Stroke Rehabilitation

Stroke is a leading cause of disability worldwide with more than seven million stroke survivors in the United States alone [4].There is a growing demand for skilled rehabilitation, and advances in research and clinical practice are of critical importance to promote the best possible clinical gains.This post will review a handful of the most promising elements and intervention techniques according to current research in neurological rehabilitation.

The Last Year of Research in Retrospect: New Advances in Science

Lets review some of the most promising research and clinical discoveries from 2017

• One study found that repetitive task-oriented training independent of time since onset of stroke, intervention type, and amount of practice time was an effective intervention [5].

• Another study set to identify intrinsic factors for predicting motor outcomes in the upper extremity. Functional integrity of the cortical spinal tract and the quantity of met alleles of the brain-derived neurotrophic factor (BDNF) gene, a gene that has been associated with neural plasticity and growth [8], were found to be predictors of motor outcomes in the upper extremity three months following stroke [9].

• The DAWN study found that there may be benefits to mechanical removal of a clot for a longer period of time following stroke onset [6]. The American Stroke Association has released new guidelines on the treatment of acute ischemic stroke this year based on the results of 400 research studies.These guidelines will increase the window for clot removal from the former 6 hr window to a 24 hr. window. Increasing this time window means that more people will be able to receive a clot-dissolving medication called Alteplase [7].

Where is Current Research Heading?

This year the National Institute of Health (NIH) identified some specific issues to concentrate on in stroke rehabilitation research. Some of these issues include Variability of healthcare delivery in acute stroke rehabilitation, Payer versus clinical needs in care delivery, the development of new study recruitment strategies, and social and personal factors affecting stroke recovery outcomes [4]. NIH also identifies value in the discovery of new stroke recovery biomarkers [4]. 

Think of incorporating some of these evidence-based interventions 

Robert Teasell, MD was awarded 2018's National Stroke Association Award For Excellence in Post-Acute Stroke. The following are a handful of UE interventions supported by Strong (level 1A) evidence in his review. To review more interventions see Teasell's EBSR

Repetitive Task oriented training... Great news! task oriented and client-centered training has been a core value in OT since the start of the profession. There is strong (level 1 A) evidence to support that this intervention technique may be superior to conventional techniques[1]. Task and context oriented training can support functional recovery [3].

Strength Training ... Strength training may increase fine motor grip strength in the upper extremities [1]. Keep on with grasp and fine motor strengthening, bring on the free weights.

Mirror Therapy and mental practice ... Mirror mirror on the wall, one of the best stroke interventions of them all? These techniques may be effective in improving motor function in the upper extremity. Mirror therapy may also be beneficial in treating spasticity [1]. 

Vibration Therapy ...Try adding vibration feedback into sensory stimulation training. New evidence suggests that whole body vibration therapy may improve upper extremity motor function [1]. 

Constraint Induced Movement Therapy (CIMT) ... Although the most effective dosing and intensity is unclear, current research supports the use of CIMT techniques for improving UE function in chronic stroke populations [1]. For more evidence supporting CIMT see the EXCITE trial.

Sensorimotor Training ... There is conflicting evidence that sensorimotor training can increase motor gains in the upper extremity in comparison to other traditional UE interventions [1]. More research needs to be done to compare sensorimotor re-training techniques to other promising UE motor training interventions. There is however, level 1A evidence that transcutaneous electrical nerve stimulation (TENS) may increase motor function in the upper extremity[1].

What about Technology?

More clinical studies are exploring technologies including robotics, functional electrical stimulation (FES), virtual reality, electromyography feedback (EMG), and even brain stimulation in combination with conventional therapy practices. New clinical research in the area of rehabilitation robotics continues to grow at a rapid pace [11]. A meta-analysis in 2012 found that robotic therapy in addition to conventional therapy techniques facilitated better motor outcomes in the affected upper extremity [12]. A study on FES found that patients participating in 120 minutes of FES and combined task-specific practice demonstrated improvement in UE Fugl-Meyer scores [15].

