journal club march 2012 a visual presentation
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IJ Hubbard 2012
Journal Club March 2012A Visual Presentation
Brain Reorganisation and Upper Limb Recovery
IJ Hubbard 2012
Objectives:
• Brain Reorganisation– What’s it all about?
• Neuroanatomy update– Brief review of brain topography
• Stroke: the disconnect– What’s happened and why?
• Upper limb (UL) recovery– Answering the all-important ‘so what’ question
Hmm…The elephant in the room, perhaps? Can we be certain that our stroke rehabilitation efforts are achieving better outcomes than if we did nothing at all (natural history)?
Hmm…The elephant in the room, perhaps? Can we be certain that our stroke rehabilitation efforts are achieving better outcomes than if we did nothing at all (natural history)?
This presentation is for your eyes only!
Work your way throughthe 22 slides, take thesuggested detours,
& then let’s chat!
Note from Isobel:
IJ Hubbard 2012
Presenter:
• Ms Isobel Hubbard– Occupational Therapist working as an Academic Researcher
• Lecturer at the University of Newcastle– Convenor of a stroke-specific Masters and Graduate Certificate– Coordinator of all stroke-specific postgraduate &
undergraduate courses
• PhD Student– Investigating early brain reorganisation & UL recovery post stroke– Track record in publications & presentations
Acknowledgingthe contribution of Drs
Parsons, Carey and Budd,the acute stroke team at John
Hunter hospital, NewcastleAustralia, the National Stroke Foundation and
the University of Newcastle’sPriority Research Centre for
Brain & Mental Health
IJ Hubbard 2012
Brain Reorganisation
Definition: Definition: Wiki plus IH: Neuroplasticity refers to the ability of the brain and nervous system.. to change structurally and functionally as a result of input from the environment. Plasticity occurs on a variety of levels, ranging from cellular changes involved in learning, to large-scale changes involved in cortical remapping in response to injury, eg stroke...During most of the 20th century, the general consensus.. was that the brain’s structure is relatively stable after a developmental period in early childhood. This belief has been challenged by new findings revealing that the brain is relatively plastic and
in turn, responsive to change, throughout an adult’s lifetime.
Definition: Definition: Wiki plus IH: Neuroplasticity refers to the ability of the brain and nervous system.. to change structurally and functionally as a result of input from the environment. Plasticity occurs on a variety of levels, ranging from cellular changes involved in learning, to large-scale changes involved in cortical remapping in response to injury, eg stroke...During most of the 20th century, the general consensus.. was that the brain’s structure is relatively stable after a developmental period in early childhood. This belief has been challenged by new findings revealing that the brain is relatively plastic and
in turn, responsive to change, throughout an adult’s lifetime.
Source: wikipedia.orgRef: T Elbert, C Pantev, C Wienbruch, B Rockstroh, E Taub. (1995) Increased cortical representation of the fingers of the left hand in string players. Science 270, 305-307.
We know from Elbert et al’s research (1995) that if you decided to learn to play the
violin, your brain would increase the cortical area
allocated to your non-dominant UL
IJ Hubbard 2012
Brain Reorganisation
To find out more: To find out more: Go to Rossini, Calautti, Pauri & Baron (2002) Post stroke plastic reorganisation in the adult brain.
Lancet Neurology, 2, 439-502Quote: “Our understanding of the mechanisms that promote or prevent recovery is fundamental to the design of
novel therapies…In this review we discuss brain imaging studies of reorganisation after stroke. Because motor function of the arms can be used to model the recovery of higher functions…we will focus on the recovery of the sensorimotor arm and hand function.
Carey & Seitz (2007) Functional neuroimaging in stroke recovery and neurorehabilitation: conceptual issues and perspectives. International Journal of Stroke, 2 (4), 245-264
Quote: “Our current mandate is to adopt a more active approach to rehabilitation by developing approaches that aim to restore underlying capacity and improve clinical outcome…Promising approaches
need to be systematically tested..”
