Whilst there are some promising and effective methods for promoting recovery of upper limb function in individuals with stroke, their impact on severe upper limb stroke is unclear. Recently, researchers have suggested that using combinations of these effective methods could lead to greater improvement of functional recovery in these individuals with severe motor impairments. Few studies investigating this approach have reported varying outcomes on stroke upper limb outcomes. This systematic review evaluates the research evidence on use of combination therapies to promote recovery of upper limb function in severe strokes.
The PRISMA guidelines was utilised to conduct a systematic review and meta-analysis. Six databases including PubMed, Cochrane Central register of controlled trials (CENTRAL), Cumulated Index to Nursing and Allied Health Literature (CINAHL), EMBASE, Physiotherapy Evidence Database (PEDro) and Web of Science were searched from 2000 to June 2024, for randomised clinical trials investigating the use of combination of common rehabilitation techniques compared to conventional care or single therapy on upper limb functional outcomes such as upper limb related motor function, activity and participation in chronic severe stroke. Participants were categorized based on the severity of stroke impairment (severe or mixed impairment). Risk of bias and overall effect sizes were assessed using the PEDro scale and Onlinemeta v1.0 was utilised to conduct meta-analysis respectively. Effect sizes were reported as standardised mean difference with confidence intervals and p-values.
After screening 1177 studies, a total of sixteen clinical trials incorporating 479 participants met the inclusion criteria. In the severe impairment group, combination interventions showed moderate positive effects on motor function (SMD 0.883 [95% CI 0.210, 1.555]) and activity limitation (SMD 0.831 [95% CI 0.315, 1.348]). In the mixed impairment group, moderate effects were observed for motor function (SMD 0.593 [95% CI 0.237, 0.949]) and small effects for activity limitation (SMD 0.498 [95% CI 0.024, 0.972]). All effects were statistically significant. Substantial heterogeneity was observed in some analyses.
Combination interventions appear more effective than conventional care alone for upper limb rehabilitation in chronic stroke, with stronger effects in severely impaired populations. However, heterogeneity and potential publication bias warrant cautious interpretation. Future research should address these limitations and explore effects on participation outcomes.
This study suggest that there may be some benefits for some combination therapies in the management of the sequelae of severe stroke affecting upper limb function.
rehabilitation
upper limb
