To investigate the effectiveness of self-directed arm interventions in adult stroke survivors.
Methods:
A systematic review of Medline, EMBASE, CINAHL, SCOPUS and IEEE Xplore up to February 2018 was carried out. Studies of stroke arm interventions were included where more than 50% of the time spent in therapy was initiated and carried out by the participant. Quality of the evidence was assessed using the Cochrane risk of bias tool.
Results:
A total of 40 studies (n = 1172 participants) were included (19 randomized controlled trials (RCTs) and 21 before–after studies). Studies were grouped according to no technology or the main additional technology used (no technology n = 5; interactive gaming n = 6; electrical stimulation n = 11; constraint-induced movement therapy n = 6; robotic and dynamic orthotic devices n = 8; mirror therapy n = 1; telerehabilitation n = 2; wearable devices n = 1). A beneficial effect on arm function was found for self-directed interventions using constraint-induced movement therapy (n = 105; standardized mean difference (SMD) 0.39, 95% confidence interval (CI) −0.00 to 0.78) and electrical stimulation (n = 94; SMD 0.50, 95% CI 0.08–0.91). Constraint-induced movement therapy and therapy programmes without technology improved independence in activities of daily living. Sensitivity analysis demonstrated arm function benefit for patients >12 months poststroke (n = 145; SMD 0.52, 95% CI 0.21–0.82) but not at 0–3, 3–6 or 6–12 months.
Conclusion:
Self-directed interventions can enhance arm recovery after stroke but the effect varies according to the approach used and timing. There were benefits identified from self-directed delivery of constraint-induced movement therapy, electrical stimulation and therapy programmes that increase practice without using additional technology.
HanCWangQMengPPet al. Effects of intensity of arm training on hemiplegic upper extremity motor recovery in stroke patients: a randomized controlled trial. Clin Rehabil2013; 27: 75–81.
2.
HaywardKSBrauerSG. Dose of arm activity training during acute and subacute rehabilitation post stroke: a systematic review of the literature. Clin Rehabil2015; 29: 1234–1243.
3.
PollockAFarmerSEBradyMCet al. Interventions for improving upper limb function after stroke. Cochrane Database Syst Rev2014; 11: CD010820.
4.
BernhardtJChanJNicolaIet al. Little therapy, little physical activity: rehabilitation within the first 14 days of organized stroke unit care. J Rehabil Med2007; 39: 43–48.
5.
ClarkeDJBurtonLJTysonSFet al. Why do stroke survivors not receive recommended amounts of active therapy? Findings from the ReAcT study, a mixed-methods case-study evaluation in eight stroke units. Clin Rehabil. Epub ahead of print 27March2018. DOI: 10.1177/0269215518765329.
6.
DemainSBurridgeJEllis-HillCet al. Assistive technologies after stroke: self-management or fending for yourself? A focus group study. BMC Health Serv Res2013; 13: 334.
7.
HigginsJPTGreenS. Cochrane handbook for systematic reviews of interventions. Hoboken, NJ: John Wiley & Sons, 2011.
Review manager (Rev Man) version 5.3. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014.
10.
MoherDLiberatiATetzlaffJet al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol2009; 62: 1006–1012.
11.
AdieKSchofieldCBerrowMet al. Does the use of Nintendo Wii sportsTM improve arm function? Trial of WiiTM in stroke: a randomized controlled trial and economics analysis. Clin Rehabil2017; 31: 173–185.
12.
BrkicLShawLvan WijckFet al. Repetitive arm functional tasks after stroke (RAFTAS): a pilot randomised controlled trial. Pilot Feasibil Stud2016; 2: 50.
13.
BrunnerICSkouenJSStrandLI. Is modified constraint-induced movement therapy more effective than bimanual training in improving arm motor function in the subacute phase post stroke? A randomized controlled trial. Clin Rehabil2012; 26: 1078–1086.
14.
Dos Santos-FontesRLDe AndradeKNSterrAet al. Home-based nerve stimulation to enhance effects of motor training in patients in the chronic phase after stroke: a proof-of-principle study. Neurorehabil Neural Repair2013; 27: 483–490.
HaraYOgawaSTsujiuchiKet al. A home-based rehabilitation program for the hemiplegic upper extremity by power-assisted functional electrical stimulation. Disabil Rehabil2008; 30: 296–304.
17.