To find out more: To find out more: Go to Rossini, Calautti, Pauri & Baron (2002) Post stroke plastic reorganisation in the adult brain.
Lancet Neurology, 2, 439-502Quote: “Our understanding of the mechanisms that promote or prevent recovery is fundamental to the design of
novel therapies…In this review we discuss brain imaging studies of reorganisation after stroke. Because motor function of the arms can be used to model the recovery of higher functions…we will focus on the recovery of the sensorimotor arm and hand function.
Carey & Seitz (2007) Functional neuroimaging in stroke recovery and neurorehabilitation: conceptual issues and perspectives. International Journal of Stroke, 2 (4), 245-264
Quote: “Our current mandate is to adopt a more active approach to rehabilitation by developing approaches that aim to restore underlying capacity and improve clinical outcome…Promising approaches
need to be systematically tested..”
Brain reorganisation: a neural mechanism that underpins stroke recovery because of its responsiveness to changes in behavioural demandsFunctional Magnetic Resonance Imaging (fMRI): a non-invasive neuroimaging technique that provides a “window” into brain reorganisation
IJ Hubbard 2012
Neuroanatomy 101
Inter-hemispheric fissure: hemispheres are similar but not exact opposites.
The surface of both hemispheres is made up of many gyri (ridges) & sulci (creases).
1. The Cortex: ≈ top 1cm of gyri and sulci2. The Subcortex: the supporting structure3. The Cerebellum, Brain Stem & Pons are
positioned to connect the brain & body.
The central sulci separates the:Pre-central and post-central gyri.
The human brain uses up 20% of
the body’s oxygen& nutrients
Before you go to the next slide, test your knowledge: Which regions of the brain are important to motor function and where are they? Where do you find the cingulate area and what is its primary function? What % of the corticospinal tracts arising from the right primary motor cortex (M1) go to the left UL?
Before you go to the next slide, test your knowledge: Which regions of the brain are important to motor function and where are they? Where do you find the cingulate area and what is its primary function? What % of the corticospinal tracts arising from the right primary motor cortex (M1) go to the left UL?
Cerebellum
IJ Hubbard 2012
Neuroanatomy 101
Left Hemisphere: Brodmanns Area (BA)
Frontal lobe
Temporal lobe
Source: wikipedia.org
Right hemisphere: similar but not exact mirror image
Pareital lobe
Central Sulci
Functional Regions of InterestFunctional Regions of InterestBA4: Primary motor cortex (M1)BA6: Premotor cortex (PMC) & Supplementary motor area (SMA) BA3,1,2: Primary somatosensory cortexBA5 & 7: Secondary somatosensory
Notes: The SMA, an area important to UL recovery post stroke, is positioned in the medial region of each hemispere (not shown). The two SMA “face-off” across the interhemispheric fissure. Do they communicate via the anterior commissure, a bundle of nerve fibres connecting the hemispheres?
To explore the imaged brain: To explore the imaged brain: Go to The Whole Brain Atlas atwww.med.harvard.edu/aanlib/home.html
Select: “NEW: normal anatomy in 3D..”. Use the arrows to navigate the imaged “slices” & try the ‘stroke’ links.
Functional Regions of InterestFunctional Regions of InterestBA4: Primary motor cortex (M1)BA6: Premotor cortex (PMC) & Supplementary motor area (SMA) BA3,1,2: Primary somatosensory cortexBA5 & 7: Secondary somatosensory
Notes: The SMA, an area important to UL recovery post stroke, is positioned in the medial region of each hemispere (not shown). The two SMA “face-off” across the interhemispheric fissure. Do they communicate via the anterior commissure, a bundle of nerve fibres connecting the hemispheres?
To explore the imaged brain: To explore the imaged brain: Go to The Whole Brain Atlas atwww.med.harvard.edu/aanlib/home.html
Select: “NEW: normal anatomy in 3D..”. Use the arrows to navigate the imaged “slices” & try the ‘stroke’ links.
