Movement therapy induced neural reorganization and motor recovery in stroke: a review

This paper is a review conducted to provide an overview of accumulated evidence on contemporary rehabilitation methods for stroke survivors. Loss of functional movement is a common consequence of stroke for which a wide range of interventions has been developed. Traditional therapeutic approaches have shown limited results for motor deficits as well as lack evidence for their effectiveness. Stroke rehabilitation is now based on the evidence of neuroplasticity, which is responsible for recovery following stroke. The neuroplastic changes in the structure and function of relevant brain areas are induced primarily by specific rehabilitation methods. The therapeutic method which induces neuroplastic changes, leads to greater motor and functional recovery than traditional methods. Further, the recovery is permanent in nature. During the last decade various novel stroke rehabilitative methods for motor recovery have been developed. This review focuses on the methods that have evidence of associated cortical level reorganization, namely task-specific training, constraint-induced movement therapy, robotic training, mental imaging, and virtual training. All of these methods utilize principles of motor learning. The findings from this review demonstrated convincing evidence both at the neural and functional level in response to such therapies. The main aim of the review was to determine the evidence for these methods and their application into clinical practice.     

Sustained prefrontal activation during ataxic gait: a compensatory mechanism for ataxic stroke?

There is accumulated evidence that cortical reorganization plays an important role in motor recovery after supratentorial stroke. However neural mechanisms underlying functional recovery of ataxia after infratentorial stroke remain unclear. We investigated cortical activations during ataxic gait in patients with infratentorial stroke to test the hypothesis that cerebral cortices were involved in compensatory mechanisms for ataxic gait. Twelve patients with infratentorial stroke (mean duration+/-S.D. from the onset: 88.3+/-44.8 days) and 11 age-matched healthy subjects participated in this study. All patients had predominant ataxia without severe hemiparesis. We measured cortical activation as assessed by task-related increase of oxygenated hemoglobin during gait on a treadmill using functional near-infrared spectroscopy. Task consisted of three repetitions of gait period alternated with rest period. In controls, cortical activations in the lateral and medial prefrontal cortex during the acceleration phase tended to be attenuated during the steady phase of the gait period while these activations were sustained throughout the gait period in ataxic patients. Repeated measures ANOVA for cortical activation revealed significant interactions (p<0.005) between phase (acceleration/steady) and group (control/stroke) in the medial and lateral prefrontal regions. These results suggest that sustained prefrontal activation during ataxic gait might be relevant to compensatory mechanisms for ataxic gait after infratentorial stroke.     

Nursing care of the stroke patient using Bobath principles. An approach to altered movement

Rehabilitation nursing care of the stroke patient is a challenge. When the nurse understands and practices rehabilitative nursing care based on neurophysiologic and neurodevelopmental principles of normal movement, the care of the stroke patient is most rewarding. The nurse becomes an equal member of the rehabilitation team because there is a sharing of knowledge of how well each patient is achieving goals outlined for and with him or her by the team. Potentially, rehabilitation goals can be achieved early; however, there is a tremendous need for research in all areas of rehabilitation nursing to build on a scientific foundation of rehabilitation nursing research.     

表面肌电图在神经肌肉功能评定中的应用

表面肌电图（sEMG）是一种无创功能测评方法，通过记录运动时肌肉肌电图的振幅、频率等指标的变化，反映肌肉功能的水平。笔者对脑卒中患者运动时sEMG信号的研究进行综述，旨在为选择脑卒中后神经肌肉康复训练的方法提供科学依据。     

视觉反馈等速肌力训练在偏瘫患者下肢运动功能康复中的应用

目的：探讨卒中恢复期偏瘫患者下肢膝关节屈伸肌行视觉反馈等速肌力训练的效果,以及下肢功能评定与步行能力之间的相关性。方法：188例脑卒中患者随机分为观察组(95例)和对照组(93例),二组患者康复训练相同,观察组增加双下肢股四头肌、腘绳肌视觉反馈等速肌力训练18d。治疗前后分别采用Fugl-Meyer法、Barthel指数法及足印法对二组患者下肢功能及步态进行分析[1]。结果：观察组患者步态较对照组有明显改善(P<0.01),运动功能与活动能力显著提高(P<0.01)。步态的对称性与下肢运动功能、平衡功能显著相关(r=-0.77,-0.73,P<0.01),与活动能力无关(r=-0.23,P>0.05) ;步速与下肢运动功能、平衡功能、活动能力均显著相关(r=0.82,0.77,0.75,P<0.01)。结论：偏瘫患者早期运用双下肢膝屈伸肌群视觉反馈等速肌力训练对提高运动功能、步态改善和日常生活活动能力提高具有重要作用。     

