Highlights on recent advances and approaches in Stroke rehabilitation

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A stroke occurs when the blood supply to part of your brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients. Brain cells begins to die in minutes. A stroke is a medical emergency, and prompt treatment is crucial. Early intervention can reduce permanent brain damage and other complications.

Stroke leads to affectations in every aspects of occupational performance (namely performance areas, performance components and performance context). Therapist can take guidance of 'Occupational therapy practice framework : Domains and Process' (OTPF) to understand and examine different domains and direct intervention towards specific problem areas. Ultimately, the central goal is to assist patient in achieving health, well-being and participation in life through engagement in occupation.

STROKE REHABILITATION : (This article will focus on the highlights of various approaches and interventions that should be used for stroke patients and also should be documented)

 Fig : Function of different lobes of brain (image taken from Pinterest)

A) Based on Contemporary approach or newer approaches : these approaches focuses on client-centered model, Top-Down intervention pattern, based on Heteroarchical organization, patient's active participation and motor-relearning principles to achieve functional movements and goals. But now a days, new approaches are combined with traditional approaches with emphasis placed on motor relearning principles to achieve functional movements. Intervention can be planned according to any one or combination of approaches namely : 

• Model of human occupation (MOHO) approach
• Motor Relearning Principle (MRP) approach
• Ecological approaches (it includes 3 different approaches namely Person-Environment-Occupation [PEO] model, the Person-Environment-Occupational Performance [PEOP] model and Ecology of Human Performance [EHP] 
• Task-oriented Approach and Functional training approach
• Canadian Model of  Occupational Performance and Engagement (CMOP-E)
• Occupational Adaptation approach

B) Occupational Therapy intervention approach: In documentation of therapy process these approaches should be mentioned because it becomes easy for the other healthcare person to understand what intervention type is focused for the patient with respect to his condition. Names of these approaches are:

1. Remedial and restoration approach
2. Compensatory or adaptation approach
3. Disability prevention and maintenance approach 
4. Skill acquisition and training approach
5. Environment Modification approach
6. Educational approach
   
7. Cognitive approach : What kind of cognitive approach to be used depends of patient's learning capabilities, chronicity and severity of disorder. It includes : 

• Cognitive disability approach and Neurofunctional approach (develop splinter skills) for severe stroke patients
• Cognitive retraining approach, Dynamic Interactional approach and Quadraphonic approach for mild to moderately affected stroke patients who has a scope for learning and retraining for lost function by developing new or alternate strategies.
  

C) Based on Traditional theories or approaches : these approaches are based on Bottom-Up approach and Hierarchal control of movements. Here, patient is a passive recipient of therapy and intervention is provided in developmental sequences (i.e from proximal to  distal) 

• Rood's approach or neurophysiological approach
• Neurodevelopmental approach (NDT)
• Proprioceptive Neuromuscular Facilitation (PNF)
• Sensory Integration (SI)
• Brunnstrom approach

(To know more about differences between Traditional Approaches and Contemporary Approaches, click on the following link : https://otpthealthcarerehab.blogspot.com/2020/07/rehabilitation-approaches-traditional.html )

On which areas does intervention focuses on during rehabilitation of Stroke patients ? 

What type of intervention to be given is decided after assessment of performance areas, components and context. Clinical reasoning and evidence based practise is important for decision making related to therapy protocol. Intervention varies with respect to patients dependency (FIM Scale scores) and cognitive levels (Allen Cognitive level). Intervention's focus includes :

• task-specific training to regain competence for specific meaningful activity.
• a repetitive task oriented program to regain body skills
• gaining strength and control
• education concerning safety issues in home or external environment
• home and activity adaptation

• need for social support 
• check for availability of community resources ( like wheelchair, cane, transportation and accessibility)
• performance areas namely BADL/ IADL, work, play, social participation, psychosocial aspect, context/environment 

All the above areas are treated by following intervention method:

• doing remediation of impairments or 
• teaching compensation/develop alternate strategy or give adaptation/adaptive devices. 
• environment modification by altering, adapting, creating a healthy just right practice environment for improving occupational performance and quality of life. Environment can be physical, social, cultural, legal, economical, virtual environments. 

