doi: 10.1161/01.STR.0000054630.33395.E2
(Stroke. 2003;34:365.)
© 2003 American Heart Association, Inc.
Advances in Stroke 2002 |
Stroke Recovery and Rehabilitation
From the Department of Physical Medicine and Rehabilitation, St Joseph’s Health Care London, Parkwood Hospital, Lawson Health Research Institute, University of Western Ontario, London, Ontario, Canada.
Correspondence to Robert Teasell, University of Western Ontario, London Health Sciences Center, Physical Medicine and Rehabilitation, 339 Windermere Rd, London, Ontario N6A 5A5, Canada. E-mail robert.teasell{at}lhsc.on.ca
Key Words: magnetic resonance imaging; • functional • recovery • rehabilitation • reorganization • stroke
One of the most exciting areas of stroke research is our increasing understanding of the brain’s plasticity and the ability of rehabilitation to influence neurological recovery and subsequently impact clinical outcomes. Pomeroy and Tallis1 note, "The recent revolution in our understanding of the nervous system as being soft-wired, of the potential for recovery through reorganization and of the central role of afferent information is ground for optimism."
Stroke Recovery
Numerous theories and hypothesis have been forwarded to explain the neurological recovery seen after an acute stroke. Functional brain imaging has offered an opportunity to visualize cerebral activation associated with recovery from a stroke. Functional MRI, PET, and transcranial magnetic stimulation are now being used to demonstrate activation after stroke associated with specific stimuli or tasks.2
Studies examining recovery of the affected upper extremity with rehabilitation therapies have shown distinct patterns of cortical reorganization. The predominate pattern, which correlates with therapy-related improvements in upper extremity movement, involves increases in fMRI activity in the premotor cortex and secondary somatosensory cortex contralateral to the affected arm and in the superior posterior regions of the cerebellum bilaterally.3 Stroke patients not only show this extended activation on the contralateral side, but unlike controls they also activate the ipsilateral motor cortex.4 Feydy et al5 were able to demonstrate that the nature of the lesion played a role in the development of cortical reorganization; involvement of the primary motor cortex resulted in increased ipsilateral activation, whereas sparing of the primary motor cortex resulted in increased contralateral sensorimotor cortex involvement. Cramer et al6 used fMRI to study unilateral stroke patients with chronic hemiplegia that spared regions of motor cortex. Activation in stroke-affected hemisphere was evaluated by stimuli/activities independent of the stroke-affected corticospinal tract. Stroke patients activated surviving cortical regions with similar frequency as controls, generally with a smaller activation volume. After a chronic hemiplegic stroke, surviving motor cortex demonstrated preserved activation for upper extremity sensorimotor functions.
Functional brain imaging has also been used in aphasic patients. Not unexpectedly, there is predominance of the left hemisphere over the right in language functions; however, language recovery depends on the restitution of the speech-relevant network that involves both hemispheres.7
Stroke Rehabilitation
Stroke rehabilitation research has enjoyed a renaissance over the past decade. A recent review of the stroke rehabilitation literature discovered 270 randomized controlled trials looking specifically at issues that involved rehabilitation of stroke patients through 2001.8 What was most remarkable was the breathtaking and exponential pace at which randomized controlled trials (RCTs) in stroke rehabilitation are being undertaken; the results from almost 100 RCTs were published from 1997 to 2001 alone.
Pettersen et al9 found that after stroke rehabilitation, deterioration occurs as a consequence of concomitant chronic disabling disorders and recurrent strokes; otherwise, patients tend to remain within their own home with >80% still doing so at 3 years. The tools we have come to rely on, the FIM and Barthel Indices, may underestimate the impact of stroke; new tools like the Stroke Impact Scale, which measure quality of life, seem to be more inclusive, with the finding that "recovered" stroke still had a negative impact on a variety of functional activities.10
There is now strong evidence when comparing RCTs that greater intensity of aphasia therapy results in improved outcomes as opposed to less intense therapy, where there seems to be little or no benefit.11 Cauraugh and Kim12 demonstrated the benefits of coupling different motor recovery treatments to improve motor outcomes after stroke. Pewrala et al13 found cutaneous stimulation combined with inpatient rehabilitation in the paretic upper extremity significantly improved motor performance and upper limb sensation. Along similar lines, Werner et al14 found treadmill training with partial body weight support accelerated restoration of gait ability in chronic nonambulatory stroke patients compared with treadmill training alone. Combining therapies, greater intensities of therapy, and increasing overall afferent input as mechanisms of improving after stroke recovery along with functional imaging studies demonstrate the brain’s plasticity and potential for recovery after stroke.
Early supported discharge, providing interdisciplinary rehabilitation in the home instead of in a hospital, seems to offer the same benefits as an in-hospital stroke rehabilitation unit, but this concept has only been tested in a less severely disabled stroke patient population. A systematic review found that such an approach could potentially save hospital beds, with a 15% reduction in overall mean costs in that subset.15
A recent Cochrane review16 reported that care pathways in stroke units actually resulted in significantly lower patient satisfaction and quality of life. The authors noted, "There is currently insufficient supporting evidence to justify routine implementation of care pathways for ... stroke rehabilitation." This was confirmed by Hoenig et al,17 who found the structure of care (systemic organization, staffing expertise, and technological sophistication) was not associated with better functional outcomes, whereas compliance with AHCPR poststroke rehabilitation guidelines improved those same outcomes. This apparent paradox may signify the importance of using evidence or guidelines to assist rehabilitation clinicians in individualizing the rehab of stroke patients as opposed to a "one size fits all" approach.
