REVIEW ARTICLE: Stroke Rehabilitation: Adapting Research Findings into Clinical Practice. Are we ready? - CLINICAL MEDICINE INFORMATICS INDIA

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:

1) Paralysis or problems controlling movement, 2) Sensory disturbances including pain, 3) Problems using or understanding language, 4) Problems with thinking and memory, 5) Emotional disturbances.

The role played by physiotherapists in stroke rehabilitation

Physical therapists specialize in treating disabilities related to motor and sensory impairments.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.

Physical therapists help stroke survivors regain the use of stroke-impaired limbs, and establish exercise programs to help people retain their newly learned skills. Disabled people tend to avoid using impaired limbs, a behaviour called learned non-use. However, the repetitive use of impaired limbs encourages brain plasticity and helps reduce disabilities. Rehabilitation teaches survivors new ways of performing tasks to circumvent for any residual disabilities. 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 guitar or learning new game.

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. Over time rehabilitation can be quite remarkable. It does take a team of professionals and the family to accomplish this. Physiotherapists take a leading role in developing appropriate policies and strategies with other exercise professionals and services to address the transition from rehabilitation to an active lifestyle following stroke.

During this recovery phase, there are many caveats which physical therapists have to address to enhance the progression of recovery. Few of these issues are as follows:

  • Paralysis or muscle weakness
  • Impaired Coordination
  • Apraxia (Patients lose their ability to plan the steps involved in a complex task and to carry the steps out in the proper sequence, having problems following a set of instructions.)
  • Impaired muscle tone
  • Loss of feeling
  • Speech and Language impairments
  • Memory & Reasoning Problems
  • Swallowing Difficulties
  • Psychological trauma (fear, anxiety, frustration, anger, sadness, and a sense of grief, clinical depression)
  • Problems with vision and visual perception

To deal with these issues, physical therapists adopt various approaches during the rehabilitation process. The approaches used currently can be broadly divided into two categories based on practical setting:

  1. Approaches used in Clinical Setting
  2. Approaches used in Research Setting

Approaches used in Clinical Setting - Early Rehabilitation

Rehabilitative therapy begins in the acute-care hospital after the patient's medical condition has been stabilized, often within 24 to 48 hours after the stroke. The first steps involve promoting independent movement because many patients 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. Patients progress from sitting up and transferring between the bed and a chair to standing, bearing their own weight, and walking, with or without assistance. Rehabilitation nurses and therapists help patients 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 functional independence.

Traditional therapeutic exercise program also consists of strengthening, mobilization, compensatory techniques, endurance training (e.g., aerobics). Traditional approaches for improving motor control and coordination: emphasize need of repetition of specific movements for learning, the importance of sensation to the control of movement, and the need to develop basic movements and postures. (Kirsteins, et al., 1999)

Approaches used in Clinical Setting - Late Rehabilitation

Bobath Approach (Neurodevelopmental Therapy)(Bobath,1990)

The Bobath approach is widely utilized in rehabilitation following stroke and other neurological conditions. It is a problem solving concept that allows for a variety of strategies flexible enough to be adapted to the strengths and impairments of the individual client rather than a prescribed treatment of exercise. Traditional Bobath approach was based on the belief that voluntary movements are built on reflexive movement and that treatment must follow the normal developmental sequence. Over the years, the Bobath approach has been modified with many changes and still today alterations continue. Current Bobath concept has accepted that neural control is not a simple hierarchial function but it is more complex where multiple body systems participate in executing movement that is organized by the specific task and constrained by physical laws and the environment. Based on this principle, NDT is redefined as a problem solving approach to the examination and treatment of the impairments and functional limitations of individuals with neuropathology, primarily children with CP and adults with stroke or traumatic brain injury (TBI).

Assumptions of NDT approach: ( these principles can come in a box with 8 font size )

Traditional 10 Principles:

  1. CP or stroke clients have impaired patterns of postural control and movement coordination
  2. These system impairments are changeable and overall function improves when the problems of motor coordination are treated by directly addressing neuromotor and postural control abnormalities in a task-specific context
  3. Sensorimotor impairments affect the whole individual
  4. Knowledge of typical adaptive motor development and how it changes across life span provides the framework for assessing functions and planning intervention
  5. NDT approach focuses on changing movement strategies as a means to achieve the best energy-efficient performance for the individual with the context of age-appropriate tasks and in anticipation of future functional tasks
  6. Movement is linked to sensory processing in two different ways: feedback and feed-forward
  7. Intervention strategies involve the individual’s active initiation and participation, combined with the therapist’s manual guidance and direct handling
  8. Intervention utilizes movement analysis to identify missing or atypical elements that link functional limitations to system impairments
  9. Ongoing evaluation occurs throughout every treatment session
  10. Aim of NDT intervention is to optimize function

Contemporary 9 Principles:

