Stroke Rehabilitation

Part A: Core Concepts
1: Introduction
(Leeanne M. Carey)
1.1 Stroke Rehabilitation: An ongoing window of opportunity
1.2 The scope of the problem: Prevalence and impact of stroke and increasing need for Stroke Rehabilitation
1.3 Recovery and Rehabilitation: Definitions
1.4 Neural plasticity and learning as a basis for stroke rehabilitation
1.5 Neuroimaging and how it may inform stroke rehabilitation
1.6 Paradigm shift in stroke rehabilitation
2: Stroke Rehabilitation: A Learning Perspective
(Leeanne M. Carey, Helene J. Polatajko, Lisa Tabor Connor and Carolyn M. Baum)
2.1 Stroke Rehabilitation: facilitation of adaptive learning
2.2 A common language for rehabilitation science
2.3 Experience and learning-dependent plasticity: Implications for rehabilitation
2.4 Role of brain networks in information processing and recovery
2.5 Skill acquisition - a learning perspective
2.5.1 Explicit, task-specific and goal-driven
2.5.2 Involve active-problem solving and be responsive to environmental demands
2.6 Application in context of recovery after stroke
2.7 Rehabilitation Learning Model: Rehab-Learn
2.8 Selected learning-based approaches to rehabilitation
2.8.1 Cognitive Orientation to daily Occupational Performance (CO-OP)
2.8.2 SENSe: A perceptual learning approach to rehabilitation of body sensations after stroke
2.8.3 Language: Constraint-Induced Aphasia Therapy
2.9 Measuring response to learning-based rehabilitation
2.10 Summary and Conclusion
3: Neural Plasticity as a basis for Stroke Rehabilitation
(Michael Nilsson, Milos Pekny and Marcela Pekna)
3.1 Neural plasticity after brain and spinal cord injury
3.1.1 Experience-dependent plasticity of the cerebral cortex
3.1.2 Spontaneous recovery of function after stroke
3.1.3 Cortical map rearrangements
3.1.4 Contralateral hemisphere involvement
3.1.5 Contralesional axonal remodelling of the corticospinal system
3.2 Implications for stroke rehabilitation
3.3 Increasing neural plasticity through behavioural manipulations and adjuvant therapies
3.3.1 Enriched environment and multimodal stimulation
3.3.2 Non-invasive brain stimulation
3.3.3 Pharmacological modulators of neural plasticity
3.3.4 Emerging targets
3.4 Individualized therapy
4: Imaging techniques provide new insights
(J-Donald Tournier, Richard Masterton and Rudiger J. Seitz)
4.1 Introduction to neuroimaging techniques and their potential to provide new insight
4.2 What neuroimaging can tell us
4.2.1 Measuring brain perfusion
4.2.2 Measuring water diffusion (Diffusion weighted imaging)
4.2.3 Measuring regional cerebral metabolism
4.2.4 Assessing structural brain lesions
4.3 Measuring brain function with MRI
4.3.1 The BOLD image contrast
4.3.2 The BOLD response to neuronal activity
4.3.2.1 The time-course of evoked BOLD signal changes
4.3.2.2 Neurovascular coupling
4.3.3 fMRI experimental design and analysis
4.3.3.1 Task-related activation studies
4.3.3.2 "Resting-state" studies of brain function
4.3.4 Applications of fMRI in stroke rehabilitation
4.4 Structural connectivity, including tractography
4.4.1 Modelling diffusion in white matter
4.4.1.1 Diffusion tensor imaging
4.4.1.2 Higher-order models