IJ Hubbard 2012
Neuroanatomy 101
Neural System: a complex labyrinthNeural System: a complex labyrinth
Cortex: The end point or journey destinationSubcortex: The connection, journey or road map
Notes re: The brain’s neural system… Communicates inter- (between) & intra- (within)
hemispherically. Lots of connectivity! Is connected to the body via corticospinal tracts
≤90% contralateral (opposite side) ≥10% ispsilateral (same side)
Is dependent on the vascular system for a reliable supply of oxygen & nutrients
Neural System: a complex labyrinthNeural System: a complex labyrinth
Cortex: The end point or journey destinationSubcortex: The connection, journey or road map
Notes re: The brain’s neural system… Communicates inter- (between) & intra- (within)
hemispherically. Lots of connectivity! Is connected to the body via corticospinal tracts
≤90% contralateral (opposite side) ≥10% ispsilateral (same side)
Is dependent on the vascular system for a reliable supply of oxygen & nutrients
Source: wikipedia.org
The brain’s neural system is like a city’s road
network
IJ Hubbard 2012
Neuroanatomy 101
http://www.youtube.com/watch?v=hUZeuzXH-zA
To appreciate the complexity of the neural system go to this youtube link. You’re looking at tractography or connectivity mapping. The different colours represent different directions
of activity along the tracts.
http://en.wikipedia.org/wiki/Diffusion_MRI
Interhemispheric connectivity
The human brain makes up only 2% of body weight, yet it accounts for 20% of the body’s total O2 consumption & receives 11% of its cardiac output (Giedde, 2006)
Ref: Gjedde A. Brain energy metabolism and the physiological response, in Functional MRI: An introduction to methods, Jezzard, Mathews & Smith, Ed. 2006, Oxford University Press
IJ Hubbard 2012
Neuroanatomy 101
Vascular System: a supply lineVascular System: a supply line
Middle Cerebral artery (MCA): Supplies much of the brain’s motor-related neural regions
Circle of Willis: The largest of the brain’s unique contralateral/collateral supply lines
Notes: • This system is responsible for a reliable
supply of O2 & nutrients to the brain• A disruption to the blood supply impacts the
neural system: Time is brain!• Hyper-acute stroke management is
about restoring the integrity of the vascular system ASAP!! FAST!!
Vascular System: a supply lineVascular System: a supply line
Middle Cerebral artery (MCA): Supplies much of the brain’s motor-related neural regions
Circle of Willis: The largest of the brain’s unique contralateral/collateral supply lines
Notes: • This system is responsible for a reliable
supply of O2 & nutrients to the brain• A disruption to the blood supply impacts the
neural system: Time is brain!• Hyper-acute stroke management is
about restoring the integrity of the vascular system ASAP!! FAST!!Time is brain!
Each minute 1.9 millionneurons die without
O2 & nutrients
The brain’s vascular
system is like its trains &
underground
Saver, J.L. (2005) Time is brain – quantified. Stroke 2006 37: 10
IJ Hubbard 2012
Neuroanatomy 101
To find out more: To find out more: Go to The Internet Stroke Centre http://www.strokecenter.org/
and you’ll find this image and lots more
IJ Hubbard 2012
Stroke: the disconnect
Stroke is a disconnection phenomenaStroke is a disconnection phenomena
The integrity of the ‘up-stream’ neural regionsis immediately threatened after any disruptionto the vascular supply, such as strokestroke.
Ischemic Stroke: Blockage: 80-85% of all strokes• Results in permanent damage ‘up-stream’• Can present as a squid-like area of damage
that’s reached into closely located gyri
Hemorrhagic Stroke: Bleed:15-20% of all strokes• More easily identified via CT scan• Also results in up-stream damage• More life-threatening
Stroke is a disconnection phenomenaStroke is a disconnection phenomena
The integrity of the ‘up-stream’ neural regionsis immediately threatened after any disruptionto the vascular supply, such as strokestroke.
Ischemic Stroke: Blockage: 80-85% of all strokes• Results in permanent damage ‘up-stream’• Can present as a squid-like area of damage
that’s reached into closely located gyri
Hemorrhagic Stroke: Bleed:15-20% of all strokes• More easily identified via CT scan• Also results in up-stream damage• More life-threatening
Hmm…The day after a stroke am I right to
assume there’s nothing wrong with the
UL muscles?
