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(added on the order of how presentation can go. Feel free to edit/add on to what's already on here)

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MEET @ 12:30 IN MRSC ATRIUM ON TUESDAY (26/02)

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MEET @ 12:30 IN MRSC ATRIUM ON TUESDAY (26/02)

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okur

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MRSC Atrium

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Global Burden of Stroke

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The Bobath Concept in Contemporary Clinical Practice

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OT Potential * Occupational Therapy Resources

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If you work in physical rehabilitation, you've probably noticed a major shift in thinking regarding stroke rehab.

These days, it's generally accepted that high-intensity dosing is vital for optimum recovery following strokes. The problem is that achieving these high-dosage levels is extremely difficult using traditional techniques.

While the demand for increased dosage continues to grow, contextual and job-related demands remain the same. That makes the problem of meeting intensity demands-without increasing physical strain on therapists-a major challenge.
Active-assistive robotic therapy is changing that.
If you're an occupational therapist, physical therapist, or physician, active-assistive robotic therapy could make a difference in your patients' lives. Here is what you need to know about active-assistive robotic therapy, current evidence supporting its use, and the major systems on the market today.

Active-assistive robotic therapy-also known as "robotic therapy," or "robot-assisted therapy"-simply refers to the use of a robotic device in therapy.

But let's take a step back and define what a robot actually is.

A robot is essentially a machine capable of performing complex tasks and actions-usually with an advanced level of speed and precision.

Robots vary in complexity and intelligence, and many people use them on a daily basis in their career fields. Some examples of robotic technologies might include industrial robotics in the car industry (which are designed for safer manufacturing processes), security and law enforcement-aiding robots, and robot-assisted surgical devices (including minimally invasive and remote surgery platforms).

Rehabilitation robots are their own breed.

Rehabilitation robots are intelligent devices that use sensors to monitor human movement and positioning, then use this feedback in order to interact with the environment.

These active-assistive robotic technologies are not only effective as clinical interventions, but can also help with assessments. Many of them are capable of measuring and storing parameters of patient function which can aid in long-term clinical evaluation. With the ability to detect and measure small changes in movements and forces, these devices can assist therapists in the process of treatment planning and goal setting.

What types of robotic therapy devices are out there?

Rehabilitation robotic devices fall into two categories: upper extremity (UE) and lower extremity (LE) systems.

LE rehabilitation robots include:

Exoskeleton devices

Foot orthoses

In-clinic body-weight support systems, such as:

Treadmill gait trainers

Stationary gait trainers

Foot-plate gait trainers

Overground gait trainers [8]

There are two types of UE rehabilitation robots:

1. Portable assistive devices or orthoses for the hand or arm

2. In-clinic devices used in occupational or physical therapy

Few portable devices are available today, but many choices are available for use in the clinic.

Major in-clinic upper extremity systems

There are two general types of in-clinic robotic therapy systems: exoskeletons and end-effectors.

End-effector systems offer a faster setup and greater adaptability when compared to exoskeleton devices, which instead offer more precise joint isolation. End-effectors usually make contact with the limb at the distal end of the device, utilizing a hand rest or arm cradle to support the affected UE.

Exoskeleton systems mirror the structure of the human skeleton and joint movements. Exoskeletons offer more precise control of joints, but they also require a longer and more complex setup time, can be a bit larger, and may feel confining for some patients.

What evidence supports robotic therapy?

New evidence shows that there's a critical window in cortical plasticity during the first two weeks following a cerebral-vascular accident (CVA) [1].

This means that clinicians are tailoring stroke programs and interventions earlier in the rehabilitation process, and they are increasing both dosing and intensity.

Therapists are also integrating new technologies such as:

EMG/Biofeedback

FES (functional electrical stimulation)

Sensor-based systems

Virtual reality

Brain stimulation for neurological rehabilitation

New evidence suggests that by increasing the number of motor repetitions earlier in the rehabilitation process, patients will enjoy improved UE functional recovery [1]. Active-assistive robotic therapy is a promising technology to address intensity and dosing in UE motor training.

In addition:

Driven by new requirements for earlier, more intensive training in stroke rehabilitation, the use of active-assistive robotic therapy is becoming increasingly common in clinical therapy settings.

How can active-assistive robotic therapy help our patients?

It provides forced use of the affected upper extremity

A review of the evidence surrounding constraint-induced movement therapy (CIMT) following stroke (such as the EXCITE trial) reveals many potential benefits of robotic therapy.

For instance, while CIMT is effective for higher-level patients with active movement in the wrist and hand, it has its limitations when used in the clinic with lower-level patients who have greater motor impairments. This has generally meant that more impaired patients miss out on the benefits of CIMT.

But one of the best applications of active-assistive robotic therapy platforms, such as the Barrett UE Robotic Trainer (BURT), is that it allows patients with trace-to-poor motor function in the upper extremity-ones who are usually considered too low-level to participate in traditional CIMT treatment-the opportunity to benefit from this type of forced-use intervention.

It creates proper intensity and dosing

Intensity is the name of the game in current clinical research. A 2012 study by John Krakauer found that animal test subjects required 400 motor repetitions per session to facilitate optimum changes in neuroplasticity following stroke [1].

But to achieve this level of high-intensity task dosing, clinicians face a dilemma: How can you meet the current standards of research and best practice-without increasing physical strain on therapists, leaving other clinical priorities unfulfilled, or breaking the rigid rules for therapy time in the clinic?

Active-assistive robotic therapies can help by providing high-dose, task-repetitive movements, while minimizing therapist fatigue and strain.

It enables gravity-eliminated planes and graded assistance

Do you ever wish that it were easier to work in gravity-eliminated planes when performing one-on-one treatments?

Upper extremity motor learning follows a natural progression-from passive to active movement, and from gravity-eliminated movements to movements against gravity. UE robots that target the shoulder let patients work in gravity-eliminated planes of the shoulder complex. Therapists can do this without compromising posture or being restricted to a tabletop surface.

Some systems even allow therapists to isolate the planes of movement associated with synergistic and reflexive movement patterns. Active robotic assistance can be graded across a spectrum, from passive range of motion (PROM) to active-assistive (AAROM) and active range of motion (AROM), individualizing each patient's needs to maximize motor gains.

