Posts Tagged post stroke

[WEB SITE] Telerehab vs In-Clinic for Post-Stroke Arm Weakness: Which One Wins?

Old woman training at home

Telerehabilitation was not inferior to in-clinic rehabilitation therapy in helping to improve arm function after stroke but could substantially increase access to therapy for those who are unable to access a rehabilitation clinic, researchers opine.

“Few patients fully recover from arm weakness after a stroke. The remainder demonstrate persistent arm impairments that are directly linked to activity limitations, participation restrictions, reduced quality of life, and decreased well-being,” Steven C. Cramer, MD, from the department of neurology at the University of California, Irvine, and colleagues write, in a study published in JAMA Neurology.

“Some rehabilitation therapies can improve these deficits, with higher doses associated with better outcomes. However, many patients do not receive high doses of rehabilitation therapy, for reasons that include cost, difficulty traveling to the location where therapy is provided, shortage of regional rehabilitation care, and poor adherence with assignments,” they continue, in a media release from Healio.

Cramer and colleagues conducted a randomized, assessor-blinded, noninferiority clinical trial to compare telerehabilitation and in-clinic rehabilitation therapy outcomes for patients who had a stroke that resulted in arm motor deficit.

Patients were enrolled in the study at 4 to 36 weeks after experiencing an ischemic stroke or intracerebral hemorrhage that resulted in arm weakness. After enrollment, participants were randomly assigned to receive intensive arm motor therapy in a rehabilitation clinic or in their home using telerehabilitation delivery services with a computer connected to the internet. Scores on the Fugl-Myer arm motor scale were measured at the baseline and after treatment to determine changes in arm motor function.

All patients received 36 treatment sessions (70 minutes) in a 6- to 8-week period, which included 18 supervised and 18 unsupervised sessions. The content of therapy was carefully matched, with each group using the same exercises and standard exercise equipment.

A total of 124 participants were included in the study. Participants had a mean age of 61 years, a mean baseline Fugl-Meyer score of 43 points and were enrolled for a mean 18.7 weeks following stroke, the release explains.

Patients in the in-clinic group were adherent to 33.6 of 36 therapy sessions (93.3%), and those who received telerehabilitation at home were adherent to 35.4 of 36 therapy sessions (98.3%).

Both groups experienced significant changes in Fugl-Meyer scores from the baseline period to 30 days after treatment, with a mean change of 8.36 points in patients who received in-clinic therapy and 7.86 points in those who received telerehabilitation therapy.

The noninferiority margin was 2.47 and fell outside the 95% confidence interval, suggesting that telerehabilitation was not inferior to in-clinic therapy.

“Our study found that a 6-week course of daily home-based [telerehabilitation] is safe, is rated favorably by patients, is associated with excellent treatment adherence, and produces substantial gains in arm function that were not inferior to dose-matched interventions delivered in the clinic,” Cramer and colleagues conclude, in the release.

[Source: Healio Primary Care]

 

via Telerehab vs In-Clinic for Post-Stroke Arm Weakness: Which One Wins? – Physical Therapy Products

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[WEB SITE] ReStore™ Exo-Suit – ReWalk – More Than Walking

ReStore Soft Exo-Suit – A Revolution in Post-Stroke Gait Training
What is the ReStore?

The ReStore is a powered, lightweight soft exo-suit intended for use in the rehabilitation of persons with lower limb disability due to stroke. It will be a first of its kind gait training solution.

Functional

The ReStore soft design combines natural movements with plantarflexion and dorsiflexion assistance that adaptively synchronize with the patient’s own gait to facilitate functional gait training.

Versatile

Individualized levels of assistance and compatibility with supplemental support aids ensure that ReStore has broad applications for patients across the gait rehabilitation spectrum.

 

Data-Driven

Real time feedback and adjustable levels of assistance enable the therapist to optimize sessions and track each patient’s progress.

How Does ReStore Compare to Other Stroke Rehabilitation Methods?

Click here to contact us for more information and to discuss bringing ReStore to your clinic. Click here to download the ReStore brochure.

via ReStore™ Exo-Suit – ReWalk – More Than Walking

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[JUST ACCEPTED] “Increased Sensorimotor Cortex Activation with Decreased Motor Performance during Functional Upper Extremity Tasks Post-Stroke” – Abstract

The following article has just been accepted for publication in Journal of Neurologic Physical Therapy.

“Increased Sensorimotor Cortex Activation with Decreased Motor Performance during Functional Upper Extremity Tasks Post-Stroke”

By Shannon B Lim, MSc, MPT; Janice J Eng

Provisional Abstract:

