Running head: BRAIN RECOVERY

Brain Recovery and Motor Rehabilitation after Ischemic Stroke

Gianna Scarpetti
University of San Francisco

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Current knowledge of brain plasticity and motor rehabilitation has lead to new
approaches for treating patients whove had an ischemic stroke. Research indicates that
motor function is disturbed by impairments caused by a stroke lesion. Neuroimaging is
being used in order to investigate how ischemic stroke influences connectivity of certain
motor areas. More importantly, how changes in these motor areas relate to limited or
impaired function. Here, researchers review what types of therapy are most successful in
improving brain and motor connections. These empirical studies also look at language
and speech deficits caused by stroke. The complexity of current research shows that there
is hope for recovery.
Neuroimaging techniques are broken down into four connectivity categories:
anatomical connectivity, functional connectivity, effective connectivity, and network
models. These models are based on the idea that our brains are strategically organized
and segregated based on the specialty of a given brain region, serving different purposes
(Jiang, Xu, & Yu, 2013). These different brain areas are all interconnected in a network
that controls motor, sensory, and cognitive processes. Anatomical connectivity is usually
analyzed by diffusion tensor imaging (DTI) because it can detect changes in anatomical
connectivity. This method of using DTI has been used to evaluate white matter damage
and restructuring in stroke patients (Jiang et al., 2013). Effective connectivity was
evaluated by Adams and Nudo (2013), showing how one brain areas can exert a causal
influence over another area. This approach is beneficial because it provides important
information about the direction of information flow by highlighting which nodes are
being influenced by which other nodes. Lastly, our brain is designed in a network model
in which nodes corresponding to certain areas in our brain are connected to

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corresponding anatomical, functional, and effective connectivity. Brain regions that show
high node degrees are considered centers that mediate functional integration between the
varying brain regions. Structural and task-based functional MRI studies have shown
deterioration in brain regions associated with the stroke lesions. Also, these MRI scans
are used to investigate the relationship between brain changes and activation, as well as
provide information about patters of reorganization after stroke.
In addition to the previous neuroimaging methods, Johansson (2011) and Adams
and Nudo (2013) emphasize that brain stimulation is becoming a popular post stroke
intervention method. Researchers proposed that intracortical competition from nearby
regions resulted in an inhibitory effect on the hand muscles. This assumption led to the
hypothesis that intensive therapy of the damaged hand significantly enhanced motor
function and productivity of the once damaged hand. One hypothesis about brain
stimulation is that such stimuli change the excitability of surviving neurons in the
damaged hemisphere. Furthermore, it is suggested by Adams and Nudo (2013) that
behavioral interventions are most effective when done in conjunction with treatments that
improve neuron excitability. These different neuroimaging techniques have enhanced
researchers understanding about regenerative mechanisms post stroke.
Brain plasticity is a term that describes how the human brain adapts to the
environment, social experiences, and challenges. These challenges consist of brain
damage due to stroke, or any other kind of traumas. Luckily, advances in technology have
led to a better understanding of how the brain reconstructs after ischemic stroke. Brain
reconstruction after stroke is a complex process primarily because treatment differs from
patient to patient, so there is not one universal recovery method. Johansson (2010) and

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Jiang et al. (2013) agreed that the substantial differences across patients depend on
location of the lesion, time since having the stroke, extent of motor damage, and
sometimes even genetics. These factors make it extremely unlikely that one universal
measure is suitable for all patients, thus making the recovery process complicated.
Brain connectivity changes after stroke can be measured at the anatomical,
functional, and effective level. Researchers Jiang et al. (2013) found that DTI is a
powerful method for detecting brain impairments and modifications in anatomical
connectivity following stroke. Researchers also investigated CST white matter
connectivity changes that took place during recovery. In many patients, researchers
discovered that motor skill greatly improved when there was a positive correlation to FA
values of both the contralesional and ipsilesional CST section at the pons level. Another
stroke recovery mechanism is seen with ipsilateral motor pathway reorganization.
However, discrepancy is seen with this mechanism because of size and location of
lesions, recovery speeds, and diagnostic methods. Recoveries of specialized functions are
highly correlated with interhemispheric resting-state functional connectivity, as stated by
Johansson (2010). Lastly, changes in effective connectivity showed that movements of
the damaged hand demonstrated inhibitory influences from the contralesional to the
ipsilesional side. In addition, interhemispheric communication was reduced when making
bimanual movements. Studies done by Johansson (2010), Jiang et al., (2013), and Adams
and Nudo (2013) suggest that a single subcortical lesion is greatly associated with
interhemispheric interactions between important motor areas.
Another finding of great importance was that enhanced pairing of prefrontal
regions might reflect improved function in cognitive-related areas that are responsible for

