I really don't care about a discussion about failed therapies in the past and present. I want to know what works right now. GET THERE! If nothing works, research until you find something. Don't just sit on your fucking asses. 10 million survivors a year need rehab and they can't wait forever until you feel like getting off your asses. I expect references to protocols not a discussion using big words to confuse. We can't wait until you find the end of the eternal path to recover, death will occur before that.
Evolution of motor therapies in stroke rehabilitation: An eternal path
Kamal Narayan Arya
Department of Occupational Therapy, Pt. Deendayal Upadhyaya National Institute for Persons with Physical Disabilities, New Delhi, India
| Date of Web Publication | 17-Sep-2018 |
Kamal Narayan Arya
Department of Occupational Therapy, Pt. Deendayal Upadhyaya National Institute for Persons with Physical Disabilities, 4 VD Marg, New Delhi
India
Source of Support: None, Conflict of Interest: None
| How to cite this article: Arya KN. Evolution of motor therapies in stroke rehabilitation: An eternal path. Neurol India 2018;66:1303-5 |
| How to cite this URL: Arya KN. Evolution of motor therapies in stroke rehabilitation: An eternal path. Neurol India [serial online] 2018 [cited 2018 Sep 21];66:1303-5. Available from: http://www.neurologyindia.com/text.asp?2018/66/5/1303/241379 |
Historically, motor therapies, such as Brunnstrom and Bobath's approach, were developed with a view to enhance motor recovery among post-stroke hemiparetic subjects. Specific or generic regimes, for instance, motor re-learning programs and proprioceptive neuromuscular facilitation (PNF) techniques are still in use. The ‘eclectic mix model' approach is the usual choice of many practitioners. Majority of these therapies were based on the clinical experience of the developer, as well as the then available neurophysiological evidence. Although the approaches are frequently practiced clinically, these techniques lacked robust effectiveness and evidence.[1]
During the last few decades, the ‘constraint-induced movement' therapy has drawn attention by proving its effectiveness both in animal models as well as in human beings, with the therapy being effective in improving both motor behaviour as well as in initiating cortical alterations. Regimes such as mirror therapy, mental imagery, robotics, virtual training, body weight-support treadmill training, and non-invasive brain stimulation are other contemporary methods that may induce motor and neural changes.[2],[3],[4]
‘Neuroplasticity’, or the ability of the brain to reorganize itself, is the underpinning mechanism responsible for the effectiveness of majority of these techniques. Thus, the biomarkers of neuroplasticity have become the benchmarks for endorsing the neuro-motor therapies. The principles of the effectiveness of motor therapy, such as its intensity, repetitiveness, and specificity, have been established for evaluating physiological and structural changes at the cortical level. Further methods to successfully harness the neural reorganization are still being explored.
Abnormal synergy, that is, an abnormal association between movements of the paretic limb, is the key challenge in post-stroke motor rehabilitation.[5] During the subject's effort to move one joint, the movements at other joints also occur involuntarily. Some of the motor therapies target the unusual linkage of the movements, whereas others focus on task-specificity or neural activation. The ultimate goal is to enhance voluntary motor control. The effort to enhance anti-synergistic movements also lessens the influence of spasticity, a passive phenomenon.
Pradhan and Bansal [6] have reported the role of corrected-assisted-synchronized-periodic (CASP) therapy among post-stroke subjects in the present issue of Neurology India. Passive as well as synchronized active movements are the key components of the novel technique. Need-based assistance was also provided either by the therapist or the trained care-taker. In contrast to the recently published stroke-rehabilitation studies, the objective of this investigation was to determine the effectiveness of the protocol of CASP therapy on spasticity reduction, muscle strength and functional independence.
Post-stroke motor recovery and the persistence of spasticity are distinctive phenomena. The recovery is linked to adaptive neuroplasticity that may be induced by the rehabilitative manoeuvres introduced. On the other hand, spasticity, being the product of hyperexcitability of the reflex arc, occurs due to maladaptive plasticity.[7] In the last few decades, prominent post-stroke rehabilitation studies have focused on enhancing the motor control through various behavioural regimes, supplemented by pharmacological interventions to deal with the associated spasticity. The abnormal synergy rather than spasticity is considered to be the major culprit in hampering the daily tasks, such as reaching for objects.(Really? Hadn't heard that before. What is the protocol to correct?) In research on neurorehabilitation, there is a paradigm shift towards improving motor control rather than working towards achieving an improvement in the muscle tone dysfunction. In comparison to working towards achieving a voluntary motor control, the focus on improving inherent muscle weakness is usually considered secondary in the management of patients. The training for improving muscle weakness is the focus of the last or chronic stage of recovery. Progressive resistance exercise is the preferred method to augment the strength of a weak muscle among patients who have had a stroke.[8]
The application of passive movement in stroke rehabilitation is primarily based on the principles of biomechanics; the objective of the movement is to maintain the length of soft tissues. The intention to apply passive movements is applicable during the chronic stage and should be used cautiously, preferably in a self-assistive manner, and only in the absence of active movements. The concern would be to avoid the induction of the stretch reflex that has the effect of increasing the muscle tone. One needs to be cautious especially during the therapist- or self-assistive passive over-head abduction or during the performing of the complete range of movement of the shoulder joint. Such movements are strongly contraindicated as they may precipitate shoulder subluxation, a common and challenging post-stroke complication. Once this shoulder subluxation occurs, the malalignment is difficult to reduce by the available rehabilitative methods. Further, the subluxation impedes motor as well as functional recovery of the limb. In such subjects, a favourable alteration in the motor performance is not exhibited in spite of an adequate cortical recovery. Rather, the individual may further experience soft tissue injuries, such as complete tear of the supraspinatus, with or without shoulder pain.