Background: Current literature has focused on identifying neuroplastic changes associated with stroke through tasks and in positions that are not representative of functional rehabilitation. Emerging technologies such as functional near-infrared spectroscopy (fNIRS) provide new methods of expanding the area of neuroplasticity within rehabilitation.
Purpose: This study determined the differences in sensorimotor cortex activation during unrestrained reaching and gripping after stroke.
Methods: 11 healthy and 11 chronic post-stroke individuals completed reaching and gripping tasks under three conditions using their 1) stronger, 2) weaker, and 3) both arms together. Performance and sensorimotor cortex activation using fNIRS were collected. Group and arm differences were calculated using mixed ANCOVA (covariate: age). Pairwise comparisons were used for post-hoc analyses. Partial Pearson’s correlations between performance and activation were assessed for each task, group, and hemisphere.
Results: Larger sensorimotor activations in the ipsilesional hemisphere were found for the stroke compared to healthy group for reaching and gripping conditions despite poorer performance. Significant correlations were observed between gripping performance (with the weaker arm and both arms simultaneously) and sensorimotor activation for the stroke group only.
Discussion: Stroke leads to significantly larger sensorimotor activation during functional reaching and gripping despite poorer performance. This may indicate an increased sense of effort, decreased efficiency, or increased difficulty after stroke.
Conclusion: fNIRS can be used for assessing differences in brain activation during movements in functional positions after stroke. This can be a promising tool for investigating possible neuroplastic changes associated with functional rehabilitation interventions in the stroke population.

Supplemental Digital Content 1. Video abstract .mp4

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via JUST ACCEPTED: “Increased Sensorimotor Cortex Activation with Decreased Motor Performance during Functional Upper Extremity Tasks Post-Stroke”

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[NEWS] UTech research provides hope for stroke patients

Published: April 18, 2019 

Research by Professor Felix Akinladejo, recently appointed professor of computer information systems in the Faculty of Engineering and Computing, University of Technology, Jamaica, on computer model and virtual reality technology for post-stroke rehabilitation, is offering hope for stroke patients.

Akinladejo elaborated on his research focusing on the use of the techno-therapy intervention technique to aid in the rehabilitation therapy of post-acute stroke patients to improve movement and/or functional ability in his inaugural professorial lecture titled ‘Computer Model and Virtual Reality Technology for Post -Stroke Rehabilitation: A Techno-Therapy Intervention Technique’, held recently at the university’s Papine campus.

The research follows from Akinladejo’s PhD dissertation, which focused on computer-supported rehabilitation management of post-acute stroke patients.

The techno-therapy rehabilitation system consists of the computer model used to measure the gait variables and the virtual reality technology used to provide the exercise that stroke patients perform for physical therapy.

Akinladejo pointed to World Health Organization data, which showed that stroke deaths in Jamaica reached 2,474 or 14.44 per cent of total deaths in 2017.

Noting that the challenge, especially in developing countries like Jamaica, is the inability to provide and sustain physical rehabilitation therapy, Akinladejo said that his research would augment present treatment options and knowledge for professionals concerned with rehabilitation management, practitioners of physical therapy, bioengineering, and all concerned with human movement. He shared examples of his work done with post-stroke patients to manage plantar flexion and dorsiflexion movements of the ankle and foot in order to approve their range of motion.

Akinladejo is also leading UTech, Jamaica’s collaborative research with the University of Pennsylvania, USA, to investigate rehabilitation after CVDs and stroke.

The partnership has led to a programme that is currently providing third-year engineering students with training in the basic elements of robotics, with a focus on rehabilitative robotics in the Jamaican context.

NCD’S ON THE RISE

Dr Christopher Tufton, minister of health, who brought greetings, highlighted the importance of Akinladejo’s research in the context of the increase in non-communicable diseases such as diabetes and hypertension affecting large segments of the population and which may lead to stroke and the subsequent need for physical rehabilitation. The health minister urged more focus on the type of applied research being done by Akinladejo to find solutions to Jamaica’s health challenges.

“We can’t confront these challenges by confining our efforts to the practitioners directly involved in public health” the minister said, adding that “the new approach to dealing with public health has to be a lot more holistic and collaborative”.

Professor Stephen Vasciannie, president of the UTech, congratulated Akinladejo on his appointment to the rank of professor at the university, noting that over his 25 years of service to the institution, he had been promoted through the various academic ranks.

The president noted that “his promotion is testament to his body of extensive research work and his distinguished teaching career in computer science and engineering, which began in his native Nigeria”.

Professor Nilza Aples, dean, Faculty of Engineering and Computing, in her congratulations to Akinladejo, pointed out that although doctoral research work is expected to provide innovative ideas and solutions to problems, not all have the impact of improving human life or augmenting recovery in post-acute stroke patients as shown from the research work spearheaded by Akinladejo.

The dean noted that the Faculty of Engineering and Computing would continue to “position itself as a source of ‘know-how’ in the areas of engineering and computer science and as a technological provider of solutions that offer national and international impact.”

 

via UTech research provides hope for stroke patients | News | Jamaica Gleaner

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[VIDEO] Post Stroke Foot Dorsiflexion: Using Electrical Stimulation to Reduce Tone & Promote Plasticity – YouTube

Further reading on electrophysiology and muscle contractions: http://strokemed.com/motor-behaviour-…

via  Post Stroke Foot Dorsiflexion: Using Electrical Stimulation to Reduce Tone & Promote Plasticity – YouTube

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[ARTICLE] A modified standardized nine hole peg test for valid and reliable kinematic assessment of dexterity post-stroke – Full Text

Abstract

Background

Impairments in dexterity after stroke are commonly assessed by the Nine Hole Peg Test (NHPT), where the only outcome variable is the time taken to complete the test. We aimed to kinematically quantify and to compare the motor performance of the NHPT in persons post-stroke and controls (discriminant validity), to compare kinematics to clinical assessments of upper extremity function (convergent validity), and to establish the within-session reliability.

