Stroke: Physiotherapy Treatment Approaches

Original Editor - Naomi O'Reilly

Top Contributors - Naomi O'Reilly, Kim Jackson, Lucinda hampton, Lauren Lopez, 127.0.0.1, Simisola Ajeyalemi, WikiSysop, Vidya Acharya, Shaimaa Eldib, Rucha Gadgil and Amrita Patro  

Introduction

A wide range of treatment techniques and approaches from different philisophical backgrounds are utilised in Neurological Rehabilitation. Research to support the different approaches varies hugely, with a wealth of research to support the use of some techniques while other approaches have limited evidence to support its use but rely on ancedotal evidence. This page provides a brief overview of some of the approaches used in Stroke Rehabilitation with evidence based clinical guideline recommendations.

State of the Evidence

Figure 1. Overview of Outcomes for which Interventions are available with Significant Summarized Effects

This graphically displays the outcomes classified according to the ICF, with corresponding interventions for which is strong evidence that they significantly affect those outcomes.Legend: A green point indicates that the intervention has a significant positive effect on the outcome, while a red point indicates that the intervention has a significant negative effect on the outcome;

Interventions 

Positioning

Practice Statement
Consensus-based Recommendation

1. Arm Support devices such as a Lap Tray may be used to assist with arm positioning for those at risk ofshoulder subluxation
2. Education and training around correct manual handling and positioning should be provided to the individual with stroke, their family/carer and health professionals, particularly nursing and other allied health staff.

Early Mobilisation

Strong Recommendation AGAINST

1. Starting intensive out of bed activities within 24 hours of stroke onset is not recommended.

Strong Recommendation FOR

1. Commence mobilisation (out of bed activity) within 48 hrs of stroke onset unless receiving palliative care.

Balance

Sitting

Strong Recommendation

1. Practising reaching beyond arm’s length while sitting with supervision/assistance should be undertaken for individuals who have difficulty with sitting. 

Standing

Strong Recommendation
Practice of standing balance should be provided for individuals who have difficulty with standing. Strategies could include:

1. Practising functional tasks while standing (van Dujjnhoven et al 2016 [108] Veerbeek et al 2014 [83]; English et al 2010 [99]
2. Walking training that includes challenge to standing balance (e.g. overground walking, obstacle courses) (van Dujjnhoven et al 2016 [108])
3. Providing visual or auditory feedback (Veerbeek et al 2014 [83]; Stanton et al 2011 [97])

Gait

Strong Recommendation

Tailored repetitive practice of walking (or components of walking) should be practiced as often as possible for individuals with difficulty walking (French et al 2007 [132]). The following modalities can be used to achieve this:

1. Circuit Class Therapy (with a focus on overground walking practice) (English et al 2010 [114]; van de Port et al [115])
2. Treadmill Training with or without body weight support (Mehrholz et al 2014 [117])
3. Virtual Reality Training (Corbetta et al 2015 [125]; Rodrigues-Baroni et al 2014 [126]; Laver et al 2015 [127])

Weak Recommendation

Other interventions may be used in addition to those above:

Electromechanically Assisted Gait Training (Mehrholz et al 2013 [121])

Biofeedback (Stanton et al 2011 [123])

Cueing of Cadence (Nascimento et al 2015 [122])

Functional Electrical Stimulation (Howlett et al 2015 [124])

Treadmill

Electromechanical Assisted

Rhythmic Cueing

Virtual Reality

Overground Walking

Community Walking

Weak Recommendation

1. Individualised goals should be set and assistance with adaptive equipment, information, and further referral on to other agencies should be provided for individuals who have difficulty with outdoor mobility in the community.
2. Walking practice may benefit some individuals and if provided, should occur in a variety of community settings and environments, and may also incorporate virtual reality training that mimics community walking. (Barclay et al 2015 [19]; Logan et al 2014 [21])

Orthotics

Weak Recommendation

1. Individually fitted lower limb orthoses may be used to minimises limitations in walking ability. Improvement in walking will only occur while the orthosis is being worn. (Tyson et al 2013 [129])

Upper Limb

Bilateral Arm Training

Weak Recommendation

1. Bilateral arm training may be used as part of comprehensive goal directed rehabilitation. However, when matched for dosage, unilateral training may be more effective. (Veerbeek et al 2014 [50]; van Delden et al 2012 [138]; Coupar et al 2010 [133])

Constrain Induced Movement Therapy

Strong Recommendation

1. Intensive Constraint Induced Movement Therapy (minimum 2 hours of active therapy per day for 2 weeks, plus restraint for at least 6 hours a day) should be provided to improve arm and hand use for individuals with some active wrist and finger extension. (Corbetta et al 2015 [144])
2. Trunk restraint may also be incorporated into the active therapy sessions at any stage post-stroke. (Wee et al 2014 [165])

