improving recovery after a stroke: evidences for contemporary approaches

ADEYEMO, ADEMOLA OLUYOMI

BMR(PT) M.Sc PT

IMPROVING RECOVERY AFTER A

STROKE: EVIDENCES FOR

CONTEMPORARY APPROACHES

Outlines

12/22/2015Msc Presentation2

Introduction

Epidemiology of stroke

Recovery after stroke

Important principles underlying recovery during

stroke

Disabilities sequel to a stroke

Post stroke rehabilitation

Approaches in stroke rehabilitation

Task specific training

Contemporary approaches based on motor training

Constraint induced movement therapy (CIMT)

Functional electrical stimulation (FES)

Body weight support treadmill training (BWSTT)

Robotics therapy

Virtual reality (VRT)


Introduction


A stroke is a medical emergency and can cause

permanent neurological damage, complications

and death (Feigin, 2006).

3rd

most common cause of death and a leading

cause of permanent disability (Lo et al, 2003;

Donnan et al, 2008).


Stroke is one of the major challenges facing

the healthcare system.

Effort at improving recovery after stroke and

effort at returning patients to pre-stroke level

has been the target of stroke rehabilitation

experts (Gbiri and Akinpelu, 2012; 2012b; Gbiri

et al, 2015a; 2015b)


Therefore, rehabilitation techniques based

on motor learning paradigms have been

developed to facilitate the recovery of

impaired movement in patients with stroke

(Langhorne et al, 2011; Langhorne et al,

2009; Johansson, 2011; Arya et al, 2011

Brewer et al, 2013).

Epidemiology


• Actual incidence and prevalence of stroke has not

been established in Nigeria because most of the

available reports are hospital based (Ogun et al,

2000; Ojini and Danesi, 2003; Ogungbo et al, 2005;

Gbiri and Akinpelu, 2009).

Effects of stroke


Stroke results:

• In impaired motor functions

• Sensory deficits

• Perceptual deficits

• Impaired balance

• Cognitive limitations

• Speech problems

• Emotional disorders (Hellstrom,

2002)

Interdisciplinary management


Stroke survivors often suffer from multiple

disabilities and hence, require a

multidisciplinary team approach through

physicians,

physiotherapists,

occupational therapists,

speech therapists,

nurses, social workers

and psychologists (Duncan et al, 2005).


Recovery after

stroke


Recovery of function which is sustained by

plasticity and rewiring in the injured brain

could be both spontaneous and secondary to

intense rehabilitative treatments (Kwakkel

et al, 1997; Luft et al, 2004; Langhorne et al,

2009).


Functional improvements may occur in the

absence of neurological recovery (Duncan

and Lai, 1997, Nakayama et al. 1994).

Time course of recovery from

stroke


• Neurologically and functionally, are rapid

within the first six-month and continues

slowly thereafter (Teasell and Foley, 2004;

Gbiri and Akinpelu, 2011; Hsieh et al, 2002)

Key outcome predictors


Initial severity of impairments

Motivation

Social support

Learning ability (Teasell et al, 2011).

Important principle underlining

recovery during stroke


Neuroplasticity

ability of the brain to reorganize and

learn new functions (Cramer, 2003;

Nudo, 2003)


It plays an important role in the

restoration of function. It can extend for a

much longer period of time than local

processes, such as the resolution of

oedema (Lo, 1986) or reperfusion of the

penumbra (Inoue et al, 1980).

Figure 1: resolution of

edema

Figure 2: lesion with

ischemic penumbra

and reperfusion



Most protocols for stroke rehabilitation

are based on motor learning, which induce

dendrite sprouting, new synapse

formation, alterations in existing

synapses, and neurochemical production

(Arya et al, 2011; Brewer et al, 2013).


Disabilities sequel to stroke


Stroke causes disability in one or more

activities of daily living (ADL) (Gill et al, 1997).

Stroke-related physical disability:

Diminish quality of daily living

Place care burden on families

Increase need for long-term institutionalization

(Stineman et al, 1997).


Evidence abounds that rehabilitation

can make a difference in stroke

survivors (Hsieh et al, 2002; Lin et al,

2004; Kollen et al, 2005).


Post stroke rehabilitation


Patient-focused interventions to reduce

severe disability and

institutionalization(Stroke Unit Trialists’

Collaboration, 2002).

