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Posts Tagged stroke recovery
[ARTICLE] Diffusion Tensor Imaging Biomarkers to Predict Motor Outcomes in Stroke: A Narrative Review – Full Text
Stroke is a leading cause of disability worldwide. Motor impairments occur in most of the patients with stroke in the acute phase and contribute substantially to disability. Diffusion tensor imaging (DTI) biomarkers such as fractional anisotropy (FA) measured at an early phase after stroke have emerged as potential predictors of motor recovery. In this narrative review, we: (1) review key concepts of diffusion MRI (dMRI); (2) present an overview of state-of-art methodological aspects of data collection, analysis and reporting; and (3) critically review challenges of DTI in stroke as well as results of studies that investigated the correlation between DTI metrics within the corticospinal tract and motor outcomes at different stages after stroke. We reviewed studies published between January, 2008 and December, 2018, that reported correlations between DTI metrics collected within the first 24 h (hyperacute), 2–7 days (acute), and >7–90 days (early subacute) after stroke. Nineteen studies were included. Our review shows that there is no consensus about gold standards for DTI data collection or processing. We found great methodological differences across studies that evaluated DTI metrics within the corticospinal tract. Despite heterogeneity in stroke lesions and analysis approaches, the majority of studies reported significant correlations between DTI biomarkers and motor impairments. It remains to be determined whether DTI results could enhance the predictive value of motor disability models based on clinical and neurophysiological variables.
Stroke is the second cause of death and the third leading cause of loss of DALYs (Disability-Adjusted Life Years) worldwide. Despite substantial advances in prevention and treatment, the global burden of this condition remains massive (1). In ischemic stroke (IS; 80–85% of the cases), hypoperfusion leads to cell death and tissue loss while in hemorrhagic stroke (HS), primary injury derives from hematoma formation and secondary injury, from a cascade of events resulting in edema and cellular death (2). In IS, cytotoxic edema is a result of glucose and oxygen deprivation, leading to a failure of ion pumps in the cell membranes and consequently to collapse of osmotic regulation, when water shifts from the extracellular to the intracellular compartment (3). In HS, heme degradation products are the primary cytotoxic event and secondarily, an inflammatory process based on degradation of the hematoma takes place (4).
Diffusion MRI (dMRI) is a powerful diagnostic tool in acute IS (5) and is widely used in clinical practice (6). dMRI sequences are sensitive to water displacement. Acute infarcts appear hyperintense on diffusion-weighted imaging (DWI) reflecting the decrease in the apparent diffusion coefficient of water molecules. DWI can be acquired and interpreted over a few minutes. It provides key information for eligibility to reperfusion therapies from 6 to 24 h after onset of symptoms (DAWN study) (7) and in wake-up strokes (8). A search on MEDLINE using the terms “stroke” and “diffusion MRI” yielded 1 article in 1991 and 279, in 2018. Diffusion tensor imaging (DTI) involves more complex post-processing, mathematical modeling of the DW signal (9) and provides measures associated with white matter (WM) microstructural properties (10).
Stroke can directly injure WM tracts and also lead to Wallerian degeneration, the anterograde distal degeneration of injured axons accompanied by demyelination (11). DTI metrics have been studied as biomarkers of recovery or responsiveness to rehabilitation interventions (12–14). The bulk of DTI studies addressed specifically the corticospinal tract (CST), crucial for motor performance or recovery (12, 15), and frequently affected by stroke lesions. Paresis occurs in the majority of the subjects in the acute phase and contributes substantially to disability (16). It is thus understandable that the CST is in the spotlight of research in the field.
Two meta-analyses included from six to eight studies and reported strong correlations between DTI metrics and upper-limb motor recovery in IS and HS (17, 18). In both meta-analyses, heterogeneity between the studies was moderate. In addition, the quality of the evidence of DTI as a predictor of motor recovery was considered only moderate by a systematic review of potential biomarkers (19). The main limitations of the reviewed studies were the lack of cross-validation and evaluation of minimal clinically important differences for motor outcomes as well as the small sample sizes. Heterogeneity in DTI data collection and analysis strategies may also contribute to inconsistencies and hinder comparisons between studies.
In this narrative review, first we review the key concepts of dMRI. Second, we present an overview of state-of-art methodological practices in DTI processing. Third, we critically review challenges of DTI in stroke and results of studies that investigated the correlation between DTI metrics in the CST and motor outcomes at different stages after stroke, according to recommendations of the Stroke Recovery and Rehabilitation Roundtable taskforce (20).
Concepts of Diffusion MRI
Different MRI paradigms address WM qualitatively and quantitatively (i.e., volume, contrast as signal hyperintensities), but only dMRI allows indirect inferences about WM microstructure by providing information about the underlying organization of the tissue. In regions of little restriction of water displacement (such as the ventricles), water molecules tend to move almost freely (randomly). On the other hand, within tracts, the environment tends to be organized within sets of axons aligned in parallel orientation. Water movement usually follows a specific orientation near axons compactly organized and constrained by the myelin packing (21).
The diffusion tensor is the most commonly used mathematical modeling of the diffusion signal and can be decomposed into its eigenvalues (λ) and eigenvectors (ε), required to characterize the signal of water displacement within a voxel. Each eigenvector represents an axis of dominant diffusion with the magnitude of diffusion determined by the corresponding eigenvalues. If the diffusion is isotropic (the same along each orientation), then the eigenvalues have approximately the same magnitude (λ1 ≈ λ2 ≈ λ3), which can be depicted by a sphere. By contrast, if there is a preferential orientation of the diffusion, then the first eigenvalue is bigger than the other two, which can be visualized typically by an ellipsoid (λ1 >> λ2, λ3) (Figure 1).
