Stroke and visual rehabilitation

Many patients will experience some type of visual dysfunction following a stroke. The visual changes associated with stroke can be categorized as sensory (visual acuity and visual field), motor (extraocular muscle motility), and perceptual. These disturbances affect the patient's quality of life and can impede overall rehabilitation. Many of these impairments can be addressed by simple yet effective techniques. As a result, vision rehabilitation specialists are becoming an important part of the multidisciplinary stroke rehabilitation team.     

Gait retraining post stroke

A major component of stroke rehabilitation focuses on gait restoration. The purpose of this review is to examine the efficacy of a variety of gait retraining techniques currently in clinical use, including strength training, functional electrical stimulation, treadmill training, partial body-weight support, EMG biofeedback, and splinting of the lower extremity. Forty-eight studies evaluating six gait enhancement techniques were reviewed. There is either strong or moderate evidence to support the use of strength training, EMG/biofeedback, and functional electrical stimulation as an adjunctive therapy in gait training, and there is either limited or conflicting evidence to support the use of ankle-foot orthosis, treadmill training, and partial body-weight support.     

Aphasia and return to work in younger stroke survivors

Background: Younger stroke patients (i.e., typically those between 18 and 65 years of age) experience fewer stokes than older patients. However, younger stroke survivors are more likely to live longer with disability, have dependants, and be engaged in full- or part-time employment. Aphasia post stroke occurs in 10% of younger survivors, and can significantly impact the ability to resume previous activities of daily living. Unfortunately traditional rehabilitation often does not account for language impairments that impact vocational status.

Aims: This review reports the rate of successful return to work (RTW) for younger stroke survivors with aphasia. Aphasia is consistently regarded as a barrier to an individual's ability to RTW post stroke. However, the degree to which working-age stroke survivors with aphasia successfully RTW remains unknown. In addition, conflicting evidence has been found as to the predictive nature of communication impairments on RTW.

Main Contribution: The primary outcome in which we were interested was the degree to which younger survivors with aphasia return to work. Secondary outcomes were the type of assessment used, the definition of work, and the age of the study sample. Nine studies were identified (aphasia N?=?415, total N?=?1612). The average rate of successful RTW for young survivors with aphasia was 28.4% compared to 44.7% for all young stroke survivors.

Conclusions: Younger survivors with aphasia were less likely to RTW post stroke than those without aphasia. Strategies to reduce this disparity, such as specialised vocational rehabilitation, should be made available to this population.     

Characteristics of basal ganglia aphasia after stroke and the rehabilitative interventions

To introduce the characteristics of basal ganglia aphasia after stroke and the rehabilitative interventions.DATA SOURCES: Articles related to stroke, subcortical aphasia, basal ganglia aphasia and language rehabilitation published in Chinese from January 1988 to December 2005 were searched in Chinese journal full-text database (CJFD) using the keywords of“stroke, basal ganglia aphasia, language rehabilitation“ in Chinese. Meanwhile, English articles about aphasia published from January 1982 to December 2005 were searched in and Pubmed database. Besides, several books associated with the contents were looked through manually.STUDY SELECTION: The data were checked primarily, the articles about the pathomechanism and neurolinguistic characteristics of basal ganglia aphasia, diagnostic methods of aphasia and language rehabilitation were selected, and those had no obvious relation with the above contents were excluded.Inclusive criteria: literatures explain the clinical characteristics of basal ganglia aphasia, neurolinguistic pathogenesis and methods of rehabilitation therapy in details. The repetitive studies were excluded.DATA EXTRACTION: Totally 95 literatures about basal ganglia aphasia were collected, including 31 about the clinical characteristics of basal ganglia aphasia, 45 about its neurolinguistic pathogenesis, 5 about the evaluation and classification of aphasia, and 14 about its rehabilitation therapy. Thirty accorded with the inclusive criteria were used for review, and the other 65 were excluded.DATA SYNTHESIS: Concisely introduced the definition, past investigation of basal ganglia aphasia after stroke, then dwelled on the multiplicity neurolinguistics characteristics. Aphasia evaluation was dependent upon clinical aphasic symptoms. The relationship between symptom and focus of infection was explored, and the mechanism of pathosis language behavior on basal ganglia aphasia patients was understood to provide consequence data that could authenticate the processing of language in brain. On the other hand, the method of rehabilitation on basal ganglia aphasia after stroke was explained.CONCLUSION: Basal ganglia aphasia is manifested as atypical aphasic symptom, the mechanism for the structure of basal ganglia in the speech formation should be further confirmed. It is effective to select pertinent language rehabilitation for basal ganglia aphasia after stroke.     