Rehabilitation therapy begins in acute

care after the person‘s overall condition

has been stabilised (often within 24hr-

48hrs post stroke).


Comprehensive stroke rehabilitation

programs(Brandstater and Basmajian ,1987 and Roth

et al,1998):

Commitment to continuity of care from the acute

phase of the stroke through long-term follow-up,

Use of multidisciplinary team,

Attention to the prevention, recognition, and

treatment of comorbid illnesses and intercurrent

medical complications,

Early initiation of goal-directed treatment that takes

maximal advantage of the patient's abilities and

minimises disabilities,

Systematic assessment of the patient's progress

during rehabilitation, with adjustment of treatment to

maximise benefits,

Family/caregivers education, attention to

psychological and social issues affecting both the

patient and family/caregiver,

Early and comprehensive discharge planning aimed

at a smooth transition to the community based

rehabilitation.


Approaches in

stroke

rehabilitation


Neurophysiological/motor learning

Orthopaedics principles:

Conventional/traditional therapeutics exercises

range of motion (ROM) exercises, muscle

strengthening exercises, splinting, mobilization

activities (Pollock et al, 2007)


Neurophysiological approaches:

Muscle Re-education Approach (1920s)

Neurodevelopmental Approaches (1940-

70s)

Sensorimotor Approach (Rood, 1940s)

Movement Therapy Approach (Brunnstrom,

1950s)

NDT Approach (Bobath, 1960-70s)

PNF Approach (Knot and Voss, 1960-70s)

Motor Control & Relearning (1980s)

Contemporary Task-Oriented Approach

(1990s)


Contemporary Task-Oriented Approach


Task specific training

This approach has been described by a

variety of terms, including repetitive task

practice, repetitive functional task

practice, and task-oriented therapy (Arya

et al, 2011; French et al, 2007; Hubbard et

al, 2009).


Motor training after stroke should be

targeted to goals that are relevant to the

functional needs of the patient (Arya et al,

2011; Brewer et al, 2013).


Task-specific training can effectively

recover a wide array of motor behaviors

involving the upper limbs, lower limbs, sit-

to-stand movements, and gait after stroke

(Hubbard et al, 2009; Monger et al, 2002;

Peurala et al, 2004).


Compared to traditional stroke

rehabilitation approaches such as simple

motor exercises, task-specific training

induces long-lasting motor learning and

associated cortical reorganization

(Peurala et al, 2004; Richards et al, 2008).


Thus, there is strong evidence

demonstrating that task-specific training

can assist with functional motor recovery,

which is driven by adaptive neural

plasticity (Langhorne et al, 2009; Kwakkel

et al, 2004; Levin et al, 2009; Peurala et al,

2004; Richards et al, 2008).


Contemporary approaches Based on Motor

Training

Studies have reported the use of novel

motor learning-based stroke rehabilitation

approaches (Langhorne et al, 2011,

Langhorne et al, 2009; Brewer et al, 2013).


Rehabilitation techniques that have

evidence to suggest cortical

reorganization as the mechanism of

change include:

Constraints induced movement therapy

Functional electrical stimulation

Body-weight supported treadmill training

Robotic therapy

Virtual reality therapy (Young et al, 2011).


Constraints induced movement

therapy (CIMT)


Learned non-use in the paretic limb limits

the subsequent gains in motor function

(Levin et al, 2009; Taub et al, 2006).

CIMT is designed to overcome learned

non-use by promoting cortical

reorganization (Taub et al, 1999).


• It involves restraining the

unaffected arm in patients with

hemiparetic stroke for 90% of

waking hours while engaging the

affected limb in a range of

everyday activities (Deluca et al,

2006; Sutcliffe et al, 2009).


Suitable candidates for CIMT are patients

with at least 20 degrees active wrist

extension and 10 degrees of active finger

extension, with minimal sensory or

cognitive deficits.

patients who have suffered profound upper

extremity paralysis from their condition are

normally not eligible

(Miltner et al, 1999; Liepert et al, 1998;

Liepert et al, 2000; Levy et al, 2001).