  1. NDT accepts that human motor behavior/function emerges from ongoing interactions among multiple internal systems of the individual
  2. Movement is organized around behavioral goals
  3. All individuals have competencies and strengths in various systems
  4. A hallmark of efficient human motor function is the ability of the individual to select and match various global neuronal maps with a potentially infinite number of movement combinations that are attuned to various factors
  5. NDT uses the model of enablement/disablement based on the International Classification of Function to categorize the individual’s health and disability
  6. Clinicians best designs intervention by establishing functional outcomes in partnership with the client and caregivers
  7. Intervention programs are designed to serve clients throughout their lifetime
  8. Learning or relearning motor skills and improving performance requires both practice and experience
  9. Treatment is most effective during recovery or phase of transitions

Limitation:

There is currently no evidence that Bobath intervention is more or less effective than other therapy approaches (Kollen, et al., 2009, Luke, et al., 2004; Paci, 2003). Hence, still NDT approach requires evidence for its effectiveness over other treatment approaches.

Proprioceptive (or peripheral) Neuromuscular Facilitation (PNF) (Knott & Voss, 1968)

PNF approach uses spiral and diagonal components of movement rather than the traditional movements in cardinal planes of motion with the goal of facilitating movement patterns that will have more functional relevance than the traditional technique of strengthening individual group muscles. It uses resistance with the goal of facilitating "irradiation" of impulses to other parts of the body associated with the primary movement.

Constraint Induced Movement Therapy (CIMT) (Taub, et al., 1968)

CIMT is a behavioral approach consisting of different components derived from neuro rehabilitation from basic neuroscience. The treatment for humans after neurological injury has three components:

(a) repetitive, task oriented training of the impaired extremity or function following shaping principles for several hours a day for 10 or 15 consecutive weekdays (depending on the severity of the initial deficit);

(b) constraining patients to use the impaired extremity or function during waking hours over the course of treatment, sometimes by restraining the unimpaired extremity; and 

(c) applying a package of behavioral methods designed to transfer gains made in the clinical setting to the real-world.

Limitations:

  • Practicality of individualized training
  • Need for valid outcome measures
  • Cost-effectiveness
  • Validation across clinics and research centers
  • Potential misrepresentation (magnitude of effect)

Uncertainties:

  • Persistence of effect
  • Distribution of training (intensity and dosing)
  • Best training methods (shaping or repetitive task practice)
  • Cultural factors contributing to adherence

Brunnstrom Approach (Movement Therapy) (Brunnstrom, 1970)

Brunnstrom approach is based on the concept that damaged CNS regressed to phylogenetically older patterns of movements (limb synergies and primitive reflexes); thus, synergies, primitive reflexes, and other abnormal movements are considered normal processes of recovery before normal patterns of movements are attained. Hence, based on this principle, Brunnstrom approach uses primitive synergistic patterns in training to improve motor control through central facilitation. Treatment includes facilitation of specific synergies through cutaneous/proprioceptive stimuli.

Motor Relearning Program/Carr and Shepard Approach (Carr et al., 1985)

This approach is based on cognitive motor relearning theory and influenced by Bobath’s approach. Goal is for the patient to relearn how to move functionally and how to do problem solving while attempting new tasks. In addition, this approach teaches general strategies for solving motor problems, instead of emphasizing repetitive performance of a specific movement for improving skills.

Sensorimotor Approach/Rood Approach (Noll, Bender, and Nelson, 1996)

This approach is based on modification of muscle tone and voluntary motor activity using cutaneous sensory motor stimulation. To facilitate muscle tone following cutaneous stimulation techniques are used: quick stretch, brisk icing, fast brushing, tendon tapping, vibration, and joint compression to promote contraction of proximal muscles. Similarly, to inhibit muscle tones, following cutaneous stimulation approaches are used: slow sustained stretch, prolonged icing, etc.

Newer approaches in late rehabilitation

Treadmill mediated gait training

Gait restoration is a major goal in post-stroke neurological rehabilitation. For this reason, the recovery of independent walking is important in rehabilitation studies. Recently, gait training on a treadmill with body-weight support (BWS) has received special attention. It consists of a suspension system to which a patient is connected so that weight shifting, balance, and stepping can be controlled; walking is facilitated by a treadmill. Increasing evidence has suggested that treadmill training in older subjects with hemiparesis improves locomotor capabilities during over-ground walking and motor relearning, because it provides task-oriented practice of walking and active repetitive movement training. It has been suggested that through training, functional movements of locomotor patterns, sensory inputs, and therefore central neuronal circuits, become activated. Hence, even with several studies have shown the feasibility of supported treadmill ambulation training in patients with stroke, but whether it is superior to other gait therapies is still under dispute.

