Update on �Stroke Rehab Modalities�

Paul Chuwn Lim, M.D.

Medical Director of Swedish Rehabilitation Services

Swedish Health Services

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Swedish Physical Medicine & Rehabilitation

Medical Director of Swedish Neurological Rehabilitation Medicine

Swedish Medical Group

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October 2023

Young Adult Stroke Survivors

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��Outline��

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• Stroke statistics: incidence, prevalence, recurrence, recovery trends, and disability rates
• Understand the evolution of rehab modalities & devices
• Cursory description of devices (low → high tech)
• Compare conventional rehab to newer strategies
• Barriers to wide-spread use of newer technology

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• No Disclosures

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Statistics

• Incidence: 795,000 (2020 AHA update*)
• 610,000 first stroke
• 185,000 recurrent stroke
• 87% ischemic, 10% hemorrhagic, 3% SAH
• 3^rd→5^th leading cause of death
• heart disease, cancer, respiratory illnesses, accidents
• 1 out of every 19 deaths are from stroke (150,005 in 2019)
• ~60% of patients receive rehab afterwards
• 80% of strokes are preventable
• Primary & secondary prevention

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*https://www.ahajournals.org/doi/pdf/10.1161/CIR.0000000000000757

Stroke Recurrence**

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Improvement Trends

• Improved recurrence rates after 1999
• No significant improvements since 2005
• More improvements in women than men

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**https://www.ahajournals.org/doi/epub/10.1161/STROKEAHA.120.028992

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Stroke Disability

• Prevalence: 7.0 million stroke survivors in 2020
• 3.2 million men, 3.8 million women
• Projected to be 10.4 million stroke survivors in 2030
• 0.45% ages 20-39, 1.85% 40-59, 5.9% 60-79, 12% >80
• 19% of Medicare patients went to inpatient rehab in 2011
• 25% went to skilled nursing facility
• 12% had home health services
• 6% received outpatient rehab
• ~40% no rehab services
• Estimated direct/indirect cost: $45.5 billion in 2014
• Projected to be $183 billion in 2030
• Leading cause of severe long-term disability
• 2.5% of the US population living with stroke disability
• Arthritis leading cause of overall disability

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Stroke Disability

• AHA/ASA 2015
• 40% moderate functional impairment
• 15-30% severe disability
• Framingham study (2003):

Ischemic stroke survivors ≥ 65 yrs @ 6 months

• 68% functionally independent (32% not independent)
• 50% had some hemiparesis
• 30% unable to walk w/out some help
• 26% dependent in ADLs
• 19% had aphasia
• 35% had depressive Sx
• 26% were in SNFs

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Recovery Rates

• “Average” stroke recovery characterized by:
• Initial improvements up to 3 months, greatest recovery in first month
• Slower rate of change: 3-6 months
• Uncertain pattern of recovery after 6 months
• Possible improvements up to 1-2 years or longer
• UK Stroke Association on Neuroplasticity & other publications

https://www.stroke.org.uk/effects-of-stroke/neuroplasticity-rewiring-the-brain

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• Carotid artery occlusion: initial severe stroke pts at 6mo (104 pts)
• 73% still had severe deficits
• 9% improved to moderate deficits
• 25% to mild deficits
• 3% full recovery
• Still severe deficits at 1 month
• Only 16% with moderate deficits
• None improved to mild deficits
• No similar or larger study since 1992

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Duncan, et al. Stroke 1992; 23:1084-1089

��Path to optimize recovery? ��

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Traditional Devices

Walkers

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Crutches

Canes

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Splints

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Widely Available Devices

Body Weight Wheelchairs

Supported Treadmill

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Orthotics

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Hospital/clinic FES

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Variable Availability

Robotic arm

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Virtual Reality

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TMS

Home FES (functional e-stim)

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Dysphagia

Biofeedback Balance

biofeedback

Many, Many More Devices

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The Future: Bionics & Robotics

I, Robot (left arm)

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RoboCop (whole body exoskeleton)

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Terminator (pure robot)

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The Six Million Dollar Man

(right arm, both legs, left eye)

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��Limits of Conventional Therapies��

• Requires hours of therapy time
• Increasing therapy labor costs
• UK: ~10% of national stroke budget
• Aging population (ex: Japan) relative to trained therapists
• Rural access to specialists
• Frequent safety risks for patients & therapists
• Lacks repetition found to optimize neuroplasticity
• Body Weight Supported training vs conventional over-ground
• Up to 1000 gait cycles in 30 min vs <50 cycles
• Low Compliance: home > hospital
• Less engaging/entertaining, 1:1 hands-on supervision

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��Benefits of Conventional Therapies��

• Teaches compensatory strategies
• Hemi technique for walking, dressing, eating, and other ADLs
• Easily adaptable and personalized
• Whole body > segmental approach
• Compensate for abnormal movement patterns
• Accounts for emotional & clinical status quickly
• Accounts for cognitive and sensory deficits
• Complex tasks such as stairs, toileting, gait on uneven terrain, etc.
• Performance of actual tasks instead of simulated tasks
• Use of cheaper and more available assistive devices

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Rehabilitation Methods

• Muscle Re-education Approach (1920s)
• Neurodevelopmental Approach (1940-70s)
• Sensorimotor Approach (Rood, 1940s)
• Movement Therapy Approach (Brunnstrom, 1950s)
• NeuroDevelopmental Technique (Bobath, 1960-70s)
• Proprioceptive Neuromuscular Facilitation (Knott/Voss, 1960-70s)
• Motor Relearning Program for Stroke (Carr/Shephard, 1980s)
• Constrained Induced Movement Therapy (Taub, 1980s)
• Contemporary Task-Oriented Approach (Shumway-

