Critically Appraised Topic (CAT)

Case Study

The present critically appraised topic (CAT) explores the effectiveness of repetitive task training for stroke on our patient Mr. X’s functional improvement over standard physiotherapy intervention. “Mr. X is an 80-year-old male who was diagnosed with a left-sided stroke.” The first CT scan of Mr. X’s brain displayed blood traces in the patient’s left parietal segment. Mr. X is currently experiencing hemolysis, the patient’s difficulty or incapability to swallow food, and the right side hemiplegia, which has translated weakening of the patient’s stability, particularly when trying to mobilize.

CAT Question

“What is the effectiveness of repetitive task training for stroke patient’s functional improvement, as compared to standard physiotherapy intervention?”

Introduction and Background of the Therapy

A stroke can translate to permanent damage to the brain, cause challenges with movement and down one side of the body. However, most patients make some recovery in most cases (Hubbard et al. 2015). While some recovery has been achieved over time, the study shows that about one-third of stroke patients continue to have post-stroke-related problems even after recovery (Hubbard et al. 2015). Repeated practice of functional tasks or repetitive task training (e.g., lifting objects) is one treatment approach to aid with the recovery of movement post-stroke. Repetitive task training is based on the notion that the patients can improve in a particular task, such as lifting an object when they practice performing the same task several times. The present critically appraised topic (CAT) explores the effectiveness of repetitive task training (RTT) to facilitate functional improvement in stroke patients compared to standard physiotherapy intervention.

Summary of Evidence from the Reviewed Studies

In comparison with the standard physiotherapy, evidence from the literature shows that stroke patients who practice repetitive task training (RTT) experience significant improvements in hand and arm function, walking distance, and other walking ability measures. Hubbard et al. (2015) noted that about one-third of patients who recover from a stroke requires continuing assistance. Upper-limb (UL) dysfunction contributes to a larger share post-stroke the disability. The researchers pointed out that extensive evidence shows that more-intensive and challenging training tasks adopted at earlier phases of post-stroke recovery help improve functional outcomes during the recovery process. Such task training contributes to influencing brain activation, which may form the beginning of neuroplasticity (Hubbard et al. 2015), enabling the brain neural networks to reorganize.

            The research by Hubbard et al. (2015) adopted a single-blinded, Random Control Trials (RCT) with patients recruited from 2 acute stroke admission units. The findings indicated that a more rigorous task-specific upper-limb exercise in the first month of stroke recovery is related to improving brain activation in the attention areas and the putative motor. The researchers further argued that intensive upper limb training also resulted in consistent clinical upper limb functioning (Hubbard et al. 2015). Post-stroke patients who get concentrated training experienced high brain activation in the supplementary motor and anterior cingulate areas alongside consistent and predictable upper limb recovery. The study’s findings highlight secondary motor and attention regions’ involvement linked to rigorous motor training involved in the early post-stroke. The association of secondary motor and attention districts is in line with the learning-based plasticity. It was noted in the study that increasing the upper limbs exercise up to 30 hours in the early stages of post-stroke was still feasible and safe (Hubbard et al. 2015).

A study by Jeon, Kim, & Park (2015) also suggests that task-oriented exercise improves post-stroke patients’ recovery outcomes. The research adopted a meta-analysis study of the consequence of task-oriented exercise. Examinations were conducted on randomized, controlled trials from studies reporting circuit or repetitive activity post-stroke impact lower and upper extremities. Eleven research studies were examined on the magnitude of the size. In their findings, the random effects models exhibited a colossal and substantial overall effect (ES51.123) by analyzing the eleven random control trials. The effects were primarily limited to training concentrated on the lower limbs (d 52.264) and the studies focusing on the acute and sub-acute stroke stage patients (d 52.031) (Jeon, Kim, & Park, 2015).

The accumulative effect of task-oriented training throughout the primary outcomes supports repetitive task training for post-stroke rehabilitation. However, the authors noted that intensive intervention is necessary to quicken the recovery of affected limb function. Regarding the timeline and the RTT frequency, the authors noted that increasing training hours provided a larger outcome. For instance, seven days per week, training was much practical than three days per week (Jeon, Kim, & Park, 2015). The findings of this study by Jeon, Kim, & Park (2015) are consistent with the assertions that RTT is effective for post-stroke recovery and that increasing training hours improves the outcomes. The two studies focus on different extremities of the limbs, upper and lower limbs. However, both obtained a positive correlation on the impact of RRT on recovery outcomes in the areas of focus, thus strongly supporting the effectiveness of RRT for stroke in improving functional outcomes in post-stroke patients compared to standard physiotherapy intervention.

A similar result is evident in French et al. (2016)’s study on the effects of repetitive task exercise for improving the patient’s functional abilities after a stroke. The authors conducted a quasi‐randomized trial in post-stroke adults. An active motor sequence was performed recurrently within a single training session to achieve a clear functional goal. In their systematic reviews of therapeutic interventions for post-stroke patients’ paretic upper limbs, the authors noted that participants benefited most from exercise programs that directly train functional tasks. There is strong evidence that intensity practice, 17 hours in ten weeks, with frequent repetition within a single therapy session can improve post-stroke patients’ functional goals (French et al. 2016). The RTT training combines features of both intensities of exercise and functional relevance.