Methods

The NHPT was modified and standardized (S-NHPT) by 1) replacing the original peg container with an additional identical nine hole pegboard, 2) adding a specific order of which peg to pick, and 3) specifying to insert the peg taken from the original pegboard into the corresponding hole of the target pegboard. Eight optical cameras registered upper body kinematics of 30 persons post-stroke and 41 controls during the S-NHPT. Four sequential phases of the task were identified and analyzed for kinematic group differences. Clinical assessments were performed.

Results

The stroke group performed the S-NHPT slower (total movement time; mean diff 9.8 s, SE diff 1.4), less smoothly (number of movement units; mean diff 0.4, SE diff 0.1) and less efficiently (path ratio; mean diff 0.05, SE diff 0.02), and used increased scapular/trunk movements (acromion displacement; mean diff 15.7 mm, SE diff 3.5) than controls (P < 0.000, r ≥ 0.32), indicating discriminant validity. The stroke group also spent a significantly longer time grasping and releasing pegs relative to the transfer phases of the task compared to controls. Within the stroke group, kinematics correlated with time to complete the S-NHPT and the Fugl-Meyer Assessment (rs 0.38–0.70), suggesting convergent validity. Within-session reliability for the S-NHPT was generally high to very high for both groups (ICCs 0.71–0.94).

Conclusions

The S-NHPT shows adequate discriminant validity, convergent validity and within-session reliability. Standardization of the test facilitates kinematic analysis of movement performance, which in turn enables identification of differences in movement control between persons post-stroke and controls that may otherwise not be captured through the traditional time-based NHPT. Future research should ascertain further psychometric properties, e.g. sensitivity, of the S-NHPT.

Background

Impaired upper limb dexterity is evident as in many as 45–70% of the stroke victims one year post-stroke [12]. Such impairment is often evaluated in clinics by performance of the Nine Hole Peg Test (NHPT) [3], which is a frequently used dexterity task in many clinical populations [4567]. The NHPT equipment consists of a container with nine small pegs and a target pegboard with nine holes. Performance of the NHPT requires the pegs to be picked up from the container one-by-one unimanually and transferred and inserted into the holes of the pegboard until it is filled, upon which the pegs are returned unimanually to the container. The test is performed as quickly as possible and the only outcome variable is the total time to complete the task. Consequently, motor performance is currently not analyzed during the NHPT despite potentially providing valuable information relating to upper limb dexterity, especially among persons with a neurological dysfunction.

Among persons with stroke, the NHPT is considered reliable [8], valid [7910], and sensitive to change [71011]. Nevertheless, and despite overall good test-retest reliability post-stroke, low test-retest reliability has been found in persons post-stroke who have spasticity in the affected hand [8]. Further, the measurement errors are large; the minimal detectable change of the NHPT is estimated to 33 s for an individual post-stroke, and even doubled in the presence of spasticity [8]. The measurement properties of computer-assisted assessments of NHPT in virtual environments have been investigated with promising results [1213]. However, high intra-subject variation indicates that haptic and virtual reality technologies are more demanding for a stroke population and for instance require more practice trials prior to the actual test than when performing a conventional NHPT.

Advantages of the NHPT include the simple, cheap and easily portable equipment as well as the test being easy to administer and time-efficient [710]. There are, however, some drawbacks when testing persons post-stroke. First, the outcome score of the test is based solely on the time for task accomplishment [14]. Hence, a time reduction of the NHPT in rehabilitation of a person post-stroke may represent either a true motor recovery (i.e. performing movement patterns in a similar way as before the stroke) or compensation (performing different movement patterns than prior to the stroke) [15]. Compensatory strategies are common during upper limb tasks post-stroke, and thus plausible in a fine manipulative task like the NHPT. Secondly, the current NHPT test procedure may provide unreliable results for repeated measures or group comparisons as there is no standardized procedure with regard to the order in which the pegs are inserted into the target holes. To increase the stringency of the NHPT, we modified and standardized the test, which we henceforth refer to as the Standardized Nine Hole Peg test (S-NHPT). The experimental setup with two pegboards was in analogy with that of a study exploring three different methods of completing the NHPT, focusing on comparisons to tests in a virtual setting [12]. However, we have standardized the experimental setup even further by stipulating the order in which the pegs should be transferred.