Current trends in stroke rehabilitation. A review with focus on brain plasticity

Johansson BB. Current trends in stroke rehabilitation. A review with focus on brain plasticity.
Acta Neurol Scand: 2011: 123: 147–159.
© 2010 John Wiley & Sons A/S. Current understanding of brain plasticity has lead to new approaches in ischemic stroke rehabilitation. Stroke units that combine good medical and nursing care with task‐oriented intense training in an environment that provides confidence, stimulation and motivation significantly improve outcome. Repetitive trans‐cranial magnetic stimulation (rTMS), and trans‐cranial direct current stimulation (tDCS) are applied in rehabilitation of motor function. The long‐term effect, optimal way of stimulation and possibly efficacy in cognitive rehabilitation need evaluation. Methods based on multisensory integration of motor, cognitive, and perceptual processes including action observation, mental training, and virtual reality are being tested. Different approaches of intensive aphasia training are described. Recent data on intensive melodic intonation therapy indicate that even patients with very severe non‐fluent aphasia can regain speech through homotopic white matter tract plasticity. Music therapy is applied in motor and cognitive rehabilitation. To avoid the confounding effect of spontaneous improvement, most trials are preformed ≥3 months post stroke. Randomized controlled trials starting earlier after strokes are needed. More attention should be given to stroke heterogeneity, cognitive rehabilitation, and social adjustment and to genetic differences, including the role of BDNF polymorphism in brain plasticity.     

The effect of two different rehabilitation treatments in cervical dystonia: preliminary results in four patients

The most widespread approach to rehabilitation of cervical dystonia is electromyographic (EMG) biofeedback. However, consensus is lacking regarding the true effectiveness of this technique. The aim of this study was to evaluate how cervical dystonia was influenced by two rehabilitative treatments, namely a standard biofeedback program and a novel physiotherapy program consisting of postural reeducation exercises and passive elongation of myofascial cervical structures. Both programs were consecutively administered to 4 patients with cervical dystonia. The study design was a behavioral analysis of single cases. The main outcome measures were a head realignment test, a disability questionnaire and a pain visual analogue scale (VAS). Each patient's performance was evaluated before the study and after the first and second program. Furthermore, the disability questionnaire and the pain VAS were administered 3, 6, and 9 months after the end of the treatments. The physiotherapy program showed therapeutic effects comparable to those of EMG biofeedback. Reductions of disability and of pain were still present 3-9 months after the end of the treatments. These preliminary results suggest that the physiotherapy program proposed in the present study may be a promising method for rehabilitation of cervical dystonia.     

The use of a treadmill with biofeedback function in assessment of relearning walking skills in post-stroke hemiplegic patients--a preliminary report

Background and purposeOne of the most important goals of rehabilitation of post-stroke hemiplegic patients is the recovery of their locomotion function. The aim of the study was to assess walking function recovery by means of in-patient rehabilitation procedures, as well as the effectiveness of treadmill gait training with the use of biological feedback.Material and methodsThe research involved groups of chronic post-stroke hemiplegic patients receiving treatment in the rehabilitation ward. Factors under scrutiny included walking speed and capacity, number of steps, weight bearing symmetry for lower extremities while standing, lower limb mobility on the Brunnström scale, and muscle tone on the Ashworth Scale. The study group patients followed a rehabilitation regime that included treadmill training aided with biofeedback function. Each study group participant exercised every day (a total of 15 times), with a single practice time ranging from 5 to 20 minutes. Control patients followed a rehabilitation regime without the additional treadmill exercises.ResultsPatients in both groups demonstrated improvement in locomotion abilities. In the group following the physiotherapy regime supplemented with treadmill training with the use of biofeedback, the measures of walking speed, weight bearing symmetry for lower extremities, and number of steps were better than in controls.ConclusionsTreadmill gait training with the use of biofeedback is effective for relearning locomotion functions in post-stroke hemiplegic patients and can constitute a significant type of exercise in a physiotherapy regime.     

