Physiotherapy Neurological Rehabilitation

1. ADEYEMO, ADEMOLA OLUYOMI
BMR(PT) M.Sc PT
IMPROVING RECOVERY AFTER A
STROKE: EVIDENCES FOR
CONTEMPORARY APPROACHES

2. Outlines
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 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)

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Introduction

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 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).

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 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)

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 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).

7. Epidemiology
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• 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).

8. Effects of stroke
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Stroke results:
• In impaired motor functions
• Sensory deficits
• Perceptual deficits
• Impaired balance
• Cognitive limitations
• Speech problems
• Emotional disorders (Hellstrom,
2002)

9. Interdisciplinary management
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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).

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Recovery after
stroke

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 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).

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 Functional improvements may occur in the
absence of neurological recovery (Duncan
and Lai, 1997, Nakayama et al. 1994).

13. Time course of recovery from
stroke
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• 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)

14. Key outcome predictors
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 Initial severity of impairments
 Motivation
 Social support
 Learning ability (Teasell et al, 2011).

15. Important principle underlining
recovery during stroke
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Neuroplasticity
 ability of the brain to reorganize and
learn new functions (Cramer, 2003;
Nudo, 2003)

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 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).

17. Figure 1: resolution of
edema
Figure 2: lesion with
ischemic penumbra
and reperfusion
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 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).

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Disabilities sequel to stroke

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 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).

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 Evidence abounds that rehabilitation
can make a difference in stroke
survivors (Hsieh et al, 2002; Lin et al,
2004; Kollen et al, 2005).

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Post stroke rehabilitation

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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).

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 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.

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Approaches in
stroke
rehabilitation

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Neurophysiological/motor learning
Orthopaedics principles:
 Conventional/traditional therapeutics exercises
range of motion (ROM) exercises, muscle
strengthening exercises, splinting, mobilization
activities (Pollock et al, 2007)

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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)

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Contemporary Task-Oriented Approach

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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).

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 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).

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 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).

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 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).

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 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).

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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).

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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).

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Constraints induced movement
therapy (CIMT)

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 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).

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• 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).

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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).

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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

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Functional electrical
stimulation (FES)

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Electrical stimulation improves
neuromuscular function in post stroke
subject
 Strengthening muscles,
 Increasing motor control,
 Reducing spasticity,
 Decreasing pain
 Increasing range of motion

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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).

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Figure 4 Ness L300®

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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).

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 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).

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Figure 4 (Maxwell et al, 1995)

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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).

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 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.

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Body-weight support treadmill Training
(BWSTT)

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 BWSTT is a rehabilitation method in
which patients with stroke walk on a
treadmill with their body weight
partially supported.

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 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).

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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).

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 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).

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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

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Robotics therapy

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 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).

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Has different techniques such as:
 Active assisted
 Active constrained
 Active resistive
 Passive exercise
 Adaptive exercise.

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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

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Virtual reality

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 Virtual reality also known as virtual
environment is a technology that allows
individuals to experience and interact
with three-dimensional environments.

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 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).

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 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.

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 When combined with conventional
physiotherapy VR demonstrated to have
significant improvements on balance,
walking speed and function.

68. Conclusion
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 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.

69. References
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Thank you for
your attention