**7. Rehabilitation**

The priorities at the acute care unit are both diagnostic as well as therapeutic interventions. Depending on medical conditions (hemorrhagic or non-hemorrhagic lesion, size and site of

Hemiplegia is the most paramount clinical feature, which is described as sided weakness of extremity, facial droop, and slurred speech. Motor function recovery follows stereotypic patterns. It initially develops flaccid hemiplegia during the acute phase. Depending on individual cases, however, flaccid hemiplegia evolves into spastic hemiplegia. It continues to evolve into spastic synergy. Typically, flexion synergy develops in hemiplegic upper extremity and extension synergy in the lower extremity. As the synergy fades, individual movement of joints emerges. The longer the length of time in flaccid hemiplegia, the poorer the prognosis of motor recovery. Motor recovery may stagnate at any phase and may skip phases. Another pattern is that proximal segment of extremity function recovers earlier than distal one. Many patients with stroke sustain typical stereotyped poor dexterity and hemiplegic gait because of residual distal extremity dysfunction. In order to facilitate motor recovery, comprehensive rehabilitation modalities, such as anti-spastic medications, orthotics, and therapeutic exercise are cooperated. Significant motor recovery usually occurs in the first three months after stroke. Further recovery may continue in the next three

Brunnstrom stage describes the evolution of hemiplegia54. Flaccid paralyzed extremity is seen at stage 1; Mild spasticity is appreciated in the flaccid paralyzed extremity at stage 2; The spasticity increases and some self-activated synergic movement of the paralyzed extremity begins at stage 3; Dominant stereotyped self-activated synergic movement of the paralyzed extremity is more prominent at stage 4; decreasing synergic movement pattern with emerging individual movement of the paralyzed extremity is the hall mark of the stage 5; normal movement pattern is seen at stage 6. Not all paralyzed extremity evolves from stage 1 to 6. Depending on stroke severity and recovery potential, the stages may progress quickly or may be skipped. Generally speaking, hemiplegia with short or absent stage 1 has better recovery;

the longer the stage 1, the worse prognosis; the lower stage, the poorer outcome, 11, 55-58.

maintain functions of the distal segments or hand.

**7. Rehabilitation** 

In addition to Brunnstrom stage, motor function recovery tends to begin in the proximal segment and then to progress to the distal segments of the extremity. This tendency is common in both upper and lower extremity. Most of stroke patients are able to move their proximal segments of arms and legs at the time of discharge from inpatient rehabilitation. However, many stroke patients sustain significant paralysis of the distal segments of arm and leg. Because of this residual impairment, most stroke survivors have difficulties to be independent with ADLs and ambulation. Another common finding is that motor recovery of the lower extremity is better than that of the upper extremity. Why is motor recovery of the proximal segments and the lower extremity better than that of the distal segments and the lower extremity? It can be partially explained by topographic distribution in the brain (the cortex corresponding to hand is much larger than one to foot in the brain) and higher developmental hierarchy (hand function develops later than foot function). Compared to the proximal segments or foot function, more neurons and synapses are to be involved to

The priorities at the acute care unit are both diagnostic as well as therapeutic interventions. Depending on medical conditions (hemorrhagic or non-hemorrhagic lesion, size and site of

**6. Motor function recovery** 

months but less extensive.

stroke, underlying health status,…), treatment options are determined. It is suggested that early rehabilitation intervention is necessary, even if diagnostic or therapeutic plan are not completed. At this phase, rehabilitation starts with less intensive approach. Passive range of motion, position changes, stimulation control, safe feeding, and joint contracture prevention are important to prevent impending complications.

Functional improvement is not always parallel with neurological recovery in patients with stroke. Analysis of the Uniform Data System for Medical Rehabilitation (UDSMR) for stroke patients in US from 2000 to 2007 shows decreased a mean length of rehabilitation unit stay from 19.6 days to 16.5 days, decrease a mean FIM (functional independence measurement) at rehabilitation unit from 62.5 to 55.1 (means more functionally dependent patients were admitted to rehabilitation unit), decrease a mean FIM at discharge from rehabilitation unit from 86.4 to 79.8 (means less functionally independent patients were discharged from rehabilitation unit), but the FIM change during rehabilitation stay remained relatively stable59. These results reflect that patients with stroke in US admit and discharge earlier than before. Patients with stroke may benefit from early discharge, but by the other hand, early discharge from rehabilitation unit increased the mortality60.

From an ADL (activities of daily living) standpoint, stair walking (downward more difficult than upward) is the hardest to be improved, and then tub/shower transfer, ambulation, and lower body dressing follow. In contrast, eating is the easiest to be improved, and then grooming, and sphincter control follow.

Poor sitting balance, poor trunk control, urinary incontinence, severity of disability, and old age (>74 years) are poor predictors for independent walking61. Standing balance ability is more important than lower extremity strength to achieve better ambulation62.

In cognitive rehabilitation, problem solving is the most severely impaired and the least potential for recovery after stroke. Learning and memory impairments are most common10. Comprehension and expression are less impaired and better improved than memory. Patients with right hemiplegia are more impaired and less likely to improve in cognitive functions than those with left hemiplegia.

Cognitive and speech-language impairment prevents patients with stroke from participation in social activities. Patients with higher cognitive level recover much better than ones with lower level. A study of return to work reports 1) no significant racial differences in left hemisphere infarction, but whites were more likely to return to work in right hemisphere infarction, 2) no significant difference of returning to work between whites and non-whites with left hemisphere infarction, 3) whites with right hemisphere infarction are most likely to return to work, while non-whites with right hemisphere infarction are least likely, 4) patients employed premorbidly at professional or managerial position, younger age group, less severe disability, white race, right hemisphere lesion were more likely to return to work following a cerebral infarction9.