Development of early comprehensive stroke inpatient rehabilitation in Poland - current status and future requirements

Background and purposeEvery stroke patient should undergo early rehabilitation. We aimed to evaluate accessibility, development and needs in early stroke inpatient rehabilitation in Poland.Material and methodsA questionnaire evaluating rehabilitation departments was prepared and sent (in 2004 and 2008) to rehabilitation wards in Poland, where stroke patients are treated and undergo early rehabilitation. We divided departments into classes: class A – having comprehensive rehabilitation (physiotherapy minimum 60 minutes/day, speech therapy minimum 30 minutes/5 days/week, rehabilitation of other cognitive impairments minimum 30 minutes/5 days/week, group physiotherapy); B – having the possibility of all types of therapy, but done less frequently; C – physiotherapy and speech therapy; D – physiotherapy and cognitive rehabilitation; E – only physiotherapy.ResultsIn 2004, we obtained responses from 115 of 172 (66.9%) rehabilitation departments. According to prespecified criteria there were 11 class A, 31 class B, 28 class C, 4 class D, and 41 class E wards. In 2008, we received response from 89 of 149 (59.7%) rehabilitation departments. According to prespecified criteria there were 17 class A, 40 class B, 22 class C, 0 class D, and 10 class E wards. In 2004, 159 beds and in 2008, 294 beds in class A departments were available for stroke patients. The minimal number of needed but lacking beds was 604 in 2004 and 469 in 2008.ConclusionsDevelopment of departments providing early comprehensive stroke rehabilitation from 2004 to 2008 is marked, but still insufficient. In 2008, 19% of rehabilitation departments could provide comprehensive stroke rehabilitation and this was 38.5% of beds actually needed.     

Recovery time of independent poststroke abilities: Part I

The purposes of this study were to determine the time of the recovery of poststroke abilities and to identify prognostic indicators associated with recovery time among stroke patients undergoing a rehabilitation program. A sample of 421 stroke participants admitted to a rehabilitation center was recruited from medical records that were available from January 1987 to December 1992. The mean age was 61.8 years (range, 17-89 years). The relationship between the achievement of independent poststroke abilities and the potential covariates associated with recovery time was assessed through the analysis of survival data. Cox maximum-likelihood proportional hazard models were used for the analysis. Independent poststroke abilities included behavior, cognitive, perceptual, communication, visual, and motor status. The time from rehabilitation admission to complete independence was introduced to the model in relation to the covariates. The mean time of recovery of poststroke abilities ranged from 18.70 to 32.40 days from the rehabilitation admission. The survival analysis revealed that the time of recovery of the selected poststroke abilities was significantly influenced (p <.05) by one or several factors, among these were neuropsychological, physical, and life habits. With this precious information, stroke rehabilitation specialists may be able to reduce the length of time required to recover independent poststroke abilities by treating the specific neuropsychological, physical, and life habit characteristics identified in this study. A faster poststroke recovery will reduce the socioeconomic impact generated by stroke disability and will ensure a better quality of life to the stroke survivor.     

Investigating the effects of visual biofeedback therapy on recovery of postural balance in stroke patients using a complexity measure

