Posts Tagged motor impairment
[Abstract] Motor Learning in Stroke. Trained Patients Are Not Equal to Untrained Patients With Less Impairment
Background and Objective: Stroke rehabilitation assumes motor learning contributes to motor recovery, yet motor learning in stroke has received little systematic investigation. Here we aimed to illustrate that despite matching levels of performance on a task, a trained patient should not be considered equal to an untrained patient with less impairment.
Methods: We examined motor learning in healthy control participants and groups of stroke survivors with mild-to-moderate or moderate-to-severe motor impairment. Participants performed a series of isometric contractions of the elbow flexors to navigate an on-screen cursor to different targets, and trained to perform this task over a 4-day period. The speed-accuracy trade-off function (SAF) was assessed for each group, controlling for differences in self-selected movement speeds between individuals.
Results: The initial SAF for each group was proportional to their impairment. All groups were able to improve their performance through skill acquisition. Interestingly, training led the moderate-to-severe group to match the untrained (baseline) performance of the mild-to-moderate group, while the trained mild-to-moderate group matched the untrained (baseline) performance of the controls. Critically, this did not make the two groups equivalent; they differed in their capacity to improve beyond this matched performance level. Specifically, the trained groups had reached a plateau, while the untrained groups had not.
Conclusions: Despite matching levels of performance on a task, a trained patient is not equal to an untrained patient with less impairment. This has important implications for decisions both on the focus of rehabilitation efforts for chronic stroke, as well as for returning to work and other activities.
Source: Motor Learning in Stroke
[Abstract] Plasticity and Reorganization in the Rehabilitation of Stroke. The Constraint-Induced Movement Therapy (CIMT) Example
Abstract. This paper outlines some actual developments in the behavioral treatment and rehabilitation of stroke and other brain injuries in post-acute and chronic conditions of brain lesion. It points to a number of processes that demonstrate the enormous plasticity and reorganization capacity of the human brain following brain lesion. It also highlights a series of behavioral and neuroscientific studies that indicate that successful behavioral rehabilitation is paralleled by plastic changes of brain structures and by cortical reorganization and that the amount of such plastic changes is obviously significantly determining the overall outcome of rehabilitation.
Lead study author Dr. Gary Steinberg, professor and chair of neurology at Stanford University School of Medicine in Palo Alto, CA, and colleagues publish their findings in the journal Stroke.
While the trial only included a small number of strokeparticipants, the results have been met with much positivity, with some health experts claiming the findings could lead to “life-changing treatments” for stroke patients.
In the United States each year, more than 795,000 people have a new or recurrent stroke.
Ischemic stroke is the most common form, accounting for around 87 percent of all strokes. It occurs when the flow of oxygen-rich blood to the brain becomes blocked, primarily due to blood clots.
Hemorrhagic stroke accounts for around 13 percent of all strokes, arising from leaking or ruptured blood vessels in the brain.
Exactly how stroke affects a person is dependent on what side of the brain it occurs and the amount of damage it causes. Some individuals may experience temporary arm or leg weakness, for example, while others may lose the ability to speak or walk.
According to the National Stroke Association, around 2 in every 3 stroke survivors will have some form of disability, and stroke is the leading cause of disability among American adults.
There are treatments available for stroke, such as tissue plasminogen activator (tPA) – considered the “gold standard” treatment for ischemic stroke. It works by dissolving the blood clot that is blocking blood flow to the brain.
However, tPA needs to be administered within hours of stroke occurrence, in order to maximize the likelihood of recovery – a time period that Dr. Steinberg and colleagues note is often exceeded by the time it takes for a patient to arrive at the hospital.
If the treatment is not received in time, the chance of a full recovery from stroke is small. But in the new study, researchers found stem cell transplantation improved patients’ recovery when administered up to 3 years after stroke.
For more Visit Site —> Stroke patients able to walk again after stem cell transplant – Medical News Today
[ARTICLE] Stroke Treatment Associated with Rehabilitation Therapy and Transcranial DC Stimulation (START-tDCS): a study protocol for a randomized controlled trial – Full Text HTML/PDF
Traditional treatment for motor impairment after stroke includes medication and physical rehabilitation. The transcranial direct current stimulation associated with a standard physical therapy program may be an effective therapeutic alternative for these patients.
