The effectiveness of the motor relearning program on upper limb function post-stroke: a systematized review

Figures & data

Table 1. Level of evidence with description (data from challoumas et al. [25]).

Level of evidence	Description
Strong	Offered by consistent^a results in numerous high-quality^b RCTs.
Moderate	Offered by consistent^a results in 1 high-quality^b RCT alongside 1 or more low-quality^b RCTs, or by consistent^a results in numerous low-quality^b RCTs.
Limited	Offered by consistent^a results in 1 low- or high-quality^b RCT.
Conflicting	Offered by inconsistent^c results from numerous RCTs.
No evidence	No RCTs.

^a : studies reporting the same findings based on statistical testing;.

^b : based on methodological quality scoring;.

^c : studies reporting different findings based on statistical testing; RCT: randomized controlled trial.

Figure 1. This PRISMA flow diagram illustrates how final articles for the review were selected from the original database searches, identifying both reasons for article inclusion and eligibility, and also reasons for article exclusion.

Table 2. Participant characteristics from each included study.

Study citation	Total (group) sample size	Sex (N. of male/female)	Mean (SD) age in years	Mean (SD) duration since stroke	Stroke type (N. per group)
Batool et al. [31]	42 (MRP group= 21, CIMT group= 21)	Between groups 28/14	MRP group 49.47 (8.19) CIMT group 49.67 (7.01)	Between groups No mean (SD) reported; ranged from 2-12 weeks	Between groups 32 Ischemic 10 Hemorrhagic
El-Bahrawy and El-Wishy [29]	40 (MRP group= 20, Bobath group= 20)	MRP group 11/9 Bobath group 13/7	MRP group 50.7 (2.618) Bobath group 49.45 (2.892)	MRP group 8.6 (1.536) months Bobath group 7.95 (1.146) months	MRP group 17 Ischemic 3 Hemorrhagic Bobath group 18 Ischemic 2 Hemorrhagic
Hesse et al. [30]	50 (IAT group= 25, RAGT group= 25)	IAT group 15/10 RAGT group 13/12	IAT group 69.7 (16.6) RAGT group 71.4 (15.5)	IAT group 4.5 (1.4) weeks RAGT group 4.5 (1.7) weeks	IAT group 19 Ischemic 6 Hemorrhagic RAGT group 22 Ischemic 3 Hemorrhagic
Immadi et al. [28]	60 (MRP group= 30, CPT group= 30)	Not reported	Not reported	Not reported	Not reported
Jan et al. [35]	66 (MRP group= 33, MT group= 33)	MRP group 21/12 MT group 25/8	MRP group 54.67 (7.131) MT group 56.21 (9.12)	Not reported	Not reported
Langhammer and Stanghelle [26,27]	61 (MRP group= 33, Bobath group= 28)	Between groups 36/25	Between groups 78 (9)	Not reported	Not reported
Pandian et al. [33]	30 (MRP group= 15, BHM group= 15)	MRP group 14/1 BHM group 10/5	MRP group 51.67 (12.55) BHM group 47.4 (8.35)	MRP group 37.27 (11.38) months BHM group 33.87 (17.45) months	MRP group 11 Ischemic 4 Hemorrhagic BHM group 10 Ischemic 5 Hemorrhagic
Paul [34]	20 (MRP group= 10, TS group= 10	MRP group 5/5 TS group 6/4	MRP group 60.60 (4.14) TS group 60 (3.71)	Not reported	All participants (20) right MCA stroke
Rehani et al. [32]	12 (MRP group= 6, MT group= 6	MRP group 4/2 MT group 3/3	MRP group 54.77 (6.392) MT group 57.85 (4.75)	MRP group 74.384 (32.523) days MT group 92.384 (30.226) days	MRP group 4 Ischemic 2 Hemorrhagic MT group 4 Ischemic 2 Hemorrhagic
Shah et al. [36]	40 (MRP group= 20, CIMT group= 20)	MRP group 8/12 CIMT group 12/8	MRP group 62.3 (14.4) CIMT group 64.6 (11.7)	Between groups No mean (SD) reported; ranged from 3-6 months	Not reported

BHM: Brunnstrom hand manipulation; CIMT: constraint-induced movement therapy; CPT: conventional physiotherapy; IAT: individual arm therapy; MCA: middle cerebral artery; MRP: motor relearning program; MT: mirror therapy; N.: number; RAGT: robot-assisted group therapy; SD: standard deviation; TS: thermal stimulation.

