Stroke Rehabilitation
Preface Stroke Rehabilitation
John Chae, MD
Pablo A. Celnik, MD Editors
We are pleased to present this latest issue of Physical Medicine and Rehabilitation Clinics of North America dedicated to stroke rehabilitation. We thank Greg Carter for giving us the opportunity to provide this update to our colleagues, especially the clinicians on the frontline of clinical care. The goals of stroke rehabilitation should be to reduce impairment and maximize the function, societal participation, and quality of life of stroke survivors. In light of these goal, we launch this issue with a comprehensive review of predictors of functional outcome to help us focus on those specific issues that impact clinically meaningful recovery following stroke. This is then followed by a series of articles that focuses on specific manifestations of stroke with major implications on outcomes. The phenomena of “nonuse,” learned “bad-use,” and “forgetting” are presented to help inform the formulation of treatment plans for the restoration of upper limb motor function. These same phenomena are present in the lower limb, but with a different set of implications leading to the characteristic hemiplegic gait and associated impact on mobility. As stroke recovery enters the chronic phase, nearly half of all stroke survivors develop spasticity. There is now emerging evidence that some treatments for spasticity not only reduce spasticity but also improve upper and lower limb functional performance. A musculoskeletal pain syndrome that uniquely impacts stroke survivors is shoulder pain. While the initial inciting factor is likely glenohumeral instability or biomechanical compromise, central mechanisms may be more dominant in the chronic phase with their unique implications on treatment strategies. The section concludes with a review of poststroke communication disorders and dysphagia, manifestations of stroke that have major learning, relational, nutrition, and societal participation implications. The second set of articles focuses on treatment modalities that are presently not yet part of the standard treatment armamentarium. Our goal is to provide the practicing clinician an update on these modalities. Neuropharmacology has been a focus of investigation for decades. However, due to inconsistent results or limited internal and external validity of the various studies, firm clinical recommendations cannot be
Phys Med Rehabil Clin N Am 26 (2015) xv–xvi http://dx.doi.org/10.1016/j.pmr.2015.08.013 1047-9651/15/$ – see front matter Ó 2015 Published by Elsevier Inc.
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presented. In contrast, there are more robust data in support of robotic therapy, especially with respect to upper limb applications. However, the rehabilitation community needs to decide whether the data are compelling enough to integrate this approach into the “standard of practice.” A novel treatment paradigm for hemiplegic gait that many practicing clinicians may not be familiar with is split-belt treadmill training. Although the technique is not ready for clinical implementation, it is an intriguing approach to address step length asymmetry, which reduces propulsive force of the paretic limb, resulting in increased walking speed and efficiency. We then provide updates on mental practice, neuromuscular electrical stimulation, and virtual reality environments, which generally show improvements at the level of impairment but less robust translation to activities. Yet, these interventions may have a role in the treatment of specific stroke survivors, and readers are invited to critically evaluate these approaches and determine relevance to their respective clinical practices. We conclude this issue with an article on brain stimulation, primarily because the approach represents a necessary shift in the treatment paradigm in stroke rehabilitation. To date, the development of interventions, for the most part, has focused on single-treatment approaches. However, in the face of only modest improvements, at best, there is a growing consensus that more meaningful clinical outcomes can only be achieved through combination therapies. Stimulating the brain via a variety of approaches may prepare the neural substrate for relearning strategies and serve as the prime candidate for testing this hypothesis. We are very appreciative of all the contributors to this issue and their willingness to share their respective expertise. It is our hope that our colleagues in the field will find this issue helpful as they explore new treatment approaches for their patients. For some, this issue may also lead to insights regarding research ideas that will translate to the development of new clinically relevant diagnostic or treatment options. John Chae, MD Case Western Reserve University MetroHealth Rehabilitation Institute 4229 Pearl Road Cleveland, OH 44109, USA Pablo A. Celnik, MD Departments of Physical Medicine and Rehabilitation, Neurology and Neuroscience Johns Hopkins Hospital Johns Hopkins University 600 North Wolfe Street Baltimore, MD 21287, USA E-mail addresses: [email protected] (J. Chae) [email protected] (P.A. Celnik)
