Stroke is a leading cause of acquired, permanent disability worldwide. Although the treatment of acute stroke has been improved considerably, the majority of patients to date are left disabled with a considerable impact on functional independence and quality of life. As the absolute number of stroke survivors is likely to further increase due to the demographic changes in our aging societies, new strategies are needed in order to improve neurorehabilitation. The most critical driver of functional recovery post-stroke is neural reorganisation. For developing novel, neurobiologically informed strategies to promote recovery of function, an improved understanding of the mechanisms enabling plasticity and recovery is mandatory. This review provides a comprehensive survey of recent developments in the field of stroke recovery.
Interventions
Treatment Strategies
Novel treatment strategies post stroke are needed to reduce stroke-induced morbidity and to increase the patient’s and caregiver’s quality of life. Functional neuroimaging, as well as non-invasive brain stimulation techniques, have significantly advanced our understanding of stroke-induced reorganisation of brain networks.
Evidence is accumulating that network effects distant to the lesion contribute to the motor deficit and recovery thereof significantly. That these effects are time and region dependent impacts future strategies to shape network reorganisation through brain stimulation techniques. Given the large variability in network responses following a stroke, individual network readouts and/or multivariate decoding techniques seem mandatory for the stratification of patients to achieve an optimal therapeutic response.
Common Goals After A Stroke
Being able to return to independent walking is a common goal after stroke. One-third of stroke survivors who are initially non ambulant do not return to independent walking. For those who are able to walk independently after stroke, many walk at reduced walking speeds and almost one-third are unable to walk unsupervised in their community.
Interventions that can improve walking include use of treadmill, biofeedback and cueing of cadence. A systematic review by Nascimento in 2021 found that treadmill training had a similar or better effect on walking speed and distance compared with overground walking for people who can walk after stroke. The participants improved walking speed by 0.13 m/s (95% CI 0.08 to 0.19) and walking distance by 46 m in the 6-minute walk test (95% CI 24 to 68). Treadmill training may be more effective in stroke survivors who are less disabled.
Therapy Settings
The setting in which therapies are delivered has also been evaluated. A systematic review by Nascimento et al in 2022 compared home-based and centre-based exercises for stroke survivors who could walk at 0.3 to 0.9 m/s.24. The home-based exercises had very similar effects as centre-based exercises: walking speed MD–0.03 m/ s (95% CI–0.07 to 0.02) and balance MD 0 points (95% CI–1to2)on the Berg Balance Scale from 0 to 56. This review provided strong evidence that home-based exercises are as effective as centre-based exercises.
Despite the prevalence of contracture, there is very little evidence for its management after stroke. Further research to understand the mechanisms, predictors and treatment for contracture are required to better manage this impairment.
Conclusion
The authors concluded that repetitive practice should be prioritised over therapy based on the Bobath concepts.
References
- 1. Cao, Z. and Elkins, M.R. (2024). Stroke rehabilitation. Journal of Physiotherapy, [online] 70(1), pp.5–6. doi:https://doi.org/10.1016/j.jphys.2023.11.003.
- Grefkes, C. and Fink, G.R. (2020). Recovery from stroke: current concepts and future perspectives. Neurological Research and Practice, [online] 2(17). doi:https://doi.org/10.1186/s42466-020-00060-6.