Excerpt from The Stroke Rehab Handbook available at

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Timothy Richardson
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1 Neuroplasticity: The Ability of the Brain to Change The 1990s were declared The Decade of the Brain, which resulted in large amounts of funding being poured into neuro-science research to better help the understanding of the brain and its amazing abilities. During this period, scientists made many interesting discoveries, and their research led to an improved understanding of many brain processes, particularly in the studies of memory and emotions. Advanced Imaging was used to help identify the areas of the brain involved in certain functions, from remembering a face to playing a computer game to the thought of physical movement. However, one important discovery was rewriting the textbooks. It is the realization that the brain at any age is not set in stone, but the brain is a malleable, plastic organ. A flood of discoveries showed that the brain continually reorganizes itself. This process is called neuroplasticity. Put simply, it means that you can create your brain from the tasks and experiences that you encounter on a daily basis. Neuroplasticity basically means that the brain is able to change and adapt. An example of this process can be seen when the brain rezones different areas or parts of the brain, following changes in its requirements or demands. For example, amputation of the right arm, following trauma, will result in re-zoning of the original area of the brain that was once responsible for receiving sensory input from the right arm. This area may now be rezoned into receiving and processing input from another area of the body. We have all learned new skills or refined and improved an old skill. Those changes require changes in the nervous system. If we continuously activate certain areas of the nervous system (i.e. make them work) or continuously use certain pathways of communication, the nervous system notes the increased use of the pathway. Additionally, it will take steps towards making that pathway more efficient. Good examples of people s nervous systems that have been refined to extraordinary levels are musicians and elite athletes. In musicians, the area of the brain responsible for processing sound is so finely tuned that they can pick out an off-key note out of a whole orchestra of instruments. Or, what about the gymnast, whose coordination and balance is so precise, that they can do a somersault and land on one leg on a thin balance beam? These are examples of nervous systems that have adapted and changed to meet the demands of the experiences or stresses repetitively placed on it. As the remarkable process of neuroplasticity does not discriminate from positive or negative influences, it is important not to underestimate the role of healthy lifestyle habits in the rehabilitation of the nervous system. This aspect of neuroplasticity is also how we are going to maximize the recovery of the brain in the shortest amount of time possible. Additionally, execution of repetitive tasks leads to the strongest re-formation of neural connectivity and pathways. The brain is a muscle. The more you use it; the stronger it

2 grows. In short, when we talk about the brain and nervous system, their jobs are simple; they send and receive information. For example, the brain may send information to the arm to tell it to move. The arm, through receptors in the skin, muscles, and joints, can send information to the brain about the movement being performed. Neuroplasticity is the reason why people, who have suffered a stroke, are able to make recoveries or improvements in some or all of their functioning. The brain and nervous system are highly adaptable. Therapies, like constraint- induced therapy, which involves forcing the stroke survivor to use their affected hand, can be successful because of neuroplasticity. Performing an activity, that originally involves the use of damaged areas of the brain, forces the brain and nervous system to adapt and to find a new way of executing that activity. Repetition, with the goal to exercise and not exhaust, is the key, especially in neuro-rehabilitation that is related to stroke recovery. When we think about neuro-rehab, we can liken it to an exercise routine that is designed to change the body. If we wanted to build muscle or lose weight, the results of our program are determined by 3 factors: time, frequency, and consistency. We understand that changing the brain is like changing the body; it takes a period of time. The process of losing weight or gaining muscle is a gradual process; you do not suddenly wake up one morning 30 pounds lighter! The same is true for improvements in brain function. I often say to my patients that lots of small steps add up to a big step. Related to the factor of time is consistency. You must be consistent with your rehab over a period of time in order to make improvements. The other factor is frequency. If we wish to change something in the body, there must be a certain amount of frequency or intensity applied to result in change. Once again, the person who wants to lose weight or gain muscle cannot just go to the gym once a week; could they? It is really not intense enough to force a change. The same is true for neuro-rehab. In the case of stroke rehab, I would recommend that you should probably be doing some form of rehab every day. Of course, some days should be more intense than others. Throughout the text, I may use the terms activate or stimulate an area of the brain. For example, when you are asked to process the sensation of an object on your arm you activate or stimulate the area of your brain responsible for processing that information. You can think of it like giving that area of the brain a little exercise work out. Now, over time, if we continually repeat this task and stimulate this area, we will cause neuroplastic changes. In simple terms, we will cause this area to improve at its job. On a more technical level, new connections are formed between nerve cells, and other cellular changes take place to make the cells more efficient at sending and receiving information. The same holds true for motor/movement output. If I continually do a task involving moving my arm, I am continually activating the area of my brain responsible for the movement of that arm. Over time, the brain will adapt to the increase in activity.

