Rehabilitation of Motor Function after Stroke: A Multiple Systematic Review Focused on Techniques to Stimulate Upper Extremity Recovery

Abstract

Stroke is one of the leading causes for disability worldwide. Motor function deficits due to stroke affect the patients' mobility, their limitation in daily life activities, their participation in society and their odds of returning to professional activities. All of these factors contribute to a low overall quality of life. Rehabilitation training is the most effective way to reduce motor impairments in stroke patients. This multiple systematic review focuses both on standard treatment methods and on innovating rehabilitation techniques used to promote upper extremity motor function in stroke patients. A total number of 5712 publications on stroke rehabilitation was systematically reviewed for relevance and quality with regards to upper extremity motor outcome. This procedure yielded 270 publications corresponding to the inclusion criteria of the systematic review. Recent technology-based interventions in stroke rehabilitation including non-invasive brain stimulation, robot-assisted training, and virtual reality immersion are addressed. Finally, a decisional tree based on evidence from the literature and characteristics of stroke patients is proposed. At present, the stroke rehabilitation field faces the challenge to tailor evidence-based treatment strategies to the needs of the individual stroke patient. Interventions can be combined in order to achieve the maximal motor function recovery for each patient. Though the efficacy of some interventions may be under debate, motor skill learning, and some new technological approaches give promising outcome prognosis in stroke motor rehabilitation.

Keywords: paresis; rehabilitation; review; stroke; systematic review; upper extremity.

Figure 1

Hypothetical pattern of recovery after stroke with timing of intervention strategies. The neurological recovery after stroke displays a nonlinear, logarithmic pattern. The greater part of recovery is reported to take place in the first three months following stroke. Rehabilitation interventions targeting at improving a stroke patients' performance should be implemented according to the phase of neurological recovery. Reprinted from Langhorne et al. (2011), Copyright [2011] by Elsevier. Reprinted with permission.

Figure 2

Suggested sequence of tests to predict the recovery of motor function in patients with subacute stroke (weeks after stroke). Although this particular algorithm requires validation, it illustrates a potentially efficient progression from simple to more complex predictive measures. SAFE, sum of muscle force on shoulder abduction and finger extension according to Medical Research Council muscle grades at 72 h after stroke; TMS, transcranial magnetic stimulation; MEP, motor evoked potentials in the affected upper limb; Asymmetry index, asymmetry index of fractional anisotropy in the posterior limbs of the internal capsules measured with diffusion-weighted MRI. From Stinear et al. (2014).

Figure 3

PRISMA diagram reporting the flowchart, exclusion criteria, and stages of the systematic review.

Figure 4

Decisional tree for upper extremity rehabilitation after stroke based on the conclusions of the multiple systematic review. Abbreviations: SSRI, selective serotonin reuptake inhibitor; NARI, noradrenalin reuptake inhibitor; CIMT, constraint-induced movement therapy; mCIMT, modified constraint-induced movement therapy; tDCS, transcranial direct current stimulation; rTMS, repetitive transcranial magnetic stimulation, NMES, neuromuscular electrical stimulation, TENS, transcutaneous electrical nerve stimulation.