If you’re unsure about recognising stroke and/or what to do, go to either of these links
http://www.youtube.com/watch?v=T_CXqfFGpvY&feature=relmfu
http://www.strokefoundation.com.au/
Time is Brain Act FAST: Face, Arm, Speech & Time
IJ Hubbard 2012
Predicting Recovery
Predicting Recovery: Acute therapists need to be able to quickly & accurately predict potential.
Notes: Strokes that affect the UL..1. Are usually an Anterior Circulation Infarct (ACI)2. Have usually impacted the pre- and/or post-central gyri
or sensorimotor ‘strip’. Ref: Oxfordshire Classification system:
http://www.strokecentre.org/trials/scales/oxford.html
Stroke topography: Imaging results assist in identifyingwhere a stroke is located. This is an important indicator ofrecovery potential:• Poorest potential: TACI (total)• Best potential: Lacuna infarct (LACI)
What about corticospinal tract integrity? Ref: Stinear et al (2007) Functional
potential in chronic stroke patients depends on corticospinal tract integrity. Brain, 130,
170-180
Predicting Recovery: Acute therapists need to be able to quickly & accurately predict potential.
Notes: Strokes that affect the UL..1. Are usually an Anterior Circulation Infarct (ACI)2. Have usually impacted the pre- and/or post-central gyri
or sensorimotor ‘strip’. Ref: Oxfordshire Classification system:
http://www.strokecentre.org/trials/scales/oxford.html
Stroke topography: Imaging results assist in identifyingwhere a stroke is located. This is an important indicator ofrecovery potential:• Poorest potential: TACI (total)• Best potential: Lacuna infarct (LACI)
What about corticospinal tract integrity? Ref: Stinear et al (2007) Functional
potential in chronic stroke patients depends on corticospinal tract integrity. Brain, 130,
170-180
Potential Poor Medium Good
Stroke type TACI PACI LACI or POCI
Supportive family
Incontinent
20/10 UL Club
Global aphasia
Stroke Unit
Care
Predicting good vs poor recovery potential
Those with ≥20°movement at the wrist & ≥10° in at least one finger
Another elephant…? Should therapists be spending their very
limited time on stroke patients who are unlikely to recover?
Another elephant…? Should therapists be spending their very
limited time on stroke patients who are unlikely to recover?
To find out more about the To find out more about the corticospinal tract: corticospinal tract: Go to
The Brain from Top to Bottom at http://thebrain.mcgill.ca/flash/i/i_06/i_06_cl/i
_06_cl_mou/i_06_cl_mou.html
IJ Hubbard 2012
Upper Limb Recovery
Before you move onto the next slide take some time-
out to consider & write down your 4 most importantmost important “best practice” principals for
post stroke upper limb rehabilitation.
IJ Hubbard 2012
Upper Limb Recovery
Four “Most Important” Principals (IH)Four “Most Important” Principals (IH)
As Early As Possible: As soon as the patient is medically stableAs Intense As Possible: As intense as the patient can reasonably tolerate, which can only be achieved if it’s mostly self-directedAs Client-centred As Possible: As meaningful as is environmentally possibleAs Task-specific As Possible: As close to real-life activities as is feasible and reasonably safe, which is only possible if we take some risks
Four “Most Important” Principals (IH)Four “Most Important” Principals (IH)
As Early As Possible: As soon as the patient is medically stableAs Intense As Possible: As intense as the patient can reasonably tolerate, which can only be achieved if it’s mostly self-directedAs Client-centred As Possible: As meaningful as is environmentally possibleAs Task-specific As Possible: As close to real-life activities as is feasible and reasonably safe, which is only possible if we take some risks
Hmm..a room of elephants..!!!Emerging evidence tells us that hospital
& rehabilitation wards are usually environmentally bereft and
occupationally de-challenging, perhaps making them the worst
spaces for people recovering from stroke!!
