Stroke Recovery Mechanisms

• Stroke recovery is heterogeneous

• Individual body function recovery patterns differ, and can be predictable in the first days after a stroke

• Post-stroke therapy can be more focused

• Stroke recovery is complex, and a combination of spontaneous and learning-dependent processes

• These processes include restitution, substitution, and compensation

Restitution

• Restores functionality of damaged neural tissue

Substitution

• Re-organization of partly spared neural pathways to relearn lost functions

Compensation

• Improves the disparity between the impaired skills of a patient and the demands of their environment

• Mechanisms of recovery include the resumption of cell function when inflammatory responses to injury subside in time

• Spontaneous recovery is the inflammatory responses to the injury subside in time without causing permanent death

• Therapeutic implications include neuroprotection to reduce edema, inflammation, and apoptosis

• Adaptive plasticity occurs along with cell genesis

• Functional plasticity is related to the modification of functions of existing synapses and neurons as well as unmasking silent synapses and increase receptors

• Structural plasticity is the physical rewiring of cortical circuits +/– Synapse formation, formation on existing dendritic spines and growth of new spines

Activity Dependent Plasticity

• Neurons that fire together wire together

• Use multiple, salient, sensorimotor inputs for strengthened neural networks

• True recovery involves recovery of function closer to "norm” with more movement options

• Compensation involves stereotyped movement patterns and soft-tissue changes

• Time limit, plateau at 6 months

• Motor impairment involves changes in therapy concepts

• Conventional rehabilitative training reinforces compensatory strategies

• Such training may drive functional improvement (activity level) but also have detrimental effects on neuroplasticity, resulting in maladaptive effects

Stroke Rehabilitation Occupational Therapy

• Conventional therapy includes neurodevelopmental therapy

• Contemporary therapy involves task-oriented practice to facilitate Neuroplastic change

• Conventional Therapy includes The Rood Approach, Proprioceptive Neuromuscular Facilitation (PNF), The Brunnstrom Approach, and Neurodevelopemental Treatment (NDT)

• Contemporary therapy includes Task-Oriented practice, Constraint-induced Therapy (CIT), Bilateral Arm Training(BAT), Robot-assisted Therapy (RT), Mirror Therapy (MT), and Hybrid Therapy

• Neural plasticity findings and concepts have led to a paradigm shift in OT treatment approaches starting in the late 90s

• Task-oriented practice is also known as Task-Specific, Repetitive Task training, Task-Specific Repetitive Training, etc.

• Definition can include systematic and repetitive practice of functional tasks, training or therapy where patients practice context-specific motor tasks and receive some form of feedback, and training approaches that include performance of goal-directed, individualized tasks with frequent repetitions of task-related or task-specific movements

• Components of "Training" include Functional Movement, Clear Functional Goal, Client-centered patient goal, Overload, Real-life object manipulation, Context-specific environment, Exercise progression, Exercise variety, Feedback, Multiple movement planes, Total skill practice, Patient customized training, Random practice, Distributed practice, and Bimanual practice

• With Task-Oriented Training, therapists may define the patients' task and know more about that task regarding involved body parts, initial alignment, the forces by prime mover(s), and the goals of movements

Ingredients of Task-Oriented Practice

• Rationale: Uses motor learning principles, is active and voluntary, involves training specificity, and stages of motor learning

• Preparation includes aligning viscoelastic properties of structures and systems

• Progression of training includes initiation, incorporation into various activities, and integration activities

• Grading to ensure motivation and efficacy during training involves therapeutic compensation, variables in activity, and appropriate context

• Dosage includes intensity via practice reps and frequency via weekly training reps

• Defining tasks includes clarifying the goal and strengthening commitment

• Analysis of the task involves deconstructing it into component parts and identifying affected skills

• Practice missing components, including preparing them and mobilizing for tightness and loss of range via skill acquisition and shaping

• Practice tasks by re-constructing task parts and gradually combining them

• Following motor learning principles involves adequate positive feedback via knowledge of performance and results with preference toward patient-generated feedback and self-efficacy

• Therapist involvement includes providing feedback, regulating factors, giving guidance, and following the Neuro-IFRAH

• Following motor learning principles also involves adequate repetitions and random practice for consolidation and generalization

• Transference of training involves generating contexts with levels of task difficulty, providing varied opportunities for practice and self-monitoring, and incorporating family and Staff

• Problem solving sequence 1 involves asking directly or indirectly for movement

• Facilitate movement through modeling, visualizing, changing alignment/environment, and giving physical cues

• Further progression involves moving through it, stretching, mobilizing, adding complexity, and developing function

Guidelines for physical facilitation

• Know the desired movement and determine a point of contact

• Also to determine the direction of force and how much pressure to apply

• The therapist is in contact on the muscle moving the part on the moving the part for greater control and faster response

• Using distal, less contact may be required; the direction of pressure is the movement direction

• Don’t Push, gradually increase and apply enough pressure for the pt. Feedback and move in that direction

• Start with easy postures and movements, and control training variables via activity and context

• Views on task-oriented training from overseas: Therapists should anticipate recovery and default to restorative strategies, and brain-based approach

• People should be offered the opportunity to attend "Booster Clinics" that use intensive, repetitive, task-specific activities based on motivated learning

• Increase of behavior training to two hours a day and structured so that participation in tasks at that level maximizes recovery

• Consider programs when they stimulate tasks at levels aimed at maximizing recovery

• Approaches that seek to advantage the brain's re-organizing abilities should be considered