The appropriate execution of therapeutic movements, especially the passive movements, has been a factor of concern in rehabilitation. The approach of the techniques of application of passive movements may vary between the therapists, irrespective of the underlying common therapeutic principle that governs all these techniques. Thus, the trained care-taker may be considered as an important confounder in any rehabilitation trial. Furthermore, the compliance of the subject as well as the care-taker in successfully carrying out the domiciliary program set for them, is often not good, and therefore, ensuring that the program is being successfully carried out warrants a stringent vigilance.
In addition to the motor therapy, the lower limb demands an assistive device in the form of an ankle- foot orthosis.[9] The support retains the ankle in a dorsiflexed position during various static and dynamic positions; for instance, for the positions of sitting-to-standing, standing, and walking. The orthosis allows for the establishment of a symmetrical and efficient gait pattern, besides ensuring a proper loading on the lower limb joints. These favourable effects of the orthosis could easily be exploited throughout the daily functional tasks, thus permitting the achievement of better biomechanical response than is possible by the exercise regimen alone.
The introduction of motor therapy inevitably reduces the need for a pharmacotherapeutic agent for the spastic muscles. However, the transient effect of the drugs should be utilized during movement training. Pharmacotherapy should be judiciously administered based upon the severity of the spasticity.
The corrected-assisted-synchronized-periodic (CASP) investigators [6] have carefully designed the protocol to counter the post stroke deforming position of the limb, especially the one that hampers the performance of a combination of movements. The intervention has some components of robotic therapy and proprioceptive neuromuscular facilitation (PNF; an advanced form of flexibility training involving both stretching and contraction of the muscle groups being focused upon). The intensity and frequency of the neurorehabilitation program, often matters of significant concern for the therapist, are being taken care of in a calibrated manner by the expensive robotic system. The therapist-guided specific movement pattern is the corner stone of PNF; however, the evidence for achieving improvement in patients who are undergoing post stroke rehabilitation utilizing this protocol is weak.
The goal of rehabilitation varies with the chronicity of stroke. In the present investigation,[6] the authors recruited subjects with the average post stroke duration of 17 months. The neural-based motor recovery usually retards after one year of the stroke onset. Therapeutic interventions in the form of bilateral movement performance, performance of active movements, the functional usage of limbs, weight bearing on lower limbs, and encouraging mobility of limbs may be beneficial during the chronic stage of stroke. The approach often prevents the occurrence of common complications such as an asymmetrical posture and gait, the development of contractures as well as deformities, the occurrence of frequent falls, and the exacerbation of functional dependence of patients undergoing rehabilitation so that they are confined to a wheelchair or bed.
After stroke, the motor recovery progresses typically and hierarchically in a pattern of stages. The recovery evolves from flaccid to reflexive, from a synergistic state to a state of mixed synergy, and from an out-of-synergy stage to a near-to-normal awkward stage. A thorough understanding and recognition of these patterns forms the foundation of any motor-rehabilitation program. The measures, such as Brunnstrom recovery stages and Fugl-Meyer assessment, based on the hierarchic model of recovery, are vastly applied in research as well as in clinical practice.[10] These measures discern the issue of abnormal synergy and its interference with motor recovery. In contrast, the principles of manual muscle testing cannot be applied in a majority of the post-stroke subjects due to the presence of abnormal synergy and/or spasticity. Further, stroke–specific functional measures, such as the Wolf motor function test, is also getting due attention for determining the upper limb functional deficits. Generic functional measures only provide a level of independence, irrespective of the method of performance. A hemiparetic subject may be independent in all the activities of daily living with the help of the non-paretic limb.
In spite of introduction of a variety of motor programs and a plethora of evidence existing related to the benefits of stroke rehabilitation, the endeavours to robustly manage motor impairment are still crucial. The assessment of biomarkers and the principles of both neuroplasticity and biomechanics should be given due consideration in planning and applying any motor intervention for the rapidly growing population of post-stroke survivors. In the current era, stroke rehabilitation should focus on motor recovery induced by cortical alterations. Further investigations must be based on the systematically compiled and well-comprehended concepts of neuroscience.
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