May 7, 2010
Rehabilitation of Arm Function After Stroke - Literature Review, Review
Here’s a great scientific literature review of Arm Function Rehabilitation After Stroke. Unfortunately, it isn’t hugely accessible to non-technical readers (not many people know what “ipsilesional corticospinal excitability” means). Here’s my review of the main points of the article, in plain terms:
- This study examined 66 other studies published between 2004 and 2008 from Medline using the keywords “stroke”, “upper limb”, and “rehabilitation”.
- Only randomized control studies were included in the review.
- High intensity rehabilitation training programs during subacute stroke rehabilitaiton (less than 6-months post-stroke) resulted in significant improvements in arm function.
- Learned non-use (gradually giving up trying to use a partially paralyzed arm) is the result of brain re-organization that starts within hours of a stroke.
- Rehabilitation that concentrates on compensation using the healthy limb can accelerate and perpetuate learned non-use. Some of the studies examined inhibition of the healthy part of the brain’s motor cortex using TMS.
- Natural plasticity of the brain after stroke, which is associated with a re-allocation of brain networks from one function to another, leads to a certain amount of natural upper extremity neurological recovery
- Training by repeating tasks directly linked to daily life activities promotes recovery. An “enriched” sensory environment (proprioceptive, visual, etc.) while performing these tasks is beneficial.
- Residual voluntary motor ability at 1-month post stroke is the best predictor of how much hand dexterity will be regained.
- In people whose stroke occurred 6 months or more previously (referred to as ”chronic”), 2 hours of transcutaneous neurostimulation (with an FES stimulator, for example) delivered just prior to rehabilitation training sessions, improves function of the weak hand
- The impact of acupuncture on upper limb motor recovery is not conclusive.
- Thermal stimulation, where patients are encouraged to take their paretic arm away when they feel an uncomfortable sensation, could promote recovery.
- Constraint-induced movement therapy is effective in reversing learned non-use of a paretic arm. It is believed that CIMT encourages the brain re-allocation referred to above.
- For higher-functioning chronic stroke survivors, mental imagery: imagining moving the paretic limb, or imagining movements performed by another person, are beneficial to recovery of motor function. No benefit has been demonstrated in lower-functioning stroke survivors and those with cognitive impairments. Mental imagery hasn’t been the subject of many randomly controlled studies.
- Unilateral task practice using the paretic limb yields improvements superior to those of bimanual task practice.
- Both transcranial magnetic stimulation (TMS) and transcranial electrical stimulation (TES) have been shown to facilitate some motor recovery, but the cost/benefit and risk/benfit ratios have yet to be evaluated.
- TMS inhibition of the healthy part of the motor cortex can temporarily improve dexterity of the paretic limb, but at this stage this is not a clinically relevant treatment. In some cases, the inhibition procedure may actually be harmful.
- Constraint of the healthy limb in CIMT doesn’t yield more functional improvements than intensive movement therapy without a constraint.
- More intensive training very soon after a stroke doesn’t yield functional improvement beyond that of standard treatment.
- One year after a stroke, 9 hours of movement therapy isn’t sufficient to yield clinically significant results, whereas 57 hours of rehabilitation training does yield results for people with moderate motor impairment.
- EMG-triggered electrical stimulation eliciting hand opening, (i.e. bursts of electrical stimulation of a muscle initiated by weak voluntary activation of the muscle), has been claimed to be more efficacious than electrical stimulation triggered by other means, but there is insufficient evidence to fully validate this conclusion.
- Electrical stimulation to open the hand during repetitive grasp and release tasks is an integral part of a functional strategy, and promotes motor relearning.
- Several studies have concluded that CIMT is better than conventional therapy, including one study of 43 patients at less than 16 weeks poststroke.
- In a very broad study of 222 patients, CIMT improved pinch grip and several fine motor tasks, but failed to show significant improvement in a patient’s ability to open his or her hand.
- The following details results for various robotics systems:
- NeReBot: A group of acute poststroke subjects (some as early as 7-days poststroke) had better voluntary hand control compared to a group who received no therapy. The results were still evident 8 months later.
- InMotion2: “The motor improvements observed after 18 hours of therapy are not clinically significant and do not spread to distal motor capacities.”
- Bi-Manu-Track: Bimanual and uni-manual rehabilitation yielded similar improvements with the use of this robot.