Table 3. Intervention characteristics from each included study.

Study citation	Intervention		Frequency	Duration per session	Intervention provider
Batool et al. [31]	MRP group Pointing and reaching WB of hemiplegic UL Bimanual tasks in sitting CIMT group Repetitive tasks Stacking blocks and cones Grasping and releasing an object Forward and sideway reaching Lifting and placing an object		Both groups 6 sessions weekly for 3 weeks	Both groups 120 min	Both groups Same therapist for exercise demonstration and supervision for both groups
El-Bahrawy and El-Wishy [29]	MRP group Drinking task Grasping cup Cup to mouth Reaching Releasing cup Bobath group Arm activity recruitment in functional conditions in numerous positions Both groups NMES to finger and wrist extensors		Both groups 3 days weekly for 6 weeks	Both groups 75 min (45 min MRP/Bobath, 30 min NMES)	MRP group Researcher of study Bobath group Physiotherapist with experience of 3 years
Hesse et al. [30]	IAT group Based on MRP with elements of IOAAT (repetition of shaping and movements) in the severely affected patients No clear description on how intervention was carried out was given RAGT group RAGT and IAT (1 session each) RAGT- Reha-Digit, Reha-Slide, Reha-Slide duo, Bi-Manu-Track IAT- same as IAT group Both groups Rehabilitation program Mobility training EMLT PT ADLs training Neuropsychological and speech therapies were given on an individual basis		Both groups 2 sessions per workdays in the week for 4 weeks Rehabilitation program Mobility- 5 times weekly EMLT- 5 times weekly PT- 3 times weekly ADLs training- every workday for 2-3 weeks	Both groups 30 min (rehabilitation program not included- no duration details given)	IAT Therapist with experience of at least 5 years in stroke rehabilitation RAGT Supervised therapy assistant
Immadi et al. [28]	MRP group Train: Thumb opposition and palmar abduction Opposition of ulnar and radial aspects of hands Object manipulation/holding Pointing and reaching CPT group Positioning Passive and active movements WB ES		Both groups 5 days weekly for 8 weeks	Both groups 60 min	Not reported
Jan et al. [35]	MRP group Task-specific activities Reaching and manipulation Wrist extension/flexion whilst object holding Forearm supination/pronation Thumb opposition Bimanual activities MT group Active UL movements with a mirror		Both groups 3 days weekly for 6 weeks	Both groups 120 min	Not reported
Langhammer and Stanghelle [26,27]	No description on how the MRP or Bobath was carried out Both groups MDT Treatment plans were given to the patient’s physiotherapist external to the hospital after D/C from hospital		Both groups 5 days weekly while hospitalized (1 week) Receipt of physiotherapy varied after D/C from hospital	Both groups Minimum 40 min while hospitalized (1 week) No details given for patients receiving physiotherapy after D/C from hospital	Both groups Physiotherapist in hospital. Unknown if same physiotherapist for both groups. Patient’s local physiotherapist after D/C from hospital.
Pandian et al. [33]	MRP group Lifting a cup Wrist extension and radial deviation Supination of forearm Palmar abduction and opposition of thumb Opposition of ulnar and radial aspect of hand Objects manipulation Reaching Grasping and releasing object BHM group Imitation synkinesis Proximal traction response Wrist fixation for grasp Release of grasp Both groups COT for LL and UL (excluding hand)		Both groups 3 days weekly for 4 weeks	Both groups 60 min (including COT)	MRP group An OT with experience of 10-15 years BHM group An OT with experience of 10-15 years
Paul [34]	MRP group No description given TS group Provided with hot and cold packs No further description given		Both groups 5 sessions weekly for 6 weeks	Both groups 30 min	Not reported
Rehani et al. [32]	MRP group Wrist extensor training Holding objects training Forearm supination training Thumb opposition Cupping of hand Object manipulation MT group Hand placed behind mirror Patient performed same movement with the affected hand whilst they were moving non-affected hand Hand opening Wrist flexion/extension Forearm supination/pronation Sliding hand on a flat surface Both groups CPT Heat pack Wrist flexor stretching ES		Both groups 6 days weekly for 4 weeks	Both groups 60 min	Not reported
Shah et al. [36]	MRP group Repeated task practice CIMT group Unaffected UL was constrained for 80% of working hours Functional activities were carried out with a task-oriented approach on affected UL		Both groups 2 weeks	MRP group 30 min CIMT group 180 min	Not reported

