STROKE INTERVENTIONS

BILATERAL ARM TRAINING

 Introduction
 Clinician Information
Bilateral Arm Training (BAT) comprises repetitive practice of bilateral arm movements in
symmetrical or alternating patterns. Traditionally, bilateral arm training was performed by
linking both hands together so that the less-affected limb facilitated passive movement of the
affected limb. Variations of bilateral arm training include bilateral isokinematic training
(spatiotemporally identical active movements performed during functional tasks), use of
mechanical or robotic devices to drive passive or active movement of the affected limb, or
bilateral arm training with rhythmic auditory cueing or electromyography (EMG) stimulation.
The use of bilateral arm training in stroke rehabilitation is based on the assumption that
symmetrical bilateral movements activate similar neural networks in both hemispheres,
promoting neural plasticity and cortical repair that result in improved motor control in the
affected limb. Bilateral arm training is suitable for use as an adjunct to other upper limb
interventions and should involve repetitive movement during performance of novel, functional
tasks.
Authors*: Annabel McDermott (OT), Dr Nicol Korner-Bitensky (PhD OT)
Evidence reviewed as of before 24-10-2012  

TASK-ORIENTED TRAINING- UPPER EXTREMITY

 Introduction
 Clinician Information
 Best Practices
Task-oriented training involves practicing real-life tasks (such as walking or answering a
telephone), with the intention of acquiring or reacquiring a skill (defined by consistency,
flexibility and efficiency). The tasks should be challenging and progressively adapted and
should involve active participation (Wolf & Winstein, 2009). It is important to note that it differs
from repetitive training, where a task is usually divided into component parts and then
reassembled into an overall task once each component is learned. Repetitive training is
usually considered a bottom-up approach, and is missing the end-goal of acquiring a skill.
Task-oriented training can involve the use of a technological aid as long as the technology
allows the patient to be actively involved. Task-oriented training is also sometimes called task-
specific training, goal-directed training, and functional task practice. This particular module
focuses on task-oriented training intended specifically to improve upper extremity function. 
NOTE: Studies were excluded if the intervention did not involve: 1) practicing a salient,
real-life task, 2) progressively adapting the task to the patient’s progress over time, or
3) active participation by the patient. As well, studies that mixed task-oriented training
with other types of exercise (e.g. aerobic, strength), or that compared one type of task-
oriented training to another type of task-oriented training (e.g. different types of
feedback, or different types of gait training) were excluded.To date 10 high quality
RCTs, 1 of fair quality and 1 pre-post single group design that meet the above inclusion
criteria have investigated this topic.  Please note that the Cochrane Review by French
et al. (2010) used different inclusion criteria and classification of outcomes, thus the
findings differ somewhat from ours.
Authors*: Annabel McDermott, BOccThy; Adam Kagan, BSc BA; Carole Richards, Ph. D
PT ; Nicol Korner-Bitensky, Ph. D OT
 Evidence reviewed as of before 13-07-2014  

TASK-ORIENTED TRAINING- UPPER EXTREMITY

 Introduction
 Clinician Information
 Best Practices
Recommendation
 Therapists should provide a graded repetitive arm supplementary program for patients to
increase activity on ward and at home. This program should include strengthening of the arm and
hand (small wrist weight, putty, hand gripper), range of motion (stretching, active exercises), and
gross, fine motor skills (e.g., blocks, Lego, pegs), repetitive goal and task-oriented activities
designed to simulate partial or whole skill required in activities of daily living (e.g. folding,
buttoning, pouring, and lifting). The GRASP protocol suggests one hour per day, six days per
week [Evidence Levels: Early-Level A; Late-Level C]. (1)
Source
1. Lindsay MP, Gubitz G, Bayley M, Hill MD, Davies-Schinkel C, Singh S, and Phillips S.
Canadian Best Practice Recommendations for Stroke Care (Update 2010). On behalf of the
Canadian Stroke Strategy Best Practices and Standards Writing Group. 2010; Ottawa, Ontario
Canada: Canadian Stroke Network.