While describing how RTT therapy works, French et al. argue that several rehabilitation facets include repetitive movements. The repetitive motor practice has proven to reduce spasticity and muscle weakness, forming a motor learning physiological foundation. On the one hand, the sensorimotor coupling contributes to the recovery and adaptation of neuron pathways (French et al. 2016). RTT has the latent resource‐efficient stroke therapy module, including self‐initiated practice in the home settings or delivery in a group environment. Besides, repetition of movement forms the elementary mechanism of action linked to several interventions that have proven to improve the motor function such as constraint‐induced movement rehabilitation, treadmill (routine) training, or training with electromechanical devices such as robots (French et al. 2016).

There is a consensus across the studies that the intensity of RTT in the first phases of the post-stroke influences recovery outcomes, and this should be the best time for engaging the patients in rehabilitation. Increasing the practice’s intensity provides an opportunity for focused task-specific motor functionality (Hubbard et al. 2015). The process is expected to include the brain regions involved with attention and motor learning, such as cingulate and supplementary motor areas—consistent with learning-dependent plasticity (French et al. 2016). Research evidence also recognizes the ipsilesional supplementary motor region as vital to UL recovery during the initial stages of post-stroke and, to a slighter extent, the ipsilesional anterior cingulate region. The relationship between more intensive RTT for the upper limbs and the ipsilesional anterior cingulate region’s activation is clinically significant. The anterior cingulate region has shown to be linked to learning, effortful tasks, attention, and error detection (Hubbard et al. 2015). The findings suggest that the therapy paradigm requires patients to be attentive to the task.

Boyne, Welge, Kissela, & Dunning (2017) also conducted a randomized controlled trial with blinded valuations to examine the impact of repeated task-oriented aerobic training on improving post-stroke patients’ physical activities. The study shows that innovative training models incorporating aerobic workout with task-repetitive loco-motor training enhance cardiovascular fitness and functional mobility in post-stroke patients (Boyne, Welge, Kissela, & Dunning 2017). Most post-stroke patients eventually regain the ability to move without assistance, but less than 10% regain adequate walking speed due to impaired motor control. However, aerobic deconditioning is also common in post-stroke and may limit the patient’s walking ability, particularly endurance, to resume independence. Therefore integrating continued task-oriented aerobic exercise is suggested post-stroke to increase aerobic conditioning and walking ability (Boyne, Welge, Kissela, & Dunning 2017).

Task-oriented aerobic training is effective in improving VO2_peak in stroke patients. The study’s adopted Bayesian models estimated a 99.7% probability that vigorous aerobic exercise intensity is related to greater effect size for VO2peak, these than moderate aerobic exercise intensity (Boyne, Welge, Kissela, & Dunning 2017). The greater effect size for VO2peak is known to improve neuronal activation and impacts on neuronal plasticity, which is essential in learning, as mentioned earlier in this paper. Therefore, repetitive aerobic task training is practical for functional improvement post-stroke, just like any other task-oriented training.

Conclusion and Recommendation

Substantial experimental and clinical evidence supports repetitive task training for post-stroke patients. Repetitive task training (RTT) operates on the philosophy that repeated task improves motor learning and strength; therefore helping in the recovery of the neural pathways.  When an individual repeats a functionality relevant task, such as moving and standing, lifting objects, the restoration of the functionality to limbs, both upper and lower, and overall mobility improves. The study further indicates that training models that integrate aerobic exercise with task-repetitive loco-motor training significantly improve functional mobility and, to an extent, cardiovascular fitness for patients with chronic hemiparesis. Aerobic exercise improves the VO2peak, which is essential for neural activation for post-stroke patients. Therefore, this study’s findings recommend repetitive task training for Mr. X’s functional improvement over standard physiotherapy intervention. The standard therapy provides little or no organized therapeutic exercise beyond the sub-acute stroke recovery period. However, from this study, it is apparent that post-stroke patients require continuous training after recovery to improve their functionality. Research evidence proves that task-oriented workouts can increase the patient’s motor function even years after stroke. RTT is even more effective when integrated with aerobic exercise. Therefore, Mr. X’s should be subjected to RTT alongside aerobic training for functional improvement instead of standard physiotherapy intervention.

References

Boyne, P., Welge, J., Kissela, B., & Dunning, K. (2017). Factors influencing the efficacy of aerobic exercise for improving fitness and walking capacity after stroke: a meta-analysis with meta-regression. Archives of physical medicine and rehabilitation, 98(3), 581-595.  doi: 10.1016/j.apmr.2016.08.484

French, B., Thomas, L. H., Coupe, J., McMahon, N. E., Connell, L., Harrison, J., … & Watkins, C. L. (2016). Repetitive task training for improving functional ability after stroke. Cochrane database of systematic reviews, (11). doi: 10.1002/14651858.CD006073.pub3

Hubbard, I. J., Carey, L. M., Budd, T. W., Levi, C., McElduff, P., Hudson, S…, & Parsons, M. W. (2015). A randomized controlled trial of the effect of early upper-limb training on stroke recovery and brain activation. Neurorehabilitation and neural repair, 29(8), 703-713. DOI: 10.1177/1545968314562647

Jeon, B. J., Kim, W. H., & Park, E. Y. (2015). effect of task-oriented training for people with stroke: a meta-analysis focused on repetitive or circuit training. Topics in stroke rehabilitation, 22(1), 34-43. DOI: 10.1179/1074935714Z.0000000035