ADLs: activities of daily living; BHM: Brunnstrom hand manipulation; CIMT: constraint-induced movement therapy; CPT: conventional physiotherapy; COT: conventional occupational therapy; D/C: discharge; EMLT: equipment-mediated locomotor training; ES: electrical stimulation; IAT: individual arm therapy; IOAAT: impairment-oriented arm ability training; LL: lower limb; MDT: multidisciplinary treatment; MRP: motor relearning program; MT: mirror therapy; NMES: neuromuscular electrical stimulation; OT: occupational therapist; PT: physical therapy; RAGT: robot-assisted group therapy; TS: thermal stimulation; UL: upper limb; WB: weight-bearing.

Table 4. Summary of measures used to test outcomes of interest along with results from each included study.

Study citation	Outcome measures			Testing times	Results
	UL function	UL impairment	HRQoL
Batool et al. [31]	MAS-UAF, -HM, -AHA	–	–	Baseline Post-treatment (3 weeks)	The MRP group significantly improved in MAS-UAF (p < 0.001*) and MAS-HM (p = 0.002) but not MAS-AHA (p = 0.059) post-treatment. The CIMT group significantly improved in MAS-UAF, -HM and -AHA (p = 0.001, 0.001, 0.002) post-treatment. The MRP group (p < 0.001*) and the CIMT group (p = 0.001) significantly improved in overall UL section of MAS. The CIMT group showed significantly greater improvements over the MRP group post-treatment (p < 0.05*).
El-Bahrawy and El-Wishy [29]	PPT	Hand dynamometer Electrogoniometer Modified Ashworth scale	–	Baseline Post-treatment (6 weeks)	All OMs significantly improved with the MRP group post-treatment (p < 0.05*). All OMs, except modified Ashworth scale (p > 0.05*), significantly improved with the Bobath group (p < 0.05*) post-treatment. Grip strength and ulnar deviation resting angle were significantly greater for the MRP group over the Bobath group post-treatment (p = 0.0001). No difference was noted between groups for PPT and modified Ashworth scale post-treatment (p > 0.05*).
Hesse et al. [30]	ARAT BBT	Modified Ashworth scale FMA-UE MRC	–	Baseline Post-treatment (4 weeks) 3 months after study ended	All OMs for both the IAT and RAGT groups significantly improved except for the modified Ashworth scale post-treatment (IAT: p = 0.873, RAGT: p = 0.134) and 3 months after study end (IAT: p = 0.884, RAGT: p = 0.373). There was no significant difference between groups post-treatment and 3 months after study end for FMA-UE (p = 0.240, 3.02), ARAT (p = 0.78, 0.044), BBT (p = 0.130, 0.235), MRC (p = 0.497, 0.403) and modified Ashworth scale (p = 0.085, 0.135).
Immadi et al. [28]	WMFT	FMA-UE	–	Baseline Post-treatment (8 weeks)	The MRP group was significantly better than the CPT group in both OMs post-treatment (p < 0.0001*). All subjects showed significant pre- to post-test differences in both OMs.
Jan et al. [35]	MAS-UAF, -HF, -AHA	–	–	Baseline Post-treatment (6 weeks)	The MRP group significantly improved in MAS-UAF, -HF and -AHA (p = 0.01, 0.00, 0.003) post-treatment. The MT group significantly improved in MAS-UAF, -HF and -AHA (p = 0.00, 0.00, 0.02) post-treatment. There were between group differences for these OMs post-treatment (p = 0.00).