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facilitating the planning of movement. The prefrontal cortex is the most important part of
the brain for humans because it controls several executive functions. These important
functions include, but are not limited to planning, motivation, decision making, and
emotion regulation. When function of the prefrontal regions is regained, it is more likely
for patients to overcome other deficits such as damage to motor pathways. New strategies
and technological advances are leading to new and better research options for treatment
of ischemic stroke patients.
Although there are ways to hopefully improve motor function after stroke, more
than half of stroke survivors have long-lasting impairments that often lead to long-term
disability. In severe cases, institutionalized care is necessary. The major fear people have
about ischemic stroke is rooted in the fact that this type of stroke tends to impair
cognitive, sensory, and motor capabilities. Although this statistic is scary, evidence
suggests much hope for stroke patients because the success rates of rehabilitative
therapies are becoming higher and higher. Adams and Nudo (2013) stress the importance
of immediate treatment. Therapy initiated within the first few hours after onset increases
the patients probability of full cognitive and motor rehabilitation. Adams and Nudo
(2013) and Johansson (2010) suggest that rehabilitation that requires the patient to relearn
or develop new compensatory techniques and strategies for muscle movement is best. It
is reported that approximately 75% of stroke survivors need some form of rehabilitative
therapy (Adams & Nudo, 2013). Motor rehabilitation is especially complex because
patients differ across the board. In patients whose sensory perception has been affected,
regaining full motor skills is more of a challenge. According to Johansson (2010), tactile
sensibility of the hand is crucial for motor performance. Sensory stimulation combined

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with activation of the fingertips has been showed to improve tactile acuity. In contrast to
motor training, this method has become more popular because it does not require active
participation of the patients. Elderly patients are especially in favor of this new method
because it makes it less rigorous on their body. It is suggested by researches Jiang et al.
(2013) that this therapeutic intervention would help improve daily activities in stroke
patients who have unfortunately damaged their motor and sensory connections.
In particular, researchers found that active rehabilitation therapies heightened by
electrical stimulation is likely to incite positive behavioral changes in chronic stroke
patients. Electrical stimulation increases white matter tract integrity in brain regions open
to sensory-motor functioning (Jiang et al., 2013). Acute and chronic stages of recovery
seem to have different rehabilitation requirements. These differences include protocols
therapy equipment, and amount of therapy, so the type of therapy really depends on the
individual patient. In some cases, bilateral training can be beneficial across the board and
has been used to improve muscle movement for patients of all severity levels.
Researchers Jiang et al. (2013), Johansson (2010), and Adams and Nudo (2013)
summarized motor recovery mechanisms as a long process that includes recovery of the
impaired lateral corticospinal tract and reorganization of subcortical lesions. Motor
rehabilitation is hard and doesnt guarantee full recovery, but there is strong evidence that
shows motor function can be restored if the right treatment options are taken.
Motor function is under the control of our motor system, comprised of various
muscles and connections. Muscle contractions control our movement and when these
different muscles are damaged impaired motor function can result. Motor ability is
crucial for every day human activities and it can be very difficult to relearn or regain