4.4.2 Estimating biologically relevant parameters
4.4.2.1 Estimating fibre orientations
4.4.2.1 Tractography
4.4.3 Application to stroke recovery
5: Multimodal neurophysiological investigations
(Cathrin M. Buetefisch and Aina Puce)
5.1 Introduction
5.2 Magnetoencephalography (MEG) and Electroencephalography (EEG)
5.2.1 Methodological considerations
5.2.1.1 Site of recording in EEG and MEG
5.2.1.2 Source modelling of EEG and MEG data
5.2.1.3 Considerations when studying reorganization the motor system with multimodal MEG/EEG
5.2.1.4 Neurophysiological rhythms and potential insights into stroke recovery
5.2.2 Multimodal MEG / EEG studies of activity in primary sensorimotor cortex in stroke recovery
5.3 Transcranial Magnetic Stimulation (TMS)
5.3.1 Methodological considerations
5.3.2 TMS measures of motor cortex
5.3.2.1 Motor threshold
5.3.2.2 MEP amplitude
5.3.2.3 MEP latency and central motor conduction time
5.3.2.4 Cortical silent period
5.3.2.5 Input-output curves
5.3.2.6 Short Interval Cortical Inhibition (SICI)
5.3.2.7 Intracortical facilitation (ICF)
5.3.2.8 Interhemispheric inhibition (IHI)
5.3.3 Repetitive transcranial magnetic stimulation (TMS)
5.3.4 Multimodal TMS/brain imaging studies of stroke recovery
5.4 The future? Neurorehabilitative studies of stroke recovery and the brain-computer interface
Part B: Stroke pathophysiology and recovery
6: Stroke: Pathophysiology, Recovery potential and Timelines for Recovery and Rehabilitation
(Rudiger J. Seitz and Geoffrey A. Donnan)
6.1 Introduction
6.2 Pathophysiology
6.2.1 From Cerebral Ischemia towards Brain Infarction
6.2.2 Reversal of Ischemia
6.2.3 Patterns of Residual Brain Infarcts after Thrombolysis
6.2.4 Functional Consequences of Brain Infarcts
6.3 Recovery Potential
6.3.1 The Role of the Penumbra
6.3.2 Perilesional Plasticity
6.3.3 Infarct induced Disconnections
6.3.4 Regenerative Therapies using Stem Cell Approaches
6.3.5 Rehabilitative Effect of Physical Training
6.3.6 Rehabilitative Effect of Mental Training
6.4 Timelines for Recovery and Rehabilitation
6.5 Conclusions
Part C: Stroke Rehabilitation: Creating the right learning conditions for rehabilitation
7: Organisation of care
(Dominique Cadilhac, Tara Purvis, Julie Bernhardt and Nicole Korner-Bitinsky)
7.1 Introduction
7.2 Models of stroke rehabilitation services
7.2.1 Inpatient care
7.2.2 Community based rehabilitation as an alternative to inpatient rehabilitation
7.2.3 Current perspectives on the way forward for providing stroke rehabilitation
7.2.4 Characteristics of stroke rehabilitation services
7.3 Factors affecting access to organised stroke rehabilitation
7.3.1 Staffing Resources and the Interdisciplinary Approach to Rehabilitation
7.4 Ensuring the quality of care
7.4.1 Monitoring and improving the quality of care in rehabilitation for stroke
7.4.2 What do clinical audits tell us about quality of rehabilitation
7.4.3 Establishing programs to increase the uptake of evidence into clinical practice
7.5 Innovations in rehabilitation and application in clinical practice
7.6 Summary of key messages
8: Motivation, mood and the right environment
(Thomas Linden and Michael Nilsson)
8.1 Introduction
8.1.1 Frequency and nature of post-stroke depression
8.1.2 Impact of post-stroke depression
8.1.3 Etiology of depression after stroke
8.2 Is post-stroke depression a specific disorder?
8.3 Predictors of post6-stroke depression
8.4 Functional and structural brain changes with depression
8.4.1 Functional brain changes
8.4.2 Morphological brain changes
8.4.3 Depression, cognition and brain networks
8.5 Treatment of depression in stroke patients
8.5.1 Non-pharmacological treatment options
8.5.2 Enriched environment
8.5.3 Cortical stimulation and depression
8.5.4 Physical activity
9: Training principles to enhance learning-based rehabilitation and neuroplasticity
(Paulette van Vliet, Thomas A. Matyas and Leeanne M. Carey)
9.1 Introduction
9.2 Task-specific activation of brain regions
9.3 Influence of task characteristics on sensorimotor performance
9.4 Task-specific nature of motor learning
9.5 Task complexity
9.6 Behavioural evidence for task-specific training
9.7 Mental practice of tasks to enhance motor learning
9.8 Increasing repetitions to enhance motor learning
9.9 Transfer of training effects
9.10 Implicit and explicit learning
9.11 Key clinical messages
10: Adjunctive therapies
(Charlotte J. Stagg and Heidi Johansen-Berg)
10.1 Introduction & Rationale
10.1.1 Insights from animal models
10.1.1.1 The need for multiple sessions of stimulation
10.1.1.2 Combination with physical therapy
10.2 Pharmacological studies
10.2.1 Amphetamines
10.2.2 Dopaminergic Agents
10.2.3 Cholinergic Agents
10.2.4 Serotoninergic Agents
10.3 Transcranial stimulation techniques
10.3.1 Abnormal interhemispheric balance
10.3.2 Introduction to the techniques
10.3.2.1 Transcranial Magnetic Stimulation (TMS)
10.3.2.2 Transcranial direct current stimulation (tDCS)
10.3.2.3 Placebo controls
10.3.3 rTMS trials
10.3.3.1 Acute Stroke
10.3.3.2 Chronic Stroke
10.3.4 tDCS trials
10.3.5 The necessity for individually targeted treatments
10.3.6 Safety of transcranial stimulation approaches
10.4 Novel therapeutic Approaches
10.4.1 Direct Cortical Stimulation
10.4.2 Robotic Therapy/Neuroprosthetics
10.4.3 Stem Cell Therapy
10.4.4 Growth Factors
10.5 Conclusions
Part D: Rehabilitation of common functions
11: Movement
(Cathy Stinear and Isobel Hubbard)
11.1 Introduction
11.2 Repetitive Task-Specific Training
11.2.1 Description
11.2.2 Behavioural Effects
11.2.3 Neural Mechanisms
11.2.4 Summary
11.3 Constraint-Induced Movement Therapy
11.3.1 Description
11.3.2 Behavioural Effects
11.3.3 Neural Mechanisms
11.3.4 Summary
11.4 Mental Practice
11.4.1 Description
11.4.2 Behavioural Effects
11.4.3 Neural Mechanisms
11.4.4 Summary
11.5 Electrostimulation and EMG Biofeedback
11.5.1 Description
11.5.2 Behavioural Effects
11.5.3 Neural Mechanisms
11.5.4 Summary
11.6 Robot-Assisted Training
11.6.1 Description
11.6.2 Behavioural Effects
11.6.3 Neural Mechanisms
11.6.4 Summary
11.7 Virtual Reality and Visuomotor Tracking Training
11.7.1 Description
11.7.2 Behavioural Effects
11.7.3 Neural Mechanisms
11.7.4 Summary
11.8 Other Approaches
11.9 Conclusions
12: Touch and body sensations
(Leeanne M. Carey)
12.1 Somatosensory function
12.2 Somatosensory Loss after Stroke
12.3 Central processing of somatosensory information
12.3.1 A model of somatosensory processing
12.3.2 Key features of central processing of somatosensory information
12.4 Neural correlates of sensory recovery after stroke
12.5 Treatment Principles and Strategies Arising from Neuroscience
12.5.1 Goal-directed attention and deliberate anticipation
12.5.2 Calibration across modality and within modality
12.5.3 Graded progression within sensory attributes and across sensory attributes and tasks
12.6 Current approaches to sensory rehabilitation
12.6.1 Passive stimulation and bombardment
12.6.2 Attended stimulation of specific body sites
12.6.3 Graded sensory exercises with feedback
12.6.4 Eclectic approach involving sensorimotor exercises
12.6.5 Perceptual learning and neuroscience based approach: Stimulus Specific and Transfer Enhanced Training
12.7 Towards a neuroscience-based model of sensory rehabilitation
13: Vision
(Amy Brodtmann)
13.1 Introduction
13.2 Anatomy of visual pathways
13.2.1 The retinogeniculate pathway
13.2.2 The geniculostriate pathway
13.2.3 Extrageniculostriate pathways
13.3 Ipsilateral representation of the visual hemifield
13.4 Striate-extrastriate connections - the "what " and "where " pathways
13.5 Ventral extrastriate cortex: visual object recognition and processing
13.6 Colour and movement
13.6.1 Dorsal extrastriate cortex: visual motion perception
13.7 Visual syndromes caused by stroke
13.7.1 Visual field deficits following stroke
13.7.1.1 Monocular visual deficits
13.7.2 Homonymous visual deficits
13.7.2.1 Lateral geniculate nucleus lesions
13.7.2.2 Quandrantanopic visual field defects
13.7.2.3 Hemianopic visual field defects
13.7.3 Disorders of higher visual cognition commonly caused by stroke
13.8 Mechanisms of recovery following stroke
13.8.1 Neural plasticity post-stroke
13.8.2 Mechanisms of recovery following injury to the visual system
13.8.3 Cross-modal plasticity in the visual system
13.8.3.1 The dorsal extrastriate pathway - a possible site for surrogacy
13.9 Visual recovery hypotheses
13.9.1 Experiments in visual recovery following stroke
13.9.1.1 PET studies in the visual system following stroke
13.9.1.2 MRI studies in the visual system following stroke
13.10 Restorative therapies: rehabilitating the human visual system
13.11 Summary
14: Goal driven Attention in Recovery Post-Stroke
(Sheila Gillard Crewther, Nahal Goharpy, Louise Bannister and Gemma Lamp)
14.1 Introduction
14.1.1 General background to stroke rehabilitation
14.1.2 Goal directed action and the visual system
14.2 What is attention?
14.2.1 Neuroanatomical interaction between the attention and visual systems
14.2.2 Attention and multisensory integration
14.3 Learning needs attention, working memory and motivation
14.3.1 Neural Plasticity: Learning in the brain
14.3.2 Attention and working memory
14.3.3 Selective attention is also guided by emotive and motivational evaluation of the target stimuli
14.3.4 The case of depression
14.4 The effect of brain lesions on attention
14.5 Rehabilitation post-stroke
14.5.1 Training attention post-stroke
14.6 Summary and conclusion
15: Executive functions
(Susan M. Fitzpatrick and Carolyn M. Baum)
15.1 Stroke Rehabilitation: The Role of Executive Functions
15.2 Overview of a multi-level understanding of executive functions
15.3 Neural Substrates of Executive Functions
15.3.1 Neural Measures and Interventions
15.4 Behavioural measures and interventions
15.4.1 Measures to Identify Brain Related Behaviours
15.4.2 Measures to identify the Behavioural Consequences of Stroke
15.4.3 Performance Based Tests
15.5 Behavioural and Performance Interventions
15.5.1 Interventions at the Behavioural Level
15.5.2 Intervention at the Performance Level
15.6 Conclusions
16: Language
(Lisa Tabor Connor)
16.1 Neuroscience of Language: Neuropsychological and lesion-symptom
mapping evidence
16.2 Functional Neuroimaging of Language and Recovery
16.2.1 White matter tractography
16.2.2 Functional connectivity MRI
16.3 Current Models of Language Rehabilitation
16.4 Treatment Principles/Strategies Arising from Neuroscience and Cognitive
Neuroscience
16.5 Toward a Neuroscientifically-Based Model of Aphasia Rehabilitation
Part E: New Perspectives and directions for stroke rehabilitation research
17: Targeting viable brain networks to improve outcomes after stroke
(Cathy Stinear and Winston Byblow)
17.1 Introduction
17.2 Measuring Connectivity to Predict Motor Outcomes
17.2.1 Functional Integrity of Motor Pathways
17.2.1.1 Crossed Corticospinal Tract
17.2.1.2 Uncrossed Corticospinal Tract
17.2.1.3 Interhemispheric Pathways
17.2.2 Structural Imaging of Motor Pathways
17.2.3 Combined Approaches
17.2.4 Algorithm for Predicting Upper Limb Motor Outcomes
17.2.5 The Lower Limb
17.2.6 Conclusions
17.3 Priming Approaches
17.4 Conclusions
18: Directions for stroke rehabilitation clinical practice and research
(Leeanne M. Carey)
18.1 Introduction
18.2 Key findings for stroke rehabilitation clinical practice
18.3 Beyond the lesion: Impact of focal lesion on brain networks and rehabilitation
18.4 Use of network-based models of recovery in stroke rehabilitation
18.5 Targeting of stroke rehabilitation to the individual
18.6 Guidelines to facilitate the translation of evidence to clinical practice
18.7 Perspectives and directions for stroke rehabilitation research
18.8 Conclusion