- MIME and BACTRAC: “The functional improvements on manual dexterous ability are limited to the execution speed of tasks that the patient had already mastered before treatment.” - Author’s therapy recommendations:
| Moderate Motor Impairment | Severe Motor Impairment | |
| Early stroke rehabilitation (< 6 months) |
Functional rehabilitation training (25 hours) including: Distal EMG-stimulation + distal bimanual movements (6 hours) | Bimanual distal robot (10 hours) or Distal EMG-stimulation + distal bilateral movements (20 hours) Then if possible: functional rehabilitation training (15 hours) |
| Chronic stroke rehabilitation (> 6 months) |
Constraint-Induced movement therapy (CI therapy) (30 hours) or Functional rehabilitation training (30 hours) (in a virtual environment setting or with verbal feedback on the performance) + Mental Imagery |
If the neurophysiological criteria are favorable: classic rehabilitation training (50 hours) with trunk restraint including distal EMG-stimulation + distal bilateral movements (20 hours) |
October 16, 2009
Modified Constraint Induced Movement Therapy Discussion
In early 2008, an online discussion took place between two researchers regarding the implementation details of Constraint Induced Movement Therapy (CIMT). Dr. Steven Wolf, the principle investigator of the 2006 EXCITE study makes some interesting comments about Dr. Steven Page’s mCIT trial (Modified Constraint Induced Therapy).The following compares a few of the main components of Dr. Wolf’s CIMT and Dr. Page’s mCIT:
| CIMT | mCIT | |
| Location | clinic | home |
| Hours of Daily Therapy | 6 hours* | 0.5 hours |
| Duration of Therapy | 3-6 weeks | 10 weeks |
| Daily Arm Restraint** | 9 hours/day for 2 weeks | 5 hours/day for 5 days/week for 10 weeks |
| Benefit to Patient | Statistically Significant: refer to article |
Statistically Significant: refer to article |
* patients experiencing fatigue are not be required to complete 6 hours/day
** CIMT and mCIT require that patients restrain their less affected limb for periods of time during the day.
October 14, 2009
Constraint Induced Therapy at Home
What is Constraint Induced Therapy (CIT)?
Initially called “forced use therapy,” constraint induced (movement) therapy (CIT) is the principle of immobilizing one hand so that the participant uses only the other hand during therapy. During hand rehabilitation in stroke, for example, participants wear a mitten on their less affected hand and perform exercise tasks with only their weak hand.
For many years researchers had known that intensive exercise therapy (IET) accelerated recovery in the central nervous system. The related term “neuroplasticity” was introduced to describe the ability of the nervous system to reorganize itself after injury.
In a 2006 randomized controlled trial, stroke rehabilitation researchers found that CIT resulted in larger improvements than conventional therapy. So, it appears that CIT can be an important component of a successful recovery after a neurological injury such as stroke or spinal cord injury.
Here’s a video of Constraint Induced Movement Therapy:
What are the limitations of CIT?
In most cases, CIT providers require subjects to have a minimum level of functional movement in their affected limb. This excludes many people with moderate levels of disability. Perhaps the major limitation of CIT in its original form is the requirement that participants spend up to 3 weeks in a clinic. This can be prohibitively expensive, sometimes costing more than $20,000 for therapy, accommodation, and travel.
Only a few rehabilitation clinics offer the “authorized” version of CIT, so you may need to relocate for a period of time to participate. In most cases, this is very expensive, so it is worth contacting your insurance company before you embark on this option. Less intensive protocols have been suggested, e.g. modified CIT (mCIT) in which a therapist supervises CIT for 30 minutes/day, 3 times/week for 10 weeks and in addition the participant performs self-directed exercise tasks 5 hours/day, 5 days/week with a mitt on the less affected hand. The supervised portions can occur at home if the therapist uses a telerehabilitation link.
Finally, you can conduct a program on your own. You will set up a regimen of training exercises for yourself and wear a mitt on your less affected hand. Do a Google search for mCIT (or Modified Constraint Induced Therapy) before beginning so that you understand what’s involved. Be sure to ask your doctor or physical or occupational therapist whether they recommend self-directed mCIT BEFORE you begin
New ways of delivering Intensive Exercise Therapy (IET)
The latest approach to upper extremity rehabilitation is to use devices that provide task-specific IET of the shoulder, arm and hand. The tasks include “range-of-motion” of the shoulder and arm as well as grasp and release tasks of the hand. The latest devices, like the ReJoyce system for example, use computers to track these movements and control highly-motivating computer games.
Telerehabilitation providers are beginning to emerge online. In this case, a provider will run through an assessment with you online. Provided you fit their criteria and have physician approval, they will ship you the necessary equipment. Your caregiver will set up the equipment and the provider will schedule rehabilitation sessions with you. During these sessions, a therapist will supervise you directly using a web cam. Often, the therapist can configure the equipment in your home to match your exercise requirements. You will likely need to have your caregiver present for these sessions for safety reasons. Telerehabilitation is usually much less expensive than in-clinic rehabilitation.
October 13, 2009
Maximize At-Home Recovery after Stroke
After a stroke, home-based rehabilitation will be an important part of your path to recovery.
