1. Physical recovery following stroke
This is not an Agored Cymru publication. It has been developed by colleagues from Cwm Taf University Health Board and is currently being hosted by Agored Cymru until a more suitable site becomes available.
Physical recovery following stroke
This session will look at the recovery of physical ability and function following stroke.
15/2/10

2. Learning objectives
To gain an understanding of the basic mechanisms of brain damage and how recovery can restore movement following stroke.
To gain insight into the motor impairments that can result.
To gain an understanding of how these impairments can impact on motor activities.

3. Learning objectives contd.
To gain knowledge of the basis of normal movement.
To gain insight into how you can influence motor recovery.

4. Normal brain activity Billions of cells (Neurones).
Trillions of connections between cells (Synapses and Neuronal networks).
Receive and send out information to and from the body.
Specific connections have specialised functions (cortical representation areas).
Cells make up the brain tissue and the connections between these cells allow messages to travel around the brain.
These connections and messages can be likened to our home telephone lines. We call certain people regularly and other people call us regularly, you call some numbers occasionally and other numbers you don’t call at all, but could if you wanted too. This is the same in the brain, many connections of which some are used frequently and some not used at all.
Neuronal networks have specific functions. If you scanned someone's brain at the same time that they were reading then the area specifically for the function of reading would be highlighted as active. This is called cortical representation.

5. Neuroplasticity
Brains are very plastic and highly adaptable, this forms the basis of normal learning (Neuroplasticity).
The more we practice tasks the more efficient the cells become and the stronger the connections in the brain get.
This allows our brains to develop areas that are responsible for certain tasks/functions (cortical representation areas).
We can train our brains to be good at what ever we want them to be good at.
In advanced scans, areas of the brain responsible for a practiced task are shown to get bigger as we become better at it. An example would be starting to play a musical instrument and getting better with practice as the brain and body adapt to the new skill.
When you drive to work, half the time you don’t remember your journey when you get there because you are so practiced at it and our brains allow it to be automatic. When you drive to a different location you have to think about it more as it’s not a familiar route and the brain pathways aren’t efficient enough for that route to be automatic. If you were to practice this route it would become automatic again due to increased efficiency and representation within the brain. Efficiency of brain pathways improves with repetition.

7. What happens when a stroke occurs?
Through a blockage to blood supply or a bleed, cells die and connections are lost or disrupted.
Think of the London tube system!
Multiple functions are lost depending on the area of the brain that the damage occurs in.
Some damage is permanent and some is adaptable.
This is a quick overview as the detail is covered in the medical presentation.
If a tube train breaks down in a tunnel then all the tubes behind it get stuck and can’t move. The tube system slowly grinds to a halt. The people stuck on the tubes can’t get to work and slowly the jobs they do fail to be done as work places remain empty. Over time people will find alternative routes to work by walking or catching the bus and jobs will start to get done again except for those jobs of the people stuck on the tubes.
This is likened to the brain following stroke as some of the functions are permanently lost through damage but others will gradually start to get going again as the brain adapts to the demands put on it.

8. How is movement restored?
Spontaneous resolution of swelling ‘rescues’ some cells from dieing.
Through neuroplasticity – The things that you do following a stroke can determine what changes take place in the brain.
Rehabilitation and practice can guide this reorganisation.
Through research and brain scanning studies there is now lots of evidence to support this.
So how does this help restore movement and help people get moving again?
In most people following stroke swelling in the brain will resolve and some cells come back to life and start functioning again.
Neuroplasticity – Practice makes perfect! If you do nothing then you brain will do nothing!
Neuroplasticity will always need guidance through rehabilitation to prevent bad habits becoming established, to maximise motivation and to give the opportunity to practice.
Evidence that these changes occur in the brain have previously been shown in monkey studies looking at brain changes during repetitive practice at new tasks involving reaching for nuts out of complex containers.
In recent years scans that highlight areas of activity of the brain in humans when they do practiced tasks have been used to show that neuroplasticity exists. An example of this is constraint therapy studies.