Functional electrical stimulation (FES)

People with hemiparesis often display abnormal gait patterns, such as equinovarus (excessive plantar flexion and inversion)or foot drop (excessive plantar flexion), in which selective control impairments are particularly prominent in the feet. During walking, a person's big toe and outer foot margin rub against the ground, thus putting the person at risk of sustaining sprains and other ankle injuries. To minimize these patterns, electrical stimulation to correct spastic foot drop in hemiplegia was first applied by Liberson and co-workers in 1961.Functional electrical stimulation (FES), based on the concepts described by Liberson et al, uses electrical signals to activate peripheral nerves and control functional movements. This technique makes use of afferent feedback during contraction, a process that, with a patient's help, may maximize motor relearning during active repetitive movement training.

In routine clinical practice Functional electrical stimulation time (in minutes) can be adjusted according to verbal feedback from the patients during the 20-to 45-minute stimulation period The patients should be instructed to say when they felt fatigue related to dorsiflexion and eversion movements of the stimulated leg. In that situation, FES should be discontinued for 5 minutes and then activated again. As volitional control improves, the FES amplitude can be reduced.

Two main advantages of using FES combined with treadmill training.

  • The first advantage was that the patients often report a preference for walking on the treadmill with BWS combined with FES. They report that gait training was more comfortable because it was easier to place their foot during early stance.
  • The other advantage was that training with FES decreased the participation of the physical therapists. Manual assistance can be provided to help the subjects optimize gait quality during training.

    No conclusive definition of a task-oriented approach exists in the literature. In the task-oriented approach, movement emerges as an interaction between many systems in the brain and is organized around a goal and constrained by the environment (Shumway Cook & Woollacott 2001). Task-oriented training includes a wide range of interventions such as treadmill training, walking, training on the ground, bicycling programmes, endurance training and circuit training, sit-to-stand exercises, and reaching tasks for improving balance. Task oriented training needs to be repetitive and meaningful for the individual. Many interventions in  task-oriented training that have proved to be effective are usable in daily nursing  practice, such as walking on the ground, moving from sitting to standing from different chairs, and sitting and reaching. Hence, such training is task and patient focused and not therapist focused. Active use of task-oriented training in the daily nursing care of stroke survivors, will lead to improvements in functional outcomes and overall health-related quality of life.

    Robotic-Assisted Therapy (Krebs et al., 1998)

    Robotic-Assisted Therapy for stroke rehabilitation started only since 1990s. In general, robotics interfaces with computer software and hardware for improving upper extremity function. Most robots that have been developed for rehabilitation allow several modes of operation including acting as a low friction passive support to the upper extremity, providing active range of motion and/or soft guidance in a movement pattern when the individual is unable to initiate or complete a movement, and offering some resistance to the movement. Five types of robots have been tested:

  • Assisted Rehabilitation and Measurement (ARM) Guide – made for straight line trajectory reaching (Reinkensmeyer, et al. 2000)
  • Mirror Image Movement Enabler (MIME) - provides unilateral or bilateral shoulder/elbow movement (Lure, et al., 2002; Kahn, et al., 2006)
  • Bi-Manu-Track - facilitates bilateral passive and active movement of the forearm (Prange et al., 2006)
  • NeReBot - enable movement of the shoulder, elbow, and wrist (Masiero, et al., 2007)
  • MIT-Manus/InMotion2 - allows the person to perform movement without interference from the robot (although the robot can help perform the motion when the person is unable to initiate or complete the motion) (Volpe, et al., 1999; 2000)
  • Robotic-assisted therapy has the potential to facilitate improvements in motor control post stroke, but it is not clear whether this therapy improves outcomes to a greater extent than conventional therapy.

    Limitations:

    Robots are very costly (this cost might drop if robots became standard equipment in therapy clinics). There is also downtime for any repairs or modifications regarding the components and computer hardware and software, which is not uncommon for any machine that relies on sophisticated technology. Robots have difficulty adequately providing therapy for people with severe tone. Also, the reduction of physical human contact during a majority of the treatment session may be a disadvantage.

    Bilateral Movement Training (Stewart et al., 2006)

    A primary reason to perform bilateral arm training is that much of what we do every day involves the use of both arms and therefore, bilateral re-training is necessary. For example, daily living activities such as bathing, dressing, feeding, toileting, as well as, many other mobility functions such as carrying objects, getting up from bed or chairs, and in driving requires use of both arms and hand. Instrumental activities such as keyboarding, shopping and cooking also rely heavily on bilateral arm use. Hence, bilateral training has potential to improve arm function post-stroke.

    Mechanism for Bilateral Movement Training:

  • Bilateral coordinated movement, the upper extremities couple and act nearly as a single unit, reflecting inter-hemispheric coupling at the supplementary motor area (SMA), lateral premotor cortex, the premotor and sensorimotor areas that may facilitate movement in the affected extremity.
  • There is a reduction in intra-cortical inhibition with bilateral movement that may facilitate reorganization in the damaged hemisphere.

