Congratulations to Dr. Janis Daly on the Recommendation of her article “Comparison of robotics, functional electrical stimulation, and motor learning methods for treatment of persistent upper extremity dysfunction after stroke: a randomized controlled trial.” This article was originally published in June 2015’s Archives of Physical Medicine and Rehabilitation and was recommended by Dr. Nick Ward from the Institute of Neurology, University College London, London, UK.
OBJECTIVE: To compare response to upper-limb treatment using robotics plus motor learning (ML) versus functional electrical stimulation (FES) plus ML versus ML alone, according to a measure of complex functional everyday tasks for chronic, severely impaired stroke survivors.
DESIGN: Single-blind, randomized trial.
SETTING: Medical center.
PARTICIPANTS: Enrolled subjects (N=39) were >1 year postsingle stroke (attrition rate=10%; 35 completed the study).
INTERVENTIONS: All groups received treatment 5d/wk for 5h/d (60 sessions), with unique treatment as follows: ML alone (n=11) (5h/d partial- and whole-task practice of complex functional tasks), robotics plus ML (n=12) (3.5h/d of ML and 1.5h/d of shoulder/elbow robotics), and FES plus ML (n=12) (3.5h/d of ML and 1.5h/d of FES wrist/hand coordination training).
MAIN OUTCOME MEASURES: Primary measure: Arm Motor Ability Test (AMAT), with 13 complex functional tasks; secondary measure: upper-limb Fugl-Meyer coordination scale (FM).
RESULTS: There was no significant difference found in treatment response across groups (AMAT: P≥.584; FM coordination: P≥.590). All 3 treatment groups demonstrated clinically and statistically significant improvement in response to treatment (AMAT and FM coordination: P≤.009). A group treatment paradigm of 1:3 (therapist/patient) ratio proved feasible for provision of the intensive treatment. No adverse effects.
CONCLUSIONS: Severely impaired stroke survivors with persistent (>1y) upper-extremity dysfunction can make clinically and statistically significant gains in coordination and functional task performance in response to robotics plus ML, FES plus ML, and ML alone in an intensive and long-duration intervention; no group differences were found. Additional studies are warranted to determine the effectiveness of these methods in the clinical setting.
The field of neurorehabilitation is littered with ‘pragmatic’ studies delivering therapy at doses that are unlikely to have any effect. This study, however, delivered upper limb therapy (of three slightly different types) to chronic stroke patients for 300 hours over 12 weeks. There was no difference in outcome for those who received robotics or electrical stimulation in addition to relatively conventional upper limb therapy. However, the key result was the magnitude of the change seen in all the groups, ranging between 8 to 11 points on the upper limb Fugl-Meyer score. A change in impairment of this magnitude was previously considered almost impossible in chronic stroke patients. The take home message is that future large scale randomized controlled trials (RCTs) of post-stroke neurorehabilitation need to investigate much bigger doses than those currently being used (either in trials or indeed in clinical practice).
This study should encourage us to think about much bigger doses of therapy post-stroke neurorehabilitation. The trial had small numbers and so we need to see replication from other groups in different settings, but this result should see a shift in stroke rehabilitation trial design.