Stroke upper limb rehabilitation and the Ten Movement Training PrinciplesJul 07, 2022
The recovery of upper limb and hand function following stroke remains both a fascination and frustration! Some stroke survivors show gradual signs of upper limb (UL) and movement recovery over 3-6 months following the stroke event. Many people who show early signs of recovery in the first few days, go on to regain 70% of their lost movement by 3 months, in what has been termed the ‘proportional recovery rule’ (1). However, predicting recovery for any individual following stroke is very difficult, and those with more severe movement deficits do not seem to follow any rule, so even the most experienced and astute health professionals cannot determine who might show some progress and respond to rehabilitation. Even computers are better at predicting! (2) This is incredibly frustrating for all concerned, because so much day-to-day function and quality of life becomes invested into therapy time with physiotherapists and occupational therapists. More importantly, stroke survivors would like more clear information that can provide hope and motivation to drive their commitment to therapy, particularly since UL therapy needs to be quite intensive!
There are many variables at play here, and many researchers have attempted to determine ways of identifying those people with upper limb rehabilitation potential. Some small but important progress has been made that may help identify those with intact neural pathways, which is one of the important determinants for hand function (3). Intact corticospinal pathways are needed for fine motor and dexterity movements of the hand, which are so critical for higher level hand and arm functions. But as we cover in our motor control courses, there is more to the story than just intact pathways. Even if pathways are intact, control of movement recovery will also be impacted other important brain functions such as sensory changes, cognitive processes that involve spatial awareness, movement ideation and planning, attention, memory, and behaviour. In addition, there are likely to be neuroplastic adaptations in brain, brainstem and spinal cord neurophysiology that influence movement recovery. Musculoskeletal adaptations in muscles, tendons and joints also influence movement. Both neural and musculoskeletal adaptions will change with time, with recovery prognosis becoming progressively more limited as time rolls on.
The challenge is clear. We are dealing with stroke damage to different brain regions, with different lesion sizes and interruption to many brain networks that influence the course of upper limb recovery. But what about therapy? How much therapy does somebody need and what should they be doing within their therapy session to drive the best outcomes?
Let’s start with how much therapy. The general consensus is that the amount of upper limb therapy provided historically is often just not enough. For people who stay in hospital for rehabilitation, it makes sense that medical stability and safe mobility become a priority that enable people to be discharged out of hospital safely. Walking recovery is often prioritised by both people with stroke due to pragmatic reasons and/or behavioural/cognitive changes. As a result, shoulder and upper limbs are somewhat neglected (by both the person and the staff!). Early upper limb therapy trials in recovering hands showed promising results when therapy was very intensive and indicated that more practice was needed in order to squeeze out the best recovery for some individuals. Over the past 20 years ‘dose’ (eg time engaged in active practice & number of practice repetitions) was considered a key factor in research trials.
“But an overemphasis on ‘dose’ in research may also be too much of a reductionist view.”
What did they find? Yes, dose is important, and upper limb therapy needs to provide opportunity for patients to engage in more practice. High numbers of repetitions of movement practice, more supervision and direction, support and behavioural modification can help increase practice for some. But an overemphasis on ‘dose’ in research may also be too much of a reductionist view. Research shows that at some point dose of repetitions cannot squeeze out any more recovery (4). So, what about types of therapy? How important is ‘what’ is included in therapy and what and how should movement be practiced?
This is where it gets tricky. It appears that early on after stroke, in that first 3 months, it does not really matter too much what types of active therapy is tried, recovery will often follow its own natural course! Recent research from here in Adelaide together collaborators in London showed that in the very first few weeks after stroke, neuroplastic processes may be heightened (5). The next stage is to figure out how we might be able to take advantage of this more excitable time by targeting certain types of therapy during this period or even finding some way to extend this period. That would be a breakthrough indeed. This early phase is also an important time to ensure that weakness, contracture, pain and stiffness don’t ruin opportunities for future progress, perhaps at a time whe the individual is ready for intensive therapy. The brain is plastic, but the body? Well, not so much!
There are many types of therapy strategies available to a skilled therapist. Sensory stimulation, movement facilitation, functional electrical stimulation, mobilisation, strengthening, practicing specific skills and tasks, as well as part-practice of important movement components of tasks. It appears that both task specific and non-task specific forms of training can be helpful in acute stages of recovery (6). Other coaching strategies can be used that incorporate constraints and restraints that force new movement strategies to emerge, behavioural modifications to improve awareness and insight about arm use, action observation and mirror-box therapy to help movement planning. Pain, swelling and musculoskeletal changes that relate to contracture, arthritis, weakness and muscle imbalances, neuropathic sensory changes all influence the choice of therapy interventions. Adjuvant treatments have also been researched with types of brain stimulation (7), vagus nerve (8) or even cervical nerve root stimulation (9), which show some promise, while research into medications such as stimulants and selective serotonin reuptake inhibitors have been disappointing. Upper limb robotics (10) and virtual reality technology (11) is also evolving quickly and provides us with some optimism for future progress.
