Time to reconcile research findings and clinical practice on upper limb neurorehabilitation

Abstract

The problem: In the field of upper limb neurorehabilitation, the translation from research findings to clinical practice remains troublesome. Patients are not receiving treatments based on the best available evidence. There are certainly multiple reasons to account for this issue, including the power of habit over innovation, subjective beliefs over objective results. We need to take a step forward, by looking at most important results from randomized controlled trials, and then identify key active ingredients that determined the success of interventions. On the other hand, we need to recognize those specific categories of patients having the greatest benefit from each intervention, and why. The aim is to reach the ability to design a neurorehabilitation program based on motor learning principles with established clinical efficacy and tailored for specific patient's needs.

Proposed solutions: The objective of the present manuscript is to facilitate the translation of research findings to clinical practice. Starting from a literature review of selected neurorehabilitation approaches, for each intervention the following elements were highlighted: definition of active ingredients; identification of underlying motor learning principles and neural mechanisms of recovery; inferences from research findings; and recommendations for clinical practice. Furthermore, we included a dedicated chapter on the importance of a comprehensive assessment (objective impairments and patient's perspective) to design personalized and effective neurorehabilitation interventions.

Conclusions: It's time to reconcile research findings with clinical practice. Evidence from literature is consistently showing that neurological patients improve upper limb function, when core strategies based on motor learning principles are applied. To this end, practical take-home messages in the concluding section are provided, focusing on the importance of graded task practice, high number of repetitions, interventions tailored to patient's goals and expectations, solutions to increase and distribute therapy beyond the formal patient-therapist session, and how to integrate different interventions to maximize upper limb motor outcomes. We hope that this manuscript will serve as starting point to fill the gap between theory and practice in upper limb neurorehabilitation, and as a practical tool to leverage the positive impact of clinicians on patients' recovery.

Keywords: motor learning; neurorehabilitation; personalized medicine; stroke; upper limb.

Figure 1

(A) Schematic representation of comprehensive upper limb neurorehabilitation assessment; (B) example of assessment algorithm for objective upper limb neurological deficits, developed and applied at Guttmann Institute (Barcelona, Spain). 9-HPT: 9-Hole Peg Test; Arm-A: Arm Activity Measure, section A; BBT: Box and Block Test; CIMT: Constraint Induced Movement Therapy; eCIMT: expanded CIMT; FM-UE: Fugl-Meyer Upper Extremity assessment; NIBS: Non-Invasive Brain Stimulation; SULCS: Stroke Upper Limb Capacity Scale.