Ref: Hubbard.et al (2009) Task-specific training: Evidence for and translation to clinical practice. Occupational Therapy International, 16(3-4), 175-189
Time is function!In the first month after stroke
each day spent doing very littleis a lost opportunity for
better recovery
IJ Hubbard 2012
Upper Limb RecoveryUnderstanding the research
We asked this question & we’re finding differences in certain We asked this question & we’re finding differences in certain regions - we’re in the process of writing this up.regions - we’re in the process of writing this up.
Do you find it difficult to understand the reporting of research Investigating changes in brain activation? Terms often used: 1. Contralesional: the stroke-affected (lesioned) hemisphere2. Ipsilesional: the non-affected hemisphere
Researchers will use analysis methods such as “flipping” thehemispheres of one group of study participants, so that they can compare results between hemispheres – as we are doing.
3. Laterality Index (LI): Shifts in activation patterns between hemispheres over time – another way of reporting changes in activation
We asked this question & we’re finding differences in certain We asked this question & we’re finding differences in certain regions - we’re in the process of writing this up.regions - we’re in the process of writing this up.
Do you find it difficult to understand the reporting of research Investigating changes in brain activation? Terms often used: 1. Contralesional: the stroke-affected (lesioned) hemisphere2. Ipsilesional: the non-affected hemisphere
Researchers will use analysis methods such as “flipping” thehemispheres of one group of study participants, so that they can compare results between hemispheres – as we are doing.
3. Laterality Index (LI): Shifts in activation patterns between hemispheres over time – another way of reporting changes in activation
Typical research question: Do different intensities of UL intervention result in different
patterns of activation?
Glass MapsThe image above shows
the between-group differencesin activation over a nominatedp-value threshold. SPM is the
program used to do the analysis
IJ Hubbard 2012
Upper Limb RecoveryWhat’s the research telling us?
All systematic reviews found activation associated with the stroke-affected UL was in ipsilesional, motor-related areas eg, the M1 & SMA.
Systematic Review Review Aim Findings associated with recovery of the Stroke-affected UL
Buma et al (2010) Neurorehabilitation & Neural Repair, 24(7), 589-608
Studies ≤6mo post stroke
In the first weeks post stroke, profound overactivation, perilesional and contralesional activation in motor-related areas. Good recovery associated with return to more normal patterns. Poor recovery associated with persistent recruitment of contralesional activation in motor areas.
Hodics et al (2006) Arch of Phys Med & Rehab, 87(12), 36-42
Intervention-specific effects
Clinical improvement even late after stroke. Mostly motor-related studies. Constraint-based interventions resulted in ipsilesional M1, PMC & SMA. Bilateral UL training influences contralesional changes
Kokolito et al (2009) Journal of Neurologic Physical Therapy, 33(1), 45-55
Force production & modulation
Changes in activity in motor-related areas including M1, PMC & SMA associated with increasing severity of stroke. Reduced recruitment of motor areas increased over time. Rehabilitation can influence activity patterns. Early task-related activation observed in motor regions including SMA & CA
Richards et al (2008) Neuropshychologia, 46, 3-11
UL motor intervention & ipsilesional activity
Association between improved UL function following behavioural intervention & neural changes in ipsilesional S1M1 over time. Targeted UL intervention increases ipsilesional engagement of motor-related areas.
IJ Hubbard 2012
Upper Limb RecoveryGood versus Poor Recoverers
Dr Leeanne Carey et al (2006) Evolution of Brain Dr Leeanne Carey et al (2006) Evolution of Brain Activation with good and poor motor Activation with good and poor motor recovery after stroke.recovery after stroke.Neurorehab & Neural Repair, 20, 24-41.Neurorehab & Neural Repair, 20, 24-41.
Participants: n=9; baseline 2-7 wks post stroke; follow-up at 6 months
Method: Compared to healthy volunteer dataFindings: Good recoverersGood recoverers with moderate
impairment (n=5) had ipsilesional SM1 activation, bilateral SMA & contralesional PMC; the bilateral SMA activation reduced over time.