Preface Stroke Rehabilitation
John Chae, MD
Pablo A. Celnik, MD Editors
We are pleased to present this latest issue of Physical Medicine and Rehabilitation Clinics of North America dedicated to stroke rehabilitation. We thank Greg Carter for giving us the opportunity to provide this update to our colleagues, especially the clinicians on the frontline of clinical care. The goals of stroke rehabilitation should be to reduce impairment and maximize the function, societal participation, and quality of life of stroke survivors. In light of these goal, we launch this issue with a comprehensive review of predictors of functional outcome to help us focus on those specific issues that impact clinically meaningful recovery following stroke. This is then followed by a series of articles that focuses on specific manifestations of stroke with major implications on outcomes. The phenomena of “nonuse,” learned “bad-use,” and “forgetting” are presented to help inform the formulation of treatment plans for the restoration of upper limb motor function. These same phenomena are present in the lower limb, but with a different set of implications leading to the characteristic hemiplegic gait and associated impact on mobility. As stroke recovery enters the chronic phase, nearly half of all stroke survivors develop spasticity. There is now emerging evidence that some treatments for spasticity not only reduce spasticity but also improve upper and lower limb functional performance. A musculoskeletal pain syndrome that uniquely impacts stroke survivors is shoulder pain. While the initial inciting factor is likely glenohumeral instability or biomechanical compromise, central mechanisms may be more dominant in the chronic phase with their unique implications on treatment strategies. The section concludes with a review of poststroke communication disorders and dysphagia, manifestations of stroke that have major learning, relational, nutrition, and societal participation implications. The second set of articles focuses on treatment modalities that are presently not yet part of the standard treatment armamentarium. Our goal is to provide the practicing clinician an update on these modalities. Neuropharmacology has been a focus of investigation for decades. However, due to inconsistent results or limited internal and external validity of the various studies, firm clinical recommendations cannot be
Phys Med Rehabil Clin N Am 26 (2015) xv–xvi http://dx.doi.org/10.1016/j.pmr.2015.08.013 1047-9651/15/$ – see front matter Ó 2015 Published by Elsevier Inc.
pmr.theclinics.com
xvi
Preface
presented. In contrast, there are more robust data in support of robotic therapy, especially with respect to upper limb applications. However, the rehabilitation community needs to decide whether the data are compelling enough to integrate this approach into the “standard of practice.” A novel treatment paradigm for hemiplegic gait that many practicing clinicians may not be familiar with is split-belt treadmill training. Although the technique is not ready for clinical implementation, it is an intriguing approach to address step length asymmetry, which reduces propulsive force of the paretic limb, resulting in increased walking speed and efficiency. We then provide updates on mental practice, neuromuscular electrical stimulation, and virtual reality environments, which generally show improvements at the level of impairment but less robust translation to activities. Yet, these interventions may have a role in the treatment of specific stroke survivors, and readers are invited to critically evaluate these approaches and determine relevance to their respective clinical practices. We conclude this issue with an article on brain stimulation, primarily because the approach represents a necessary shift in the treatment paradigm in stroke rehabilitation. To date, the development of interventions, for the most part, has focused on single-treatment approaches. However, in the face of only modest improvements, at best, there is a growing consensus that more meaningful clinical outcomes can only be achieved through combination therapies. Stimulating the brain via a variety of approaches may prepare the neural substrate for relearning strategies and serve as the prime candidate for testing this hypothesis. We are very appreciative of all the contributors to this issue and their willingness to share their respective expertise. It is our hope that our colleagues in the field will find this issue helpful as they explore new treatment approaches for their patients. For some, this issue may also lead to insights regarding research ideas that will translate to the development of new clinically relevant diagnostic or treatment options. John Chae, MD Case Western Reserve University MetroHealth Rehabilitation Institute 4229 Pearl Road Cleveland, OH 44109, USA Pablo A. Celnik, MD Departments of Physical Medicine and Rehabilitation, Neurology and Neuroscience Johns Hopkins Hospital Johns Hopkins University 600 North Wolfe Street Baltimore, MD 21287, USA E-mail addresses: [email protected] (J. Chae) [email protected] (P.A. Celnik)
