MOTOR REHABILITATION FOLLOWING A STROKE

Motor Rehabilitation Following a Stroke

Matt Lizmore
University of Guelph-Humber

MOTOR REHABILITATION FOLLOWING A STROKE

Abstract
Motor impairment typically affects 80% of stroke patients, and in the United States alone there
are roughly 700,000 stroke patients every year, thus stroke rehabilitation through the restoration
of motor function is a matter of explicit clinical importance, and is the central emphasis of this
paper. CIMT, robotic-assisted therapy, physical fitness training, and electromechanical-assisted
training are further reviewed in this paper, due to each rehabilitation strategies apparent
effectiveness and distinctiveness. The four outlined rehabilitation therapies in this paper should
provide a baseline of choice for specialized care in patients undergoing motor rehabilitation after
experiencing a stroke. Findings showed that constraint-induced movement therapy (CIMT) can
be used to effectively improve paralytic upper-extremity motor function in stroke patients.
Robotic training may be effective in combination with usual and customary care if the patient is
experiencing upper limb hemiparesis. The inclusion of physical fitness training in the form of
cardiorespiratory intervention after stroke displays efficacy in improving lower limb motor
function. Finally, stroke patients who suffer from a high degree of lower limb motor impairment
may also benefit from the use of electromechanical-assisted training devices. Therefore, in the
attempt to restore motor function in the upper and/or lower limbs, it is the recommendation of
this paper that stroke patients receive high-intensity, repetitive task-specific practice with
feedback on performance.

MOTOR REHABILITATION FOLLOWING A STROKE

A stroke is defined as the sudden loss of brain function, and is caused by the interruption
of blood flow of the brain or by the sudden rupture of blood vessels in the brain (Langhorne,
Coupar, & Pollock, 2009). When the blood supply to a specific part of the brain is cut off, or
impaired, the patient is subjected to numerous adverse and damaging effects. Body functions
affected by stroke include, but are not limited to, consciousness, intellect, personality, energy,
drive, sleep, memory, proprioception, joint mobility and stability, muscular power, tone, reflexes
and endurance. Furthermore, some of the connecting nerve fibers perish and the patient typically
suffers partial paralysis on one side of the body, known as hemiplegia (Freeman, Rogers,
Hughes, Burridge, & Meadmore, 2012). An ischemic stroke is caused by the obstruction of blood
flow within a blood vessel, occurring in roughly 80% of all patients, and a hemorrhagic stroke is
caused by the rupture of a typically weakened blood vessel, and is significantly less common
(Langhorne, Bernhardt, & Kwakkel, 2011; Sacco et al., 2006). Because most patients will
survive the initial stroke, the long-term consequences on health and daily life activities of these
patients is of considerable importance (Langhorne et al., 2011). As stated above, after surviving a
stroke there are various physiological impairments that occur; one of the most common and
significant of these affected body functions being motor impairment (Langhorne et al., 2009).
Motor impairment can be defined as the partial or total loss of function in muscle control,
function or mobility, typically occurring in the limbs or face (Langhorne et al., 2009). After
suffering a stroke, the patient typically has to re-learn specific skills through sensory feedback
(Freeman et al., 2012). Unfortunately, these patients cannot move making sensory feedback on
their performance nonexistent, and leaving the patient in a situation where adequate motor
control is crucial (Freeman et al., 2012). Motor impairment typically affects 80% of stroke
patients, and in the United States alone there are roughly 700,000 stroke patients every year, thus