Figure 1. Model of the tensor showing the eingenvalues. Diffusivities are depicted in FA representation (λll—parallel or axial diffusivity—AD, λ⊥perpendicular or radial diffusivity—RD).
Hence, the tensor calculation is typically based on a 3 × 3 symmetric matrix, in which the eigenvalues derived from each combination of directions provide different metrics. At least one b0 (non-diffusion-weighted) and 6 non-collinear directions of diffusion-weighted acquisitions are required to minimally describe water displacement with DTI (10). Generally, the more directions, the better.
The most widely used DTI metrics are: fractional anisotropy (FA), mean diffusivity (MD), radial diffusivity (RD), and axial diffusivity (AD). FA describes the degree of anisotropy (represented as an ellipsoid), a value between 0 (isotropic) and 1 (the most anisotropic). Anisotropy tends to increase in the presence of highly oriented fibers (Figure 1). The biggest value is supposed to be found in the center of the tracts. In particular, for CST analysis in stroke or other focal brain lesions, FA results can be reported as ratios between FA extracted from the ipsilesional and the contralesional hemispheres (rFA = FA ipsilesional/FA contralesional). Alternatively, asymmetry in FA can be described (aFA = (FA ipsilesional – FA contralesional)/(FA ipsilesional + FA contralesional).
MD describes the magnitude of diffusion and the biggest value is supposed to be found in the ventricles. RD represents the average diffusivity perpendicular to the first eigenvector and AD is the first eigenvalue (λ1) representing the diffusivity along the dominant diffusion direction.
Many studies have focused exclusively on FA. The proper interpretation of FA often demands knowledge about results of the other three DTI metrics (22). Changes in anisotropy may reflect several biological underpinnings, such as axonal packing density, axonal diameter, myelinization, neurite density, and orientation distribution (21, 23). FA can be decreased in conditions that injure the WM but also when multiple crossing fibers are present in the voxel. In case of partial volume effects, both FA and MD may be altered (24, 25).[…]
[Abstract] High-Intensity Interval Training After Stroke: An Opportunity to Promote Functional Recovery, Cardiovascular Health, and Neuroplasticity.
Stroke is the leading cause of adult disability. Individuals poststroke possess less than half of the cardiorespiratory fitness (CRF) as their nonstroke counterparts, leading to inactivity, deconditioning, and an increased risk of cardiovascular events. Preserving cardiovascular health is critical to lower stroke risk; however, stroke rehabilitation typically provides limited opportunity for cardiovascular exercise. Optimal cardiovascular training parameters to maximize recovery in stroke survivors also remains unknown. While stroke rehabilitation recommendations suggest the use of moderate-intensity continuous exercise (MICE) to improve CRF, neither is it routinely implemented in clinical practice, nor is the intensity always sufficient to elicit a training effect. High-intensity interval training (HIIT) has emerged as a potentially effective alternative that encompasses brief high-intensity bursts of exercise interspersed with bouts of recovery, aiming to maximize cardiovascular exercise intensity in a time-efficient manner. HIIT may provide an alternative exercise intervention and invoke more pronounced benefits poststroke.
To provide an updated review of HIIT poststroke through ( a) synthesizing current evidence; ( b) proposing preliminary considerations of HIIT parameters to optimize benefit; ( c) discussing potential mechanisms underlying changes in function, cardiovascular health, and neuroplasticity following HIIT; and ( d) discussing clinical implications and directions for future research.
Preliminary evidence from 10 studies report HIIT-associated improvements in functional, cardiovascular, and neuroplastic outcomes poststroke; however, optimal HIIT parameters remain unknown.
Larger randomized controlled trials are necessary to establish ( a) effectiveness, safety, and optimal training parameters within more heterogeneous poststroke populations; (b) potential mechanisms of HIIT-associated improvements; and ( c) adherence and psychosocial outcomes.
[ARTICLE] Device designed for fabrication of finger rehabilitation along with virtual reality – Full Text PDF
This paper presents a virtual reality-enhanced
hand rehabilitation support system with a systematic
master-slave motion assistant for independent
rehabilitation therapies. Our aim is to provide a more
interactive way of providing hope losing patients a
better way to improve themselves. The VR system will
be able to track the motion of the finger virtually in the
desktop and encourage the patient to move along with
the displaying module. Here the stiffness and the
intensity of the patient’s stroke which has impact on its
finger reusability will be understood and the facilitating
animation will be provided. All these are assisted by a set
of tests after which the patient for the particular
program is qualified and grouped accordingly.
The VR framework will have the capacity to track
the movement of the finger for all intents and purposes
in the work area and urge the patient to move alongside
the showing module.
• The VR support for this device takes it to an
egde from the remaining system.
• Interactive sessions will be provided to the
patient for easy way to provide service
• Patients will be further tested for group
formation based on the stiffness, duration after
stroke, intensity of impact or any brains
The abnormal behavior of the brain tends to make it
difficult for the patient to recover after some time, but
now such an interactive session can even encourage
them with a believe of their improvements.
The hand restoration is to some degree troublesome
in light of the fact that the hand has numerous degrees of
freedom of movement, and movement is facitated by this
gadget that could be wore in hand as it is little in
estimate (small in size).
The proposed system under development works as a
motion facilitating assistant for the patients who are in
learning process. This system has three main parts: 1)
An Virutal Reality which provides an interactive
environment 2) A rehabilitation device controller and 3]
with the help of safety supervisor who will guide with
the appropriate attributes for the rehabilitation facility
asked by the patient. […]
If someone in your family has a stroke, you may experience a significant change in your life. That person will need great care and support, and there may be a variety of emotional and behavioral changes that you’ll have to be prepared for. This can especially be the case if the stroke occurs at a young age. Not only will a stroke survivor need guidance and encouragement, but a young person recovering from a stroke will need assistance with a wide range of other tasks. According to an article published by Stroke Research and Treatment Magazine, there are many outcomes that “are attributable to the effects of stroke on age-normative roles and activities, self-image, and the young person’s stage in the life-cycle, especially family and work. ‘Hidden’ cognitive impairments, a disrupted sense of self, and the incongruity of suffering an ‘older person’s’ disease is salient.”