It promotes targeted and individualized treatment

Every patient is different, with different treatment needs, and occupational therapists are constantly looking for that "just right" challenge for each and every one of their patients. With active-assistive robotic therapy, you can be picky about detailed task parameters, cues, and visual stimuli, and you'll be able to create individualized performance feedback options.

Robotic systems also offer targeted interventions to the shoulder, elbow and forearm, or hand. During robotic therapy, patients experience a sense of increased independence in the early phases of therapeutic treatment, increasing patient initiation and encouraging early volitional movement.

In traditional interventions, especially in inpatient settings, UE motor training can be limited if you don't have a second person to assist with the treatments. Active-assistive robotic therapies help to provide a sensory-rich environment and targeted individualized treatments-without the risk of therapist fatigue.

What should we consider when purchasing robotic devices?

With several rehabilitation robotics companies in the market, UE active-assistive robotic therapy devices are becoming increasingly affordable. Here are a few factors to consider when looking at these devices.

What's the cost?

Consider what your facility wants to invest in technology. One of the major critiques of robot-assisted therapy has been the cost; however, one analysis concluded that there was very little difference in cost between using active-assistive robotic therapy, compared to traditional intensive therapy [6]. Many rehabilitation robots have a sticker price of six figures, with exoskeletons tending to be the most expensive. In an effort to make rehabilitation robots more accessible to patients and clinics, some device manufacturers, like Barrett Technology, are coming in around $60,000.

Is the user interface engaging?

One of the major strengths of these devices is they increase patient engagement. Make sure that the games the system offers are fun and motivating for your patents.

What area do I want to target?

Devices may target the hand, wrist, elbow, shoulder complex, or a combination of these.

Does the device have the features you want?

Pay attention to the available range of motion (ROM) and anatomical movements the device features. Active-assistive robotic therapy devices may include some or all of these features:

Active exercise

Active robotic assistive exercise

Passive exercise

Gravity elimination

Haptic features (typically vibration or resistance)

Coaching feedback [7]

Also, ask if the device has features to combat tone/reflexive movement, and inquire about any additional cognitive features. Ask about setup time, and then ask yourself whether the time required is appropriate for your facility, given your setting and therapy time constraints.

What types of robotic rehabilitation devices are out there?

The Barrett Upper Extremity Robotic Trainer (BURT)

BURT is a rehabilitation robot for the shoulder complex and elbow that was designed based on the latest research on high-intensity repetitions and dosage.

This active-assistive robotic therapy tool is designed as a supplement to UE neuromuscular re-education, providing gravity-elimination and robotic active-assistance to the shoulder complex. BURT provides three anatomical planes of movement to the shoulder, and you can grade UE exercise across the motor learning spectrum, from PROM to AAROM and AROM.

BURT is highly adaptable, can be set up in less than five minutes, and can be easily moved to accommodate the patient. BURT includes a gaming system that motivates patients and is highly customizable; it supports therapist task-grading with features such as easy modification of cognitive stimuli, set and therapist-controlled initiation of robotic assistance, vibration, and visual feedback. BURT also aids in training normative functional movement patterns in the presence of reflexive synergies, by setting the precise isolation of a desired functional movement.

BURT isn't just for treatment of stroke. The device provides UE ROM and repetitive motor training, which therapists can use to treat other diagnoses such as traumatic brain injury, spinal cord injury, and Parkinson's disease.

The InMotion ARM and Motorika ReoGo

The ARM and Motorika ReoGo are end-effector robots for the shoulder and elbow. The former is a well-studied clinical edition of the original MIT-Manus robot, which performs robotic assistance and resistance in two anatomical planes of movement. Additional hand and wrist attachments are available.

The Motorika ReoGo has a large distal point-one that resembles a joystick-upon which the patient's hand rests. The device applies active or passive assistance to the shoulder complex. (Hand and wrist attachments are available.)

Tyromotion Diego

The Tyromotion Diego is a cable-driven bilateral device for adults and children. It has harness support at the wrist and forearm, which provides active-assisted shoulder flexion and extension.

Exoskeletons

Exoskeletons include the Armeo Power and Armeo Spring. Upper extremity exoskeletons are large mechanical devices that encompass the arm and hand and have multiple, precise attachment points between the anatomical joints and kinematic structure [9].

The Armeo Power provides robotic assistance for patients with more densely impaired motor functions, and it offers many advanced, research-grade features. The Armeo Spring provides gravity elimination for volitional movement, with no robotic assistance.

Portable assistive devices and orthoses

There are just a few robotic orthoses and portable devices on the market. The Hand of Hope and Tyromotion Amadeo are active-assistive robotic exoskeleton hands that attach to a workstation. The Hand Mentor Pro system is a distal semi-portable robotic device for the wrist and hand. The Myomo Myopro is a custom wearable myoelectric robotic orthosis for the elbow, wrist, and hand.

Rehabilitation trends are certainly changing.

Now that we know that cortical reorganization peaks in those first two weeks post-CVA, rehab interventions are adapting to increase intensity and dosage as quickly as possible. The movement toward earlier and more intensive task-repetitive training can put stress on therapists who are striving to balance patients' needs with safety and other workplace demands.

Active-assistive robotic therapy can meet these needs by providing high-intensity treatment, without causing physical strain to therapists.These new technologies offer new opportunities for increasing patient engagement, improving patient outcomes, and providing a way to keep therapists healthy and injury-free in the process.

About the Author

Holly Mitchell, OTR, is clinical manager at Barrett Technology a Newton, Massachusetts-based manufacturer of the Barrett UE Robotic Trainer (BURT), an active-assistive robotic therapy system for the treatment of stroke and UE motor rehabilitation. She is an occupational therapist and member of AOTA with experience in the inpatient clinical rehabilitation setting. Holly has worked with neurological and orthopedic conditions and has additional training in stroke and prosthetic rehabilitation. She combines her passion for writing, rehabilitation and adaptive technologies in the OT Corner Blog. She is an alumna of the Bay Path University Master of Occupational Therapy (MOT) program in Longmeadow, MA.

