Table Of ContentSTROKE REHABILITATION
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STROKE REHABILITATION
Insights from Neuroscience and Imaging
Leeanne M. Carey, PhD
EDITED BY
HEAD, NEUROREHABILITATION AND RECOVERY
AND AUSTRALIAN RESEARCH COUNCIL FUTURE FELLOW
NATIONAL STROKE RESEARCH INSTITUTE
FLOREY NEUROSCIENCE INSTITUTES
MELBOURNE BRAIN CENTRE
AND
PROFESSOR
DEPARTMENT OF OCCUPATIONAL THERAPY
SCHOOL OF ALLIED HEALTH
FACULTY OF HEALTH SCIENCES
LA TROBE UNIVERSITY
MELBOURNE, AUSTRALIA
1
3
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Library of Congress Cataloging-in-Publication Data
Carey, Leeanne M.
Stroke rehabilitation : insights from neuroscience and imaging / Leeanne M. Carey.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-19-979788-2 (hardcover : alk. paper)
I. Title.
[DNLM: 1. Stroke—rehabilitation. 2. Brain—physiopathology.
3. Neuroimaging. WL 356]
616.8′106—dc23
2011048829
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I would like to dedicate this book to the many individuals who
have inspired and challenged me during their journey of recovery
after stroke. These individuals have the goal to ‘be the best they
can be’. It is a goal we collectively aspire to. This book offers
hope, discovery, and translation. It is hoped that the partnership
between the stroke survivor and informed therapist will ensure
that this journey does not end, but rather keeps open the ‘window
of opportunity’.
I would like to thank all the contributors to this book. These
authors come from backgrounds of basic science, neuroimaging,
neuroscience, psychology, neurophysiology, clinical sciences,
neurology, occupational therapy, physiotherapy, and nursing. All
are dedicated to researching and translating evidence from these
fi elds to address the challenges of stroke rehabilitation. Thank you
for sharing your knowledge and insights.
I would also like to thank all the other individuals who have
contributed to the book. To colleagues and friends who have
assisted with proofi ng and editing, to Oxford University Press and
their team for their ongoing support, and most importantly to the
individuals who have volunteered to be research participants in
the numerous studies referred to in this book.
Finally I would like to acknowledge and thank my colleagues,
friends and family who have ‘lived through’ and supported this
journey. Thank you to the many colleagues and friends across the
globe who have shared their knowledge, mentored, challenged,
and inspired along the way. To my parents who opened the door
with their belief, to my husband who provides support, and to my
children who have got their futures ahead.
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PREFACE
Th e aim of Stroke Rehabilitation: Insights fr om Neuroscience by the potential to “change the brain” in therapy but
and Imaging is to inform and challenge rehabilitation cli- as yet do not have the knowledge and skills to do so.
nicians to adopt more restorative and scientifi c approaches Th e challenging, yet critical, task we must achieve is the
to stroke rehabilitation based on current evidence from the translation of neuroscience to clinical practice. It is the
neuroscience and neuroimaging literatures. Th e fi elds of intention of this book to stimulate clinicians to refl ect
cognitive neuroscience and neuroimaging are advancing on how we can apply this science within the context of
rapidly and providing new insights into human behavior stroke rehabilitation.
and learning. Similarly, improved knowledge of how the Recent discoveries in neuroscience suggest it is timely
brain processes information aft er injury and recovers over for neuroscientists and clinicians to work together to
time is providing new perspectives on what we aim to develop a framework and language to facilitate this trans-
achieve through rehabilitation. lation. In this book our aim is to provide a framework
Historically, rehabilitation has focused on compen- that is meaningful and accessible to clinicians. It includes
satory strategies rather than addressing the underlying a model of rehabilitation, core concepts related to neural
mechanisms and brain changes associated with impair- plasticity and imaging, and neuroscience evidence for cre-
ment and recovery. To improve function and adopt a ating the right learning environment for rehabilitation.
more restorative approach to rehabilitation, clinicians are Th is is followed by a series of chapters that review current
challenged to consider how we can “change the brain to neuroscience and imaging evidence in relation to common
change the behavior.” It is envisaged that in the not too functions, and provide examples of how this evidence can
distant future, clinicians will have the opportunity to be translated and operationalized within the context of
design treatment for an individual stroke patient based on rehabilitation. Finally, the book concludes with key chap-
knowledge of the individual’s viable brain networks that ters on new perspectives and directions for stroke rehabili-
may be accessed in therapy. Th is knowledge, together with tation research.
