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All-in-One Guide to Stroke Rehabilitation

Occupational Therapy’s Role in Stroke

According to AOTA, the “focus of occupational therapy is to help individuals achieve health, well-being, and participation in life through engagement in occupations.”1 Some services that occupational therapy professionals may provide include but are not limited to: 

  • Retraining activities of daily living (such as showering, dressing or grooming) and/or training compensatory strategies.2 
  • Providing education to transfer from a wheelchair to a chair or different surfaces.2 
  • Adaptive equipment and home recommendations2 
  • Work-site evaluations or ergonomics2  
  • Treating impairments in strength, range of motion, vision, sensation or other.2 
  • Teaching coping strategies for mental health (such as relaxation or meditation).2 

For more information visit AOTA’s stroke fact sheet.2 

Stroke Rehabilitation

Each year about 795,000 people experience a stroke in the United States.3 Research is progressing in the field of occupational therapy, but one thing remains true; stroke remains one of the leading causes of death and disability in the United States. It is an ever-present threat to the health of millions of Americans. It can be overwhelming when working in a clinical setting to keep up with current research on this important topic. This article will examine a collection of the most current evidence-based treatments for stroke rehabilitation in occupational therapy.   

Therapist with InMotion Arm and Patient in a Powerchair

Types of Strokes

There are three basic categories of strokes. You can find the basic definitions below. Learn more on the CDC website 

Ischemic stroke 

Often occurs when blood flow of an artery becomes blocked. They are the most common types of strokes (87% of all strokes).4 

Hemorrhagic Stroke 

 This type of stroke happens when an artery in the brain leaks or ruptures.4 

Transient Ischemic Attack (TIA) 

These are sometimes known as ‘mini strokes.’ Blood flow to the brain is blocked for a shorter time than a typical ischemic stroke.4 

*** Any type of stroke is a medical emergency. If you think you or someone you know is experiencing a stroke call 911***  

A New Treatment Window

A new study in 20215 suggests that the optimal ‘window’ for stroke rehabilitation might actually be 2-3 months out from stroke.5 The study was a randomized phase II clinical trial that involved 72 patients and was led by Georgetown University and Medstar National Rehabilitation Hospital. This research suggests that skilled rehabilitation for stroke is needed for much more time than insurance currently permits.5 Larger studies are needed to further examine this finding. One thing is certain, this information could change the way we look at stroke rehabilitation.  

Circuit Brain

Resources for Occupational Therapy Intervention

Promising Interventions From AJOT and Gillen (2015)3 

According to a 2015 ‘Evidence Connection’ article from the American Journal of Occupational Therapy (AJOT), which provides sample clinical applications in response to evidence-based reviews, evidence was found for occupational therapy intervention in these categories. You can read this clinical practice resource here.6

  1. Visual scanning training  

Evidence level: Strong Evidence6  

  1. Repetitive task-training to improve mobility, balance and upper extremity motor function  

Evidence level: Strong Evidence6  

  1. Occupation or activity-based interventions to increase leisure participation   

Evidence level: Moderate to Strong Evidence6  

  1. Treatment combining a task-oriented intervention and a cognitive strategy  

 Evidence level: Moderate Evidence6 

Resources from the Canadian Partnership for Stroke Recovery

The Canadian Partnership for Stroke Recovery provides a fantastic resource for occupational therapy practitioners everywhere. It is called the Evidence-based Review of Stroke Rehabilitation (EBRSR). Now publishing its 19th edition, the EBRSR, written by Edwin Teasell and his colleagues, includes reviews of over 2,170 randomized clinical trials7 and is one of the largest reviews of stroke rehabilitation. One of the reasons the EBRSR is such a great resource, is that it provides not only an evidence-based review, but also an easy-to-digest clinician’s handbook divided by different categories in stroke rehabilitation including upper extremity and lower extremity motor rehabilitation.  

See the chart below for definitions of the levels of academic research.  

Level of evidence (LOE)  Description 
Level I  Evidence from a systematic review or meta-analysis of all relevant RCTs (randomized controlled trial) or evidence-based clinical practice guidelines based on systematic reviews of RCTs or three or more RCTs of good quality that have similar results. 
Level II  Evidence obtained from at least one well-designed RCT (e.g. large multi-site RCT). 
Level III  Evidence obtained from well-designed controlled trials without randomization (i.e. quasi-experimental). 
Level IV  Evidence from well-designed case-control or cohort studies. 
Level V  Evidence from systematic reviews of descriptive and qualitative studies (meta-synthesis). 
Level VI  Evidence from a single descriptive or qualitative study. 
Level VII  Evidence from the opinion of authorities and/or reports of expert committees. 