“Problems with labelling and classifying the active ingredients of rehabilitation is well recognised, and this is a big problem if we are to implement new findings and collaborate with other fields of research and practice.”
With so many therapy strategies available, it now becomes imperative that people with stroke, therapists and researchers understand what components of recovery can be targeted. Problems with labelling and classifying the active ingredients of rehabilitation is well recognised, and this is a big problem if we are to implement new findings and collaborate with other fields of research and practice. We need to improve these aspects of we are take the next step for true innovation and progress. Currently stroke guidelines, while useful, are limited by their vague language and many stroke intervention research trials are very poor at informing the reader about the specifics of the therapy used (12). This limits the ability of guidelines and research to guide therapy at an operational level, making it difficult to navigate through these muddy waters.
The ‘Ten Movement Training Principles’ (10-MTPs) (13) were developed to guide patients, therapists and researchers through these muddy waters. The 10-MTPs draw upon current knowledge from exercise prescription, motor control theories, coaching philosophies, human movement biomechanics, neuroplasticity & learning. These guiding principles have a very broad application to physical rehabilitation; however, it is useful to discuss how they might guide us through the specific challenges of stroke upper limb rehabilitation.
Join me for a webinar that explores the 10 Movement Training Principles specifically in relation to the recovery & rehabilitation of hands and upper limbs following stroke.
Register here if you are interested in joining me on Tuesday August 2nd for a lecture + Q & A discussion.
See you then!
Associate Professor James McLoughlin
- Krakauer JW, Marshall RS. The proportional recovery rule for stroke revisited. Ann Neurol. Wiley Online Library; 2015 Dec;78(6):845–7.
- Harmeling-van der Wel BC, Kwakkel G. Accuracy of physical therapists’ early predictions of upper-limb function in hospital stroke units: the EPOS Study. Physical [Internet]. 2013; Available from: https://academic-oup-com.ezproxy.flinders.edu.au/ptj/article-abstract/93/4/460/2735324
- Ackerley SJ, Smith MC, Cramer SC, Stinear CM. Biomarkers for Patient Selection Improve Stroke Rehabilitation Trial Efficiency. Stroke [Internet]. 2019; Available from: https://www-ahajournals-org.ezproxy.flinders.edu.au/doi/abs/10.1161/str.50.suppl_1.114
- Lang CE, Strube MJ, Bland MD, Waddell KJ, Cherry-Allen KM, Nudo RJ, et al. Dose response of task-specific upper limb training in people at least 6 months poststroke: A phase II, single-blind, randomized, controlled trial. Ann Neurol. 2016;80(3):342–54.
- Hordacre B, Austin D, Brown KE, Graetz L, Pareés I, De Trane S, et al. Evidence for a Window of Enhanced Plasticity in the Human Motor Cortex Following Ischemic Stroke. Neurorehabil Neural Repair. 2021 Feb 12;1545968321992330.
- Krakauer JW, Kitago T, Goldsmith J, Ahmad O, Roy P, Stein J, et al. Comparing a novel neuroanimation experience to conventional therapy for high-dose, intensive upper-limb training in subacute stroke: The SMARTS2 randomized trial. medRxiv [Internet]. 2020; Available from: https://www.medrxiv.org/content/10.1101/2020.08.04.20152538v1.full.pdf+html
- León Ruiz M, Rodríguez Sarasa ML, Sanjuán Rodríguez L, Benito-León J, García-Albea Ristol E, Arce Arce S. Current evidence on transcranial magnetic stimulation and its potential usefulness in post-stroke neurorehabilitation: Opening new doors to the treatment of cerebrovascular disease. Neurologia. 2018 Sep;33(7):459–72.
- Dawson J, Liu CY, Francisco GE, Cramer SC, Wolf SL, Dixit A, et al. Vagus nerve stimulation paired with rehabilitation for upper limb motor function after ischaemic stroke (VNS-REHAB): a randomised, blinded, pivotal, device trial. Lancet. 2021 Apr 24;397(10284):1545–53.
- Capogrosso M, Powell M, Verma N, Sorensen E, Carranza E, Boos A, et al. Epidural stimulation of the cervical spinal cord improves voluntary motor control in post-stroke upper limb paresis [Internet]. Research Square. 2022. Available from: http://dx.doi.org/10.21203/rs.3.rs-1523403/v1
- Brackenridge J, V. Bradnam L, Lennon S, J. Costi J, A. Hobbs D. A Review of Rehabilitation Devices to Promote Upper Limb Function Following Stroke. Neuroscience and Biomedical Engineering. 2016;4(1):25–42.
- Levin MF. What is the potential of virtual reality for post-stroke sensorimotor rehabilitation? Expert Rev Neurother. 2020 Mar;20(3):195–7.
- Janzen S, McIntyre A, Richardson M, Britt E, Teasell R. Building a Knowledge to Action Program in Stroke Rehabilitation. Can J Neurol Sci. 2016 Sep;43(5):619–25.
- McLoughlin J. OpenPhysio| Journal. openphysiojournal.com [Internet]. Available from: https://www.openphysiojournal.com/article/ten-guiding-principles-for-movement-training-in-neurorehabilitation/
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