FUNCTIONAL ELECTRICAL STIMULATION- HEMIPLEGIC SHOULDER

 Introduction
 Patient Information
 Clinician Information
 Best Practices
Functional electrical stimulation (FES), also called functional neuromuscular stimulation
(FNS), is a technique used to replace or assist a voluntary muscle contraction during a
functional task by applying low-level electrical current to the nerves that control muscles or
directly over the motor end-plate of the muscle (just like a pacemaker makes a heart beat).
The term “FES” is commonly used to describe electrical stimulation used as a treatment
modality for loss of shoulder function, pain, spasticity and subluxation following stroke. The
U.S. AHCPR Post Stroke Rehabilitation Guidelines defines FES as “bursts of electrical
stimulation applied to the nerves or muscles affected by the stroke, with the goal of
strengthening muscle contraction and improving motor control.”
Neuromuscular electrical stimulation, or simply “electrical stimulation” (ES), is a modality used
for strengthening muscles. ES may be considered a FES when a muscle contraction is
facilitated during a functional task. Despite the use of all three terms in the literature (FES,
FNS and ES) the applications to the hemiplegic shoulder all focus on the stimulation of the
supraspinatus and deltoid muscles. Therefore, this module includes the modalities that elicit
muscular contraction of the rotator cuff muscles. TENS and other therapeutic electrical
stimulation that do not elicit muscular contraction are reviewed in other modules.
Theoretically, FES should help to compensate or facilitate flaccid shoulder muscles, which in
turn should reduce the risk of shoulder subluxation, by involuntary muscle contractions. The
effectiveness of FES in improving function, tone, EMG activity and in reducing pain and
subluxation has been reported.
Authors*: Marc-André Roy, MSc; Nicol Korner-Bitensky, PhD; Robert Teasell, MD; Norine
Foley, BASc; Sanjit Bhogal, MSc; Jamie Bitensky, MScOT; and Mark Speechley, MD
Evidence reviewed as of before 29-10-2010
FUNCTIONAL ELECTRICAL STIMULATION- HEMIPLEGIC SHOULDER
 Introduction
 Patient Information
 Clinician Information
 Best Practices
Recommendations
 

 Functional Electrical Stimulation (FES) should be used for the wrist and forearm to reduce
motor impairment and improve functional motor recovery [Evidence Levels: Early-Level A; Late-
Level A]. (1)
 Consider using FES to increase pain free range of motion of lateral rotation of the shoulder
[Evidence Level A]. (1)
 The Ottawa Panel Evidence-Based Clinical Practice Guidelines for Post-Stroke
Rehabilitation recommends the treatment of shoulder subluxation as well as the use of electrical
stimulation, based on the synthesis of research evidence (2).
Sources
1. Lindsay MP, Gubitz G, Bayley M, Hill MD, Davies-Schinkel C, Singh S, and Phillips S.
Canadian Best Practice Recommendations for Stroke Care (Update 2010). On behalf of the
Canadian Stroke Strategy Best Practices and Standards Writing Group. 2010; Ottawa, Ontario
Canada: Canadian Stroke Network.
2. Ottawa Panel, Khadilkar A, Phillips K, et al. EBRSR: evidence-based clinical practice
guidelines for post-stroke rehabilitation. Top Stroke Rehabil 2006; 13(2): 1-269.

FUNCTIONAL ELECTRICAL STIMULATION- UPPER EXTREMITY

 Introduction
 Patient Information
 Clinician Information
 Best Practices
Functional electrical stimulation (FES), also called functional neuromuscular stimulation (FNS), is a
technique used to replace or help a muscle contraction during a functional activity by applying
electrical current to the nerves that control muscles. The goal of this treatment modality is to
strengthen muscle contraction and improve motor control. The most familiar type of electrical
stimulation is probably the use of pacemakers to control heart contractions.
Neuromuscular electrical stimulation, or simply ‘electrical stimulation’ (ES), is a modality used
primarily for strengthening muscles, without the purpose of integrating a functional task as done with
FES. Despite the use of all three terms in the literature (FES, FNS and ES), these modalities
basically focus on eliciting muscular contractions.
This module summarizes the electrical stimulation modalities used to elicit muscular contraction of
the upper extremities (FES of the shoulder is reviewed independently). Transcutaneous electrical
nerve stimulation (TENS) and other therapeutic electrical stimulation that do not elicit muscular
contraction are reviewed in other modules. The effectiveness of FES for improving functional
independence/burden of care, strength, spasticity, range of motion, hand function, motor function
and reaction time has been reported.
Authors*: Jamie Bitensky, MSc. OT, Nicol Korner-Bitensky, Ph. D OT
Evidence reviewed as of before 26-10-2010
FUNCTIONAL ELECTRICAL STIMULATION- UPPER EXTREMITY
 Introduction
 Patient Information
 Clinician Information
 Best Practices
Best Practice Recommendation 5.4.1
Management of the Arm and Hand
Recommendations
 Functional Electrical Stimulation (FES) should be used for the wrist and forearm to reduce
motor impairment and improve functional motor recovery [Evidence Levels: Early-Level A; Late-
Level A]. (1)
 Consider using FES to increase pain free range of motion of lateral rotation of the shoulder
[Evidence Level A]. (1)
 The Ottawa Panel Evidence-Based Clinical Practice Guidelines for Post-Stroke
Rehabilitation recommends the use of electrical stimulation based on the synthesis of research
evidence (2).
Sources
1. Lindsay MP, Gubitz G, Bayley M, Hill MD, Davies-Schinkel C, Singh S, and Phillips S.
Canadian Best Practice Recommendations for Stroke Care (Update 2010). On behalf of the
Canadian Stroke Strategy Best Practices and Standards Writing Group. 2010; Ottawa, Ontario
Canada: Canadian Stroke Network.
2. Ottawa Panel, Khadilkar A, Phillips K, et al. EBRSR: evidence-based clinical practice
guidelines for post-stroke rehabilitation. Top Stroke Rehabil 2006; 13(2): 1-269. Available
at: http://www.canadianstrokenetwork.ca/index.php/tools/

