Is More Better? Using Metadata to Explore Dose–Response Relationships in Stroke Rehabilitation

Lohse, Keith R.; Lang, Catherine E.; Boyd, Lara A.

doi:10.1161/strokeaha.114.004695

Cited by 507 publications

(450 citation statements)

References 59 publications

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“…Because it had not been previously established that rehabilitation drives enhancement of brain structure immediately surrounding a lesion site, the value and importance of intense rehabilitation of lost functions may not have been fully appreciated. Although studies generally support the concept that more frequent rehabilitation is associated with improved outcomes after stroke (30)(31)(32)(33)(34), few clinical trials have specifically tested whether highly repetitive, narrowly focused rehabilitation improves motor outcomes (29). Prospective, controlled, and adequately powered studies addressing this specific point have not been performed.…”

Section: Discussionmentioning

confidence: 99%

Rehabilitation drives enhancement of neuronal structure in functionally relevant neuronal subsets

Wang

Conner

Nagahara

et al. 2016

Proc. Natl. Acad. Sci. U.S.A.

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We determined whether rehabilitation after cortical injury also drives dynamic dendritic and spine changes in functionally distinct subsets of neurons, resulting in functional recovery. Moreover, given known requirements for cholinergic systems in mediating complex forms of cortical plasticity, including skilled motor learning, we hypothesized that cholinergic systems are essential mediators of neuronal structural and functional plasticity associated with motor rehabilitation. Adult rats learned a skilled forelimb grasping task and then, underwent destructive lesions of the caudal forelimb region of the motor cortex, resulting in nearly complete loss of grasping ability. Subsequent intensive rehabilitation significantly enhanced both dendritic architecture and spine number in the adjoining rostral forelimb area compared with that in the lesioned animals that were not rehabilitated. Cholinergic ablation markedly attenuated rehabilitation-induced recovery in both neuronal structure and motor function. Thus, rehabilitation focused on an affected limb robustly drives structural compensation in perilesion cortex, enabling functional recovery.cell filling | corticospinal neurons | cholinergic | morphology | plasticity S tudies over the past decade have indicated that the adult brain is structurally dynamic (1-3). Indeed, dendritic spines dynamically turn over in the adult brain (3, 4), and learning of novel tasks is associated with further increases in spine turnover (4). Moreover, total and stable increases in spine number together with enhanced dendritic complexity can be detected when analyses are focused specifically on neuronal subpopulations that are functionally related to a newly learned motor skill (5). For example, we recently reported that cortical layer V pyramidal neurons, which project to spinal segment C8 and are specifically engaged when learning a skilled forelimb grasping task, elaborate a 22% increase in apical dendritic spines and exhibit significant increases in dendritic branching and total dendritic length (5); an adjoining control population of cortical layer V pyramidal neurons that project to C4, which are not specifically shaped by the skilled motor task, exhibits no change in spines or dendritic complexity when the same task is learned (5). The detection of stable structural increases in neurons engaged by skilled motor learning in contrast to a lack of change in adjacent neurons that are not engaged by learning advances our understanding of mechanisms underlying experience-dependent cortical plasticity.Damage to the adult CNS also generates adaptive brain plasticity. For example, focal cortical lesions evoke cortical map plasticity (6, 7), extension of new axonal connections (7,8), and neurogenesis (9). A very important and unresolved question in the neural plasticity and injury fields is whether rehabilitation-that is, specific retraining of injured neural circuits-can drive, alter, or enhance neural plasticity subsequent to brain lesions. Whereas extensive literature has shown that rehab...

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Section: Discussionmentioning

confidence: 99%

Rehabilitation drives enhancement of neuronal structure in functionally relevant neuronal subsets

Wang

Conner

Nagahara

et al. 2016

Proc. Natl. Acad. Sci. U.S.A.

