Elsevier

The Lancet

Volume 377, Issue 9778, 14–20 May 2011, Pages 1693-1702
The Lancet

Series
Stroke rehabilitation

https://doi.org/10.1016/S0140-6736(11)60325-5Get rights and content

Summary

Stroke is a common, serious, and disabling global health-care problem, and rehabilitation is a major part of patient care. There is evidence to support rehabilitation in well coordinated multidisciplinary stroke units or through provision of early supported provision of discharge teams. Potentially beneficial treatment options for motor recovery of the arm include constraint-induced movement therapy and robotics. Promising interventions that could be beneficial to improve aspects of gait include fitness training, high-intensity therapy, and repetitive-task training. Repetitive-task training might also improve transfer functions. Occupational therapy can improve activities of daily living; however, information about the clinical effect of various strategies of cognitive rehabilitation and strategies for aphasia and dysarthria is scarce. Several large trials of rehabilitation practice and of novel therapies (eg, stem-cell therapy, repetitive transcranial magnetic stimulation, virtual reality, robotic therapies, and drug augmentation) are underway to inform future practice.

Introduction

Stroke is a global health-care problem that is common, serious, and disabling.1 In most countries, stroke is the second or third most common cause of death and one of the main causes of acquired adult disability.1, 2, 3 Because most patients with stroke will survive the initial illness, the greatest health effect is usually caused by the long-term consequences for patients and their families. The prevalence of stroke-related burden is expected to increase over the next two decades. Although impressive developments have been made in the medical management of stroke, without a widely applicable or effective medical treatment most post-stroke care will continue to rely on rehabilitation interventions.4

In this Review, we focus mainly on the evidence underlying stroke rehabilitation, including the principles of rehabilitation practice, systems of care, and specific interventions. We also discuss the effects of interventions for stroke-related impairment and disability. Questions about these issues are the most common ones that are posed by clinicians.5 Most research of stroke rehabilitation has been about the effect of interventions on recovery in different forms of impairment and disability. Our emphasis on randomised trials and systematic reviews is particularly important in stroke, for which variable and spontaneous recovery is an important confounder of rehabilitation interventions in observational studies in the first 3 months after stroke.6

Section snippets

Classification of the effect of stroke

Disabling disorders such as stroke can be classified within WHO's international classification of function, disability, and health,7 which provides a framework for the effect of stroke on the individual (figure 1) in terms of pathology (disease or diagnosis), impairment (symptoms and signs), activity limitations (disability), and participation restriction (handicap).

Stroke recovery is heterogeneous in its nature. The long-term effect of stroke is determined by the site and size of the initial

Rehabilitation after stroke

In this Review we use a broad definition of rehabilitation, including stroke-care interventions, which are selected after a problem-solving process that aims to reduce the disability and handicap resulting from a stroke.

Stroke rehabilitation typically entails a cyclical process1 involving: (1) assessment, to identify and quantify the patient's needs; (2) goal setting, to define realistic and attainable goals for improvement; (3) intervention, to assist in the achievement of goals; and (4)

Challenges in evidence-based stroke rehabilitation

Stroke rehabilitation presents specific challenges for research and for the application of evidence-based practice. First, although learning of skills and theories of motor control are crucial to many rehabilitation interventions,12 the neurophysiology underpinning stroke rehabilitation is often poorly established. Second, interventions tend to be complex and contain several interrelated components.13 Third, treatments might target several different problems from relieving very specific

Principles of stroke rehabilitation

Several general principles underpin the process of stroke rehabilitation, and some have been studied in randomised trials and systematic reviews. Substantial evidence supports multidisciplinary team care as the basis for delivery of stroke rehabilitation.15, 17 Research of integrated care pathways is limited by few randomised trials, suggesting that such formal pathways might be no more effective than care from a well-functioning multidisciplinary team.24 Good rehabilitation outcome seems to be

Organised inpatient (stroke-unit) care

Panel 2 summarises evidence for complex rehabilitation interventions. Stroke rehabilitation occurs in specific systems of care many of which have been assessed in randomised trials and systematic reviews to form the basis of service planning. A package of rehabilitation in an organised multidisciplinary stroke unit results in more patients surviving, returning home, and regaining independence in daily activities than does rehabilitation in general wards. Good descriptions indicate which

Motor impairment

Panel 3 summarises evidence for specific rehabilitation treatments. 19 categories of intervention have been identified from systematic reviews or randomised trials.10 Panel 1 outlines some of the main approaches that have been described and panel 3 shows the related evidence. Bilateral training,64 constraint-induced movement therapy at modified doses,49 electrical stimulation,53 high-intensity therapy,10 repetitive task training,63 robotics,59 and splinting71 have all been tested to improve

Novel therapies

Several novel therapies are being developed and tested, including stem-cell therapy,84 repetitive transcranial magnetic stimulation and transcranial direct-current stimulation,85 motor imagery,86 virtual reality,87 novel robotic therapies,59 drug augmentation of exercise training with amphetamines,88 dopamine agonists, and antidepressants. These interventions are typically combined with traditional task-specific training and trials. Although these interventions are not yet known to improve

Conclusions

Major advances have occurred in the past 20 years in the development and testing of interventions for stroke rehabilitation, but there are many gaps and shortcomings in the evidence base to inform clinical practice. Therefore, for the foreseeable future many clinical decisions will continue to rely on the knowledge and judgment of individual health professionals. Although improvements in management have been noted, research is still needed to clearly define the effect of specific rehabilitation

Search strategy and selection criteria

We searched the Cochrane Library from first publication to October, 2010, with the search terms “stroke” and “rehabilitation” and various topic-specific terms. We also searched the Cochrane Stroke Group section of the Cochrane Library, which contains more than 137 reviews and protocols (reviews under development) of which 39 completed reviews and 13 protocols were directly relevant to this Review. If a Cochrane systematic review was identified that fully covered the intervention of

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