3 At times, we may start with severe sensory or motor deficits; our goal is to improve on the functioning of those deficits. Basic Principles of Constraint-Induced Movement Therapy The following is based on the article: Constraint-Induced Movement Therapy: Characterizing the Intervention Protocol. Eura medicophys 2006; 42: Morris, D.M., et al. Constraint-induced movement therapy (CI therapy) is a rehabilitation treatment approach that improves the more affected extremity use, following a stroke, especially helping in daily functional tasks. For an upper limb example, it requires the participant to wear a mitt or arm sling on the less affected arm, while they use the more affected arm to perform tasks. One of the main ideas behind CI therapy is the theory of learned disuse. We have spoken earlier about the concept of neuroplasticity and the ability of the brain and nervous system to adapt and learn. What CI therapy proposes is that the brain can learn disuse also. Just like a muscle, the brain has a use it or lose it principle. Following a stroke that affects motor movement of a limb, people will be less inclined to use that limb. People may engage in some light rehab for a small period of time each day, but, a majority of the time, they will use their less affected limb. Because of the severe lack of use of the more affected limb, the brain area responsible for that limb will become unfit or lazy. The brain learns not to use that limb, and it gets better at not using that limb. In a sense, it s a catch 22; because the limb s movement is poor people use that limb less for everyday tasks. The brain recognizes this and starts to learn the disuse. Thus, the limb movement stays poor and the cycle continues. CI therapy applies principles to break this cycle. CI therapy is on the cutting edge of the latest neuro-rehabilitation techniques for stroke recovery of movement. Right from the start, I will tell you, it will take hard work and dedication. But there is no doubt that CI therapy works. To date, more than 150 scientific papers have been published on CI therapy, and all have reported positive results. Let s discuss some key aspects of CI therapy. Although not crucial, but often very helpful, wearing a sling or mitt of some sort on the less affected limb is a good idea. This really emphasizes that this limb will not be used, and all focus should be on using the more affected limb. You can use a simple cooking mitt to accomplish this. CI therapy should be performed for 10 or 15 consecutive days, depending on the severity of the initial deficit. The greater the deficit; the longer the therapy period will need to be.

4 The original protocol called for 6 hours a day for training. More recent studies indicate that a shorter, daily, training periods of 3 hours a day is just as effective. You will perform two sorts of activities: shaping activities and task practices. They define shaping activities as simple activities focused on one objective. Shaping activities use the principles of peel back, or tailoring the therapy. The difficulty of the task can be adjusted according to capabilities, and the speed of performance can also be progressively adjusted. Each shaping activity is practiced for a set of ten 30-second trials. (Perform the activity for 30 seconds, stop, and repeat another 9 times.) After each 30-second trial, your caregiver should provide feedback on how you did, based on objective measures. The feedback used is more of an objective record of all completed exercises. The caregiver should carefully record all notes, and they can serve as a benchmark to be bettered next time. Activity examples for shaping include the following: reaching, tracing, peg board, supination/pronation (turning forearm palm up then palm down), threading, arc and rings, finger tapping, and object flipping. A detailed example of a shaping activity will be given using an example of moving wooden blocks. Activity Description Difficulty Progressions Easy Create a divider line across the table with some tape or a piece of string. The line should be parallel to your chest. Like the finish line of a running race. Place the line approximately (15cm/6inches) away from you. The goal is to push small, wooden blocks across the finish line. Starting position: The hand may start on the table or on the thigh so that it must be lifted onto the table. Distance: The distance of the finish line. Reverse the game: Start with the blocks over the finish line, and they must be moved Hard A box and several blocks are used for this task. Seated at a table, the goal is to move small, wooden blocks from the table to the top of the box. Distance: The box can be moved further away to challenge the straightening of the elbow. Height: A higher box can be used to challenge movement at shoulder. Block size: Larger or smaller blocks can be

Feedback Parameters Movements Emphasized back to your half of the table. Number of repetitions: The number of blocks pushed across the finish line in a given period of time.

5 Feedback Parameters Movements Emphasized back to your half of the table. Number of repetitions: The number of blocks pushed across the finish line in a given period of time. Time: The time required to push a set number of blocks across the finish line. Elbow extension Shoulder flexion used to challenge wrist and hand control. Number of repetitions: The number of blocks placed on the box in a given period of time. Time: The time required to place a set number of blocks on the box. Pincer grip Wrist extension Elbow extension Shoulder flexion These are two simple suggestions for shaping activities. Hopefully, they will get you thinking about other exercises that you can do. Children s stores or educational game stores can open up a world of potential exercises that you can start incorporating into your routine. Other examples could include the following: completing a simple puzzle, placing cut out shapes into their correct position, moving a marble around a maze, placing donut type objects on a vertical stick, etc. Stacking rings is an advanced example of CI therapy. Task practices are functionally based activities, performed continuously for a period of minutes. Some examples may include wrapping a present or writing. In successive periods of task practice, the amount of work accomplished in a set time, or the set time itself, can be increased to challenge patients.