HarrisJEEngJJMillerWCet al. A self-administered Graded Repetitive Arm Supplementary Program (GRASP) improves arm function during inpatient stroke rehabilitation: a multi-site randomized controlled trial. Stroke2009; 40: 2123–2128.
18.
KimberleyTJLewisSMAuerbachEJet al. Electrical stimulation driving functional improvements and cortical changes in subjects with stroke. Exp Brain Res2004; 154: 450–460.
19.
MichielsenMESellesRWVan Der GeestJNet al. Motor recovery and cortical reorganization after mirror therapy in chronic stroke patients: a phase II randomized controlled trial. Neurorehabil Neural Repair2011; 25: 223–233.
20.
NijenhuisSMPrange-LasonderGBStienenAHet al. Effects of training with a passive hand orthosis and games at home in chronic stroke: a pilot randomised controlled trial. Clin Rehabil2017; 31: 207–216.
21.
SmaniaNGandolfiMPaolucciSet al. Reduced-intensity modified constraint-induced movement therapy versus conventional therapy for upper extremity rehabilitation after stroke: a multicenter trial. Neurorehabil Neural Repair2012; 26: 1035–1045.
22.
StandenPJThreapletonKRichardsonAet al. A low cost virtual reality system for home based rehabilitation of the arm following stroke: a randomised controlled feasibility trial. Clin Rehabil2017; 31: 340–350.
23.
StinearCMBarberPACoxonJPet al. Priming the motor system enhances the effects of upper limb therapy in chronic stroke. Brain2008; 131: 1381–1390.
24.
SullivanJEHurleyDHedmanLD. Afferent stimulation provided by glove electrode during task-specific arm exercise following stroke. Clin Rehabil2012; 26: 1010–1020.
25.
TariahHAAlmaltyASbeihZet al. Constraint induced movement therapy for stroke survivors in Jordon: a home-based model. Int J Ther Rehabil2010; 17: 638–646.
26.
TurtonAJCunninghamPvan WijckFet al. Home-based reach-to-grasp training for people after stroke is feasible: a pilot randomised controlled trial. Clin Rehabil2017; 31: 891–903.
27.
WolfSLSahuKBayRCet al. The HAAPI (Home Arm Assistance Progression Initiative) trial: a novel robotics delivery approach in stroke rehabilitation. Neurorehabil Neural Repair2015; 29: 958–968.
28.
ZondervanDKAugsburgerRBodenhoeferBet al. Machine-based, self-guided home therapy for individuals with severe arm impairment after stroke: a randomized controlled trial. Neurorehabil Neural Repair2015; 29: 395–406.
29.
BurridgeJHLeeACWTurkRet al. Telehealth, wearable sensors, and the internet: will they improve stroke outcomes through increased intensity of therapy, motivation, and adherence to rehabilitation programs?J Neurol Phys Ther2017; 41(suppl. 3): S32–S38.
30.
AlonGMcBrideKRingH. Improving selected hand functions using a noninvasive neuroprosthesis in persons with chronic stroke. J Stroke Cerebrovas Dis2002; 11: 99–106.
31.
AlonGSunnerhagenKSGeurtsACHet al. A home-based, self-administered stimulation program to improve selected hand functions of chronic stroke. Neurorehabilitation2003; 18: 215–225.
32.
BurridgeJHTurkRMerrillDet al. A personalized sensor-controlled microstimulator system for arm rehabilitation poststroke. Part 2: objective outcomes and patients’ perspectives. Neuromodulation2011; 14: 80–88.
33.
BrownEVMcCoySWFechkoASet al. Preliminary investigation of an electromyography-controlled video game as a home program for persons in the chronic phase of stroke recovery. Arch Phys Med Rehabil2014; 95: 1461–1469.
34.
LanganJDelaveKPhillipsLet al. Home-based telerehabilitation shows improved upper limb function in adults with chronic stroke: a pilot study. J Rehabil Med2013; 45: 217–220.
35.
LeeHSKimJU. The effect of self-directed exercise using a task board on pain and function in the upper extremities of stroke patients. J Phys Ther Sci2013; 25: 963–967.
36.
MawsonS. The SMART rehabilitation system for stroke self-management: issues and challenges for evidence-based health technology research. J Phys Ther Educ2011; 25: 48–53.
37.
MouawadMRDoustCGMaxMDet al. Wii-based movement therapy to promote improved upper extremity function post-stroke: a pilot study. J Rehabil Med2011; 43: 527–533.
38.