a clinical appreciation of physical and cognitive capacities, Th is book is intended for clinicians, rehabilitation spe-
mood, and patient goals, will help to bridge the current cialists, and neurologists who are interested in using these
gap in achieving optimal outcomes. new discoveries in neuroscience and imaging to achieve
Clinicians are encouraged to read the neurosci- more optimal outcomes. Equally important, it is intended
ence and imaging literature so that we can better select for neuroscientists, clinical researchers, and imaging spe-
intervention approaches that are founded on neurosci- cialists to help frame important clinical questions and to
ence and have relevance for therapy. Equally, we may better understand the context in which their discoveries
need to make an informed decision not to continue a may be used.
given intervention, even if it has been historically part
of routine clinical practice. Many clinicians are excited
PREFACE | vii
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CONTENTS
Contributors xv 2.8.2 SENSe: A Perceptual Learning Approach
to Rehabilitation of Body Sensations after
Stroke 19
2.8.3 Language: Constraint-Induced Aphasia
PART A
Therapy 20
CORE CONCEPTS 1
2.9 Measuring Response to Learning-Based
Rehabilitation 20
1. INTRODUCTION 3
2.10 Summary and Conclusion 21
Leeanne M. Carey
1.1 Stroke Rehabilitation: An Ongoing Window of
3. NEURAL PLASTICITY AS A BASIS FOR STROKE
Opportunity 3
REHABILITATION 24
1.2 The Scope of the Problem: Prevalence and
Michael Nilsson, Milos Pekny, and
Impact of Stroke and Increasing Need for
Marcela Pekna
Stroke Rehabilitation 4
3.1 Neural Plasticity after Brain and Spinal Cord
1.3 Recovery and Rehabilitation: Defi nitions 5
Injury 24
1.4 Neural Plasticity and Learning as a Basis
3.1.1 Experience-Dependent Plasticity of the
for Stroke Rehabilitation 5
Cerebral Cortex 24
1.5 Neuroimaging and How it May Inform Stroke
3.1.2 Spontaneous Recovery of Function after
Rehabilitation 7
Stroke 24
1.6 Paradigm Shift in Stroke Rehabilitation 8
3.1.3 Cortical Map Rearrangements 24
3.1.4 Contralateral Hemisphere
2. STROKE REHABILITATION: A LEARNING Involvement 25
PERSPECTIVE 11
3.1.5 Contralesional Axonal Remodeling
Leeanne M. Carey, Helene J. Polatajko, of the Corticospinal System 25
Lisa Tabor Connor, and Carolyn M. Baum
3.2 Implications for Stroke Rehabilitation 26
2.1 Stroke Rehabilitation: Facilitation of Adaptive
3.3 Increasing Neural Plasticity through
Learning 11
Behavioral Manipulations and Adjuvant
2.2 A Common Language for Rehabilitation Therapies 26
Science 12
3.3.1 Enriched Environment and Multimodal
2.3 Experience and Learning-Dependent Plasticity: Stimulation 26
Implications for Rehabilitation 13
3.3.2 Noninvasive Brain Stimulation 27
2.4 Role of Brain Networks in Information
3.3.3 Pharmacological Modulators of Neural
Processing and Recovery 14
Plasticity 28
2.5 Skill Acquisition—A Learning Perspective 14
3.3.3.1 D-amphetamine 28
2.5.1 Explicit, Task-Specifi c, and Goal-Driven 15
3.3.3.2 Sigma-1 Receptor Agonists 28
2.5.2 Involve Active Problem Solving and
3.3.3.3 Fluoxetine 28
Be Responsive to Environmental Demands 16
3.3.3.4 Niacin 29
2.5.3 Provide Opportunities for Variation and
Practice 16 3.3.3.5 Inosine 29
2.6 Application in Context of Recovery after 3.3.3.6 Nugo-A Inhibition 29
Stroke 17
3.3.3.7 Reducing Tonic Inhibition 30
2.7 Rehabilitation Learning Model: Rehab-Learn 17
3.3.4 Emerging Targets 30
2.8 Selected Learning-Based Approaches to
3.3.4.1 Stem Cells 30
Rehabilitation 18
3.3.4.2 Targeting the Astrocytes 30
2.8.1 Cognitive Orientation to Daily
Occupational Performance (CO-OP) 19 3.4 Individualized Therapy 31
CONTENTS | ix
