Robert W. Teasell and Lalit KalraWhat's New in Stroke Rehabilitation

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What’s New in Stroke RehabilitationRobert W. Teasell, MD; Lalit Kalra, MD

Stroke rehabilitation has been revolutionized in the lastdecade through a combination of new imaging tech-niques looking at brain recovery and clinical trials into

what is working in stroke rehabilitation. The fear that reha-bilitation was a long way from being rooted in science1 hasbeen overcome by an increasing understanding of neuronalrecovery processes and their modulation by various physicaland pharmacological interventions. More than 300 random-ized controlled trials provide a sound foundation forevidence-based practice in stroke rehabilitation, supplement-ing and often confirming decades of clinical experience. Thisgrowing body of knowledge has been enriched by severalstudies in 2003. Advances in basic sciences and clinicalresearch are beginning to merge and show that the humanbrain is capable of significant recovery after stroke, providedthat the appropriate treatments and stimuli are applied inadequate amounts and at the right time. What is particularlyexciting is the introductions of new technologies such asrobotic enhancement of therapies and virtual reality to furtherenhance that recovery.

Intensity Versus Task-Specificity After StrokeStroke rehabilitation is therapy intensive and one of theunresolved debates has been around the issues of quality andquantity. Evidence is building that intensity of therapy isimportant. This is particularly true for language recovery.Bhogal et al2 identified 8 randomized controlled trials(RCTs), which compared the intensity of speech and lan-guage therapy (SLT) delivered by a trained therapist versus anon-therapist or a non-SLT control. Four of the studies werepositive and these studies provided a mean of 8.8 hours oftherapy per week for 11.2 weeks when compared with the 4negative trials that provide approximately 2 hours of therapyper week for a total of 22.9 weeks. On average, positive RCTsprovided 98.4 hours of therapy over half the time that thenegative RCTs provided 43.6 hours. Intensive therapy isrequired to achieve optimal speech outcomes and producesignificant improvements in language. The picture is not asclear for physiotherapy and occupational therapy interven-tions, where recent studies have shown little benefit from

“intensive” therapy on arm function3 or general functionalabilities.4 However, the intensity of treatment provided in theactive limb of these studies is a subject for debate. Evidencefrom the bulk of clinical and functional imaging studiessuggest that more intense therapy over a shorter period oftime provides a better outcome.

In addition to quantity, the quality of interventions isequally important. Evidence suggests that the nature ofinterventions is important. Little benefits were seen withtreatments such as repetitive training or resistance strength-ening exercises.5,6 On the other hand, task-specific therapy inwhich treatment is specifically designed to deal with lostabilities or tasks showed best results. An excellent example ofthis is left-sided neglect, where task-specific training (en-hanced visual scanning techniques) improves visual neglectwith associated improvements in function. Similarly, shortperiods of prism adaptation improve not only visual neglectfor several days but also perception of contralateral tactilestimuli.7 Page,8 on reviewing the evidence in favor ofless-intense, task-specific rehabilitation treatments, arguedthat intensity did not need to be altered to result in significantclinical improvements. This is supported by a recent studyshowing that increased used of the paretic hand recruitedpreviously silent ipsilateral corticospinal pathways even inpoorly recovered stroke patients.9 Hence, task-specific ap-proaches, especially with stroke motor therapy, can be moreefficacious than traditional approaches, which focus onimpairment.

Robotic-Assisted RehabilitationIn an attempt to supplement the use of therapists in providinga more intensive therapeutic environment, there has beenincreasing interest in the use of robotics in stroke rehabilita-tion. Volpe et al10 and Krebs et al11 have noted that robot-aided sensorimotor training, especially in the upper extrem-ity, has been showing data consistent with other controlledstudies that demonstrate that more activity leads to greatermotor recovery12 and that such recovery is sustained over thelong-term and is limb and muscle group specific. Fasoli et al13

actually showed that robotic therapy, which involved goal-directed planar reaching tasks to exercise the hemipareticshoulder and elbow, reduced motor impairment in chronicstroke patients with moderate to severe impairments. Roboticdevices provide a means by which therapists can increase theamount and intensity of movement of the plegic limb,allowing them to focus more time on more task-specific andcomplex functional movements. Lum et al14 has noted thatefforts to bring these devices to the commercial market areunderway. Similar albeit less complicated uses of computersto facilitate rehabilitation activities are becoming morecommonplace.

The opinions expressed in this editorial are not necessarily those of theeditors or of the American Stroke Association.

Received November 19, 2003; accepted December 3, 2003.From Physical Medicine and Rehabilitation (R.W.T.), St Joseph’s

Health Care, London, Ontario, Canada; and Stroke Medicine (L.K.),GKT School of Medicine, King’s College Hospital, London, UK.

