Upper Limb Rehabilitation in First Year After Stroke Using Modern Treatment Strategies (rTMS, Robot Assisted Training and Intensive Motor Training ) - a Single Case Study

Introduction Stroke is a major cause of disability in worldwide, causing billions of euros direct and indirect costs to the community. Upper limb motor dysfunction is seen in about 50% stroke survivors. Upper extremity paresis is identified as a strong component for performing ADL (Veerbeek 2011, 1). Hemi-paretic upper extremity causes reduction of capacity to carry out different types of functional tasks like reaching, grasping and manipulation that may lead to difficulty in activities of daily life (Yavuser 2008, 2). Upper-limb rehabilitation is crucial during the first three to six months since the onset of stroke because the motor and ADL-performance recovery of stroke survivors declines afterward (Kwakkel & Kollen, 2013, Wade et al., 1983) (3-4).

Improvement probably occurs through a complex combination of spontaneous and learning-dependent processes including: restitution, substitution, and compensation (Kwakkel et al., 2004; Langhorne et al., 2011)(5-6). Until the third month after stroke onset, a variable spontaneous neurological recovery can be considered a confounder of rehabilitation intervention (Kwakkel et al., 2006)(7). Progresses in functional outcome appearing after 3 months seem largely dependent on learning adaptation strategies (Kwakkel et al., 2004)(5). Evidence suggests that neurological repair through brain reorganization supporting true recovery or, alternatively through compensation, may also take place in the subacute and chronic phase after stroke (Krakauer, 2006)(8).

Since upper limb paresis is shown to be major factor for performing ADL activities and is strongly related to independence in self-care, there is urgent need to find methods to improve the function of paretic upper limb.

Motor training, functional training and goal-setting are traditional rehabilitation methods that are widely used and are often the treatment standard for stroke patients.

In the recent Cochrane review it was concluded that robot assisted therapy can improve activities of daily living, arm function, and muscle strength of the paretic arm (Mehrholz, 2018)(9). The main advantages of using robot-assisted therapy are to deliver high-dosage and high-intensity training (Sivan et al., 2011)(10). Robot-assisted training enables a greater number of repetitive tasks to be practised in a consistent and controllable manner. Repetitive task training is known to drive Hebbian plasticity, where wiring of pathways that are coincidently active is strengthened (Hallett 1999, Hebb 1949)(11,12). A dose of greater than 20 h of repetitive task training improves upper limb motor recovery following a stroke (Pollock 2014)(13) and, therefore, robot-assisted training has the potential to improve arm motor recovery after stroke.