I'm not wasting my time critiquing this. Suffice to say this is all still guidelines:NOT PROTOCOLS!
Revisiting the core principles of physical rehabilitation after stroke: It’s not only what you do but how you do it that matters
Background
In
the second of two linked editorials, we build on the discussion of
interventions for motor rehabilitation after stroke recommended by the
UK 2023 National Clinical Guidelines for Stroke (Royal College of Physicians, 2023). Specifically, we will explore the key elements of motor learning (Carr and Shepherd, 2000)
which underpins repetitive task practice, one of two principal
rehabilitation approaches (the other being exercise) recommended in the
UK Guidelines for motor recovery.
Repetitive task practice, which appears synonymous to task-oriented training (French et al., 2016),
can enable individuals with some activity in their upper-limb to
actively practice movements and is informed by skilled movement analysis
(as discussed in editorial 1). For patients with no activity or those
who are unable to select or activate movement without significant
assistance (apraxia, significant sensory loss, inattention(and most importantly spasticity!)), the
approach would be different and so will not be explored in this
editorial.(So, you're only working with the higher functioning survivors. There is this thing called: 'Leave no survivors behind! Don't you believe in that?)
You'll want 100% recovery when you are the 1 in 4 per WHO that has a stroke so, you better start working on it now.
Repetitive task practice and motor learning
Repetitive
task practice is frequently recognised as including many hundreds of
repetitions of task or goal-oriented movements. Importantly, these
repetitions are not identical but comprise incremental challenge and
should be engaging to build on previous attempts to refine existing and
generate new strategies for movement. This explicitly recognises that
repetitive task practice requires a detailed understanding of how someone moves, rather than a sole focus on task completion, and an engaging environment conducive to intensive practice (Carr and Shepherd, 2000).
In
addition to promoting a high number of repetitions, the motor learning
theories that underpin repetitive task practice highlight that
interventions should include five other key elements (Maier et al., 2019):
Specific
– training should be goal-directed with clear parameters targeting the
chosen element of movement. Ongoing skilled movement analysis enables
the design of an exercise or a task set-up that directly links to an
individual’s specific goals and function to ensure they are meaningful
to each individual and that patients are motivated to practice
intensively; accordingly, some goals can be targeted to achieve in a
session, whilst others may span weeks or months.
Graded
– the level of difficulty should be frequently altered so that
individuals are continually challenged, yet it is possible to achieve a
threshold of success. This adaptation may include altering accuracy
requirements, distance reached or repetitions within a timeframe.
Practice should be designed to restrict degrees of freedom and provide
stability as required. Whilst therapists can use their hands to provide
feedback and physical support, the ultimate aim is for the patient to
practice independently and so configuring the environment (such as
positioning against a wall) and use of external supports or devices to
limit compensatory movements is ideal. Compensations can cause
complications such as pain, non-use, contractures, may limit real-world
arm use and are characterised by decreased movement speed, increased
variability of the movement and a loss of spatial and temporal
inter-joint coordination (Levin et al. 2009; Lum et al., 2009).
Their presence is often indicative of an exercise or set-up needing
alteration, muscle weakness or fatigue. In addition to configuring the
environment to limit unwanted compensations, patients can use
technologies that provide real-time feedback on movements, can be
trained to govern their own movement patterns (e.g. using mirrors) or
therapists can provide feedback and manual guidance.
Active
– individuals should be actively engaged in their training and not rely
upon passive assistance to move whenever possible. The majority of
people after stroke will have some cognitive deficits in the first weeks
and months after stroke and may need demonstration and physical, graded
guidance at least initially, plus simple task set-ups and clear
feedback (Lowder et al., 2022; Milosevich et al. 2024).
If possible, the environment should be arranged so that an individual
with stroke can undertake training with no, or limited assistance so
they can practice frequently, outside of therapist delivered sessions.
Enlisting the help of others (e.g. carers) may also facilitate practice.
Whilst the rehabilitation environment can initially be adapted to
enable function (e.g. using adapted cutlery), ultimately it should
provide the spatial and temporal challenges of a real-world setting,
(e.g. using cutlery in a busy restaurant).
Variable
– in addition to titrating difficulty to maintain challenge, the
training objects and goal should be varied to provide ‘flexibility’ of
performance (such as varying plane or speed of movement). Movements can
be practiced in their entirety or in parts which enable concentration
upon a difficult part of a movement before being incorporated into a
whole goal-oriented movement.
Feedback –
clear feedback to highlight that a movement has been successful is vital
to underpin learning and continued motivation. Feedback can be provided
by therapists (i.e. video and verbal feedback) during the session using
a coaching approach; however, attention and planning are required to
ensure patients receive feedback intrinsically or environmentally when
practicing outside of therapist-delivered sessions. This could be
provided by carers, technology (e.g. virtual reality gaming, biofeedback
or sensors) or by features included in the task set-up.
Conclusions and implications for research and practice
This
editorial highlights that whilst completion of many repetitions of
movements is important, inclusion of the other core principles of motor
learning (comprising specific, graded, variable, active practice and the
provision of feedback) is also needed to elicit motor recovery after
stroke. This relies upon skilled movement analysis (discussed in our
first editorial) to guide therapy planning and the provision of tailored
support to actively engage patients in their own rehabilitation
wherever possible. These approaches can also be augmented by adjuncts
recommended in the guidelines, including electrical stimulation, mental
imagery and mirror box (Royal College of Physicians, 2023).
We
hope that these editorials provide occupational and physiotherapists
with a succinct summary of the core principles which guide how
the currently recommended rehabilitative interventions for motor
recovery can be delivered to provide the greatest benefit for people
after stroke. To ensure relevance to, and impact upon clinical practice,
we recommend that future research of treatments for motor recovery
after stroke must clearly articulate the principles upon which
interventions are designed and how interventions were delivered
(e.g. by using existing resources such as the TIDieR checklist and
frameworks for recovery and dose; Bernhardt et al., 2017; Hoffmann et al., 2014).
This clarity empowers therapists to accurately utilise effective
interventions in clinical practice to provide the most favourable
outcomes for the many thousands of people who require rehabilitation
after stroke.
Acknowledgments
The authors would like to acknowledge Prof Nick Ward, Dr Kate Hayward and Dr Kathryn Jarvis for their comments on this work.
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