MIRROR THERAPY
 Introduction
 Patient Information
 Clinician Information
 Clinician How-To
 Best Practices
Mirror therapy is a form of motor imagery in which a mirror is used to convey visual stimuli to
the brain through observation of one’s unaffected body part as it carries out a set of
movements. The underlying principle is that movement of the affected limb can be stimulated
via visual cues originating from the opposite side of the body. Hence, it is thought that this
form of therapy can prove useful in patients who have lost movement of an arm or leg
including those who have had a stroke.
NOTE: Some of the effects of mirror therapy on the brain have already been
demonstrated. In a crossover study on healthy individuals, Garry, Loftus & Summers
(2004) showed that viewing the mirror image of one’s active hand increased the
excitability of neurons in the ipsilateral primary motor cortex significantly more than
viewing the inactive hand directly (no mirror). As well, a trend toward significance was
found in favour of viewing a mirror image of the active hand compared to viewing the
active hand directly (no mirror). This study was not included in the in depth review
below as it involved only neurologically healthy patients (non-stroke).
Authors*: Annabel McDermott OT, Adam Kagan, B.Sc.; Samuel Harvey-Vaillancourt, PT U3;
Shahin Tavakol, PT U3; Dan Moldoveanu, PT U3; Phonesavanh Cheang, PT U3; Elissa
Sitcoff, BA BSc; Nicol Korner-Bitensky, PhD OT
Evidence reviewed as of before 04-03-2013
 Mirror Therapy Exercises
10 Easy Exercises to try with clients suffering from neurological injuries such as stroke
are listed below. The key is to go at a slow pace and imagine the “hand in the mirror” is
truly the affected side.
 

1. Make a fist and then open your hand slowly. Repeat 3 sets of 15 reps.
2. Touch your thumb to the tip of each finger. Repeat 3 sets of 15 reps for each
finger.
3. Turn your palm up and down. Repeat 3 sets of 15 reps.
4. Pretend to play the piano, pushing each finger on the table one at a time.
Continue for 2 minutes.
5. Place a washcloth on the table. Wipe the table in a circular motion, back and
forth, and up and down for 2 minutes.
6. Place a water bottle on the table, grasp it with your hand, lift it up 2 inches, place
it back on the table and let go. Repeat 3 sets of 15 reps.
7. Place 5 coins on the table. Pick them up one at a time until they are all in your
palm. Place them back on the table, one at a time, using your thumb and your
index and middle fingertips. Repeat 5 times.
8. Place a foam ball on the table. Pick up the ball, squeeze it and place back down
on the table and let go. Repeat 3 sets of 15 reps.
9. Place 20 small objects (marbles, poker chips, blocks) on the table. Position a
bowl next to the small objects. Place the small objects, one at a time, into the
bowl. Repeat 3 times.
10. Crawl your fingers along the mirror in various directions (up, down, diagonally) for
2 minutes.

