L4: ABI Recovery & Neurologic Treatment Approaches

Recovery definition at ICF health condition level

Restoring function in neural tissue that was initially lost after injury

(may be seen as reactivation in brain areas previously inactivated)

Recovery definition at ICF body function/structure level

Restoring the ability to perform a movement in the same manner as it was performed before injury

Recovery definition at ICF activity level

Successful task accomplishment using limbs or end effectors typically used by nondisabled individuals

Compensation definition at ICF health condition level

Neural tissue acquires a function that it did not have prior to injury

Compensation definition at ICF body function/structure level

Performing an old movement in a new manner

Compensation definition at ICF activity level

Successful task accomplishment using alternate limbs or end effector

(opening chips with 1 hand and mouth)

Motor recovery definition

• “Getting better”

• Improvement in the strength, speed, or accuracy of arm and leg movements

Functional recovery definition

• “Doing better”

• Improvements in performance

Motor recovery assessments

• MMT

• ROM

• Observational movement analysis

• Coordination

• 9 hole peg test

• Modified Ashworth Scale

Functional recovery assessments

• Patient reports outcome measures

  • Stroke impact scale

  • 10 MWT

  • 6 MWT

• Goal attainment scale

• TUG

• 5x STS

• AM-PAC (6 clicks)

• Functional impairment measures

Every person will have a ________ recovery journey after ABI

Unique

Recovery after ABI depends on

• Injury

  • Location

  • Timing (neuroplasticity)

  • Size

• PLOF

• Cognition

• Compliance

• Social determinants of health

  • Ability to access quality rehabilitation

Motor recovery concepts - deficit severity post stroke

• Mild UE deficits = greater potential for full or near full recovery

• Significant UE deficits = more variable trajectory

Stroke recovery timeline

• 0-24 hours = Hyperacute phase

• 1-7 days = Acute phase

• 1 week - 3 months = Early subacute

• 3-6 months = Late subacute

• > 6 months = Chronic

When do the most significant motor improvements happen in stroke recovery?

During the first couple of weeks

What happens during the Hyperacute phase?

• Spontaneous neurological recovery

  • Plasticity enhancing mechanisms lead to neuroplastic changes in the brain

    • New synapses, axonal sprouting, & dendritic growth

  • Will continue into subacute phase

Interhemispheric connectivity in the hyperacute phase initially ________?

Decreases

• Connectivity drops significantly during first 2 weeks

• Gradually recovers & parallels spontaenous motor recovery

What happens during the Acute phase?

• Spontaneous neurological recovery continues

• Neuroplastic changes and motor recovery are enhanced by specific, intensive rehabilitation

  • Sitting EOB

  • Bed mobility

  • Transfer training

Motor recovery is most rapid during the first ________ post-insult

3-6 months

On average, people will recover ________ previous function

70%

What happens for Physiologic Recovery during the Subacute phase?

• Axonal sprouting, synaptogenesis, dendritic spine expansion

• Synaptic effectiveness

• Reperfusion

• Diaschisis reversal

What happens for Motor Recovery during the Subacute phase?

• Recovery shaped by experience

  • Focused on impairments to target deviations

  • Task-oriented

  • Specific

Axonal sprouting

New axons start growing

Synaptogenesis

New connections are made between previously unconnected areas

Dendritic spine expansion

Dendrites lengthen to connect to new, more remote areas

Synaptic effectiveness

• Resolution of local edema

• May continue for up to 8 weeks

Reperfusion

• Return of adequate blood supply may lead to resumption of neural activity

• Arteriolar collateral growth and new capillaries form in ischemic border (Penumbra)

Diaschisis

Loss of function within a region distant to the site of the lesion and results from deafferentation of neurons as a result of axon damage caused by stroke

The more severe the insult, the ________ and more severe diaschisis

Longer

Diaschisis commonly presents as neurological signs including

• Impaired consciousness

• Cognitive impairments, including dementia

• Dyspraxias, dystaxias, dysphasias

• Incoordination

• Sensory neglect

(all require talking across cortices)

Recovery of function from diaschisis is associated with recovery of ________ & ________

Local perfusion, Metabolism

Diaschisis reversal may be related to ________

Resolution of edema

Diaschisis at rest

Focal lesion induces a remote reduction of metabolism (red)

Functional diaschisis

Normal brain activations (yellow) during a selected task may be altered, either increased (green) or decreased (red) after a lesion

Connectional diaschisis

Distant strengths and directions of connections in a selected network may be increased (green) or decreased (red)