References

Krakauer, J. W., Carmichael, S. T., Corbett, D., & Wittenberg, G. F. (2012). Getting Neurorehabilitation Right - What Can We Learn From Animal Models? Neurorehabilitation and Neural Repair, 26(8), 923-931. http://doi.org/10.1177/1545968312440745

Kim, G., Lim, S., Kim, H., Lee, B., Seo, S., Cho, K., & Lee, W. (2017). Is robot-assisted therapy effective in upper extremity recovery in early stage stroke? -a systematic literature review. Journal of Physical Therapy Science, 29(6), 1108-1112. http://doi.org/10.1589/jpts.29.1108

Teasell, R., Foley, N., Salter, K., Bhogal, S., Jutai, J., & Speechley, M. (2016). Evidence-Based Review of Stroke Rehabilitation: Executive Summary, 17th Edition. Topics in Stroke Rehabilitation: 17th edition.

Saposnik, G., Teasell, R., Mamdani, M., Hall, J., McIlroy, W., & Cheung, D. (2010). Effectiveness of Virtual Reality Using Wii Gaming Technology in Stroke Rehabilitation: A Pilot Randomized Clinical Trial and Proof of Principle. Stroke, 41(7), 1477-1484. doi:10.1161/strokeaha.110.584979

Wolf, S. L., Thompson, P. A., Winstein, C. J., Miller, J. P., Blanton, S. R., Nichols-Larsen, D. S., ... Sawaki, L. (2010). The EXCITE Stroke Trial: Comparing Early and Delayed Constraint-Induced Movement Therapy. Stroke, 41(10), 2309-2315. doi:10.1161/strokeaha.110.588723

Wagner, T. H., Lo, A. C., Peduzzi, P., Bravata, D. M., Huang, G. D., Krebs, H. I., ... Guarino, P. D. (2011). An Economic Analysis of Robot-Assisted Therapy for Long-Term Upper-Limb Impairment After Stroke. Stroke, 42(9), 2630-2632. doi:10.1161/strokeaha.110.606442

Maciejasz, P., Eschweiler, J., Gerlach-Hahn, K., Jansen-Troy, A., & Leonhardt, S. (2014). A survey on robotic devices for upper limb rehabilitation. Journal of NeuroEngineering and Rehabilitation, 11(1), 3. doi:10.1186/1743-0003-11-3

Díaz, I., Gil, J. J., & Sánchez, E. (2011). Lower-Limb Robotic Rehabilitation: Literature Review and Challenges. Journal of Robotics, 2011, 1-11. doi:10.1155/2011/759764

Jarrassé, N., Proietti, T., Crocher, V., Robertson, J., Sahbani, A., Morel, G., & Roby-Brami, A. (2014). Robotic Exoskeletons: A Perspective for the Rehabilitation of Arm Coordination in Stroke Patients. Frontiers in Human Neuroscience, 8, 947. http://doi.org/10.3389/fnhum.2014.00947

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Robotic Therapy Is on the Rise. Here's Why.

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If you work in physical rehabilitation, you've probably noticed a major shift in thinking regarding stroke rehab. These days, it's generally accepted that high-intensity dosing is vital for optimum recovery following strokes. The problem is that achieving these high-dosage levels is extremely difficult using traditional techniques.

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Robot-assisted Therapy in Stroke Rehabilitation

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Introduction and background

As physicians, we are most often asked two questions after a patient suffers from a stroke: "How am I going to return to my work, pay my bills, and get my life back in order?" and "What caused my stroke?" Many patients, especially young adults, are surprised to learn that their current job may actually have contributed to the risk factors leading to stroke, particularly since their occupation is often directly related to their lifestyle and is one of the determinants as to how much daily physical activity and inactivity is involved. Thus, the understanding that one's occupation may be a stroke-related risk is an issue that physicians often need to address with their patients in clinical practice. According to Harvey Cushing, "A physician is obligated to consider more than a diseased organ, more even than the whole man - he must view the man in his world." There is a rising concern to understand the risk factors of stroke in young adults due to the high negative impact on the productivity of young adults, mainly because it has a disproportionately large economic impact by leaving victims disabled during their most productive years [ 1]. Furthermore, while there are rising figures of stroke incidence in young adults (ages: 20 - 54) [ 2], studies have shown that etiology remains unknown in 30% - 40% of these patients. However, modifiable risk factors, such as physical activity, account for a large part of stroke occurrence in younger adults with four risk factors (high blood pressure, diabetes, smoking, and high LDL (low-density lipoprotein) levels) explaining almost 80% of stroke risk [ 3]. Regular physical activity can help lower elevated blood pressure, reduce LDL, and better regulate blood glucose in diabetes.

The first presentation of losing motor control over a body part or changing sensation in a young adult is very worrisome and would be considered an alarming sign to seek medical attention; the patient usually requests to know about the causes, as well as risk factors, of the condition. In fact, risk factors related to lifestyle and physical activity are becoming more popular among the general population. Moreover, there is a growing concern about the health aspects of the work type and working conditions.

There is a growing interest in identifying stroke risk factors linked to performing certain types of jobs, e.g., jobs with high physical demand such as construction and mining jobs. Furthermore, returning stroke patients to these jobs may intervene in the rehabilitation process. For instance, low physical activity jobs and a high-strain work environment could have a specific role initially, as well as an assessment of recovery post-stroke. This paper explores whether there is a significant role or not in this regard, as well as expected clinical implications of this role.

Review

There has been increasing interest in the rising figures of stroke incidents in working young adults. According to one transversal retrospective study which analyzed electronic medical records (EMR) data during a four-year period for 134 patients aged 18 - 45, the average age of stroke patients appeared to be 33 years, and the majority were females (56%) [ 4]. However, the proportion of the first-ever stroke in young adults differed from country to country, ranging from < 5% to 20% of all strokes [ 1]. Another issue is multiple and variable risk factors leading to stroke in young adults which may require an individualized approach. One study examining the contribution of established potentially modifiable cardiovascular risk factors to the burden of stroke in young adults concluded that there were eight risk factors which explained 78.9% (95% confidence interval (CI), 76.3 - 81.4) of all strokes. However, low physical activity and hypertension were the most critical risk factors, accounting for 59.7% (95% CI, 56.3 - 63.2) and 27.1% (95% CI, 23.6 - 30.6), respectively, of all strokes [ 3].