**This chart has been pulled from Winona University’s ‘Evidence-Based Practice Toolkit**8  

According to the upper extremity motor rehabilitation section of the 2020 Stroke Rehabilitation Clinician Handbook, the treatment interventions identified below have a high-level of evidence (level one evidence)9. The interventions below are a selection of interventions from this report. To see the full list of recommended interventions and research levels visit the link 

  • Task oriented training – May improve motor function, muscle strength, ROM, Spasticity.9 
  • Strength training – May improve ROM and motor function.9  
  • Constraint-Induced Movement Therapy (CIMT) – may be indicated for improving muscle strength and spasticity in the acute phase, and Motor function and ADLs in the chronic phase.9  
  • Action observation – could be beneficial for spasticity and dexterity.9  
  • Mirror therapy – May improve motor function, stroke severity and dexterity proprioception.9 
  • Mental practice – May be associated with improvements in muscle strength and motor function.9 
  • Bilateral arm training – may be associated with improvements in motor function, but not ADLs.9 

***This is just a small sampling of treatment interventions that the EBRSR examines. To check out evidence for other treatment interventions including NMES, FES, acupuncture and EMG/biofeedback check out the Stroke Rehabilitation Clinician Handbook.*** 

New Evidence for Rehabilitation Robotics and Technology

While the sheer number of studies being done in regard to rehabilitation robotics is down due to covid-19, there are great studies continuing to be released every year. A fascinating result in the most recent year’s selection of academic research, is that most of the new studies are unique in their perspectives and findings. We highly suggest checking out some of these articles if you are interested in learning about rehabilitation robotics. The best thing about these articles is that all of them are free with open public access! 

An observational retrospective study performed on the InMotion Robot. Movements were found to be smoother and more accurate with a shorter time to finish tasks at end-of-treatment.10 Kinematic parameters demonstrated improvements in motor functions in the first five sessions.10

This review of 35 clinical trials found that robot-assisted therapy showed slightly better improvements in motor impairment compared to traditional treatment.11

This randomized controlled trial found that in a comparison between an exoskeleton device and the InMotion Robot end-effector, more improvements were seen in activity and participation in the end-effector group (InMotion Robot group).12

This study faced off a group of patients receiving CIMT and traditional therapy and a group of patients receiving robot-assisted therapy and traditional therapy. Upper limb function improved significantly in each group, and there was no statistically significant difference when comparing each group.13 

Gaming and Virtual Reality

In a recent small study on robot-assisted game training, patients in a robotic therapy group when compared to a conventional upper extremity therapy treatment group were more satisfied in the study.14 Lee and his colleagues cite other recent research in his article including a pilot trial by Saposnik16 and a group of case studies by Edmans16 stating, “Games also inspire, motivate, and trigger pleasure and interest in rehabilitation by utilizing the player’s intrinsic sense of competition and desire for interaction, thereby promoting learning movements”.14 15 16   

It should be noted that more evidence-based reviews and meta-analyses need to be performed in the area of gaming and VR. The Stroke Rehabilitation Clinician Handbook states that “virtual reality can be useful as an adjunct to other interventions”.9 

Certificates and Training Opportunities

Looking to gain more expertise in the area of neurological rehabilitation? Maybe you need to complete some more CEUs, or you want to bone-up on your clinical skills to improve your career prospects. Here are some popular courses and certifications for occupational and physical therapists with every budget level in mind. 

American Occupational Therapy Association (AOTA)17 

AOTA’s continuing education opportunities have really expanded in recent years. The organization now offers a plus and premium membership, which includes access to a fairly large CEU library. This membership is around the same cost that just the AOTA membership by itself used to cost a few years ago. The library consists of all different types of CEU materials, from written research articles, to CEU videos and digital badges. One area, that can often be neglected in stroke and neurological rehabilitation is vision. AOTA offers a low vision level 1 and level 2 badge.  

NEURO-IFRAH18  

Defines itself as a “whole person approach to rehabilitation and habilitation.”18 They have a wide-range of courses on upper extremity treatment and gait.  

