We all know the saying “less is more,” but when it comes to neuro rehab, we are finding that the opposite is true.
It turns out that neuro patients benefit from a “more is more” mentality—the more therapy provided, the greater the functional outcomes. So where exactly is that sweet spot of therapy intensity? And what are some of the barriers to actually achieving the intensity required to see results?
The biggest question stroke patients (and their families) have is:
“What type of therapy will I receive, and how much is needed for best outcomes?”
This question has been the subject of multiple studies over the past few decades, and we are still homing in on the exact answer—not to mention trying to wrap our minds around the outcomes we are seeing.
How Much Therapy Yields the Best Outcomes for Our Patients?
There is level 1a evidence (the best kind!) that suggests greater intensities of physiotherapy and occupational therapy will lead to improved functional outcomes in patients.
The Evidence-Based Review of Stroke Rehabilitation (EBRSR) Clinical Guide states that 17 hours per week of physiotherapy and occupational therapy over a 10-week period of time is considered ideal for improving motor outcomes.1
The therapy should also be task specific. Kalra and Langhorne have noted that “there is evidence from neuroimaging studies showing that increased intensity of rehabilitation therapies results in greater activation of areas associated with the function towards which this therapy is directed.”2
Tempting as it might be to spend lots of time on the upper body ergometer (UBE), integrating therapeutic tasks that relate directly to cooking, self-care, and other daily activities will yield much better results for our patients. Plus, these tasks are just more fun.
How Many Repetitions Should We Shoot For?
This topic has been under much debate lately with seemingly conflicting research published.3 But the numbers explored in research are around 300 to 400 repetitions per day, as this has been shown to yield significant improvement in animal test subjects.4 We don’t know the exact numbers that are most beneficial, but we do know that these repetitions are much higher than patients receive in therapy.
Researchers are still sorting the actual numbers indicated for study in humans, but the short answer here is that repetitions beyond 300 per day are likely needed to show significant improvement.
Barriers to Achieving the Preferred Amount of Rehab Intensity
While we now have a clearer picture of the ideal rehab intensity, we need to own up to the fact that we typically do not deliver this level of therapy. In 2009, Lang, et al., monitored OTs in the inpatient stroke rehab setting. The research team found that task-specific, functional upper extremity (UE) movements were being used in only about half of the UE sessions.5 Plus, therapists only employed 32 repetitions on average—a fraction of those shown to be clinically significant in animal research.
What Does This Mean for Therapists?
We are falling short. This does not mean we are bad therapists. It simply means that we have to put ourselves out there, scrutinize our current practice, and brainstorm how to bridge the gap between the latest research around neuro-rehab dosing and what’s actually happening in the clinic.
We know that the average length of stay for inpatient stroke rehab is ten to fourteen days (about eight weeks short of our preferred ten-week therapy.)
Of course, patients often continue receiving therapy after discharge in the home health, skilled nursing, or outpatient settings. Nonetheless, we must keep in mind that these settings simply are not staffed to provide high-intensity motor rehab. And even if they were, there are more barriers to overcome such as financial challenges, caregiver support, and other factors specific to the individual patient.
How Can We Provide the Needed Level of Rehab Intensity to Our Patients?
Now that we know that the recommended amount of therapy is seventeen hours over ten weeks, the million dollar question is this: How can we provide that to our patients?
We know that high-repetition, task-specific training every day is key. Encouraging our patients to utilize their impaired upper extremities as much as is (safely) possible is also a must.
The reality is that to obtain these repetitions, especially in an inpatient setting, you practically have to be a superhero. Because insurance dictates that we see results quickly, we wind up focusing too soon on patients achieving maximum independence of ADLs—even if that means the patient develops compensatory techniques.6
We know this is not the best care for our patients. Recent evidence states that learned non-use develops during the early stages of stroke,7 so that’s when we really need to focus on high repetitions of healthy movements. Instead, we overlook motor recovery and skip to maximum function, and patients may or may not receive a focus on motor recovery in an outpatient setting. We all know that many patients fall through the cracks at this point.