Astoundingly, 10% of stroke patients are under the age of 50. The rehabilitation process after a stroke is difficult at any age, and this younger demographic of stroke patients often goes unnoticed, so it’s important to pay special attention to the particular challenges that arise in these cases. With the information provided here, combined with a proactive mindset, you can better a young survivor’s recovery experience.
7 Challenges to Consider for Younger Stroke Patients
Someone who is just starting out in life — beginning a new career, embarking on a new relationship, pursuing a degree, parenthood — must deal with the pressures of finding success and, when you add in the severity of a stroke, the weight of that pressure can be insurmountable. To gain a better perspective of what they’re going though, here are a few things to consider:
1. Loss of Employment
Having a job that provides a sense of responsibility and independence is crucial for a young person trying to find their way in the world. Working gives people purpose and fulfillment, but unfortunately, when a young person experiences a stroke, they will most likely require a substantial amount of time off. In some cases, an individual may not be able to perform their job in the same way, or they may need to stop working altogether. On the bright side, studies have shown that “most of the investigations in long-term prognosis have described good functional recovery in young adults with ischemic stroke, since most patients are independent and at least 50% return to work.”
2. Financial Debt
When a stroke is experienced by someone who doesn’t have the support of a retirement fund, the financial toll can be devastating for both the individual and their family. Combine this strife with the frustration of not being able to work — not to mention that a spouse or other family members may have to stop working as well — and the task of recovery becomes even more daunting. To alleviate this issue, there are disability programs that can aid in paying for medical bills, but the approval process can be arduous, and the wait time can result in the accrual of exorbitant debt.
3. Young People Think They’re Not at Risk
One of the biggest misconceptions young people today have about strokes is that one could never happen to them. They believe that they are simply too young to have health problems that are typically associated with older people, but this is exactly why strokes are on the rise. Risk factors such as tobacco use and hypertension are prevalent among young adults and adolescents, which directly relates to a spike in ischemic strokes throughout this demographic.
In conjunction with number three, medical professionals and family members are quick to incorrectly diagnosis a stroke as something else entirely, because the individual is so young. Because of this error, a person may not receive the care they need to survive. An extreme example of this occurred when a 24-year-old named Lauren Rushen suffered a stroke, and for two weeks her doctors wrote off her symptoms as an infection and inflammation. Finally, after she collapsed on the floor of her home, she was rushed to her local hospital where yet again her attack was ruled a result of substance abuse. Luckily for Lauren, she was able to recover, but others should be aware that there is only a small window of time available for a patient to maximize their chances of rehabilitation.
5. They Have a Long Life Ahead of Them
It’s important to remember that young people who experience a stroke will have time on their side, but a lot of that time will be spent adapting to their setbacks. Arrangements for physical care, mental redevelopment, and financial needs could be necessary for an extended period, especially since the rehabilitation process can last many years (or for a lifetime).
Because many people are not eligible for Medicare until the age of 65, countless young people who experience a stroke may be left without coverage due to multiple factors. First of all, a young person may not even have had insurance prior to their stroke, and if they did, they will most likely become uninsured from not being able to work. The cycle of applying for Medicare and SSDI is difficult to endure, let alone while facing a debilitating ailment.
7. Family Life
For a stroke survivor who is older, family life is typically already structured around support for themselves. This means that an older person has raised their children and now has no immediate responsibility to care for someone else. However, for a younger person, the case is entirely different. A younger survivor may have small children to look after, or might have dreams of one day starting a family. Having a stroke as a young person means these plans are put on hold, or other family members may have to take on more responsibility at home. This can be incredibly stressful to deal with and affects everyone involved.
2 Key Ways to Be Proactive about Stroke Recovery in Young People
As a family member, caregiver, or stroke patient, you need to be ready to deal with the fact that stroke recovery is a serious, delicate, and lengthy process. Not only does it demand attention in all developmental areas, but it also comes along with a severe risk of mortality. In a journal published by the National Institute of Health, studies show that “the long-term prognosis for ischemic stroke in the young is better than in the elderly, but the risk of mortality in young adults with ischemic stroke is much higher than in the general population of the same age.” Taking charge of the situation can make a huge difference in ensuring a stroke survivor’s future, and two things in particular have proven to make the greatest improvements:
Put Stroke Survivors in a Position to Succeed and Prevent a Second Attack
After someone suffers a stroke, they will be faced with a tremendous array of challenges that may seem impossible to overcome. They may feel hopeless and unsure of where to begin their recovery, but this is where the diligence and support of others can make all the difference. If a loved one is going to have a successful recovery, they must be put into a position to succeed. This means that they will require a strong system of mental, physical, and emotional support from family and healthcare professionals, and it also means that certain precautions must be put into place to combat future complications. For example, practicing good habits like eating healthy foods, properly managing medication, engaging in physical activity, and monitoring current conditions can greatly lower the risk of a second attack, while improving a survivor’s current state of health. With over a quarter of stroke patients undergoing a second attack within their lifetime, maintaining good habits is essential and combining them with a consistent rehabilitation program is the surest way to generate positive and lasting results.
