Improving rehabilitation after stroke

Abstract

Stroke imposes one of the largest burdens of disease worldwide. In Australia there are more than 420,000 people currently living with the effects of stroke and this number will rise with the ageing population and epidemics of obesity, physical inactivity and diabetes. One of the most common and disabling deficits after stroke is hemiparesis or a weakness on one side of the body, and although both the upper- and lower-limbs may be affected, changes in the upper-limb have a larger impact on functional disability. With no cure for stroke, rehabilitation remains the only way to improve function and reduce the burden of disease. Stroke survivors are a heterogeneous population and effective rehabilitation is dependent on the delivery of ongoing and individually tailored therapy. However, access to rehabilitation is limited by time, resources and stroke severity. A multidisciplinary approach is necessary to create a balance between the evidence and the limitations of clinical practice to improve the availability and efficacy of ongoing rehabilitation options. This thesis presents three strategies to aid the development of individualised rehabilitation programs for the wider stroke population. First, a quick and objective stratification system was developed to classify patients according to upper-limb motor function to help guide rehabilitation options in the post-acute period. Second, a comparison was made of commonly used upper-limb post stroke assessments to determine the most appropriate and sensitive tools for each level of motor function. Finally, a novel and versatile upper-limb rehabilitation program was investigated. Wii-based Movement Therapy allows rehabilitation to be tailored to patients with very low, low, moderate and high motor function. The efficacy of Wii-based Movement Therapy was established by comparing it in an assessor-blind randomised controlled trial with an equivalent dose of modified-Constraint-Induced Movement Therapy (i.e. a modified form of the current best practice). The three strategies outline salient and efficacious alternatives to increase the availability of individually tailored programs for post-acute patients. Each strategy implements existing tools and technologies and does not require an increase in therapist load or resources, therefore reducing the barriers to translation into clinical practice.