What is the Top of stroke Rehabilitation?

A Historical Study in Birmingham  of the University of Alabama Researchers used a randomized controlled trial -- the gold standard method for evaluating treatment effectiveness -- to show that stabilizing the good arm and intensive exercise of the weaker arm in stroke patients actually improved recovery. Even when performed long after the stroke occurred. At one level, randomized controlled trials in rehabilitation medicine have been so rare that the publication of each should be commended. On another level, the results of this study are so satisfactory in terms of what we think about brain function that even if the results are not true, they should be.

a controlled trial is one in which there is a comparison group of patients who are either not treated or treated differently. When a controlled trial is also randomized, it means that upon entering the study, participants agree to be assigned to one group or the other on a basis equivalent to a coin-toss. Randomization eliminates bias that can come from assigning more promising patients to one group and less promising patients to another.

The loss of circulation in a stroke damages a part of the brain, resulting in impairment of whatever mental or physical functions control that part of the brain. Stroke often causes weakness in one arm with or without concurrent numbness. Stroke is the leading cause of long-term disability in America.

The researchers included stroke victims in their study who had mild to moderate impairment in the use of the affected arms, but excluded those with severe impairment. The CI patients had 10 workday sessions with the physician, lasting 6 h each. During those sessions, patients received one-on-one therapy that was personalized to their needs and abilities and included specific, practical tasks of gradually increasing difficulty. Every time the physicians praised the patients, their performance improved even slightly.

The abilities of CI and placebo-treated patients were compared in two main ways. In one, research subjects were videotaped in the lab attempting specific tasks, such as holding a book, raising a glass, and brushing teeth. Their performance was rated by the audience, who were deliberately not told what treatment the subject had received. Researchers found significant improvements in CI-treated patients in their own initial abilities and in patients who received placebo treatment. 

The CI patients showed a slight improvement in their laboratory skills and a major improvement in the use of the affected arms in their daily lives.

The researchers explain the improvement as due to two factors. The first factor, perhaps more important for rapid gains, was in overcoming the "learned non-use" of the weaker arm. The idea is that after a stroke, patients quickly learn to avoid using the weaker arm, as its impairment may warrant, and CI training forces them to put it back into action. 

In 1992 researchers at Hammersmith Hospital in London used PET scans to examine patterns of brain usage in stroke patients. PET scans are good at showing which parts of the brain are most engaged in specific tasks. Subjects in this study repeatedly moved an arm while their brains were being scanned.

Tab and colleagues at the National Institute of Neurological Disorders and Stroke used similar methods to compare patterns of brain activation in 9 CI-treated stroke patients with those in 7 less-intensely treated stroke patients. In this 2003 study, CI-treated patients showed a change in the extent to which different parts of the brain participated in moving the fingers of the weaker hand. Thus, CI treatment appears to modify the brain pathways responsible for finger movements.