UCLA Neurological Rehabilitation and Research Program

Stroke may cause physical and mental impairments, such as near paralysis of one side of the body, difficulty understanding or finding words, slow thinking, and fatigue. About 20% of initial survivors are unable to manage themselves in the first week or two and require inpatient rehabilitation. The goal during the 2-5 week stay is to become independent

What Works: Practice Body-Weight Supported Treadmill Training (BWSTT) Constraint Induced Movement Therapy (CIMT-UE) Speech and Language Strategies that may help: Acupuncture Electrical Stimulation Medications Strategies that do not help: Hyperbaric Oxygen Strategies for the future: Transplantation

enough in walking and self care to return home and then continue therapy as an outpatient for 2-6 months. Remarkably, one-half of victims of a stroke have no weakness 6 months after the onset. Many patients are still disabled, however. About 20% cannot walk alone, 30% can not carry out their daily self care without physical help, and 2 of 3 no longer socialize much. Many studies of recovery convey a misconception about gains. They say that recovery only happens in the first 3, or at most 6 months after stroke.

Studies from our laboratory and others show the value of intensive practice at relearning a skill, even in the face of brain or spinal cord damage. Two formal therapies emphasize how gains are made by practice. Constraint-induced movement therapy requires that the patient try to use the effected hand or arm as much as possible to practice reaching and grasping items for 2-8 hours a day for at least several weeks. There is no magic about this approach. Patients must be able to voluntarily cock up the weak wrist at least 20 degrees and extend the fingers at least 10 degrees, meaning that they already have fair control of the hand. If the hand can not move or only clenches a bit, then this approach will not work. In general, the person who cannot extend the wrist and some fingers this much by a month after stroke is not likely to get back much functional use of the hand. However, many patients can practice and learn to extend the second finger (key pinch) to use a very weak arm to assist themselves. The gain only comes from spending blocks of time daily in practice.

For walking, treadmill training with partial weight body support, provided by a lift attached to a harness worn by the patient, helps some patients who cannot walk to partially recover. Other people who can walk by themselves, but at a slow or tiring pace, can relearn to walk at faster speeds, so they can get about more naturally in the community. This technique is really only a way to practice stepping faster, as fast as the treadmill belt is set. Most patients do not feel safe when they practice overground walking at a speed that approaches normal walking speeds. The key to this training is that the therapist provide hands-on and verbal cues to help make each step as normal and smooth as possible.

Proper practice leads to changes in how nerve cells in the brain come to represent the relearned movement. Undamaged cells and pathways spared from the stroke, and pathways that ordinarily play only a minor role in carrying out reaching and grasping or stepping, come to be trained to assist the control of what is practiced. The brain and spinal cord pay close attention to the details of that practice. They respond best to receiving sensation from the skin, muscles and joints that is similar to what the nervous system would have recognized as typical movements before the partial paralysis occurred. This practice, then, may require the help of others, such as the physical and occupational therapist or spouse, to assist the early attempts at movement. Further practice leads to more complete and earlier actions.

Practice also works for learning how to hold a spoon, to read when vision is partially lost off to one side of the environment, and to speak or make gestures despite an aphasia. Settle on what you want to practice, get some help in setting up the best conditions for practicing just a few activities several hours a day, aim for small advances day by day, and concentrate on how and what you are doing. No one ever learned to hit a tennis ball by practicing golf. You will improve only in the real-world activities that you choose and that you work hard to reacquire.


Frequently Asked Questions

1. Scientists say that the brain "reorganizes" after a stroke. Exactly what does that mean on the neuronal level -- are there new neurons or do the old neurons grow new axons, or is it something else entirely?

Reorganization describes a number of physiological and likely anatomical changes. The most important drive for reorganization is dependent on the activity of assemblies of nearby neurons and their more distant connections in a network. This is called activity-depenndent plasticity and includes a number of types of reorganizational change. For example, neurons of the motor cortex that "represent" or have primary responsibility for carrying out a particular movement, such as tapping a finger or cocking up the ankle as a person swings the leg for walking, also have synaptic connections with nearby neurons that do not have the same primary role. If some of the axons of the former are damaged by a stroke, these nearby neurons may come to play a greater role in helping to control aspects of the movement formerly modulated by the original set. Latent synaptic connections are strengthened by repeated practice that leads to better skilled movement.

