Motor Rehabilitation After Acute Stroke

Motor Rehabilitation After Acute StrokeDr. Sunil Kumar SharmaSenior ResidentDept. of NeurologyGMC Kota

DefinitionFrom Latin habilitas to make able

Literal translation to make able again

The process of helping a person to achieve the highest level of functioning, independence and quality of life

According to the WHO, 15 million people suffer stroke worldwide each year. Of these, 5 million die and another 5 million are permanently disabled.

A number of neurological functions are impaired by stroke, the most common of which is motor disability contralateral to the stroke lesion side

Neurological RecoveryMajority of neurological recovery in first 3 months

5% of patients continue to show recovery for up to 1 year

Return of motor power not synonymous with recovery of function

Neurological RecoveryImprovement in independence in areas of self care and mobility

Dependent on quality and intensity of therapy and extent of lesion

Dependent on patients motivation

Modifiable by interventions

Neurological RecoveryNeurological recovery Early recovery (Local Processes)Late recovery (Neuroplasticity) modification in structural and functional organization

Functional recoveryRecovery in everyday function with adaptation and training in presence/ absence of natural neurologic recoveryDependent on quality ,intensity of therapy & patients motivation

Early recovery ( Local processes )

Resolution of post stroke edema

Reperfusion of ischemic penumbra

Resorption of local toxins

Recovery of partially damaged ischemic neurons

Late recovery ( Neuroplasticity )

Ability of nervous system to modify structural and functional organisation

Collateral sprouting of new synaptic connections

Unmasking of previously latent functional pathways

Reversibility from diaschisis

Motor RehabilitationReacquisition of previously learned movement & skills that are lost due to pathology or sensory, motor or cognitive impairment.

Stroke rehabilitation requires a sustained and coordinated effort from a large team.

Communication and coordination among these team members are of paramount importance .

Principles of Stroke Rehabilitationmotor learning induces Dendrite sprouting,

New synapse formation,

Alterations in existing synapses,

Neurochemical production

Principles of Stroke RehabilitationMotor learning is known to be better if thepractice method is

Meaningful,

Repetitive,

Intensive

Task-specific

Enriched environment

Early MobilisationIf condition stable To start active mobilisation within 24-48 hours

Physiologically sound changes in bed position & ROM exercise.

Specific tasks ( sitting up, turning from side to side ) & Self care activities ( feeding, grooming, dressing )

Tolerance for therapy affected by stroke severity, medical stability, mental status, cardiac instability & level of Consciousness.

Early MobilisationEarly mobilisation reduces complications and enhances functional recovery (Level 1) Strong positive psychological benefit

High-dose, very early mobilization within 24 hours of stroke onset can reduce the odds of a favorable outcome at 3 months and is not recommended.

Gait trainingInitial gait training between parallel bars then outside bars with aids & then without aids

In all direction & turning

Foot clearance Orthoses & FES

PBWSTT with higher speed improve overall locomotor activity & over ground speed

Improving Trunk ControlTrunk forms a foundation for any posture & movement.

Post hemiparesis - loss of selective muscle activity in trunk & tone .

Rx focus on -Trunk rotation, side flexion . -Combination of movement -Balance reaction[Anticipatory & Reactive] -Functional Activity

Improve UE Function Relearning of movement pattern & retraining of missing component

Upper body initiated wt shift pattern[reaching & picking object]

UL weight bearing & Dynamic stabilization exercise

Improve UE Function Functional movement & Combination movement.

Power production Throwing

Fine motor function- Object Manipulation

Adjuncts Orthoses, CIMT, NMES, VR, Robotics

Improve LE function Strengthening muscles in appropriate pattern & Functional pattern.Training for posterior weight shift, Anterior weight shift & Lateral weight shift (sitting). Co-ordinated combination movementPower production [Kicking] Cycling & treadmill training

SpasticityProper positioning of limbPassive ranging and stretchingFunctional electrical stimulationPharmacological ( baclofen, clonazepam, dantrolene)Alcohol/phenol neurolysis IM botoxSurgical options eg. Intrathecal baclofen pumps, tendon release

Current Treatment MethodsConstraint-induced movement therapy (CIMT), Body weight-supported treadmill training (BWSTT), Robotic training, Transcutaneous neuromuscular electrical stimulation, Noninvasive brain stimulation (NIBS), Mirror therapyVirtual reality (VR) training, Brain-computer interface (BCI).SSRI

Mirror Therapy and ImageryThere is increasing experimental evidence that some motor neural structures are recruited not only when actions are actually executed but also when the actions of another person are simply observed or a movement is imagined.

