Remarkable progress in therapy

The most important goal of neurorehabilitation is to achieve adapted participation through activity training. Through interdisciplinary collaboration among all treatment groups, realistic therapy goals are continually adjusted. Personal factors and the environment play a decisive role in the success of therapy. Clinical trials and new developments contribute to evidence-based neurorehabilitation.

Like acute stroke treatment, stroke rehabilitation has made remarkable progress in recent years. Adaptation processes and the structure of the brain as a network are becoming better understood through imaging studies [1,2] and noninvasive brain stimulation [3–5], so that specific treatment strategies can take into account and influence the natural course of adaptation ( Fig. 1).

Realistic and measurable participation goals

Rehabilitation after a stroke is integrated into an overall concept with the aim of enabling the patient to participate in social activities as optimally and functionally adapted as possible (according to the WHO International Classification of Functioning [ICF] ) (Fig. 2) [6].

The most important functions have also been defined for cerebral stroke (Table 1) [7]. A stroke is a drastic event that often throws the patient and the relatives off track. Therefore, social environment and personality are crucial factors for motivation, which contributes significantly to improvement and adaptation.

The core of neurological rehabilitation is the definition of realistic and measurable participation goals that can be achieved through training of functions and activities. At the beginning of rehabilitation, an assessment is carried out with all the treatment providers involved, which enables realistic interdisciplinary goal setting. In the course of rehabilitation, these goals are repeatedly adjusted together with the patient.

At least three hours of therapy daily

Fundamental to this are the experiences of the treatment groups involved and the results of clinical trials [8]. Most recently, treatment recommendations from the American Heart Association/American Stroke Association were presented in 2016. They indicate the levels of evidence for the respective therapies and are incorporated into evidence-based rehabilitation [9].

Studies could show that interdisciplinary rehabilitation by speech therapists, physiotherapists and occupational therapists should start already in the acute hospital on the stroke unit, whereas mobilization is recommended only after one day [10]. Rehabilitation should be intensive and include at least three hours of therapy per day. Age, cognition, function (e.g., more difficult rehabilitation in neglect), incontinence, but also etiology (hemorrhage versus ischemia) and localization (left versus right-sided symptoms) play an important role for duration and recovery potential. While a youthful brain still allows for a great deal of plastic change, this potential diminishes as we age. However, plastic changes can be achieved at any age, but it takes a lot of practice as well as the help of appropriately trained practitioners. The most important medical tasks, in addition to goal setting and coordination of therapies, are the prevention and treatment of complications. Inpatient neurorehabilitation needs are especially higher in elderly patients, memory impairment, poorer function, and incontinence. A neglect or gait disorder also increases the need for rehabilitation.

Barthel index and FIM

The assessment begins with a neurological examination. In stroke units, the standardized National Institute of Health Stroke Score (NIHSS) is usually used for this purpose. This is being replaced in rehabilitation by assessments that relate to activities and participation (activities of daily living, ADL). The Barthel Index and the FIM (Functional Independence Measure) are suitable for this purpose, as they also correlate with progression and further care [11]. In addition, there are special measurement methods that relate to the respective functions, such as motor skills, cognition and emotions. They are used by the therapists involved in multimodal therapy (nursing, physiotherapy, occupational therapy, speech therapy and neuropsychology).

Patients with low muscle strength and impaired balance, as well as patients taking many medications, are prone to falls. Therefore, balance training is recommended during the inpatient stay as well as afterwards. The effects of mood and cognition are very important to the rehabilitation process. In addition, antidepressants can be used here. Most importantly, physical activity during neurorehabilitation has an antidepressant effect. Recent studies find a positive effect on outcome and processing when patient-specific information is provided about the clinical picture. Therefore, patient education is becoming increasingly important.

