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CloseApproaches to Stroke Rehabilitation
Rehabilitation of Motor Deficits after Stroke
As a general rule of thumb, the earlier patients show recovery after stroke the better the outcome at 6 months. Spontaneous recovery is strongest within the first 4 weeks and then tapers off over the next five to six months. Traditionally, rehabilitation during this time period is more effective than after six months. A number of methods currently are used to facilitate movement in affected extremities (arms/legs) and teach compensatory techniques to perform activities of daily living (ADL).
Traditional Methods
- Conventional - range of motion/strengthening exercises, training in mobility for functional independence
- Neurodevelopmental Training (NDT) - also known as the Bobath technique. This technique was developed in the 1940s and the principle is to reduce muscle spasticity by focusing on normal patterns of movement.
- Proprioceptive neuromuscular facilitation (Knott & Voss) - relies on quick stretching and manual resistance of muscle activation of the limbs in functional directions, which often are spiral and diagonal in direction.
- Brunnstrom technique - facilitates synergistic patterns of movement that develop during recovery from hemiplegia (paralysis of one side of the body). Development of flexor and extensor synergies is encouraged during early recovery with the hope that synergic activation of muscles will transition into voluntary activation of movements
- Rood technique - modifies movement with cutaneous sensory stimulation
When these approaches to stroke recovery are compared to each other, no one method appears to be more effective than another. However, NDT alone may require prolonged periods of time to produce functional results which may be accomplished faster in conjunction with other methods. Some rehabilitation facilities also incorporate biofeedback into their program to complement other types of therapy.
Approaches Based on Motor Learning Theory
Many approaches to motor recovery after stroke are goal oriented, task specific approaches which developed from the application of motor learning theory. This stresses structured practice of goal oriented tasks with specific feedback patterns for successful transfer and retention of a new skill. Stroke survivors practice changing motor behavior rather than normalizing movement patterns. Because of impairments in motor or sensory systems, transfers, activities of daily living (ADL) and ambulation become new skills, and must be taught and performed in different ways.
- Constraint Induced Movement Therapy (CIMT) - the unaffected limb is immobilized in a splint inside a sling for 90% of waking hours over 2-week period, except weekends. The affected limb is used repeatedly in a number of exercises for a period of 6 to 7 hours per day, for 10 weekdays. The most recent studies have demonstrated improvements in the amount and quality of movement by at least 100% in both laboratory and "real-world" settings. However, constraint-induced movement therapy requires movement of at least 10 degrees of finger extension and 20 degrees of wrist extension in the affected limb. Furthermore, the endurance to tolerate the intensity of training significantly limits the number of stroke survivors who can participate in this protocol.
- Partial weight support treadmill training - stroke survivors are trained to ambulate in a harness system which decreases the amount of weight-bearing required to walk. The efficacy of this technique appears to increase with treadmill speed. Training in the support system may significantly improve balance, motor recovery, overground walking speed, and possibly overground walking endurance. It is not clear whether training with body-weight support decreases the length of inpatient rehabilitation.
In general, performance improvement of tasks depends on the amount of practice. Practice can be achieved in several ways, including:
- Massed practice where the patient repeats the exact same task or movement many times
- Distributed practice where there are rest periods of increasing frequency and duration during a practice session
- Variability of the practice tasks where there are variations of different intensities in the practice session - e.g. reaching randomly for a few different items in a random order instead of focusing on one target object. The introduction of variability into practice session has been shown to improve "retention" of the skill being practiced on subsequent sessions. In addition, variability of practice is thought to increase "generalization" of the movement being practiced to new tasks, meaning that the patient is able to transfer the skill of what they are practicing to other situation, hopefully involving activities of daily living (ADL).
These elements of practice are all incorporated into the various applications and techniques which have been developed based on the motor learning theory.
Other Rehabilitation Techniques
- Arm ability training for patients with mild hemiparesis. The mild deficits experienced by these patients are most likely to affect their return to work after their stroke. Training tasks include arm-hand steadiness, hand grip, aimed reaching, tracking, and wrist-finger speed.
- Neuromuscular stimulation, also called functional electric stimulation, may significantly increase motor recovery
- Interactive robotic therapy where the patient initiates a movement and a robot then assists them in completing the movement or provides resistance either to an improper movement or as progressive resistance training for the affected arm. Use of robotic therapy, in additional to conventional rehabilitation, has been shown in a limited number of subjects to have significantly greater benefit on measurements of impairment and on ADLs than conventional therapy alone.
- Bilateral movement training based on the theory of interlimb coordination, meaning that voluntary movements of the healthy, unaffected limb may facilitate movement in the affected limb. Cumulative evidence from a review of several studies that investigated results from bilateral movement training for paretic arms indicates that bilateral movement training, with or without auditory cuing or sensory feedback, is effective in improving motor capabilities and functional outcome for poststroke patients with a paretic limb in the sub-acute or chronic (6 months or longer from stroke onset) phase of recovery. This applies when the training is used either as a single protocol or combined with other training.
- Virtual reality training has been used in small pilot studies but has not undergone controlled clinical trials. A simulated environment is created for retraining exercises for motor function. The extent to which training carries over from the simulated environment to an actual physical environment is not clear.
- Transcutaneous electrical nerve stimulation (TENS) may increase motor function without affecting pain or spasticity.
- Electromyographic (EMG) biofeedback may significantly improve motor recovery in the arm, but not in the leg. To date, studies examining the efficacy of EMG biofeedback are inconclusive. It may be more effective when combined with other training such as robotic training and other types of feedback such as positional biofeedback which helps patients orient themselves in space. EMG biofeedback may also be combined with neuromuscular stimulation.
- Myomo e100 NeuroRobotic System was cleared by the U.S. Food and Drug Administration (FDA) in July 2007 for use by stroke patients with partial paralysis of the arm(s). The devise is designed to allow stroke patients to initiate and control movement of partially paralyzed limbs using their own neurological and muscular signals. It is a non-invasive devise (arm/elbow brace with attachments) that helps people relearn how to move affected limbs.
Medication for Stroke Rehabilitation
Drugs may also have a role in motor recovery, including:
- Methylphenidate, a mild central nervous system stimulant, may decrease depression and improve function in the early stages after stroke.
- Dextroamphetamine may improve function 1 year after strokes in a small number of survivors.
- Fluoxetine may help to facilitate motor recovery independent of its effect as an antidepressant.
- Piracetam, a derivative of gamma-amino butyric acid (G-ABA), may facilitate recovery of language function.
- Clonidine, prazosin, neuroleptics and other dopamine receptor antagonists, benzodiazepenes, phenytoin, and phenobarbital actually may impair motor recovery due to reasons not fully understood.
- Dopamine agonists and selective serotonin reuptake inhibitors (SSRIs) have been shown in small studies to improve motor function when combined with conventional exercise therapy, however, further investigation is needed to confirm this data.
Researchers are investigating the possibility that some treatments, both physical and medications, may actually interfere with recovery following stroke. For example, there is concern that intense use of the paretic limb may increase neurologic damage since the brain tissue is so vulnerable after a stroke. There is also concern, based on animal studies, that certain drugs may interfere with recovery, although human data is very limited and needs to be investigated.
To read more about treatments being used for motor recovery for the poststroke patient, please click on the following link: