Recovery of function after stroke: principles of motor rehabilitation

Transcription

1 Recovery of function after stroke: principles of motor rehabilitation Horst Hummelsheim NRZ Neurologisches Rehabilitationszentrum Leipzig Universität Leipzig Berlin,

2 Target symptoms in motor rehabilitation strength dexterity precision endurance spasticity and associated phenomena

3 ...crucial elements of occupational and physiotherapy 3

4 Gait dysfunction 4

5 The classical paper Hesse S, Bertelt C, Jahnke M, Schaffrin A, Baake P, Malezic M, Mauritz KH (1995) Treadmill training with partial body weight support compared with physiotherapy in nonambulatory hemiparetic patients. Stroke 26:

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7 A-B-A single case study design (A=treadmill training, B=Bobath). Nonambulatory chronic hemiparetic stroke patients (admission to the study between 91 and 362 days poststroke). 30 minutes treadmill vs. 45 minutes Bobath training (5x per week). Body weight release for 30% at the beginning of the study, reduction towards 0% as rapidly as possible. Treadmill speed was low to permit gait corrections and to avoid interruptions. Symmetrical gait pattern stressed. 7

8 Outcome measures Gait speed Cadence Stride length Functional Ambulation Category (FAC) Rivermead Motor Assessment (gross function, leg function) Motricity Index Modified Ashworth Scale (arm and leg) 8

9 Results (1) 3,5 Function Ambulation Category (0-5) 3 2,5 2 1,5 1 0,5 0 A1 B A Measurement No. Line graph shows mean Functional Ambulation Category scores over time. Treadmill training applied during the A1 and A2 phases was more effective than physiotherapy applied during the B period (P<.05). 9

10 Results (2) 10

11 Training features Repetitive execution of identical or similar movements for a rather short period (30 minutes). "Focussing training". Shaping only scarce: Reduction of body weight release, mild increase of gait speed. Task-specific training. Applicable to everyday situations. 11

12 Treadmill training: advanced version Pohl M, Mehrholz J, Ritschel C, Ruckriem S (2002) Speed-dependent treadmill training in ambulatory hemiparetic stroke patients. Stroke 33:

13 Inclusion of sport physiological approaches: It is known from sport physiological research that training at maximum performance brings about optimum improvement of performance (Paavolainen et al. 1999). Prospektive randomized controlled clinical trial. Ambulatory poststroke patients (n=60) (duration of hemiparesis > 4 weeks). Interval paradigm to raise treadmill velocity stepwise according to the patients' performance (STT), compared to a training with a slow increase of treadmill speed (LTT) and conventional gait training (CGT). 4-week period of altogether 12 training sessions, release of body weight only during the first 3 sessions. During 1 to 2 minutes, the belt speed is increased to the highest speed at which the patient can walk safely and kept constant for 10 seconds (Vt1). After a (short) period of recovery the speed is increased by 10% for 10 seconds (Vt2). No physiotherapeutic assistance during STT. 13

14 CGT Group LTT Group STT Group (n = 20) (n = 20) (n = 20) Component 1 12 x 45 minutes of CGT 12 x 30 minutes of LTT 12 x 30 minutes of STT Component 2 8 x 45 minutes of conventional physiotherapy, gait training allowed 8 x 45 minutes of conventional physiotherapy, gait training allowed 8 x 45 minutes of conventional physiotherapy, gait training allowed Total 15 hours of treatment 12 hours of treatment 12 hours of treatment 14

15 Outcome measures Overground walking speed Cadence Stride length Functional Ambulation Category (FAC) 15

16 Variable CGT Group LTT Group STT Group Overall (n = 20) (n = 20) (n = 20) Significance* Fastest comfortable overground walking speed, m/s At baseline 0.66 ± ± ± 0.32 After 2 weeks 0.84 ± ± ± 0.59 P<0.001 At end of study 0.97 ± ± ± 0.80 Cadence, steps/min At baseline 79.9 ± ± ± 22.8 After 2 weeks 91.4 ± ± ± 28.4 P<0.001 At end of study 96.8 ± ± ± 30.1 Stride length, m At baseline 0.46 ± ± ± 0.13 After 2 weeks 0.51 ± ± ± 0.16 P<0.001 At end of study 0.56 ± ± ± 0.21 FAC score At baseline 3.9 ± ± ± 0.8 P<0.001 At end of study Values are mean ± SD. 4.3 ± ± ± 0 *Interaction between factors order (STT, LTT, and CGT) and treatment (values at baseline, after 2 weeks, and at end of study) revealed by ANCOVA. 16

17 Training features Repetitive execution of identical or similar movements for a rather short period (30 minutes). "Focussing Training". Training near the patients' individual maximum performance. Shaping: Treadmill speed is raised in relation to the patients' individual increase of performance. Task-specific training. Applicable to everyday situations. 17

18 Motor dysfunction of arm and hand 18

19 Repetitive training of simple movements of the hand Bütefisch C, Hummelsheim H, Denzler P, Mauritz KH (1995) Repetitive training of isolated movements improves the outcome of motor rehabilitation of the centrally paretic hand. J Neurol Sci 130:

20 Multple baseline study design. 27 stroke patients (admission to the study 3 to 19 weeks poststroke). Training of grip strenth (resistance is raised with increasing voluntary grip power) and velocity of isotonic extensions at the wrist (resistance is raised with increasing velocity) for 15 minutes twice daily (5x per week). 20

21 Outcome measures Grip strength Velocity of isometric extensions at the wrist Acceleration of isotonic extensions at the wrist Rivermead Motor Assessment (arm section) Ashworth-Scale (for hand-, finger und elbow flexors) 21

22 D A B C RMA C 3,5 3,0 2,5 2,0 1,5 1,0 0,5 0,0-0,5-1,0-1,5 baseline training weeks peak acceleration (Score) peak force (Score) A B ,0 1,5 1,0 0,5 0,0-0,5-1,0-1,5 grip strength (Score)

23 Results Grip strength Velocity of isometric extensions at the wrist Acceleration of isotonic extensions at the wrist Rivermead Motor Assessment (arm section) Ashworth-Scale (for hand-, finger und elbow flexors) 23

24 Training features Repetitive execution of simple contractions for a rather short period (2 x 15 minutes). Isometric and isotonic contractions were trained. Trained parameters: Strength and velocity of single contractions. "Focussing training". Training near the patients' individual maximum performance. Shaping: Increase of resistance. Training is not task-specific. Trained movements are not applicable to everyday situations. 24

25 Repetitive training of complex movements of arm and hand (1) Woldag H, Heuschkel G, Waldmann G, Hummelsheim H (2003) Is the repetitive training of complex hand and arm movements beneficial for motor recovery in stroke patients? Clin Rehabil 17:

26 Multple baseline study design. 21 stroke patients (admission to the study 2 to 46 weeks poststroke). Training of: 1. Complex movement 1: Repetitive execution of a precise grasping and transport movement for 10 minutes twice daily (5x per week). 2. Complex movement 2: Repetitive execution of a sawing movement in a sagittal plane at a comfortable speed for 10 minutes twice daily (5x per week). 26

27 Grasping and transport movement 27

28 Sawing movement 28

29 Outcome measures Grip strength Maximum acceleration of isotonic contractions at the wrist 3-dimensional motion analysis (precision) Rivermead Motor Assessment (arm section) 29

30 Results Grip strength. Maximum acceleration of isotonic contractions at the wrist. 3-dimensional motion analysis (precision). Rivermead Motor Assessment (arm section). 30

31 Training features Repetitive execution of complex movements. Precision is trained (not velocity, nor strength). Training of complex movements (no "focussing" training). Use of objects. Training far from the individual limit of performance (as to speed and strength). No shaping. Task-specfic training. Applicable to everyday situations. 31

32 Repetitive training of complex movements of arm and hand (2) Woldag H, Stupka K, Hummelsheim H (2009) The repetitive training of complex hand and arm movements with shaping is beneficial for motor recovery in stroke patients (submitted). 32

33 A-B-A study design. 15 stroke patients (admission to the study between 4 and 39 weeks poststroke). Training of: 1. Complex movement 1: Repetitive execution of a grasping and transport movement as fast as possible - for 10 minutes twice daily (5x per week). Increasing weigths to be transported. 2. Complex movement 2: Repetitive execution of a sawing movement as fast as possible - in a sagittal plane at a comfortable speed for 10 minutes twice daily (5x per week). 33

34 Grasping and transport movement 34

35 Sawing movement 35

36 Outcome measures Grip strength Maximum acceleration of isotonic contractions at the wrist 3-dimensional motion analysis (precision) Rivermead Motor Assessment (arm section) 36

37 Results Grip strength. Maximum acceleration of isotonic contractions at the wrist. 3-dimensional motion analysis (precision). Rivermead Motor Assessment (arm section). 37

38 Training features Repetitive execution of complex movements. Shaping: Training with increasing velocity and increasing strength. Training near the individual limit of performance (as to speed and strength). Use of objects. Task-specfic training. Applicable to everyday situations. 38

39 Constraint-induced movement therapy (CIMT) at high intensity Miltner WH, Bauder H, Sommer M, Dettmers C, Taub E (1999) Effects of constraint-induced movement therapy on patients with chronic motor deficits after stroke: a replication. Stroke 30:

40 The first studies using CIMT aimed at reducing the "learned nonuse". 15 stroke patients (0,5 to 17 years poststroke). Immobilization of the non-affected arm for 90% of waking hours. Intensive training of the affected arm for 7 hours daily during 8 weekdays. Shaping: Demands concerning the difficulty of motor tasks is increased. 40

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42 Outcome measures Motor Activity Log (MAL) covering 'amount of use' and 'quality of movement' Wolf Motor Function test (WMFT) 42

43 Results Motor Activity Log (MAL) covering 'amount of use' and 'quality of movement'. Wolf Motor Function test (WMFT). No decrement in performance at 6- month follow-up. 43

44 Training features Repetitive and long lasting motor activity. Training of complex movements (no "focussing" training). Use of objects. Shaping: Difficulty of the motor tasks is increased in small increments. "Forced-use" by immobilization of the intact arm. Task-specific training. Applicable to everyday situations. 44

