Emerging treatments for motor rehabilitation after stroke

Abstract

Although numerous treatments are available to improve cerebral perfusion after acute stroke and prevent recurrent stroke, few rehabilitation treatments have been conclusively shown to improve neurologic recovery. The majority of stroke survivors with motor impairment do not recover to their functional baseline, and there remains a need for novel neurorehabilitation treatments to minimize long-term disability, maximize quality of life, and optimize psychosocial outcomes. In recent years, several novel therapies have emerged to restore motor function after stroke, and additional investigational treatments have also shown promise. Here, we familiarize the neurohospitalist with emerging treatments for poststroke motor rehabilitation. The rehabilitation treatments covered in this review will include selective serotonin reuptake inhibitor medications, constraint-induced movement therapy, noninvasive brain stimulation, mirror therapy, and motor imagery or mental practice.

Keywords: hemiparesis; mental imagery; mirror neurons; physiotherapy; stroke recovery; transcranial direct current stimulation; transcranial magnetic stimulation.

Figure 1.

Demonstration of constraint-induced movement therapy. During treatment, the patient wears a mitt or constraint on their intact limb, and the impaired limb is used for tasks during therapy and daily activities.

Figure 2.

Schematic representation of noninvasive brain stimulation techniques. A, Transcranial magnetic stimulation (TMS) of the brain using a figure-of-8 coil. B, Transcranial direct current stimulation (tDCS) of the brain with the active electrode (red wire, anode) placed over the primary motor cortex and the reference electrode (black wire, cathode) placed over the contralateral supraorbital region.

Figure 3.

Schematic representation of noninvasive brain stimulation techniques for facilitating motor recovery after stroke. The overarching aim of these techniques is to upregulate (↑) cortical excitability of the lesioned hemisphere or to downregulate (↓) cortical excitability of the contralateral nonlesioned hemisphere. The rationale for inhibiting cortical excitability of the nonlesioned hemisphere is that it is expected to minimize the amount of interhemispheric inhibition from the nonlesioned hemisphere to the lesioned hemisphere while performing active movements of the paretic limb. Note that cortical excitability can be facilitated by applying anodal tDCS or high-frequency rTMS and can be diminished by applying cathodal tDCS or low-frequency rTMS. Red-filled circle labeled with stroke indicates lesioned hemisphere. tDCS indicates transcranial direct current stimulation; rTMS, repetitive transcranial magnetic stimulation.

Figure 4.

Demonstration of mirror therapy. The patient places their intact limb and head on the same side of the mirror, outside the mirror box. The impaired limb is placed in the mirror box out of view by the patient while the patient executes movements with the intact limb or both limbs.