Connectomal diaschisis

Lesion of the connectome includes widespread changes in brain network organization including decrease (red) or increase (green) in connectivity

Post stroke patients exhibit more ________ functional connectivity than healthy controls

Complex

• Impacted by compensatory mechanisms, new connections, & overall efforts to restore functionality

________ functional connectivity is associated with better motor recovery

Interhemispheric

• Specifically connections between motor areas (M1 → M1) & primary motor area to the supplementary motor area of the unaffected hemisphere (M1 → SMA)

Cognitive recovery is associated more with ________

Default mode networks

• Large scale brain network primarily active when an individual is not focused on the external environment

What happens during the Subacute to Chronic phase

• Cortical reorganization

• Maintenance

Cortical reorganization definition

Use dependent changes in cortical maps/ representations

Three ways cortical reorganization can happen?

1. Increase in the absolute number and concentration of synapses on dendrites

2. Unmasking of latent neural networks

3. Surviving neurons reorganize connectivity patterns to support partial restoration or compensatory substitution for lost function (occurs in bilateral hemispheres)

Ranchos Los Amigos level I

• Outcome:

  • No response

• Patient Response:

  • No response to sounds, sights, touch, or movement

Ranchos Los Amigos level II

• Outcome:

  • Generalized response

• Patient Response:

  • Limited response, which is inconsistent and nonpurposeful

  • Response to sounds, sights, touch, or movement

Ranchos Los Amigos level III

• Outcome:

  • Localized response

• Patient Response:

  • Inconsistent but purposeful response in a more specific manner to stimuli

  • May follow simple commands

Ranchos Los Amigos level IV

• Outcome:

  • Confused & agitated

• Patient Response:

  • Confused and often frightened

  • Overreactions to stimuli by hitting or screaming

  • Highly focused on basic needs (eating, toileting)

  • Difficulty following directions

Ranchos Los Amigos level V

• Outcome:

  • Confused & inappropriate

• Patient Response:

  • Appears alert and responds to commands

  • Easily distracted by the environment

  • Frustrated and verbally inappropriate

  • Focused on basic needs

Ranchos Los Amigos level VI

• Outcome:

  • Confused & appropriate

• Patient Response:

  • Follows simple directions consistently

  • May have some memory but lacks details

  • Attention span of about 30 minutes

Ranchos Los Amigos level VII

• Outcome:

  • Automatic & appropriate

• Patient Response:

  • Follows a set schedule

  • Does routine self-care without help

  • Attention difficulty in distracting or stressful situations

  • Problems in planning and following through

Ranchos Los Amigos level VIII

• Outcome:

  • Purposeful & automatic

• Patient Response:

  • Realizes difficulties with thinking and memory

  • Less rigid and more flexible thinking

  • Able to learn new things

  • Demonstrates poor judgement

  • May need guidance on decisions

Recovery after mild TBI (concussion)

• For most people, symptoms resolve within 1 month

• If symptoms persist longer than 6 weeks, refer to neurology

What is post concussion syndrome (PCS)?

• Lingering symptoms following a concussion or mild traumatic brain injury

• Symptoms may last weeks, months, or occasionally a year or more

Most common symptoms of mild TBI

1. Poor concentration - 71%

2. Irritability - 66%

3. Fatigue - 64%

4. Depression - 63%

5. Memory problems - 59%

6. Headaches - 59%

7. Anxiety - 58%

8. Trouble thinking - 57%

9. Dizziness - 52%

10. Blurry or double vision - 45%

11. Sensitivity to bright light - 40%

Mild TBI returning to play protocol Step 1

Back to regular activities

Mild TBI returning to play protocol Step 2

Light aerobic exercise (5-10 minute walk/ light jog)

Mild TBI returning to play protocol Step 3

Moderate activity (submax lifting, jog/run/bike)

Mild TBI returning to play protocol Step 4

Heavy, non-contact activity (weight lifting)

Mild TBI returning to play protocol Step 5

Practice and full contact

Mild TBI returning to play protocol Step 6

Competition

Patients must spend a minimum of ________ at each level

24 hours

T/F: Patients can move to the next step after 24 hours but with a return of symptoms

FALSE!