Work environment has changed remarkably during the last two decades, and with more technological advancement in work fields, there is less need for physical effort at most types of jobs. As a result, less physically active job types are increasing. This, therefore, may contribute to obesity and thereby increase stroke risks. Furthermore, there is the additional challenge for workers in operations to maximize their work output. Therefore, an additional mental strain is added to perform well in current work fields. For instance, according to a meta-analysis study done using three databases (Pubmed, Embase, and PsychINFO), there were six prospective cohort studies comprising a total of 138,782 participants. The results showed an increase in stroke risk with high-strain jobs (relative risk (RR) 1.22, 95% CI 1.01 - 1.47) and were significant in women (RR 1.33, 95% CI 1.04 - 1.69) in comparison to men (RR 1.26, 95% CI 0.69 - 2.27). There was a lower risk with low-strain jobs regardless of gender type [ 5].

Physical activity/vascular accidents relationship model

There is a diverse relationship between physical activity and vascular accidents. For instance, one study about the relationship of physical activity and vascular incidents concluded that an inverse relationship was evident: the more the patient was physically active, the less he/she would develop vascular accidents, particularly peripheral vascular accidents [ 6]. The study analyzed the data of 16,446 patients using univariate and multivariate-adjusted logistic regression analysis. The data included the occupational physical activity intensity, measurement of the brachial-ankle index, health history, physical examinations, medication use, and blood biochemistry of the 16,446 subjects from nine areas throughout China. They classified the jobs into five categories depending on physical activity intensity of the job (jobless, very light, light, moderate, and heavy intensity). The results of the analysis showed that a steady reduction of peripheral vascular disease was correlated with an increase in physical activity intensity. When compared to the jobless group, the odds ratio (OR) for the other study groups was 0.65 (95% CI: 0.52, 0.82), 0.70 (95% CI: 0.56, 0.87), 0.57 (95% CI: 0.44, 0.73), and 0.65 (95% CI: 0.53, 0.80), respectively. However, when an analysis was done with an adjustment for gender, age, smoking, obesity/overweight, history of hypertension, hypercholesterolemia, diabetes, cardiovascular disease, and stroke, it showed OR 1.02 (95% CI: 0.80, 1.31), 0.91 (95% CI: 0.72, 1.15), 0.92 (95% CI: 0.70, 1.19), and 0.90 (95% CI: 0.72, 1.12), respectively (P trend < 0.05). The conclusion of this study attributed to occupational physical activity and peripheral vascular disease. However, direct analysis between occupational physical activity and stroke, specifically, was not included in this study [ 6].

The role of stress in vascular accidents

In their systemic review article, Huang et al. revealed their findings of the molecular contribution of acute stress hormones with vascular accidents, particularly cardiovascular accidents, in 2013, four years after a similar review. The article relied on sympathetic-adrenal-medullary (SAM) axis activation where the catecholamines, norepinephrine (NE) and epinephrine (EPI), played a significant role in cardiovascular response and rising vascular accident risks, which we elaborated in Figure below [ 7].

In contrary, physical activity as a stress relieving factor also assessed in associated with a reduction of mortality according to a prospective cohort study that surveyed 13,241 person-months with a follow-up period of 71.96 months. Primarily, physical activity measured with accelerometry (ActiGraph 7164, ActiGraph, LLC, Pensacola, FL) and stroke incidents were reported with self-report of physician diagnosis. Interestingly, it showed for every 60 minutes/day increase in total physical activity there was a reduction of 28% of all-cause mortality related to stroke [ 8]. Additional validation for the positive impact of physical activity on stroke risk, as well as the degree of insult, was revealed in a subanalysis of data from a randomized clinical trial done in 2017 where patients with high pre-stroke physical activity (mainly treated with t-PA) had a reduction in the size of infarct growth in 24 hours, as well as the final infarct size [ 9].

Post-stroke occupational physical activity

The predictive factors for recovery potential were enhanced in relation to the motor function recovery process, and the algorithm utilized to support this finding was the Predict Recovery Potential (PREP) algorithm, where it modified therapy content and increased rehabilitation efficiency after stroke without compromising clinical outcome [ 10]. Therefore, prediction models for motor function recovery, particularly for the upper limb (UL), were revealed by a cross-sectional study that included 104 stroke patients with first-ever stroke and impaired motor function in the upper extremity. The findings were that models including grip strength or finger extension gave the most accurate predictions, with an overall predictive ability of 90.4% (95% CI 0.847 - 0.961) and a sensitivity of 92.9% (95% CI 0.851 - 1.0) and 90.5% (95% CI 0.816 - 0.979), respectively [ 11]. Recovery time and ability to regain motor function were used to guide rehabilitation and post-stroke recommendations. For instance, when the insult occurs in the brain white matter, we expect a poorer recovery over time [ 12]. However, some genetic variation and behavioral factors showed a positive influence on recovery (for instance, compensatory movement strategies developed after motor impairment through neural remodeling responses) [ 13]. When the condition became chronic, the similar use of dominant and nondominant ULs was evident, according to the Bailey et al. 2015 study [ 14].

The role of physical activity required in a job type not only influences stroke management and rehabilitation, it has, in addition, an important role in stroke prevention [ 15]. Furthermore, it augments public health efforts in the alleviation of long-term impact, especially among older workers [ 16]. Moreover, the nature of the job activity also helps in the management of the post-stroke state. For instance, during the recovery period from stroke, physical activity alone is considered an essential factor for improving motor functions, and this conclusion is confirmed through measurement of the brain-derived neurotrophic factor (BDNF). In fact, neuroplasticity recovery appeared to be positively influenced by aerobic exercise and also associated with the rise in BDNF [ 17].

The extreme form of physical activity (fast and strong action in a short duration) in some job types, e.g., mining jobs, has another positive influence in post-stroke skills retention. In fact, one study including 22 motor stroke patients showed that a single bout of high-intensity interval training performed for 15 minutes immediately after motor practice improved skill retention, thus, potentially accelerating motor recovery in these individuals [ 18].