9. Brain scanning studies

10. NOT ALL OF THESE PLASTIC CHANGES ARE BENEFICIAL THOUGH!
If you don’t use the cells and connections you can loose them - Not using the movement you have on the stroke side will reduce the brain area for it and this will become normal (LEARNED NON-USE).
Any bad habits can become established in the brain.
The spinal cord can produce unwanted changes in muscles.
This all sounds great and suggests that most stroke patients should recover very well, but sadly not all of the changes that occur in the brain after a stroke are beneficial.
Learned non-use – some stroke patients will recover previously lost activity in their limbs over time but unless they make use of this movement and avoid using established alternative ways of doing things, such as eating with one arm or standing up on one leg, they risk loosing the brain representation essential for long term returned of use of their affected limb. Over time these established bad habits will become further established and the brain patterns will change in relation to it and patients will loose cortical representation and therefore activity in the affected limb.
Examples of bad habits are standing with all the weight on one leg when standing up, eating meals with one hand, never taking a full step with the good leg and always pulling up on rails, furniture and frames to stand up.
The spinal cord can produce activity on it’s own without the influence of the brain upon it. This was proved by de-cerebrating cats and placing them in a harness over a treadmill and it was found that the cats could walk. This is fine for walking in straight lines on even surfaces but we need the influence of the brain on the spinal cord to allow us to adapt and change our walking patterns.
This provides evidence that the spinal cord can produce activity in muscles independently of the brain but the effects are not always as desirable as walking.

11. Those unwanted changes are known as the Upper Motor Neurone syndrome
UMN’s are the sections from the cell’s in the brain (neuron) to the spinal cord.
They control or influence movement and muscle tone, by influencing activity of the spinal cord to the muscle.
This topic can be complicated but the examples given and the photographs shown will help make the topic relevant.
An UMN is the bit from your head down to your neck or back.
The UMN tells the spinal cord what to do or what not to do in relation to movement produced.

12. UMN Syndrome
Develops from brain or spinal lesions, such as stroke, because of interruption of brain control on the spinal cord.
The symptoms of it are broadly divided into negative and positive phenomena.
Negative characterised by reduced motor activity, whereas positive characterised by excessive motor activity.
When the spinal cord looses it’s control from the brain it can produce very varied and unwanted symptoms.
This effect can be likened to a class of children (clusters of cells in the spinal cord) and a teacher (brain). When the teacher is not in the class room some children will become scared and quiet and other children will become wild and hyperactive, this could be compared to the output from the spinal cord when the brain input is lost, both negative and positive effects on the body.
This divides the UMN symptoms into negative symptoms, which dampen down muscle activity, and positive phenomena which produce excess amounts of muscle activity.

13. Clinical Features of the UMN Syndrome
Negative Features:
Acute hypotonia (‘shock’ – floppy muscles)
Weakness due to inadequate muscle activation of specific movements
Loss of dexterity - clumsiness
Loss of cutaneous reflexes
Fatiguability

14. Clinical features contd.
Positive Features:
At rest, in response to stimulation:
Proprioceptive (what we feel)
Increased tendon reflexes
Clonus
Spasticity
Nociceptive (unpleasant sensation)
Positive Babinski
Extensor / flexor spasms
Mass reflex
Produces over exaggerated reflexes.
Clonus can be seen when someone's leg repetitively shakes following pressure on the ball of the foot.
Spasticity is a very complex topic and could be a presentation in it’s self but simplified, muscles become overactive and tight.
A Babinski test can be seen on the next slide. A normal response causes your toes to go down but when a stroke occurs the opposite can happen. Although this is a test often used for diagnosis by doctors it can be disabling when trying to get socks, shoes and splints on.

