Dr Kate Scrivener is a clinician, researcher and educator in neurological physiotherapy in Sydney, Australia. Kate has expertise in rehabilitation after stroke, with a particular interest in using exercise and technology to empower people with stroke to drive their rehabilitation. She is a Senior Lecturer at Macquarie University and is part of the StrokeEd Collaboration. As the head of neurology at Concentric Rehabilitation Centre, Kate is a consultant physiotherapist as well as a mentor to staff. An important aspect of this role is ensuring that all staff are actively engaged with translating the latest evidence into their clinical practice.
A major challenge in stroke rehabilitation is how best to drive recovery in arm function and prevent secondary complications like pain. Kate has recently read three research articles on this topic.
This is a rigorous, large-scale (n=770) randomised controlled trial involving people with stroke who had moderate to severe limitation in arm function. There were three treatment arms: robot-assisted training, intensive repetitive practice, and usual care. Both the robot-assisted and intensive repetitive practice groups completed about 24 hours of arm training over the over a 12-week period. There were no between-group differences in the primary outcome (Action Research Arm Test) at the 3-month follow-up. This means that robot-assisted training was not superior to usual care, and nor was intensive repetitive practice. Kate says: “In Australia there is minimal access to robotics in clinical practice. This large trial suggests that there is no advantage to having robotics over usual care.” Kate was interested that 42-50% of participants in each group made a clinically meaningful change in their Action Research Arm Test score. Kate says: “This suggests that change in arm function is possible for some individuals after stroke, and there is research in progress to better determine who those individuals are.”
This article also challenges the assumption that it is not possible to improve arm function after stroke, especially in the chronic phase. This is a single-group, uncontrolled study involving a large cohort (N=224) of people with stroke (but people with with complete paralysis and severe spasticity were excluded), with intervention starting an average of 18 months post-stroke. The intervention involved repetitive task practice and was intensive, with 90 hours of intervention delivered over a 3-week period. At the 6-month follow up 62% of participants had made a clinically meaningful change in their Action Research Arm Test score. Kate says: “This article shows us how much practice is possible. A 90-hour intervention is substantial, I have not seen this intensity of practice reported in previous research.” Kate is mindful, however, that the article only reports the change scores for a single group and that the intervention does need to be evaluated in a randomised controlled trial.
Andringa A, et al. Effectiveness of botulinum toxin treatment for upper limb spasticity after stroke over different ICF domains: a systematic review and meta-analysis. Arch Phys Med Rehabil 2019;100(9):1703-25
This large (40 trials, 2,718 participants) systematic review and meta-analysis quantifies the effects of botulinum toxin on upper limb spasticity after stroke. Interestingly, the outcomes were reported using the International Classification of Functioning, Disability and Health framework. The review concludes that botulinum toxin reduces resistance to passive movement and improves self care, but does not change arm or hand function, pain or range of motion. Kate says: “I find this review very useful because patients commonly ask me about this treatment. This review provides data to empowers individuals with stroke (and therapists) to make informed decisions about treatment.”