GOAL is to :

• decrease supervision and dependency in activities of daily living
• decrease amount of time needed to complete task 
• increasing efficiency and task flexibility in various context
• transfer of training and learning
• improve quality of life
  

For treating Cognitive areas work on patients :

• By improving their self awareness about cognitive or visual perceptual problems. It can be done by teaching and practising various techniques like mental imagery, verbalization, self-cueing, situational strategies, self-monitoring strategies. Feedback about his/ her performance should also be provided intermittently. 
• For visual-perceptual disorder : Teaching self monitoring strategies which includes anticipation of error causing situations, checking or double checking activity, pacing response in familiar and unfamiliar environment, stimulus reduction i.e avoiding clutters and organizing daily used objects in specific patterns. Teaching situational strategies which includes scanning of things or environment in an organized manner (taking your own time), visually imagining the object patient is searching for, verbalizing the shape or colour or size or thickness of object patient is searching for. All these strategies will reduce confusion, decrease time for searching things, improve self esteem of patient, reduce chances of mistakes and dependency on others. 
  
• making use of remedial or compensatory approaches for training cognitive areas like attention, memory, executive functions, neglect, apraxia, concentration.

For treating Sensorimotor areas work on patient by :

• giving balance training : facilitate equilibrium reactions, protective extension reactions, postural control training on static and dynamic surfaces
• practising transfer of training in different environment. Challenging the task by bring variations in speed, time and environmental barriers.
• giving flexibility training and strengthening exercises. Teaching self-stretching or manual stretching techniques to relatives to improve range of motion. Facial muscles and oro-motor exercises and its facilitation. Deep breathing exercises to improve respiratory capacity. Facial splint (for UMN facial palsy) to prevent asymmetry or deviation of affected side.
• Mirror therapy : a mirror is used to create a reflection of the unaffected arm or leg in place of affected limbs. When the unaffected limb is moved, the mirror image "tricks" the brain into thinking that the affected limb is moving. This illusion has said to cause changes in the brain that helps person recover their mobility.
• Neurodevelopmental techniques : encourage normal movement pattern and inhibit abnormal movement patterns. Weight-bearing exercises in quadruped position to improve co-contraction, control and strength of scapular, shoulder, elbow musculature plus helps in normalising tone and prevent elbow, wrist and finger flexors contracture or tightness. Manual assistance to be given to patients when practising functional upper-limb or lower-limb movements during any activity.
• Proprioceptive Neuromuscular facilitation : utilizes mass movement patterns that are spiral and diagonal. These movements patterns mimics the gross movments patterns used for peforming daily activities. It provides multimodal sensations to body.
• Rood's techniques : sensorimotor facilitatory and inhibitory techniques.
• Sensory Integration : it emphasizes importance of sensory input to promote normal posture and reflexes.
• Joint protection techniques, energy conservation techniques so that patient does not overstress the joints. Due to functional impairments these patients has to put extra efforts and energy to complete the task thus there are chances of overburdening muscles, early tiredness 
• Normalization of tone by prescribing splints, educate about upper and lower limb anti-deformity positions.
• Educating patients about energy conservation techniques (ECT). In stroke or hemorrhage there are signs of paralysis or weakness and impaired voluntary control of the unilateral side of the body initially, which is followed by development of spasticity, muscle tightness. Patient is not able to generate sufficient force (muscle force and motor neurons recruitment) which produces movements effective in controlling the body position in space. These pathological changes cause debilitating fatigue and muscle weakness since patients has to put extra effort and energy to perform activities, thus often greatly limiting activity performance. (click on the link to know more about ECT : Importance of ECT in daily living )

Recent advances and newer approaches in stroke rehabilitation: these advances have evidence of bringing cortical reorganization after regular practice.

• Constrained Induced Movement therapy (CIMT) for upper limb : forced use of affected upper limbs in daily activities.
• Virtual Reality : it is a computer based, interactive, multi-sensory stimulatory environment that occurs in real time and allows for increased intensity of training while providing augmented sensory feedback. It mimic the features and visual images of real life thus making it fun and interesting for patient to continue with therapy.