A case report: application of the upright motor control test on physical therapy intervention of an individual following a stroke

This case report shows the application of the upright motor control test in the physical therapy management of an individual following a stroke. The individual is a 43-year-old male who sustained an infarct of the right thalamus 2 days prior to inpatient rehabilitation admission. Observational gait analysis and the upright motor control test isolated the primary gait deficit as left hip and ankle extension in the stance phase of gait. Physical therapy interventions focused on specific functional tasks that challenged hip extension so that he could resume the activities in which he engaged prior to the stroke. After a 3 week length of stay in inpatient rehabilitation, the individual demonstrated an improvement in the outcome measures, functional progression with ambulation (level and stairs), and transfers sufficient to be discharged home. This case illustrates how standardized outcome measures assisted the clinician in isolating the gait impairments that limited his ability to ambulate within his home environment. Subsequently, the plan of care and physical therapy interventions focused on these deficits to maximize the functional outcomes.     

A case report: Application of the upright motor control test on physical therapy intervention of an individual following a stroke

This case report shows the application of the Upright Motor Control Test in the physical therapy management of an individual following a stroke. The individual is a 43-year-old male who sustained an infarct of the right thalamus 2 days prior to inpatient rehabilitation admission. Observational gait analysis and the Upright Motor Control Test isolated the primary gait deficit as left hip and ankle extension in the stance phase of gait. Physical therapy interventions focused on specific functional tasks that challenged hip extension so that he could resume the activities in which he engaged prior to the stroke. After a 3 week length of stay in inpatient rehabilitation, the individual demonstrated an improvement in the outcome measures, functional progression with ambulation (level and stairs), and transfers sufficient to be discharged home. This case illustrates how standardized outcome measures assisted the clinician in isolating the gait impairments that limited his ability to ambulate within his home environment. Subsequently, the plan of care and physical therapy interventions focused on these deficits to maximize the functional outcomes.     

Bilateral step length estimation using a single inertial measurement unit attached to the pelvis

Background

The use of automated electromechanical devices for gait training in neurological patients is increasing, yet the functional outcomes of well-defined training programs using these devices and the characteristics of patients that would most benefit are seldom reported in the literature. In an observational study of functional outcomes, we aimed to provide a benchmark for expected change in gait function in early stroke patients, from an intensive inpatient rehabilitation program including both robotic and manual gait training.

Methods

We followed 103 sub-acute stroke patients who met the clinical inclusion criteria for Body Weight Supported Robotic Gait Training (BWSRGT). Patients completed an intensive 8-week gait-training program comprising robotic gait training (weeks 0-4) followed by manual gait training (weeks 4-8). A change in clinical function was determined by the following assessments taken at 0, 4 and 8 weeks (baseline, mid-point and end-point respectively): Functional Ambulatory Categories (FAC), 10 m Walking Test (10 MWT), and Tinetti Gait and Balance Scales.

Results

Over half of the patients made a clinically meaningful improvement on the Tinetti Gait Scale (> 3 points) and Tinetti Balance Scale (> 5 points), while over 80% of the patients increased at least 1 point on the FAC scale (0-5) and improved walking speed by more than 0.2 m/s. Patients responded positively in gait function regardless of variables gender, age, aetiology (hemorrhagic/ischemic), and affected hemisphere. The most robust and significant change was observed for patients in the FAC categories two and three. The therapy was well tolerated and no patients withdrew for factors related to the type or intensity of training.

Conclusions

Eight-weeks of intensive rehabilitation including robotic and manual gait training was well tolerated by early stroke patients, and was associated with significant gains in function. Patients with mid-level gait dysfunction showed the most robust improvement following robotic training.     