 

Limitation: Subjects trained on a motor task in a virtual environment demonstrated the ability to improve performance on the task in that environment, but the learning did not always transfer to the real-world task. Hence, these protocols should be explored more in order to ascertain the use of virtual reality training as an enhancement to traditional stroke therapy.

Non-Invasive Cortical Stimulation Approach

With the development of   non-invasive cortical stimulation techniques, it has become possible to evaluate and influence cortical activity in awake, behaving humans. Transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (TDCS) can contribute to the understanding of mechanisms of rehabilitative processes and may lead to the generation of new therapeutic strategies in neuro rehabilitation

  • This study reaffirms the benefits of early rehabilitation for functional recovery after stroke.
  • It is possible that alternative approaches in the chronic phase may prove more effective (Clarke J,et al).
  • Taking a cue from this study, researchers even in India could try to resolve some of the dilemmas associated with rehabilitation of the stroke patient.

    Planning a clinical trial of rehabilitation in stroke patients

    When conducting a clinical trial to evaluate the efficacy of techniques of rehabilitation in stroke patients, the basic principles would remain the same as for any other trial.

  • The primary question has to be well defined
  • The patient population must be defined with adequate inclusion and exclusion criteria but the criteria must NOT be overtly stringent as this may result in excluding the majority of patients and one may end up with a poor patient recruitment.
  • The methodology should be simple to implement
  • The assessment parameters should not preclude patient compliance

The recent FIT-Stroke trial could be a good prototype to learn from when planning a trial of rehabilitation in stroke patients (van de Port IG,et al).

  • Based on assumptions about the effect of intensity of practice and specificity of treatment effects, FIT-Stroke will address two key aims. The first aim is to investigate the effects of task-oriented CCT on walking competency and HRQoL compared to usual face-to-face physiotherapy. The second aim is to reveal the cost-effectiveness of task-oriented CCT in the first 6 months post stroke.

    Simple study methodology

  • The multicentre single-blinded randomized trial will include 220 stroke patients discharged to the community from inpatient rehabilitation, who are able to communicate and walk at least 10 m without physical, hands-on assistance.
  • After discharge from inpatient rehabilitation, patients in the experimental group will receive task-oriented CCT two times a week for 12 weeks at the physiotherapy department of the rehabilitation centre. Control group patients will receive usual individual, face-to-face, physiotherapy.
  • The task-oriented CCT will be applied in groups of 4 to 6 patients. Outcome will be defined in terms of gait and gait-related ADLs after stroke.
  • The trial will also investigate the generalization of treatment effects of task-oriented CCT in terms of perceived fatigue, anxiety, depression and perceived HRQoL.
  • Assessment parameters

  • Primary outcomes are the mobility part of the Stroke Impact Scale (SIS-3.0) and the EuroQol.
  • Secondary outcomes are the other domains of SIS-3.0, lower limb muscle strength, walking endurance, gait speed, balance, confidence not to fall, instrumental ADL, fatigue, anxiety, depression and HRQoL.
  • It would be of interest to read the results of such well planned clinical trials. A lot of lessons of clinical relevance emerge from such studies.

    Correlating the lessons from the research setting into clinical practice

    Rehabilitation professionals now have the benefit of evidence that motor therapy after stroke can improve motor skills. However, there is a paucity of evidence regarding the relative efficacy of different kinds of therapy.

    Discussions at this time should revolve around how to design clinical programs that allow for the provision of motor practice at a sufficient intensity to produce the most motor gains. It will be critical in the near future to investigate the questions of protocol optimization and client-to-protocol matching before rehabilitation efficiency and effectiveness can be maximized.

    A recent study published in 2009 demonstrated that music-supported rehabilitation therapy leads to marked improvements of motor function after stroke and these are accompanied by electrophysiological changes indicative of a better cortical connectivity and improved activation of the motor cortex. Results showed that music-supported therapy yielded significant improvement in fine as well as gross motor skills with respect to speed, precision, and smoothness of movements. Neurophysiological data showed a more pronounced event-related desynchronization before movement onset and a more pronounced coherence in the music-supported therapy group in the post-training assessment (Altenmüller E,et al).

    The question arises ….

  • Are we open to experiment with new techniques for improving the outcomes in our patients or will we continue to use our old classroom training today as well as tomorrow and resist change?
  • How do we adapt such findings in our clinical practice?- These questions can be answered effectively if the clinical practice is integrated with research. Hence, we all as rehabilitation clinicians need to incorporate research in our clinics so that we can test the established protocols and add evidence to the current stroke rehabilitation literature. By doing this, we will help researchers to advance stroke rehabilitation at a much faster rate.
  • Thus, at this stage, collaboration between rehabilitation clinicians and researchers is one of the most important transitions required to develop effective protocols for stroke rehabilitation.

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