Background and purpose: Postural balance deficit is one of the common post-stroke disabilities. Providing visual biofeedback while balance activities are performed is a way to improve postural balance disorders following stroke. But among the research publications, there is incoherency about the positive effects of visual biofeedback therapy. The purpose of this study was to investigate the effects of using visual biofeedback as an adjunct to physical therapy exercises on recovery of postural balance of stroke patients. Materials and methods: A total of 31 hemiplegic stroke patients were recruited in this study and randomly assigned into case and control groups. Both groups received conventional physical therapy interventions and balance training exercises. During balance training, the case group received visual biofeedback, whereas the control group did not receive visual information. Balance performance of stroke patients were examined quantitatively using the EquiTest testing system. Center of pressure data were collected before starting, during, and after completion of the rehabilitation program and a nonlinear complexity measure, approximate entropy (ApEn), calculated and used for the analysis. Results: No significant between-group differences were detected after completion of the program. Noticeable increase was found in ApEn values of both groups along anterior–posterior direction, whereas no statistically significant improvement was found along mediolateral direction after rehabilitation. Conclusion: Both rehabilitation routines created advances in the postural control system of stroke patients. Visual biofeedback balance training did not produce extra advantage for balance ability of participants who received this treatment program in comparison with those who were treated without visual biofeedback.     

The perspectives of adults with aphasia and their team members regarding the importance of nine life areas for rehabilitation: a pilot investigation

Objectives: Client-centred rehabilitation implies that persons with aphasia and their significant others are actively involved in all decisions regarding rehabilitation, including the setting of rehabilitation priorities and goals. This study aimed to describe and compare the perspectives of adults with aphasia, their significant others and their speech-language pathologists (SLPs) regarding the importance of nine life areas for the rehabilitation of adults with aphasia.

Method: A total of 15 adults with expressive aphasia rated the importance of nine life areas using the Talking Mats? framework. A questionnaire was used to obtain the ratings of 15 of their significant others and the 15 SLPs treating them.

Results: Most life areas were rated as important to work on in rehabilitation by most participants. The adults with aphasia rated the areas as important more frequently than their significant others and SLPs. All participants rated Communication as important. Statistically significant differences were noted for three of the nine life areas.

Discussion: The life areas which the participants were questioned about seem to provide a good starting point for rehabilitation teams to find common ground for collaborative goal setting. The Talking Mats? approach allowed adults with aphasia to participate in the process. It can be a useful tool to promote client-centred rehabilitation for adults with expressive communication difficulties.     

PERFORMANCE ON FIGURE GROUND PERCEPTION FOLLOWING STROKE INDUCED HEMIPLEGIA: A COMPAIRSON OF PRE-AND POST-REHABILITATION WITH THE NEUROLOGICALLY UNIMPAIRED

This article compares performance times on the Figure Ground Perception (FGP) of the Sensory Integration and Praxis Tests (SIPT) in persons with stroke-induced hemiplegia and unimpaired older persons. Two hundred and twelve right dominant persons with hemiplegia on admission and discharge from comprehensive rehabilitation and 321 neurologically unimpaired persons in the community were evaluated on the FGP subtests of the SIPT. There were significant differences in performance between unimpaired persons and those with hemiplegia following a stroke. Among the persons with stroke-induced hemiplegia, performance on discharge was significantly better than on admission across all five FGP subtests. Age, sex, and severity of hemiplegia also affected performance on specific subtests; the influence of laterality was significant in persons with right hemispheric lesions; and persons with Wernicke's aphasia performed more poorly. Although further investigation is clearly needed, the association of increasing age (particularly males 75 years and over), severity of hemiplegia, and presence of aphasia on FGP performance suggest that these factors should be considered in the development of rehabilitation programs for stroke patients.     

Performance on figure ground perception following stroke induced hemiplegia: a compairson of pre-and post-rehabilitation with the neurologically unimpaired

This article compares performance times on the Figure Ground Perception (FGP) of the Sensory Integration and Praxis Tests (SIPT) in persons with stroke-induced hemiplegia and unimpaired older persons. Two hundred and twelve right dominant persons with hemiplegia on admission and discharge from comprehensive rehabilitation and 321 neurologically unimpaired persons in the community were evaluated on the FGP subtests of the SIPT. There were significant differences in performance between unimpaired persons and those with hemiplegia following a stroke. Among the persons with stroke-induced hemiplegia, performance on discharge was significantly better than on admission across all five FGP subtests. Age, sex, and severity of hemiplegia also affected performance on specific subtests; the influence of laterality was significant in persons with right hemispheric lesions; and persons with Wernicke's aphasia performed more poorly. Although further investigation is clearly needed, the association of increasing age (particularly males 75 years and over), severity of hemiplegia, and presence of aphasia on FGP performance suggest that these factors should be considered in the development of rehabilitation programs for stroke patients.     

