Recent advances in stroke rehabilitation

Dr. So Kar Kui

Specialist in Geriatric Medicine

Important of stroke rehabilitation

• 30000+ stroke per year in HK• 3443 died (2009), 4th leading cause of mortality, first

leading cause of disabilities• ~ 40% reduction in mortalities: increase stroke survivors• Ageing population: 7% over 65 (1983), 14% in 2013 & 21%

in 2024• Physicians like to focus on acute stroke management: t-PA,

surgical or endoscopic treatments - no. of clients beneficial is actually small

• Others focus on primary & secondary prevention, community reintegration or long term care.

• Demand for stroke rehabilitation will dramatically increase in future 10-20 years

Major determinants of stroke recovery

Message 1: Recovery

Functional recovery not equal to Neurological recovery

Recovery process

• Restitution: Restoring the functionality of damaged neural tissue

• Substitution: Reorganization of partly spared neural pathways to relearn lost functions

• Compensation: Improvement of the disparity between the impaired skills of a patient and the demands of their environment

Pharmacology

• Restitution: stem cell therapy, Growth factors (Vascular Endothelial, fibroblast, BD, glial cells etc)

• Antidepressants: fluoxetine,

• Dopamine agonists

• Cholinesterase Inhibitors, memantin

Post-stroke recovery mechanism

Neural PlasticityKleim & Jones 2008

• Use it or Lose it

• Use it and Improve it

• Specificity matters

• Repetition Matters

• Intensity Matters

• Time Matters

• Salience Matters

• Age Matters

• Transference

• Interference

Message 2:Acute stroke vs. Subacute stroke vs.

Chronic stroke

Chronic stoke can be improved through training and special methods

Neurological impairments or disabilities in stroke

• Motor manifestations• Sensory manifestations• Language: aphasia, alexia & dysarthria• Dysphagia• Cognitive dysfunction• Right hemispheric neurobehavioral syndromes• Bladder & bowel dysfunction• Depressions or other psychological Complications• Loss of visual acuity, visual field• Lack of energy, motivation, fatigue

Exercise / training (TEARIA)

Task specific

Early

ADL relevant

Repetitive

Intense

Active

Message 3:Top down approach vs. Top up approach

Motor Dysfunctions

• LMN lesion: flaccid weakness

• UMN lesion: Muscle spasticity, co-contractions, hyper-reflexia

• Hemiplegia shoulder pain

Interventions for flaccid weakness in chronic stroke

• CIMT / mod. CIMT• Bilateral arm therapy• Mirror therapy• Mental practice• Electric Stimulation (TENS, FES)• Robotic assisted training• +- virtual reality system• Transcranial magnetic stimulation (rTMS)• Transcranial Direct current stimulation (tDCS)• Brain Computer Interface (BCI)

Constraint Induced Movement Therapy

– Restraint of good limb

– Forced use of the affected limb

– Increased practice time: 6 hr/day• Adaptive task practice

• Repetitive task specific practice (15-20 min continuous)

• Shaping strategies

EXCITE trial JAMA 2006

Trial• Multicenter RCT• 222 first stroke• Post-stroke 3-9 m• Intact cognition, language• Extend wrist 20 degree• Extend finger 10 degree• 6 hr per day, 2 week program

of CIMT• Repetitive task practice• Statistically significant

improvement persist at least 1 year

Mod. CIMT

• 3 hr/day

• 3 times per week

• 2 weeks prolong to 10 weeks

• Acute phase

• + mental practice

• + donepezil

• + automated device

BAT meta analysis 2010

Bilateral arm training

• Useful in severe functional deficit

• CIMT better in hand function vs. BAT better in proximal arm function

• ? who will benefit or training protocol

Mirror Therapy

• Convey visual stimuli to the brain through observation of one's unaffected body part as it carries out a set of movements.

• Upper limb as well as lower limb

Mirror therapy

• Cochrane 2012: 14 RCTs: modest benefit, improve in ADL, pain & neglect

• Esp in neglect cases, subacute phase

• + NMES

• 30 mins per session, total 20 sessions in 5 weeks

• Safe, cheap, home based treatment, less labor dependent

Mirror therapy

Mental practice

• Mental practice is a training method during which a person cognitively rehearses a physical skill using motor imagery in the absence of overt, physical movements for the purpose of enhancing motor skill performance

Using mental practice in stroke rehabilitation: a framework Clinical Rehabilitation 2008; 22: 579–591

Effects of functional task training with mental practice in stroke: A meta analysis. NeuroRehabilitation 2012

Electric stimulation (ES)

• Trancutaneous electric nerve stimulator (TENS)

• ES + prosthetic application = FES

• EMG triggered neuromuscular electric stimulator

• Parameters: current Intensity, frequency, pulse form, pulse width, pulse repetition rate etc

• Useful in all phases

Electric stimulation (FES)

