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Recovering Motor Function After Stroke
Stroke and Motor Learning
Strategies for Recovering Motor Function after Stroke
Strategies for Recovering Motor Function after Stroke
On an annual basis, close to a million U.S. citizens are hospitalized for stroke and their length of stay averages 5.3 days (NHLBI, 2013). Close to 60% of these are first time stroke patients. In terms of morbidity, stroke is responsible or 1.7 million Americans currently suffering from chronic physical and/or cognitive impairment. With nearly 80% of all stroke survivors suffering from limb impairment (reviewed by Thieme et al., 2012), there is a great need for remedial strategies that minimize the level of disability these patients suffer from. This report will review recent research in the area of upper limb rehabilitation strategies to better understand progress being made in this area of research.
Assessing Upper Limb Motor Impairment
As Higgins and colleagues (2011) discuss, there is a lack of standardization concerning functional evaluation of upper limbs following a stroke. To try and remedy this situation they developed an instrument designed to provide an accurate, score-based assessment of upper limb disability in stroke patients. The obvious advantages would be to create criteria that will allow doctors and researchers to establish baseline data and track the progress of rehabilitation efforts, and then directly compare patient data nationally and internationally.
Towards this goal, Higgins and colleagues (2011) collected assessment items from a number of different sources and combined them to create a prospective Stroke Arm Ladder. Some of the items included were how flexible arm and shoulder joints were, whether certain hand and arm manipulations could be demonstrated, and whether the patient could bathe and feed themselves or pick up a coin. The starting list contained 99 items and these were tested statistically...
Divergent and convergent validity was determined by comparing their findings to other tests and indices.
Using the ?2 and F. statistic, the 99 items were pared down to just 34 (Higgins, Finch, Kopec, and Mayo, 2011). Two important criteria used to test the items were (1) time since stroke event and (2) whether the item could be quantified numerically. Based on their analysis, time since stroke event was not a significant influence on item scores. This implied that the Stroke Arm Ladder can be used to assess upper limb function independent of time since stroke. Gender was also found to have little influence on item scores.
Some of the tasks on the final Stroke Arm Ladder included opening a jar or pill bottle, addressing and stamping an envelope, shrugging, picking up coins, bouncing a ball, clapping hands overhead and behind back, and clipping toenails (Higgins, Finch, Kopec, and Mayo, 2011). The Stroke Arm Ladder was also assessed for reliability, which is a measure of the instrument's ability to accurately determine a patient's disability severity, and sensitivity, which is a measure of the instrument's ability to detect differences between patients.
Based on their results, Higgins and colleagues (2011) argue that the Stroke Arm Ladder represents a reasonable prospective instrument for assessing the level of upper limb disability a stroke patient may be suffering from. However, further testing on patients and by randomized caregivers will be needed before the Stroke Arm Ladder will be ready for clinical use.
Retraining the Mind-Body Connection
A number of different strategies have been utilized to improve limb motor control following a stroke (reviewed by Thieme et al., 2012). These strategies include robotic training, biofeedback, electrical stimulation, and motor imagery. However, Thiele and colleagues (2012) argue that while…
All instruments, except the modified Ashworth Scale and Star Cancellation Test, revealed all treatment groups experienced significant improvement after 20 therapy sessions over the course of 5-week intervention (p < 0.002) (Thieme et al., 2012). In contrast to this finding, the Ashworth Scale and Star Cancellation Test revealed between group differences. The Ashworth scale, which is used to assess changes in passive finger and wrist movement resistance, revealed that individual mirror therapy patients experienced significant improvement in finger flexors (p < 0.001), but not for wrist flexors (p = 0.08) and that intergroup difference were significant for finger flexors only (p < 0.05). The Star Cancellation Test, which is designed to measure visuospatial neglect, revealed individual therapy patients improved significantly more compared to the control group (p < 0.01). Importantly, the five-week intervention reduced the level of visuospatial neglect experienced by individual and group patients, but the mock therapy group had increased visuospatial neglect. These findings suggest that individual mirror therapy can significantly reduce the magnitude of visuospatial neglect for the affected arm of a stroke patient.
A similar approach for improving a patient's mind-body connection is constraint-induced movement therapy (reviewed by Brunner, Skouen, and Strand, 2012). This is done by restricting the good arm during tasks requiring the use of an arm, thereby forcing the patient to rely more heavily on the impaired arm. In contrast, bilateral arm training is believed to be superior to constraint-induced therapy by some researchers based on the theory that both sides of the brain are required for proper retraining of the impaired arm.
To try and resolve this controversy, Brunner and colleagues (2012) conducted a randomized controlled study to directly compare the efficacy of both strategies. They found no statistically-significant difference between the two strategies for a number of tasks after 4 hours of training for 4 weeks. The outcomes were measured using the Action Research Arm Test, Nine-Hole Peg Test, and the Motor Activity Log and both treatment groups improved significantly by the post-treatment and 3-month follow-up assessments (p < 0.010-0.001). These findings suggest that either the constraint-induced movement or bilateral arm training therapy approaches are equally effective in improving the use of the impaired arm
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