This form of practice is routinely used by athletes and dancers before a performance to reactivate in working memory the representation of a motor memory

The neurophysiological basis for this recruitment is associated with mirror neuron system

According to the mirror neuron paradigm, action observation appears to activate the motor system similar to execution by generating an internal representation of action that can be targeted for motor learning .

This form of practice is routinely used by athletes and dancers before a performance to reactivate in working memory the representation of a motor memory

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Studies evaluating the benefits of adding MT to routine stroke rehabilitation have generally demonstrated statistically significant improvements in motor and functional outcomes although interpretation of these studies is limited by small sample sizes

Future studies will hopefully clarify the optimal timing, dose, frequency, and duration of MT as well as which patient populations respond best to treatment

CIMTThe underlying concept of CIMT is that restricting the use of the unaffected upper extremity by a mitt or sling will force an individual to use the affected limb to complete task based activities, affecting neuroplastic change and improving upper extremity function over time.

The aim of CIMT is to overcome what is theorized as learned nonuse of the paretic limb

Aerobic exercises

CIMT

During treatment, the patient wears a mitt or constraint on their intact limb, and the impaired limb is used for tasks during therapy and daily activities

CIMTThe typical intervention consists of restricting the unaffected limb for 90% of waking hours for 14 days with 6 hours of therapy for 10 of those days.The inclusion criteria for CIMT The ability to actively extend the wrist, thumb, and fingersAbsence of cognitive impairment, excessive spasticity, or impaired balance

CIMTstudies evaluating the effects of CIMT on upper extremity recovery in poststroke patients have demonstrated significant improvements in motor and functional outcomes, although there have been mixed results.in the acute stage of stroke, high-intensity CIMT results in less improvement than low-intensity CIMT

Selective Serotonin Reuptake Inhibitor MedicationsA Cochrane Review published in 2012 evaluating 52 clinical trials found significant benefits of SSRI medications in reducing disability and dependency as well as on neurological deficit depression, and anxiety.Risks and side effects of treatment with SSRI, including the increased risk of bleeding events, will need to be noted and considered.

Noninvasive Brain Stimulation

Noninvasive brain stimulation involves the application of weak electric or magnetic fields to the brain via the surface of the scalp with the goal of changing or normalizing brain activity.

Noninvasive brain stimulation modulates brain excitability and functional plasticity with relative safety and facilitates motor learning when combined with a motor task

Noninvasive Brain Stimulation2 most common forms are Transcranial magnetic stimulation (TMS)Transcranial direct current stimulation (tdcs)Neither modality is FDA approved in stroke rehabilitation, but both are currently being studied under off label research purposes.

Transcranial magnetic stimulation (TMS) of the brain using a figure-of-8 coil. B, Transcranial direct current stimulation (tDCS) of the brain with the active electrode (red wire, anode) placed over the primary motor cortex and the reference electrode (black wire, cathode) placed over the contralateral supraorbital region.

Schematic representation of noninvasive brain stimulation techniques for facilitating motor recovery after stroke- The aim of these techniques is to upregulate () cortical excitability of the lesioned hemisphere or to downregulate () cortical excitability of the contralateral nonlesioned hemisphere.

The rationale for inhibiting cortical excitability of the nonlesioned hemisphere is that it is expected to minimize the amount of interhemispheric inhibition from the nonlesioned hemisphere to the lesioned hemisphere while performing active movements of the paretic limb. Note that cortical excitability can be facilitated by applying anodal tDCS or high-frequency rTMS and can be diminished by applying cathodal tDCS or low-frequency rTMS. 33

NIBSStudies have explored the efficacy of NIBS for improving motor recovery after stroke .

A metaanalysis of 50 randomized clinical trials and 1282 patients with stroke found that both TMS and tDCS were effective in improving motor outcomes after stroke

NIBSAlthough the results from several smallscaleclinical trials appear promising andencouraging, the role of NIBS in strokerehabilitation remains unclear for a varietyof reasonsdearth of largescale clinical studies with adequate longterm followup of patients with stroke. the observed improvements are of modest clinical significance with questionable effect size.

NIBSThe optimal way of combining NIBS with physical rehabilitation (ie, whether TMS or tDCS should precede, follow, or be combined with therapy) is still unclear.

The uncertainty about the timing of NIBS

Finally, TMS or tDCS induced directional modulation of motor cortical excitability is known to be variable both within and between patients

BWSTTThe addition of partial body weight support to treadmill training (BWSTT) has been tested in patients with stroke, SCI, Parkinson, MS, and cerebral palsy.

Subjects wear a chest harness that is attached to an overhead lift. The amount of weight borne by the lower extremities is adjusted to optimize the stance and swing phases of gait.

One or more therapists may manually assist the lower extremities and pelvis during step training to optimize the step pattern.