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“…Task-specific motor training involves high intensity practice. Intensity is not consistently defined in the rehabilitation literature, referring to number of repetitions (Taub et al, 2013), amount of work or effort (Kwakkel, 2006) or duration of practice (Lohse, Lang, & Boyd, 2014). Amount of work or effort is difficult to measure for tasks such as handwriting that do not involve a defined energy output.…”

Section: High Intensity Practicementioning

confidence: 99%

“…Intensity is important in stroke rehabilitation, with greater doses of therapy yielding greater improvements in function. A meta-analysis was conducted on the effects of increased therapy time on motor recovery post-stroke (Lohse et al, 2014). This meta-analysis of 37 RCTs found that adults with stroke who received more hours of therapy time (mean 33 hours extra) had greater improvements in motor function than those who received less hours of therapy (g = 0.35; 95% CI: 0.26 to 0.45).…”

Section: High Intensity Practicementioning

confidence: 99%

Feasibility of a home-based program to improve handwriting after stroke: a pilot study

Simpson

McCluskey

Lannin

et al. 2015

Disability and Rehabilitation

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facilities, health-related websites and in a seniors' newspaper. Eligibility criteria included having sustained a stroke at least three months previously, having self-reported difficulties with, and goals related to, handwriting, being able to hold a pen, and having sufficient cognitive and communication skills to complete a daily home program.A four-week, home-based handwriting training program was delivered by an occupational therapist. The intervention applied principles of task-specific motor training, involving intensive practice of meaningful handwriting tasks related to participant goals. Whole handwriting tasks were practised, as well as problematic handwriting task components. An occupational therapist provided supervised practice and coaching, giving feedback on task performance and using shaping to achieve the right level of challenge. Two 1-hour therapy sessions were provided per week. Another three hours per week of independent, unsupervised practice was prescribed to increase practice intensity. Participants were taught cognitive strategies to analyse their handwriting performance and problem-solve ways to improve specific handwriting features.Handwriting performance was measured at baseline, after the training program (at four weeks) and four weeks later. The primary outcome measure was the modified Evaluation Tool of Children's Handwriting-Words (mETCH-W), a subtest of the Handwriting Assessment Battery (HAB). Secondary outcome measures included other subtests of the HAB, the modified Four Point Scale, and the modified Disability of the Arm, Shoulder and Hand (DASH) Scale. Legibility was scored by a blinded rater.Feasibility of recruitment, intervention and outcome measures was evaluated using descriptive statistics, including means, standard deviations and proportions. Utility of the outcome measures was also evaluated by comparing participant score at baseline, postintervention and follow-up. Mean or median change scores were then calculated between these three time points and reported with a 95% confidence interval or interquartile range.Results: Seven adults with stroke were recruited over 18 months (eligibility fraction 43% of those screened, and enrolment fraction 78% of those eligible). There were no dropouts. Mean time post stroke was 2.6 years (range: 3 months to 7 years). Mean age was 71 years (range: 50 to 87 years). Mean disability measured using the Modified Rankin Scale was 2.3 (range 1 to 4). Although recruitment was slow, the intervention was feasible. Participants completed a mean of 7.9 hours of occupational therapy supervised handwriting practice (range: 7.6 to 8.3 hours) and 10 hours of independent practice (range: 6 to 14 hours). Participants were able to

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“…However, the authors did not comment on the lower than intended dosage or explicitly consider how this may have impacted their findings. Given our emerging understanding of the relation between dose of therapy and functional gains, 8,9 this may be a key limitation of the present work. The venue for therapy was at home for Home CIMT but the authors do not state whether the majority of sessions took place in a clinic setting for the standard care group.…”

Section: Boyd and Walker Critique Of Home Cimt Trialmentioning

confidence: 98%

Critique of Home Constraint-Induced Movement Therapy Trial

Boyd

Walker

2016

Stroke

Self Cite

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Is More Better? Using Metadata to Explore Dose–Response Relationships in Stroke Rehabilitation

Cited by 507 publications

References 59 publications

Rehabilitation drives enhancement of neuronal structure in functionally relevant neuronal subsets

Rehabilitation drives enhancement of neuronal structure in functionally relevant neuronal subsets

Feasibility of a home-based program to improve handwriting after stroke: a pilot study

Critique of Home Constraint-Induced Movement Therapy Trial

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