Stroke & Neuro-Rehab Study Notes

Background & Speaker Credentials

• Speaker: Occupational therapist (OT) with
  • 4 yrs exclusively in stroke rehabilitation research
  • 6 yrs in acute neuro/ICU care
  • 1 yr in outpatient therapy
• Personal bias: “If you can treat stroke, you can treat anything” because lesion presentations are heterogeneous (“If you’ve seen one stroke, you’ve seen one”).
• Fascination with lesion-specific impairments → drives individualized, impairment-informed OT practice.

Paradigm Shift: Neuro-rehab in the Last Decade

• Functional MRI (fMRI) now visualises live neural network connectivity → informs prognosis & targeted intervention.
• Many legacy frames of reference still matter but must be updated with modern evidence & technology (e.g., robotics, neuromodulation, data-driven measurement).

Foundational Framework: ICF Model

• Domains
  • Body Functions & Structures
  • Activities (limitations)
  • Participation (restrictions)
• Clinical question guides outcome-measure choice (pain? strength? balance? participation?) → bucket assessments accordingly.

Historic Recovery Model: Brunnström / Twitchell

• Observed 25 in-patients post-stroke ⇒ 6 recovery stages
  1. Flaccid paralysis
  2. Emerging spasticity
  3. Synergistic, uncoordinated mass patterns (Q&A confirmed: synergistic movement appears Stage 3)
     4–6. Increasing isolated, volitional control, tone normalisation
• Limitation: small sample, not universal; modern imaging shows people deviate (e.g., good hand function but weak shoulder).

Bobath / Neuro-Developmental Treatment (NDT)

• 1970 s frame of reference prioritising
  • Normalising tone before function
  • Alignment/core/proximal control
  • Handling & posture to inhibit abnormal synergy
• Still taught/certified; many clinicians list “NDT” after name.
• Evidence summary (multiple systematic reviews):
  • Inconclusive superiority vs. other treatments (NOT «doesn’t work»: Q&A corrected misconception) ⇒ use as tool, not dogma.

Impairment Deep-Dive ① Muscle Tone

Definitions

• Resting muscle tone = baseline tension in all humans.
• Hypertonicity = high tone at rest, limb feels stiff.
• Spasticity = velocity-dependent hyper-excitability of stretch reflex; may include clonus.
• They can coexist or appear separately.

Anatomical correlate

• Corticospinal tract injury (stroke, MS, SCI) ⇒ severe motor impairment + tone dys-regulation (2023 study).

Assessment Toolkit

• Clinical ROM screen (active & passive) → first indication of tone & contracture risk.
• Standardised
  • Modified Ashworth Scale (MAS) 0–4
  • 0 = no ↑ tone; 4 = rigid
  • Modified Tardieu Scale (velocity-specific)
• MAS grading nuances:
  • 1 = slight catch/release or min resistance at end-range
  • 1+ = catch + min resistance <½ ROM
  • 2 = resistance through most ROM, easy movement
  • 3 = marked resistance, PROM difficult
  • 4 = rigid ↔ hypertonicity overlapping

Treatment Options (multidisciplinary)

• Therapist-led
  • Manual stretching/PROM ➔ MUST follow with active use to consolidate length.
  • Strengthen antagonist muscles (quiz answer: strengthen antagonist after stretch).
  • Weight-bearing, isometrics, positioning.
• Medical
  • Botulinum toxin type A (Botox) every 3–6 mo; peak effect 2–6 wk; risk of over-weakening functional tone (esp. wrist flexors, calf).
  • Dry needling (emerging)—similar temporary effect without systemic ADR; can repeat more often.
  • Oral baclofen: systemic side-effects (sedation). Intrathecal baclofen pump for severe cases (SCI, CP, MS).
• Adjunctive sensory techniques (legacy NDT): tapping, quick-ice, vibration. Short-lived; pair with voluntary reps.
• Tech horizon: wearable vibratory devices on radial/median nerve—promising sustained tone reduction.
• Splinting
  • Evidence mixed/low for contracture prevention but valuable for hygiene, pain, night positioning.
  • Wear 6–8 h per episode (quiz) ➔ follow with active therapy.
  • Dynamic splints preferred (allow startle-flexion) over rigid immobilisation.