Kinematic assessments may detect changes in movement performance that are not captured by only considering the time taken to complete the NHPT [14], and provide objective measures that may be more sensitive and not vulnerable to ceiling effects [16]. Recent research calls for parameters indicating quality of movements in persons post-stroke by means of kinematic analysis in order to better understand motor recovery [141517]. However, a test of fine upper limb fine dexterity like the NHPT has not been investigated. Our modifications and standardization enabled our first aim to kinematically characterize S-NHPT performance in a group of persons post-stroke and compare it to that of a non-disabled control group (discriminant validity). A second aim was to determine the convergent validity of the S-NHPT by comparing kinematics (movement time, peak speed, number of movement units, reach-grasp ratio, path ratio, acromion vertical displacement and trunk displacement) to the total movement time and to other clinical assessments (the Fugl-Meyer Assessment, the Stroke Impact Scale and grip strength). A third aim was to establish the within-session reliability of the S-NHPT, i.e., the consistency of the hand trajectories during the nine pick-up and transfer movements of the test.[…]

 

Continue —-> A modified standardized nine hole peg test for valid and reliable kinematic assessment of dexterity post-stroke | Journal of NeuroEngineering and Rehabilitation | Full Text

 

Fig. 1Experimental setup and movement phases. a) Marker positions used for the calculations of the kinematic variables. Markers displayed with a dot in the center of the marker were positioned on the trunk. The enlarged pegboard shows the standardized order of which peg to pick and which hole to fill, referred to as the “vertical row strategy”. The S-NHPT consists of 9 pegs (3.8 cm long, 0.64 cm wide) and two pegboards (12.7 cm × 12.7 cm) with 9 holes (0.70 cm wide) spaced 3.2 cm apart. The two pegboards were attached to a wooden panel with a distance of 18 cm between the center holes of the pegboards. The arrow indicates the direction of the movement. b) The velocity of the index finger marker in the medial direction displays the events defining the transfer phases Peg Transfer (positive curve) and Hand Return (negative curve). The manipulative phases Peg Grip and Peg In Hole are between those transfer movements (see Methods)

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[Abstract] Design a solution and a prototype for hand rehabilitation after trauma injures and post stroke

Abstract

Hand injuries are common but if left untreated, it may result in loss of function. Common causes of upper limb injuries are Post Stroke or Trauma. Trauma include falls, cuts from knives or glass as well as workplace injuries. The impairment of finger movements after injures results in a significant deficit in hands everyday performances.

Rehabilitation helps the patient to regain the hands full functionality. Hand therapy is the art that fills the gap between surgery and practical life. It helps the patient to regain the hands full functionality after a certain injury, surgery or Stroke. Hand therapy could be a very tedious process that implies physical exhaustion. Rehabilitation at home is a long process . And it should be done under therapist control. Also finding appointments with the therapist frequent enough for an efficient healing process, is difficult and costly.

Since trying new technologies is usually exciting to people, using the advancements in the field of artificial intelligence could be a solution to this. Different rehabilitation techniques have been developed, nevertheless, they require the presence of a tutor to be executed. To overcome this issue have been designed several apparatuses that allow the patient to perform the training by itself. Trying new technologies is exciting to people.

Hand exoskeleton was implemented to help the patients do their exercises at home in an engaging gamified environment. The objective is to design a portable, lightweight exoskeleton with adjustment fast assemble system. The device support fingers and excluding second injuries. It reproduce pinch exercise. Thus, an easy to use and effective device is needed to provide the right training and complete the rehabilitation techniques in the best way.

In this paper, a review of state of the art in this field is provided, along with an introduc- tion to the problems caused by a hand injuries and the consequences for the mobility of the hand. Then follows a complete review of the exoskeleton project design. The objective is to design a device that can be used at home, with a lightweight and affordable structure and a fast mounting system. For implementing all these features, many aspects have been analysed, starting from the rehabilitation requirements and the ergonomic issues. This device should be able to reproduce the training movements on an injured hand without the need for assistance by an external tutor.

The control system is based on Arduino UNO board, and the user interface is based on UNITY, the objective is to create an online media that allows the patient to exploit the capabilities of the exoskeleton, following the indication of its medic. On the other side, this interface should provide all the data related to the performances of the patient to allow a more precise therapy.

via Design a solution and a prototype for hand rehabilitation after trauma injures and post stroke | POLITesi – Politecnico di Milano

 

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[Abstract] Design of a Low-Cost Exoskeleton for Hand Tele-Rehabilitation After Stroke

Abstract

The impairment of finger movements after a stroke results in a significant deficit in hands everyday performances. To face this kind of problems different rehabilitation techniques have been developed, nevertheless, they require the presence of a therapist to be executed. To overcome this issue have been designed several apparatuses that allow the patient to perform the training by itself. Thus, an easy to use and effective device is needed to provide the right training and complete the rehabilitation techniques in the best way. In this paper, a review of state of the art in this field is provided, along with an introduction to the problems caused by a stroke and the consequences for the mobility of the hand. Then follows a complete review of the low cost home based exoskeleton project design. The objective is to design a device that can be used at home, with a lightweight and affordable structure and a fast mounting system. For implementing all these features, many aspects have been analysed, starting from the rehabilitation requirements and the ergonomic issues. This device should be able to reproduce the training movements on an injured hand without the need for assistance by an external tutor.

via Design of a Low-Cost Exoskeleton for Hand Tele-Rehabilitation After Stroke | SpringerLink

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[WEB SITE] Post-Stroke Rehabilitation – National Institute of Neurological Disorders and Stroke

Post-Stroke Rehabilitation

In the United States more than 700,000 people suffer a stroke each year, and approximately two-thirds of these individuals survive and require rehabilitation. The goals of rehabilitation are to help survivors become as independent as possible and to attain the best possible quality of life. Even though rehabilitation does not “cure” the effects of stroke in that it does not reverse brain damage, rehabilitation can substantially help people achieve the best possible long-term outcome.