Address Rehabilitation as Soon as Possible
Instilling good health practices is always something to keep in mind, but what really makes an impact on a person’s recovery is the rehabilitation process. Rehabilitation is important, because it actively fights against the damage a stroke has caused. Stimulation of the muscles and the mind will aid the body in repairing its impaired functions, and over time, abilities that were lost have the potential to resume normal operation. With the help of rehabilitation, a process known as cortical plasticity begins to take place. Also referred to as neuroplasticity, cortical plasticity is the process the brain undergoes in order to form new neural connections, which leads to regained physicality. The sooner this development can begin, the better a patient’s odds of recovery will be, so working with a healthcare professional and setting goals is a top priority.
The 3 Biggest Things You Can Do to Help Young Stroke Survivors
You have to accept that a person is going to be different after a stroke and, no matter how old they are, they are going to face enormous challenges. The recovery process will no doubt be an uphill battle, but there are three things you can do that will drastically improve a young person’s chances of rehabilitation.
1. Keep Them Motivated
One of the issues that a survivor will face during stroke recovery is lethargy, so it’s important for you to impassion and motivate them whenever possible. A great way to do this is to combine their personal interests with their rehabilitation program. For example, if part of their routine is getting dressed in the morning, you can play a favorite song that will motivate them through the process and make it fun. Even the smallest displays of thoughtfulness can go a long way, so do whatever you can to make them feel loved and supported.
2. Help Them Counteract Learned Non-Use
A difficult thing to overcome for any stroke survivor is the process of learned non-use. After a stroke occurs, a person may not be properly able to move their limbs, and if their extremities aren’t exercised on a consistent basis, they are susceptible to atrophy, or muscle degeneration. To combat this issue, daily movements of the affected areas are highly encouraged. A specific method that has shown success in physical recovery is a form of therapy called Constraint-Induced Movement Therapy (CIMT). This technique restrains the healthy limbs while the survivor works at improving use of the damaged ones however, the survivor must meet specific criteria in order to qualify for this approach.
3. Watch Out for the Recovery Plateau Stage
A stroke survivor’s recovery will always have ups and downs, but something to be wary of is the possibility of a loved one experiencing a plateau phase during their rehabilitation. A recovery plateau refers to a period during which a stroke survivor may encounter a slowed progression in their recovery. This can happen especially if a survivor is dealing with severe physical impairments or cognitive disabilities. The most dramatic phases of recovery tend to occur during the first three to six months after a stroke, and this stage is not a given, so take heart in all the successes of that sub-acute phase to maintain enthusiasm and motivation moving forward.
We Can All Help Young Stroke Survivors Help Themselves
Regardless of a survivor’s age or degree of impairment, stroke recovery support should be offered with the utmost patience and care. Nobody can perfectly predict when a stroke will occur or how survivors and their loved ones will react, but anyone can learn how best to handle the situation, to give survivors the help they need. With the information listed above, you can become a source of encouragement for anyone who has experienced a stroke and, more importantly, you can help them regain lost abilities with dignity.
All content provided on this blog is for informational purposes only and is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. If you think you may have a medical emergency, call your doctor or 911 immediately. Reliance on any information provided by the Saebo website is solely at your own risk.
The process of stroke recovery is a long one. It takes hard work and dedication to regain full function. There are no quick-fixes that can make stroke recovery happen overnight; however, certain strategies can help you speed up the process. Curious? Below, we offer a few ways to rise above stroke-driven challenges and fasten the stroke recovery.
- Focus on a reason for stroke recovery (such as getting back to work, being able to peruse things you enjoy) and to associate it with your plan of action. This will give you motivational support at all times.
- Exercise regularly. To maintain that, set specific and meaningful goals to keep you focused. Take a sheet of paper and write down 3 or more concrete goals (and deadlines to achieve them by), the consequences of not achieving them and the desired benefit/outcome.
- Start with passive exercises to rewire the brain and fasten the recovery. This simply means using your non-affected muscles to move your affected muscles. Though you are not “doing it on your own”, you are still rewiring your brain.
- Include additional arm support during rehab exercises to avoid the arms becoming weaker due to learned non-use*.
- Consistently repeat the exercises and stretches to strengthen the brain-muscle connections. This will activate neuroplasticity to the maximum, and you will see results faster.
- Be proactive about working around fatigue, which can drain you physically and mentally. Take time to squeeze in a nap or rest as often as possible to combat the constant drowsiness and return to pre-stroke energy levels.
- To combat foot drop after stroke, use assistive equipment (such as foot drop brace) as an aid in rehabilitation. Low-impact strength and stretching leg exercises are good complement to use.
- If stroke has left you with “curled toes”, regain strength and movement with a variety of exercises. Include toe taps, floor grips, finger squeezes, and toe-extensor strengthening to make a huge difference in stroke recovery.
- Mirror therapy gives neuroplasticity a boost. Place a mirror over your paralyzed limb to ‘trick’ your brain into thinking that you’re moving your affected muscles when it’s merely just a reflection.
- Visualize your paralyzed muscles moving – again a great way to activate neuroplasticity. This works in your favor when you combine mental practice with physical practice. Spend time both visualizing your arm moving and doing passive arm exercises (to regain movement in a paralyzed arm).
- Stay stress free whenever possible. When stress begins to take hold, cortisol (a hormone) floods the body, causing pH levels to become imbalanced with acidity. This can ultimately weaken your immune system. Eating a natural probiotic like yogurt, practicing yoga and deep breathing can limit cortisol levels, sustaining your body for speedy stroke recovery.
- Depression after stroke often slows the recovery process and sometimes intervenes as a roadblock. Talk to your doctor if you are experiencing any symptoms, to get them treated with prescription antidepressants or therapy. Eat healthy food for improved mental health.
- Watch out for the recovery plateau stage. Here are 6 ways to get past Plateau after stroke.