Occupational choice in stroke

There was one study done to elucidate the relationship between exercise and brain tissue injury after cerebral ischemia in adult rats [ 19]. It showed that after clamping the middle cerebral artery of rats and subjecting them to exercises in a specific time frame there was a rising expression of pro-inflammatory cytokines (intercellular adhesion molecule-1 (ICAM-1), vascular adhesion molecule-1 (VCAM-1), tumour necrosis factor (TNF)-α, and interleukin (IL)-1β), as well as cell stress markers (heat shock protein 70 (HSP70) and hypoxia-inducible factor 1α (HIF-1α)), within three days post-clamping; however, there was less expression of these molecules if the patient began exercising after three days post-insult. While the physician's decision on returning patients to the same pre-stroke job is judged by the patient's ability to perform the job functions, the degree of physical activity allowed in the specific job should be timed so that it does not occur too early after the insult.

Also, motor function and cognitive task ability required to achieve the tasks influence the choice of the job after stroke. Interestingly, according to a cross-sectional study done in 2017, patients with chronic stroke showed that cognitive tasks had a more significant influence than the motor tasks when patients were assessed during the completion of the study requirement. In other words, patients with chronic stroke tend to prioritize task accuracy and completion over maintaining activity speed [ 20].

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Occupational Physical Activity in Young Adults and Stroke: Was It Due to My Job?

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As physicians, we are most often asked two questions after a patient suffers from a stroke: "How am I going to return to my work, pay my bills, and get my life back in order?" and "What caused my stroke?"

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Occupational Therapy Interventions for Adults With Stroke | American Journal of Occupational Therapy

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My Beautiful Broken Brain | Netflix Official Site

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After suffering a stroke at age 34, a woman documents her struggles, setbacks and eventual breakthrough as she relearns to speak, read and write. Watch trailers & learn more.

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In the United States more than 700,000 people suffer a stroke each year, and approximately two-thirds of these individuals survive and require rehabilitation. The goals of rehabilitation are to help survivors become as independent as possible and to attain the best possible quality of life. Even though rehabilitation does not "cure" the effects of stroke in that it does not reverse brain damage, rehabilitation can substantially help people achieve the best possible long-term outcome.

Rehabilitation helps stroke survivors relearn skills that are lost when part of the brain is damaged. For example, these skills can include coordinating leg movements in order to walk or carrying out the steps involved in any complex activity. Rehabilitation also teaches survivors new ways of performing tasks to circumvent or compensate for any residual disabilities. Individuals may need to learn how to bathe and dress using only one hand, or how to communicate effectively when their ability to use language has been compromised. There is a strong consensus among rehabilitation experts that the most important element in any rehabilitation program is carefully directed,well-focused, repetitive practice-the same kind of practice used by all people when they learn a new skill, such as playing the piano or pitching a baseball.

Rehabilitative therapy begins in the acute-care hospital after the person's overall condition has been stabilized, often within 24 to 48 hours after the stroke. The first steps involve promoting independent movement because many individuals are paralyzed or seriously weakened. Patients are prompted to change positions frequently while lying in bed and to engage in passive or active range of motion exercises to strengthen their stroke-impaired limbs. ("Passive" range-of-motion exercises are those in which the therapist actively helps the patient move a limb repeatedly, whereas "active" exercises are performed by the patient with no physical assistance from the therapist.) Depending on many factors-including the extent of the initial injury-patients may progress from sitting up and being moved between the bed and a chair to standing, bearing their own weight, and walking, with or without assistance. Rehabilitation nurses and therapists help patients who are able to perform progressively more complex and demanding tasks, such as bathing, dressing, and using a toilet, and they encourage patients to begin using their stroke-impaired limbs while engaging in those tasks. Beginning to reacquire the ability to carry out these basic activities of daily living represents the first stage in a stroke survivor's return to independence.

For some stroke survivors, rehabilitation will be an ongoing process to maintain and refine skills and could involve working with specialists for months or years after the stroke.

The types and degrees of disability that follow a stroke depend upon which area of the brain is damaged. Generally, stroke can cause five types of disabilities: paralysis or problems controlling movement; sensory disturbances including pain; problems using or understanding language; problems with thinking and memory; and emotional disturbances.

Paralysis or problems controlling movement (motor control)

Paralysis is one of the most common disabilities resulting from stroke. The paralysis is usually on the side of the body opposite the side of the brain damaged by stroke, and may affect the face, an arm, a leg, or the entire side of the body. This one-sided paralysis is called hemiplegia (one-sided weakness is called hemiparesis). Stroke patients with hemiparesis or hemiplegia may have difficulty with everyday activities such as walking or grasping objects. Some stroke patients have problems with swallowing, called dysphagia, due to damage to the part of the brain that controls the muscles for swallowing. Damage to a lower part of the brain, the cerebellum, can affect the body's ability to coordinate movement, a disability called ataxia, leading to problems with body posture, walking, and balance.

Sensory disturbances including pain

Stroke patients may lose the ability to feel touch, pain, temperature, or position. Sensory deficits also may hinder the ability to recognize objects that patients are holding and can even be severe enough to cause loss of recognition of one's own limb. Some stroke patients experience pain, numbness or odd sensations of tingling or prickling in paralyzed or weakened limbs, a symptom known as paresthesias.

The loss of urinary continence is fairly common immediately after a stroke and often results from a combination of sensory and motor deficits. Stroke survivors may lose the ability to sense the need to urinate or the ability to control bladder muscles. Some may lack enough mobility to reach a toilet in time. Loss of bowel control or constipation also may occur. Permanent incontinence after a stroke is uncommon, but even a temporary loss of bowel or bladder control can be emotionally difficult for stroke survivors.

Stroke survivors frequently have a variety of chronic pain syndromes resulting from stroke-induced damage to the nervous system (neuropathic pain). In some stroke patients, pathways for sensation in the brain are damaged, causing the transmission of false signals that result in the sensation of pain in a limb or side of the body that has the sensory deficit. The most common of these pain syndromes is called "thalamic pain syndrome" (caused by a stroke to the thalamus, which processes sensory information from the body to the brain), which can be difficult to treat even with medications. Finally, some pain that occurs after stroke is not due to nervous system damage, but rather to mechanical problems caused by the weakness from the stroke. Patients who have a seriously weakened or paralyzed arm commonly experience moderate to severe pain that radiates outward from the shoulder. Most often, the pain results from lack of movement in a joint that has been immobilized for a prolonged period of time (such as having your arm or shoulder in a cast for weeks) and the tendons and ligaments around the joint become fixed in one position. This is commonly called a "frozen" joint; "passive" movement (the joint is gently moved or flexed by a therapist or caregiver rather than by the individual) at the joint in a paralyzed limb is essential to prevent painful "freezing" and to allow easy movement if and when voluntary motor strength returns.