Neuromuscular electric stimulation effect on lower-extremity motor recovery and gait kinematics of patients with stroke: a randomized controlled trial

OBJECTIVE: To evaluate the effects of neuromuscular electric stimulation (NMES) of the tibialis anterior muscle on motor recovery and gait kinematics of patients with stroke. DESIGN: Randomized, controlled, assessor-blinded trial. SETTING: Rehabilitation ward and gait laboratory of a university hospital. PARTICIPANTS: A total of 25 consecutive inpatients with stroke (mean age, 55y), all within 6 months poststroke and without volitional ankle dorsiflexion. INTERVENTION: Both the NMES group (n=12) and the control group (n=13) participated in a conventional stroke rehabilitation program, 5 days a week for 4 weeks. The NMES group also received 10 minutes of NMES to the tibialis anterior muscle of the paretic limb. MAIN OUTCOME MEASURES: Brunnstrom stages of motor recovery and kinematic characteristics of gait. RESULTS: Brunnstrom stages improved significantly in both groups (P<.05). In total, 58% of the NMES group and 61% of the control group gained voluntary ankle dorsiflexion. Between-group difference of percentage change was not significant (P>.05). Gait kinematics was improved in both groups, but the difference between groups was not significant. CONCLUSIONS: NMES of the tibialis anterior muscle combined with a conventional stroke rehabilitation program was not superior to a conventional stroke rehabilitation program alone, in terms of lower-extremity motor recovery and gait kinematics.     

Positive consequences of surviving a stroke.

This exploratory study focused on gaining insight into the psychological experience of stroke survivors undergoing inpatient rehabilitation. Specifically it investigated whether stroke survivors undergoing inpatient rehabilitation were able to identify any positive consequence of their stroke. This phenomenon, also know as benefit finding or positive reframing, has recently received more attention in the coping literature examining reactions to severe illness. Using a case series methodology and qualitative analytic techniques, 16 stroke survivors were interviewed using standardized open-ended questions related to identification of positive consequences attributed to surviving a stroke. Sixty-three percent of the patients interviewed were able to identify positive consequences of their stroke. The following five themes regarding positive consequences of stroke emerged from this case series: increased social relationships, increased health awareness, change in religious life, personal growth, and altruism. It was concluded that some individuals who have survived an acute stroke are able to reframe their experience in a positive light. This study provides occupational therapists and others with further insight into the coping mechanisms of those individuals who have survived a stroke. The need for further research is stressed.     

Task-oriented treadmill exercise training in chronic hemiparetic stroke

Patients with stroke have elevated hemiparetic gait costs secondary to low activity levels and are often severely deconditioned. Decrements in peak aerobic capacity affect functional ability and cardiovascular-metabolic health and may be partially mediated by molecular changes in hemiparetic skeletal muscle. Conventional rehabilitation is time delimited in the subacute stroke phase and does not provide adequate aerobic intensity to reverse the profound detriments to fitness and function that result from stroke. Hence, we have studied progressive full body weight-support treadmill (TM) training as an adjunct therapy in the chronic stroke phase. Task-oriented TM training has produced measurable changes in fitness, function, and indices of cardiovascular-metabolic health after stroke, but the precise mechanisms for these changes remain under investigation. Further, the optimal dose of this therapy has yet to be identified for individuals with stroke and may vary as a function of deficit severity and outcome goals. This article summarizes the functional and metabolic decline caused by inactivity after stroke and provides current evidence that supports the use of TM training during the chronic stroke phase, with protocols and inclusion/exclusion criteria described. Our research findings are discussed in relation to associated research.     

Finger tapping as a proxy for gait: Similar effects on movement variability during external and self-generated cueing in people with Parkinson's disease and healthy older adults

BackgroundRhythmic auditory cueing has been widely studied for gait rehabilitation in Parkinson's disease (PD). Our research group previously showed that externally generated cues (i.e., music) increased gait variability measures from uncued gait, whereas self-generated cues (i.e., mental singing) did not. These different effects may be due to differences in underlying neural mechanisms that could be discerned via neuroimaging; however, movement types that can be studied with neuroimaging are limited.ObjectiveThe primary aim of the present study was to investigate the effects of different cue types on gait, finger tapping, and foot tapping, to determine whether tapping can be used as a surrogate for gait in future neuroimaging studies. The secondary aim of this study was to investigate whether rhythm skills or auditory imagery abilities are associated with responses to these different cue types.MethodsIn this cross-sectional study, controls (n = 24) and individuals with PD (n = 33) performed gait, finger tapping, and foot tapping at their preferred pace (UNCUED) and to externally generated (MUSIC) and self-generated (MENTAL) cues. Spatiotemporal parameters of gait and temporal parameters of finger tapping and foot tapping were collected. The Beat Alignment Task (BAT) and Bucknell Auditory Imagery Scale (BAIS) were also administered.ResultsThe MUSIC cues elicited higher movement variability than did MENTAL cues across all movements. The MUSIC cues also elicited higher movement variability than the UNCUED condition for gait and finger tapping.ConclusionsThis study shows that different cue types affect gait and finger tapping similarly. Finger tapping may be an adequate proxy for gait in studying the underlying neural mechanisms of these cue types.     