- Understand and combat memory loss after stroke. Incorporate technology into daily rehab exercises to show quick improvements. Use smartphones to set reminders, schedule appointments, and overseeing your functional performance.
- Sleep at least 7 hours a night, and more when you need it. It will help you fasten movement recovery by turning the short-term memory from the day’s rehab exercises into long-term memory.
Stroke recovery can be a long process. Managing the ongoing need to rebuild bodily control and strength after neurological damage is no easy task. Each year nearly 800,000 people in the United States alone will suffer from a stroke, leaving them with ongoing physical and neurological damage.
If you have suffered from a stroke, loss of balance and control can make standing and walking difficult. While outpatient stroke recovery therapy is vital to improving this problem, you can also continue improving after returning home with the help of these leg exercises for stroke recovery.
Leg Exercises for Stroke Recovery
Richard Sealy, director of The Rehab Practice, a private neuro-therapy rehabilitation program in the United Kingdom, regularly works with individuals, families, and caregivers to establish custom exercise routines to aid in recovery from from long-term neurological problems, like the damage caused by stroke. While he acknowledges that each patient should have a custom exercise routine specific and personal to their struggles, he recommends a series of exercises to help strengthen the legs and improve range of motion during stroke recovery.
Sealy understands the importance of fast progress after a stroke, and including ongoing at-home exercises can improve health and well-being. These low-impact strength and stretching leg exercises for stroke recovery are a good complement to use in conjunction with the Saebo MyoTrac Infiniti biofeedback system.
As with any exercise program, please consult your healthcare provider before you begin. If you notice increased pain, discomfort, or other troubling systems, stop these exercises immediately and talk to your doctor.
Exercise #1 – Standing and Balance
Balance and coordination are often lost after a stroke. This can make simple actions, like standing and walking,
difficult. In addition, weakness can occur around the muscles on the exterior of the hip area.
Exercises for standing and balance are vital to helping you regain your quality of life after a stroke. When performing these exercises, always hold onto a table or similar stable surface to avoid a fall.
Basic Level Standing and Balance Exercise
Hold on to a stable surface, standing straight and tall while you transfer your weight to one side. Swing the other leg to the side. Use your balance to hold this position for 10 seconds. Slowly lower your leg back down. Repeat a few times, as long as you have the strength, and then switch legs.
Intermediate Standing and Balance Exercises
Once you have mastered the first exercise, move on to the intermediate level. Again, hold on to a stable surface, keeping your back tall and straight. Transfer your weight to one leg, and bring the other leg up in front of you, bending the knee. Hold this position for a count of 10, and slowly lower it back down. Repeat, then switch legs.
Advanced Standing and Balance Exercises
Finally, progress to the advanced level. This time, stand straight and tall and transfer your weight to one leg. Swing the other leg out behind you as far as you can. Hold for 10 seconds, if you can, and lower it back down slowly. Repeat and switch legs.
This progression of exercises will strengthen the hip muscle and improve balance, so you can regain normal use of your legs. This exercise series pairs well with the Saebo MayoTrac Infiniti biofeedback triggered stimulation system.
Exercise #2 – Bridging
Often after a stroke, the hips and the core muscle groups, which are crucial to standing and walking, become weak. Bridging exercises help to strengthen these core muscles. Like the standing and balance exercises, bridging exercises move through a progression to help rebuild your strength and coordination.
Basic Bridging Exercise
The basic bridging exercise, called “Inner Range Quad Movement”, builds strength in the thigh muscles. To perform this exercise, lay down and place a pillow or rolled towel under the knee joint. Then, press the back of the knee into the pillow or rolled towel to lift your heel off the floor.
Intermediate Bridging Exercise
“Ski Squats” take bridging exercises to the next level. For this exercise, lean against a flat wall, placing your feet in front of you. Using the wall to support your weight and your back, slowly bend your knees to lower yourself down. Hold this position for 10 seconds, if you can. Slide back up, supporting your weight on the wall, until you are in a standing position.
Advanced Bridging Exercise
To take bridging exercises to the advanced level, repeat the “Ski Squat”, but place a gym ball between yourself and the wall when you bend your knees into the squat position.
Exercise #3 – Clams
If the lower legs are affected after a stroke, Clams can provide strengthening and improved range of motion. Clams focuses on building strength and coordination in the lower leg, increasing range of motion and control.
Basic Clams Exercise – In Sitting
Before starting Clams, you must stretch the calf muscle and build coordination in the lower body. In Sitting helps with this. In a sitting position, create a stirrup around one foot using a towel or belt, placing the stirrup around the ball of the foot. Gently pull the stirrup up towards your body to stretch the calf muscle. Then, pull it with the outer hand to turn the foot out, continuing to stretch the muscle.
Intermediate Clams Exercise
Once you have build some flexibility, you are ready for the Clams exercise. Lay down on your side, and bend your knees, resting one on top of the other. Then, while you keep your feet together, lift the upper knee away from the other knee, holding them apart for a count of 10 seconds. Slowly lower your knee back down. While performing this exercise, make sure that you do not roll your hips back.
Advanced Clams Exercise
After mastering Clams, take it to the next level by lifting the knee and the foot of the upper leg. Again, hold the position for a count of 10 seconds. Lower it back down. Repeat a few times to build strength and range of motion.
Rebuild Strength and Coordination with Stroke Recovery Exercises
Strokes can occur in people of any age, although nearly 75% of all strokes occur after the age of 65, and an individual’s risk doubles after 55. Each year, approximately 600,000 people suffer from their first stroke, and an additional 185,000 have a recurrent stroke.
If you have suffered one or more strokes, it can be easy to feel discouraged at the lack of mobility and control you experience. Stroke exercises, like these, can help you regain that control and build up your strength again, so you can recover from the neurological damage of a stroke.