Niama NattaDDAlagnideEKpadonouGTet al. Feasibility of a self-rehabilitation program for the upper limb for stroke patients in Benin. Ann Phys Rehabil Med2015; 58: 322–325.
39.
NijenhuisSMPrangeGBAmirabdollahianFet al. Feasibility study into self-administered training at home using an arm and hand device with motivational gaming environment in chronic stroke. J Neuroeng Rehabil2015; 12: 89.
40.
PageSJLevineP. Modified constraint-induced therapy extension: using remote technologies to improve function. Arch Phys Med Rehabil2007; 88: 922–927.
41.
PageSJLevinePHillV. Mental practice–triggered electrical stimulation in chronic, moderate, upper-extremity hemiparesis after stroke. Am J Occup Ther2015; 69: 1–88.
42.
PickettTCFritzSLKettersonTUet al. Telehealth and constraint-induced movement therapy (CIMT): an intensive case study approach. Clin Gerontol2007; 31: 5–20.
43.
SivanMGallagherJMakowerSet al. Home-based computer assisted arm rehabilitation (hCAAR) robotic device for upper limb exercise after stroke: results of a feasibility study in home setting. J Neuroeng Rehabil2014; 11: 163.
44.
SullivanJEHedmanLD. Effects of home-based sensory and motor amplitude electrical stimulation on arm dysfunction in chronic stroke. Clin Rehabil2007; 21: 142–150.
45.
TurkRBurridgeJHDavisRet al. Therapeutic effectiveness of electric stimulation of the upper-limb poststroke using implanted microstimulators. Arch Phys Med Rehabil2008; 89: 1913–1922.
46.
WittmannFHeldJPLambercyOet al. Self-directed arm therapy at home after stroke with a sensor-based virtual reality training system. J Neuroeng Rehabil2016; 13: 75.
47.
WittmannFLambercyOGonzenbachRRet al. Assessment-driven arm therapy at home using an IMU-based virtual reality system. In: Proceedings of the 2015 IEEE international conference on rehabilitation robotics (ICORR), Singapore, 11–14 August 2015, pp.707–712. New York: IEEE.
48.
ZhangHAustinHBuchananSet al. Feasibility studies of robot-assisted stroke rehabilitation at clinic and home settings using RUPERT. In: Proceedings of the IEEE international conference on rehabilitation robotics, Zurich, 29 June–1 July2011.
49.
Da-SilvaRHFrederike vanWShawFet al. Prompting arm activity after stroke: a clinical proof of concept study of wrist-worn accelerometers with a vibrating alert function. J Rehabil Assis Technol Eng2018; 5: 1–8.
50.
ChenJNicholsDBrokawEBet al. Home-based therapy after stroke using the hand spring operated movement enhancer (HandSOME). IEEE Trans Neural Syst Rehabil Eng2017; 25: 2305–2312.
51.
FryerCELukerJAMcDonnellMNet al. Self management programmes for quality of life in people with stroke. Cochrane Database Syst Rev2016; 8: CD010442.
52.
WrayFClarkeDForsterA. Post-stroke self-management interventions: a systematic review of effectiveness and investigation of the inclusion of stroke survivors with aphasia. Disabil Rehabil2018; 40: 1237–1251.
53.
KrakauerJW. Motor learning: its relevance to stroke recovery and neurorehabilitation. Curr Opin Neurol2006; 19: 84–90.
54.
KorpershoekCvan der BijlJHafsteinsdottirTB. Self-efficacy and its influence on recovery of patients with stroke: a systematic review. J Adv Nurs2011; 67: 1876–1894.
55.
JonesFRiaziA. Self-efficacy and self-management after stroke: a systematic review. Disabil Rehabil2011; 33: 797–810.
56.
BrownECairnsP. A grounded investigation of game immersion. In: Proceedings of the extended abstracts of the 2004 conference on human factors in computer systems, Vienna, 24–29 April 2004, pp.1297–1300. New York: ACM Press.
57.
WadeD. Rehabilitation – a new approach. Part four: a new paradigm, and its implications. Clin Rehabil2016; 30: 109–118.
58.
FarmerSEDurairajVSwainIet al. Assistive technologies: can they contribute to rehabilitation of the upper limb after stroke?Arch Phys Med Rehabil2014; 95: 968–985.
59.
HibbardJHStockardJMahoneyERet al. Development of the Patient Activation Measure (PAM): conceptualizing and measuring activation in patients and consumers. Health Serv Res2004; 39: 1005–1026.
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
