Recovery of Body Awareness After Stroke: An Observational Study

The extremely obvious question is: WHOM is going to do the research that will create a rehab protocol that increases body awareness?  But nothing will occur. We have NO stroke leadership or strategy.

Recovery of Body Awareness After Stroke: An Observational Study

Ines Serrada^*, Brenton Hordacre and Susan Hillier

• Allied Health and Human Performance, Innovation, Implementation and Clinical Translation in Health, University of South Australia, Adelaide, SA, Australia

Background: Body awareness (BA) is a process that involves sensory awareness originating from the body's physiological states, processes and actions, and is shaped by one's attitudes, perceptions, beliefs and experience of social and cultural context. Impairments in body awareness after stroke are believed to be common and may be an important influence on recovery outcomes. However, recovery of body awareness is poorly understood and receives little consideration in rehabilitation.

Aims: To investigate if body awareness changes over time following stroke; and identify if body awareness after stroke is associated with sensation, motor impairment, self-efficacy and quality of life.

Methods: An exploratory longitudinal observational study was performed. Participants with a stroke diagnosis and associated motor impairment were recruited from an acute stroke unit. An assessment battery consisting of sensory and motor impairment and function, body awareness, self-efficacy and quality of life measures were used at baseline, 1, 3 and 6 months.

Results: A total of 105 people with stroke were recruited. Most recovery in sensation and body awareness occurred within the first month after stroke (all p < 0.01). Sensation and body awareness were correlated with other clinical outcomes (motor impairment, self-efficacy and quality of life), demographics, and stroke specific clinical characteristics (all p < 0.01).

Conclusions: This is the first study to track recovery of body awareness after stroke and investigate the relationship it may have in recovery of sensation, motor impairment and function, self-efficacy and quality of life. Further research is now warranted to continue investigation of body awareness and to develop effective stroke-specific assessment and intervention strategies.

Introduction

Body awareness is considered an interactive process that includes awareness of the body's physiological states, processes (including pain and emotion) and actions (including movement), and is shaped by an individual's attitudes, perceptions, beliefs and social/cultural context experiences (1) (p.2). The nature of impairments post-stroke would suggest that body awareness may likely be impacted in stroke survivors how this has received little attention in the literature.

Awareness has been proposed to develop from a body schema (unconscious representation of the position of the body in space plus the position of sensation on the body surface) (2–31), and body image (a conscious representation of one's self) (2, 3, 7–10, 13, 17, 19, 32–34).

Considering recent literature, the triadic model has been proposed to further explain the nature and properties of body representations. The triadic model retains the dyadic (schema and image) notion however subdivides body image into two further representations: body structural descriptions and body semantics. Body structure describes a topological map primarily derived from visual input but also somatic perception. It provides a structural description of the relationships between body parts boundaries, proximity and relative position (2, 9, 12, 15, 25–28, 35–38). Body semantics describes the relationship between words and meaning and represents semantic and lexical information about the body (including functions of body parts, associations between body parts and objects, and body part names) (9, 12, 15, 25–28, 35–40).

The importance of body awareness lies in its' role in constantly monitoring, updating and providing feedback about the position and movement of one's body through space. It is also the main process used in integrating information for perception, decision making and action, making accurate body information essential for the precise control of movements (10, 41). The neuroanatomical basis influencing body awareness is understood to include an integrated system of brain regions and functional networks. The main regions within the somatosensory network (and important for body schema) are found primarily in the parietal cortex (SI and SII) as well as the thalamus, insula and cerebellum (50, 75, 94). A more distributed network, including attention and visual networks, is involved in the conscious processing of somatosensory information (50, 75, 95). Information processing of sensation for perception, and sensation for action, is described to involve both parallel and serial processing (75). It is important to note that all senses (exteroception and interoception) feed into the representation/s. Furthermore, body image involves affective and memory input from the limbic system and the semantic and lexical aspects require input from the language and spatial areas of the parietal lobes in their respective hemispheres.

Intact body awareness is thought to be a major factor that supports motor function and recovery of individuals following stroke (10, 41). One in two people experience impairments in sensation and perception after a stroke which interrupts the representation of the body that is held in the brain (42) and has a profound impact on an individual's body awareness (43–46). Altered motor and sensory cortical processing leads to inaccurate body information which can manifest in many different ways such as altered perception of limb size, position, shape or weight. This impairs the precision and control of one's movements (including postural control, dynamic balance, coordination) and the individual's ability to explore the immediate environment safely (41, 43–45). Subsequently it affects one's functional abilities, execution of daily activities and quality of life (35, 41, 47–49), making simple actions such as preparing breakfast, taking a shower or going for a walk challenging (10, 40). Further, reduced body awareness often interferes with the duration of rehabilitation and discharge destination (43, 45, 50).

Emphasising further the important role of body awareness in stroke recovery, body awareness training has been linked to positive rehabilitation outcomes, particularly with balance and mobility (51–53). However, we currently have little understanding of body awareness during stroke recovery or whether it is important for enabling behavioural restitution. While much work has been focussed on initial motor impairment, structural damage and the neurobiological course of the recovery process (54), little attention has been directed to body awareness (43). Indeed, from sensory and motor impairment studies, research suggests recovery is most marked within the first 3 months after stroke, although ongoing recovery can be observed at 6 months and later (54–56). In particular, evidence from sensory rehabilitation studies have indicated the potential for marked recovery from months to years after stroke (43), and body awareness similarly may continue to evolve over the first 2 years (7, 49). There is some suggestion that individuals within the first 2–6 months direct their attention toward the way their body functions and try to find new ways to manage daily activities and actions. Subsequently from 6 to 12 months the focus shifts to forming an understanding and acceptance of their bodily changes (7).

The purpose of this study was to first investigate if body awareness is impaired after a stroke and if it recovers over time, and second, identify if body awareness is associated with sensation, motor impairment, self-efficacy and quality of life. It was hypothesised that body awareness will initially be impaired after stroke, improve within the first few months and will be associated with improvements in motor, sensory and quality of life measures.