PHYSIOTHERAPY INTERVENTIONS PROMOTE FUNCTIONAL OUTCOMES FOLLOWING SEVERE STROKE: A SYSTEMATIC REVIEW AND META-ANALYSIS

I. Sorinola^1,2, A. McCaul², A. Winter², K. Mehta³

¹London Metropolitan University, School of Human Sciences, London, United Kingdom, ²King's College London, School of Population Health and Environmental Science, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom, ³King's College London, Centre for Education, Faculty of Life Sciences and Medicine, London, United Kingdom

Background: In spite of considerable rehabilitation efforts, the prognosis for post stroke upper limb function recovery remains poor, with up to 28% experiencing no recovery, leading to severe upper limb impairment, reduced quality of life and dependency. Furthermore, these individuals have reported complex psychological impact of a dysfunctional arm which compounds their often unmet physical disabilities (Smith R et al. 2018). These points justify the search for interventions to further optimise rehabilitation upper limb outcomes for these individuals. The goal of this review is to evaluate the effect size of rehabilitation interventions for severe upper limb deficits after stroke.

Purpose: To investigate the effect sizes of commonly used physiotherapy rehabilitation interventions for promoting upper limb function in severe stroke.

Methods: A systematic search for randomised controlled trials published between January 1990 and May 2021 was conducted in the following databases: Ovid MEDLINE, PEDro, EMBASE, AMED, CINAHL, Cochrane (CENTRAL) and Web of Science. Clinical trials investigating the effect of single physiotherapy interventions delivered to optimise functioning in severe upper limb stroke deficits were selected for inclusion in the review. Studies which investigated individuals within one year of stroke, with severe upper limb deficits defined as < 3 on the Brunnstrom classification ; < score of 9 on the Action Research Arm Test (ARAT); < 54 on the Functional Independence Measure (FIM); <60 on the Barthel Index (BI) score ; between 21 and 45 on the NIH stroke scale (NIHSS); scores between 3 or 4 on only the arm component of the NIH stroke scale (NIHSS); ≤ 27 on the Fugl Meyer Assessment (FMA) or ≤ 21 on the FMA upper extremity component only (component 6) (FMAUE); ≥ 3 for arm related spasticity the Modified Ashworth Scale (MAS), were selected. Effect sizes of the effect of rehabilitation interventions on primary outcome measures (OM) within the International Classification of Functioning (ICF) domains, including sub-group analyses for individual interventions were determined.

Results: Forty studies were included in the analysis totalling 2317 participants. Physiotherapy interventions identified for severe stroke were robotic training (RT), neuromuscular electrical stimulation (NMS), mirror therapy (MT), increased conventional therapy training, brain stimulation (BS) and virtual reality (VR). These interventions showed an overall effect size of standardised mean difference (SMD) of 0.55 (95% confidence interval (CI): 0.2, 0.9; p=0.002) on upper limb motor function. For upper limb functional ability (activity), an overall effect size of SMD = 0.36 (95% CI: -0.02, 0.73; P=0.06) and for global functioning, SMD = 0.33 (95% CI: -0.09, 0.76; P=0.13. Sub group analyses indicate that RT, NMS and MT interventions showed the largest effect sizes for motor function; only RT showed the largest effect size for functional ability and BS and NMS showed the largest effect sizes for global functioning.

Conclusions: There are rehabilitation interventions that could optimise functional improvement in individuals with severe upper limb deficits for whom therapists may not prioritise continuing interventions for.

Implications: Rehabilitation therapists should consider these interventions for individuals who have severe arm deficit as a part of the regular care approach for these individuals.

Funding acknowledgements: Nothing Applicable

Keywords:
Stroke
Upper limb
Physiotherapy

Topics:
Neurology: stroke
Disability & rehabilitation
Neurology

Did this work require ethics approval? No

Reason: This is secondary analysis of already published data.