After stroke, immediate treatment in specialized centers is essential for a good therapeutic outcome. Early mobilization – taking into account the neurological-medical condition of the patient – promotes his functional independence. For neurorehabilitation to succeed, the interdisciplinary team must work closely together.
A stroke event is among the most common causes of long-term disability in adulthood. Despite progress in the acute treatment of stroke by recanalizing therapies, improved acute management, nationwide organization with certified stroke units and stroke centers, many affected patients require neurorehabilitative measures from the beginning, which are applied according to the integrative stroke unit concept already in the early phase [1,2]. Therefore, disciplines such as physical therapy, occupational therapy, speech therapy, etc., in addition to specialized stroke nursing, are central to the successful operation of the stroke unit team.
The approach on a stroke unit has many similarities with that on inpatient neurorehabilitation in a rehabilitation center. Essentially, the goal is to promote adequate learning and recovery (neuroplasticity) through a patient-centered approach. The main goal is to restore the patient’s independence and bodily functions, as well as to prevent complications (e.g. infections, venous thrombosis and pulmonary artery embolisms). Early measures of neurorehabilitation in the stroke unit initially aim, among other things, at adequate mobilization, support of vital functions, promotion of initial motor recovery and basal stimulation. Appropriate care plans are specified over the treatment period.
A high proportion of patients subsequently require intensive further care within the framework of inpatient neurorehabilitation, which is why the rehabilitation center represents an important pillar of cerebral stroke treatment. The timing of the transfer must be determined individually. However, it has been shown that an early start of intensive and multimodal treatment at the rehabilitation center is crucial for a good therapy outcome. The decisive factor is the application of specific therapeutic procedures with high intensity and a large proportion of active therapies by a specialized and multidisciplinary team with overriding goal planning. The treatment is medically guided and there are regular re-evaluations regarding the course and therapy program by the treatment team.
Neuroplasticity
Whereas in the last century and in the early days of neuroscience it was assumed that the possibilities for adaptations in the structural neural network after damage in adults were very limited [3], in the 21st century, a new approach was taken. A paradigm shift took place in the twentieth century: Neuroscience, first by measuring the effect of neurorehabilitative interventions, and later using animal models, neurophysiological and functional imaging techniques, was able to demonstrate that the adult human brain has an amazing potential for adaptivity and recovery, which can be selectively promoted [4]. Nevertheless, the extent of this recovery ability after cerebral stroke depends on many factors, including the size and location of the lesion. Furthermore, the recovery curve flattens with increasing temporal distance from the initial event, which highlights the importance of the early phase. In general, processes of neuroplasticity involve first functional and subsequently also structural changes, which was first described on the basis of modulations of synaptic activity [5] and later observed in larger contexts of neurons and networks. Neuroplasticity manifests itself in functional changes at synapses, changes in protein synthesis and proteinase activity in neurons, formation of new structural connections or morphological changes at synapses, apoptotic processes, and other mechanisms. In particular, the change in representation of cortical areas has been well studied. More distant brain areas also change their activity predominantly in the early phase of compensation. Using functional imaging, successful courses were shown to return to activation patterns similar to those before the onset of the stroke during subsequent reorganization. The functional balance between the hemispheres is also significant: harmful overactivity of the contralesional hemisphere may occur, and attempts are being made to counteract this with neurophysiological methods [1].
Principles of neurorehabilitation
There are parallels between postlesional relearning after brain stroke and normal learning processes in human development, with behavior change and skill learning occurring through repeated interactions primarily in social settings and problem-solving situations. In clinical neurorehabilitation after cerebral stroke, multidisciplinary teamwork is used to create neuroplasticity-stimulating learning situations through specifically applied therapeutic procedures that are tailored to the individual needs and learning goals of patients [1,2]. This refers to both everyday functions in the clinic (e.g., interactions with the treatment team) and therapies. Individual practice-oriented goal setting, mostly based on the “International Classification of Functioning, Disability and Health” (ICF, WHO 2001), is important.
