilitation, and in particular the work of physiotherapists and occupational therapists, is on the recovery of impaired movement and the associated functions. There seems to be a direct relation between motor impairment and function; for example, independence in walking (function) has been correlated with lower-limb strength (impairment).4 Therefore, the ultimate goal of therapy for lower-limb motor impairment is to improve the function of walking and recovery of movement. In this Review, motor impairment and its associated functional activities are regarded as part of a continuum. Motor impairment can be caused by ischaemic or haemorrhagic injury to the motor cortex, premotor cortex, motor tracts, or associated pathways in the cerebrum or cerebellum.1 Such impairments affect an individual’s ability to complete everyday activities (disability) and affect participation in everyday life situations.5 A lack of consistency is evident among researchers and clinicians in the use of terminology that describes changes in motor ability after stroke.6 Changes in motor ability might occur via several mechanisms: restitution, substitution, or compensation.7 Levin and co-workers,6 however, distinguished motor recovery and motor compensation in accordance with the WHO International Classifi cation of Functioning, Disability and Health framework and proposed that motor recovery relates to: restoration of function in neural tissue that was initially lost; restoration of ability to perform movement in the same way as before injury; and successful task completion as typically done by individuals who are not disabled. Types of motor compensation in these three areas include the acquisition by neural tissue of a function that it did not have before the injury; performance of a movement in a new way; and successful task completion by use of different techniques.6 In accordance with these definitions, in this Review we focused on outcomes associated with body functions or structure (impairment) and activity (functional). We favoured activity outcomes when these were used in addition to impairment outcomes as these were believed to be more clinically useful. However, we did not focus on motor recovery or motor compensation separately, as many of the outcomes (particularly those measuring activity) do not distinguish between improvements associated with increasing compensation and movement patterns. Although we recognise the potential limitations of this approach, this Review can only outline the outcomes used in the trials. Motor recovery after stroke is complex and confusing. Many interventions have been developed to try to aid motor recovery (recovery of impairment and associated function), and many randomised controlled trials and systematic reviews have been done.8 Most of these interventions do not explicitly target a specific pathophysiological process and have been tested using a variety of patient groups and outcome measures. We have, therefore, taken a pragmatic, empirical approach to describing and reviewing these interventions. In this Review, we summarise the available evidence for the treatment of motor impairment and restoration of motor function after stroke. Our aims were to: (i) summarise the available evidence from systematic reviews of randomised controlled trials; (ii) identify areas for which interventions show promise of efficacy; and (iii) relate this information to the current guideline advice on clinical management.