Poor recoverersPoor recoverers with severe impairment (n=4) had limited ipsilesional S1M1 and SMA activation & no significant change over time.
Conclusion: In the sub-acute phase, there is evidence of reversion to more normal patterns
in good recoverers over time. SMA is important to UL recovery SMA is important to UL recovery following stroke.following stroke.
Dr Leeanne Carey et al (2006) Evolution of Brain Dr Leeanne Carey et al (2006) Evolution of Brain Activation with good and poor motor Activation with good and poor motor recovery after stroke.recovery after stroke.Neurorehab & Neural Repair, 20, 24-41.Neurorehab & Neural Repair, 20, 24-41.
Participants: n=9; baseline 2-7 wks post stroke; follow-up at 6 months
Method: Compared to healthy volunteer dataFindings: Good recoverersGood recoverers with moderate
impairment (n=5) had ipsilesional SM1 activation, bilateral SMA & contralesional PMC; the bilateral SMA activation reduced over time.
Poor recoverersPoor recoverers with severe impairment (n=4) had limited ipsilesional S1M1 and SMA activation & no significant change over time.
Conclusion: In the sub-acute phase, there is evidence of reversion to more normal patterns
in good recoverers over time. SMA is important to UL recovery SMA is important to UL recovery following stroke.following stroke.
Important research question: Are there
differences in activation patterns between good and poor recoverers?
SMA
IJ Hubbard 2012
Upper Limb Recovery
Joining up the dots….. Knowing what activation
patterns are associated with good recovery means
researchers can investigate which UL interventions elicit
those patterns
IJ Hubbard 2012
Upper Limb RecoveryThe “hopping” problem
Post Stroke : Upper Limb vs Lower LimbPost Stroke : Upper Limb vs Lower Limb
Lower limb: Fortunately it’s more difficult to hop than walk, therefore learned non-use is not an issue.Upper Limb: Unfortunately it’s quite easy to learn to do things one-handed so learned non-use is a big problem that is best challenged ASAP!Constraint-based Intervention: Forces the person to stop UL “hopping”! It challenges learned non-use by forcing the engagement of the stroke-affected UL & demands involvement from both hemispheres. Not suitable for those with no observable movement.
Behavioural Demands: Brain reorganisation is a normal response to behavioural changes. Learn the violin and the brain reorganises! Have a stroke and the brain reorganises! Start to walk, speak and/or use the affected UL and the brain reorganises.
Post Stroke : Upper Limb vs Lower LimbPost Stroke : Upper Limb vs Lower Limb
Lower limb: Fortunately it’s more difficult to hop than walk, therefore learned non-use is not an issue.Upper Limb: Unfortunately it’s quite easy to learn to do things one-handed so learned non-use is a big problem that is best challenged ASAP!Constraint-based Intervention: Forces the person to stop UL “hopping”! It challenges learned non-use by forcing the engagement of the stroke-affected UL & demands involvement from both hemispheres. Not suitable for those with no observable movement.
Behavioural Demands: Brain reorganisation is a normal response to behavioural changes. Learn the violin and the brain reorganises! Have a stroke and the brain reorganises! Start to walk, speak and/or use the affected UL and the brain reorganises.
Time is function!Adequate dose should be a primary consideration
irrespective of time post stroke
IJ Hubbard 2012
In Conclusion
Evidence concerning post stroke brain activation patterns tells us that: • The brain can reorganise post stroke• Brain reorganisation underpins sub-acute recovery• Our selection of UL interventions should consider their impact on brain activation• Best practice for most stroke-affected upper limbs is early more intensive, task-specific intervention
In 2011 we built ourselves a new house with an upstairs and downstairs area. Q: Have we lost sight of the fact that stroke is an “upstairs” disconnection, because our UL assessments & interventions are often focussed on what’s happening “downstairs”. Journal Club Author: Isobel Hubbard
IJ Hubbard 2012
Thank you
Post your questions or comments in the March Journal Club discussion
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