Evidence for CIMT

Acute stage of stroke is conflicting

Chronic stage studies (Suputtitida et al,

2004; Wolf et, al 2006; Wolf et al, 2010 and

Dromerick et al, 2009) show superior

benefit in comparison to

traditional/conventional therapies


Functional electrical

stimulation (FES)


Electrical stimulation improves

neuromuscular function in post stroke

subject

Strengthening muscles,

Increasing motor control,

Reducing spasticity,

Decreasing pain

Increasing range of motion


Methods:

Therapeutic electrical stimulation

FES

The defining feature of FES is that it

provokes muscle contraction and

produces a functionally useful movement

during stimulation (Schuhfried et al, 2012).


Figure 4 Ness L300®


FES is becoming popular management

upper extremity

shoulder subluxation,

spasticity

weakness

FES has positive effect on upper-limb

motor function in both acute and chronic

stages of stroke (Alon et al, 2007; Alon et

al, 2002).


Lowerlimbs

in hemiplegic gait

quadriceps stimulations

FES in the lower extremity has been used

to enhance ankle dorsiflexion during the

swing phase of gait (Kim et al, 2012).


Figure 4 (Maxwell et al, 1995)


Evidence for FES

upper extremity function

a number of RCTs (Powell et al, 1999; Page et

al, 2012) show strong evidence that FES

treatment improves function in acute stroke

(<6 months post onset) and chronic stroke (>6

months post onset).


Lowerlimb hemiplegic gait

Improvements in gait speed, cadence, and

stride length have resulted from this

treatment (Kim et al, 2012).

Systematic reviews (Kottink et al, 2004;

Robbins et al, 2006) both showed a benefit

for walking speed.


Body-weight support treadmill Training

(BWSTT)


BWSTT is a rehabilitation method in

which patients with stroke walk on a

treadmill with their body weight

partially supported.


Partial unloading of the lower extremities by

the body weight support system results in

straighter trunk and knee alignment during

the loading phase of walking (Visintin and

Barbeau, 1989; Lindquist et al, 2007).


BWSTT

Augments the ability to walk by enabling

repetitive practice of complex gait cycles

(Hesse, 2004; Ifejika-jones et al, 2011).

Improves swing time asymmetry, stride

length, and walking speed (Laufer et al,

2001; Lindquist et al, 2007; Dawes et al,

2008).


Allows practice nearly normal gait patterns

avoiding compensatory walking habits,

such as hip hiking and circumduction

(Ifejika-jones et al, 2011; Chen et al, 2006).


Evidence for BWSTT

Studies (Laufer et al, 2001; Visintin and

Barbeau, 1989; Mayr et al, 2007) show

evidence of gait improvement after

BWSTT, compared to conventional therapy

in patients with acute stroke and those

with chronic stroke


Robotics therapy


Robot training can provide the intensive

and task-oriented type of training that

has proven effective for promoting

motor learning (Langhorne et al, 2009;

Belda-Lios et al, 2011).


Has different techniques such as:

Active assisted

Active constrained

Active resistive

Passive exercise

Adaptive exercise.


Evidence of benefit of Robots therapy

Study by Lo et al (2010) show that robotic

devices improves upper extremity functional

outcomes, and motor outcomes of the

shoulder and elbow.

Robotic devices are not superior to

conventional gait training studies(Pohl et al,

2007; Schwartz et al, 2009; Mehrholz et al,

2007; Morone et al, 2012) showing mixed

outcome results


Virtual reality


Virtual reality also known as virtual

environment is a technology that allows

individuals to experience and interact

with three-dimensional environments.


Virtual reality has the potential to create

stimulating and fun environments and develop

a range of skills and task-based techniques to

sustain participant’s interest and motivation

(Ku et al, 2003; Holden, 2005).


Recent studies (Saposnik et al, 2010; Dunsky

et al, 2013; Hammond et al, 2014) show

evidence that virtual reality treatment can

improve motor function in the chronic stage of

stroke.


When combined with conventional

physiotherapy VR demonstrated to have

significant improvements on balance,

walking speed and function.

Conclusion


There are growing evidences supporting the

superiority of some of the contemporary

approaches over conventional therapy for

effective recovery of functional independence

after stroke.

Therefore understanding and effective use of

these approaches will be a compliment for

reducing functional dependency and

disabilities after stroke. Hence, there is a call

for effective deployment of these approaches

for a paradigm shift in stroke rehabilitation.

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improving recovery after a stroke: evidences for contemporary approaches

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