How We Can Facilitate These Needs
There are things we can do to put these best practices into action, and both low-tech and high-tech options are at our fingertips!
A basic motor activity log tracked on regular notebook paper can make a huge difference for our patients. This log can help patients stay focused on regularly using their impaired upper extremity in daily activities.
More modern solutions can help, too. Emerging technologies can assist patients with creating intentional movements—while maxing out as many repetitions as possible in the process.
There are several robotic therapy devices on the market, many of which can increase the number of repetitions patients receive by staggering amounts; this can give hope even to stroke patients in the chronic phase, who might otherwise feel they’ve plateaued.8 These devices are still costly, but you can bet that the price will continue to go down. Furthermore, technologies like telehealth and remote monitoring also increase access to care––and, hopefully, the likelihood that patients will stick with home exercise programs. Lastly, new business models such as rehab gyms make it possible for patients to retain access to therapy equipment following discharge.
By blending task-specific training with tech designed to encourage max repetitions, we can work to provide the best possible motor outcomes for our patients. One option for honing your foundational neuro OT knowledge is MedBridge’s Neurologic Occupational Therapy: Upper Extremity Motor Rehabilitation Certificate Program. The MedBridge GO app reminds patients to complete their assigned exercise program through push notifications, and MedBridge’s home exercise library contains over 1,000 different stroke exercises to address a variety of conditions and rehabilitation goals.
While this information may feel equal parts discouraging and encouraging, we’re choosing an optimistic approach. We can feel empowered simply by knowing that the latest research points us toward a more structured approach to delivering post-stroke neuro rehab. Plus, although we are becoming painfully aware of how we’ve fallen short of delivering the intensity our patients need, technology is progressing at a rate that shows a plausible solution.
- Teasell, R., Foley, N., Hussein, N., Wiener, J., & Speechley, M. (2018). The elements of stroke rehabilitation. In Evidence-Based Review of Stroke Rehabilitation. Retrieved from http://www.ebrsr.com/sites/default/files/v18-SREBR-CH6-NET.pdf
- Kalra, L., & Langhorne, P. (2007). Facilitating recovery: evidence for organized stroke care. Journal of Rehabilitation Medicine,39(2), 97-102.
- Lang, C. E., Strube, M. J., Bland, M. D., Waddell, K. J., Cherry-Allen, K. M., Nudo, R. J., et al. (2016). Dose response of task-specific upper limb training in people at least 6 months poststroke: a phase II, single-blind, randomized, controlled trial. Annals of Neurology, 80(3): 342–54.
- Krakauer, J. W., Carmichael, S. T., Corbett, D., & Wittenberg, G. F. (2012). Getting neurorehabilitation right: What can be learned from animal models? Neurorehabilitation and Neural Repair, 26(8): 923–31.
- Lang, C. E., Macdonald, J. R., Reisman, D. S., Boyd, L., Jacobson Kimberley, T., Schindler-Ivens, S., et al. (2009). Observation of amounts of movement practice provided during stroke rehabilitation. Archives of Physical Medicine and Rehabilitation, 90(10): 1692-1698.
- Carvalho, E., Bettger, J. P., & Goode, A. P. (2017). Insurance coverage, costs, and barriers to care for outpatient musculoskeletal therapy and rehabilitation services. North Carolina Medical Journal, 78(5), 312-314.
- Grotta, J. C., Noser, E. A., Ro, T., Boake, C., Levin, H., Aronowski, J. & Schallert, T. (2004). Constraint-induced movement therapy. Stroke, 35(11): 2699–2701.
- Cho, K. H. & Song, W-K. (2019). Robot-assisted reach training with an active assistant protocol for long-term upper extremity impairment poststroke: a randomized clinical trial. Archives of Physical Medicine and Rehabilitation, 100(2): 213–219.