A didactically valuable principle to promote learning after cerebral stroke is the CIT method (constraint-induced therapy), which, however, cannot be applied in the majority of cerebral stroke patients and especially in the early phase. In this case, provided there is sufficient selective function, the healthy limb is immobilized and the impaired function is given increased training.
Stimulation techniques and medications
For some time, the use of various electrophysiological stimulation techniques in neurorehabilitation has been scientifically evaluated. In repetitive magnetic stimulation, for example, a recurrent magnetic field from an appropriately placed magnetic coil is used to influence underlying cortex activity. Depending on the protocol, both inhibitory and activating activity changes can be induced. To date, however, no treatment regimen derived from this exists for everyday clinical use. In addition to its application in motor rehabilitation, it may have special significance in the treatment of neglect disorders, where the functional imbalance of the hemispheres is particularly evident.
Regarding drug promotion of (motor) rehabilitation, no evidence class I recommendation exists for any drug. Some studies showed positive effects of L-dopa, amphetamine derivatives, and other stimulants, as well as drive-enhancing SSRIs. However, results have been inconsistent; large multicenter studies could provide clarity. In contrast, other substances such as benzodiazepines, high- and low-potency neuroleptics, clonidine, and anticholinergics showed negative effects and should be avoided if possible.
Neurorehabilitation in the stroke unit
Stroke unit treatment is highly effective, even if specific recanalizing therapies were not feasible [6]. For stroke units in Switzerland, the principle of so-called “comprehensive stroke units” applies: therapeutic elements are conceptually integrated ( Fig. 1). An overview of central elements of successful acute rehabilitation after stroke is provided in table 1.
In principle, early movement-promoting measures lead to significantly improved walking ability. One study shows that the advantage of the early mobilized cannot be made up by the group with later mobilization [7]. However, patients with major cerebral strokes, medically unstable patients, or those with critical cerebral perfusion still require delayed, staged mobilization. Pathophysiological backgrounds are thought to include the fact that brain perfusion is better when the patient is lying down, and systemic dysregulations such as blood pressure drop can lead to negative effects. Importance must also be given to concomitant cardiovascular disease with respect to any complications.
In the AVERT study [8], where early and higher-dose mobilization in the early phase was systematically investigated, it was shown that too high early-onset therapy intensity in severe cerebral strokes was even associated with increased mortality and poorer functional outcome, which the study authors describe strikingly and in terms of the early phase as “too much of a good thing.” These study results point to the paramount importance of individualized assessment of each stroke patient by the specialized team.
Neurologic deterioration in the early phase occurs in 35% of patients. Therefore, as part of the neurological complex treatment on the stroke unit, the acute rehabilitation team takes measures to monitor and prevent complications, while being aware of possible interactions with therapeutic procedures. If necessary, further diagnostics and therapy will be initiated. Information on the major reversible and possibly irreversible etiologic causes of neurologic deterioration is provided in Table 2.
Therapy intensification in the rehabilitation center
A further increase in therapy intensity takes place as the patient’s resilience and stability increases during transfer to the rehabilitation center. Close cooperation between stroke unit and rehabilitation center makes sense in terms of content and is therefore also specified in the certification guidelines for stroke units. Conversely, the rehabilitation center works closely with the acute hospital if complications arise or clarification steps are still open. In many facilities, therefore, there are networks of therapeutic and medical specialists in accordance with the treatment chains.
Several studies have demonstrated the benefits of early transfer to a rehabilitation center or a hospital. of a timely start of the organized intensive neurorehabilitation, whereby this refers not only to an improved functional outcome, but also to the quality of life of the affected persons [10]. In addition to early onset, there is also research on therapy intensity, with meta-analyses [11] showing that a high density of actively directed therapies across different modalities is associated with higher levels of mobility, independence, and active abilities. Also, regarding place of residence after follow-up treatment, patients treated with specialized neurorehabilitation were significantly more likely to be able to return home independently [12].
