**6. Physical therapy as a coadjuvant to neural restoration through stimulation of neural plasticity**

Post-stroke physical rehabilitation (PR) is of utmost importance as a nonpharmacological strategy for neuroprotection and neurorestoration but, most significantly, should be aimed at restoring and regaining motor impairment during the chronic period [90], and to promote the functional autonomy of the patient [4]. Recovery of body function assessment depends on whether the patients can perform everyday activities on their own and is measurable by several different scales such as UE-FM score for the upper extremity, and the Barthel Index for Activities for Daily Living scale [4].

Functional and cognitive deficit severity is related to tissue integrity [91], and it is not clear whether recovery results from biological processes or physical rehabilitation [91, 92]. Some clinical parameters that can be observed at the bedside, such as early finger extension and shoulder abduction, can act as predictors of long-term (over 6 months) recovery after stroke [93]. Spontaneous recovery of upper and lower limbs occurs depending on the type, location, and severity of the lesion, in approximately 60–70% of cases [93] during the first 2–6 months [4, 94], period after which most people believe they have achieved maximal recovery and stop with either physical or pharmacological therapy [4, 95]. Interventions should be designed according to the stage of neurological recovery the patient is in, with the consideration that early chronicity is not a contraindication for continuing rehabilitation [4].

Physical rehabilitation must start early, if possible, during the first week poststroke [96], because there is an intensification in neuroplasticity during the early stages [91], employing different mechanisms such as the axon regeneration [88], and the higher expression of growth-promoting genes, such as GAP-43. This lesioninduced plasticity that happens during the first days post-stroke [90, 97, 98] reportedly lasts around 6 months after stroke [4, 91, 95, 97]. Also, therapy must continue after such a period, to take advantage of behavior-induced plasticity [95], which is still possible after 1 year of having had the stroke [4].

PR has also been proven to elicit neuroprotection and neurorestoration in other neurological disease models, such as Parkinson's, through the upregulation of BDNF and GDNF and prevention of inflammatory response [99]. The following therapies are currently under study for neurorestorative purposes during the post-stroke chronic period:

Environmental enrichment focuses on inducing adaptation to different environments, including toys and complex tasks, to improve functional outcomes [97]. Also, this type of therapy has shown to enhance angiogenesis by increasing CD31 and VEGF [97]. Furthermore, environmental enrichment upregulates BDNF secretion, and other neurotrophic factors [85, 90].

Wang et al. found improvements in spatial learning and memory, number of synapses, and an increase in the expression of synaptogenesis markers. GAP-43, a protein involved in neural plasticity through axonal growth, is upregulated during the first 28 days after stroke in mice exposed to environmental enrichment. Likewise, other markers involved in synaptogenesis like SYN and PSD-95 achieve better concentrations in the brains of mice treated with environmental enrichment [97].

#### *Available Therapeutics after a Stroke: Current and Promising Options DOI: http://dx.doi.org/10.5772/intechopen.91282*

neurotrophins, and the impact on patient mobility, as in the proposal developed by Scalzo et al. [89] that gives rise to the continued development of a well-founded

**6. Physical therapy as a coadjuvant to neural restoration through**

*New Insight into Cerebrovascular Diseases - An Updated Comprehensive Review*

Post-stroke physical rehabilitation (PR) is of utmost importance as a nonpharmacological strategy for neuroprotection and neurorestoration but, most significantly, should be aimed at restoring and regaining motor impairment during the chronic period [90], and to promote the functional autonomy of the patient [4]. Recovery of body function assessment depends on whether the patients can perform everyday activities on their own and is measurable by several different scales such as UE-FM score for the upper extremity, and the Barthel Index for Activities

Functional and cognitive deficit severity is related to tissue integrity [91], and it is not clear whether recovery results from biological processes or physical rehabilitation [91, 92]. Some clinical parameters that can be observed at the bedside, such as early finger extension and shoulder abduction, can act as predictors of long-term (over 6 months) recovery after stroke [93]. Spontaneous recovery of upper and lower limbs occurs depending on the type, location, and severity of the lesion, in approximately 60–70% of cases [93] during the first 2–6 months [4, 94], period after which most people believe they have achieved maximal recovery and stop with either physical or pharmacological therapy [4, 95]. Interventions should be designed according to the stage of neurological recovery the patient is in, with the

consideration that early chronicity is not a contraindication for continuing

which is still possible after 1 year of having had the stroke [4].

tion, and other neurotrophic factors [85, 90].