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muscle control post stroke. Researchers have discovered that muscle disability is the most
common discrepancy seen in patients who suffer from having an ischemic stroke (Jiang et
al. (2013). After a stroke, it is likely that motor function is damaged because the stroke
lesions usually disturb cortical or subcortical areas necessary for movement. Studies on
stroke patients and rats have shown that spontaneous motor recovery is linked to brain
plasticity. This highlights the important connections between on brain and muscles. When
damage is done to the brain, we can expect to see motor damage and other impairments.
It is reported that motor rehabilitation can be heightened by such therapies like robotassisted therapy, popular restorative therapies, and virtual reality therapy.
The main key to successful motor rehabilitation or brain plasticity has to do with
when therapy begins. Research has shown numerous times that patients who receive
immediate care have the highest recovery rates (Adams & Nudo, 2013). Beyond
spontaneous recovery of certain functions, patients who take part in some type of
additional rehabilitative therapy will see the most improvement. Rehabilitative therapies
have even induced increased FA values in the lesion region, thus reflecting a high density
of myelin, axons, and dendrites (Jiang et al., 2013). Research suggests that the more
axons and dendrites, the more connections and likelihood of firing an action potential.
With stroke patients, physical therapists and physicians are pleased when new
connections and synapses are being made. The best therapy focuses on intense practice
frequently, targets specific activities, and begins immediately after the stroke occurs
(Johansson, 2010). So far, stroke units by and large stress the importance of active
participation and patients who receive care from these units are pleased with the
outcomes. Furthermore, ischemic stroke patients benefit from active rehabilitative

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therapies that bring on positive behavioral (i.e. increased motor function, more walking,
eating, talking, etc) changes.
There are many unique therapies out there that are recently starting to get more
attention. For example, Jiang et al. (2013) researched more into acupuncture therapy
because there is evidence that this type of treatment can facilitate motor function
recovery. Of course, restorative therapies have also become more popular methods for
treating stroke patients. Adams and Nudo (2013) stated that due to our advancing
knowledge about technology, we are becoming more aware of the benefits of restorative
therapy. More and more knowledge about our central nervous system in connection with
neuroplasticity is leading to a better understanding about the foundation of post stroke
recovery. Once again, such plasticity is greatly time-dependent. This kind of plasticity has
a narrow window of opportunity for neural repair after ischemic stroke. It is important to
take advantage of this small window because time is critical when looking at repairing
the damage done by a stroke. Ultimately, the goal of these restorative therapies is to help
the brain naturally recover from the stroke by means of enhancing the processes
necessary for healing.
Interestingly, recent articles are discussing and experimenting with the potential
affect of antidepressant medications. Researchers are discovering more about the utility
of such medications. It is speculated that antidepressants, in particular selective serotonin
reuptake inhibitors (SSRIs), can indirectly influence recovery through restorative
therapies. SSRIs are already being used to treat patients that suffer from depression after
stroke, so the question now is can these medications be used to facilitate healing in other
ways? Laboratory experiments display that antidepressants may increase post stroke

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recovery through various mechanisms. These drugs have been tested and show
stimulation in areas such as the subventricular zone, dentate gyrus, and hippocampus. In
addition, these medications increased sprouting of axons as well as formed new synapses.
Moreover, there is much attention currently focused on the positive effects
antidepressants might have on stroke recovery.
In addition to motor deficits, stroke can leave a patient with severe language
deficits. Speech therapy needs to begin as soon as possible because it is imperative that
stroke patients start to relearn vocabulary as soon as possible, as well as relearn how to
convey ideas and produce sound. We can trace the damage back to the left hemisphere
because this hemisphere is highly associated with language, whether its written or verbal
language. Another key principle of language and speech rehabilitation is motivation.
Brain reorganization for language and speech is a difficult process that often takes a lot of
effort and time. Patients have reported symptoms of depression, saying that their high
levels of frustration are causing them to be depressed, tired, and even angry (Johansson,
2010). In summary, speech therapy is necessary as soon as possible in order to correct
both mental a physical language deficits.
To summarize, ischemic stroke can have a broad range of effects on a patient,
ranging from acute impairments to long term disabilities. The greatest recovery rates are
seen when patients receive immediate care. Still, there is a need to broaden the research
done on stroke care in order to shift the focus more on therapies and mechanisms that
best speed up or improve post stroke recovery.