It has long been known that improved social support improves outcomes, and although not studied yet in a formal RCT, the evidence that social support improves outcomes has been impressive. Grant et al18 in an RCT examining a social problem-solving telephone partnership intervention acquired better problem-solving skills, less depression, greater caregiver preparedness, and significant gains in social functioning and emotional health. The importance of social support in community reintegration continues to be an underestimated factor.
Despite the explosion of clinical stroke rehabilitation research, there remain many important unanswered questions. The next few years promise to be an exciting time in stroke rehabilitation research.
Footnotes
The opinions expressed in this editorial are not necessarily those of the editors or of the American Stroke Association.
Received December 11, 2002; accepted December 11, 2002.
References
1. Pomeroy V, Tallis R. Neurological rehabilitation: a science struggling to come of age. Physiother Res Int. 2002; 7: 76–89.[CrossRef][Medline] [Order article via Infotrieve]
2. Thirumala P, Hier DB, Patel P. Motor recovery after stroke: lessons from functional brain imaging. Neurol Res. 2002; 24: 453–458.[CrossRef][Medline] [Order article via Infotrieve]
3. Johansen-Berg H, Dawed H, Guy C, Smith SM, Wade DT, Matthews PM. Correlation between motor improvements and altered fMRI activity during rehabilitative therapy. Brain. 2002; 125(pt 12): 2731–2742.
4. Kato H, Izumiyama M, Koisumi H, Takahashi A, Itoyama Y. Near infrared spectroscopic topography as a tool to monitor motor reorganization after hemiparetic stroke: a comparison with functional MRI. Stroke. 2002; 33: 2032–2036.
5. Feydy A, Carlier R, Roby-Brami A, Bussel B, Caalis F, Pierot L, Burnott Y, Maier MA. Longitudinal study of motor recovery after stroke: recruitment and focusing of brain activation. Stroke. 2002; 33: 1610–1617.
6. Cramer SC, Mark A, Barquist K, Nhan H, Stegbauer KC, Price R, Bell K, Odderson IR, Esselman P, Maravilla KR. Motor cortex activation is preserved in patients with chronic hemiplegic stroke. Ann Neurol. 2002; 52: 607–616.[CrossRef][Medline] [Order article via Infotrieve]
7. Kuest J, Karbe H. Cortical activation studies in aphasia. Curr Neurol Neurosci Rep. 2002; 2: 511–515.[Medline] [Order article via Infotrieve]
8. Teasell RW, Doherty T, Speechley M, Foley N, Bhogal SK. Evidence-Based Review of Stroke Rehabilitation. Heart and Stroke Foundation of Ontario and Ministry of Health and Long-Term Care of Ontario, 2002. Available at http://www.sjhc.london.on.ca/parkwood/ebrsr/ebrsr/htm.
9. Pettersen R, Dahl T, Wyller TB. Prediction of long-term functional outcome after stroke rehabilitation. Clin Rehabil. 2002; 16: 149–159.
10. Lai SM, Studenski S, Duncan PW, Perera S. Persisting consequences of stroke measured by the Stroke Impact Scale. Stroke. 2002; 33: 1840–1844.
11. Bhogal S, Teasell R, Speechley M. Intensity of aphasia therapy impact on recovery. Stroke. In press.
12. Cauraugh JH, Kim S. Two coupled motor recovery protocols are better than one: electromyogram-triggered neuromuscular stimulation and bilateral movements. Stroke. 2002; 33: 1589–1594.
13. Pewrala SH, Pittanen K, Sivenius J, Tarkka IM. Cutaneous electrical stimulation may enhance sensorimotor recovery in chronic stroke. Clin Rehabil. 2002; 16: 705–716.
14. Werner C, Bardeleben A, Mauritz KH, Kirker S, Hesse S. Treadmill training with partial body weight support and physiotherapy in stroke patients: a preliminary comparison. Eur J Neurol. 2002; 9: 639–644.[CrossRef][Medline] [Order article via Infotrieve]
15. Anderson C, Ni Mhurchn C, Brown PM, Carter K. Stroke rehabilitation services to accelerate hospital discharge and provide home-based care: an overview and cost analysis. Pharmacoeconomics. 2002; 20: 537–552.[CrossRef][Medline] [Order article via Infotrieve]
16. Kwan J, Sandercock P. In-hospital care pathways for stroke. Cochrane Database Syst Rev. 2002; CD002924.
17. Hoenig H, Duncan PW, Horner RD, Reker DM, Samsa GP, Dudley TK, Hamilton BB. Structure, process, and outcomes in stroke rehabilitation. Med Care. 2002; 40: 1036–1047.[CrossRef][Medline] [Order article via Infotrieve]
18. Grant JS, Elliott TR, Wesaver M, Bartolucci AA, Giger J. Telephone intervention with family caregivers of stroke survivors after rehabilitation. Stroke. 2002; 33: 2060–2065.
This article has been cited by other articles:
 |
|
 |
|
  S. Svensson, U. Sonn, and K. S. Sunnerhagen Reliability and validity of the Northwick Park Dependency Score (NPDS) Swedish version 6.0 Clinical Rehabilitation, April 1, 2005; 19(4): 419 - 425. [Abstract] [PDF]
|
|
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||