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Rehabilitating the Brain > L3 - Current Principles of Motor Rehabilitation > Flashcards

L3 - Current Principles of Motor Rehabilitation Flashcards

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1
Q

Describe statistics for stroke recovery.

A

77% of stroke survivors will have upper limb symptoms after acute stroke and only 5-20% achieve full recovery of the paretic upper limb at 6 months.

70% is the general recovery rate. Some patients do not follow this recovery rule, and these tend to be the most impaired (rather than the highest functioning)

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2
Q

What is the corticospinal tract?

A

Pathway between the cortex and muscles.

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3
Q

If patients have damage to their corticospinal tract, what is the outlook?

A

No improvements in condition are possible through rehab.

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4
Q

Describe the signs post-stroke which increase the likelihood for full recovery (and decrease likelihood).

A

Patients showing some movement within the first 4 weeks post-stroke have more than 90% likelihood of improving.

Patients showing no movement within the first 4 weeks will be unlikely to show any recovery, less than 10% chance of improvement.

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5
Q

What is the critical period after a stroke called, and what is the duration?

A

Spontaneous recovery period - window of between 2 and 90 days.

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6
Q

What does the critical period allow for?

A

Aggressive neurorehabilitation when movement is apparent within the first 4 weeks.

Outside of this period, improvements are still possible but are much slower.

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7
Q

What is a stroke?

A

The prevention of blood flow to the brain due to a blood clot or bleeding on the brain, resulting in cell death.

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8
Q

What are the two types of stroke called, and what do they each refer to?

A

Ischemic - prevention of blood blow to the brain due to a blood clot

Haemorrhagic - prevention of blood flow in the brain due to bleeding on the brain.

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9
Q

What is the effect of time elapsed until post-stroke medication on stroke severity?

A

The longer the delay between stroke and medication, the more cell death.

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10
Q

Why do children have a higher chance of recovery after stroke?

A

There is greater scope for regeneration and replacement of dead cells, as neurogenesis still occurs in the brain. In older adults, neurogenesis no longer occurs so damaged cells cannot be replaced.

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11
Q

How soon after a stroke can rehab begin? What does this initial rehab typically focus on?

A

If medication is supplied within 3 hours post-stroke, rehab can be given as soon as possible - on the same day even.

Immediate rehab targets fine motor control, as this can be the most difficult part of rehab.

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12
Q

Which period is the most intensive for rehab?

A

The first 5/6 weeks - physical therapy takes place on 5/6 days each week (depending on the NHS)

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13
Q

When are the most improvements seen post stroke?

A

Within the first 3 months (2-90 days).

Due to spontaneous biological recovery, a natural repair process which does not require task-specific rehab.

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14
Q

What is spontaneous recovery?

A

A natural repair process post-stroke which does not require task-specific rehab, or any rehab at all!

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15
Q

Which neurological disorders has spontaneous recovery been observed in?

A

Only apparent after strokes.

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16
Q

What does the brain do automatically after a stroke, aside from spontaneous recovery?

A

Re-arranging of the cortex to ensure functions are maintained and still controlled for somewhere.

i.e. the function of a damaged area will be moved to an intact area.

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17
Q

Are improvements still possible after the critical period has passed?

A

Yes, but improvements are slower and more dependent on rehab - based on a completely different process to that seen in the first 3 months.

This secondary improvement phase lasts for only another 3 months - the majority of improvements occur within the first 6 months.

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18
Q

What are the 3 phases after a stroke?

A

Acute - from stroke occurrence to 7 days.

Sub-acute - between 7 days and 6 months post-stroke.

Chronic - 6 months + post-stroke

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19
Q

Most interventions are tested in patients in which stage of stroke, and why?

A

Tested in patients in the chronic stage.

  • Recovery has begun to plateau.
  • easier to recruit, they have come to terms with their health.
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20
Q

What is the proportional recovery rule?

A

Impairment after 48/72 hours is highly predictive of impairment at 3 months.

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21
Q

Are there brain areas which predict the extent of later improvements from strokes?

A

Motor areas such as the primary motor cortex (M1), and sensorimotor cortex, are important. Areas that send the signals to the muscles are the most predictive of later recovery/

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22
Q

How is diffusion tensor tractography used within stroke, and what do studies on it show?

A

Used to examined the extent of impairment of corticospinal tracts. This is then correlated with functional impairments.

The integrity of corticospinal tracts is highly correlated with Fugl Meyer across all types of stroke and independent of rehab supplied.

23
Q

What does MEP stand for?

A

Motor evoked potential

24
Q

Studies using MEPs to analyse stroke severity typically find what?

A

The size of MEP is used to represent the integrity of corticospinal tracts.
Smaller MEPs are typically found in the affected hemisphere of stroke patients.

The lower the intensity of the TMS used to cause a muscle twitch, the stronger the spinal tract.

25
Q

For grip strength, which motor areas are most predictive of stroke outcomes?

A

The corticospinal tracts of the motor cortex and the PMd (dorsal premotor area) are the most predictive of outcomes for grip strength.

The SMA and PMv are not predictive.

26
Q

What is the combination of functioning corticospinal tracts and functioning MEPs leading to the best and worst improvements in recovery?

