Are there any interventions beyond physiotherapy to improve functional outcomes 9 months post-stroke?

Interventions Beyond Physiotherapy for Functional Improvement 9 Months Post-Stroke

Beyond traditional physiotherapy, strength training, electrical stimulation, aerobic exercise, and balance training are effective interventions for improving functional outcomes in patients who are 9 months post-stroke. 1

Strength Training

• Resistive exercise training increases gait speed and muscular strength in the hemiparetic leg, with strong evidence supporting its benefits for functional mobility and walking 1
• The knee extensors are the most important muscle group on the hemiparetic leg for predicting gait speed, making them a key target for interventions aimed at improving walking outcomes 1
• Lower extremity strengthening interventions improve strength and activity without increasing spasticity 1
• For upper extremity, strength training does not increase spasticity but may have less long-term benefit than functional task training 1

Electrical Stimulation

• Strong evidence supports the efficacy of electrical stimulation for individuals with chronic stroke 1
• Functional electrical stimulation (FES) combined with biofeedback produces better results than standard physical therapy, FES, or biofeedback alone 1
• FES combined with physical therapy is superior to physical therapy alone in improving gait speed while reducing energy cost 1
• Implantable nerve stimulators are safe and effective in reducing foot drop during ambulation in stroke survivors, improving gait speed and walking endurance 1, 2
• Electrical stimulation promotes neural reorganization by providing sensory input and facilitating more complete muscle contractions 2

Aerobic Exercise and Physical Activity

• Regular physical activity reduces stroke risk, positively affects risk factors (blood pressure, cholesterol, weight), improves endothelial function, and reduces platelet aggregation 1
• Exercise interventions positively affect disability, aerobic fitness, mobility (walking speed), and functional balance indices after stroke 1
• Patients should aim for 40-minute sessions, 3 to 4 times per week of moderate to vigorous-intensity aerobic activity 1
• Exercise-based interventions with counseling compared to usual care can reduce systolic blood pressure by approximately 5.3 mm Hg 1
• Exercise interventions initiated within 6 months of stroke/TIA have a larger effect on blood pressure (-8.46 mm Hg) than those initiated after 6 months (-2.33 mm Hg) 1

Balance Training

• Cycle training can improve standing balance through muscle strength and control of the lower extremity 1
• Visual feedback with dynamic balance activities in conjunction with traditional therapy can significantly improve dynamic balance and reduce falls even 6 months after training 1
• Breaking up sedentary time with intervals as short as 3 minutes of standing or light exercise every 30 minutes may be beneficial for cardiovascular health 1

Adjunctive Techniques

• Visual feedback tracking for knee extensor movements can improve walking, with evidence of cortical reorganization 1
• Electromyography biofeedback added to task practice with FES can enhance upper extremity function to a greater extent than task practice with FES alone 1
• Visual feedback with a force platform used for standing balance appears beneficial according to Cochrane reviews 1

Adaptive Devices and Technology

• Adaptive devices designed to improve safety and function may be considered if other methods of performing specific functional tasks are not available 1
• Functional dynamic orthoses can facilitate repetitive task-specific training 1
• Repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) may be considered as adjuncts to upper extremity therapy 1

Timing Considerations

• While maximum medical improvement typically occurs within 5-6 months after stroke onset, continued therapy beyond this period can still yield benefits 3
• For patients with moderate strokes (26% of population), maximum recovery occurs within 3 months, but continued intervention can address specific functional limitations 3
• Neurological recovery (measured by stroke scales) typically precedes functional recovery by approximately 2 weeks 3
• Even at 9 months post-stroke, task-oriented and task-specific training can still provide benefits 4

Implementation Strategy

1. Assess current functional status to identify specific limitations in mobility, strength, balance, and activities of daily living 1
2. Implement strength training focusing particularly on knee extensors for improved gait 1
3. Add electrical stimulation as an adjunctive therapy to motor practice rather than as a standalone treatment 2
4. Incorporate aerobic exercise with 40-minute sessions, 3-4 times weekly at moderate to vigorous intensity 1
5. Include balance training with visual feedback components 1
6. Consider adaptive devices and emerging technologies like rTMS or tDCS as needed 1

Common Pitfalls and Caveats

• Independent balance training without proper guidance may not improve balance 1
• The effects of electrical stimulation on maintaining functional gains can be variable; benefits may only be evident when the stimulator is used 1, 2
• Mental imagery techniques have conflicting evidence regarding their effectiveness for improving upper extremity motor function 1
• Neurological treatment approaches (e.g., Bobath) show equal or unfavorable effects compared to other training interventions 4
• Monitoring for late-onset cognitive decline is important, particularly in patients with risk factors such as stroke recurrence 3