BWSTTBWSTT allows repetitive practice guided by the verbal and physical cues of the therapist to improve components of the step cycle.

The Locomotor Experience Applied Post Stroke (LEAPS) Trial randomized 400 subjects. It compared usual care to BWSTT.

Improvements were significant for supervised home-based exercise and for BWSTT compared to usual care when started at 2 months.

Functional Neuromuscular Stimulation

Functional neuromuscular stimulation systems activate one or more muscle groups synchronously or sequentially to enable single-joint and multijoint movements.

Surface and intramuscular electrical stimulation systems have become more widely available in the past 5 years, but despite extensive study and commercial development, they have not come into sustained use.

Functional Neuromuscular StimulationThe first commercial surface electrode-driven device for grasping is the Ness System, which has found some use in quadriplegic patients with at least C5 intact and in hemiplegic patients with poor hand function .

Electrodes attached to a molded forearm orthosis that reaches across the wrist stimulate the wrist and finger flexors and extensors in synchrony.

The external control unit operates from a button managed by the patient for the level of output that allows grasp, holding, or release.

The hemiparetic right arm is assisted by an orthosis with functional neuromuscular stimulation that helps dorsiflex the wrist and produce a palmar grasp or finger pinch (NESS by Bioness, Inc.). Practical utility depends on the ability to lift and extend the proximal arm

Functional Neuromuscular StimulationPeroneal nerve stimulation to aid foot dorsiflexion to clear the foot during the swing phase can increase step length and walking speed in hemiparetic persons.

A growing number of commercial devices are available that use an accelerometer to switch on the below-the-knee stimulus.

VR trainingVR is a computer-based technology that engages users in multisensory simulated environments, including real-time feedback (e.g., visual, auditory, and tactile feedback), allowing users to experience simulated real-world objects and events .

May be nonimmersive to fully immersive.

VR trainingImmersive VR systems use large-screen projections, head-mounted displays, cave systems, or videocapture systems to immerse the user in a virtual environment

In contrast, nonimmersive VR systems simply use a computer screen to simulate an experience with or without interface devices.

VR trainingVR exercise provide repetitive, intensive, and task-specific training which can promote neural plasticity that produce motor function improvements after stroke.

Several studies have shown that the use of immersive VR results in practice-dependent enhancement of the affected arm by facilitating cortical reorganization

VR trainingSmall clinical trials also have revealed encouraging results for cognitive rehabilitation assessment and for the treatment of attention and spatial memory deficits and apraxia.

Mechanical and Robotic-Assistive Devices

Electromechanical robotic devices have been developed to provide assistance for intensity and reproducibility of practice.

Portable exoskeleton devices work in concert with the paretic arm and leg movements .

Neural Prostheses and BrainComputer Interfaces

To aid the highly disabled persons(ALS, locked-in syndrome after stroke or trauma, MS, cerebral palsy, or muscular dystrophy ), to manage their surroundings and communicate, a variety of brain-computer interfaces (BCI) have been developed and tested (Hochberg et al., 2012).

BCIThe devices use surface and intracortical neural signals picked up by microelectrode from defined regions of the brain

Selected signals are digitized and processed by algorithms to extract specific features.

A translation algorithm converts the particular electrophysiological features chosen to simple commands to a device such as a word processor or keyboard, a website, or an upper-extremity neuroprosthesis.

(SIGNAL DECODING COMMAND)

BCIThe error rate is often in the range of 10% to 20%.

Major improvements in signal processing and interfaces should offer greater utility for paralyzed patients.

Mobile Health and Wireless Sensing Devices

Smartphones, Web-based tele-rehabilitation, and wearable accelerometers with pattern-recognition algorithms that can calculate the type, quantity and quality of movements in the community are now available.

These technologies may improve compliance with exercise and skills learning via continuous monitoring of gait or use of an upper extremity.

Simpler devices that serve as step monitors, worn on the wrist, trunk or on one leg are used.

Take home messageTeam Approach

Evidence Based Practice

Early Mobilisation

Aerobic Training

Neuroplasticity & Motor learning principle

Thank you

ReferencesBradleys Neurology In Clinical Practice 7th Edition.

Emerging Treatments for Motor Rehabilitation After Stroke; Edward S. Claflin, MD, Chandramouli Krishnan, PhD, PT, and Sandeep P. Khot, MD

Promoting Neuroplasticity for Motor Rehabilitation After Stroke: Considering the Effects of Aerobic exercise and Genetic Variation on BrainDerived Neurotrophic Factor; Cameron S. Mang, Kristin L. Campbell, Colin J.D. Ross, Lara A. Boyd

Rehabilitation with Poststroke Motor Recovery: A Review with a Focus on Neural Plasticity ; Naoyuki Takeuchi and Shin-Ichi Izumi