POSITIONING
 Introduction
 Patient Information
 Clinician Information
 Best Practices
Proper positioning post-stroke is essential in order to reduce the risk of shoulder subluxation,
contractures and pain. Proper positioning may also enhance motor recovery, range of motion, and
oxygen saturation.
In this module we identify the evidence for optimal positioning of the patient when:
-lying: supine, on affected side and on non-affected side,
-sitting: in bed, chair and wheelchair,
-standing and transferring.
Authors*: Adam Kagan, BSc; Nicol Korner-Bitensky, PhD OT; Leila Goulamhoussen, BSc OT;
Rabiaa Laroui, BSc OT; Sheila Liu, BSc OT; Anita Petzold, BSc OT; Anna Rentoulis, BSc OT;
Stephen Tang, BSc OT
Evidence reviewed as of before 14-12-2009
POSITIONING
 Introduction
 Patient Information
 Clinician Information
 Best Practices
Recommendations
 Spasticity and contractures should be treated or prevented by antispastic pattern positioning,
range-of-motion exercises, stretching and/or splinting [Evidence Levels: Early- Level C; Late-
Level C]. (1)
 In the assessment and prevention of shoulder pain, joint protection strategies include:
a.    Positioning and supporting the limb to minimize pain [Evidence Level B]. (1)
 Lower limb spasticity and contractures should be treated or prevented by antispastic pattern
positioning, range-of-motion exercises, stretching and/or splinting. (SCORE) [Evidence Levels:
Early-Level C; Late-Level C]. (1)
 

Sources
1. Lindsay MP, Gubitz G, Bayley M, Hill MD, Davies-Schinkel C, Singh S, and Phillips S.
Canadian Best Practice Recommendations for Stroke Care (Update 2010). On behalf of the
Canadian Stroke Strategy Best Practices and Standards Writing Group. 2010; Ottawa, Ontario
Canada: Canadian Stroke Network.

MOTOR IMAGERY / MENTAL PRACTICE

 Introduction
 Patient Information
 Clinician Information
 Best Practices
Motor imagery or mental practice/mental imagery/mental rehearsal involves activation of the neural
system while a person imagines performing a task or body movement without actually physically
performing the movement. Motor imagery has been used after a stroke to attempt to treat loss of
arm, hand and lower extremity movement, to help improve performance in activities of daily living, to
help improve gait, and to minimize the effects of unilateral spatial neglect. Motor imagery can be
used in the acute phase, sub-acute phase or chronic phase of rehabilitation. It has been shown that
while motor imagery is beneficial by itself, it is most effective when used in addition to physical
practice. In fact, many of the first studies on motor imagery were designed to investigate whether
motor imagery improved motor performance in athletes. Brain scanning techniques have shown that
similar areas of the brain are activated during motor imagery and physical movement. In addition,
motor imagery has been shown in one study to help the brain reorganize its neural pathways, which
may help promote learning of motor tasks after a stroke.
Authors*: Tatiana Ogourtsova, MSc BSc OT, Annabel McDermott, OT, Angela Kim, B.Sc., Adam
Kagan, B.Sc.; Emilie Belley B.A. Psychology, B.Sc PT; Mathilde Parent-Vachon Bsc PT; Josee-
Anne Filion; Alison Nutter; Marie Saulnier; Stephanie Shedleur, Bsc PT; Tsz Ting Wan, BSc PT;
Elissa Sitcoff, BA BSc; Nicol Korner-Bitensky, PhD OT
Expert Reviewer: Stephen Page, PhD (C)
Evidence reviewed as of before 01-06-2017
MOTOR IMAGERY / MENTAL PRACTICE
 Introduction
 Patient Information
 Clinician Information
 Best Practices
Recommendations
 Following appropriate cognitive and physical assessment, mental imagery should be used to
enhance sensory-motor recovery in the upper limb [Evidence Levels: Early-Level A; Late-Level
B]. (1)
Sources
1. Lindsay MP, Gubitz G, Bayley M, Hill MD, Davies-Schinkel C, Singh S, and Phillips S.
Canadian Best Practice Recommendations for Stroke Care (Update 2010). On behalf of the
Canadian Stroke Strategy Best Practices and Standards Writing Group. 2010; Ottawa, Ontario
Canada: Canadian Stroke Network.