Impairment Deep-Dive ② Shoulder in Hemiplegia

Prevalence & Impact

• Post-stroke shoulder pain ranges 5\%–84\%; correlates with greater arm weakness & poorer outcome.
• Subluxation ≈ 50\% of stroke pts—gap measured by finger-breadth (2–2.5 fingers in example).
• Surprisingly, subluxation ≠ direct predictor of pain yet ↑ risk of secondary injuries.

Biomechanics & Injury Spectrum

• Impingement (biceps tendon, subacromial bursa, rotator-cuff) most common source of pain.
• Other conditions
  • Rotator-cuff tear
  • Glenohumeral arthritis (pre-existing/exacerbated)
  • Heterotopic ossification (esp. traumatic brain injury, SCI)
  • Traction injuries to brachial plexus; distal nerve entrapments.

Scapular Complex Essentials

• Shoulder = interplay of 18 muscles & 4 joints: glenohumeral, acromioclavicular, sternoclavicular, scapulothoracic (functional).
• Healthy scapulo-humeral rhythm (± 2{:}1 ratio) + early external rotation (≈ 16–60^\circ flexion) prevent impingement.
• Neurologic lesions disrupt synchrony → evaluate & treat scapula FIRST.

Positioning & Slings

• Traditional collar-&-cuff slings cause
  • Elbow flexion contracture
  • Shoulder internal-rotation contracture
  • Balance impairment (arm pinned, no counter-weight)
• Desired effect = shoulder approximation; therefore choose alternatives.
• GivMohr™ sling (back-pack style)
  • Cradles humerus in neutral, allows swing, maintains approximation, supports balance.

Evidence-Based Neuro-Rehab Principles

• Core ingredients for neuroplasticity (“active ingredients”):

  1. High repetition / high dose (hundreds of reps per session, thousands per week)
  2. Task-specific / goal-oriented (occupation-based, ADL-centred)
  3. Adequate challenge → errors/failure drive learning
  4. Motivation & salience to individual

• Effective modalities (per 2023 AOTA Practice Guidelines for Stroke)

  • Task-oriented training (TOT)
  • High-intensity gaming (e.g., MusicGlove)
  • Mirror therapy (motor & pain benefits)
  • Constraint-Induced Movement Therapy (CIMT)
  • Vagal Nerve Stimulation + TOT (FDA-approved implant)
  • Cognitive strategy training / guided problem solving (tele-rehab example: preparing breakfast via Zoom)

• Adjuncts with growing evidence: robotics, neuromuscular electrical stimulation, virtual reality, telehealth platforms.

Caregiver & Long-Term Support

• Early caregiver integration → better carry-over, home programme adherence, psychosocial support.
• New CPT codes allow billable caregiver training.
• Group programmes (community exercise, social participation) show strong evidence for sustained gains.

Measurement & Data-Driven Planning

• PatientProgress.org “Keyform Ability Maps”
  • Rasch analysis orders test items from easy → hard, giving therapists a roadmap of incremental goals.
  • Available for multiple standardized assessments (some temporarily offline).
• Continuous measurement critical because some neurologic impairments change slowly; objective data justify intensity and track plateaus/re-assessment points.

Ethical & Practical Implications

• Do NOT rely solely on legacy branded courses; ground interventions in up-to-date evidence.
• Balance pharmacologic with functional practice to avoid over-weakening useful tone.
• Consider cost, access & patient values when selecting tech (e.g., implants vs. low-tech ADL practice).
• OT uniquely positioned to merge biomechanical expertise with occupation-focus, bridging impairment ↔ participation.

Quick-Reference Equations & Numbers

• MAS grades 0–4 (see above list).
• Splint wear time 6–8\;\text{h} per episode.
• Botox cycle 3–6\;\text{mo}; peak 2–6\;\text{wk}.
• Shoulder muscle count 18; joints 4.
• Scapulo-humeral rhythm ≈ 2:1 (glenohumeral:scapular) after first 30^\circ elevation.

Key Takeaways / Exam Cram

• Stage 3 Brunnström = synergistic spastic movement.
• NDT/Bobath not superior—use selectively; posture & scapular alignment still matter.
• Distinguish spasticity (velocity-dependent) vs. hypertonicity (static).
• After stretch, immediately activate antagonist muscles.
• Effective spasticity management = multimodal (manual, active, pharmacologic, tech).
• Traditional slings may harm; GivMohr™ preferred.
• Shoulder pain work-up: always screen scapula & cervical spine before assuming distal diagnoses.
• Neuroplastic interventions must be repetitive, challenging, salient, goal-directed.
• Involve caregivers early; use outcome measures aligned to ICF goals.