Cover Story

Strokes are the No. 1 cause of disability — and the No. 3 cause of death — in the United States. Some of those disabilities could be prevented if stroke victims received better care, suggests new research. A study in Stroke (Vol. 34, No. 1), found that less than 10 percent of those who’d had a stroke within two years were receiving occupational or physical therapy — but patients who did get such care reported lower levels of disability and problems over time.

“Often, there’s attention to the more obvious medical aspects, but as soon as the patient is able to walk, it’s goodbye,” says geropsychologist and stroke rehabilitation expert Robert Katz, PhD, director of psychology at the Peninsula Center for Extended Care in Far Rockaway, N.Y. “There are so many huge issues that aren’t being addressed.”

In addition, once patients return home, the skills they learned in the hospital aren’t reinforced, says psychologist Tamara Bushnik, PhD, director of the Rehabilitation Research Center at the Rusk Institute for Rehabilitation in New York.

“While people might be quite independent in the inpatient facility, once they get home, the skills don’t always transfer,” she says.

And with the state of insurance reimbursement, she points out, in-home therapists can’t always come in to help people during the crucial transition time.

These challenges have inspired a new wave of stroke research that aims at closing the gap between short- and long-term care and dramatically improving stroke survivors’ long-term quality of life. Researchers are pinpointing the most successful components of already-proven treatments, developing therapy systems that patients can use at home, and testing treatments for patients with stroke-related problems that tend to go unnoticed and untreated, such as a subtle inability to attend to one side of one’s visual space. Psychologists are also designing interventions based on new research that details how our brains recover from injury.

“It’s an exciting time in stroke rehab because there’s a lot of progress being made at the basic science level, in particular in our understanding of how malleable our nervous systems are,” says psychologist Gitendra Uswatte, PhD, associate professor of psychology at the University of Alabama at Birmingham. “We’re just starting to learn more about how you harness that neuroplasticity to the advantage of the patient.”

Taking gains home

Research suggests that transferring skills from stroke survivors’ hospital rooms to their homes is a crucial part of rehabilitation, says Uswatte, associate director of the lab headed by Edward Taub, PhD. For more than two decades, Taub’s lab has been developing a behavioral intervention called Constraint-Induced Movement Therapy, or CI therapy, which trains people to better use their stroke-affected arms or lower limbs.

CI therapy has three components. One is a behavioral “shaping” component, in which therapists use verbal praise to encourage patients to engage in increasingly challenging daily tasks with their more affected arms, such as spooning beans into their mouth or drinking from a soda can. The second component is physical restraint of the “better” arm to force repeated use of the affected one. The third is a “transfer package,” a set of techniques that helps patients transfer gains from the lab into real world. These include elements like behavioral contracts, progress diaries, phone calls with their therapists and physical restraint of the arm outside the training setting.

In a multisite randomized controlled trial reported in the Journal of the American Medical Association (Vol. 296, No. 17), the researchers showed the intervention was significantly superior to treatment as usual in helping people use their affected arms. Gains persisted even after two years.

The researchers have since attempted to tease out which elements make CI therapy so effective. In an unpublished study, stroke survivors received repetitive training of their affected arms and restraint of their other arms either with or without shaping elements. Within each group, half received transferpackage elements and half did not.

To their surprise, treatment success didn’t hinge on whether or not people received shaping: Only those who received transfer elements improved significantly in either training condition, Uswatte says.

“We didn’t think about the transfer package as being something that was particularly interesting about the therapy,” he says. “We just thought of it as something we automatically included when we did a behavioral intervention.”

In a study published in May 2008 in Stroke (Vol. 39, No. 5), the team also analyzed structural magnetic resonance images of participants’ brains before and after treatment. They found that only participants who received the transfer package showed a significant increase in gray matter. While it’s unclear why the transfer package holds such power, it may be that it encourages and reinforces a person’s attention or engagement, says Uswatte. Future studies will further parse elements of the package to see which might have the biggest effect, he adds.

Transferring the gains patients make through CI therapy might be even easier if the patients receive the initial therapy at home, Uswatte adds. Such therapy could be more convenient for patients and allow one therapist to work with four or more patients at a time, according to a preliminary study published in the Journal of Rehabilitation Research and Development (Vol. 43, No. 3). In that paper, Peter Lum, PhD, of the Catholic University of America in Washington, D.C., Uswatte and Taub described a way to deliver CI therapy on automated, home-based work stations with therapy supervision provided by telehealth technology. The stations consist of arm-training devices, such as a pegboard and a tower with buttons, that are embedded with sensors wired to a personal computer. Computer software monitors patient progress using the information from these sensors and provides automated feedback and instruction. Meanwhile, a therapist at a base station observes how the patient is doing and overrides the automation depending on patient need, Uswatte explains.

In addition to potentially bringing a proven rehab technique to millions of homebound stroke survivors, the study shows how psychologists’ expertise in learning can be applied directly to a physical problem, Uswatte adds. “While most rehab psychologists work on people’s adjustment to a physical or cognitive disability or on cognitive rehabilitation,” he says, “we work on the physical rehabilitation process itself.”

Mysterious symptoms

While a paralyzed arm is often the target of rehabilitation experts, up to half of stroke survivors suffer from a less visible disability: spatial neglect. People with this condition may fail to see objects on one side of their body or even their own body parts. In one famous case, a woman only applied makeup to the right side of her face following a stroke.

For many patients, however, spatial neglect’s symptoms are subtle and go undetected and untreated, says neurologist Anna Barrett, MD, who directs the Stroke Rehabilitation Research Laboratory at the Kessler Foundation Research Center in New Jersey. However, even mild cases of spatial neglect can lead to injury when people fail to notice steps on their left side, or oncoming traffic for instance.

“Failure to pay attention to this condition can be absolutely devastating,” says Barrett’s colleague Katz.

There are, however, few proven tests and treatments for spatial neglect, says Barrett, who closely studies the condition. To add to the arsenal of techniques that rehabilitation psychologists and other professionals can use, she’s testing treatments for people with different types of spatial neglect. In a study of 80 right-hemisphere stroke patients, funded by the National Institute of Neurological Disorders and Stroke, Barrett’s team is randomizing participants to one of two experimental treatments that they receive along with standard occupational therapy. Participants get two weeks of the intervention, then are assessed weekly for four weeks.

One intervention, a drug called bromocriptine, works to stimulate dopamine systems in the brain. Dopamine systems are thought to be dysfunctional in stroke patients with “aiming” problems — a type of spatial neglect characterized by trouble moving leftward. The other intervention, called prism adaptation therapy, uses special goggles that systematically shift patients’ visual space to the right. Over time, researchers posit, the goggles might help people recalibrate their internal maps so that they orient more accurately to the left. In the study, participants wear the goggles for 15 minutes a day for two weeks and practice pointing at objects and marking the middle of a line.

In addition to testing participants using standard strokerelated measures, the team will observe how well subjects perform on daily tasks, such as dressing on their left side or paying attention to their caregivers on their left side, Barrett says.

Barrett’s study is also training occupational and physical therapists to assess participants’ daily functioning. It’s a small but important step toward sharing what researchers are learning about stroke recovery with the larger medical community, she says.

“That’s great for our study,” she notes, “but it’s even better for the purposes of giving these therapists more understanding of what is going on with patients and to help make care more standardized and research-based.”

Tori DeAngelis is a writer in Syracuse, N.Y.