NIHR DC Discover

NIHR Signal Repetitive task training can help recovery after stroke

Published on 25 April 2017

doi: 10.3310/signal-000410

Following a stroke, people who received repetitive task training showed greater improvements in performing functional tasks, such as picking up a cup, standing up and walking. These improvements were sustained for up to six months.

Disability following stroke is common, affecting around half of all stroke survivors. This NIHR-funded review of over thirty trials found that repetitive task training provided small gains in arm and leg function, balance and walking distance (about 35 metres).

We do not yet know the optimum number of sessions, or the ideal duration or intensity. However, it is a versatile and relatively easy intervention which can be delivered by physiotherapists/occupational therapists in groups, individually, in hospital, in the community or at home. Depending on the nature of the exercise, there is also potential for people to continue to practice on their own or with carer support.

This review shows that it can help people to improve functionality and mobility and should be considered as part of routine rehabilitation, in line with national guidance.

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Why was this study needed?

There are over 1.2 million stroke survivors in the UK, with around 152,000 cases reported every year. Stroke is the leading cause of long-term neurological disability, affecting balance, coordination and mobility. According to figures quoted by the Stroke Association, around 77% of stroke patients experience arm weakness and 72% experience leg weakness. It is important to understand which rehabilitation interventions might offer the best outcomes for patients to improve independence and quality of life. Repetitive task training is currently a component of stroke care so it is important to validate its effectiveness.

This Cochrane review is an update of an earlier review, last updated in 2007. Since then, 19 new trials have published results and the reporting standards have improved so these were added to the evidence base. 

What did this study do?

This updated Cochrane systematic review included 32 randomised controlled trials and one quasi-randomised trial, involving 1,853 participants in all. 

The trials were from various countries, including the UK, Australia, Canada and Korea.  Repetitive task training consisted of repeating a series of movements, with the aim of being able to perform a functional task. The training might involve the whole task, such as lifting a cup, or part of a task, such as grasping a cup. Most therapy interventions under evaluation lasted two to four weeks for between 10 to 21 hours.

Due to poor reporting in many of the original trials, it is difficult to assess the risk of bias. In addition, a wide range of interventions were used in the comparison groups. These factors mean researchers had a low to moderate degree of confidence in the main results.

What did it find?

  • For arms, repetitive task training had a small impact on improving function (standardised mean difference [SMD] 0.25, 95% confidence interval [CI] 0.01 to 0.49) - 11 studies, 749 participants.
  • For legs, repetitive task training provided small improvements in metres walked over six minutes (mean difference 34.8m, 95% CI 18.19m to 51.41m); walking ability (SMD 0.35, 95% CI 0.04 to 0.66); leg function (SMD 0.29, 95% CI 0.10 to 0.48); standing up from sitting (SMD 0.35, 95% CI 0.13 to 0.56) and standing balance (SMD 0.24, 95% CI 0.07 to 0.42).
  • There were no differences in functional ability after treatment according to the number of hours of training, the time from stroke to training or in the type of training delivered.
  • Repetitive task training was effective in the first six months, but no difference between groups was seen after six months.
  • Few trials reported on falls and other adverse effects making it difficult to assess the risks.

What does current guidance say on this issue?

Guidance from Royal College of Physicians in 2016 and NICE in 2013 recommends people are offered repetitive task training to improve arm and leg weakness, using activities such as reaching, grasping, sit to stand transfers and walking. The guidance recommends physiotherapists support people with movement difficulties and that rehabilitation continues until the person is able to maintain or improve functionality on their own or with the help of family or support staff.

What are the implications?

Given the range of participants included in these trials, repetitive task training could be appropriate for most people with weakness following a stroke. Clinicians and healthcare providers currently deliver repetitive task training as part of routine rehabilitation and through one-to-one or group training sessions.

There is insufficient information to draw conclusions on the optimal duration of sessions and the impact of current practices on therapist resource. The review suggests training is well received though it may be worthwhile to work with local patient groups to better understand their needs and preferences. Mechanisms to ensure adverse effects are reported and monitored are important.

An overview of NIHR funded research on stroke was published in March 2017, including aspects of recovery and rehabilitation after stroke. This can be downloaded free here.

Citation and Funding

French B, Thomas LH, Coupe J, et al. Repetitive task training for improving functional ability after stroke. Cochrane Database Syst Rev. 2016; (11):CD006073. 

This project was funded by the National Institute for Health Research Cochrane Review Incentive Scheme and the Department of Health Research and Development Health Technology Assessment Programme.