This study is a sham-controlled, double-blind, randomized clinical trial aiming to evaluate the efficacy of transcranial direct current stimulation in activities of daily living and motor function post subacute stroke. In total there will be 40 patients enrolled, diagnosed with subacute, ischemic, unilateral, non-recurring stroke. Participants will be randomized to two groups, one with active stimulation and the other with a placebo current. Patients and investigators will be blinded. Everyone will receive systematic physical therapy, based on constraint-induced movement therapy. The intervention will be applied for 10 consecutive days. Patients will undergo three functional assessments: at baseline, week 2, and week 4. Neuropsychological tests will be performed at baseline and week 4. Adverse effects will be computed at each session. On completion of the baseline measures, randomization will be conducted using random permuted blocks. The randomization will be concealed until group allocation.
This study will investigate the combined effects of transcranial direct current stimulation and physical therapy on functional improvement after stroke. We tested whether the combination of these treatments is more effective than physical therapy alone when administered in the early stages after stroke.
A stroke is defined as an acute neurological dysfunction of vascular origin, with sudden development of clinical signs of brain function disorders, lasting more than 24 h .
In this sense, new therapeutic modalities have been developed for monitoring patients after a stroke . Simis et al.  conducted a placebo-controlled clinical trial and found that transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS) can cause increased hand motor function compared to placebo stimulation. TMS has been used to minimize the limitations post stroke, such as functional independence and motor recovery , , but it is not portable/mobile and is expensive. In contrast, tDCS offers some advantages compared to TMS, being portable, more economical, and easy to operate. The effects are polarity-dependent, leading to an increase or a decrease in cortical excitability . Although some studies have shown that increasing the current intensity is related to more robust effects , this is also true for adverse effects such as headache and discomfort under the electrode . Therefore, the maximum current intensity used is generally 2 mA, and the cortex density varies between 0.029 and 0.08 mA/cm 2. Animal studies with a higher current density of 25 mA/cm 2 did not induce lesions in the brain tissue, meaning that limits well above those applied in humans did not result in potential adverse effects , thereby demonstrating that it is a safe technique.
There is evidence that repeated sessions of tDCS may be associated with a longer duration of the behavioral effects . Monte-Silva et al.  demonstrated that the interval between the sessions can be critical to performance. The authors found that when an extra session of tDCS is applied for 1 hour after the first session, the effects last for a longer time (120 minutes) compared to the effect of only one or two consecutive sessions, while an extra session of tDCS applied beyond that period (that is, 3 hours) did not influence the effect of the first session. These findings show that studies with the aim of achieving lasting effects should consider the timing-dependent plasticity stimulation regulation in the human motor cortex .
Regarding physical therapy, different approaches can be found for motor recovery, such as mirror therapy , repetitive task practice , and robotic training . However, the type of training that is combined with stimulation determines how generalizable the benefits would be. Improvements are specific for tasks that are strategically paired with stimulation .
In this perspective, efforts are currently being made to standardize the application of the methods that can be combined with tDCS for the treatment of stroke. Bolognini et al.  developed a placebo-controlled trial to investigate the neuropsychological and behavioral effects of bihemispheric tDCS (cathodic stimulation in the unaffected hemisphere and anode in the affected cortex) combined with a standard physical therapy program called constraint-induced movement therapy (CIMT) . The data show that CIMT applied alone only seems to be effective in modulating cortical excitability, but is not able to restore the balance of transcallosal inhibition. According to the authors, bihemispheric tDCS can already achieve this goal and promote greater functional recovery. Studies show that CIMT is associated with functional improvement in acute and subacute stages of stroke –. Although most studies in neurostimulation therapy involve post-stroke patient monitoring for short periods , , longitudinal studies would clarify the action mechanisms and the effective duration of this association (tDCS plus CIMT) from the early stages of stroke.
The effectiveness of stroke interventions is often described by measures of disability, or functional assessment. Evaluations that deal with activities of daily living (ADLs) generally include the Functional Independence Measure, the Katz index and the Barthel index (BI), the latter being a prevalent measure for the clinical evaluation of stroke patients, with substantial supporting research –. However, there are few studies involving the ADLs as the primary outcome for a marker of functional recovery after neurostimulation. For example, in a systematic review where the efficacy of tDCS in ADLs and motor function after stroke were analyzed, the authors found that the results are inaccurate and the effect was not sustained when studies of high methodological quality were included. There were 15 studies involving a total of 455 participants included, with only randomized controlled trials and randomized controlled cross-over trials evaluated. Of the total, the analysis of five studies involving 286 participants to examine the effects of tDCS on our primary outcome (ADLs evaluated by BI) has shown that no effect was observed on the performance at the end of the intervention. In three studies from this systematic review involving 99 participants to evaluate the effects of tDCS in BI scores at the end of follow-up, evidence suggested an effect on the ADL performance, but the confidence intervals were wide, and the effect was not sustained when they only included studies with low risk of bias. Thus, the authors point to the need for future research in this area to improve the generalization of the results .
Although clinical trials can be found that measure the efficacy of tDCS in ADLs pointing to positive effects ,
 among other factors, in general they only include participants in the chronic stage with brain injuries in different areas and varying levels of functional incapacity.
Therefore, central questions remain: For a daily protocol of 10 days, does the active tDCS applied under a 2 mA current and associated with CIMT have a superior response to the simulated (placebo) current applied with CIMT, and if so, what is the size of the effect? What adverse effects are associated with the therapy? Does functional improvement in the ADLs persist over time?
In light of this, a clinical trial phase II/III will be developed to evaluate the therapeutic effects of tDCS in patients in the subacute stage after stroke. The purposes are two: 1) discuss topics related to safety, adverse effects, feasibility, and effectiveness of tDCS in the treatment of stroke patients; 2) present the work protocol prior to clinical trial results, ensuring adherence to protocol. Our hypothesis is that the active stimulation in the affected hemisphere is more effective than a simulated (placebo) current in activities of daily living in subacute stroke. Secondly, we are interested in knowing whether tDCS is effective in the recovery of the following motor variables: spasticity, use of the affected limb, balance, posture, fall risk, muscle strength, and upper and lower limb function. Also, we aim to analyze if a possible functional improvement produces a change in the patients’ perception of their quality of life. We hope that the study will contribute to the discussion of the methodological procedures of clinical trials phase II/III involving neuromodulation for the treatment of patients after stroke.
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[ARTICLE] Combined transcranial direct current stimulation and home-based occupational therapy for upper limb motor impairment following intracerebral hemorrhage: a double-blind randomized controlled trial
Purpose: To investigate the combined effect of transcranial direct current stimulation (tDCS) and home-based occupational therapy on activities of daily living (ADL) and grip strength, in patients with upper limb motor impairment following intracerebral hemorrhage (ICH).
Methods: A double-blind randomized controlled trial with one-week follow-up. Patients received five consecutive days of occupational therapy at home, combined with either anodal (n = 8) or sham (n = 7) tDCS. The primary outcome was ADL performance, which was assessed with the Jebsen–Taylor test (JTT).
Results: Both groups improved JTT over time (p < 0.01). The anodal group improved grip strength compared with the sham group from baseline to post-assessment (p = 0.025). However, this difference was attenuated at one-week follow-up. There was a non-significant tendency for greater improvement in JTT in the anodal group compared with the sham group, from baseline to post-assessment (p = 0.158).
Conclusions: Five consecutive days of tDCS combined with occupational therapy provided greater improvements in grip strength compared with occupational therapy alone. tDCS is a promising add-on intervention regarding training of upper limb motor impairment. It is well tolerated by patients and can easily be applied for home-based training. Larger studies with long-term follow-up are needed to further explore possible effects of tDCS in patients with ICH.
Implications for Rehabilitation
- Five consecutive days of tDCS combined with occupational therapy provided greater improvements in grip strength compared with occupational therapy alone.
- tDCS is well tolerated by patients and can easily be applied for home-based rehabilitation.
via Combined transcranial direct current stimulation and home-based occupational therapy for upper limb motor impairment following intracerebral hemorrhage: a double-blind randomized controlled trial, Disability and Rehabilitation, Informa Healthcare.
[ARTICLE] Is mental practice an effective adjunct therapeutic strategy for upper limb motor restoration after stroke? A systematic review and meta-analysis.
Stroke is one of the most common conditions requiring rehabilitation, and its motor impairments are a major cause of permanent disability. Hemiparesis is observed by 80% of the patients after acute stroke. Neuroimaging studies showed that real and imagined movements have similarities regarding brain activation, supplying evidence that those similarities are based on the same process. Within this context, the combination of mental practice (MP) with physical and occupational therapy appears to be a natural complement based on neurorehabilitation concepts.
Our study seeks to investigate if MP for stroke rehabilitation of upper limbs is an effective adjunct therapy. PubMed (Medline), ISI knowledge (Institute for Scientific Information) and SciELO (Scientific Electronic Library) were terminated on 20 February 2015. Data were collected on variables as follows: sample size, type of supervision, configuration of mental practice, setting the physical practice (intensity, number of sets and repetitions, duration of contractions, rest interval between sets, weekly and total duration), measures of sensorimotor deficits used in the main studies and significant results. Random effects models were used that take into account the variance within and between studies. Seven articles were selected. As there was no statistically significant difference between the two groups (MP vs control), showed a – 0.6 (95% CI: -1.27 to 0.04), for upper limb motor restoration after stroke. The present meta-analysis concluded that MP is not effective as adjunct therapeutic strategy for upper limb motor restoration after stroke.
Despite extensive rehabilitation post-stroke gait remains slow, variable and asymmetric. There is a need for simple interventions to improve lower-extremity motor control and walking ability.
Mirror therapy is a promising intervention though little attention has focused on its use on the lower-extremities post-stroke. This thesis investigates the feasibility and potential effects of a bilateral lower-extremity mirror therapy intervention (LE-MT) post-stroke.
A case series involving three participants, who performed twelve 30 minute sessions of LE-MT over four weeks, is presented. Session duration and number of repetitions completed improved over the course of the intervention indicating LE-MT poststroke is feasible.
Some cases demonstrated improved motor recovery of the leg and clinically meaningful improvements to gait velocity and step variability post-intervention indicating some potential benefits of LE-MT. Future directions will identify who may respond best to LE-MT, investigate the dose-response relationship and the underlying mechanisms of the observed improvements associated with LE-MT.
[ARTICLE] Applying Tai Chi as a rehabilitation program for stroke patients in the recovery phase Full Text PDF
Background: As the second commonest cause of death and a major cause of disability worldwide, stroke has greatly influenced patients’ quality of life and created a huge public health burden. As a special form of physical activity that has been widely practiced in China, and even throughout the world, Tai Chi may be favorable for the rehabilitation of stroke patients. Several studies have been conducted to investigate the rehabilitative effects of Tai Chi for stroke patients, but none of them have been focused on the recovery phase (2 to 24 weeks) of stroke.
Methods: This study is an assessor-blinded randomized controlled trial. A total of 50 eligible participants will be randomly assigned to either a control group or a Tai Chi group. Patients in the control group will receive standard, conventional rehabilitation therapies, and a combination of Tai Chi and conventional rehabilitation programs will be applied in the Tai Chi group. The recovery of motor impairment, functional activity and balance abilities as measured with the Fugl-Meyer Assessment, Barthel Index and Berg Balance Scale will be assessed as primary outcome measures. The secondary outcome measures to be used are the scores on the Stroke-Specific Quality of Life Scale, the National Institutes of Health Stroke Scale and the objective parameters of the RSscan footscan gait system. All assessments will be conducted at baseline, 4 weeks after the rehabilitation course and at the end of 3-month follow-up.
Discussion: The results of this study will provide preliminary evidence regarding the efficacy and feasibility of Tai Chi as an additional rehabilitative program for stroke patients in the recovery phase.
Trial registration: Chinese Clinical Trial Register ID: ChiCTR-TRC-13003661 (7 October 2013)
The complete article is available as a provisional PDF. The fully formatted PDF and HTML versions are in production.
This pilot study tested the effectiveness of an intense, short-term upper-limb robotic therapy for improvement in motor outcomes among chronic stroke patients. We enrolled 30 subjects with upper-limb deficits due to stroke of at least 6 mo duration and with a Motor Power Assessment grade of 3 or less. Over 3 wk, 18 sessions of robot-assisted task-specific therapy were delivered with the use of a robotic exercise device that simulates a conventional therapy known as skateboard therapy.
Primary outcome measures included reliable, validated impairment and disability measures of upper-limb motor function. Statistically significant improvements were observed for severely impaired participants when we compared baseline and posttreatment outcomes (p < 0.05).
These results are important because they indicate that improvement is not limited to those with moderate impairments but is possible among severely impaired chronic stroke patients as well. Moderately and severely impaired patients in our study were able to tolerate a massed-practice therapy paradigm with intensive, frequent, and repetitive treatment. This information is useful in determining the optimal target population, intensity, and duration of robotic therapy and sample size for a planned larger trial.