Rehabilitation Medicine

Adira Vinograd: Physical Therapist

Recent years have seen the development of several new approaches to help improve arm and leg function after a stroke. The Rehabilitation Medicine Department at New York Presbyterian is leading many new developments in this area. While none of these developments can be considered a cure for stroke, many of them can help stroke survivors improve the use of affected limbs, thereby improving their quality of life.

Injections of botulinum toxin can help ease spasticity and stiffness in the muscles of stroke survivors. While spasticity and hemiparesis typically occur together, there is some controversy over whether reducing spasticity with the injections could also help improve movement. While Botox is the most well-known form of botulinum toxin injections, and is the most commonly studied, Dysport (a second variation of botulinum toxin type A) and Myobloc (botulinum toxin type B) seem to be equally effective.

Constraint Induced Movement Therapy (CIMT) is a therapy that involves intense exercise of the affected arm, while the unaffected arm is restrained to encourage use of the weakened limb. Originally, this therapy involved six hours of exercise five days a week for two weeks. Variations of this may involve less intensive therapy for longer periods. 

Dynamic splinting, such as that used in the Saeboflex Functional Arm Training System, mechanically helps stroke patients straighten their fingers and wrist.

Electrically stimulating the nerves and muscles in the affected limb causes movement in the limb. Some evidence suggests that this type of treatment, when used repeatedly, can help restore some movement. Functional electrical stimulation for arms can be performed using devices such as the NESS H200 and the NeuromoveT™. Devices used for electrical stimulation of the legs include NESS L300, and the WalkAide®. Devices used on the lower limbs can be partially used as a substitute for a leg brace.

Robotic therapy devices are used to encourage improved function in paralyzed limbs. These devices are essentially high-tech exercise machines which guide the user through specific movements. For the arms, these devices include InMotion2, InMotion3, ReoGo, Amadeo, and Myomo e100. Robotic devices for the legs include Lokomat, ReoAmbulator, Anklebot, and PK100.

Partial body-weight supported treadmill training is a therapeutic technique that involves placing the stroke survivor into a harness that supports part of the weight, so that less weight is placed on the legs. While in the harness, the stroke survivor practices walking on a treadmill. This approach seems to be the most helpful for survivors early in the recovery process, when there is more difficulty with regaining ability to walk. Robotic devices such as Lokomat and Ambulator work to automate this therapy.

Virtual reality is a therapy that uses a computer screen to place the survivor into an artificial environment in which movements may be practiced to improve the function of arms or legs. This type of therapy is still fairly new, though preliminary studies are promising. This therapy may be used in conjunction with robot-assisted exercise. The Armeo device uses virtual reality combined with mechanical assistance to reduce the effects of gravity during the process.

Brain Stimulation uses TMS (transcranial magnetic stimulation) or TDCS (transcranial direct current stimulation) in an attempt to encourage the brain to rewire itself. These treatments are still in the experimental stages.

Acupuncture is an age-old therapy intended to treat weakness and other stroke symptoms. Some research suggests that acupuncture may be helpful, though it still remains unproven. Because acupuncture is considered to be safe and is usually well-tolerated, many doctors consider it a therapy worth trying if the patient wishes to do so, though they do not typically recommend or encourage its use.

Mental practice uses an audio recording to help the stroke survivor focus on imagining use of the affected limb. Significant research exists that suggest this type of practice may actually improve motor function. Mental practice may be used in conjunction with modified constraint induced movement therapy for added benefits.

Mirror Therapy involves having the stroke survivor use the unaffected arm in front of a mirror in such a way that it seems the affected arm is moving symmetrically. This technique has not been thoroughly studied, though it does show promise.

Hyperbaric oxygen therapy is a potentially dangerous therapy that has not been proven to provide any benefit in the restoration of function after a stroke and is not currently recommended.

 Rehabilitation Medicine

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