This document outlines an MSc presentation on improving recovery after stroke through contemporary rehabilitation approaches. It discusses the epidemiology of stroke and common disabilities caused by stroke. Key principles for recovery like neuroplasticity are explained. Contemporary task-specific training approaches and motor learning paradigms are described in detail, including constraint-induced movement therapy, functional electrical stimulation, bodyweight supported treadmill training, robotics therapy, and virtual reality therapy. Evidence for how these approaches can enhance recovery through cortical reorganization is provided.

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