丰富康复训练与神经可塑性

神经可塑性是指神经系统对外界环境刺激可做出适应性改变的特性。神经可塑性的理论研究最早开始于脑卒中后的功能恢复。脑卒中后的运动功能恢复主要出现在数周或数月内,通常归因于脑神经的可塑性。已证实将丰富环境和一般康复训练相结合的丰富康复训练可以使大脑达到最佳的功能恢复。如何掌握丰富康复训练的时机和持续时间是当前研究的热点。     

Feasibility and effects of patient-cooperative robot-aided gait training applied in a 4-week pilot trial

ABSTRACT: BACKGROUND: Functional training is becoming the state-of-the-art therapy approach for rehabilitation of individuals after stroke and spinal cord injury. Robot-aided treadmill training reduces personnel effort, especially when treating severely affected patients. Improving rehabilitation robots towards more patient-cooperative behavior may further increase the effects of robot-aided training. This pilot study aims at investigating the feasibility of applying patient-cooperative robot-aided gait rehabilitation to stroke and incomplete spinal cord injury during a therapy period of four weeks. Short-term effects within one training session as well as the effects of the training on walking function are evaluated. METHODS: Two individuals with chronic incomplete spinal cord injury and two with chronic stroke trained with the Lokomat gait rehabilitation robot which was operated in a new, patient-cooperative mode for a period of four weeks with four training sessions of 45 min per week. At baseline, after two and after four weeks, walking function was assessed with the ten meter walking test. Additionally, muscle activity of the major leg muscles, heart rate and the Borg scale were measured under different walking conditions including a non-cooperative position control mode to investigate the short-term effects of patient-cooperative versus non-cooperative robot-aided gait training. RESULTS: Patient-cooperative robot-aided gait training was tolerated well by all subjects and performed without difficulties. The subjects trained more actively and with more physiological muscle activity than in a non-cooperative position-control mode. One subject showed a significant and relevant increase of gait speed after the therapy, the three remaining subjects did not show significant changes. CONCLUSIONS: Patient-cooperative robot-aided gait training is feasible in clinical practice and overcomes the main points of criticism against robot-aided gait training: It enables patients to train in an active, variable and more natural way. The limited number of subjects in this pilot trial does not permit valid conclusions on the effect of patient-cooperative robot-aided gait training on walking function. A large, possibly multi-center randomized controlled clinical trial is required to shed more light on this question.     

Changes in muscle group work associated with changes in gait speed of persons with stroke

BACKGROUND: Knowledge of associations between changes in muscle work with changes in gait speed could assist gait training in persons with stroke. The purpose of the study was to determine changes in the work of major muscle groups during gait that were associated with increases in walking speed of persons with stroke following training. METHODS: The gait of 28 subjects (14 males, 14 females) with mean age of 64.2 (SD 11.7) years, at 4.8 (SD 6.9) years post stroke was studied using two-dimensional motion analysis before and after a strength training program. Outcome variables were changes in gait speed and changes in work associated with the hip flexors and extensors, knee flexors and extensors and ankle plantar flexors bilaterally. A stepwise linear regression analysis determined best positive work predictors of changes in gait speed. FINDINGS: Hip extension work in early stance and ankle plantarflexion work in late stance of the affected side accounted for 74.9% of the variance in change of gait speed; a second model showed that hip extension work in early stance of the affected and less-affected sides accounted for 74.3%, a similar amount of variance. INTERPRETATION: This work is the first to explore the changes in muscle work during gait that are associated with speed increases in persons with stroke. Augmenting hip extensor work in early stance on both sides, as well as ankle plantarflexion thrust on the affected side may be particularly beneficial in increasing the speed of walking of persons with stroke.     

