There is considerable evidence that the amount of time spent practising tasks after stroke is directly related to rehabilitation outcome. This was a key theme at a focused symposium on stroke rehabilitation, held at the WCPT Congress in Amsterdam in June.
Delegates heard that what was important was not so much the amount of time a person spent practising tasks with affected limbs, but the number of repetitions they achieved. This means that devices that aid repetition in shorter periods, such as robots, can be of genuine value.
Catherine Dean, Director and Head of Physiotherapy Program at Macquarie University in Sydney, Australia, said that reviews had indicated the value of constrained movement. But it was practice, not just the constraint, that was important.
Devices like treadmills enabled constrained movements of the lower limbs to be repeated again and again, especially if they provided body weight support. Walking with a patient up and down a gym was unlikely to be as effective, and it was too labour intensive for the physical therapist.
People’s workstations could be adapted so that they could also perform repetitions. “There’s nothing magic about this,” she said. “It’s just to do with practice, and it is far more likely to give people independence in walking.”
“There isn’t any magic apparatus: it’s just that it facilitates our practice.” Doing exercises in groups had the advantage of providing competition and co-operation.
The speakers also discussed robotic rehabilitation devices on the market. Gert Kwakkel, Chair of neurorehabilitation at the VU University Medical Centre in Amsterdam, said that an analysis of randomised controlled trials on rehabilitation of upper limbs using robotics showed 7% gains in arm scores.
“This suggests that they are very effective,” he said. “However, it may not be the type of robotics but the intensity that is in favour of this equipment.”
“It’s the dose that is important, not the type, so I would always get the cheapest type of robotics you can find on the market.”
He pointed out that although it was clear that more practice meant better results, there was no good protocol available for dose-response trials.
“The key message from randomised controlled trials is that everyone improves with practice, so can we influence this pattern by speeding up the improvement?”