Cook/Woolacott, 1990s)

• High-Intensity Gait Training 2010s-present

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��High-Intensity Gait Training��

• Conventional inpatient PT works on progressive function
• Static/dynamic sitting and standing balance, transfers, pre-gait
• If sufficiently improved enough, then will start gait activities
• Gait activities also slowly advanced progressively
• Emphasis shifting towards earlier and higher intensity gait training – paradigm shift for older inpatient PTs
• Much more therapy minutes dedicated for gait >> pre-gait activities
• Practice, practice, practice – intensity makes perfect
• Aim to correct biomechanical and kinematic errors earlier
• Emphasis on repetition, gait efficiency, overall function
• Recommended by the Academy of Neurologic Physical Therapy with a Clinical Practice Guideline in Jan 2020

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��Paradigm Shift��

• Conventional therapy shifting

towards earlier gait and

technology assisted rehab

• Move away from hospital care to

home/clinic based care

• Technological advances
• Smaller processors, more complex software
• Light weight/stronger materials, better batteries
• Telemedicine: distant supervision, multiple pts
• Innovative human-machine interfaces
• Accurate physiological sensors and actuators
• Haptics, gyroscopes, EMG, FES, electrocortical

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Gaming

• Easy accessibility
• Improving technology
• Simulated rehab scenario, task specific
• Safe and controlled environment (indoors)
• Multiple repetition
• Proprioceptive feedback, biofeedback
• Interactive, fun
• Nintendo Wii Fit, Virtual Reality,

Sony Eye Toy, Xbox Kinect,

Rapael smart glove

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Cutting Edge Technology

Exoskeleton Devices

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Robotic Gait

Prosthetics

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Brain Computer Interfaces

EEG Intracortical

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EMG/FES NASA

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��Paradigm Shift��

• Economic and marketing forces
• Marketing advantage for rehab facilities (East/Midwest > West)
• Widespread use leads to cheaper gaming devices
• Commercialization of devices
• Patients and families drawn to new technology
• ? ultimate rationale: escalating labor costs
• Debate on its inevitability
• Benefits of robotics
• Simulated tasks when actual tasks are dangerous
• More entertaining therapy (increase compliance)
• Increased repetition to promote neuroplasticity
• Replace missing or damaged body parts
• Psychological benefits

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Cutting Edge Technology

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• NHK World (Japan’s public broadcasting network)

https://www.youtube.com/watch?v=2Ysb-Oko3Bg&ebc=ANyPxKpw1JnXV44_5lLShrAUOFkCvttgc6ji7qbZrd8nB06c695691jpEWtRrjWkAi7pLPG4-Nok

• Most exoskeleton devices are passive devices like orthotics
• Some devices can be used both actively and passively
• ? of neuroplasticity and persistent functional improvements with device taken off after completion of an active rehab program

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2016-19 HAL Exoskeleton Study

• 30 chronic SCI, TBI, stroke, and MS patients
• Must have trace motor function at KE, KF, HF, ± HE to trigger the exoskeleton EMG surface electrodes
• Already completed acute & subacute rehab
• Exoskeleton training with BWSTT: 5 days/week x12 weeks for 90- minute sessions (device donning/doffing & therapy)
• Functional outcome measures: treadmill walking distance/speed/time, 10-meter walk test, time-up and go, 6-minute walk test, walking index for SCI II (WISCI ii)
• Physiologic measures: modified Ashworth scale, lower extremity motor score

��Summary ��

• Discovery Channel: Dr. Michael Boninger, University of Pittsburg, PM&R Department

https://www.youtube.com/watch?v=STUBkUvKjJQ

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• Many fascinating devices
• Increasing public curiosity
• Technology outpacing useful clinical protocols
• Similar efficacy to conventional therapy
• Limited use in clinical practice currently
• Most rehab centers with limited high-tech devices

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��Barriers to Wide Spread Use��

• Expensive devices generally not covered by insurance
• No compelling evidence of its superiority
• Primarily viewed as an adjunct to conventional therapy
• Era of healthcare cost containment
• Primarily at large rehab centers (east > mid-west > west)
• Generally from research or rehab facility marketing funds
• No additional therapy billing charges
• Marketing advantage primarily in competitive rehab environments
• Limited ability for out-of-pocket purchase by vast majority of pts

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��Robotics Summary��

• Many pros/cons to conventional and robotic therapy
• Ultimately a blending of the two approaches
• Optimize neurological recovery while addressing

compensatory strategies

• Ongoing need for clinical studies
• Financial barriers for widespread use
• Innovation > insurance coverage
• Marketing advantage for large rehab centers

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��Final Remarks��

• Coordinated post-stroke therapy and medical care
• Many exciting devices and studies
• Future: combining therapy principals, traditional devices, robotics, body-computer interfaces, medications (SSRIs), and regenerative techniques (TMS, gene/stem cell)
• Keep up and stay informed about innovations

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��Great Web Summary ��

OPEN ACCESS PEER-REVIEWED CHAPTER

Current Trends in Stroke Rehabilitation

WRITTEN BY Pratap Sanchetee

September 2020

https://www.intechopen.com/chapters/74822

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