NDT (Neuro-Developmental Treatment)19  

The NDTA defines its mission as to “improve treatment and outcomes for clients with neuromuscular dysfunction by providing advanced therapist education that improves skills in assessment, evaluation and salient, functional treatment.”19 The NDTA offers many certificates and advanced classes.  

LSVT BIG20  

BIG is a certification for Parkinson’s Disease treatment. It focuses on improving movement quality.20 LSVT BIG is a certificate that can be completed by Occupational or Physical Therapists.  

CBIS (Certified Brain Injury Specialist)21  

This is a certificate for individuals working with the brain injury population. To apply you must have at least 500 hours of experience with brain injury populations and take an exam.  

MEDBRIDGE22 

MEDBRIDGE offers online classes in neurological treatment for OT/PT and the neurologic upper extremity.  

CNS (certified Neuro Specialist)23  

The CNS certification puts a special focus on the stroke and brain injury population. This continuing education course consists of a 10-hour lab and 20 hours of self-study modules. This certification is intended for Occupational and Physical Therapists.   

Certified Stroke Rehabilitation Specialist (CSRS)24  

CSRS defines its program as a ‘four-tiered stroke education platform’.24 This course is delivered via nine hours of self-study and then culminates in a live lab.  

Occupationaltherapy.com25  

Occupationaltherapy.com has some exciting new offerings called ‘master classes’ included into their yearly subscription. What’s nice about occupationaltherapy.com, is it’s all-inclusive for a reasonable set-rate for the year. Most notably a four-hour master class in traumatic brain injury, and another four-hour masterclass in ‘Cognitive Evaluation and Intervention in Neurorehabilitation.’25  

That’s a wrap everybody.

In this guide we have reviewed new research for evidence-based practice in occupational therapy, the definition and value of occupational therapy in stroke rehabilitation and a selection of continuing education resources for the busy clinician. Stay tuned for more articles from us on stroke rehabilitation 

 References

  1. American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68, S1–S48. doi:10.5014/ajot.2014.682006. Go, A., Mozaffarin, D., Roger, V. L., Benjamin, E., Berry, J. D., Borden, W., …Turner, M. (2013). Heart disease and stroke statistics 2013 update. Circulation, 127, e6–e245. 
  2. Stroke rehab fact sheet – aota. (n.d.). Retrieved February 3, 2022, from https://www.aota.org/-/media/Corporate/Files/AboutOT/Professionals/WhatIsOT/RDP/Facts/Stroke-Rehab-fact-sheet.pdf  
  3. Wolf, T. J., & Nilsen, D. M. (2015). Occupational therapy practice guidelines for adults with stroke. Bethesda, MD: AOTA Press. 
  4. Centers for Disease Control and Prevention. (2021, August 2). Types of stroke. Centers for Disease Control and Prevention. Retrieved February 3, 2022, from https://www.cdc.gov/stroke/types_of_stroke.htm  
  5. Critical Period After Stroke Study (CPASS): A phase II clinical trial testing an optimal time for motor recovery after stroke in humans.Dromerick AW, Geed S, Barth J, Brady K, Giannetti ML, Mitchell A, Edwardson MA, Tan MT, Zhou Y, Newport EL, Edwards DF. Proc Natl Acad Sci U S A. 2021 Sep 28;118(39):e2026676118. doi: 10.1073/pnas.2026676118. PMID: 34544853. 
  6. Dawn Nilsen, Glen Gillen, Marian Arbesman, Deborah Lieberman; Occupational Therapy Interventions for Adults With Stroke. Am J Occup Ther September/October 2015, Vol. 69(5), 6905395010p1–6905395010p3. doi: https://doi.org/10.5014/ajot.2015.695002
  7. Introduction. EBRSR. (n.d.). Retrieved February 3, 2022, from http://www.ebrsr.com/Research hub: Evidence based practice toolkit: Levels of evidence. WSU. (n.d.). Retrieved February 3, 2022, from https://libguides.winona.edu/ebptoolkit/Levels-Evidence  