Treatment interventions for the paretic upper limb of stroke survivors: a critical review

Despite a threefold increase in treatment interventions studies during the past 10 years, "best practice" for the rehabilitation of the paretic upper limb is still unclear. This review aims to lessen uncertainty in the management of the poststroke upper limb. Two separate searches of the scientific literature from 1966-2001 yielded 333 articles. Three referees, using strict inclusion and exclusion criteria, selected 68 relevant references. Cohort studies, randomized control trials, and systematic reviews were critically appraised. Mean randomized control trial quality (n = 33) was 17.1/27 (SD = 5.2, 95% CI = 15.2-19.0, range = 6-26). Mean quality of cohort studies (n = 29) was 11.8/27 (SD = 3.8, 95% CI = 10.4-13.2, range = 4-19). Quantitative syntheses were done using the Z-statistic. This systematic review indicated that sensorimotor training; motor learning training that includes the use of imagery, electrical stimulation alone, or combined with biofeedback; and engaging the client in repetitive, novel tasks can be effective in reducing motor impairment after stroke. Furthermore, careful handling, electrical stimulation, movement with elevation, strapping, and the avoidance of overhead pulleys could effectively reduce or prevent pain in the paretic upper limb. Rehabilitation specialists can use this research synthesis to guide their selection of effective treatment techniques for persons with impairments after stroke.     

Quality of life in aphasia in the first post-stroke year

Abstract

The term quality of life (QOL) is used by both scientists and lay persons and is defined in many different ways. One of the major challenges in measuring QOL results from the fact that it is a latent trait not subject to direct observation or countable phenomena. Specific attention to QOL in the stroke survivor has been rare. This paper reviews the literature, identifies some of the issues, and reports a study of QOL in 59 consecutively admitted post-stroke aphasic patients who were treated in a comprehensive rehabilitation medicine programme and followed from three to twelve months post onset. The results suggest that improved QOL in aphasic persons of all types in the first poststroke year relates to the intensity and duration of aphasia rehabilitation services which addresses language, communication strategies, copying skills, and psychosocial issues.     

The effectiveness of physiotherapy for cervical dystonia: a systematic literature review

Cervical dystonia is a form of adult-onset, focal dystonia characterized by involuntary contractions of the neck muscles, leading to a disabling, abnormal head posture. CD has a great impact on the activities of daily living (ADL) and quality of life. Currently, the most widely used and recommended first line treatment is botulinum toxin type A (BoNT/A) injections. Physiotherapy is a potentially useful adjuvant, but little is known about its effectiveness. Consequently, our objective was to investigate the effectiveness of physiotherapy alone or as an adjuvant treatment to BoNT/A injections in cervical dystonia (CD) by means of a systematic literature review. Two online databases, PubMed and Web of Science, were searched for articles describing the effectiveness of physiotherapy treatment for CD. After screening, based on predefined in- and exclusion criteria, 16 studies were retained. Their methodological quality was assessed according to Cochrane guidelines. The methodological quality of most studies was low. Examples of shortcomings are small sample sizes, lack of randomization or blinding, and diversity in therapeutic techniques and outcome measures. Only seven studies were clinical trials; the remaining were either case reports or case series. The reported physiotherapy treatments included EMG biofeedback training, muscular elongation, postural exercises and electrotherapy. Improvements in head position, pain, cervical range of motion, quality of life and ADL have been reported, which is promising. Cautious interpretation on the effectiveness of physiotherapy as an adjuvant therapy is required. Before firm conclusions can be drawn, additional high quality trials are needed.     

An individual rehabilitation program: Evaluation by Parkinsonian patients and their physiotherapists

Objectives

The purpose of this work was to study the feasibility of an individual Parkinson disease (PD) rehabilitation program based on each patient's prevalent symptoms and to determine the effects of this program on patient's quality of life as well as the level of patient's and physiotherapist's satisfaction with the program.