Further therapy recommendations

Other significant measures include decubitus prophylaxis and specific therapy for spasticity and contractures (orthoses, botulinum toxin, and stretching). For immobile patients, thromboprophylaxis is important and should be continued for the initial period of immobility (including cerebral hemorrhage) until some mobility is achieved. Elastic compression for thromboprophylaxis is not recommended because of skin complications [12]. Bladder function may be impaired, especially in elderly and cognitively impaired patients, and should be diagnostically clarified and adequately treated (pelvic floor training and medication). Bladder disorders correlate with mortality and need for institutionalization [13]. A urinary catheter should be removed after 24 hours whenever possible. Treatment strategies are also available for shoulder-arm syndrome on the paretic side and infrequent central pain. For example, shoulder-arm syndrome can already be prevented and treated by taking a few precautions (e.g. supporting the arm).

Improved therapy through technical advancements

Medically complicating impairments such as dysphagia can be better diagnosed and appropriately treated. Technical developments are improving therapies, and clinical studies can be used to objectively assess the effectiveness of individual procedures. For each patient, an individual therapy program is determined based on the therapy goals, which should take into account the most important functions.

Dysphagia: It affects about half of patients and can lead to pneumonia and malnutrition. Therefore, it must be detected early in the stroke unit. If the risk cannot be clearly assessed, a fiberendoscopic examination of the swallow (FEES) may be performed. Insertion of a gastric tube and percutaneous endoscopic gastrostomy (PEG) may be necessary during the course to reduce the risk of aspiration [14].

Cognitive impairment, attention deficits, unilateral visual impairment, communication limitations: These factors can influence the patient’s participation. Since stroke doubles the likelihood of dementia (especially vascular dementia) occurring, cognitive rehabilitation is of great importance. Technical innovations such as a pager have already been successfully investigated. Physical activity has been shown to improve fatigue and endurance compared to cognitive therapy alone, primarily through improved circulation and mood elevating effects [15]. The technique of cognitive training depends on the severity, in case of low impairment internal techniques (imagination) can be used. Here, too, a face-to-face strategy has been shown to be superior to computer-assisted procedures.

Communication disorders: Here, mainly speech and language disorders (aphasia and dysarthria) are distinguished. The treatment goal is to improve the ability to participate in language interaction, which may include learning alternative communication strategies or using electronic communication aids, if appropriate. In aphasia, it has been shown that very early therapy, i.e., starting after three days, is useful. But therapy after six months can still be effective. Based on the clinical studies, intensive therapy over the longest possible period is recommended. As part of the treatment, it is common to use computer-assisted therapy programs as well. It has also been shown that training the communication partner or even participating in group therapy can contribute to improvements. In speech disorder (dysarthria), breathing, voice, and articulation movements are affected. The therapy is geared to the respective deficits: The scope of disturbance is to be reduced and participation in everyday interaction facilitated. Depending on the severity of the dysarthria, alternative communication aids to spoken language may also be used.

Hemiparesis inattention (neglect): it can affect different modalities (visual-sensory or motor), is often noticeable even in contact, and usually occurs on the left side. It can be distinguished from visual field deficit and proprioceptive disorder and treated specifically. Already in contact, addressing from the affected side is useful; further, procedures such as neck stimulation and prism adaptation have been successfully studied [15]. Visual field training (e.g. with ^NovaVision®) allows compensation of visual field defects by training attention towards the affected side. This visual impairment is often critical for driving aptitude testing, which is also part of neurorehabilitation.

Task specific training

Motor neurorehabilitation is aimed at achieving the greatest possible mobility and participation [8]. Occupational therapy pays more attention to the upper extremities, while physiotherapy focuses on training the ability to walk. Adjusted orthoses and sufficient physical fitness can be supportive. In motor rehabilitation, adapted therapy is based primarily on the type and severity of impairment.