Problems using or understanding language (aphasia)

At least one-fourth of all stroke survivors experience language impairments, involving the ability to speak, write, and understand spoken and written language. A stroke-induced injury to any of the brain's language-control centers can severely impair verbal communication. The dominant centers for language are in the left side of the brain for right-handed individuals and many left-handers as well. Damage to a language center located on the dominant side of the brain, known as Broca's area, causes expressive aphasia. People with this type of aphasia have difficulty conveying their thoughts through words or writing. They lose the ability to speak the words they are thinking and to put words together in coherent, grammatically correct sentences. In contrast, damage to a language center located in a rear portion of the brain, called Wernicke's area, results in receptive aphasia. People with this condition have difficulty understanding spoken or written language and often have incoherent speech. Although they can form grammatically correct sentences, their utterances are often devoid of meaning. The most severe form of aphasia, global aphasia, is caused by extensive damage to several areas of the brain involved in language function. People with global aphasia lose nearly all their linguistic abilities; they cannot understand language or use it to convey thought.

Problems with thinking and memory

Stroke can cause damage to parts of the brain responsible for memory, learning, and awareness. Stroke survivors may have dramatically shortened attention spans or may experience deficits in short-term memory. Individuals also may lose their ability to make plans, comprehend meaning, learn new tasks, or engage in other complex mental activities. Two fairly common deficits resulting from stroke are anosognosia, an inability to acknowledge the reality of the physical impairments resulting from stroke, and neglect, the loss of the ability to respond to objects or sensory stimuli located on the stroke-impaired side. Stroke survivors who develop apraxia (loss of ability to carry out a learned purposeful movement) cannot plan the steps involved in a complex task and act on them in the proper sequence. Stroke survivors with apraxia also may have problems following a set of instructions. Apraxia appears to be caused by a disruption of the subtle connections that exist between thought and action.

Emotional disturbances

Many people who survive a stroke feel fear, anxiety, frustration, anger, sadness, and a sense of grief for their physical and mental losses. These feelings are a natural response to the psychological trauma of stroke. Some emotional disturbances and personality changes are caused by the physical effects of brain damage. Clinical depression, which is a sense of hopelessness that disrupts an individual's ability to function, appears to be the emotional disorder most commonly experienced by stroke survivors. Signs of clinical depression include sleep disturbances, a radical change in eating patterns that may lead to sudden weight loss or gain, lethargy, social withdrawal, irritability, fatigue, self-loathing, and suicidal thoughts. Post-stroke depression can be treated with antidepressant medications and psychological counseling.

Post-stroke rehabilitation involves physicians; rehabilitation nurses; physical, occupational, recreational, speech-language, and vocational therapists; and mental health professionals.

Physicians

Physicians have the primary responsibility for managing and coordinating the long-term care of stroke survivors, including recommending which rehabilitation programs will best address individual needs. Physicians also are responsible for caring for the stroke survivor's general health and providing guidance aimed at preventing a second stroke, such as controlling high blood pressure or diabetes and eliminating risk factors such as cigarette smoking, excessive weight, a high-cholesterol diet, and high alcohol consumption.

Neurologists usually lead acute-care stroke teams and direct patient care during hospitalization. They sometimes participate on the long-term rehabilitation team. Other subspecialists often lead the rehabilitation stage of care, especially physiatrists, who specialize in physical medicine and rehabilitation.

Rehabilitation nurses

Nurses specializing in rehabilitation help survivors relearn how to carry out the basic activities of daily living. They also educate survivors about routine health care, such as how to follow a medication schedule, how to care for the skin, how to move out of a bed and into a wheelchair, and special needs for people with diabetes. Rehabilitation nurses also work with survivors to reduce risk factors that may lead to a second stroke, and provide training for caregivers.

Nurses are closely involved in helping stroke survivors manage personal care issues, such as bathing and controlling incontinence. Most stroke survivors regain their ability to maintain continence, often with the help of strategies learned during rehabilitation. These strategies include strengthening pelvic muscles through special exercises and following a timed voiding schedule. If problems with incontinence continue, nurses can help caregivers learn to insert and manage catheters and to take special hygienic measures to prevent other incontinence-related health problems from developing.

Physical therapists

Physical therapists specialize in treating disabilities related to motor and sensory impairments. They are trained in all aspects of anatomy and physiology related to normal function, with an emphasis on movement. They assess the stroke survivor's strength, endurance, range of motion, gait abnormalities, and sensory deficits to design individualized rehabilitation programs aimed at regaining control over motor functions.

Physical therapists help survivors regain the use of stroke-impaired limbs, teach compensatory strategies to reduce the effect of remaining deficits, and establish ongoing exercise programs to help people retain their newly learned skills. Disabled people tend to avoid using impaired limbs, a behavior called learned non-use. However, the repetitive use of impaired limbs encourages brain plasticity and helps reduce disabilities.

Strategies used by physical therapists to encourage the use of impaired limbs include selective sensory stimulation such as tapping or stroking, active and passive range-of-motion exercises, and temporary restraint of healthy limbs while practicing motor tasks.

In general, physical therapy emphasizes practicing isolated movements, repeatedly changing from one kind of movement to another, and rehearsing complex movements that require a great deal of coordination and balance, such as walking up or down stairs or moving safely between obstacles. People too weak to bear their own weight can still practice repetitive movements during hydrotherapy (in which water provides sensory stimulation as well as weight support) or while being partially supported by a harness. A recent trend in physical therapy emphasizes the effectiveness of engaging in goal-directed activities, such as playing games, to promote coordination. Physical therapists frequently employ selective sensory stimulation to encourage use of impaired limbs and to help survivors with neglect regain awareness of stimuli on the neglected side of the body.

