Lindberg P1, Pomeroy V2, Plow E3, McNulty P4
1Université Paris Descartes, Inserm, Paris, France, 2Acquired Brain Injury Rehabilitation Alliance, University of East Anglia, Norwich, United Kingdom, 3Cleveland Clinic, Cleveland, United States, 4Neuroscience Research Australia and UNSW Australia, Sydney, Australia
- To describe current state of science on brain imaging and neurophysiology methods used to measure and modulate brain plasticity in people after stroke.
- To understand emerging plasticity principles for physical therapy and how best to utilize these in planning of treatment interventions.
- To recognize technology-derived opportunities and challenges for improving sensorimotor recovery after stroke.
Understanding the mechanisms of brain plasticity and its relation to sensorimotor recovery after stroke is considered a major scientific and clinical goal. A key challenge today is how best to translate knowledge on brain plasticity into clinically beneficial and feasible interventions. Neuroimaging studies have shown that both structural and functional reorganization occurs in sensorimotor brain networks after stroke and that this reorganization is important for recovery of voluntary movement. Various magnetic resonance imaging (MRI) techniques together with transcranial magnetic stimulation (TMS) studies have shown that the degree of stroke lesion to the corticospinal tract (CST) is a main predictor of upper limb recovery. Other studies using functional MRI have shown that functional connectivity between cortical areas may change after stroke and normalize with motor recovery, e.g., interhemispheric connectivity between primary motor cortices. Some of these imaging approaches are clinically feasible and offer new possibilities to predict and better target therapy for persons with stroke. Activation of sensorimotor circuits seems to be use-dependent and training may re-activate sensorimotor networks (1). This speaks to the need for intense and regular therapy to maximize cortical representation in the brain. How insights from these various neuroimaging and neurophysiology methods can be used to create more targeted therapeutic approaches remains a challenge.
One promising approach translating knowledge on brain plasticity into clinical interventions is the use of neurostimulation: a term used to describe non-invasive magnetic or electric stimulation techniques that can be used to modulate brain excitability. TMS can be applied repetitively to modulate brain excitability and a growing number of studies point to potential benefits of this technique when combined with an active training therapy in stroke. Transcranial direct current stimulation (tDCS) is another promising stimulation approach which may enhance motor learning in healthy subjects and in persons with stroke. This symposium will provide an update on latest evidence concerning neurostimulation and highlight some recent studies on tailoring of physical therapy interventions. Special reference will be made to predictive markers for response to specific physical therapies and an evidenced-based algorithm to support physiotherapists in clinical decision-making. Neurophysiological measures are expected to provide important information for further advances in clinical decision-making. Potential clinical methods will be explored including: transcranial magnetic stimulation; structural magnetic resonance imaging; and use of electromyography to identify muscle activity patterns during standardized functional movement tasks. Learning from use of these methods in recently completed clinical research will be shared (2).
Most often, neurostimulation approaches aim at enhancing excitability in the primary motor cortex in the stroke hemisphere. However, since the primary motor cortex and its CST are often damaged adapting stimulation to individual patterns of injury location and functional deficits may be more advantageous. Such approaches appear to maximize sensori-motor and clinically measured benefits of neurostimulation and several groups have begun to emphasize the importance of such targeted stimulation (3). The symposium will include presentations addressing such target-plasticity approaches.
The symposium will also include presentation and discussion of how best to implement plasticity-inspired principles into clinically feasible techniques. Wii-based Movement Therapy is one such technique. Wii-based Movement Therapy is an engaging and intense form of therapy that can be as effective for upper limb rehabilitation as current best practice, Constraint-induced Movement Therapy but with better lifestyle outcomes at 6 months and higher patient preference, acceptance and persistence (4). Neurophysiological recordings made during therapy sessions also demonstrate improved cardiovascular fitness and improved kinematics. Sensori-motor and functional improvements are accompanied by reorganization of brain networks.
Implications / Conclusions
This symposium will discuss recent findings on brain plasticity and how to use this knowledge to improve physiotherapy services for stroke patients.
- Brain plasticity
Relevance to physical therapy globally
Brain imaging and neurophysiology measures have advanced understanding of stroke recovery mechanisms and how these could be driven for better sensori-motor recovery. This symposium will present some novel plasticity-inspired interventions with potential for use in clinical practice, e.g., transcranial direct current stimulation. Potential benefit from neuroplasticity measures will also be explored e.g. measurement of corticospinal tract integrity and electromyography. In addition, we will highlight plasticity-inspired principles requiring consideration when planning therapy for stroke survivors.
This symposium is of interest for practitioners and managers in Neurology. A general interest discussion on innovation in physiotherapy services will be included.
Programme subject to change