BIOFEEDBACK- UPPER EXTREMITY

 Introduction
 Patient Information
 Clinician Information
 Best Practices
Biofeedback (BFB) is commonly used as a treatment intervention for stroke rehabilitation. Following
a stroke, the main central motor pathways that regulate normal muscle tone and functioning can be
disrupted or even damaged. However, some motor pathways that are often unused remain relatively
unaffected by the stroke. Individuals may learn how to activate these unused pathways with the help
of electromyographic biofeedback (EMG-BFB) and this may lead to improvements in their muscle
tone and functioning. Given that hemiparesis of the upper extremity can result in functional disability
following stroke and can affect important aspects of daily living (i.e. feeding and dressing), the use of
EMG-BFB as an effective means of treatment for upper extremity hemiparesis has been carefully
studied. Specifically, studies have examined the use of biofeedback to improve hand function as well
as upper extremity range of motion and function.
Authors*: Robert Teasell, MD; Norine Foley, BASc; Sanjit Bhogal, MSc; Jamie Bitensky, MSc OT;
Mark Speechley, MD; Nicol Korner-Bitensky, PhD OT
Evidence reviewed as of before 26-10-2010

BIOFEEDBACK- UPPER EXTREMITY

 Introduction
 Patient Information
 Clinician Information
 Best Practices
Recommendations
 EMG biofeedback systems should not be used on a routine basis. (adapted from RCP)
[Evidence Levels: Early- Level A; Late- Level A]. (1)
 The Ottawa Panel recommends the use of EMG biofeedback for the upper and lower
extremities at all stages of stroke recovery based on the synthesis of evidence (2)
Sources
 1. Lindsay MP, Gubitz G, Bayley M, Hill MD, Davies-Schinkel C, Singh S, and Phillips S.
Canadian Best Practice Recommendations for Stroke Care (Update 2010). On behalf of the
Canadian Stroke Strategy Best Practices and Standards Writing Group. 2010; Ottawa, Ontario
Canada: Canadian Stroke Network.
2. The Ottawa Panel, Khadilkar, A., Phillips, K., et al. (2006). EBRSR: evidence-based clinical
practice guidelines for post-stroke rehabilitation. Top Stroke Rehabil, 13(2), 1-269. Available
at:http://www.canadianstrokenetwork.ca/index.php/tools/

ECONDARY STROKE PREVENTION

 Introduction
 Patient Information
 Best Practices
Overview
Those who experience a stroke are at a higher risk for subsequent cardiac and cerebrovascular
events including recurrent stroke. Of those who have already had a stroke, 14% will have a second
stroke within a year and have a 20% higher chance of having another stroke within 2 years
compared to the general population. Recent evidence suggests that comprehensive behavioral risk
factor management will potentially improve quality of life and reduce the risk of subsequent stroke.
Risk factor management includes:
1) Patient education
2) Exercise
3) Diet modification
4) Stress management skills
5) Smoking cessation
 

NOTE: While pharmacological interventions play an important role in secondary stroke

prevention, this review focuses on the behavioral management.
Authors*: Sabrina Godbout; Jessica Goldberger; Genevieve Dupont; Sabrina Mansour; Stephanie
Rosenthal; Valerie Robert
Evidence reviewed as of before 16-12-2009