Correspondence to Dr. Robert Teasell, University of Western Ontario,Physical Medicine and Rehabilitation, Parkwood Hospital, 801 Commis-sioners Rd E, London, Ontario, Canada N6C 5J1. E-mailrobert.teasell@sjhc.london.on.ca

(Stroke. 2004;35:383-385.)© 2004 American Heart Association, Inc.

Stroke is available at http://www.strokeaha.orgDOI: 10.1161/01.STR.0000115937.94104.76

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Sensory Stimulation Facilitates RecoveryThe importance of sensory stimulation in stimulating thebrain and facilitating recovery has been shown with func-tional MRI and is likely the physiological underpinning forthe use of acupuncture and TENS for facilitating motorrecovery. Several modalities of sensory input (optokinetic,neck proprioceptive, vestibular, attentional, somatosensory-magnetic) have been investigated and shown to result indramatic improvements in patients with neglect.15 Therecontinues to be debate about the pathways involved; a recentstudy demonstrated that subconscious proprioceptive afferentinformation was as effective as exteroceptive somatosensorystimulation for improving hemispatial neglect, even whensevere somatosensory loss was present.16 More intermittentpneumatic compression results in dramatically greater im-provements in somatosensation.17

Virtual Reality and Motor ImageryOne of the newest potential therapies currently under study isvirtual reality as a training tool in stroke rehabilitation.Virtual reality is computer technology that simulates real-lifelearning and allows for increased intensity of training whileproviding augmented sensory feedback.18

An even more interesting concept that is being used inrehabilitation is the concept of motor imagery, which is beingincorporated into rehabilitation trials, particularly for motorretraining of hemiparetic limbs. It has been shown that motorimagery can result in increased functional MRI activity, apotential precursor of recovery. Stevens et al19 in 2 chronichemiparetic stroke survivors used imagination and mirrors totrick patients’ brains into thinking that they were movingtheir arms and legs. Patients underwent intensive trainingutilizing motor imagery consisting of imagined wrist move-ments and mental stimulations of reaching and object manip-ulation using a mirror box whereby they move their unaf-fected limbs in a mirror but which appears like they aremoving their affected limb. In addition, patients were told toimagine that they were moving their paralyzed limb. Patientswho used this technique showed improvement in the motorfunction of the paretic limb.

Extended Therapy Helps Stroke SurvivorsRegain Mobility

Duncan et al20 found that a structured and progressiveprogram of physical therapy in stroke survivors who wereliving in the community and had completed acute strokerehabilitation allowed for continued improvements in lostmobility, balance, and endurance. The authors concluded thata home-based exercise program that was more aggressivethan what is typically prescribed for stroke survivors who aredischarged home can improve walking, balance, and cardio-vascular endurance beyond that attributable to spontaneousrecovery and usual care. More recently, a study in patients 6months to 7 years after stroke showed that 12 hours ofsensory or motor training significantly improved task-specificfunctional abilities.21 The concept that intensive therapyprovides improved outcomes extends even into the outpatientphase of rehabilitation.

Home-Based RehabilitationFjaertoft et al22 in a follow-up to a previous trial23 evaluatedthe long-term effects of an extended stroke unit service(ESUS). The ESUS consisted of stroke unit care with theaddition of a mobile interdisciplinary team which coordinatedearly supported discharge and further rehabilitation in thehome. Patients were randomized to stroke unit care or theESUS and follow-up provided at 52 weeks. Although therewere no significant differences in the Barthel Score or theirfinal residence, more patients were deemed to be independentas measured by a Rankin score �2. Patients with moderate tosevere strokes seemed to benefit the most. Determinants ofsuccessful domiciliary rehabilitation include less disabled andyounger patients, absence of cognitive impairments, premor-bid functional status, and early initiation of rehabilitativeprocedures. Teng et al24 in a cost analysis of an earlier study25

reported that an early supported discharge program forhigh-functioning stroke patients was a cost-effective alterna-tive to usual care. Disler and Wade26 have noted that theconcept of early supported discharge remains a promising oneand not surprisingly reduces hospital lengths of stay, but theavailable data do not yet support or condemn the practice andmany questions remain unanswered. Nevertheless, the trendtoward moving stroke rehabilitation into the communityfaster for certain patients is likely to continue.

ConclusionsThis is an exciting time in stroke rehabilitation. There is a realsense in the research community that stroke rehabilitation isbeginning to realize its potential and the concepts of intensityof therapy, task-specific training, and increased sensorystimulation are now being supported by strong scientificevidence. The potential for using technology to assist in therehabilitation process is now beginning to be realized. Thereis also a trend toward moving interdisciplinary stroke reha-bilitation increasingly out into the community. Although thisdecade began with the promise of thrombolytics, increasinglyit appears that the future of stroke care will be with therefinement and improvement of rehabilitation therapies.

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KEY WORDS: Advances in Stroke � rehabilitation

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