MOTOR REHABILITATION FOLLOWING A STROKE

stroke rehabilitation through the restoration of motor function is a matter of explicit clinical
importance, and is the central emphasis of this paper (Langhorne et al., 2009; Sacco et al., 2006).
In a review of motor recovery strategies after stroke by Langhorne et al. (2009), a
summary of 31 randomized control trials (RCTs) observing arm and hand function indicated
constraint-induced movement therapy (CIMT) to be the most robust intervention with a large
effect size, large number of participants, and high quality of trials. However, Langhorne et al.
(2009) reviewed various other rehabilitation strategies, with mixed results. A reoccurring theme
of the interventions outlined in this study was that most interventions involved task-specific,
repetitive and intensive practice. Electromyographic (EMG) biofeedback was shown to have a
positive impact on arm function, as well as robotics, with electrostimulation and repetitive task
training showing a borderline effect. Physical fitness training involving lower limb
cardiorespiratory and strength training was shown to be effective in 22 RCTs at improving
walking ability (gait). In 17 RCTs, repetitive task training in the lower limbs was found to be
effective in improving mobility and gait. High-intensity therapy was shown to improve lower
limb gait in 6 RCTs. Observing upper limb impairments, robotic-assisted therapy was shown to
be effective in 10 RCTs at improving arm function, and electrostimulation therapy was shown to
be effective in 13 RCTs, at improving arm function. Mental practice with motor imagery and
moving platform interventions were shown in a small number of RCTs to be effective as well. A
slew of other rehabilitation strategies were reviewed and showed unknown effectiveness
including, mixed approaches, motor learning approaches, bilateral training, biofeedback,
splinting and walking aids. Thus, in conclusion, recommendations from Langhorne et al. (2009)
state:

MOTOR REHABILITATION FOLLOWING A STROKE

At present, the evidence base for clinical practice can provide only broad indicative
guidance. The main general recommendations seem to be that the alleviation of motor
impairment and restoration of motor function should (as much as possible) focus on highintensity, repetitive task-specific practice with feedback on performance. (p. 750)
Based on the findings of Langhorne et al. (2009) an exploration of CIMT, robotic-assisted
therapy, physical fitness training, and electromechanical-assisted training will be further
reviewed in this paper, due to each rehabilitation strategies apparent effectiveness and
distinctiveness. CIMT and robotic-assisted therapy were shown to be likely beneficial in upper
limb impairment, while physical fitness training and electromechanical-assisted training were
found to be beneficial in lower limb impairment.
Constraint-induced movement therapy (CIMT) involves restriction of the unaffected
limb, in combination with a large number of repetitions focused on training specific to the task
solely in the affected limb (Langhorne et al., 2009). Typically, after suffering a stroke that affects
the motor pathways of the upper limbs, the patient may feel discouraged by the difficulty of
struggling to use his or her affected limb, resulting in the dependence on the unaffected limb
leading to a condition called learned non-use (Grotta et al., 2004). Learned non-use will severely
impede the rehabilitation progress, and specifically the neuroplasticity in the affected limb
(Grotta et al., 2004). Engaging in repetitive task-specific exercise with the affected limb, while
simultaneously immobilizing the intact limb, will grow new neural pathways through
neuroplasticity (Grotta et al., 2004). Thus, CIMT encourages the patient to use his or her affected
upper limb through daily life, in order to facilitate the regrowth of damaged or dead neurons. A
benchmark study conducted by Wolf et al. (2006) examined the effects of CIMT on upper

MOTOR REHABILITATION FOLLOWING A STROKE

extremity function 3 to 9 months after stroke. The 222 subjects had predominantly suffered
ischemic stroke and were assigned to either receive CIMT (n = 106), or usual and customary
care, which served as the control (n = 116). Participants were assessed using the Wolf Motor
Function Test (WMFT) and a structured participant interview of real-world arm use (MAL). All
testing was conducted on 5 separate occasions- baseline, posttreatment (2 weeks), and 4, 8, and
12 month follow-up. The CIMT group showed larger improvements than the control group for all
measures of upper limb function except for 2 of the 17 WMFT tests. At each follow up time the
CIMT group displayed statistically significant improvements compared to the control group in
all WMFT Performance Time tests and both participant MAL tests. There were no observed
differences between groups at the 12 month mark for scores on the WMFT Functional Ability
scale (2 tests). It should be noted that control subjects also had significant improvements at the
12 month mark from baseline, though the improvements were smaller. The observed
improvements through usual and customary care can therefore also be constructive in the
rehabilitation process following a stroke, and should not be overlooked. Interestingly, Wolf et al.
(2006) noted the amount of tasks performed by the paretic arm without the assistance of the lessimpaired upper extremity nearly tripled at 12 months compared to the control group, inferring
that long-term use in daily activities in the paretic arm was due to the CIMT rehabilitation.
Therefore, the findings of this study show that CIMT can be used to effectively improve
paralytic upper-extremity motor function in stroke patients.
Robot-assisted therapy utilizes a type of machinery that employs robotics to assist the
patient, providing intensive training in a consistent manner without the fatigue normally
associated with other rehabilitation strategies (Freeman, Rogers, Hughes, Burridge, &
Meadmore, 2012). Furthermore, robotics can be precisely programmed, allowing for

