[ARTICLE] Intensive upper limb neurorehabilitation in chronic stroke: outcomes from the Queen Square programme – Full Text

Abstract

Objective Persistent difficulty in using the upper limb remains a major contributor to physical disability post-stroke. There is a nihilistic view about what clinically relevant changes are possible after the early post-stroke phase. The Queen Square Upper Limb Neurorehabilitation programme delivers high-quality, high-dose, high-intensity upper limb neurorehabilitation during a 3-week (90 hours) programme. Here, we report clinical changes made by the chronic stroke patients treated on the programme, factors that might predict responsiveness to therapy and the relationship between changes in impairment and activity.

Methods Upper limb impairment and activity were assessed on admission, discharge, 6 weeks and 6 months after treatment, with modified upper limb Fugl-Meyer (FM-UL, max-54), Action Research Arm Test (ARAT, max-57) and Chedoke Arm and Hand Activity Inventory (CAHAI, max-91). Patient-reported outcome measures were recorded with the Arm Activity Measure (ArmA) parts A (0–32) and B (0–52), where lower scores are better.

Results 224 patients (median time post-stroke 18 months) completed the 6-month programme. Median scores on admission were as follows: FM-UL = 26 (IQR 16–37), ARAT=18 (IQR 7–33), CAHAI=40 (28-55), ArmA-A=8 (IQR 4.5–12) and ArmA-B=38 (IQR 24–46). The median scores 6 months after the programme were as follows: FM-UL=37 (IQR 24–48), ARAT=27 (IQR 12–45), CAHAI=52 (IQR 35–77), ArmA-A=3 (IQR 1–6.5) and ArmA-B=19 (IQR 8.5–32). We found no predictors of treatment response beyond admission scores.

Conclusion With intensive upper limb rehabilitation, chronic stroke patients can change by clinically important differences in measures of impairment and activity. Crucially, clinical gains continued during the 6-month follow-up period.

Introduction

Stroke remains common1 and persistent difficulty in using the upper limb is a major contributor to ongoing physical disability.2 The general consensus remains that most spontaneous recovery of the upper limb occurs over the first 3 months after stroke and current levels of rehabilitation result in little improvement after that, particularly at the level of impairment.3 Improving outcomes through higher dose (time in rehabilitation or number of repetitions) and intensity (dose per session) of rehabilitation is an attractive option.4 However, clinical trials of higher dose upper limb rehabilitation have generally not produced the magnitude of improvement that will change clinical practice,5 whether delivered in the early6 or chronic stages post-stroke.7–9 A common factor in these trials is that the dose (in hours) of additional therapy remained relatively low (18–36 hours). Despite scepticism that stroke patients could tolerate much higher doses,8 one study managed to deliver 300 hours of upper limb therapy to chronic stroke patients over 12 weeks and reported changes in measures of both impairment and activity that were far greater than those in lower dose studies.10 Three hundred hours represents an order of magnitude higher than any dose of rehabilitation offered in previous upper limb rehabilitation trials and deserves further consideration. However, this idea is challenging because of the logistics of setting up such a trial in healthcare settings where the ethic of high-dose, high-intensity rehabilitation is not supported. In this context, it is important to report the findings of clinical services that are able to deliver higher doses than conventionally seen. The Queen Square Upper Limb (QSUL) Neurorehabilitation programme is a single-centre clinical service that provides 90 hours of timetabled treatment focusing on the post-stroke upper limb in chronic (>6 months post-stroke) stroke patients. Here, we report (i) outcomes for patients admitted to this programme at the National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Trust (UCLH), including 6-month follow-up data to look at whether any clinical benefits were maintained, (ii) the characteristics of the patients admitted and any predictors of response and (iii) the relationship between changes in impairment and activity.[…]

Continue —> https://jnnp.bmj.com/content/90/5/498

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