Rehabilitation is Initiated Early After Stroke, but Most Motor Rehabilitation Trials Are Not

Stroke is the third most common cause of death and the most common cause of acquired adult disability in developed countries.1 Motor impairment is common after stroke, and a critical factor influencing the patient’s ability to live independently.2,3 The neurobiological mechanisms of plasticity and spontaneous recovery during the initial days and weeks after stroke have been reasonably well characterized using animal models.4,5 These mechanisms include cell genesis, functional plasticity, and structural adaptations, such as axonal sprouting and synaptogenesis. The nature and time course of these mechanisms map onto the trajectory of motor recovery observed in human patients, most of whom reach their recovery plateau within 3 months of stroke.6,7 Rehabilitation is primarily delivered in this time period, to capitalize on the unique physiological conditions that prevail, and shape the spontaneous recovery process for the patient’s benefit. Recovery of function is likely to be enhanced by novel treatments that interact with and facilitate the underlying mechanisms of spontaneous recovery.A variety of neurorehabilitation techniques aimed at improving motor recovery after stroke have been developed and trialed over the past 3 decades. These include repetitive task training, biofeedback, constraint-induced movement therapy, robotics, virtual reality, motor imagery, noninvasive brain stimulation, and pharmacological agents.8,9 However, despite almost 1000 randomized control trials (RCTs) in stroke rehabilitation,10 there is very little translation of this evidence base into clinical practice.11,12 Research efforts to develop the evidence base are challenged by difficulties in recruiting patients, resulting in small sample sizes; the heterogeneity of impairments after stroke and the complexity of their interactions with factors affecting recovery; and limited collaboration between scientists, clinicians, patient groups, and industry.11 Even when the research evidence base supports the development of clinical guidelines, significant barriers …