15. Babinski Reflex

16. Flexor Spasms

17. Clonus

18. Spasticity

19. Clinical features contd.
Positive Features contd.
During Movement:
Patterns of co-contraction
Associated reactions
Flexor withdrawal reflexes
Positive support reaction
Extensor thrust
‘Pushing’ reaction
Co-contraction means all the muscles tighten (contract) at the same time and leads to a very stiff limb.
Associated reactions are as they sound, involuntary movements associated with an activity (e.g. coughing, sneezing, walking). Very often seen as the affected arm bending up across the body.
The affected leg will often pull up on standing or withdraw from a stimulus on it.
The affected leg will straighten and push up onto toes on standing.
Extensor thrust can be seen in sitting, lying and standing and is a strong thrust backwards.
There is often a push to the affected side off the good side and can be severe enough to push them off balance, and anyone sat/stood next to them.

20. Associated Reactions

21. Commonly seen patterns of UMN dysfunction

22. Problems resulting from the UMN Syndrome
Soft Tissue changes.
 ROM in muscles, joints and limbs.
Pain.
Excessive or inappropriate movement.
Tissue and skin damage.
Limited involvement in rehab due to fatigue.
Changes in posture and positioning.
All of these factors affect activity.

23. Other impairments that affect motor recovery
Changes in muscle tone.
Altered cutaneous sensory input.
Other factors not included in this session (motor planning, motor sequencing, cognition etc)
As well as the problems resulting from the UMN syndrome stroke patients also experience other problems that will impact on their physical recovery, for example a change in sensation, change in tone, motor planning, perception and cognition. We will continue with the focus on tone and sensation as the other factors are considered in other sessions.
We all have a normal level of tone, we are either naturally low or high toned.
The demands put upon us will also influence our tone. If you have been sat down for hours then your tone level would be low but if the fire alarm went off your level of tone would increase considerably and you would be very ready to move.
We rely on the information we receive through our senses for normal motor activity and therefore recovery following stroke.

24. What is tone? postural tone
“The state of activity in a muscle or group of muscles, indicating the body’s readiness to move and it’s ability to resist the downward pull of gravity”. (Modified from Ryerson and Lewit, 1998)
We don’t control our level of tone.

25. Postural Tone Postural control is normally automatic.
It varies depending upon the demands put upon it.
E.g. Less postural tone when lying on flat firm bed compared to lying on inflatable mattress.
We use it
To maintain a position
Dynamically to move
We are either more predominantly high or low toned but this is influenced by the demands put on the body.
For patients you can think of examples like lying or sitting on an air mattress. It is similar to being fully relaxed and low toned on a airbed on holiday in a swimming pool as apposed to being on the same airbed in rough seas! Your tone will increase drastically.
Tone is important because is keeps us upright and allows us to move easily by providing a background of activity.

26. Think of other factors that will increase or decrease tone
Noise
Visual distractions
Spatial restrictions e.g. if lying on a narrow bed
Other environmental issues
Infection
Other internal factors e.g. constipation / pain etc
Postural Sets [i.e. sitting standing etc]
Interest / boredom
Fear / anxiety
Other emotional issues including confidence in staff
General wellness
Tiredness
Temperature

27. Problems that can result from pathological tonal changes
Pain
Reduced ROM
Shoulder subluxation
Reduced balance
Pressure areas
Reduced activity levels – trunk and both upper and lower limb
Adverse long term neuroplasticity and musculo-skeletal system changes

28. What is cutaneous sensation?
Ability to feel a stimulus on a part of the body and to interpret appropriately what that stimulus is.
To know where your body parts are in space, and in relation to each other and what your body consists of (Body Schema).
So if someone was to pinch you, you would feel it and act appropriately by moving away or pinch back. Feel it and choose to act or not.