Physical rehabilitation must start early, if possible, during the first week poststroke [96], because there is an intensification in neuroplasticity during the early stages [91], employing different mechanisms such as the axon regeneration [88], and the higher expression of growth-promoting genes, such as GAP-43. This lesioninduced plasticity that happens during the first days post-stroke [90, 97, 98] reportedly lasts around 6 months after stroke [4, 91, 95, 97]. Also, therapy must continue after such a period, to take advantage of behavior-induced plasticity [95],

PR has also been proven to elicit neuroprotection and neurorestoration in other neurological disease models, such as Parkinson's, through the upregulation of BDNF and GDNF and prevention of inflammatory response [99]. The following therapies are currently under study for neurorestorative purposes during the post-stroke

Environmental enrichment focuses on inducing adaptation to different environments, including toys and complex tasks, to improve functional outcomes [97]. Also, this type of therapy has shown to enhance angiogenesis by increasing CD31 and VEGF [97]. Furthermore, environmental enrichment upregulates BDNF secre-

Wang et al. found improvements in spatial learning and memory, number of synapses, and an increase in the expression of synaptogenesis markers. GAP-43, a protein involved in neural plasticity through axonal growth, is upregulated during the first 28 days after stroke in mice exposed to environmental enrichment. Likewise, other markers involved in synaptogenesis like SYN and PSD-95 achieve better concentrations in the brains of mice treated with environmental enrichment [97].

physical therapy for patients with cerebral ischemia.

**stimulation of neural plasticity**

for Daily Living scale [4].

rehabilitation [4].

chronic period:

**288**

Functional electrical therapy has been used alongside other types of electrical stimulation to induce repetitive muscular contraction to mobilize certain joints [6]. Somatosensory stimulation might enhance neurorehabilitation after stroke through the stimulation of corticomotoneuronal excitability [6]. It has been proposed that this type of therapy increases muscle strength, reduces spasticity, and facilitates voluntary movements, among other motor benefits [6].

Guided self-rehabilitation (GSR) is a method in which the intensity of training can be increased inside the home environment. While combined with conventional rehabilitation, it has proven to be efficacious in engaging the patients in their recovery through a contract between the patient and the therapist, allowing for an increased sense of responsibility and motivation for the patients, who are required to register their progress in a diary [100]. Although not many physical therapists accept such an approach [100], positive changes have been observed after 1 year of GSR and conventional rehabilitation in ultrasound measuring of the soleus' and medial gastrocnemius' thickness and fascicle length, as well as clinical improvement, observed in soleus extensibility and ambulation speed [101] in chronic stroke patients.

Constraint-induced therapy requires constraining the non-affected limb for 90% of the waking hours, forcing the patient to use the paretic limb, inducing the increase of use-dependent plasticity, although this therapy is not practical for most of the population [6].

Videogame- or virtual reality-based (VRb) therapies have been under study for upper extremity functional recovery in acute and subacute or chronic patients [91, 96, 99, 102]; the rationale for such approaches is that they promote motor learning and repetitive, intense movements, and in the specific case of virtual reality, the patient is exposed to interactive visual, auditive, and proprioceptive feedback [91, 102]. Different videogame and VRb therapies have reported improvements in fine dexterity, grip strength [96], and grasp force [99] in upper extremities, and, activities of daily living [91] and cognition [102] in young and elderly patients after several weeks of rehabilitation. Better results have been observed when combined with conventional therapy, although it is still not known whether it enhances or speeds up recovery [91].