Patients and methods

In association with physiotherapists with expertise in PD, a physical medicine and rehabilitation physician, we elaborated a physical therapy program based on the core areas for physical therapy in PD: transfers; posture; balance and falls; physical capacity and inactivity. Within this program, we selected exercises tailored to each patient's main impairment and proposed this selection to their local physiotherapist for three months. Quality of life was evaluated with PDQ-39 at baseline and after three months of the individualized physical therapy program. We built an anonymous satisfaction questionnaire for patients and physiotherapists that was filled out at the end of the program.

Results

One hundred and three individuals with moderately advanced but clinically stable idiopathic PD were included. Significant improvement was found for the emotional well-being, bodily discomfort and stigma domain (P ≤ 0.05). No significant improvement was found for the other PDQ-39 domains. The mean global satisfaction figures for this program were 6.0 ± 2.4 and 7.2 ± 2.1 for patients and physiotherapists respectively. Most of the patients felt improved by the physiotherapy program and especially for transfer, balance, gait, and mobility.

Conclusion

Our study found evidence of the potential benefits of a patient-tailored physiotherapy program. Such a program was feasible and had a favorable impact on patients’ quality of life and on physiotherapists’ practices for PD patients. Specific physiotherapy may be effective to limit physical mobility impairment. Our results also pointed out that physiotherapy may be efficient to confine the negative impact of social isolation, pain and emotional reactions. Such a program should be associated with a therapeutic education intervention such as encouraging patients to perform physical therapy exercises alone.     

Age and aphasia: a review of presence,type, recovery and clinical outcomes

Background: Each year approximately 100,000 stroke survivors are diagnosed with aphasia. Although stroke is associated with age, the relationship between age and aphasia is less clear.

Objectives: To complete a review of the literature to examine the relationship between age and: (a) presence or likelihood of aphasia after stroke, (b) aphasia type, (c) aphasia recovery patterns, and (d) aphasia clinical outcomes.

Data Sources: Articles were identified by a comprehensive search of “OneSearch,” PubMed, and individual journals: Aphasiology, Stroke and the Journal of Stroke and Cerebrovascular Diseases.

Study Selection: Inclusion criteria included: age and incidence of aphasia, likelihood of aphasia, aphasia recovery, and aphasia clinical outcome.

Data Extraction: Independent searches were completed by the authors. Each author independently assessed the full text of reports meeting inclusion criteria. Differences regarding study eligibility and need to proceed with data extraction were resolved by consensus.

Results: 1617 articles were identified during the initial search. Forty studies including 14,795 study participants were included in the review. The review generally demonstrated that: (a) stroke patients with aphasia are typically older than stroke with patients without aphasia and (b) aphasia type and age are associated as younger patients with aphasia are more likely to exhibit non-fluent or Broca’s type of aphasia. In contrast, studies examining aphasia recovery and aphasia clinical outcomes did not demonstrate a positive relationship between age and recovery or clinical outcomes.

Conclusions: Stroke is a condition of the elderly. However, age appears to only influence likelihood of aphasia and aphasia type.     

Recovery and treatment of aphasia after stroke: functional imaging studies

PURPOSE OF REVIEW: In this review of papers published between May 2006 and May 2007, we discuss functional neuroimaging studies of recovery and treatment of patients with aphasia after stroke. RECENT FINDINGS: Studies of recovery of aphasia have highlighted the importance of right inferior frontal gyrus activation, especially early after stroke, when it correlates with language recovery. In contrast, in the later stages after stroke left hemisphere activations predict chronic aphasia; speech production recovery appears to depend on left frontal activation, whereas speech comprehension depends on left temporal activation. There have been few studies of treatment of aphasia, but preliminary evidence suggests that treatment of speech production difficulties, even years after stroke, may be effective and deserves further study. SUMMARY: Recent studies of aphasia recovery allow a deeper appreciation of the changing neuronal activation patterns associated with time after stroke. The distinction between neuronal reorganization that does and does not sustain recovery in the chronic phase after stroke, either spontaneous or in response to treatment, remains controversial and further studies are necessary. Clinical diagnosis and treatment of aphasia requires many more longitudinal studies with larger patient numbers and more detailed behavioural and lesion characterization of stroke patients.