  8. Research hub: Evidence based practice toolkit: Levels of evidence. WSU. (n.d.). Retrieved February 3, 2022, from https://libguides.winona.edu/ebptoolkit/Levels-Evidence  
  9. Teasell, et al. (2020). Hemiplegic Upper Extremity Rehabilitation. EBRSR.com. Retrieved February 3, 2022, from http://www.ebrsr.com/sites/default/files/EBRSR%20Handbook%20Chapter%204_Upper%20Extremity%20Post%20Stroke_ML.pdf  
  10. Goffredo, M., Mazzoleni, S., Gison, A., Infarinato, F., Pournajaf, S., Galafate, D., Agosti, M., Posteraro, F., & Franceschini, M. (2019). Kinematic parameters for tracking patient progress during Upper Limb Robot-assisted rehabilitation: An observational study on subacute stroke subjects. Applied Bionics and Biomechanics, 2019, 1–12. https://doi.org/10.1155/2019/4251089  
  11. Chen, Z., Wang, C., Fan, W., Gu, M., Yasin, G., Xiao, S., Huang, J., & Huang, X. (2020). Robot-assisted arm training versus therapist-mediated training after stroke: A systematic review and meta-analysis. Journal of Healthcare Engineering, 2020, 1–10. https://doi.org/10.1155/2020/8810867  
  12. Lee, S. H., Park, G., Cho, D. Y., Kim, H. Y., Lee, J.-Y., Kim, S., Park, S.-B., & Shin, J.-H. (2020). Comparisons between end-effector and exoskeleton rehabilitation robots regarding upper extremity function among chronic stroke patients with moderate-to-severe upper limb impairment. Scientific Reports, 10(1). https://doi.org/10.1038/s41598-020-58630-2  
  13. Terranova, T. T., Simis, M., Santos, A. C., Alfieri, F. M., Imamura, M., Fregni, F., & Battistella, L. R. (2021). Robot-assisted therapy and constraint-induced movement therapy for motor recovery in stroke: Results from a randomized clinical trial. Frontiers in Neurorobotics, 15. https://doi.org/10.3389/fnbot.2021.684019  
  14. Lee, K. W., Kim, S. B., Lee, J. H., Lee, S. J., & Kim, J. W. (2017). Effect of robot-assisted game training on upper extremity function in stroke patients. Annals of Rehabilitation Medicine, 41(4), 539. https://doi.org/10.5535/arm.2017.41.4.539
  15. Edmans J, Gladman J, Hilton D, Walker M, Sunderland A, Cobb S, et al. Clinical evaluation of a non-immersive virtual environment in stroke rehabilitation. Clin Rehabil. 2009;23:106–116. 
  16. Saposnik G, Teasell R, Mamdani M, Hall J, McIlroy W, Cheung D, et al. Effectiveness of virtual reality using Wii gaming technology in stroke rehabilitation: a pilot randomized clinical trial and proof of principle. Stroke. 2010;41:1477–1484.  
  17. Aota.org. (n.d.). Retrieved February 3, 2022, from https://www.aota.org/  
  18. Neuro-Ifrah. (n.d.). Retrieved February 3, 2022, from https://www.neuro-ifrah.org/About NDT certification. Neuro-Developmental Treatment Association. (n.d.). Retrieved February 3, 2022, from https://www.ndta.org/Education/NDT-Certification  
  19. About NDT certification. Neuro-Developmental Treatment Association. (n.d.). Retrieved February 3, 2022, from https://www.ndta.org/Education/NDT-Certification  
  20. Physical therapy for parkinson’s: LSVT big. Physical therapy for Parkinson’s | LSVT BIG. (n.d.). Retrieved February 3, 2022, from https://www.lsvtglobal.com/LSVTBig  
  21. Information & eligibility. Brain Injury Association of America. (2021, May 10). Retrieved February 3, 2022, from https://www.biausa.org/professionals/acbis/certified-brain-injury-specialist/cbis-information-eligibility 
  22. Healthcare Education and patient engagement platform. MedBridge. (2022, January 7). Retrieved February 3, 2022, from https://www.medbridgeeducation.com/  
  23. Certification: CNS Certified Neuro Specialist. Certified Neuro. (n.d.). Retrieved February 3, 2022, from https://www.neurospecialist.org/certification  
  24. Certified Stroke Rehabilitation Specialist (CSRS™): Stroke certification. Certified Stroke Rehabilitation Specialist (CSRS™) | Stroke Certification. (n.d.). Retrieved February 3, 2022, from https://strokecertification.com/seminars/csrs/  
  25. Occupational therapy continuing education. OccupationalTherapy.com. (n.d.). Retrieved February 3, 2022, from https://www.occupationaltherapy.com/  

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