Electrical Stimulation

Strong Recommendation

1. Use of electrical stimulation in conjunction with motor training should be used to improve upper limb function after stroke . (Howlett et al 2015 [124])

Robot Assisted Arm Training

Strong Recommendation

1. Mechanically assisted arm training (e.g. robotics) should be used to improve upper limb function in indivduals with mild to severe arm weakness after stroke. (Mehrholz et al 2015 [156])

Virtual Reality

Strong Recommendation

1. Virtual Reality and interactive games should be used to improve upper limb function in individuals with mild to moderate arm impairment after stroke. Virtual reality therapy should be provided for at least 15 hours total therapy time. (Laver et al 2015 [96])

Mirror Therapy

Weak Recommendation

1. Mirror Therapy may be used as an adjunct to routine therapy to improve arm function after stroke for individuals with mild to moderate weakness, complex regional pain syndrome and/or neglect. (Thieme et al 2012 [162])

Mental Practice

Weak Recommendation

1. Mental practice in conjunction with active motor training may be used to improve arm function for individuals with mild to moderate weakness of their arm,. (Kho et al 2014 [157]; Barclay-Goddard et al 2011 [158]; Braun et al 2014 [128])

Splinting

Strong Recommendation AGAINST

1. Routine practice should not include Hand and wrist orthoses (splints) as they have no effect on function, pain or range of movement (Tyson et al 2011 [129])

Cardiorespiratory Training

Strong Recommendation

1. Rehabilitation should include individually tailored exercise interventions to improve cardiorespiratory fitness.

Practice Statement
Consensus-based Recommendations

1. Commence cardiorespiratory training during their inpatient stay.
2. Encourage to participate in ongoing regular physical activity regardless of level of disability.

Strength Training

Strong Recommendation

1. Progressive resistance training should be offered to those with reduced strength in their arms or legs.

Circuit Class

Aquatherapy

Electrotherapy

Weak Recommendation

1. Electrical stimulation may be used for those with reduced strength in their arms or legs (particularly for those with less than antigravity strength).
2. Electrical stimulation may be used to prevent or reduce shoulder subluxation. (Vafadar et al 2015 [75])

Neuromuscular Electrical Stimulation

TENS

Electromyographic Biofeedback

Spasticity Management

Stretch

Weak Recommendation AGAINST

1. Routine use of stretch to reduce spasticity is not recommended.(Katalinic et al 2010 [64]; Kim et al 2013 [65]; Jung et al 2011 [66])
2. Adjunct therapies to Botulinum toxinum A such as electrical stimulation, casting, taping and stretching may be used to reduce spasticity. (Stein et al 2015 [56]; Krewer et al 2014 [57]; Etoh et al 2015 [58]; Ochi et al 2013 [59]; Wu et al 2014 [60]; Yamaguchi et al 2012 [61]; Mills et al 2016 [62]; Santamato et al 2015 [63])

Botulinum Toxin

Weak Recommendation

1. Botulinum Toxin A in addition to rehabilitation therapy may be used to reduce upper limb spasticity but is unlikely to improve activity or motor function. (Foley et al 2013 [38]; Dashtipour et al 2015 [39]; Baker et al 2015 [40]; Gracies et al 2014 [42])
2. Botulinum Toxin A in addition to rehabilitation therapy may be useful for improving muscle tone in patients with lower limb spasticity but is unlikely to improve motor function or walking. (Wu et al 2016 [60]; McIntyre et al 2012 [51]; Olvey et al 2010 [52])

Contracture Management

Strong Recommendation AGAINST

1. For people with stroke at risk of developing contracture, routine use of splints or prolonged positioning of upper or lower limb muscles in a lengthened position (stretch) is not recommended. (Katalinic et al 2010 [64])

Practice Statement
Consensus-based Recommendations

1. For stroke survivors, serial casting may be trialled to reduce severe, persistent contracture when conventional therapy has failed.
2. For stroke survivors at risk of developing contracture or who have developed contracture, active motor training to elicit muscle activity should be provided.

Fatigue Management

Practice Statement
Consensus-based Recommendations

1. Therapy for stroke survivors with fatigue should be organised for periods of the day when they are most alert.
2. Information and education about fatigue should be provided to individuals with Stroke and their Families/Carers
3. Potential modifying factors for fatigue should be considered including avoiding sedating drugs and alcohol, screening for sleep- related breathing disorders and depression
4. While there is insufficient evidence to guide practice, possible interventions could include exercise and improving sleep hygiene

Recent Related Research (from Pubmed)

References

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