Occupational and recreational therapists

Like physical therapists, occupational therapists are concerned with improving motor and sensory abilities, and ensuring patient safety in the post-stroke period. They help survivors relearn skills needed for performing self-directed activities (also called occupations) such as personal grooming, preparing meals, and housecleaning. Therapists can teach some survivors how to adapt to driving and provide on-road training. They often teach people to divide a complex activity into its component parts, practice each part, and then perform the whole sequence of actions. This strategy can improve coordination and may help people with apraxia relearn how to carry out planned actions.

Occupational therapists also teach people how to develop compensatory strategies and change elements of their environment that limit activities of daily living. For example, people with the use of only one hand can substitute hook and loop fasteners (such as Velcro) for buttons on clothing. Occupational therapists also help people make changes in their homes to increase safety, remove barriers, and facilitate physical functioning, such as installing grab bars in bathrooms.

Recreational therapists help people with a variety of disabilities to develop and use their leisure time to enhance their health, independence, and quality of life.

Speech-language pathologists

Speech-language pathologists help stroke survivors with aphasia relearn how to use language or develop alternative means of communication. They also help people improve their ability to swallow, and they work with patients to develop problem-solving and social skills needed to cope with the after-effects of a stroke.

Many specialized therapeutic techniques have been developed to assist people with aphasia. Some forms of short-term therapy can improve comprehension rapidly. Intensive exercises such as repeating the therapist's words, practicing following directions, and doing reading or writing exercises form the cornerstone of language rehabilitation. Conversational coaching and rehearsal, as well as the development of prompts or cues to help people remember specific words, are sometimes beneficial. Speech-language pathologists also help stroke survivors develop strategies for circumventing language disabilities. These strategies can include the use of symbol boards or sign language. Recent advances in computer technology have spurred the development of new types of equipment to enhance communication.

Speech-language pathologists use special types of imaging techniques to study swallowing patterns of stroke survivors and identify the exact source of their impairment. Difficulties with swallowing have many possible causes, including a delayed swallowing reflex, an inability to manipulate food with the tongue, or an inability to detect food remaining lodged in the cheeks after swallowing. When the cause has been pinpointed, speech-language pathologists work with the individual to devise strategies to overcome or minimize the deficit. Sometimes, simply changing body position and improving posture during eating can bring about improvement. The texture of foods can be modified to make swallowing easier; for example, thin liquids, which often cause choking, can be thickened. Changing eating habits by taking small bites and chewing slowly can also help alleviate dysphagia.

Vocational therapists

Approximately one-fourth of all strokes occur in people between the ages of 45 and 65. For most people in this age group, returning to work is a major concern. Vocational therapists perform many of the same functions that ordinary career counselors do. They can help people with residual disabilities identify vocational strengths and develop résumés that highlight those strengths. They also can help identify potential employers, assist in specific job searches, and provide referrals to stroke vocational rehabilitation agencies.

Most important, vocational therapists educate disabled individuals about their rights and protections as defined by the Americans with Disabilities Act of 1990. This law requires employers to make "reasonable accommodations" for disabled employees. Vocational therapists frequently act as mediators between employers and employees to negotiate the provision of reasonable accommodations in the workplace.

Rehabilitation should begin as soon as a stroke patient is stable, sometimes within 24 to 48 hours after a stroke. This first stage of rehabilitation can occur within an acute-care hospital; however, it is very dependent on the unique circumstances of the individual patient.

Recently, in the largest stroke rehabilitation study in the United States, researchers compared two common techniques to help stroke patients improve their walking. Both methods-training on a body-weight supported treadmill or working on strength and balance exercises at home with a physical therapist-resulted in equal improvements in the individual's ability to walk by the end of one year. Researchers found that functional improvements could be seen as late as one year after the stroke, which goes against the conventional wisdom that most recovery is complete by 6 months. The trial showed that 52 percent of the participants made significant improvements in walking, everyday function and quality of life, regardless of how severe their impairment was, or whether they started the training at 2 or 6 months after the stroke.

At the time of discharge from the hospital, the stroke patient and family coordinate with hospital social workers to locate a suitable living arrangement. Many stroke survivors return home, but some move into some type of medical facility.

Inpatient rehabilitation units

Inpatient facilities may be freestanding or part of larger hospital complexes. Patients stay in the facility, usually for 2 to 3 weeks, and engage in a coordinated, intensive program of rehabilitation. Such programs often involve at least 3 hours of active therapy a day, 5 or 6 days a week. Inpatient facilities offer a comprehensive range of medical services, including full-time physician supervision and access to the full range of therapists specializing in post-stroke rehabilitation.

Outpatient units

Outpatient facilities are often part of a larger hospital complex and provide access to physicians and the full range of therapists specializing in stroke rehabilitation. Patients typically spend several hours, often 3 days each week, at the facility taking part in coordinated therapy sessions and return home at night. Comprehensive outpatient facilities frequently offer treatment programs as intense as those of inpatient facilities, but they also can offer less demanding regimens, depending on the patient's physical capacity.

Nursing facilities

Rehabilitative services available at nursing facilities are more variable than are those at inpatient and outpatient units. Skilled nursing facilities usually place a greater emphasis on rehabilitation, whereas traditional nursing homes emphasize residential care. In addition, fewer hours of therapy are offered compared to outpatient and inpatient rehabilitation units.

Home-based rehabilitation programs

Home rehabilitation allows for great flexibility so that patients can tailor their program of rehabilitation and follow individual schedules. Stroke survivors may participate in an intensive level of therapy several hours per week or follow a less demanding regimen. These arrangements are often best suited for people who require treatment by only one type of rehabilitation therapist. Patients dependent on Medicare coverage for their rehabilitation must meet Medicare's "homebound" requirements to qualify for such services; at this time lack of transportation is not a valid reason for home therapy. The major disadvantage of home-based rehabilitation programs is the lack of specialized equipment. However, undergoing treatment at home gives people the advantage of practicing skills and developing compensatory strategies in the context of their own living environment. In the recent stroke rehabilitation trial, intensive balance and strength rehabilitation in the home was equivalent to treadmill training at a rehabilitation facility in improving walking.