Langhammer and Stanghelle [26,27]	SMES part 2	–	NHP	3 days after hospital admission 2 weeks thereafter 3 months, 1- and 4-years post-stroke	The MRP group significantly improved in SMES part 2 at 2 weeks (p = 0.0001) and 3 months (p = 0.001). The Bobath group significantly improved at 2 weeks (p = 0.0001) and 3 months (p = 0.003). The MRP group had a greater effect over time from test 1 to 3 (p = 0.018). No significant difference was noted between groups at 1- or 4-years (p > 0.05*). There was no significant difference between groups at 3 months (p = 0.7), 1- and 4-years (p > 0.05*) for HRQoL.
Pandian et al. [33]	BRS-H	FMA-WH	–	Baseline Post-treatment (4 weeks)	The MRP group significantly improved in FMA-WH (p < 0.001*) and BRS-H (p = 0.004) post-treatment. The BHM group significantly improved in FMA-WH (p < 0.001*) and BRS-H (p = 0.003) post-treatment. The BHM group showed statistically better results than the MRP group for FMA-WH post-treatment (p = 0.004). There was no significant difference between groups for BRS-H post-treatment (p = 0.346).
Paul [34]	STREAM MMAS	–	–	Baseline Post-treatment (6 weeks)	Both groups significantly improved in STREAM (p < 0.0001*) and MMAS (p < 0.0001), with the MRP group having greater effects over the TS group post-treatment for both OMs (p < 0.0001*).
Rehani et al. [32]	CAHAI	–	–	Baseline Post-treatment (4 weeks)	No significant findings within or between groups post-treatment (p > 0.05*).
Shah et al. [36]	9-HPT MAL	FMA-UE	–	Baseline Post-treatment (2 weeks)	There was no significant difference within the MRP group (p = 0.435) or the CIMT group (p = 0.78) for 9-HPT post-treatment. There was no significant difference between groups for 9-HPT post-treatment (p = 0.562). There was a significant difference within the MRP group (p = 0.001) and CIMT group (p = 0.001) for MAL, with the CIMT group reporting significantly better than the MRP group (p = 0.02). There was a significant difference within the CIMT group for FMA-UE post-treatment (p = 0.031) but not for the MRP group (p = 0.201). There was no significant difference between groups for the FMA-UE (p = 0.186).

<: less than; >: greater than; *: no exact P-value given; 9-HPT: 9-hole peg test; ARAT: action research arm test; BBT: box and block test; BHM: Brunnstrom hand manipulation; BRS-H: Brunnstrom recovery stages of the hand; CAHAI: Chedoke arm and hand activity; CIMT: constraint-induced movement therapy; CPT: conventional physiotherapy; FMA-UE/-WH: Fugl-Meyer assessment-upper extremity/-wrist and hand; HRQoL: health-related quality of life; IAT: individual arm therapy; MAL: motor activity log; MAS: motor assessment scale; MAS-UAF/-HM/-AHA/-HF: motor assessment scale-upper arm function/-hand movement/-advance hand activities/-hand function; MMAS: modified motor assessment scale; MRC: medical research council; MRP: motor relearning program; MT: mirror therapy; NHP: Nottingham health profile; OMs: outcome measures; P: probability value; PPT: Purdue pegboard test; RAGT: robot-assisted arm group therapy; SMES: Sødring motor evaluation scale; STREAM: stroke rehabilitation assessment of movement scale; TS: thermal stimulation; UL: upper limb; WMFT: Wolf motor function test.

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