• Cyclic NMES, EMG triggered NMES, neuroprosthetic

• Kroon review 2002, Cochrane review 2006 (ES better than no Tx or placebo)

• Meilink 2008: EMG Triggered NMES to extensor muscles – non statistically significant treatment

• Improves UL function < 6 months, less effect in chronic cases

Functional Electric Stimulation

• Common peroneal nerve• Weak ankle dorsiflexion• Single channel vs. multiple

channel• 10-60 mins, 3-5 times per

week, 1 weeks to 4 weeks• + PT vs. PT alone• + treadmill test with PWS• + robotic assisted training• + Biofeedback• Effect disappear after removed• Meta analysis on 8 studies

(Kottink 2004): 38% increase in walking speed

Upper limb robots

Lower Limb robots – PBW, treadmill test, exoskeleton and virtual reality

JRRD 2012

Virtual reality

• an approach to user-computer interface that involves real time stimulation of an environment, scenario or activity that allows for user interaction via multiple sensory channels.

• Immersion (HMD) vs. non immersion• With robots, movement tracking,

sensory glove system• 13.7% to 20% improvement in

impairment level (Levin 2011)• Cochrane review 2011• Popular gaming system: Playstation

EyeToy and Ninetendo Wii gaming system

• Tele-rehabilitation

Virtual reality

Home video game system Wii game

Meta-analysis of RCTs using VR systems in upper extremity

impairment (A) and motor function (B, C).

Saposnik G et al. Stroke 2011;42:1380-1386

Copyright © American Heart Association

Inter-hemispheric inhibition

25mm

15mm20mm

70x60

55x4540x30

0

5mm

Practical Considerations - stimulation depth

Cannot stimulate medial or sub-cortical areas

Transcranial magnetic stimulation

rTMS

The Concept• Inter-hemispheric inhibition

• High frequency >5Hz –excitatory – lesion brain

• Low frequency <= 1Hz -inhibitory – normal brain

• Apply on normal, lesion or both

• Post-stroke: motor recovery, aphasia, dysphagia, depression, dementia

• No adverse effects

• Safe, seizures only occur at high intensity and prolong duration

• Subacute or chronic

• 20 minutes per session

• 10 days treatment

• Caution: epilepsy, on SSRI

Transcranial Direct Current Stimulation

• Safe, non invasive brain stimulation

• Weak constant direct current 1-2 mA provided by 9-V alkaline battery

• Active & reference electrode: Saline soaked electrodes 15-25 cm2 applied to targeted cortex

• 10-20 mins, 10-14 days

tDCS

• Anodal stimulation (excitatory) to lesion side as the active electrode

• Cathodal (inhibitory)stimulation to normal side as active electrode

• Anode stimulation to lesion M1 area together with Cathodal stimulation to normal M1 area

• Modulate NMDA receptors, augment synaptic plasticity, affect regional blood flow

t DCS in stroke

Applications

• Stroke motor recovery

• Aphasia

• Dysphagia

• Neglect

• Depression

• Dementia

Side effects

• Safe

• Cheap

• Side effects are mild

• Local itching, tingling or burning sensation

• Skin irritation, transient headache or insomnia

Study Year No Design Stimulation IntensityDuration

Results

Fregni 2005 6 CO C & A 1 mA / 20 m Hand+

Hummel 2005 6 CO A 1 mA / 20 m Hand+

Hummel 2006 11 CO A 1 mA / 20 m decrease RT

Boggio 2007 9 RCT C & A 1 mA / 20 m 4 weeks

Hand+

Hesse 2007 10 OL A & robots 1.5 mA / 7 m20 m RT for 30 s

3+7-

Jeffery 2009 8 RCT C & A & Sham

2 mA / 10 m Increase MEP

Kim 2010 10 CO A 1 mA / 20 m Finger+

Lindenberg 2011 20 RCT Bispheric 1.5 mA / 20 m 5 days Improve

Bolognini 2011 14 RCT Bispheric 2 mA / 40 m 10 days Improve

Madhaven 2011 9 OL A 0.5 mA / 15 m Increase effects

Tanka 2011 8 CO A 2 mA / 10 m Increase force

Hesse 2011 96 MC RCT C+R, A+R, S+R

2 mA / 20 m All improve but not stat. difference

Meta analysis J of Hand Therapy 2013

Motor Dysfunctions

• LMN lesion: flaccid weakness

• UMN lesion: Muscle spasticity, co-contractions, hyper-reflexia

• Hemiplegia shoulder pain

What is spasticity?

• A common upper motor syndrome.

• Has a range of definitions.