What is post-stroke rehabilitation?

Rehabilitation helps stroke survivors relearn skills that are lost when part of the brain is damaged. For example, these skills can include coordinating leg movements in order to walk or carrying out the steps involved in any complex activity. Rehabilitation also teaches survivors new ways of performing tasks to circumvent or compensate for any residual disabilities. Individuals may need to learn how to bathe and dress using only one hand, or how to communicate effectively when their ability to use language has been compromised. There is a strong consensus among rehabilitation experts that the most important element in any rehabilitation program is carefully directed,well-focused, repetitive practice—the same kind of practice used by all people when they learn a new skill, such as playing the piano or pitching a baseball.

Rehabilitative therapy begins in the acute-care hospital after the person’s overall condition has been stabilized, often within 24 to 48 hours after the stroke. The first steps involve promoting independent movement because many individuals are paralyzed or seriously weakened. Patients are prompted to change positions frequently while lying in bed and to engage in passive or active range of motion exercises to strengthen their stroke-impaired limbs. (“Passive” range-of-motion exercises are those in which the therapist actively helps the patient move a limb repeatedly, whereas “active” exercises are performed by the patient with no physical assistance from the therapist.) Depending on many factors—including the extent of the initial injury—patients may progress from sitting up and being moved between the bed and a chair to standing, bearing their own weight, and walking, with or without assistance. Rehabilitation nurses and therapists help patients who are able to perform progressively more complex and demanding tasks, such as bathing, dressing, and using a toilet, and they encourage patients to begin using their stroke-impaired limbs while engaging in those tasks. Beginning to reacquire the ability to carry out these basic activities of daily living represents the first stage in a stroke survivor’s return to independence.

For some stroke survivors, rehabilitation will be an ongoing process to maintain and refine skills and could involve working with specialists for months or years after the stroke.

What disabilities can result from a stroke?

The types and degrees of disability that follow a stroke depend upon which area of the brain is damaged. Generally, stroke can cause five types of disabilities: paralysis or problems controlling movement; sensory disturbances including pain; problems using or understanding language; problems with thinking and memory; and emotional disturbances.

Paralysis or problems controlling movement (motor control)

Paralysis is one of the most common disabilities resulting from stroke. The paralysis is usually on the side of the body opposite the side of the brain damaged by stroke, and may affect the face, an arm, a leg, or the entire side of the body. This one-sided paralysis is called hemiplegia (one-sided weakness is called hemiparesis). Stroke patients with hemiparesis or hemiplegia may have difficulty with everyday activities such as walking or grasping objects. Some stroke patients have problems with swallowing, called dysphagia, due to damage to the part of the brain that controls the muscles for swallowing. Damage to a lower part of the brain, the cerebellum, can affect the body’s ability to coordinate movement, a disability called ataxia, leading to problems with body posture, walking, and balance.

Sensory disturbances including pain

Stroke patients may lose the ability to feel touch, pain, temperature, or position. Sensory deficits also may hinder the ability to recognize objects that patients are holding and can even be severe enough to cause loss of recognition of one’s own limb. Some stroke patients experience pain, numbness or odd sensations of tingling or prickling in paralyzed or weakened limbs, a symptom known as paresthesias.

The loss of urinary continence is fairly common immediately after a stroke and often results from a combination of sensory and motor deficits. Stroke survivors may lose the ability to sense the need to urinate or the ability to control bladder muscles. Some may lack enough mobility to reach a toilet in time. Loss of bowel control or constipation also may occur. Permanent incontinence after a stroke is uncommon, but even a temporary loss of bowel or bladder control can be emotionally difficult for stroke survivors.

Stroke survivors frequently have a variety of chronic pain syndromes resulting from stroke-induced damage to the nervous system (neuropathic pain). In some stroke patients, pathways for sensation in the brain are damaged, causing the transmission of false signals that result in the sensation of pain in a limb or side of the body that has the sensory deficit. The most common of these pain syndromes is called “thalamic pain syndrome” (caused by a stroke to the thalamus, which processes sensory information from the body to the brain), which can be difficult to treat even with medications. Finally, some pain that occurs after stroke is not due to nervous system damage, but rather to mechanical problems caused by the weakness from the stroke.  Patients who have a seriously weakened or paralyzed arm commonly experience moderate to severe pain that radiates outward from the shoulder. Most often, the pain results from lack of movement in a joint that has been immobilized for a prolonged period of time (such as having your arm or shoulder in a cast for weeks) and the tendons and ligaments around the joint become fixed in one position. This is commonly called a “frozen” joint; “passive” movement (the joint is gently moved or flexed by a therapist or caregiver rather than by the individual) at the joint in a paralyzed limb is essential to prevent painful “freezing” and to allow easy movement if and when voluntary motor strength returns.

