Physiotherapy plus psychology: new ideas on stroke rehabilitation

Physiotherapist With PatientThe latest research conducted at Victoria University in Melbourne may provide useful applications for the care of stroke patients who have restricted use of their upper limbs. If stroke sufferers practice the techniques recommended in the study, it could potentially help maintain activity in movement-related brain areas, especially when used together with more traditional physiotherapy techniques where the same movements are also practiced physically.

Using innovative research methods, the team of investigators under supervision of Dr. David Wright and Prof Paul Holmes studied activity in an area of the brain responsible for controlling movement. In the study healthy participants observed a video showing simple hand movements and simultaneously imagined that they were performing the observed movements.

Researchers used transcranial magnetic stimulation (TMS)—a technique where a coil placed over the scalp delivers stimulation to the brain, activates neurons in the underlying area, and causes a muscular contraction in the participant’s hand. The study found that the strongest activity in the brain was demonstrated when combining imagery (imagining the feelings associated with performing the movements) with observation (watching the movements). While using electrodes on the participant’s hand, the researchers showed that muscle contractions in response to the cortical stimulation was larger when participants were concurrently imagining themselves moving their muscle whilst watching a video of a hand moving on screen (compared to when they used the imagery or observation techniques alone or engaged in various control conditions).

This research, published in the open-access journal Frontiers in Human Neuroscience, may provide useful applications for the care of stroke patients who have restricted use of their upper limbs. In particular, if stroke patients practice the recommended techniques, it could potentially help maintain activity in movement-related brain areas, especially when used in conjunction with more traditional physiotherapy techniques where the same movements are also practiced physically.

Dr Wright stated: “The idea is that because imagery and observation techniques share some characteristics with physical movement in terms of activating similar areas of the brain, if someone can’t perform the movements themselves physically, it might be possible to keep those areas of the brain active through imagery and observation techniques. This might help contribute to the recovery of motor function”.

So far, imagery and, less frequently, observation have been used separately alongside physical therapy during the rehabilitation of stroke patients. However, Prof Holmes suggests that combining the two techniques may support re-learning of movement patterns for some patients. “After a stroke, parts of the brain die and will not recover. To compensate, other parts of brain can alter their function to take control of the lost behaviour—a form of brain plasticity. We think that combining imagery and observation, in addition to physical therapy, may allow the brain to speed up this plastic change as well as benefitting more psychological aspects of recovery such as movement confidence. The research team’s work in this area has the potential to make a real impact on the way physiotherapists, occupational therapists and nurses work with the stroke community” said Holmes.

“These changes may happen without the intervention—it is certainly not a miracle cure—but the combined imagery and action observation approach should speed up the process of relearning movements that have been lost”.

The study was funded by Manchester Metropolitan University’s Knowledge Exchange Innovation Fund and a Research Accelerator Grant awarded to Dr Wright (an early career researcher in the Motor Cognition Research section of the Centre of Health, Exercise and Active Living).

Future research by the team will be focused on optimal methods for delivering these psychological interventions for stroke rehabilitation by investigating the effects of different types of instruction given to participants and different video presentation methods on activity in the brain during combined imagery and observation. In addition, his team expects to release a stroke rehabilitation App in early 2015.

Journal reference: David J. Wright, Jacqueline Williams, Paul S. Holmes. Combined action observation and imagery facilitates corticospinal excitability. Frontiers in Human Neuroscience, 2014; 8 DOI: 10.3389/fnhum.2014.00951

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