SECONDARY STROKE PREVENTION

 Introduction
 Patient Information
 Best Practices
Recommendations
Secondary prevention recommendations are directed to those risk factors most relevant to
stroke, including lifestyle (diet, sodium intake, exercise, weight, smoking, and alcohol intake),
hypertension, dyslipidemia, previous stroke or transient ischemic attack, atrial fibrillation and
stroke, and carotid stenosis. Secondary prevention recommendations can be addressed in a
variety of settings—acute care, stroke prevention clinics, and community-based care settings.
They pertain to patients initially seen in primary care, those who are treated in an emergency
department and then released and those who are hospitalized because of stroke or transient
ischemic attack.
Recommendations for secondary prevention of stroke should be implemented throughout the
recovery phase, including during inpatient and outpatient rehabilitation, reintegration into the
community and ongoing follow-up by primary care practitioners.
Secondary prevention should be addressed at all appropriate healthcare encounters on an
ongoing basis following a stroke or transient ischemic attack.
Persons at risk of stroke and patients who have had a stroke should be assessed for vascular
disease risk factors and lifestyle management issues (diet, sodium intake, exercise, weight,
smoking and alcohol intake). They should receive information and counseling about possible
strategies to modify their lifestyle and risk factors [Evidence Level B].
Lifestyle and risk factor interventions should include:
2.1.1 Healthy balanced diet: Eating a diet high in fresh fruits, vegetables, low-fat dairy
products, dietary and soluble fibre, whole grains and protein from plant sources and low in
saturated fat, cholesterol and sodium, in accordance with Canada’s Food Guide to Healthy
Eating [Evidence Level B].
2.1.2 Sodium: Following the recommended daily sodium intake from all sources, known as
the Adequate Intake. For persons 9 to 50 years, the Adequate Intake is 1500 mg. Adequate
Intake decreases to 1300 mg for persons 50 to 70 years and to 1200 mg for persons over 70
years. A daily upper consumption limit of 2300 mg should not be exceeded by any age group
[Evidence Level B].78
2.1.3 Exercise: Participating in moderate exercise (an accumulation of 30 to 60 minutes)
such as walking (ideally brisk walking), jogging, cycling, swimming or other dynamic exercise
four to seven days each week in addition to routine activities of daily living. High-risk patients
(e.g., those with cardiac disease) should engage in medically supervised exercise programs
[Evidence Level A].
2.1.4 Weight: Maintaining a body mass index (BMI) of 18.5 to 24.9 kg/m2 or a waist
circumference of <80 centimetres for women and <94 centimetres for men [Evidence Level
B].49
2.1.5 Smoking: Addressing smoking cessation and a smoke-free environment every
healthcare encounter for active smokers.48
i.  In all healthcare settings along the stroke continuum, patient smoking status should
be assessed and documented [Evidence Level A].
ii. Provide unambiguous, non-judgmental, and personally relevant advice regarding the
importance of cessation to all smokers, and offer assistance with the initiation of a
smoking cessation attempt–either directly or through referral to appropriate resources
[Evidence Level A].
iii.  A combination of pharmacological therapy and behavioural therapy should be
considered [Evidence Level A].
iv.  The three classes of pharmacological agents that should be considered as first- line
therapy for smoking cessation are nicotine replacement therapy, bupropion, and
varenicline [Evidence Level A].
2.1.6 Alcohol consumption: Limiting consumption to two or fewer standard drinks per day;
fewer than 14 drinks per week for men; and fewer than nine drinks per week for women
[Evidence Level C].
Hypertension management
Hypertension is the single most important modifiable risk factor for stroke. Blood pressure
should be monitored and managed in all persons at risk for stroke.
2.2.1 Blood pressure assessment
All persons at risk of stroke should have their blood pressure measured routinely, ideally at
each healthcare encounter, but no less than once annually [Evidence Level C].
i.  Proper standardized techniques as described by the Canadian Hypertension
Education Program should be followed for blood pressure measurement including
office, home, and community testing.50 Details regarding proper blood pressure
monitoring techniques for clinicians and patients can be found
athttp://hypertension.ca/chep/wp- content/uploads/2008/03/bpposterenglish.jpg50
 ii.  Patients found to have elevated blood pressure should undergo thorough
assessment for the diagnosis of hypertension following the current guidelines of the
Canadian Hypertension Education Program [Evidence Level A].
iii.  Patients with hypertension or at risk for hypertension should be advised on lifestyle
modifications [Evidence Level C].
Refer to recommendation 2.1 for additional information.
Source
1. Lindsay MP, Gubitz G, Bayley M, Hill MD, Davies-Schinkel C, Singh S, and Phillips S.
Canadian Best Practice Recommendations for Stroke Care (Update 2010). On behalf of the
Canadian Stroke Strategy Best Practices and Standards Writing Group. 2010; Ottawa, Ontario
Canada: Canadian Stroke Network.

VIDEO GAME TRAINING- UPPER EXTREMITY

 Introduction
 Patient Information
 Clinician Information
Video game training (VGT) refers to the use of commercial video games (e.g. Nintendo Wii,
Sony Playstation EyeToy) for post-stroke rehabilitation. VGT is potentially beneficial in that it
is affordable, designed to be entertaining and fun, and can be used at home.  Prior to
recommending the use of VGT for widespread clinical practice for upper limb rehabilitation, it
is important to understand the current evidence regarding its effectiveness. To date 1 high
quality RCT, 1 fair quality RCT and 3 non-experimental studies have investigated the effect of
video game training on upper-extremity rehabilitation. Authors*: Adam Kagan BSc, Dr. Nicol
Korner-Bitensky PhD OT Evidence reviewed as of before 14-05-2012 NOTE: *The authors
and expert reviewers have no direct financial interest in any tools, tests or interventions
presented in Stroke Engine.