Problems using or understanding language (aphasia)

At least one-fourth of all stroke survivors experience language impairments, involving the ability to speak, write, and understand spoken and written language. A stroke-induced injury to any of the brain’s language-control centers can severely impair verbal communication. The dominant centers for language are in the left side of the brain for right-handed individuals and many left-handers as well. Damage to a language center located on the dominant side of the brain, known as Broca’s area, causes expressive aphasia. People with this type of aphasia have difficulty conveying their thoughts through words or writing. They lose the ability to speak the words they are thinking and to put words together in coherent, grammatically correct sentences. In contrast, damage to a language center located in a rear portion of the brain, called Wernicke’s area, results in receptive aphasia. People with this condition have difficulty understanding spoken or written language and often have incoherent speech. Although they can form grammatically correct sentences, their utterances are often devoid of meaning. The most severe form of aphasia, global aphasia, is caused by extensive damage to several areas of the brain involved in language function. People with global aphasia lose nearly all their linguistic abilities; they cannot understand language or use it to convey thought.

Problems with thinking and memory

Stroke can cause damage to parts of the brain responsible for memory, learning, and awareness. Stroke survivors may have dramatically shortened attention spans or may experience deficits in short-term memory. Individuals also may lose their ability to make plans, comprehend meaning, learn new tasks, or engage in other complex mental activities. Two fairly common deficits resulting from stroke are anosognosia, an inability to acknowledge the reality of the physical impairments resulting from stroke, and neglect, the loss of the ability to respond to objects or sensory stimuli located on the stroke-impaired side. Stroke survivors who develop apraxia (loss of ability to carry out a learned purposeful movement) cannot plan the steps involved in a complex task and act on them in the proper sequence. Stroke survivors with apraxia also may have problems following a set of instructions. Apraxia appears to be caused by a disruption of the subtle connections that exist between thought and action.

Emotional disturbances

Many people who survive a stroke feel fear, anxiety, frustration, anger, sadness, and a sense of grief for their physical and mental losses. These feelings are a natural response to the psychological trauma of stroke. Some emotional disturbances and personality changes are caused by the physical effects of brain damage. Clinical depression, which is a sense of hopelessness that disrupts an individual’s ability to function, appears to be the emotional disorder most commonly experienced by stroke survivors. Signs of clinical depression include sleep disturbances, a radical change in eating patterns that may lead to sudden weight loss or gain, lethargy, social withdrawal, irritability, fatigue, self-loathing, and suicidal thoughts. Post-stroke depression can be treated with antidepressant medications and psychological counseling.

What medical professionals specialize in post-stroke rehabilitation?

Post-stroke rehabilitation involves physicians; rehabilitation nurses; physical, occupational, recreational, speech-language, and vocational therapists; and mental health professionals.

Physicians

Physicians have the primary responsibility for managing and coordinating the long-term care of stroke survivors, including recommending which rehabilitation programs will best address individual needs. Physicians also are responsible for caring for the stroke survivor’s general health and providing guidance aimed at preventing a second stroke, such as controlling high blood pressure or diabetes and eliminating risk factors such as cigarette smoking, excessive weight, a high-cholesterol diet, and high alcohol consumption.

Neurologists usually lead acute-care stroke teams and direct patient care during hospitalization. They sometimes participate on the long-term rehabilitation team. Other subspecialists often lead the rehabilitation stage of care, especially physiatrists, who specialize in physical medicine and rehabilitation.

Rehabilitation nurses

Nurses specializing in rehabilitation help survivors relearn how to carry out the basic activities of daily living. They also educate survivors about routine health care, such as how to follow a medication schedule, how to care for the skin, how to move out of a bed and into a wheelchair, and special needs for people with diabetes. Rehabilitation nurses also work with survivors to reduce risk factors that may lead to a second stroke, and provide training for caregivers.

Nurses are closely involved in helping stroke survivors manage personal care issues, such as bathing and controlling incontinence. Most stroke survivors regain their ability to maintain continence, often with the help of strategies learned during rehabilitation. These strategies include strengthening pelvic muscles through special exercises and following a timed voiding schedule. If problems with incontinence continue, nurses can help caregivers learn to insert and manage catheters and to take special hygienic measures to prevent other incontinence-related health problems from developing.

Physical therapists

Physical therapists specialize in treating disabilities related to motor and sensory impairments. They are trained in all aspects of anatomy and physiology related to normal function, with an emphasis on movement. They assess the stroke survivor’s strength, endurance, range of motion, gait abnormalities, and sensory deficits to design individualized rehabilitation programs aimed at regaining control over motor functions.

Physical therapists help survivors regain the use of stroke-impaired limbs, teach compensatory strategies to reduce the effect of remaining deficits, and establish ongoing exercise programs to help people retain their newly learned skills. Disabled people tend to avoid using impaired limbs, a behavior called learned non-use. However, the repetitive use of impaired limbs encourages brain plasticity and helps reduce disabilities.

Strategies used by physical therapists to encourage the use of impaired limbs include selective sensory stimulation such as tapping or stroking, active and passive range-of-motion exercises, and temporary restraint of healthy limbs while practicing motor tasks.