## **8. Traditional and new therapeutic approaches to stroke rehabilitation**

Traditional physical therapy and occupation therapy are still largely mainstays of the rehabilitation. Many therapeutic techniques to facilitate movement of paralyzed side, based on motor developmental hierarchy, repetition of motor pattern, and task-oriented training.

Stroke Rehabilitation 29

Childhood stroke is defined as occurring between 30 days of postnatal age and 18 years old. The incidence is reported 2-3/100,000 per year in US81, 2.7/100,000 in Canada (ischemic stroke only)82, and 13/100,000 in France83. Its mortality rate is reported 7-28% and higher in males than females and in blacks than white, respectively. Stroke is less common in children than in adults, but is one of the top ten causes of death in children in the US. It results in one of the leading causes of disability in young generations. The pathophysiology of childhood stroke is same as adults, but underlying premorbidities or etiologies are different. Most of adult stroke patients have pre-existing medical conditions, such as hypertension, diabetes mellitus, hyperlipidemia, arteriosclerosis, heart disease, or obesity, but in contrast one third of child stroke patients do not have any evident pre-existing medical conditions. In childhood stroke, congenital heart disease is the most common known etiology (about 30%), and sickle cell disease is the leading cause of stroke in African American ethnic group. Arteriovenous malformation is the leading cause of hemorrhagic stroke in childhood. Various coagulation disorders-factor V Leiden and prothrombin mutation, protein C and S deficiency, anti-phospholipid antibody, and inherited coagulation abnormalities and arterial vasculitis are related to pediatric strokes. Venous stroke is not uncommon in children. Venous:arterial stroke ratio is 1:4-6 in non-hemorrhagic stroke84. Venous stroke develops, when cerebral venous drainage to the internal jugular veins is significantly obstructed by thrombosis in the cerebral venous sinus (sinus venous thrombosis). The obstructed venous drainage consequently impedes arterial supply to the brain. Progressive insufficient arterial supply to the brain eventually leads to ischemia. Because of this slow process, compared with arterial stroke, clinical symptoms and signs progress slowly in venous stroke. High risks of sinus venous thrombosis are head and neck infection (meningitis, mastoiditis), dehydration, coagulation disorder, and perinatal complications. The outcome of a venous

The ratio of hemorrhagic to nonhemorrhagic stroke in childhood stroke is about 5:3 in the US85 . It is understood that the incidence of homorrhagic stroke is higher than adult, but it is similar to a recent stroke registry data3. Diagnostic interventions of pediatric stroke are similar to those of adult stroke. In addition, hematologic and metabolic work up for coagulopathy is important. It is not easy to recognize neonatal stroke because of limited clinical presentations. It is partially plausible to explain that patients with hemiplegic cerebral palsy might have unrecognized neonatal stroke. It is supported by the fact that patients with hemiplegic cerebral palsy showed elevated antiphospholipid and/or factor V Leiden mutation than normal control86-87. Patients with sickle cell disease has 200-400 times

In order to prevent stroke recurrence, aspirin is recommended for high risk of stroke patients in both adult and children. Apirin used for stroke prophylaxis does not complicate Reye's syndrome in children. Regular brain MRA is suggested to patient with hemorrhagic

Since human cerebral hemispheres are already specialized at an early stage of development, pediatric stroke patients also demonstrate adult pattern of side specificity for brain lesions88- 89.

Outcomes vary among studies because of differences in population characteristics, stroke type, duration of follow-up, and outcomes measurement tools. Long-term outcome study

Therefore clinical features are side specific and similar to adult stroke.

stroke is excellent.

high risk and 50% of recurrence risk by three years.

stroke secondary to aneurysm.

Abnormal muscle tone leads to abnormal positioning and abnormal movement pattern, and vice versa. To break this vicious cycle, comprehensive rehabilitation should include muscle tone management, proper bracing and positioning, and stimulation control. Repetitive task training is a commonly used in current rehabilitation therapy, but a literature review reported it is not effective in upper extremity motor function63.

Constraint-induced movement therapy (CIMT or CIT) was introduced with a hypothesis of forceful usage of paralytic arm facilitate neuroplasticity of the brain, which in turn leads to recovery of the arm motor function64. There are many supportive reports to its effectiveness65, 66, however, there is a lack of large randomized controlled study67. CIMT is indicated for subjects who have no significant spasticity and some strength of the paralyzed upper extremity. It is not effective in acute phase of stroke68.

Development in neruoscience and computer technology provides novel ideas to overcome the limitation of traditional rehabilitation for stroke. Originally, robotic treatment was introduced to alleviate the labor-intensive aspects of physical therapy by preinstalled programs to perform a goal-directed movement autonoumously or semi-autonomously69. It induces movement of paralyzed limbs by activation of the motor cortex of the side of the lesion and the movement of the limb also activates the motor cortex in a positive feedback. Most of devices are designed to lead task-oriented movement by intensive repetitive patterns. Functional brain MRI studies of robotic treatments, demonstrated an increased activation of the sensorimotor cortex during grasping tasks greater than non-practiced tasks70. However, the effectiveness of robotic treatment is still in question71-73. It is likely effective for shoulder and elbow function recovery, but may lack effectiveness of hand function improvement.

EEG/MEG-based motor imagery brain-computer interface utilizes neuronal activities of the motor cortex of lesion side while performing motor imagery74, 75. Currently combined braincomputer interface with robotic feedback technique is being tried76.

Virtual reality training, although needs further study, appears to be effective in improvement of motor function77, 78.