For extra support in advancing your recovery after a stroke, check out the many advanced products from Saebo to help you every step of the way.
[ARTICLE] Shaping neuroplasticity by using powered exoskeletons in patients with stroke: a randomized clinical trial – Full Text
The use of neurorobotic devices may improve gait recovery by entraining specific brain plasticity mechanisms, which may be a key issue for successful rehabilitation using such approach. We assessed whether the wearable exoskeleton, Ekso™, could get higher gait performance than conventional overground gait training (OGT) in patients with hemiparesis due to stroke in a chronic phase, and foster the recovery of specific brain plasticity mechanisms.
We enrolled forty patients in a prospective, pre-post, randomized clinical study. Twenty patients underwent Ekso™ gait training (EGT) (45-min/session, five times/week), in addition to overground gait therapy, whilst 20 patients practiced an OGT of the same duration. All individuals were evaluated about gait performance (10 m walking test), gait cycle, muscle activation pattern (by recording surface electromyography from lower limb muscles), frontoparietal effective connectivity (FPEC) by using EEG, cortico-spinal excitability (CSE), and sensory-motor integration (SMI) from both primary motor areas by using Transcranial Magnetic Stimulation paradigm before and after the gait training.
A significant effect size was found in the EGT-induced improvement in the 10 m walking test (d = 0.9, p < 0.001), CSE in the affected side (d = 0.7, p = 0.001), SMI in the affected side (d = 0.5, p = 0.03), overall gait quality (d = 0.8, p = 0.001), hip and knee muscle activation (d = 0.8, p = 0.001), and FPEC (d = 0.8, p = 0.001). The strengthening of FPEC (r = 0.601, p < 0.001), the increase of SMI in the affected side (r = 0.554, p < 0.001), and the decrease of SMI in the unaffected side (r = − 0.540, p < 0.001) were the most important factors correlated with the clinical improvement.
Ekso™ gait training seems promising in gait rehabilitation for post-stroke patients, besides OGT. Our study proposes a putative neurophysiological basis supporting Ekso™ after-effects. This knowledge may be useful to plan highly patient-tailored gait rehabilitation protocols.
Most of the patients with stroke experience a restriction of their mobility. Gait impairment after stroke mainly depends on deficits in functional ambulation capacity, balance, walking velocity, cadence, stride length, and muscle activation pattern, resulting in a longer gait cycle duration and lower than normal stance/swing ratio in the affected side, paralleled by a shorter gait cycle duration and a higher than normal stance/swing ratio in the unaffected side .
Conventional gait training often offers non-completely satisfactory results. Specifically, patients with stroke receiving intensive gait training with or without body weight support (BWS) may not improve in walking ability more than those who are not receiving the same treatment (with the exception of walking speed and endurance) [2, 3, 4, 5]. Moreover, only patients with stroke who are able to walk benefit most from such an intervention [2, 3, 4, 5]. Therefore, there is growing effort to increase the efficacy of gait rehabilitation for stroke patients by using advanced technical devices. Neurorobotic devices, including robotic-assisted gait training (RAGT) with BWS, result in a more likely achievement of independent walking when coupled with overground gait training (OGT) in patients with stroke. Specifically, RAGT combined with OGT has an additional beneficial effect on functional ambulation outcomes, although depending on the duration and intensity of RAGT [6, 7]. Further, RAGT requires a more active subject participation in gait training as compared to the traditional OGT, which is a vital feature of gait rehabilitation [7, 8].
Even though no substantial differences have been reported among the different types of RAGT devices , a main problem with neurorobotic devices is the provision for the patient of a real-world setting ambulation [10, 11]. To this end, wearable powered exoskeletons, e.g., the Ekso™ (Ekso™ Bionics, Richmond, CA, USA), have been designed to improve OGT in neurologic patients.
Notwithstanding, the efficacy of wearable powered exoskeletons in improving functional ambulation capacity (including gait pattern, step length, walking speed and endurance, balance and coordination) has not been definitively proven, and any further benefit in terms of gait performance remains to be confirmed. However, a recent study showed that Ekso™ could improve functional ambulation capacity in patients with sub-acute and chronic stroke . Therefore, a first aim of our study was to assess whether Ekso™ is useful in improving functional ambulation capacity and gait performance in chronic post-stroke patients compared to conventional OGT.
The neurophysiologic mechanisms harnessed by powered exoskeletons to favor the recovery of functional ambulation capacity are still unclear. It is argued that the efficacy of neurorobotics in improving functional ambulation capacity depends on the high frequency and intensity of repetition of task-oriented movements . This could guarantee a potentially stronger entrainment of the neuroplasticity mechanisms related to motor learning and function recovery following brain injury, including sensorimotor plasticity, frontoparietal effective connectivity (FPEC), and transcallosal inhibition, as compared to conventional therapy [14, 15, 16]. Moreover, the generation and strengthening of new connections supporting the learned behaviors, and the steady recruitment of these neural connections as preferential to the learned behaviors occur through these mechanisms, thus making the re-learned abilities long lasting [13, 14, 17, 18, 19, 20, 21, 22, 23].
Such neurophysiologic mechanisms have been tested in neurorobotic rehabilitation using stationary exoskeletons (e.g. Lokomat™) [13, 14]. Therefore, the second aim of our study was to assess whether there are specific neurophysiological mechanisms (among those related to sensorimotor plasticity, FPEC, and transcallosal inhibition) by which Ekso™ improves functional ambulation capacity in the chronic post-stroke phase. The importance of knowing these mechanisms is remarkable in order to implement patient-tailored rehabilitative training, given that any further advance in motor function recovery mainly relies on motor rehabilitation training, whereas spontaneous motor recovery occurs within 6 months of a stroke . This is also the reason why we focused our study on patients with chronic stroke.[…}
[Abstract+References] Non-invasive Cerebellar Stimulation: a Promising Approach for Stroke Recovery?