6 Activity Description Adjusting the Difficulty Suggested Feedback Easy Subjects sit/stand at a table with a laundry basket in front of them. The basket is filled with washcloths and towels of different colors. The subject removes the items and sorts them into piles of different colors. After sorting, the subject proceeds to fold the items. Folding items can be graded from washcloths, to towels of different sizes, to clothes, etc. Number of items sorted/folded in a set period Time required sorting and folding entire basket of laundry Quality of folding (e.g cloths folded symmetrically) Improvement in hand function in performing these tasks( e.g. thumb movement for grip) Hard Writing: even if the affected arm/hand is the nondominant arm/hand, writing is a great motor skill to help the brain. Begin by copying text. Progress to name writing, alphabet, numbers, a shopping list, etc. Number of lines/characters done in a set time period( e.g 20mins) Time required to copy a certain amount of text. Quality of neatness with respect legibility, equal size, staying on horizontal etc. A lower limb example could involve just stepping the foot onto a stool or step. Not even actually stepping up onto the stool or step, just the action of raising that foot to a higher surface and practicing the action that would be used with climbing stairs. With CI therapy, it is important for the caregiver to provide coaching or encouragement during the activities. This should be given both during the 30-second shaping activities and the 15- to 20-minute task practices. Feedback in the form of specific knowledge of performance should also be given at the end of each 30-second shaping activity trial

7 (not at the end of the set of 10 of them) and the end of the 15- to 20-minute task practice. This feedback is in the form of the objective measures that the caregiver has recorded, like the number of blocks placed on the box or number of clothes folded. Now, to really make the transition from therapy and practicing to real world application, CI therapy uses what they call the transfer package. Basically, it means that you need to practice, practice, and practice using your more affected limb outside of your CI therapy sessions. The following are a couple of tips: Use your more affected limb, especially in life situations, where the interventionist (caregiver) is not present. Obtain appropriate assistance from the caregiver, if present, (assistance to prevent you from struggling excessively but allowing you to try as many tasks by yourself as is feasible), and to wear the mitt on the good hand as much as possible (when safe to do so). Of course, please practice common sense with this. Do not attempt to pour a hot cup of coffee or shave using a razor blade with your affected limb! Choose 10- or 15-consecutive-day periods to perform your CI therapy. I suggest starting with a 10-day period. Each day, 3 hours of therapy should be performed. Intersperse regular breaks into your therapy session. After your 10 consecutive days, continue to use your more affected limb for daily activities as much as possible. Remember the theory of learned disuse. Pick some regular safe activities that will always be done with your affected limb. If you wish to do another 10 consecutive days of intense CI therapy, you may. Sensory Rehab (Click Here For Equipment Examples) With a stroke, you may have sensory loss on one half of the body. Sensory loss may feel like nothing. You may just be unaware when objects are touching your skin or there may be an overall sensation, such as tingling, pins and needles, or like cotton wool between your skin and an object. If any of these are present, then sensory work should be included in your rehab program. If you are unsure, please follow the below recommendations with a caregiver to test your sensory capabilities. As spoken about earlier in the neuroplasticity section, the nervous system s job is to send and receive information. If you continually send information (for example, sensory information like sound) to the area of the brain responsible for processing sound, it will create change in that area. Over time, just like continually exercising a muscle, that area will become stronger.

8 You can see great examples of how neuroplasticity has shaped the brains of many highly specialized individuals. Take, for example, a musician. After years and years of listening to music, the auditory part of his/her brain is so finely skilled that he/she can hear an off note in the string section of the whole orchestra. Or, how about a chef? His palate (or more correctly the area of his brain that is responsible for processing taste) is so attuned to different tastes, what tastes like a spicy sauce for most people is immediately discerned by him to be the 15 ingredients that went into producing it. That is the goal with applying sensory work in stroke rehabilitation. It is to send and receive information to areas of the nervous system and brain. It is to ask damaged areas, or areas that have lost some ability, to start to try and do their job again. At first, just like someone who is out of shape and goes back to the gym for the first time, it can be very difficult. We may need to peel back the activity to a suitable level. (This could involve a passive form of the activity or decreasing the level of discrimination of the activity.) You will see that I have included both passive and active sensory tasks. Many sensory stimulation programs are passive in nature, and, while these may be effective, I really think a lot of extra benefits can be gained from making the task more active. It will involve a higher level of processing, and, that means, a better work out for the brain. For some sensory tasks, I recommend establishing a baseline. This will give an objective measure of how well certain areas are processing sensory information. This can be useful to monitor progress. Somatosensory Exercise Introduction Establishing a baseline: test the discrimination between a sharp object (like a pin, but be careful not to draw blood or pierce the skin) and a dull object (like the back of the pin if it has a large head). Close your eyes, have someone randomly touch certain areas of your body with the sharp or dull object, and tell them what you think the object was, either sharp or dull. If there are no deficits, there should not be any mistakes. Check areas that are questionable. Remember, it s a 50% chance to guess correctly, so there should be no mistakes. Areas to test are: -top of foot -front shin -calf area -thigh, front, outside, inside - shoulder (area where a military patch would go on uniform) -little lower down, outside above elbow, -forearm -hand (palm and individual fingers) - face

9 Areas to test sensory perception The above are just a small sample of the exercises and methodology included in The Stroke Rehab Handbook. There are more in depth explanations and many more exercise examples. For more info:

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1 GRASP Terms and Conditions UBC means The University of British Columbia, a corporation continued under the University Act of British Columbia with offices at 103-6190 Agronomy Road; The Developers means: