Learning Objective Number 5. Identify emerging technologies and approaches used in stroke rehabilitation. Constraint-Induced Movement Therapy, or CIMT. This involves the forced use of the impaired weak upper extremity, restricting the use of the uninvolved upper extremity, employing the former in activities of daily living. This is based on the theory of learned non-use, that a limb weakened by stroke will not improve if it is not actively rehabilitated. Traditional CIMT involved two consecutive weeks of up to 36 hours per week of therapy, and patient selection is important. This is a slide from Rusk Rehabilitation involving a patient using a modified CIMT approach. I'm making this look easy. That's it. Good. Probably the most important trial in the medical literature involving CIMT was from 2006 in the Journal of the American Medical Association called the EXCITE trial. It was two weeks of traditional CIMT versus usual care with patients with initial stroke within three to nine months. They looked at 106 patients using CIMT and 116 controls. The CIMT patients were subdivided into higher functioning categories and lower functioning categories. And the CIMT patients, both higher and lower functioning, demonstrated greater improvement in wolf motor function test scores than those receiving usual care. Some additional thoughts about CIMT. Modified CIMT is probably much more realistic due to logistical issues. No insurance carrier is going to cover seven hours a day for two weeks of CIMT. So it's going to be more appropriate to do this on a modified level or a less intensive type of level. CIMT has also been used online in computer training sessions and also been combined with robotic therapy. CIMT clearly requires a high level of patient motivation and commitment. Some people have reported that the compliance with CIMT may be as low as one third. And the question remains, how much of the gain observed from CIMT is due to the treatment intensity? How much is due to the intervention genre itself? Sort of an opposite approach to CIMT is bilateral movement therapy, which is task-specific rehabilitation techniques, kind of the mirror image of CIMT, where if you want to improve, say, wrist flexion, is to try to do both upper limbs at the wrist at the same time. And the idea behind bilateral movement therapy is that there may be a cross-transfer effect mediated through the corpus callosum. The mechanism effect has not been completely elucidated, and it has been essentially involved in upper limb training. Mirror therapy is the use of mirrors during rehabilitation therapy to provide a degree of contralateral side feedback. There hasn't been an enormous amount of evidence base regarding this efficacy, but it's thought to be helpful in selected cases. Functional electric stimulation may improve voluntary movement and has often been used in concert with orthoses, using computer technology for improved syncopated movement. Robotic therapy can provide passive range of motion in a repetitive fashion to stroke patients. They can utilize computer programs with games, providing immediate feedback. Changes in motor skills can be tracked readily. They can be used more in the upper than the lower extremity, more proximally than distally, but have also been used in other types of settings. Some of the types of robotics include the MIT Manus, the Mirror Image Motion Enabler, the Myomo, the Assisted Rehabilitation and Measurement, or ARM, the CyberGlove, the Rutgers Master II-ND, Bimanutrac. There have been mixed results in the literature. In the New England Journal of Medicine from 2010, looking at upper limb robotics, the conclusion was it was not shown to be superior at 12 or 36 weeks compared with intensive rehabilitation. This is a video of an upper limb robotic device in a stroke patient, courtesy of Dr. Joel Stein from New York Presbyterian. This video of the local med is from Dr. Alberto Eskenazi from Moss Rehab. In a situation where patients can provide some ambulatory function. Transcranial Magnetic Stimulation, or TMS. This is when a short magnetic pulse is applied over the skull to induce an electrical current in the cortex. Again, to repeat, TMS does not provide magnetic stimulation into the brain. It provides an electrical stimulation. Evoked potentials can be reported over the corresponding muscles over the primary cortex. And it's an examination of cortical motor representation following stroke. TMS is independent of subject performance. It's a passive intervention. And there's some concern about seizure potentiation that I think has largely been of very low concern. There are different methods of delivery. Repetitive TMS, or RTMS, is a common delivery method. It's generally felt to be safe and a possible agent to induce neuroplasticity or the remodeling of the central nervous system after an event has occurred. TMS has also been thought to possibly be helpful in aphasia when combined with traditional speech language therapy techniques. Deep cortical brain stimulation. Application of electric stimulation to the cortex of the brain with the goal of inducing neuroplasticity cortical reorganization to improve function. Virtual reality. With advances in computer technology, one can do virtual reality and stroke rehabilitation involving individualized simulated scenario in a safe and controlled environment. It has been shown in some cases to enhance motor recovery. And in some studies, cortical reorganization or neuroplasticity have been demonstrated. This has also been used in the field of driver's rehabilitation. Body weight supported treadmill training. This is when a patient has a harness with supportive equipment to unload a certain percentage of your body weight to try to facilitate a normal gait pattern. The idea is that gains obtained with this type of training will carry over to ambulation without the supportive equipment and training. This has become fairly mainstream in the field of neuro-rehabilitation. In the New England Journal of Medicine in 2011, Duncan et al did not find it to be superior to home physical therapy. But again, body weight supported treadmill training has become standardized in most neuro-rehabilitative settings. With all of these emerging therapies and techniques, often these are used in concert or in combination, such as constraint-induced movement therapy with robotics, robotics with transcranial magnetic stimulation, transcranial magnetic stimulation with constraint-induced movement therapy, et cetera, et cetera.

stroke rehabilitation

Constraint-Induced Movement Therapy

patient selection

EXCITE trial

emerging technologies