(ONLY move to next step if no return of symptoms/ new symptoms)

Functional outcomes over first year after moderate/severe TBI

Approximately ½ of those with severe TBI & ¾ of those with moderate TBI recovered the ability to function independently at home for at least 8 hours per day

Glascow Outcome Scale - Extended

8 levels

• Minimum score = 1 (death)

• Maximum score = 8 (resumption of normal activity without disability)

12 months post severe TBI ________ of patients scored an 8 and ________ of patients scored a 7

25%, 16%

T/F: If a patient discharges from the hospital, the chance of dying increases significantly

FALSE

(38% chance prior/ at discharge and 39% chance at 1 year)

Explain the neural plasticity principle of use it or lose it.

Failure to drive specific brain functions can lead to functional degradation

Explain the neural plasticity principle of use it and improve it.

Training that drives a specific brain function can lead to an enhancement of that function

Explain the neural plasticity principle of specificity

The nature of the training experience dictates the nature of the plasticity

Explain the neural plasticity principle of repetition matters.

Induction of plasticity requires sufficient repetition

Explain the neural plasticity principle of intensity matters.

Induction of plasticity requires sufficient training intensity

Explain the neural plasticity principle of time matters.

Different forms of plasticity occur at different times during training

Explain the neural plasticity principle of salience matters.

The training experience must be sufficiently salient to induce plasticity

Explain the neural plasticity principle of age matters.

Training induced plasticity occurs more readily in younger brains

Explain the neural plasticity principle of transference.

Plasticity in response to one training can enhance the acquisition of similar behaviors

Explain the neural plasticity principle of interference.

Plasticity in response to one experience can interfere with the acquisition of other behaviors

Good evidence for improving walking function in chronic CVA & TBI

• Clinicians should perform:

  • Walking training at moderate to high aerobic intensities

  • Walking training with virtual reality

Moderate evidence for improving walking function in chronic CVA & TBI

• Clinicians may consider:

  • Strength training at ≥ 70% 1RM

  • Circuit training, cycling, or recumbent stepping at 75-85% of HRmax

  • Balance training with virtual reality

Poor evidence for improving walking function in chronic CVA & TBI

• Clinicians should not perform:

  • Static or dynamic balance activities including pre-gait

  • BWSTT with emphasis on kinematics

  • Robot assisted gait training

To improve walking function in chronic CVA/TBI

• Train at moderate to high intensity

• Virtual reality makes it salient

Why might calculating HRmax using HR reserve be better after CVA?

It accounts for variations in resting HR

HR reserve equation

HRR = HRmax - HRresting

Description of muscle re-education

• Improve strength for injuries that affect LMN

• Foundation of MMT

• Focus on isolated muscle strengthening & stretching

Strengthening is ________ for patients with neurologic disorders

VITAL

Strengthening ________ exacerbate disease process or ________ spasticity if implemented correctly

Will not, Worsen

Muscle re-education limitations

Increasing strength/ROM ≠ change in movement pattern

Neurofacilitation Approach description

• Application of appropriate sensory inputs = normal movement patterns

• Built on reflex theory and hierarchical organization of reflexive development

• Focus on progression through stages of recovery/ motor control using sensory facilitation

Neurofacilitation current use

• Fugl-Meyer Motor Assessment of Motor Recovery outcome measure

• Postural control

• Progression of task difficulty

• Application of sensory cueing

Neurofacilitation limitations

Voluntary movement is not entirely reflexive in nature

Brunnstrom Stage 1

Flaccid paralysis

Brunnstrom Stage 2

Development of minimal movement in synergies (some spasticity)

Brunnstrom Stage 3

Voluntary movement synergy dependent (marked spasticity)

Brunnstrom Stage 4

Some movements out of synergy (less spastic)

Brunnstrom Stage 5

Movements almost independent of synergy

Brunnstrom Stage 6

Normal movement with normal speed

Treatment during Brunnstrom Stage 1

• PROM

• Positioning

• Weight bearing through UE

• Hand-over-hand assistance

Treatment during Brunnstrom Stage 2

• Sensory re-education

• AAROM/ reduced friction/ gravity eliminated

• Mirror therapy

• More weight bearing

Treatment during Brunnstrom Stage 3

• Mirror therapy

• Spliniting

• Functional movements

• Task specific

• High intensity

• Salient

Treatment during Brunnstrom Stages 4 & 5

• Functional movements

• Constraint induced movement therapy

• Strengthening

Treatment during Brunnstrom Stage 6

• Functional activities & participation with progressing complexity

• Dual tasking

Proprioceptive Neuromuscular Facilitation (PNF) description

• Use of diagonal movement patterns to promote functional recovery

• Focus on use of sensory inputs to elicit compound muscle activation in diagonal planes