Non-invasive brain stimulation (NIBS) combined with behavioral training is a promising strategy to augment recovery after stroke. Current research efforts have been mainly focusing on primary motor cortex (M1) stimulation. However, the translation from proof-of-principle to clinical applications is not yet satisfactory. Possible reasons are the heterogeneous properties of stroke, generalization of the stimulation protocols, and hence the lack of patient stratification. One strategy to overcome these limitations could be the evaluation of alternative stimulation targets, like the cerebellum. In this regard, first studies provided evidence that non-invasive cerebellar stimulation can modulate cerebellar processing and linked behavior in healthy subjects. The cerebellum provides unique plasticity mechanisms and has vast connections to interact with neocortical areas. Moreover, the cerebellum could serve as a non-lesioned entry to the motor or cognitive system in supratentorial stroke. In the current article, we review mechanisms of plasticity in the cortico-cerebellar system after stroke, methods for non-invasive cerebellar stimulation, and possible target symptoms in stroke, like fine motor deficits, gait disturbance, or cognitive impairments, and discuss strategies for multi-focal stimulation.
[ARTICLE] Functional Electrical Stimulation with Augmented Feedback Training Improves Gait and Functional Performance in Individuals with Chronic Stroke: A Randomized Controlled Trial – Full Text
Continue —> Functional Electrical Stimulation with Augmented Feedback Training Improves Gait and Functional Performance in Individuals with Chronic Stroke: A Randomized Controlled Trial (PDF Download Available)
Life after a stroke can be challenging. Many patients wonder if they will ever fully recover their muscle coordination, or how long or difficult the process of recovery may be. Fortunately, the field of occupational and physical therapy has come a long way in developing approaches that help patients regain controlled muscle movements after a stroke.
There are seven recognized stages of stroke recovery through which most patients progress. Also known as the Brunnstrom Approach, the seven stages framework views spastic and involuntary muscle movement as part of the process and uses them to aid in rehabilitation.
What Is The Brunnstrom Approach?
The Brunnstrom Approach was developed in the 1960’s by Signe Brunnstrom, an occupational and physical therapist from Sweden. With seven stages, the Brunnstrom Approach breaks down how motor control can be restored throughout the body after suffering a stroke.
Normally, muscle movements are the result of different muscle groups working together. Researchers have termed this collaboration between muscles as “synergies”. The brain has the delicate task of coordinating these movements, many of which become severely affected after a stroke.
After the stroke has occurred, your muscles become weak due to the lack of coordination between the brain and body. This causes the muscle synergies to move in abnormal patterns. Most treatments offered to stroke patients will focus on trying to inhibit atypical muscle synergies and movements. The Brunnstrom Approach, on the other hand, teaches patients how to use the abnormal synergy patterns to their advantage.
This approach has become a popular choice among both occupational and physical therapists as well as patients since its inception. It can be effective in clinical settings and can dramatically improve voluntary muscle movements after suffering a stroke.
Stage 1: Flaccidity
The first stage in Brunnstrom’s Approach is the initial period of shock immediately after stroke where flaccid paralysis sets in. Flaccid paralysis (flaccidity) is the medical term for a complete lack of voluntary movement. This paralysis is caused by nerve damage that prevents the muscles from receiving appropriate signals from the brain, whether or not the brain is still capable of moving those muscles.
In the early state of flaccid paralysis, the stroke survivor cannot initiate any muscle movements on the affected side of their body. If this continues for long enough without intervention or physical therapy, the unused muscles become much weaker, and begin to atrophy. Simply put, muscles need to be used in order to retain their tone and definition, and flaccid paralysis prevents muscles from doing this important work.
The medical term for this loss of muscle tone is hyptonia. Hyptonia causes weakness and sometimes numbness that seriously interferes with a patient’s quality of life. In addition to therapy exercises and treatments that reduce the severity of hypotonia, this Stage 1 condition also requires lifestyle modifications to protect the affected limbs from injury.
Though stroke does serious neurological damage, other healthy brain cells and muscles can help make up for some of this damage. In fact, the patient’s own body is full of tools that reduce complications and increase their likelihood of entering new stages of recovery. It’s never too early to start retraining the body and brain after stroke, even if patients are still experiencing flaccid paralysis and hypotonia.
Stage 2: Dealing with the Appearance of Spasticity
The second stage in stroke recovery marks the redevelopment of some basic limb synergies as certain muscles are stimulated or activated and other muscles in the same system begin to respond. Muscles begin to make small, spastic, and abnormal movements during this stage. While these movements are mostly involuntary, they can be a promising sign during your recovery. Minimal voluntary movements might or might not be present in stage two.
Muscle synergies result from muscles coordinating movements to perform different tasks. These synergies allow common patterns of movement that involve either cooperative or reciprocal activation of muscle. Because the muscles are linked, one activated muscle may lead to partial or complete responses in other muscles. These synergies may limit patient’s muscles to certain movements, preventing them from completing the voluntary movements they want to make. However, as neurological development and cell regrowth occurs after a stroke, some new connections may be formed to impaired muscle tissue.
Two limb synergies determine a patient’s reactions to cell regrowth during Stage 2 of recovery. The first, the flexor synergy, includes the external rotation of the shoulder, flexion of the elbow, and supination of the forearm. The second, the extensor synergy, includes internal rotation of the shoulder with elbow extension and pronation of the forearm. These synergies may produce one or both of the following postures, which indicate varying levels of brain trauma after stroke.