VIDEO GAME TRAINING- UPPER EXTREMITY

 Introduction
 Patient Information
 Clinician Information
NOTE: This review focuses ONLY on therapies involving commercially available video
game systems. For a review that includes all virtual environments for stroke rehabilitation,
please see our ‘Virtual Reality’ modules.
To date 1 high quality RCT, 1 fair quality RCT and 3 non-experimental studies have investigated
the effect of video game training on upper-extremity rehabilitation.
SUBACUTE: VIDEO GAME TRAINING VS. CONTROL CONDITIONS
Functional independence More effective1b

Grip strength Not more effective2a

Manual dexterity Not more effective2a

Motor function More effective2a

Motor recovery Not more effective1b

Pain No evidence5

Quality of life Not more effective2a

 Spasticity No evidence5

CHRONIC: VIDEO GAME TRAINING VS. CONTROL CONDITIONS

Cognition No evidence5

Depression No evidence5

Hand function and dexterity No evidence5

Motor activity No evidence5

Motor function No evidence5

Range of motion No evidence5

Spasticity No evidence5

EXECUTIVE FUNCTION
 Introduction
 Patient Information
 Clinician Information
 Clinician How-To
 Best Practices
Executive functions (EF) refer to high-level cognitive functions that are responsible for the
initiation, planning, sequencing, and monitoring of complex goal-directed behaviour. Disorders
in EF after stroke are very common and can affect performance of activities of daily living and
self-care, participation in social activities, and independence in more complex activities (e.g.
returning to work, driving, caring for others). Executive functions include skills such as
inhibition/impulse control, flexible thinking, emotional control, task initiation, memory and
attention, planning, organisation of self and materials, and self-monitoring. The range of
assessments used to evaluate EF after stroke This module includes these outcomes where
possible, as well as the other outcomes targeted by the included studies.
There are a variety of treatment approaches for EF deficits. Some interventions reviewed in
this module focus on remediation of specific EF abilities affected by stroke (e.g. memory
retraining using computer-based tasks, virtual reality programs). Other interventions
use compensation approaches, for instance through cognitive strategies (e.g. Cognitive
Orientation to daily Occupational Performance training, problem-solving training) or external
mechanisms (e.g. electronic paging systems).
Authors*: Valérie Poulin, OT,  PhD cand.; Nicol Korner-Bitensky, PhD OT; Annabel
McDermott, OT; Deirdre Dawson, PhD OT; Tatiana Ogourtsova, PhD Cand. MSc OT
Evidence reviewed as of before 19-08-2017

EXECUTIVE FUNCTION
 Introduction
 Patient Information
 Clinician Information
 Clinician How-To
 Best Practices
Recommendations
All patients with vascular risk factors and those with clinically evident stroke or
transient ischemic attack should be considered at increased risk for vascular cognitive
impairment (VCI), particularly those patients with cognitive, perceptual or functional
changes that are clinically evident or reported during history taking.
 

7.2.1 Screening and Assessment

i. Patients with significant vascular risk factors for VCI, such as hypertension, diabetes,
transient ischemic attack or clinical stroke, neuroimaging findings of covert stroke or
white matter disease, hypertension-associated damage to other target organs, atrial
fibrillation, other cardiac disease, and/or sleep apnea should be considered for VCI
screening [Evidence Level A].
ii. Screening for VCI should be conducted using a validated screening tool, such as
the Montreal Cognitive Assessment (MoCA) test [Evidence Level C]. 
iii. Screening to investigate a person’s cognitive status should address arousal,
alertness, attention, orientation, memory, language, agnosia, visual-spatial/perceptual
function, praxis, and executive function. Executive function screening may include
assessment of initiation, insight, planning and organization, judgment, problem solving,
abstract reasoning, and social cognition [Evidence Level C].
iv. Post-stroke patients with suspected cognitive impairment should also be screened
for depression, given that depression has been found to contribute to vascular cognitive
impairment. A validated screening tool for depression should be used [Evidence Level
A].
v. Patients who demonstrate cognitive impairments in the screening process should be
managed by a healthcare professional with expertise in the assessment and
management of neurocognitive functioning.* This assessment should include cognition,
perception and/or function as appropriate to guide comprehensive management
[Evidence Level B]. If required, a referral should be made to an appropriate cognitive
specialist [Evidence Level C].
a. Additional assessments should be undertaken to determine: the nature and
severity of cognitive impairments; the presence of remaining cognitive abilities
and straights;
b. The impact of deficits on function and safety in activities of daily living and
instrumental activities of daily living, and occupational and school functioning
should also be assessed.
c. The results of these assessments should be used to guide selection and
implementation of appropriate remedial, compensatory and/or adaptive
intervention strategies according to client-centred goals and current or
anticipated living environment (e.g. to help with discharge planning) [Evidence
Level B].
* Experts in neurocognitive assessment may include a neuropsychologist, psychologist,
occupational therapist, speech-language pathologist, clinical nurse specialist, psychiatrist,
physiatrist, geriatrician, neurologist, and developmental pediatricians. Experts require specific
qualifications to administer many of the identified assessments.
 

