State-of-the-art physiotherapy for stroke rehabilitation

Stroke rehabilitation is a rapidly evolving field of research, and so it is necessary to periodically re-evaluate what constitutes state-of-the-art in stroke rehabilitation practices.

Interdisciplinary rehabilitation including the work of physiotherapists, occupational therapists, and social workers is the standard for post stroke care. Stroke physiotherapy is a key component of this rehabilitation, with its focus on restoring the individual’s activities of daily living.  Physical rehabilitation is usually initiated within the first few days post-stroke, and continues over the long term for optimal outcomes.

What is state-of-the-art in stroke rehab?

Physiotherapy ‘best practices’ in stroke rehabilitation continue to evolve.  A new high-profile review (‘meta-analysis’) was recently published examining the results of 467 published clinical trials (‘randomized controlled trials’) of physiotherapy interventions for stroke rehabilitation (ref 1). This review is a revisit and update of the authors’ previous review published in 2004. A well warranted effort given that the number of clinical trials on this topic has nearly quadrupled since then! Many of the interventions investigated in these studies are actively practiced by physiotherapists in rehabilitation centres in Toronto and around the world.

As expected, the study strongly supports the central role that physiotherapy plays in stroke rehabilitation. The authors’ analysis suggests that 30 out of 53 physiotherapy interventions included in the 467 clinical trials had strong evidence of beneficial effects on one or more outcome measures for stroke recovery. These beneficial effects were mostly limited to the specific functions and activities that were being trained.

A small handful of the 53 interventions were found to hinder specific rehabilitation outcomes, the remaining 20 were found to be without statistically significant effect either good or bad (with the current state of available data). This suggests that for many of the interventions studied, the same stroke rehabilitation gains can be achieved using the control intervention as the experimental one.  In other words, ‘conventional’ stroke rehabilitation practices were often found to be equivalent to the experimental technique being studied.

In Figure 1 below you can see their summary of physiotherapy interventions with strong evidence of either aiding or hindering specific stroke rehabilitation outcomes.

Figure 1: Physiotherapy interventions with significant positive (green dot) or negative (red dot) effect on specified rehabilitation outcomes (figure reproduced from reference 1). [BWSTT: Body-weight supported treadmill training; CIMT: Constraint-induced movement therapy; EMG-NMS: Electromyography-triggered neuromuscular stimulation; ES: Electrostimulation; mCIMT: modified Constraint-induced movement therapy; NMS: Neuromuscular stimulation; prox.: Proximal; TENS: Transcutaneous electrical nerve stimulation.]

A key finding of their research is that the intensity of practice is a primary factor in determining the benefits of physiotherapy for stroke rehabilitation, and specifically, that more practice is better.  This is reflected in the ‘Canadian Best Practice Recommendations for Stroke Care’ (ref 2), where it is recommended that patients undergoing outpatient and community-based rehabilitation should be enabled to practice their exercise therapy programs at least 45 minutes per day (and up to 3 hrs), 3-5 days per week, based on individual needs and goals.

Conclusions

As is stated by the authors, this review “endorses the central role of physical therapy in interdisciplinary evidence-based stroke rehabilitation.”

Importantly, the data in this review needs to be interpreted through the lens of the patient-physiotherapist relationship. The absence of benefit for many ‘experimental’ methods over ‘conventional’ methods found in this review may be true on average for the population, but to the individual patient there may be valuable reasons for choosing one method over another.  Likewise, the use of interventions with an apparent negative effect on one functional outcome measure may have a beneficial effect on another, and may therefore be desirable, if accompanied by appropriate monitoring.

While the total variety of stroke rehabilitation interventions can appear overwhelming, a clear path forward exists. Stroke rehabilitation is best achieved through high-intensity physiotherapy programs customized to individual patients, and targeted on specific task-oriented functional outcomes desired by the patient.  Although new techniques and equipment such as our clinic’s AlterG anti-gravity treadmill can be exciting and valuable tools for some patients, the core of a successful stroke rehabilitation program is personalized, task-oriented exercise therapy, with lots of practice.

References

1. Veerbeek J.M., van Wegen E., et al. What is the evidence for physical therapy poststroke? A systematic review and meta-analysis. PLoS One. 2014 Feb 4;9(2).
2. http://www.strokebestpractices.ca