29. Cutaneous sensations that can be altered following a stroke.
Light or deep touch.
Hot and cold temperatures.
Pain (external and internal).
What position our body parts are in (proprioception).
‘Gating’ of incoming sensory information – cutaneous input can trigger tonal changes.
How much pressure you can feel, for example how tight shoes might be.
You need to be able to feel the temperature of bath or shower water, radiator of heater, hot water bottle and hot drinks and foods. If you can’t feel the temp the risk of burns is high and people need to learn compensation strategies.
Pain can be perceived to minimal stimulus or you can experience constant pain for no reason.
This can cause you too loose an arm or leg in the bed sheets, put your clothes on and not know if your arm and leg is in appropriately. People need to learn to check visually as a compensation.
This controls information in and out of the brain via the spinal cord and allows us to act appropriately on it.

30. Problems resulting from cutaneous sensory changes
Poor posture
Neglect of limbs
Injuries – bangs, scrapes, burns
Allodynia
Reduced ability in activities
Pressure areas
Altered body schema
Can result in poor posture and neglect by only moving one side of your body as forget that the other side is there.
Limbs can get caught in wheelchair wheels and can be left dangling over the side of chairs. This can cause injury and trauma to hemiplegic shoulders.
Allodynia is a pain response to minimal touch.
If you can’t feel where your limbs are then you don’t use them (learned non-use can develop).
If you can’t feel pressure or pain then your more prone to pressure areas.
When your sensation is altered you become at risk of perceiving your body in a different way.

31. PRACTICAL
In groups, take turns to carry out the instruction on the sheets.
This will replicate one of the previously discussed impairments.
When you have all carried out the task complete the proforma at the station.

32. So how do we move normally? Normal postural control
Certain systems within the body are required for us to move normally:
Musculo-skeletal system
Cognition
Nervous system
Motor control
Sensory system

33. The basis for normal Movement
Normal postural tone
Normal reciprocal innervation
Normal sensory-motor feedback system
Normal balance reactions (Righting, Equilibrium and Saving)
A background of muscle activity that allows us to move appropriately.
Groups of muscles usually work in synchronised patterns. Some switch on the same time as others and others switch off the same time as others this allows smooth co-ordination of movement.

34. What stroke related causes can alter our normal movement patterns?
Features of the Upper Motor Neurone Syndrome.
Loss of muscle innervation.
Muscle weakness.
Altered touch/temperature/pain/proprioception.
Attention problems.
Spatial/perceptual problems.
Motor planning problems.
Co-ordination problems (Ataxia).
Think of stroke patients you might have seen, the things we have discussed in this presentation and things you experienced during the practical sessions. What reasons might make it difficult to move normally?

35. Think of some non-stroke causes than can change normal movement patterns
Distractions (noise, visual and auditory stimuli)
Pain
Confidence/fear
Fatigue
Time of day
Clothing and footwear
Continuity (instructions, walking aids, seating etc)
Inappropriate handling
Dehydration/hunger
What might make you and me stop moving normally?
These things also apply to stroke patients.

36. Ways we can help restore normal movement
Physiotherapists use a combination of:
- Facilitation of active movement and movement experience
- Alignment and stretching
- Balance work
- Sensory retraining
- Motor re-learning through practice and repetition of specific activities
- Gait re-education and mobility practice
- Strengthening of muscle groups and motor patterns
- Controlling over activity on the affected side and compensatory movement patterns
- Prevent learned non-use of affected limbs
Give the experience of moving normally again and educating on it.

37. MDT Approach
To enable a patient to maximise potential the multi-disciplinary team need to have a co-ordinated approach underpinned by effective communication.
All doing the same thing for the same task for the same people!

38. MDT Approach contd. Adequate and appropriate handling techniques.
Conducive environment.
Chance to practice ++
Consistent sequence of task and instructions.
Encouragement and motivation.
Correct and consistent use of appliances.
24 hour management
So how can you help stroke patients physical recovery?

39. Questions
What is the term used to describe recovery and remodelling in the brain?
Neurophysiology
Neuroplasticity
Neuropsychology
List 3 things that can affect the way we move?
List 2 of the components that we need for the basis of normal movement?