Bibliography

French B, Leathley M, Sutton C, et al. A systematic review of repetitive functional task practice with modelling of resource use, costs and effectiveness. Health Technol Assess. 2008;12(30).

NICE. Stroke rehabilitation in adults. CG162. London: National Institute for Health and Care Excellence; 2013.

RCP. National clinical guidelines for stroke. London; Royal College of Physicians, Intercollegiate Stroke Working Party; 2016.

Stroke Association. State of the Nation. Stroke statistics 2016. London: Stroke Association; 2015.

Why was this study needed?

There are over 1.2 million stroke survivors in the UK, with around 152,000 cases reported every year. Stroke is the leading cause of long-term neurological disability, affecting balance, coordination and mobility. According to figures quoted by the Stroke Association, around 77% of stroke patients experience arm weakness and 72% experience leg weakness. It is important to understand which rehabilitation interventions might offer the best outcomes for patients to improve independence and quality of life. Repetitive task training is currently a component of stroke care so it is important to validate its effectiveness.

This Cochrane review is an update of an earlier review, last updated in 2007. Since then, 19 new trials have published results and the reporting standards have improved so these were added to the evidence base. 

What did this study do?

This updated Cochrane systematic review included 32 randomised controlled trials and one quasi-randomised trial, involving 1,853 participants in all. 

The trials were from various countries, including the UK, Australia, Canada and Korea.  Repetitive task training consisted of repeating a series of movements, with the aim of being able to perform a functional task. The training might involve the whole task, such as lifting a cup, or part of a task, such as grasping a cup. Most therapy interventions under evaluation lasted two to four weeks for between 10 to 21 hours.

Due to poor reporting in many of the original trials, it is difficult to assess the risk of bias. In addition, a wide range of interventions were used in the comparison groups. These factors mean researchers had a low to moderate degree of confidence in the main results.

What did it find?

  • For arms, repetitive task training had a small impact on improving function (standardised mean difference [SMD] 0.25, 95% confidence interval [CI] 0.01 to 0.49) - 11 studies, 749 participants.
  • For legs, repetitive task training provided small improvements in metres walked over six minutes (mean difference 34.8m, 95% CI 18.19m to 51.41m); walking ability (SMD 0.35, 95% CI 0.04 to 0.66); leg function (SMD 0.29, 95% CI 0.10 to 0.48); standing up from sitting (SMD 0.35, 95% CI 0.13 to 0.56) and standing balance (SMD 0.24, 95% CI 0.07 to 0.42).
  • There were no differences in functional ability after treatment according to the number of hours of training, the time from stroke to training or in the type of training delivered.
  • Repetitive task training was effective in the first six months, but no difference between groups was seen after six months.
  • Few trials reported on falls and other adverse effects making it difficult to assess the risks.

What does current guidance say on this issue?

Guidance from Royal College of Physicians in 2016 and NICE in 2013 recommends people are offered repetitive task training to improve arm and leg weakness, using activities such as reaching, grasping, sit to stand transfers and walking. The guidance recommends physiotherapists support people with movement difficulties and that rehabilitation continues until the person is able to maintain or improve functionality on their own or with the help of family or support staff.

What are the implications?

Given the range of participants included in these trials, repetitive task training could be appropriate for most people with weakness following a stroke. Clinicians and healthcare providers currently deliver repetitive task training as part of routine rehabilitation and through one-to-one or group training sessions.

There is insufficient information to draw conclusions on the optimal duration of sessions and the impact of current practices on therapist resource. The review suggests training is well received though it may be worthwhile to work with local patient groups to better understand their needs and preferences. Mechanisms to ensure adverse effects are reported and monitored are important.

An overview of NIHR funded research on stroke was published in March 2017, including aspects of recovery and rehabilitation after stroke. This can be downloaded free here.

Citation and Funding

French B, Thomas LH, Coupe J, et al. Repetitive task training for improving functional ability after stroke. Cochrane Database Syst Rev. 2016; (11):CD006073. 

This project was funded by the National Institute for Health Research Cochrane Review Incentive Scheme and the Department of Health Research and Development Health Technology Assessment Programme.

Bibliography

French B, Leathley M, Sutton C, et al. A systematic review of repetitive functional task practice with modelling of resource use, costs and effectiveness. Health Technol Assess. 2008;12(30).

NICE. Stroke rehabilitation in adults. CG162. London: National Institute for Health and Care Excellence; 2013.

RCP. National clinical guidelines for stroke. London; Royal College of Physicians, Intercollegiate Stroke Working Party; 2016.

Stroke Association. State of the Nation. Stroke statistics 2016. London: Stroke Association; 2015.