The effect of treadmill training on the ambulation of stroke survivors in the early stages of rehabilitation: a randomized study

The objective of this study was to compare the effects of conventional over-ground gait training with treadmill training on the restoration of gait in people with hemiparesis following a stroke. Twenty-five individuals in the early stages of rehabilitation were alternately assigned to one of two treatment groups. In addition to conventional physical therapy, the experimental group participated in 15 treadmill-training sessions in which a handrail was used for external support. The control group received the same number of equal length sessions of over-ground ambulation. Treatment effects were established by pre- and posttreatment assessment of: 1) functional walking ability, 2) walking speed, 3) stride length, 4) temporal characteristics of gait, and 5) electromyographic activity of calf muscles. Normal values were obtained from eight healthy individuals of approximately the same age as the stroke survivors. The study demonstrates that individuals following a stroke are well able to tolerate treadmill training in the early stage of their rehabilitation process without the use of a weight support apparatus. Furthermore, the findings suggest that treadmill training may be more effective than conventional gait training for improving some gait parameters such as functional ambulation, stride length, percentage of paretic single stance period, and gastrocnemius muscular activity.     

手功能康复器对脑卒中后偏瘫患者手功能康复的效果研究

目的对比研究自由康复法、针灸疗法及手功能康复器配合自由康复法3种不同诊治方法对新发脑卒中偏瘫患者手运动功能、感觉功能以及运动模式的康复效果。方法将49例首次发病的新发脑卒中患者随机分为自由康复组16例,针灸组16例和手功能康复器训练组17例,分别接受相应的治疗及护理。采用盲法对3组患者治疗前后的手运动功能、感觉功能以及运动模式进行对比。结果3组治疗后Brunnstrom-手的感觉运动功能评定,Fugl-Meyer评定得分比治疗前有明显进步,Carr-shepherd-手精细功能评定得分无显著改善。治疗2周后Brunnstrom-手的感觉运动功能评定、Fugl-Meyer评定分值自由康复组和针灸治疗组比较无显著差异;手功能康复器训练组与另2组比较差异显著;Carr-shepherd-手精细功能评定分值3组间两两比较均无显著差异。治疗1个月后,Brunnstrom-手的感觉运动功能评定分值3组间两两比较差异显著;Fugl—Meyer评定分值自由康复组和针灸治疗组比较无显著差异,手功能康复器训练组与另2组比较差异显著;Carr—shepherd-手精细功能评定分值3组间两两比较均无显著差异。结论针灸、自由康复及手功能康复器对脑卒中后偏瘫患者的手运动功能、感觉功能改善均有效,手功能康复器配合自由康复的治疗效果最佳。但其对手精细功能的改善有待提高。     

Rehabilitation of arm function after stroke. Literature review

IntroductionIn the recent literature we can find many articles dealing with upper extremity rehabilitation in stroke patients. New techniques, still under evaluation, are becoming the practical applications for the concept of post-stroke brain plasticity.MethodsThis literature review focuses on controlled randomized studies, reviews and meta-analyses published in the English language from 2004 to 2008. The research was conducted in MEDLINE with the following keywords: “upper limb”, “stroke”, “rehabilitation”.ResultsWe reviewed 66 studies. The main therapeutic strategies are: activation of the ipsilesional motor cortex, inhibition of the contralesional motor cortex and modulation of the sensory afferents. Keeping a cortical representation of the upper limb distal extremity could prevent the learned non-use phenomenon. The modulation of sensory afferents is then proposed: distal cutaneous electrostimulation, anesthesia of the healthy limb, mirror therapy, virtual reality. Intensifying the rehabilitation care means increasing the total hours of rehabilitation dedicated to the paretic limb (proprioceptive stimulation and repetitive movements). This specific rehabilitation is facilitated by robot-aided therapy in the active-assisted mode, neuromuscular electrostimulation and bilateral task training. Intensifying the rehabilitation training program significantly improves the arm function outcome when performed during subacute stroke rehabilitation (< six months). Ipsilesional neurostimulation as well as mental practice optimize the effect of repetitive gestures for slight motor impairments. Contralesional neurostimulation or anesthesia of the healthy hand both improve the paretic hand's dexterity via a decrease of the transcallosal inhibition. This pathophysiological mechanism could also explain the positive impact of constraint-induced movement therapy (CI therapy) in an environmental setting for chronic stroke patients.ConclusionTo ensure a positive functional outcome, stroke rehabilitation programs are based on task-oriented repetitive training. This literature review shows that exercising the hemiparetic hand and wrist is essential in all stages of a stroke rehabilitation program. New data stemming from neurosciences suggest that ipsilesional corticospinal excitability should be a priority.