MOTOR REHABILITATION FOLLOWING A STROKE

individualization based on the patients needs, and can also provide specific visual and auditory
feedback (Liao, Wu, Hsieh, Lin, & Chang, 2012). Mild to severe upper limb hemiparesis is
experienced by most patients after suffering a stroke. While most patients will regain walking
ability, upper limb hemiparesis remains a concern in stroke patients (Liao et al., 2012). The
current recommendations by the Royal College of Physicians states that robot-assisted therapy
should be used as an aide to conventional therapy when the goal is to reduce arm impairment
(Langhorne et al., 2009). However, only 15% of patients with initial upper limb paralysis will
fully recover, making robotic-assisted therapy a promising rehabilitation strategy, which is not
yet fully valued for its potential benefits to patients experiencing upper limb paralysis in the
clinical stroke rehabilitation setting (Freeman et al., 2012). A study conducted by Liao at al.
(2012) looked at the effects of robot-assisted upper limb rehabilitation on daily function and realworld arm activity in patients who have suffered a stroke. 20 subjects who were already
attending outpatient rehabilitation programs were assigned to either robot-assisted therapy or a
dose-matched active control group. Each group received the specific therapy for 5 days per week
for a total of 4 weeks. Each training session was 90-105 minutes in duration. Subjects were
evaluated before and after 4 weeks, primarily measuring arm activity through an accelerometer,
and secondary measurements were taken using the Fugl-Meyer Assessment Scale of the upper
extremity, the Functional Independence Measure, the Motor Activity Log, and the ABILHAND.
The results showed a significant difference between the robot-assisted therapy and the active
control group, with the robot-assisted therapy group handling more daily tasks than the control
group. There was no change in the Functional Independence Measure. All other secondary
measures showed a significant difference between groups. The authors stated that active daily
living critically requires bimanual arm activity, which was improved superiorly through robot-

MOTOR REHABILITATION FOLLOWING A STROKE

assisted therapy. Some studies previous to the work of Liao at al. (2012) failed to demonstrate
changes in motor improvement, possibly due to less intensive protocols (60 minutes per session,
3 times per week), patient criteria and study design. So, there may be a dose-response
relationship associated with robot-assisted therapy. The discrepancy observed with the
Functional Independence Measure can be explained by the fact that robotic training does not
emulate real life, and practicing motor skills in a natural context would eliminate this
incongruity. Therefore, it is recommended that robotic training is used in combination with usual
and customary care if the patient is experiencing upper limb hemiparesis. It is not advised that
robotic-assisted therapy is used on its own, as it has been shown in multiple RCTs to have no
significant differences when compared to usual and customary care when duration and intensity
are matched (Norouzi-Gheidari, Archambault, & Fung, 2012).
The current recommendations by the Royal College of Physicians states that all patients
should participate in aerobic training, unless there are contraindications unrelated to stroke
(Langhorne et al., 2009). Understanding that muscle weakness (paresis) is one of the primary
impairments caused by stroke, and that altered muscle tone and a decrease in cardiorespiratory
fitness by as much as 60% are consequences of stroke indicates that compromised physical
fitness levels can be particularly detrimental to the post-stroke rehabilitation process (Tang, &
Eng, 2014). A review article conducted by Brazzelli, Saunders, Greig, & Mead (2011) observed
32 RCTs involving 1,414 participants and the effects of physical fitness training in post-stroke
patients. The review documented the results of three training modalities; cardiorespiratory
training, resistance training, and mixed training. Cardiorespiratory training was shown to be
more effective than the control interventions at improving preferred gait speed, maximal gait
speed, and 6-minute walk test distance. All of these three measurements are positively related to