Repetitive task training for improving functional ability after stroke

Published on 15 November 2016

French, B.,Thomas, L. H.,Coupe, J.,McMahon, N. E.,Connell, L.,Harrison, J.,Sutton, C. J.,Tishkovskaya, S.,Watkins, C. L.

Cochrane Database Syst Rev Volume 11 , 2016

BACKGROUND: Repetitive task training (RTT) involves the active practice of task-specific motor activities and is a component of current therapy approaches in stroke rehabilitation. OBJECTIVES: Primary objective: To determine if RTT improves upper limb function/reach and lower limb function/balance in adults after stroke. Secondary objectives: 1) To determine the effect of RTT on secondary outcome measures including activities of daily living, global motor function, quality of life/health status and adverse events. 2) To determine the factors that could influence primary and secondary outcome measures, including the effect of 'dose' of task practice; type of task (whole therapy, mixed or single task); timing of the intervention and type of intervention. SEARCH METHODS: We searched the Cochrane Stroke Group Trials Register (4 March 2016); the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library 2016, Issue 5: 1 October 2006 to 24 June 2016); MEDLINE (1 October 2006 to 8 March 2016); Embase (1 October 2006 to 8 March 2016); CINAHL (2006 to 23 June 2016); AMED (2006 to 21 June 2016) and SPORTSDiscus (2006 to 21 June 2016). SELECTION CRITERIA: Randomised/quasi-randomised trials in adults after stroke, where the intervention was an active motor sequence performed repetitively within a single training session, aimed towards a clear functional goal. DATA COLLECTION AND ANALYSIS: Two review authors independently screened abstracts, extracted data and appraised trials. We determined the quality of evidence within each study and outcome group using the Cochrane 'Risk of bias' tool and GRADE (Grades of Recommendation, Assessment, Development and Evaluation) criteria. We did not assess follow-up outcome data using GRADE. We contacted trial authors for additional information. MAIN RESULTS: We included 33 trials with 36 intervention-control pairs and 1853 participants. The risk of bias present in many studies was unclear due to poor reporting; the evidence has therefore been rated 'moderate' or 'low' when using the GRADE system. There is low-quality evidence that RTT improves arm function (standardised mean difference (SMD) 0.25, 95% confidence interval (CI) 0.01 to 0.49; 11 studies, number of participants analysed = 749), hand function (SMD 0.25, 95% CI 0.00 to 0.51; eight studies, number of participants analysed = 619), and lower limb functional measures (SMD 0.29, 95% CI 0.10 to 0.48; five trials, number of participants analysed = 419). There is moderate-quality evidence that RTT improves walking distance (mean difference (MD) 34.80, 95% CI 18.19 to 51.41; nine studies, number of participants analysed = 610) and functional ambulation (SMD 0.35, 95% CI 0.04 to 0.66; eight studies, number of participants analysed = 525). We found significant differences between groups for both upper-limb (SMD 0.92, 95% CI 0.58 to 1.26; three studies, number of participants analysed = 153) and lower-limb (SMD 0.34, 95% CI 0.16 to 0.52; eight studies, number of participants analysed = 471) outcomes up to six months post treatment but not after six months. Effects were not modified by intervention type, dosage of task practice or time since stroke for upper or lower limb. There was insufficient evidence to be certain about the risk of adverse events. AUTHORS' CONCLUSIONS: There is low- to moderate-quality evidence that RTT improves upper and lower limb function; improvements were sustained up to six months post treatment. Further research should focus on the type and amount of training, including ways of measuring the number of repetitions actually performed by participants. The definition of RTT will need revisiting prior to further updates of this review in order to ensure it remains clinically meaningful and distinguishable from other interventions.

Repetitive task training is based on the theory that repeated tasks will improve strength, encourage motor learning and assist the recovery of neural pathways. The person repeats functionally relevant tasks, such as lifting a cup or moving from sitting to standing, to help restore functionality to limbs and overall mobility. In some settings, training is delivered to groups of patients, sometimes using circuit training, where each station involves performing a different task.

Expert commentary

This is a very useful review for clinical practice. It shows that repetitive task training improves mobility and upper limb function for people with stroke in both the short and long term, whether undertaken soon or long after the stroke. Although the evidence is only moderately strong, it eclipses the evidence for current commonly used approaches. The challenge now is to develop rehabilitation to incorporate as much repetitive task training as possible, during patients’ daily routines as well therapy sessions. There is, of course, further work to be done to develop individualised doses and types of practice but in the meantime just do it.

Sarah F Tyson, Professor of Rehabilitation, University of Manchester