“ a motor disorder characterized by a velocity

dependent increase in the tonic stretch reflex

(muscle tone) with exaggerated tendon jerks,

resulting from hyper excitability of the stretch

reflex, as one component of the upper motor

neuron syndrome”

(Lance 1980)

Management StrategyManagement Strategy

Prevention of Provocative Factors

Team Decision Making

Treatment OptionsPhysical Medical

Generalised

Spasticity

Regional

Spasticity

Botulinum Toxin

Phenol Blockade

Focal

Spasticity

Intra-Thecal

BaclofenOral Agents

Treatment options

• Prevention and removal of noxious stimulus

• Physical (stretching exercise) and occupational therapies (splinting or casting)

• Oral medications: Baclofen, diazepam, mydocalm, tizanidine, dantrolene etc

• Chemodenervation: Botn & phenol injection

• Intrathecal Baclofen

• Neurosurgery

• Orthopedic surgery

Oral Agents: Baclofen

40% Side-effects

Narrow margin for

tolerance, therapeutic effect and

side-effects

Motor Point Block:

• Intra-muscular injection (BoT: dysport or botox) in the target muscle

• Ultrasound guided

• Nerve stimulator guided / EMG guided

• Follow anatomical site injection

• Use accompany with PT / OT

• Last ~ 3 months

• Improves the spasticity but may increase weakness, not increase in function

Upper limb spasticity

Joints Movements Muscles

Shoulder AdductedInternal rotated

Pectoralis major Lattisimus dorsiSubscapularisTeres major

Elbow Flexed BicepsBrachialisBrachioradialis

Forearm Pronated Pronator teresPronator quadratus

Wrist Flexed FCR, FCU

Fingers Flexed FDS, FDP

Thumb FlexedAdducted

FPL, FPB, OP, AP, First DI

Lower limb spasticity

Joint Movements Gait Muscles

Hip Flexed Iliacas, Psoas

Adducted Scissor leg Adductor L, B, M

Knee Extended Stiff knee gait QuadricepsRectis F, VM, VI, VL

Flexed Crouch gait Medial & lat harmstringsGastrocnemius

Ankle Planter-flexed

Inverted

Equinovarus Gastrocnemius & Soleus, FDL, FHLTA & Tibialis Post.

Toe Flexed Clawed toe FDL, FDB, FHL

Extended great toe Striatal toe EHL

Motor Dysfunctions

• LMN lesion: flaccid weakness

• UMN lesion: Muscle spasticity, co-contractions, hyper-reflexia

• Hemiplegia shoulder pain

Causes of hemiplegic shoulder pain

• Muscles: Subscapularis spasticity, Pectoralisspasticity, Rotator cuff disease,

• Joint capsule: Frozen shoulder (Adhesive Capsulitis)

• Joint: Subluxation, OA GH, OA AC

• Bursa: Bursitis

• Tendon: Bicep Tendonitis

• Nerve: CRPS type I (RSD),

• Brain: Central post-stroke syndrome (CPSP)

• Brachial plexus traction injury

Managements

• Diagnosis: clinical, special tests, Ultrasound, MRI• Prevention• Physical modalities: Transcutaneous electric

stimulation (TENS), Functional electric stimulation (FES)• OT: splinting• Pharmacological: Pain killers, Anti-spastic medications,

Anti-neuropathic medications, Subscapular nerve block, botulinum toxin injection & intra-articular steroid injection to shoulder joint,

• Others: trigger point injection, aromatherapy, Bowen’s therapy, acupuncture

Treatment modalities

All causes Good position, handling, exercise

Hemiplegicshoulder pain

TENS

Spasticity Anti-spastic medicationsBoTn injecion to subscapularis / pectoralis major

Rotator cuff disease

Intra articular injection of steroid

Tendonitis Bursitis

Intra articular steroid injection

OA joints Analgesic medicationsIntra articular injection of steroid

Adhesive capsulitis Intra articular steroid injection

Subluxation Strapping, Splinting, Functional Electric Stimulation

CPSP TCA, lamotrigine, pregabalin

CRPS Oral steroid, calcitonin, ganglion block, CIMT

Post stroke dysphagia

• Positioning, diet modifications

• Swallowing maneuver

• Vitalstim stimulation (sensory)

• Neuromuscular electrical stimulation (NMES)

• Transcranial direct current stimulation (tDCS)

• Repetitive transcranial magnetic stimulation (rTMS)

• +- Kinesio-taping in swallowing

VitalStim therapy

NMES in dysphagia

Quardian AmpCare

Kinesio taping

Post-stroke aphasia

• Intense language therapy

• Computer assisted program

• Melodic intonation therapy

• Transcranial direct current stimulation (tDCS)

• Repetitive transcranial magnetic stimulation (rTMS)

• Piracetam, donepazil, galantamine, memantin

Future directions

• Stem cell therapy

• Growth factor therapy

• Mixed or combination therapies

• Best protocols

• Non invasive neurostimulative devices

• Brain computer interface: Neuro-prosthesis

• Telerehabilitation

• Home exercise training etc

The End