New Therapies in Stroke Rehabilitation

In recent years, several new approaches have been developed in an effort to improve the use of the arm or leg after stroke. The Rehabilitation Medicine Department at NewYork-Presbyterian is at the forefront of new developments in the area of stroke rehabilitation. Although none of these approaches represent a cure, several can provide meaningful improvements, allowing stroke survivors to increase their use of the affected arm or leg.

Some stroke survivors use multiple therapies over the course of recovery. Our doctors and therapists are trained in the use of many different approaches and new technology, including the Bioness H200 and L300, the Saeboflex Functional Arm Training System and the Myomo and InMotion2 and InMotion3 (also known as the MIT-Manus) robotic systems. Read the descriptions below to learn more about these approaches.

Botulinum toxin injections are often used to treat spasticity or muscle stiffness in stroke survivors. While spasticity and hemiparesis typically coexist, there is controversy regarding whether botulinum toxin injection might also help restore some degree of movement by reducing spasticity selectively. There are three forms of botulinum toxin available Botulinum toxin type A, also called Botox® and Dysport, and type B called Myobloc. Although Botox® has been the most thoroughly studied, they all appear effective for spasticity treatment.

Constraint Induced Movement Therapy (CIMT) consists of an intensive upper limb exercise program, coupled with placing the unaffected arm in a restrictive mitt to encourage use of the weak upper limb. Classic CIMT includes six hours of supervised therapy five days per week for a two week period. Modified versions of CIMT may involve less intensive therapy programs over of a longer period of time. Our facility utilizes modified Constraint Induced Therapy (mCIT) which includes supervised therapy three days per week for a ten week period.

Dynamic splinting has been developed for the wrist and hand to mechanically assist stroke survivors in straightening their wrist and fingers. The Saeboflex Functional Arm Training System is an example of this type of device.

Electrical stimulation of the nerves or muscles in the arm or leg can cause movement of the weak limb, and there is some evidence that repeated use of this treatment can result in some degree of restoration of movement. Functional Electrical stimulation devices used for the upper limb include the NESS H200 and the NeuromoveT™. Functional Electrical stimulation devices for the leg include the NESS L300, and the WalkAide®. The lower limb devices are often used as a partial substitute for a plastic leg brace.

Robotic therapy devices are designed to promote return of movement and function in a paralyzed limb. These devices are sophisticated exercise machines, and guide the user through repeated movements. Upper limb devices include the InMotion2 and InMotion3, the ReoGo, the Amadeo, and the Myomo e100, all of which are available within our department (some only in research studies). Lower limb devices include the Lokomat, the ReoAmbulator, the Anklebot, and the PK100; our department is currently conducting a study of the PK100.

Partial body weight-supported treadmill training is a technique that uses a harness to reduce the amount of weight the stroke survivor is bearing through the legs, and combines this with practice walking on a treadmill. This technique appears most useful for stroke survivors who are early in their recovery and having more substantial difficulty in regaining walking ability. Robotic therapy such as the Lokomat or Ambulator represents an attempt to automate this type of therapy. Our facility uses the Lite Gait® Partial-Weight-Bearing Gait Therapy Device.

Virtual reality (including Wii-hab) uses an artificial environment on a computer screen as a technique to help stroke survivors practice movements and improve arm or leg movement. Preliminary studies are encouraging, and some institutions offer this therapy. This type of therapy is sometimes combined with robot-assisted exercise treatment. The Armeo is a device with virtual reality training that uses a mechanical assist to reduce the limiting effects of gravity.

Brain Stimulation using transcranial magnetic stimulation, also known as TMS and transcranial direct current stimulation (TDCS) are both experimental therapies that may enhance the brains ability to rewire itself after a stroke.

Acupuncture has long been used in an attempt to treat a variety of stroke symptoms, including weakness. While some research exists hinting at benefit; this therapy remains unproven for balance. Since acupuncture is generally safe and well-tolerated, many physicians consider this a reasonable therapy for a patient to try if they wish, but may not specifically encourage its use.

Mental practice involves the stroke survivor imagining movement of the affected limb; usually the arm. An audio recording is used to help the user stay focused on the therapy. Interestingly, there is some research suggesting that this type of practice actually improves motor abilities. Mental practice has been combined with modified constraint induced movement therapy in a recent study, and may have additive benefits.

Mirror Therapy is the use of a mirror to make it appear to the stroke survivor that the affected arm is moving normally in a symmetric two-armed activity. However, the survivor is actually looking at the unaffected arm in the mirror. This is an intriguing technique that has not yet been very well studied.

Hyperbaric oxygen therapy is a potentially toxic therapy and is of no proven benefit for recovery of neurologic function after stroke. It is not recommended at this time.



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