Been there, done that, so what's next for arm and hand rehabilitation in stroke?

BACKGROUND: The extraordinary advances in technology such as body-worn sensors, health information technologies, technological advances in neuroimaging, and computational approaches to predictive modelling using biomarkers offers considerable promise to literally transform our thinking, our approach to the problem, and the design of future clinical trials about arm and hand rehabilitation after stroke. OBJECTIVE: To provide a focused review that considers the past, present and future of arm and hand rehabilitation in stroke. METHOD: We organized this perspective into three parts: 1) Past-we summarize the past decade of the clinical trial enterprise in neurorehabilitation, 2) Present-we provide a brief review of three research areas where mechanistic studies that rely on uniquely human neural circuits provide a basis for promising intervention tools, and 3) Future-we highlight three unique research domains that are likely to provide the biggest impact on the future of post-stroke arm and hand recovery. RESULTS: The past has not been a complete failure-in particular, the EXCITE RCT put arm and hand rehabilitation on the map. Unfortunately, the majority of clinical trials that followed were based on an immature science of neurorehabilitation. We got drawn in by the seductive preclinical animal model work which suggested that dose and intensity of task-oriented training was the most important ingredient for fostering recovery in humans. While dose, and intensity are clearly important, they are of little value unless the stroke survivor is engaged, motivated, and the neural infrastructure provides enough resource to allow the recovery process. Recently, we noticed an increase in mechanistic and theory-driven studies, findings from which will not only advance our understanding of critical brain-behavior mechanisms, but will provide a more mature science moving into the future. CONCLUSIONS: The good news is that there is evidence that we learned from the past and have invented a future that appears to be much more exciting and promising than the past.