Guided Self-rehabilitation Contract vs conventional therapy in chronic stroke-induced hemiparesis: NEURORESTORE, a multicenter randomized controlled trial

Abstract

BackgroundAfter discharge from hospital following a stroke, prescriptions of community-based rehabilitation are often downgraded to “maintenance” rehabilitation or discontinued. This classic therapeutic behavior stems from persistent confusion between lesion-induced plasticity, which lasts for the first 6 months essentially, and behavior-induced plasticity, of indefinite duration, through which intense rehabilitation might remain effective. This prospective, randomized, multicenter, single-blind study in subjects with chronic stroke-induced hemiparesis evaluates changes in active function with a Guided Self-rehabilitation Contract vs conventional therapy alone, pursued for a year.MethodsOne hundred and twenty four adult subjects with chronic hemiparesis (> 1 year since first stroke) will be included in six tertiary rehabilitation centers. For each patient, two treatments will be compared over a 1-year period, preceded and followed by an observational 6-month phase of conventional rehabilitation. In the experimental group, the therapist will implement the diary-based and antagonist-targeting Guided Self-rehabilitation Contract method using two monthly home visits. The method involves: i) prescribing a daily antagonist-targeting self-rehabilitation program, ii) teaching the techniques involved in the program, iii) motivating and guiding the patient over time, by requesting a diary of the work achieved to be brought back by the patient at each visit. In the control group, participants will benefit from conventional therapy only, as per their physician’s prescription.The two co-primary outcome measures are the maximal ambulation speed barefoot over 10 m for the lower limb, and the Modified Frenchay Scale for the upper limb. Secondary outcome measures include total cost of care from the medical insurance point of view, physiological cost index in the 2-min walking test, quality of life (SF 36) and measures of the psychological impact of the two treatment modalities. Participants will be evaluated every 6 months (D1/M6/M12/M18/M24) by a blinded investigator, the experimental period being between M6 and M18. Each patient will be allowed to receive any medications deemed necessary to their attending physician, including botulinum toxin injections.DiscussionThis study will increase the level of knowledge on the effects of Guided Self-rehabilitation Contracts in patients with chronic stroke-induced hemiparesis.Trial registrationClinicalTrials.gov: NCT02202954, July 29, 2014.

Added Value of Dynamic EMG in the Assessment of the Equinus and the Equinovarus Foot Deviation in Stroke Patients and Barriers Limiting Its Usage

“…Actually, knowing the causes for an alteration in the gait pattern of a patient, allows to set specific targets tailored to the patients' impairment, integrating the predefined physiotherapy protocols that are often used in everyday practice (29). Tailored physiotherapy should include intensive motor training, daily stretching at high load and exercises characterized by maximal amplitude rapid alternating movements (30).…”

“…If PFs have a bursts-like signal, the patient could benefit from a treatment to recover muscle extensibility and decrease linear resistance caused by an increase in transverse collagen fibers and a decrease of the slide between muscle and fascia, respectively (35). This could be achieved by stretching exercises and exercises characterized by maximal amplitude rapid alternating movements to prevent contracture, to improve joint range of motion and flexibility and by muscle strengthening (30,(36)(37)(38)(39)(40)(41)(42)(43). Soft tissue manual treatments could be helpful too (35,44).…”

Available Therapeutics after a Stroke: Current and Promising Options

“…Some clinical parameters that can be observed at the bedside, such as early finger extension and shoulder abduction, can act as predictors of long-term (over 6 months) recovery after stroke [93]. Spontaneous recovery of upper and lower limbs occurs depending on the type, location, and severity of the lesion, in approximately 60-70% of cases [93] during the first 2-6 months [4,94], period after which most people believe they have achieved maximal recovery and stop with either physical or pharmacological therapy [4,95]. Interventions should be designed according to the stage of neurological recovery the patient is in, with the consideration that early chronicity is not a contraindication for continuing rehabilitation [4].…”

“…Physical rehabilitation must start early, if possible, during the first week poststroke [96], because there is an intensification in neuroplasticity during the early stages [91], employing different mechanisms such as the axon regeneration [88], and the higher expression of growth-promoting genes, such as GAP-43. This lesioninduced plasticity that happens during the first days post-stroke [90,97,98] reportedly lasts around 6 months after stroke [4,91,95,97]. Also, therapy must continue after such a period, to take advantage of behavior-induced plasticity [95], which is still possible after 1 year of having had the stroke [4].…”

“…This lesioninduced plasticity that happens during the first days post-stroke [90,97,98] reportedly lasts around 6 months after stroke [4,91,95,97]. Also, therapy must continue after such a period, to take advantage of behavior-induced plasticity [95], which is still possible after 1 year of having had the stroke [4].…”