The activity is centered on the individual patient with the involvement of the relatives. Doctors, nursing team, physiotherapists, occupational therapists, speech therapists, psychologists and neuropsychologists, social services, recreational therapists and other specialists work together in a coordinated manner in the multidisciplinary team. At the beginning of treatment, a multidisciplinary assessment is performed in addition to a neurological examination, and functional performance such as activities of daily living (ADL) and specific scales are also evaluated. There is a joint setting of treatment goals, taking into account, among other things, the social and professional contextual factors and the re-evaluations in the course of treatment.
The required therapy density is achieved with the help of individual and group therapies as well as self-training sessions. The intensity can be further enhanced by the additional use of therapy robots, with walking and grasping robots in particular being used, sometimes in conjunction with virtual reality technology. Robots offer an advantage in terms of treatment options for high-level paresis and gait disorders, in addition to relieving the burden on therapists. In contrast, no general superiority of robot-assisted versus therapeutically delivered therapies has been demonstrated to date [13,14]. However, in augmenting and creating a multifaceted rehabilitation program, therapy robots have some value beyond the core indications mentioned.
Brain stroke patients who show decreased drive to participate in therapies should first be carefully evaluated regarding a depressive disorder (poststroke depression) and treated with a stimulant antidepressant if necessary. In individual cases, treatment with L-dopa or other central stimulating agents may also be considered, although principles of off-label use must currently be observed. Large controlled multicenter studies are needed (and some are in preparation) before general recommendations on pharmacotherapy can be made.
Take-Home Messages
- Stroke treatment in certified treatment units (stroke units, stroke centers) leads to reduced mortality, increased functional independence, and more successful discharges, regardless of age.
- Early therapy with mobilization units promotes – taking into account the neurological-medical condition as well as the resilience of the patient – a good long-term therapy result.
- Inpatient neurorehabilitation succeeds through a high intensity of actively directed therapies.
- Complementary, e.g., electrophysiological, stimulation techniques can induce both inhibitory and activating cerebral activity changes. To date, however, there are no generally accepted guidelines.
- There are no Class I recommendations yet for drug promotion of neuroplasticity. It is important to diagnose and, if necessary, treat poststroke depression. Positive effects have been observed e.g. on L-dopa, stimulants as well as SSRIs.
Literature:
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- Albert SJ, Kesselring J: Neurorehabilitation practice for stroke patients. In: Brainin M, Heiss WD, eds: Textbook of Stroke Medicine (2nd Edition). Cambridge: Cambridge University Press, 2014: 371-398.
- Cajal R: Degeneration and regeneration of the nervous system. London: Oxford University Press, 1928.
- Kesselring J: Neurorehabilitation: a bridge between basic science and clinical practice. Eur J Neurol 2001; 8(3): 221-225.
- Hebb DO. The organization of behavior: a neuropsychological approach. New York: Wiley, 1949.
- Chochrane Database Authors: Organised inpatient (stroke unit) care for stroke. Cochrane Database Sys Rev 2013; 9: CD000197.
- Musicco M, et al: Early and long-term outcome of rehabilitation in stroke patients: the role of patient characteristics, time of initiation, and duration of interventions. Arch Phys Med Rehabil 2003; 84(4): 551-558.
- AVERT Authors: Efficacy and safety of very early mobilisation within 24 h of stroke onset (AVERT): a randomised controlled trial. Lancet 2015; 386(9988): 46-55.
- Siegler JE, et al: A proposal for the classification of etiologies of neurologic deterioration after acute ischemic stroke. J Stroke Cerebrovasc Dis 2013; 22(8): e549-556.
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- Liston R, et al: Conventional physiotherapy and treadmill re-training for higher-level gait disorders in cerebrovascular disease. Ageing 2000; 29(4): 311-318.
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