7.2.2 Timing of Screening and Assessments

i. All patients considered at high risk for cognitive impairment should be assessed
periodically throughout the stages of care as indicated by the severity of clinical
presentation, history and/or imaging abnormalities to identify cognitive, perceptual
deficits, depression, delirium and/or changes in function [Evidence Level C].
ii.Stages of care across the continuum may include:
 a. during presentation to emergency when cognitive, perceptual or functional
concerns are noted;
b.during acute care stay, particularly if cognitive, perceptual or functional
concerns, or evidence of delirium is noted;
c.throughout rehabilitation within inpatient, outpatient, and home-based settings,
according to client progress;
d. following hospital discharge from the emergency department or inpatient
setting to an outpatient or community-based healthcare setting.
iii. While assessment at different stages of care is important for guiding diagnosis and
management, it is also important to be aware of the potential impact of multiple
assessments on both the validity of the results as well as on the patient (e.g. test
fatigue, practice effects) [Evidence Level B].
iv. Effects of age must also be considered, particularly in children with stroke where
outcomes will evolve in parallel with development and deficits may not be fully realized
until many years later [Evidence Level C].
 

7.2.3 Management of Vascular Cognitive Impairment

i. Vascular risk factors (e.g. hypertension, atrial fibrillation) should be managed
aggressively to achieve optimal control of the pathology underlying cognitive
impairment following a stroke or TIA [Evidence Level A].
ii.Interventions should be tailored according to the following considerations:
a. Goals should be patient-centred and sensitive to the values and expectations
of patient, family and caregivers [Evidence Level B];
b. Goals should be developed in the context of both the cognitive impairments as
well as patients’ intact cognitive abilities, with the aim to facilitate resumption of
desired activities and participation (e.g. self-care, home management, leisure,
social roles, driving, volunteer participation, financial management, return to
work) [Evidence Level B].
NOTE: Issues such as intensity and dose of therapy, stage of treatment, and
impact of severity of deficits can modify effectiveness of therapy, and require
more research.
iii. Evidence for interventions for cognitive impairment is growing, although more
research is required. Interventions with the patient can be broadly classified as
either compensatory strategy training, or direct remediation/cognitive skill training.
These approaches are not mutually exclusive, and, depending upon the impairments
and goals, may be offered together.
NOTE: It should be noted, however that if the level of impairment has reached the
moderate dementia stage, interventions may be more focused on providing education
and support for the caregiver in addition to, or in lieu of, cognitive rehabilitation with the
patient.
a. Compensatory Strategy training focuses on teaching strategies to address
impairments and is often directed at specific functional limitations in activities of
daily living to promote independence. Compensatory strategies can include
learning to use external devices (e.g., memory notebooks or alarms), adapting
the external environment (e.g., additional social supports or reorganization of
living space), and/or learning to use internal mental operations or processes
(e.g., problem-solving techniques) that enhance the impaired cognitive domain.
Certain types of strategy training have been shown to be effective for improving
attention, memory, language, praxis and executive function domains [Evidence
Level B].
 b. Direct remediation/cognitive skill training focuses on providing intensive
specific training to directly improve the impaired cognitive domain. Computer-
based training has been shown to be effective in improving attention and working
memory impairments as well as language impairments [Evidence Level B]. The
impact of direct skill training on achievement of goals at the activities and
participation levels of functioning requires more research.
c. New developments in cognitive intervention that may be of potential benefit
include repetitive transcranial magnetic stimulation or direct stimulation, the use
of virtual reality environments or simulations, and application of constraint-
induced therapy for the impaired cognitive domain. These strategies require
more research before recommendations can be developed on their use.
iv. Patients with cognitive impairment and evidence of changes in mood (e.g.,
depression, anxiety), or behavioural changes on screening should be referred and
managed by an appropriate mental healthcare professional [Evidence Level B].
 

Source
Eskes G, Salter K, on behalf of the Mood and Cognition in Stroke Writing Group and the
Evidence-Based Review in Stroke Rehabilitation Team. Chapter 7: Mood and Cognition in
Stroke.
In Lindsay MP, Gubitz G, Bayley M, and Phillips S (Editors) on behalf of the Canadian Stroke
Best Practices and Standards Advisory Committee. Canadian Best Practice
Recommendations for Stroke Care: 2013; Ottawa, Ontario Canada: Canadian Stroke
Network.