Coupled with the presence of muscle synergies, between 30 and 40 percent of stroke survivors also experience spasticity. This is a velocity-dependent increase in your normal stretch reflexes, and during Stage 2, it presents as aresistance to passive movement. Stage 2 spasticity contributes to the jerky upper body movements characteristic of the flexor and extensor synergies.
Unused limbs still need stimulation to maintain or form connections to neurons. Though the nerves and connections that originally controlled your affected limbs may be damaged too much to create voluntary movements, it could still be possible to regain movement in later stages of recovery. In order to leave this possibility open and prevent the body’s tendency toward learned non-use, it’s important to continue using and moving your affected limbs and muscles as much as possible.
Stage 3: Increased Spasticity
Spasticity in muscles increase during stage three of stroke recovery, reaching its peak. Spasticity is a feeling of unusually stiff, tight, or pulled muscles. It is caused by damage from a stroke to nerve pathways within the brain or spinal cord that control muscle movement. The lack of ability to restrict the brain’s motor neurons causes muscles to contract too often. Spasticity causes an abnormal increase in muscle stiffness and tone that can interfere with movement, speech, or cause discomfort and pain.
During stage 3, synergy patterns also start to emerge and minimal voluntary movements should be expected. The increase in voluntary movement is due to being able to initiate movement in the muscle, but not control it (yet). The appearance of synergy patterns and coordination between muscles facilitate the voluntary movements which become stronger with occupational and physical therapy.
Muscles with severe spasticity, like the ones in stage 3 of stroke recovery, are likely to be more limited in their ability to exercise and may require help to do this. Patients and family/caregivers should be educated about the importance of maintaining range of motion and doing daily exercises. It is important to minimize highly stressful activities this early in training.
Passive exercises, also known as passive range-of-motion (PROM) exercises, should be continued during this stage to improve your range of motion. Treatment includes how far the therapist can move your joints in different directions, like raising your hand over your head or bending your knee toward your chest.
Stage 4: Decreased Spasticity
During stage four of stroke recovery, spastic muscle movement begins to decline. Patients will regain control mostly in the extremities, and they will have a limited ability to move normally. The movements may still be out of sync with muscle synergies, but this will improve quickly over the length of this stage.
The focus during this stage is to strengthen and improve muscle control. Now that you are regaining motor control and can start to make normal, controlled movements on a limited basis, you can start to build strength back in your limbs and continue work on your range of motion. Continuing to stretch out your muscles is still important in this stage.
Therapists use active-assisted range of motion (AAROM) exercises when a stroke patient has some ability to move but still needs help to practice the exercises or complete the movement. A therapist may help guide the movement with their own body (hold the limb, for example) or use bands and other exercise equipment to support the patient. Gravity-assisted devices such as the SaeboMAS, are beneficial in helping the patient perform the movements.
You can begin active range-of-motion (AROM) exercises once you have regained some muscle control and can perform some exercises without assistance. They often involve moving a limb along its full range of motion, like bending an elbow or rotating a wrist. AROM exercises increase flexibility, muscle strength, and endurance. Range-of-motion exercises should be practiced equally on both the affected and unaffected sides of the body.
Of course, when it comes to building a stage 4 stroke recovery exercise program, you should always consult with a professional physical or occupational therapist. They can help you with exercise specifics, finding the right tools and equipment, and, of course, to provide assistance, especially in the beginning.
Stage 5: Complex Movement Combinations
In stage 5, spasticity continues to decline and synergy patterns within the muscles also become more coordinated, allowing voluntary movements to become more complex. Abnormal movements also start to decline dramatically during stage 5, but some may still be present.
The patient will be able to make more controlled and deliberate movements in the limbs that have been affected by the stroke. Isolated joint movements might also be possible.
All voluntary movements involve the brain, which sends out the motor impulses that control movement. These motor signals are initiated by thought and must also involve a response to sensory stimuli. The sensory stimuli that trigger voluntary responses are dealt with in many parts of the brain.
Voluntary movements are purposeful and goal directed. They are learned movements that improve with repetition or practice and require less attention. Some examples include combing hair, swinging a bat, driving a car, swimming, and using eating utensils.
Stage 6: Spasticity Disappears
At stage six, spasticity in muscle movement disappears completely. You are able to move individual joints, and synergy patterns become much more coordinated. Motor control is almost fully restored, and you can coordinate complex reaching movements in the affected extremities. Abnormal or spastic movements have ceased, and a full recovery may be on the horizon.
Stage 7: Normal Function Returns
The last stage in Brunnstrom’s Approach is when you regain full function in the areas affected by the stroke. You are now able to move your arms, legs, hands, and feet in a controlled and voluntary manner.
Since you have full control over your muscle movements, synergy patterns have also returned to normal. Reaching stage seven is the ultimate goal for therapists and patients alike.
Stroke Recovery In 7 Stages: Spasticity As A Process
With the seven stages of recovery, Brunnstrom effectively changed the way stroke recovery is approached by occupational and physical therapists. She theorized that spastic and primitive muscle movements were a natural part of the recovery process after a stroke. Moreover, she developed an approach that allows patients to use these involuntary movements to their advantage instead of trying to inhibit them.
During each phase, an increasing amount of synergies are available to use. Using the Brunnstrom Approach, occupational and physical therapists will teach you how to use the synergies that are currently available to you. These techniques are used to improve movement and regain motor control.
There is no one approach to stroke recovery, and the stages laid out in these guides may not apply to everyone. Since the Brunnstrom Approach can be effective, however, therapists still use this method to help patients recover after suffering a stroke. Thanks to new medical technology, therapists can use the Brunnstrom Approach in conjunction with tools like the SaeboGlove, SaeboReach, and SaeboMAS to help patients reach new levels of independence.