These technologies continue to become more advanced and studied in recent years. As more study characteristics suggesting improved clinical outcomes appear such as earlier treatment, and increased intensity and dosing (see Kleim, 2008; EXCITE trial; Krakauer, 2012), a new focus becomes apparent; future studies need to further define these characteristics to shape optimal treatment protocols for motor recovery following stroke.

Which interventions do you prefer to use in clinical practice? Stay tuned for the latest information on rehabilitation technology.

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Post by Holly Mitchell, MOT, OTR/L

Check out the References and Resources below

Teasell, R. (2018). Evidence-Based Review of Stroke Rehabilitation 18th edition. Retrieved from http://www.ebrsr.com/

Teasell, R. (2015). Evidence-Based Review of Stroke Rehabilitation 17th edition. Retrieved from http://www.ebrsr.com/sites/default/files/documents/executive-summary-srebr_final_16ed.pdf

Brewer, L., Horgan, F., Hickey, A., & Williams, D. (2012). Stroke rehabilitation: Recent advances and future therapies. Qjm,106(1), 11-25. doi:10.1093/qjmed/hcs174

Cramer, S. C., Wolf, S. L., Adams, H. P., Chen, D., Dromerick, A. W., Dunning, K., … Broderick, J. P. (2017). Stroke Recovery & Rehabilitation Research: Issues, Opportunities, and the NIH StrokeNet. Stroke, 48(3), 813–819. http://doi.org/10.1161/STROKEAHA.116.015501

Bernhardt, J., Zorowitz, R., Becker, K., Keller, E., Saposnik, G., Strbian, D., Dichgans, M., Woo, D., Reeves, M., Thrift, A., Kidwell, C., Olivot, J., Goyal, M., Pierot, L., Bennett, D., Howard, G., Ford, G., Goldstein, L., Planas, A., Yenari, M., Greenberg, S., Pantoni, L., Amin-Hanjani, S. and Tymianski, M. (2018). Advances in Stroke 2017.

Alberts, M. J., Ollenschleger, M. D., & Nouh, A. (2018). DAWN of a New Era for Stroke Treatment: Implications of the DAWN Study for Acute Stroke Care and Stroke Systems of Care. Circulation. doi:10.1161/circulationaha.118.033579

Top heart disease and stroke research advances of 2017. Retrieved from https://newsroom.heart.org/news/top-heart-disease-and-stroke-research-advances-of-2017

Domschke, K., Lawford, B., Laje, G., Berger, K., Young, R., Morris, P., . . . Baune, B. T. (2009). Brain-derived neurotrophic factor ( BDNF) gene: No major impact on antidepressant treatment response. The International Journal of Neuropsychopharmacology,13(01), 93. doi:10.1017/s1461145709000030

Chang, W. H., Park, E., Lee, J., Lee, A., & Kim, Y. (2017). Association Between Brain-Derived Neurotrophic Factor Genotype and Upper Extremity Motor Outcome After Stroke. Stroke,48(6), 1457-1462. doi:10.1161/strokeaha.116.015264

Wolf et al., (2006). The EXCITE Trial: Predicting a Clinically Meaningful Motor Activity Log Outcome. Neurorehabilitation and Neural Repair 22(5), 486 - 493.

Chang, W. H., & Kim, Y. (2013). Robot-assisted Therapy in Stroke Rehabilitation. Journal of Stroke,15(3), 174. doi:10.5853/jos.2013.15.3.174

Norouzi-Gheidari, N., Archambault, P. S., & Fung, J. (2012). Effects of robot-assisted therapy on stroke rehabilitation in upper limbs: Systematic review and meta-analysis of the literature. The Journal of Rehabilitation Research and Development,49(4), 479. doi:10.1682/jrrd.2010.10.0210

Kleim (2008). Principles of Experience-Dependent Neural Plasticity: Implications for Rehabilitation After Brain Damage

Krakauer (2012). Getting Rehabiliation Right: What Can We Learn from Animal Models.

Page, S. J., Levin, L., Hermann, V., Dunning, K., & Levine, P. (2012). Longer Versus Shorter Daily Durations of Electrical Stimulation During Task-Specific Practice in Moderately Impaired Stroke. Archives of Physical Medicine and Rehabilitation,93(2), 200-206. doi:10.1016/j.apmr.2011.09.016