Different therapies are available for the upper and lower extremities. Important principle of task-specific training is repetition of challenging and goal-oriented activities. For upper extremity training, additional assisted procedures such as the ^ARMEO® Spring can be used to provide low-motion support. In Constrained-Induced Movement Therapy (CIMT), the compensatory use of the healthy hand is avoided by using a glove. On the lower extremities, walking ability is used to assess whether free walking, treadmill training, ^Lokomat®, ^ERIGO®, or standing are already in use (graded by function) [17]. On the upper and lower extremities, the often troublesome spasticity can be treated by stretching, but also by botulinum toxin injections. If necessary, serial casts of the foot can also sometimes restore the ability to walk. Orthotics such as a foot lift splint (or “foot-up”) or a dorsal splint can improve walking safety. New methods that also promote motivation are computer-game-based brain-beat-adapted training programs (e.g., on the ^ARMEO® Spring, the ^Lokomat®, or the ^Mindmaze®).

Progress also possible in the long term

Once a patient is discharged from inpatient neurorehabilitation, continued therapeutic and medical care is critical, as significant progress can be achieved even in the long term during outpatient treatment. In eastern Switzerland, there are neurological therapy centers in the Silberturm in St. Gallen and in the Kreuzspital in Chur, in addition to the therapists in private practice. There it is possible to continue all therapies together in one place. The new technical developments are currently also being investigated in clinical studies at the Valens clinics. Included in this are, for example, movement analysis in motor rehabilitation and the effect of direct current stimulation on aphasia.

Literature:

Saur D, et al: Ventral and dorsal pathways for language. Proc Natl Acad Sci U S A. 2008;105: 18035-18040.
Saur D, et al: Dynamics of language reorganization after stroke. Brain. 2006; 129: 1371-1384.
Hamilton RH, et al: Mechanisms of aphasia recovery after stroke and the role of noninvasive brain stimulation. Brain Lang. 2011; 118: 40-50.
Lefaucheur JP, et al: Evidence-based guidelines on the therapeutic use of transcranial direct current stimulation (tdcs). Clin Neurophysiol. 2017; 128: 56-92.
Mylius V, et al: Stroke rehabilitation using non-invasive cortical stimulation: aphasia. Expert Reviews of Neurotherapeutics 2012; 12: 973-982.
World Health Organization. International Classification of Functioning, Disability, and Health (ICF), 2001.
Geyh S, et al: Icf core sets for stroke. J Rehabil Med 2004: 135-141.
Langhorne P et al: Stroke. Rehabilitation. Lancet 2011; 377: 1693-1702.
Winstein CJ, et al: Guidelines for adult stroke rehabilitation and recovery: A guideline for healthcare professionals from the american heart association/american stroke association. Stroke 2016; 47: e98-e169.
Avert Trial Collaboration group: Efficacy and safety of very early mobilisation within 24 h of stroke onset. Lancet 2015; 386: 46-55.
Chumney D, et al: Ability of functional independence measure to accurately predict functional outcome of stroke-specific population: Systematic review. J Rehabil Res Dev 2010; 7: 17-29.
Clots Trials Collaboration: Effectiveness of thigh-length graduated compression stockings to reduce the risk of deep vein thrombosis after stroke. Lancet 2009;373: 1958-1965.
Pettersen R, Wyller TB: Prognostic significance of micturition disturbances after acute stroke. J Am Geriatr Soc. 2006; 54: 1878-1884.
Dennis MS, et al: Effect of timing and method of enteral tube feeding for dysphagic stroke patients. Lancet 2005; 365: 764-772.
Zedlitz AM, et al: Cognitive and graded activity training can alleviate persistent fatigue after stroke. Stroke 2012; 43: 1046-1051.
Saevarsson S, et al: Strength in numbers: Combining neck vibration and prism adaptation produces additive therapeutic effects in unilateral neglect. Neuropsychol Rehabil 2010;2 0: 704-724.
Dobkin BH, Duncan PW: Should body weight-supported treadmill training and robotic-assistive steppers for locomotor training trot back to the starting gate? Neurorehabil Neural Repair 2012; 26: 308-317.
Albert SJ, Kesselring J: Neurorehabilitation of stroke. J Neurol 2012; 259: 817-832.