ReviewMotor recovery after stroke: a systematic review
Introduction
Stroke is a common global health-care problem that is serious and disabling.1 In high-income countries, stroke is the third most common cause of death and is the main cause of acquired adult disability.1, 2 However, as most patients with stroke survive the initial injury, the biggest effect on patients and families is usually through long-term impairment, limitation of activities (disability), and reduced participation (handicap).
The most common and widely recognised impairment caused by stroke is motor impairment, which can be regarded as a loss or limitation of function in muscle control or movement or a limitation in mobility.3 Motor impairment after stroke typically affects the control of movement of the face, arm, and leg of one side of the body1 and affects about 80% of patients. Therefore, much of the focus of stroke rehabilitation, and in particular the work of physiotherapists and occupational therapists, is on the recovery of impaired movement and the associated functions. There seems to be a direct relation between motor impairment and function; for example, independence in walking (function) has been correlated with lower-limb strength (impairment).4 Therefore, the ultimate goal of therapy for lower-limb motor impairment is to improve the function of walking and recovery of movement. In this Review, motor impairment and its associated functional activities are regarded as part of a continuum.
Motor impairment can be caused by ischaemic or haemorrhagic injury to the motor cortex, premotor cortex, motor tracts, or associated pathways in the cerebrum or cerebellum.1 Such impairments affect an individual's ability to complete everyday activities (disability) and affect participation in everyday life situations.5 A lack of consistency is evident among researchers and clinicians in the use of terminology that describes changes in motor ability after stroke.6 Changes in motor ability might occur via several mechanisms: restitution, substitution, or compensation.7 Levin and co-workers,6 however, distinguished motor recovery and motor compensation in accordance with the WHO International Classification of Functioning, Disability and Health framework and proposed that motor recovery relates to: restoration of function in neural tissue that was initially lost; restoration of ability to perform movement in the same way as before injury; and successful task completion as typically done by individuals who are not disabled. Types of motor compensation in these three areas include the acquisition by neural tissue of a function that it did not have before the injury; performance of a movement in a new way; and successful task completion by use of different techniques.6
In accordance with these definitions, in this Review we focused on outcomes associated with body functions or structure (impairment) and activity (functional). We favoured activity outcomes when these were used in addition to impairment outcomes as these were believed to be more clinically useful. However, we did not focus on motor recovery or motor compensation separately, as many of the outcomes (particularly those measuring activity) do not distinguish between improvements associated with increasing compensation and movement patterns. Although we recognise the potential limitations of this approach, this Review can only outline the outcomes used in the trials.
Motor recovery after stroke is complex and confusing. Many interventions have been developed to try to aid motor recovery (recovery of impairment and associated function), and many randomised controlled trials and systematic reviews have been done.8 Most of these interventions do not explicitly target a specific pathophysiological process and have been tested using a variety of patient groups and outcome measures. We have, therefore, taken a pragmatic, empirical approach to describing and reviewing these interventions.
In this Review, we summarise the available evidence for the treatment of motor impairment and restoration of motor function after stroke. Our aims were to: (i) summarise the available evidence from systematic reviews of randomised controlled trials; (ii) identify areas for which interventions show promise of efficacy; and (iii) relate this information to the current guideline advice on clinical management.
We used a range of approaches to identify relevant interventions, which included expert opinion,9 the views of multidisciplinary focus groups, and systematic searching of relevant texts and guidelines.10 A focus on recovery of impairment of specific muscles, muscle groups (such as muscle tone or muscle length), or related impairments (such as pain or contractures) was beyond the scope of this Review. Instead, we focus on the effect of interventions on recovery in four key areas of movement and function that were believed to best encapsulate the targets of the available interventions: (1) upper-limb (arm and hand) movement and function; (2) gait (walking ability; as this is a primary function of the lower limbs); (3) balance (as this is a primary function of the trunk); and (4) mobility (as this combines upper-limb function, lower-limb function, and balance to enable normal movements).
Section snippets
Search strategy and selection criteria
We hand-searched the Cochrane Library for all systematic reviews that included randomised trials of interventions to promote motor recovery (recovery of impairment or related function) after stroke and that had been registered with the Cochrane Stroke Group by March, 2009. We chose this approach because several systematic reviews have been done in (or overlap with) this area. We therefore sought to use the best available systematic reviews and to supplement these (when necessary) with
Interventions identified
We identified 19 categories of intervention relevant to motor recovery after stroke that were included in a Cochrane review, other review, or individual randomised trial (figure 1; table 1). We identified one intervention (the use of walking aids) for which we were unable to identify any relevant evidence.
Evidence identified
Table 1 outlines the intervention categories (with an accompanying description and rationale for that intervention), intervention targets (upper limb or lower limb, balance, or gait), and the
Conclusions
We have identified a broad range of interventions that have been developed to assist motor recovery (movement and related functions) after stroke. Many of these interventions have been subjected to evaluation in randomised controlled trials and their results synthesised in systematic reviews. Before discussing the implications of our Review, it is worth considering the strength and weaknesses of our approach.
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