This text based course is a transcript of the live webinar titled, "Return of a Second Hand: Studies in Neuroplasticity after Stroke", presented by Mary Harley, OT/L.
Mary Harley: I would like to share some recent studies and understandings that we now have about the brain, a person's ability to recover after stroke, and how this affects the treatment we provide as occupational therapists.
Introduction/Objectives
Figure 1. This slide shows the learning objectives of the course.
By the end of today's presentation, you will be proficient with principles of what we call motor relearning theory. The first thing we will discuss is neural plasticity and its relation to stroke recovery. We will also touch on learned nonuse. As busy therapists, I would really like for each of you to have a toolbox of methods to treat stroke survivors in ways that promotes the use of both of their hands in daily activities and helps them to become two-handed people once again. I am going to talk about recent studies that I am involved with such as electrical stimulation therapy at the Cleveland FES Center. I want to tell you about the research that is being done with FES post-stroke, including contralateral control using the strong arm to control the simulation to the weak arm. Finally I will share a website with you regarding clinical trials for stroke survivors.
Probably everyone here today has treated stroke survivors at one point. Only about 50% of stroke survivors regain full use of their arm and hand. We need to improve functional outcomes for people who have had strokes with resultant upper limb hemiparesis.
Figure 2. This slide shows the reasons people do not regain hand function.
Can you think of why people do not regain use of their arm and hand after a stroke? People come into the hospital, go through rehab, and then through outpatient therapies. Often after therapy, they do not use their hand anymore. Using the arm is often thought of as end-use dependent. If I cannot move my fingers, move my computer mouse, or other grasping activities, my arm is useless. It is easy to get into that mindset, even though you use your whole arm, not just your hand.
It is not necessary to use both arms to function. If you have a sore foot, you are probably not going to get up and move around much because you need both feet to be able to walk. However it is very easy to get through part or all even all of your day using just one arm. How many of us use one hand on the steering wheel while we are drinking our coffee? It is easy just to use one arm to do things.
People do not get enough therapy. Length of stay or number of approved visits can be very limited.
Another thing is that improved hand movement does not always translate to improved hand use. I am going to talk a lot about that today. How many times have we seen patients that come in and they say, “Wow, look at how much I can move my hand. I can close it. I can open it a little bit.” Then, they pack up their bag with one hand, they get up with one hand, and they put on their jacket with one hand. They do not end up using their hand functionally. This is very common.
Sometimes they do not use their hand because they are not patient enough to continue trying. It is really frustrating to try to use something that does not work. Often patients will reach forward right after a stroke and try to open a door or do something with their affected hand, and then they will remember that their hand does not work. They will say, “Oh shoot, that’s right. I had a stroke,” and they will switch to the other hand. Sometimes it is easy to just switch to the other hand instead of using their affected hand.
Sometimes I think we, as therapists, lack an effective toolkit to really address arm and hand function.
Rehabilitation After Stroke
Traditional PT, OT, speech therapy and other services are sometimes very limited. We are all in a hurry to get people out of acute care into rehab because it is really expensive. Additionally, we do not want them to stay in rehab for very long because it too can be very expensive. Finally, they get to outpatient with limited visits approved. This process can take a toll on what we are able to do as therapists. We have a shorter length of stay in every phase of stroke recovery and that forces us to shift our focus to the good arm instead of focusing on the weaker arm and hand. We set goals at the beginning, such as “Patient will be independent with dressing. Patient will be independent with feeding themselves.” We need our patient to be independent in order to go home.