45 Constraint-induced movement therapy (CIMT) at an intermediate intensity Sterr A, Elbert T, Berthold I, Kölbel S, Rockstroh B, Taub E (2002) Longer versus shorter daily constraintinduced movement therapy of chronic hemiparesis: An exploratory study. Arch Phys Med Rehabil 83:

46 Intervention study, 2-group randomized trial, 13 stroke patients, 2 TBI patients (1 to 17 years since cerebral lesion). The study addresses the issue whether the 'forced use' (by immobilization of the intact arm) or the repetitive motor practice (with shaping) of the affected arm is crucial within CIMT. Comparison of a 3-hour and a 6-hour treatment protocol (with identical durations of immobilization of the intact arm, i.e. 90% of waking hours). 46

47 Outcome measures Motor Activity Log (MAL) covering 'amount of use' and 'quality of movement' Wolf Motor Function test (WMFT) 47

48 Ergebnisse Motor Activity Log (MAL) covering 'amount of use' and 'quality of movement'. Wolf Motor Function test (WMFT). The beneficial effects were significantly greater in the 6h/d training schedule, although the duration of immobilization of the non affected arm was identical with the 3h/d group. 48

49 Training features Repetitive and long lasting motor activity. Training of complex movements (no "focussing" training). Use of objects. Shaping: Difficulty of the motor tasks is increased in small increments. "Forced-use" by immobilization of the intact arm (possibly of minor significance) Task-specific training. Applicable to everyday situations. 49

50 Constraint-induced movement therapy (CIMT) at a convenient intensity Sterr A, Freivogel S (2003) Motorimprovement following intensive training in low-functioning chronic hemiparesis. Neurology 61:

51 90 minutes of training without 'constraint'. 13 patients (11 with TBI, 2 with stroke, 24 to 150 months after cerebral lesion). A: Baseline with 90 minutes occupational therapy daily for 3 weeks. B: Training phase mit 90 minuten CIMTanalogous motor tasks for 3 weeks. Training of the affected arm using motor tasks of progressively increasing difficulty (shaping). 4 to 10 motor tasks per session. Each task is repeated during 8 to 15 minutes. Feedback on task performance is continuously given, and the slightest improvement is positively reinforced. 4-week follow-up. 51

52 Outcome measures Motor Activity Log (MAL) covering 'amount of use' and 'quality of movement' Wolf Motor Function test (WMFT) Frenchay Arm test (FAT) 52

53 Results (1) AOU-units 4 3,5 3 2,5 2 1,5 1 0,5 0 p<.01 n.s. n.s. b1 A pre B post f-up post 2 53

54 Results (2) QOM-units 4 3,5 3 2,5 2 1,5 1 0,5 0 p<.01 n.s. n.s. A B f-up b1 pre post post 2 54

55 Results (3) Motor Activity Log (MAL) covering 'amount of use' and 'quality of movement' during the training phase. Wolf Motor Function Test (WMFT) during the training phase. Frenchay Arm Test (FAC) during the training phase. Component 'velocity' within WMFT. No improvement during the baseline phase (OT). Stable results in the 4-week follow-up. Exchange of the phases (B before A) reveals a lacking effect of OT and a significant improvement during the CIMT. 55

56 Training features Repetitive and long lasting motor activity. Training of complex movements (no "focussing" training). Use of objects. Feedback on task performance is given. Shaping: Difficulty of the motor tasks is increased in small increments. No "Forced-use" by immobilization of the intact arm. Task-specific training. Applicable to everyday situations. 56

57 Renner CI, Bungert-Kahl P, Hummelsheim H (2009) Change of strength and rate of rise of tension relate to functional arm recovery after stroke. Arch Phys Med Rehabil 90:

58 Biomechanical parameters (t0, after 3 weeks, after 6 weeks) grip strength (N) rate of rise of grip strength (N/s) isometric extension at the wrist (N) rate of rise of tension during extension at the wrist (N/s) acceleration during isotonic extension at the wrist isometric extension und flexion at the elbow (N) rate of rise of tension during isometric elbow extension and flexion (N/s) 58

59 Funktional assessments (t0, after 3 weeks, after 6 weeks) Rivermead Motor Assessment, arm section Action Research Arm Test (ARAT) Box & Block Test 59

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62 Development of the biomechanical und functional parameters 62

63 Relationship between biomechanical and functional parameters 63

64 Conclusions The rate of rise of grip strength and the rate of rise of tension during extension at the wrist correlate with improvement in the Arat score. These two parameters combined explain, according to multiple regression analysis, 77% of the variance in the ARAT and can serve as predictors. 64

65 The essentials Repetitive active movement execution (massed motor practice) Shaping Training close to the individual limits of performance Training of simple movement parameters (strength, velocity etc.) Task-specific training Applicable to everyday situations 65

66 The essentials Repetitive active movement execution (massed motor practice) Shaping Training close to the individual limits of performance Training of simple movement parameters (strength, velocity etc.) (Task-specific training) (Applicable to everyday situations) 66