In general, physical therapy emphasizes practicing isolated movements, repeatedly changing from one kind of movement to another, and rehearsing complex movements that require a great deal of coordination and balance, such as walking up or down stairs or moving safely between obstacles. People too weak to bear their own weight can still practice repetitive movements during hydrotherapy (in which water provides sensory stimulation as well as weight support) or while being partially supported by a harness. A recent trend in physical therapy emphasizes the effectiveness of engaging in goal-directed activities, such as playing games, to promote coordination. Physical therapists frequently employ selective sensory stimulation to encourage use of impaired limbs and to help survivors with neglect regain awareness of stimuli on the neglected side of the body.

Occupational and recreational therapists

Like physical therapists, occupational therapists are concerned with improving motor and sensory abilities, and ensuring patient safety in the post-stroke period. They help survivors relearn skills needed for performing self-directed activities (also called occupations) such as personal grooming, preparing meals, and housecleaning. Therapists can teach some survivors how to adapt to driving and provide on-road training. They often teach people to divide a complex activity into its component parts, practice each part, and then perform the whole sequence of actions. This strategy can improve coordination and may help people with apraxia relearn how to carry out planned actions.

Occupational therapists also teach people how to develop compensatory strategies and change elements of their environment that limit activities of daily living. For example, people with the use of only one hand can substitute hook and loop fasteners (such as Velcro) for buttons on clothing. Occupational therapists also help people make changes in their homes to increase safety, remove barriers, and facilitate physical functioning, such as installing grab bars in bathrooms.

Recreational therapists help people with a variety of disabilities to develop and use their leisure time to enhance their health, independence, and quality of life.

Speech-language pathologists

Speech-language pathologists help stroke survivors with aphasia relearn how to use language or develop alternative means of communication. They also help people improve their ability to swallow, and they work with patients to develop problem-solving and social skills needed to cope with the after-effects of a stroke.

Many specialized therapeutic techniques have been developed to assist people with aphasia. Some forms of short-term therapy can improve comprehension rapidly. Intensive exercises such as repeating the therapist’s words, practicing following directions, and doing reading or writing exercises form the cornerstone of language rehabilitation. Conversational coaching and rehearsal, as well as the development of prompts or cues to help people remember specific words, are sometimes beneficial. Speech-language pathologists also help stroke survivors develop strategies for circumventing language disabilities. These strategies can include the use of symbol boards or sign language. Recent advances in computer technology have spurred the development of new types of equipment to enhance communication.

Speech-language pathologists use special types of imaging techniques to study swallowing patterns of stroke survivors and identify the exact source of their impairment. Difficulties with swallowing have many possible causes, including a delayed swallowing reflex, an inability to manipulate food with the tongue, or an inability to detect food remaining lodged in the cheeks after swallowing. When the cause has been pinpointed, speech-language pathologists work with the individual to devise strategies to overcome or minimize the deficit. Sometimes, simply changing body position and improving posture during eating can bring about improvement. The texture of foods can be modified to make swallowing easier; for example, thin liquids, which often cause choking, can be thickened. Changing eating habits by taking small bites and chewing slowly can also help alleviate dysphagia.

Vocational therapists

Approximately one-fourth of all strokes occur in people between the ages of 45 and 65. For most people in this age group, returning to work is a major concern. Vocational therapists perform many of the same functions that ordinary career counselors do. They can help people with residual disabilities identify vocational strengths and develop résumés that highlight those strengths. They also can help identify potential employers, assist in specific job searches, and provide referrals to stroke vocational rehabilitation agencies.

Most important, vocational therapists educate disabled individuals about their rights and protections as defined by the Americans with Disabilities Act of 1990. This law requires employers to make “reasonable accommodations” for disabled employees. Vocational therapists frequently act as mediators between employers and employees to negotiate the provision of reasonable accommodations in the workplace.

When can a stroke patient begin rehabilitation?

Rehabilitation should begin as soon as a stroke patient is stable, sometimes within 24 to 48 hours after a stroke. This first stage of rehabilitation can occur within an acute-care hospital; however, it is very dependent on the unique circumstances of the individual patient.

Recently, in the largest stroke rehabilitation study in the United States, researchers compared two common techniques to help stroke patients improve their walking.  Both methods—training on a body-weight supported treadmill or working on strength and balance exercises at home with a physical therapist—resulted in equal improvements in the individual’s ability to walk by the end of one year. Researchers found that functional improvements could be seen as late as one year after the stroke, which goes against the conventional wisdom that most recovery is complete by 6 months. The trial showed that 52 percent of the participants made significant improvements in walking, everyday function and quality of life, regardless of how severe their impairment was, or whether they started the training at 2 or 6 months after the stroke.

Where can a stroke patient get rehabilitation?

At the time of discharge from the hospital, the stroke patient and family coordinate with hospital social workers to locate a suitable living arrangement. Many stroke survivors return home, but some move into some type of medical facility.

Inpatient rehabilitation units

Inpatient facilities may be freestanding or part of larger hospital complexes. Patients stay in the facility, usually for 2 to 3 weeks, and engage in a coordinated, intensive program of rehabilitation. Such programs often involve at least 3 hours of active therapy a day, 5 or 6 days a week. Inpatient facilities offer a comprehensive range of medical services, including full-time physician supervision and access to the full range of therapists specializing in post-stroke rehabilitation.

Outpatient units

Outpatient facilities are often part of a larger hospital complex and provide access to physicians and the full range of therapists specializing in stroke rehabilitation. Patients typically spend several hours, often 3 days each week, at the facility taking part in coordinated therapy sessions and return home at night. Comprehensive outpatient facilities frequently offer treatment programs as intense as those of inpatient facilities, but they also can offer less demanding regimens, depending on the patient’s physical capacity.

Nursing facilities

Rehabilitative services available at nursing facilities are more variable than are those at inpatient and outpatient units. Skilled nursing facilities usually place a greater emphasis on rehabilitation, whereas traditional nursing homes emphasize residential care. In addition, fewer hours of therapy are offered compared to outpatient and inpatient rehabilitation units.

Home-based rehabilitation programs

Home rehabilitation allows for great flexibility so that patients can tailor their program of rehabilitation and follow individual schedules. Stroke survivors may participate in an intensive level of therapy several hours per week or follow a less demanding regimen. These arrangements are often best suited for people who require treatment by only one type of rehabilitation therapist. Patients dependent on Medicare coverage for their rehabilitation must meet Medicare’s “homebound” requirements to qualify for such services; at this time lack of transportation is not a valid reason for home therapy. The major disadvantage of home-based rehabilitation programs is the lack of specialized equipment. However, undergoing treatment at home gives people the advantage of practicing skills and developing compensatory strategies in the context of their own living environment. In the recent stroke rehabilitation trial, intensive balance and strength rehabilitation in the home was equivalent to treadmill training at a rehabilitation facility in improving walking.

What research is being done?

The National Institute of Neurological Disorders and Stroke (NINDS), a component of the U.S. National Institutes of Health (NIH), has primary responsibility for sponsoring research on disorders of the brain and nervous system, including the acute phase of stroke and the restoration of function after stroke.  The NIH’s Eunice Kennedy Shriver National Institute of Child Health and Human Development, through its National Center for Medical Rehabilitation Research, funds work on mechanisms of restoration and repair after stroke, as well as development of new approaches to rehabilitation and evaluation of outcomes.  Most of the NIH-funded work on diagnosis and treatment of dysphagia is through the National Institute on Deafness and Other Communication Disorders.  The National Institute of Biomedical Imaging and Bioengineering collaborates with NINDS and NICHD in developing new instrumentation for stroke treatment and rehabilitation.  The National Eye Institute funds work directed at restoration of vision and rehabilitation for individuals with impaired or low vision that may be due to vascular disease or stroke.

The NINDS supports research on ways to enhance repair and regeneration of the central nervous system. Scientists funded by the NINDS are studying how the brain responds to experience or adapts to injury by reorganizing its functions (plasticity)—using noninvasive imaging technologies to map patterns of biological activity inside the brain. Other NINDS-sponsored scientists are looking at brain reorganization after stroke and determining whether specific rehabilitative techniques, such as constraint-induced movement therapy and transcranial magnetic stimulation, can stimulate brain plasticity, thereby improving motor function and decreasing disability. Other scientists are experimenting with implantation of neural stem cells, to see if these cells may be able to replace the cells that died as a result of a stroke.

*An ischemic stroke or “brain attack” occurs when brain cells die because of inadequate blood flow. When blood flow is interrupted, brain cells are robbed of vital supplies of oxygen and nutrients. About 80 percent of strokes are caused by the blockage of an artery in the neck or brain. A hemorrhagic stroke is caused by a burst blood vessel in the brain that causes bleeding into or around the brain.

**Functions compromised when a specific region of the brain is damaged by stroke can sometimes be taken over by other parts of the brain. This ability to adapt and change is known as neuroplasticity.

NIH Publication No. 14 1846
September 2014

via NINDS | Post-Stroke Rehabilitation

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[Abstract+References] Restoring Motor Functions After Stroke: Multiple Approaches and Opportunities

More than 1.5 million people suffer a stroke in Europe per year and more than 70% of stroke survivors experience limited functional recovery of their upper limb, resulting in diminished quality of life. Therefore, interventions to address upper-limb impairment are a priority for stroke survivors and clinicians. While a significant body of evidence supports the use of conventional treatments, such as intensive motor training or constraint-induced movement therapy, the limited and heterogeneous improvements they allow are, for most patients, usually not sufficient to return to full autonomy. Various innovative neurorehabNIBSilitation strategies are emerging in order to enhance beneficial plasticity and improve motor recovery. Among them, robotic technologies, brain-computer interfaces, or noninvasive brain stimulation (NIBS) are showing encouraging results. These innovative interventions, such as NIBS, will only provide maximized effects, if the field moves away from the “one-fits all” approach toward a “patient-tailored” approach. After summarizing the most commonly used rehabilitation approaches, we will focus on  and highlight the factors that limit its widespread use in clinical settings. Subsequently, we will propose potential biomarkers that might help to stratify stroke patients in order to identify the individualized optimal therapy. We will discuss future methodological developments, which could open new avenues for poststroke rehabilitation, toward more patient-tailored precision medicine approaches and pathophysiologically motivated strategies.

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