Another example - neurons of the movement network, which is distributed in at least a half-dozen regions of the cortex on the side of the injury, as well as on the unaffected side of the brain and within the lower centers such as the brain stem and spinal cord, will come to play a greater role in contributing to the learning of a skilled movement in the person with weakness after stroke (or any injury). As the skill becomes better learned, less of that network is needed. We and others show this change over the time of training using functional neuroimaging techniques. These changes are no different than what occurs during normal learning of a skill (or of a fact) - neurons that work together by receiving the same sensory feedback and participate to produce a particular force and direction of skilled movement increasingly come to fire together, thus forming a stronger representation for the action. The spinal cord reorganizes when it has lost some of its inputs from above and learns to take advantage of what inputs do remain after a stroke. Also, the fine connections between neurons, called dendrites, will grow and make new connections with nearby neurons that have lost some of their inputs due to a stroke. This growth is accompanied by formation of additional dendritic spines, tiny regions where new "memories" or synaptic strengthening occurs to allow these neurons to work efficiently in the future to carry out a learned movement. Also, some new neurons from within the layers of cells in the walls of the inner fluid-filled ventricles of the brain may migrate to near the area of the stroke and provide some support for reorganization - but no one yet knows what if any role such cells may play. Finally, certain drugs that resupply chemical messengers such as dopamine and serotonin may enhance activity among neurons as they "relearn" how to represent a movement. The combination of using such pharmacotherapy or using forms of direct electircal stimulation during practice may enhance gains.

2. How can rehabilitation for walking trigger the reorganization of the brain?

The lower spinal cord contains networks that simplify a stereotyped movement
such as alternately flexing one leg as the other extends, which is the simplest form of step-like activity. The networks, called pattern generators, oscillate in this flexion-extension rhythm when stimulated by sensory feedback that is similar to the timing of inputs from the muscles and joints that occur during normal walking. The sensory feedback seems to best drive these spinal neurons in relation to certain levels of loading of the leg that is bearing weight as the opposite leg unloads its body weight to start to swing through to take a step. This feedback also takes a certain minimum speed of walking to work best - we find that practice at the very slow speeds (usually less than 1 mph) that is feasible during conventional physical therapy is not likely to provide the optimal sensory feedback to the spinal cord and brain. At the speeds permitted by treadmill training, we can better activate thee automatic stepping network.

The brain's walking regions must drive the firing of these spinal cells, however. The brain's motor regions must initiate the stepping movement and maintain it, and of course will come into greater play for any skilled movement such as kicking a soccer ball or dancing or stepping over a log. The treadmill training and the Lokomat are simply a way to put patients into a position tto better practice. Conventional physical therapy can accomplish the same in the majority of patients; the intensive practice permitted by using a treadmill with body weight support or adding a robotic assistive device (such as the Lokomat) is best reserved for research studies and for patients who are not able to walk well more than 4-6 months after the stroke. Patients do assist the Lokomat - the device allows itself to be over-rided by the effort made by the patient - but the device is still a work in progress. It has no feedback system and is too expensive for routine use.

3. Why did doctors originally assume patients couldn't get much better after six months of rehab? What caused the shift in thinking that's going on now?

The myth arose form the types of test used to measure the effects of rehabilitation. The tests would, for example, use the best outcome for walking ability as the ability to walk without human assistance for 150 feet. This does not take into account the notion that you have to be able to walk at least 1500 feet at a speed of at least 2 mph to be able to walk independently in the community - you cannot cross a street before the traffic light changes if you cannot walk 2 mph (normal speed is about 3mph), so disabled people will not try, for fear of becoming road kill. Therapy stops too soon or the goals of therapy are set too low, in part because of what Medicare and insurers will cover and in part because therapists and doctors are not being as creative as they could be and are not drawing deeply enough into the scientific bases for rehabilitation as they could to figure out how to best help patients.. The notion of maximal gains has been set too low, stealing from many patients who do retain some motor control the opportunity to maximize their recovery. The same holds for other disabilities such as aphasia - loss of the ability to fully speak or comprehend speech.

4. Are the new, longer-term treatments more effective for younger stroke victims? Do they work better for men than women, or vice versa?

Studies so far have not revealed differences based on age or gender in the ability to benefit from creative approaches to rehabilitation after stroke. Strong motivation to improve, good thinking skills, good family support, and commitment to practice are far more important than age. Older folks may have more underlying physical and mental problems unrelated to the stroke than younger folks - that can work against them.


Home Practice Activities for the Affected Arm

March 2004 Newsweek article on stroke rehabilitation:
Rehabilitation: How a Brain Heals

2004 updated Neural Repair information: Basic Advances and New Avenues in Therapy of Spinal Cord Injury

New England Journal of Medicine article 2005: Rehabilitation after Stroke

On April 7, 2003 the Los Angeles times has published an article of interest on stroke therapy. You can view an electronic copy of Stroke Therapy sets it's sights higher, farther by Jane E. Allen at http://www.latimes.com under archives.