Here are some tips to maximize your recovery at home:
1. Getting active about your stroke care. After discharge from an acute care or rehabilitation facility, you may be inclined to let a caregiver take the reigns. It is vital to make sure you work with your caregiver and take an active stance on your health and rehab including: discussing your disabilities with your caregiver as soon as possible, acquiring the appropriate assistive devices, establishing a supervised exercise regimen (in accordance with your physician’s recommendations, of course).
2. Finding the right assistive devices. These include “reachers” (for dressing yourself if you have weakness in your arm or hand), large-handled cutlery to assist you with eating, analysis of your diet if you have trouble swallowing, canes and/or walkers to maximize your independence and mobility, an ankle-foot orthosis (AFO) or functional electrical stimulator (FES) for your leg if you suffer from foot-drop or for your hand to help with grasp and release. Your physician, therapist, caregiver and personal research will yield some very handy results to help you regain independence.
3. Recognizing and treating signs of depression quickly. Depression is common in people who have had a stroke, especially after the acute phase of stroke rehab has ended. If you develop signs of depression, make sure you let your caregiver and doctor know.
4. Getting involved in a rehabilitation program as soon as possible. Establishing a routine of exercise and rehabilitation early on will help you get motivated about your recovery. There are lots of options ranging from self-guided exercises with simple equipment to Internet-based stroke exercise therapy, in some cases with clinical supervision. All are available to you at varying costs. The sooner you get involved, the sooner you can accelerate your recovery. It is important to note that, even if you had a stroke several years ago, supervised movement rehabilitation may help you.
5. Getting social. Many people living with stroke complain of feeling isolated due to poor mobility. Telerehabilitation is a great way of reducing this feeling of isolation. It allows you regularly to speak with a therapist while you engage in home-based rehabilitation. Other options include support groups, online social networking, family visits and assistive devices that allow you to regain mobility.
6. Being consistent. Recovering from stroke is hard work, but it is rewarding. Try scheduling your rehabilitation into 6-week blocks and be consistent! After every 6-week block, determine how much you’ve improved (some stroke rehabilitation systems will let you track your progress) and plan your next 6-week block based on your experience.
7. Exercising at home. Stroke survivors in the past received health services, including therapy in a rehabilitation facility for up to 3 months. Healthcare systems can now only afford to provide this for 2 to 3 weeks. This increases the attractiveness of home-based rehabilitation alternatives.
Home-based stroke therapy offers major advantages, such as the elimination of travel to a clinic, frequent rehabilitation sessions, a more familiar and relaxed environment, and heightened family awareness. The disadvantage is that hands-on contact between client and therapist is missing. Fortunately, recent advances in home-based telerehabilitation provides an exciting solution. Direct contact between client and therapist is restored and in fact it can be greatly increased in frequency, maximizing the effectiveness of the therapy. Telerehabilitation allows clients and therapists to communicate using an audio/video link over the Internet. Furthermore, specially designed exercise devices installed in the participant’s home allow the therapist not only to supervise standardized exercises but also to control the difficulty of the exercises and get precise data on how the participant is improving. This eliminates the need for the therapist to travel to the client’s home (which can take up to 8% of their day, according to a study conducted by Forster and Young in 1990). Additionally, it reduces isolation of clients from their therapists and therapists from their multi-disciplinary team in the clinic.
8. Is home-based rehabilitation effective? A scientific group in New Zealand (Baskett et al.) published results of a study in 1999 indicating that clients engaged in home-based therapy improved as much as those engaged in outpatient-based therapy. There was no significant advantage to outpatient therapy. Home-based recovery has the further advantage of improving caregiver confidence and reducing the social isolation of the patient, likely improving psychosocial well being.
9. What does home-based stroke therapy consist of? Home-based stroke rehab can be directed either by a therapist or by the client. In the case of physical rehabilitation, clients undertake a daily exercise regimen with a focus on recovering movement in their affected limb. In addition to verbal advice from clinicians, written descriptions of preferred exercises to improve tasks of daily living and improve mobility.are sometimes made available.
Several medical devices are also available to help complement home-based stroke exercise and recovery. These include FES (Functional Electrical Stimulation) devices available for the arm, hand and leg. These FES devices provide trains of electrical pulses that activate the nerves and muscles in a client’s affected limb. Most of these devices have exercise modes that patients can use to reduce stiffness and spasticity. Some can be used to augment a patient’s ability during normal daily activities - this type is typically called a neuroprosthetic.
Specialized at-home exercise devices are available commercially for at-home stroke recovery. These range from simple rubber meshes for hand grasp and release, to sophisticated (and expensive) bicycles with FES components. Several telerehabilitation devices are available for at-home stroke rehabilitation - try a Google search for “stroke telerehabilitation” to find a list of these providers.
Home-based stroke rehabilitation is tremendously valuable to both patients and society in general. It saves time, cost, and can yield very positive results.