MOTOR REHABILITATION FOLLOWING A STROKE

active daily living and lower limb motor function (Langhorne et al., 2009; Tang, & Eng, 2014).
Mixed training showed similar but slightly more diminished outcomes than cardiorespiratory
training alone. There were 2 RCTs for resistance training, showing improvements in composite
measures of muscle strength. Therefore, current evidence suggests that the inclusion of physical
fitness training in the form of cardiorespiratory intervention after stroke displays efficacy in
improving lower limb motor function, as well as a number of other health benefits unrelated to
motor rehabilitation, such as cardiorespiratory fitness.
Electromechanical-assisted training devices were developed to reduce the reliance on
therapists when performing treadmill training on patients with paretic limbs, a difficult task for
therapists to practice (Mehrholz, Elsner, Werner, Kugler, & Pohl, 2013). These training devices,
or advanced treadmills, utilize an electromechanical solution, with two foot plates which are
used to simulate normal gait (Mehrholz et al., 2013). Three months after stroke 20% of patients
remain wheelchair bound, and 70% walk at a reduced capacity and velocity, meaning that
restoring lower limb motor function is a common and necessary procedure for most stroke
patients. A review of the current literature conducted by Mehrholz et al. (2013) included 23
RCTs with a total of 999 participants. This review found that the use of Electromechanicalassisted training devices in combination with physiotherapy may improve walking function after
stroke. Interestingly, it was found that subjects in the first 3 months after stroke had significantly
better results than the subjects after the first 3 months, meaning that the first 3 months poststroke were crucial for rehabilitation outcomes. Furthermore non-ambulatory walkers, or
dependent walkers benefitted more from electromechanical-assisted training than the ambulatory
walkers. A study by Morone et al. (2011) found that robotic-assisted gait therapy, which utilizes
an electromechanical-assisted training device, combined with conventional therapy may be more

MOTOR REHABILITATION FOLLOWING A STROKE

10

effective than conventional therapy alone in patients with greater motor impairment during
stroke rehabilitation. 48 participants experiencing lower limb motor and gait dysfunction
following stroke were split up into high and low motor impairment groups. Each arm of motor
impairment groups were then randomized to a robotic or control group, with each therapy
session performed 2 times per day, 5 days per week, for a total of 3 months. A measure of
functional ambulation category (FAC) was the primary outcome of the study, while Rivermead
mobility index (RMI) and 6-minute walking distance were secondary measures. The results
indicated that in the lower motor impairment arm conventional and electromechanical-assisted
scores were equivalent, showing no differences. This finding means that patients who show high
motricity index scores, or who are more ambulatory, do not benefit from electromechanicalassisted training. However, subjects in the high motor impairment arm who performed
electromechanical-assisted training showed clinically and statistically significant differences in
the FAC, RMI, and walking distance tests. Therefore, the results of Morone et al. (2011) and
Mehrholz et al. (2013) studies suggest that stroke patients who suffer from a high degree of
lower limb motor impairment may benefit from the use of electromechanical-assisted training
devices.
In conclusion, motor impairment typically affects 80% of stroke patients, and in the
United States alone there are roughly 700,000 stroke patients every year, thus stroke
rehabilitation through the restoration of motor function is a matter of explicit clinical importance,
and is the central emphasis of this paper (Langhorne et al., 2009; Sacco et al., 2006). The
findings of the study by Wolf et al. (2006) showed that CIMT can be used to effectively improve
paralytic upper-extremity motor function in stroke patients. Evidence from a study by Liao at al.
(2012) suggests that robotic training may be effective in combination with usual and customary

MOTOR REHABILITATION FOLLOWING A STROKE

11

care if the patient is experiencing upper limb hemiparesis. The current recommendations by the
Royal College of Physicians states that all patients should participate in aerobic training, unless
there are contraindications unrelated to stroke (Langhorne et al., 2009). Current evidence from
Brazzelli et al. (2011) suggests that the inclusion of physical fitness training in the form of
cardiorespiratory intervention after stroke displays efficacy in improving lower limb motor
function. The results of the Morone et al. (2011) and Mehrholz et al. (2013) studies suggest that
stroke patients who suffer from a high degree of lower limb motor impairment may benefit from
the use of electromechanical-assisted training devices. Finally, each patient is different and will
require an individualized rehabilitation program. The four outlined rehabilitation therapies in this
paper should provide a baseline of choice for specialized care in patients undergoing motor
rehabilitation after experiencing a stroke. Therefore, in the attempt to restore motor function in
the upper and/or lower limbs, it is the recommendation of this paper that stroke patients receive
high-intensity, repetitive task-specific practice with feedback on performance.

MOTOR REHABILITATION FOLLOWING A STROKE

12

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