Bottom-up versus Top-down designed rehabilitation sessions in chronic stroke survivors: a pilot randomized controlled trial

Abstract

Purpose

The present study aimed to compare the effectiveness of Top-down and Bottom-up approaches on levels of the International Classification of Functioning, Disability and Health Framework (ICF), including impairments, activities, and participation.

Materials and methods

Thirty-nine chronic stroke survivors were recruited for this single-blinded randomized clinical trial. Participants were assigned to Top-down, Bottom-up interventions, or control group, and received a 6-week intervention. They were assessed before/after treatments and at follow-up (6 weeks later). Impairments were measured through kinematic analysis, Trail Making Tests (TMT), and Fugl-Meyer Assessment (FMA). Activity and participation were evaluated via Box and Block Test, Motor Activity Log (MAL), and Canadian Occupational Performance Measure (COPM), respectively.

Results

We found significant improvements in impairment (FMA) and participation (COPM) in all groups, however, COPM scores improved beyond the MCID only in the Top-down, and FMA scores exceeded the MCID in Top-down and Bottom-up groups. Use of the upper limb in daily activities (MAL) enhanced in the Top-down group, although was not clinically significant.

Conclusion

In most of the outcome measures, no significant difference was observed between groups. It seems that Top-down, Bottom-up, and traditional interventions have relatively comparable effectiveness in chronic stroke survivors.

Trial Registration

IRCT20150721023277N2

IMPLICATIONS FOR REHABILITATION

• Sensory-motor, cognitive, and psychological impairments are the most common consequences of stroke that lead to activity limitations and participation restrictions in stroke survivors.

• There are various rehabilitation approaches for stroke survivors.

• Some rehabilitation approaches address underlying impairments (Bottom-up), while others focus on enhancing individuals’ ability to participate in meaningful roles (Top-down).

• Top-down, Bottom-up, and traditional interventions seem to have relatively comparable effectiveness in chronic stroke survivors, and occupational therapists should use their clinical reasoning to select the most appropriate approach for each client.

Keywords:

• Stroke
• participation
• rehabilitation
• cognitive orientation to daily occupational performance
• exercise

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was financially supported by the Iran University of Medical Sciences.