A

If you have normal tracts and MEP, you have higher Fugl-Meyer scores and good recovery.

If either the tracts or the MEP is abnormal/not present, a higher level of impairment is likely.

27
Q

What’s an example of a tract alternative to the corticospinal tract, and what is it’s usefulness for movement?

A

Reticulospinal tract.

Can be used as an alternative but will never be as effective as corticospinal tracts, as they are not responsible for high level motor control.

28
Q

What is the relationship between rehab doses and recovery in animals?

A

Very strong link between rehab dose and recovery in animals.

29
Q

What is the idealised goal that stroke clinicians have, in terms of rehabilitation?

A

Maximising the function that patients have, within the boundaries of their impairment.

30
Q

What is the effect of extra doses of rehab?

A

An extra 30 minutes of rehab within 14 days of the stroke appears to have o benefit in upper limb function.

However, 2-3 hours a day for 6 weeks 1-2 months after stroke does have significant benefits.

31
Q

How does the size of the dose relate to recovery outcomes in rats?

A

Lower levels of rehab doses leads to no improvement in success/recovery.

High doses lead to doubling of BDNF levels in the motor cortex and improved recovery rates.

32
Q

What does BDNF stand for?

A

Brain derived neurotrophic factor

33
Q

What is BDNF a marker for?

A

Neuroplasticity

34
Q

What percentage of the day are stroke patients active?

A

About 50%

35
Q

Describe current rehab doses in the NHS.

A

In a typical day, patients were engaged in activities to improve mobility 13% of the time, and were left alone for 60% of the time.

36
Q

Describe the efficacy of rehab activities by the NHS.

A

When patients were engaged in sessions designed to improve upper limb movement, only 51% actually involved the practice of task-specific upper limb movements.

37
Q

What is the average total time of physical therapy that stroke patients receive on the NHS?

A

7.3 hours.

38
Q

What are the respective definitions of impairment and function with regards to stroke?

A

Impairment - amount of movement possible with a limb.

Function - number of tasks possible with a limb.

39
Q

What does FST stand for, and what is it?

A

Functional strength training.

Combining strength training with functional tasks e.g. picking up a cup with their arm weighted down.

Builds muscles, tendons and ligaments, and increases neural signal efficacy.

40
Q

What is the effectiveness of FST?

A

Good. You get improvements in impairment and in function.

41
Q

What is trunk restraint?

A

Restricting movement of the trunk (torso) in order to encourage use of distal limbs (e.g. fingers) while completing function tasks.

42
Q

What does NPT stand for, and what is it?

A

Non-paretic training.

Patient uses the good limb, with the idea that learning will transfer to the paretic limb.

43
Q

What is the effectiveness of NPT and why?

A

Low. Interlimb transfer is very small, and happens at the cognitive level not the motor level. Actually has a negative impact on outcomes for the paretic limb.

44
Q

What does CIMT stand for and what is it?

A

Constrained induced-movement therapy.

The less affected/intact limb is restricted using a mitten or sling, and then task-oriented practice is used on the affected limb, using shaping.

45
Q

What is the effectiveness of CIMT?

A

People stop using their affected limb as they know they could use their good limb much more easily- leads to disuse.

Doesn’t lead to any reduction in impairment, but does improve function - the task that they practice. Suggests use of compensatory techniques rather than neuroplasticity as the reason for improved task performance.

46
Q

What is shaping?

A

A form of reinforcement learning typically used in conjunction with CIMT, where successive approximations to a function behaviour are incrementally rewarded.

47
Q

What is bilateral arm training?

A

Practice of the same movement with both upper limbs. Mainly symmetrical movements which are either in or anti-phase.

48
Q

What is neuromuscular electrical stimulation?

A

Electrical stimulation of lower motor neurons to cause muscle contraction. Applied during a task/movement that a patient is unable to do.

Stimulation is then decreased as practice goes on, gradually increasing ability of patients to activate the muscles by themselves.

49
Q

What is the effectiveness of neuromuscular electrical stimulation?

A

Only works in relatively non-impaired people - effect is more significant in those with only mild impairments.

But there is clear evidence that it can improve motor function/acuity early after stroke.

50
Q

What percentage of patients have spasticity a year after stroke?

A

25%

51
Q

How could neuroplasticity be increased?

A

Supply glutaminergic excitation. Decreasing GABAnergic inhibition.
This increases spike-timing dependent plasticity, long term potentiation and BDNF secretion.

Cell based therapy & calorie restriction.

But application to humans is limited, as changes to neuroplasticity in stroke rehab has been sparse across the board (using any technique)

52
Q

What can help reduce spasticity, and how?

A

Botox - leads to muscle weakness in targeted muscles.

But does not lead to neuroplasticity - only changes muscle tone at the lowest level, and termination of injections would quickly lead to a return of spasticity.

53
Q

What is cell based therapy; what does it aim to do?

A

Aims to induce stem cells into the motor cortex, in order to induce neuroplasticity. Works in animals but not replicated in humans.

54
Q

Why would calorie restriction be used to improve neuroplasticity?

A

Reducing calorie intake by a third starves the brain, leading it to increase in neuroplasticity.
Works in animals, but not tested in humans.

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