• Music therapy has been shown to help improve motor skills and therefore can be used during gait training to help stroke survivors improve their walking ability. For example, playing familiar music with a strong beat and having patients walk in time with it may help fix their uneven gait or enable them to walk further and faster than they could without music. The response of mood to music may be conscious or subconscious. Music can be helpful to evoke past memories and interpersonal connections. Positive feeling has been effective in Stroke recovery. 
• Melodic Intonation Therapy (MIT) is a technique which uses a person with aphasia’s unaffected ability to sing familiar songs, in order to teach them how to sing and eventually generate speech output of functional phrases through the use of the melodic and rhythmic elements of speech. Evidence has shown that by using the stepwise process of MIT, the brain is able to bypass damaged left-hemisphere networks and engage right-hemisphere language resources via the rerouting of speech pathways, therefore aiding in the restoration of propositional speech. It was effective for patients with non-fluent Aphasia (Broca's Aphasia)
• Robotic therapy : it is used to improve performance of selective arm movement and control by using different robotic devices like ARMEO (for arm), AMADEO ( for finger and hand motion). This devices can be combined with virtual reality games.
• High technology for Lower extremity gait and balance training : Body weight support treadmill training (BWSTT), Robowalk, Biodex balance system. 
• Functional Electric stimulation (FES) applied within 2 months of stroke showed statistically significant benefits in ADL performance but no significant benefit if applied 1 year after stroke. FES for facial muscle stimulation. Evidence shows that it improved Facial muscle strength and oral functions.
• Computer application for cognitive rehabilitation :  various software that are available are RehaCom, MIRA Rehab, ARMEO. It involves interesting computer games in software program which boosts patients motivation and also provides immediate feedback to the patient and therapists about the performance and progress.
• EMG - Biofeedback: Electromyographic biofeedback (techniques using visual or sound signals to monitor muscle activity) has an uncertain impact on recovery after stroke. Electromyographic biofeedback (EMG-BFB) uses electrodes placed on a patient's muscles to generate a feedback signal (in vision or sound) in response to muscle activation. It is believed that this may allow patients to learn a more effective way of using their disabled limb. It can be used to improve range of motion, gain muscle control and improve gait patterns.
• Hydrotherapy, also known as aquatic therapy or aqua therapy, is a type of recreational therapy that includes completing exercises in a therapy pool. Here, most of the body is submerged in water and the natural buoyancy of water reduces the body weight of the patient. The viscosity of water provides resistance when the body moves, and the pressure of the water on the body forces the body to work harder to circulate blood. As a result, patients get an excellent strength and cardio workout while simultaneously protecting their joints and cushioning their bodies from falls. It helps the stroke patients to improve gait pattern, range of motion, cardiovascular health, muscle strength. It also brings about muscle relaxation and pain relief since therapy is taken under warm or room temperature water.

Training specially applied to Upper limb functioning and motor control like interlimb transfer, bimanual/ bilateral arm training, CIMT, ARMEO, AMADEO. Teaching one-handed techniques to substitute for lack of skills in affected side by teaching, augmenting and practising body skills of nonaffected side by training in tying shoelace, cutting food, signing name, performing simple task, manipulating items.

Consideration for Disability certificate : it can be temporary or permanent certificate based on the duration of impairment, dependency levels in activities of daily living, sensorimotor impairments, presence of deformity, cognitive functioning. Disability should be 40 % and above to avail government benefits and provision of adaptive facility subsidy. 

Thankyou for reading!!!

( Dr.Ashwini Sangar, Dr. Sheetal Tatar-Dhande, Dr. Pallavi Khadse-Kolhe)

REFERENCES:

• Cognitive and percetual dysfunction : A clinical reasoning approach to evaluation and intervention. Carolyn Unsworth.
• Willard and Spackman's Occupational Therapy. (11th edition)
• Evidence collected from various RCTs  and systematic studies on Stroke rehabilitation
• Neurological Rehabilitation: Darcy Ann Umphred