The National Institute of Neurological Disorders and Stroke (NINDS), a component of the U.S. National Institutes of Health (NIH), has primary responsibility for sponsoring research on disorders of the brain and nervous system, including the acute phase of stroke and the restoration of function after stroke. The NIH's Eunice Kennedy Shriver National Institute of Child Health and Human Development, through its National Center for Medical Rehabilitation Research, funds work on mechanisms of restoration and repair after stroke, as well as development of new approaches to rehabilitation and evaluation of outcomes. Most of the NIH-funded work on diagnosis and treatment of dysphagia is through the National Institute on Deafness and Other Communication Disorders. The National Institute of Biomedical Imaging and Bioengineering collaborates with NINDS and NICHD in developing new instrumentation for stroke treatment and rehabilitation. The National Eye Institute funds work directed at restoration of vision and rehabilitation for individuals with impaired or low vision that may be due to vascular disease or stroke.

The NINDS supports research on ways to enhance repair and regeneration of the central nervous system. Scientists funded by the NINDS are studying how the brain responds to experience or adapts to injury by reorganizing its functions (plasticity)-using noninvasive imaging technologies to map patterns of biological activity inside the brain. Other NINDS-sponsored scientists are looking at brain reorganization after stroke and determining whether specific rehabilitative techniques, such as constraint-induced movement therapy and transcranial magnetic stimulation, can stimulate brain plasticity, thereby improving motor function and decreasing disability. Other scientists are experimenting with implantation of neural stem cells, to see if these cells may be able to replace the cells that died as a result of a stroke.

*An ischemic stroke or "brain attack" occurs when brain cells die because of inadequate blood flow. When blood flow is interrupted, brain cells are robbed of vital supplies of oxygen and nutrients. About 80 percent of strokes are caused by the blockage of an artery in the neck or brain. A hemorrhagic stroke is caused by a burst blood vessel in the brain that causes bleeding into or around the brain.

**Functions compromised when a specific region of the brain is damaged by stroke can sometimes be taken over by other parts of the brain. This ability to adapt and change is known as neuroplasticity.

Where can I get more information?

For more information on neurological disorders or research programs funded by the National Institute of Neurological Disorders and Stroke, contact the Institute's Brain Resources and Information Network (BRAIN) at:

Information also is available from the following organizations:

Dallas, TX 75231-4596

Arlington, TX 76016

Washington, DC 20005

Centennial, CO 80112-3747

"Post-Stroke Fact Sheet", NINDS, Publication date September 2014.

NIH Publication No. 14-1846
Stroke fact sheet available in multiple languages through MedlinePlus
Back to Stroke Information
See a list of all NINDS disorders Publicaciones en Español Ataque Cerebral
Prepared by:
Office of Communications and Public Liaison
National Institute of Neurological Disorders and Stroke
National Institutes of Health
Bethesda, MD 20892

NINDS health-related material is provided for information purposes only and does not necessarily represent endorsement by or an official position of the National Institute of Neurological Disorders and Stroke or any other Federal agency. Advice on the treatment or care of an individual patient should be obtained through consultation with a physician who has examined that patient or is familiar with that patient's medical history.

All NINDS-prepared information is in the public domain and may be freely copied. Credit to the NINDS or the NIH is appreciated.

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What is post-stroke rehabilitation? What disabilities can result from a stroke? What medical professionals specialize in post-stroke rehabilitation? When can a stroke patient begin rehabilitation? Where can a stroke patient get rehabilitation? What research is being done? Where can I get more information?

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Emily Cane's dance career was cut short and now she has communication difficulties.

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A new project helps stroke survivors with communication difficulties through music and song.

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Based on the 28 bedded Stroke Unit at Leighton Hospital, Crewe, the rehabilitation therapy team introduced group therapy sessions as a project in September 2017 and audited the results.

Stroke therapy group sessions were implemented to:

Improve patients experience, improve the 24 hour rehabilitation approach-by increasing therapy input patients receive

Reduce patient time spent inactive on the ward

Promote rehabilitation to wider multi-disciplinary team (MDT)

Facilitate training of therapy assistants and junior members of the team in a supportive environment.

Key aims and objectives were set to measure the new stroke therapy group project against NICE guideline for stroke rehabilitation in adults: (CG162).

To measure the benefits of group therapy on improving patient contacts

To review the impact of group work on the 24 hour approach on the ward

To review the impact of group work on emotional support for patients.

To run a group for 5 days of the week to ascertain whether this is a realistic standard to achieve long term.

Achieve 45 minute treatment therapy treatments, and review practicality of groups being delivered additionally to this.

Intensity of stroke rehabilitation relates to NICE recommendation 1.2.16: Offer initially at least 45 minutes of each relevant stroke rehabilitation therapy for a minimum of 5 days per week to people who have the ability to participate, and where functional goals can be achieved.

If more rehabilitation is needed at a later stage, tailor the intensity to the person's needs at that time. This relates to NICE recommendation 1.2.17: Consider more than 45 minutes of each relevant stroke rehabilitation therapy 5 days per week for people who have the ability to participate and continue to make functional gains, and where functional goals can be achieved.

Repetitive task training relates to NICE recommendation 1.9.23: Offer people repetitive task training after stroke on a range of tasks for upper limb weakness (such as reaching, grasping, pointing, moving and manipulating objects in functional tasks) and lower limb weakness (such as sit-to-stand transfers, walking and using stairs).

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Therapy Stroke Groups: Improving patient activity on the Stroke unit and efficiency of the workforce

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Based on the 28 bedded Stroke Unit at Leighton Hospital, Crewe, the rehabilitation therapy team introduced group therapy sessions as a project in September 2017 and audited the results.

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https://www.ted.com/talks/jill_bolte_taylor_s_powerful_stroke_of_insight/discussion?nolanguage=nor

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Jill Bolte Taylor got a research opportunity few brain scientists would wish for: She had a massive stroke, and watched as her brain functions -- motion, speech, self-awareness -- shut down one by one. An astonishing story.

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Evidence Based Upper Limb Rehabilitaion after Stroke

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Evidence Based Upper Limb Rehabilitaion after Stroke

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Evidence Based Upper Limb Rehab After Stroke. Part 1

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Occupational Therapy Interventions for Adults with Stroke

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Cognitive Assessment (specifically for stroke patients)

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Cognitive Assessment (specifically for stroke patients)

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Administering the Oxford Cognitive Screen (OCS): A demonstration

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https://www.strokengine.ca/en/assess/

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Mirror Box Therapy &  NEUROPLASTICITY  Following Stroke