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Difficulty moving arm/hand after stroke? Neurofeedback

Tom Balchin
March 27, 2018
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Heidi Johansen-Berg is Professor of Cognitive Neuroscience and Director of The Wellcome Centre for Integrative Neuroimaging at the University of Oxford. There, she leads the Centre for Functional MRI of the Brain. Her research focuses on how the brain changes with learning, experience, and damage.

As well as shedding light on how the healthy brain responds to change, her team’s work also has implications for understanding and treating disease. For example, they are testing new methods for rehabilitation after stroke and assessing whether taking up exercise could slow the effects of age on the brain.

DO YOU HAVE DIFFICULTY USING YOUR HAND/ARM AFTER STROKE?

If so, Professor Johnsen Berg-has asked us to disseminate a study in which you may be interested in participating – or you may know someone who is.

The aim for this study is to research a treatment method to see if can improve upper limb function.

Many stroke survivors experience weakness to one side of the body, leaving them with difficulties in daily activities. Current physical therapies are limited in their success and are very time demanding. Therefore, treatments to use alongside rehabilitation are sought.

Learning is an important part of rehabilitation after stroke. When learning a new movement or skill it is important to get feedback so that you can repeat movements that were successful or try to adapt ones that did not work as well. What if there was a way to also get feedback of your brain activity when trying different movements?

Researchers at the University of Oxford are currently testing a new type of treatment for stroke survivors using MRI Neurofeedback. Neurofeedback involves participants being shown a live visual display of their brain activity whilst in an MRI scanner so that they can see which kinds of movements are best to increase the activity in the brain hemisphere where the stroke occurred.

Participants are asked to lie in the scanner and try to move their affected hand in different ways. The activity of their brain is recorded while they perform these movements and then shown to them as a ‘thermometer type’ bar that gets bigger with more activity.

Previous neurofeedback studies by Dr Heather Neyedli of the University of Oxford (Neyedli et al., Neuroscience, 2017) tried showing real or placebo feedback while volunteers who had not had a stroke moved their hands. They found that people could use this technique to change their brain activity while moving their hand.

There has been limited work with stroke survivors using this technique and researchers at Oxford are currently looking for people who have difficulty using their hand/arm after a stroke to take part in some MRI neurofeedback sessions to see if this treatment can improve motor function.

If you would like to join this study/find out more, please feel free to contact the researchers:

Mr Tom Smejka: thomas.smejka@ndcn.ox.ac.uk

Dr Melanie Fleming: melanie.fleming@ndcn.ox.ac.uk

Professor Heidi Johansen-Berg: heidi.johansen-berg@ndcn.ox.ac.uk

CALL 01865 611461

Example of visual display showing increasing brain activity

Below is a talk given by Professor Johansen-Berg – click and play!

Upper limb after stroke: can we predict recovery?

Tom Balchin
December 29, 2017
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Upper limb impairment affects most patients at the time of the stroke, with persisting problems for between a half and three quarters of survivors. This can be partly explained by where the injury is in the cortex. But because regaining lost function in the upper extremities has been found to be more difficult to achieve than return of normal function in the lower extremities, only 14% of these will regain any useful function. Between 55% and 75% continue to experience upper extremity functional limitations.

Professor Nick Ward (who has kindly taught my ARNI instructor groups at UCL for around 10 years now) runs the UK’s first and to date only dedicated (and outstanding) Upper Limb Service at Queen Square. He states that upper limb recovery after stroke is unacceptably poor – and gives some stats:

60% of patients with non-functional arms 1 week post-stroke didn’t recover

(Wade et al, 1983)

18 months post-stroke 55% of patients had limited or no dextrous function

(Welmer et al, 2008)

4 years post-stroke only 50% had fair to good function

(Broeks et al, 1999)

If you’re a stroke survivor, you know already that regaining upper body function is a very different task to rehabilitating the lower body. Nevertheless, the two ‘halves’ of the body are not so different after stroke. New evidence says that both the upper and lower limb are as weak as each other after-stroke, which suggests that the poorer recovery of the arm, so frequently seen in stroke patients, may not be an inevitable consequence of the stroke.

An excellent research paper by Professor Sarah Tyson and colleagues in 2006 called ‘Distribution of weakness in the upper and lower limbs post-stroke’ advises that the effectiveness and intensity of rehabilitation interventions should be considered. This may well be so: the majority of stroke survivors whom I’ve met, when describing their prior physiotherapy and any other rehabilitative efforts, will report that the focus of consistent therapy was usually on the lower limb and walking practice. A minority remembered consistently focusing on practising upper limb exercises.

This happens for a number of reasons, but primarily because it is critical to get stroke survivors walking, and also essential to keep spirits up with the recognition of progress, which probably is facilitated better by the thought of being able to walk again. So hospitals often do not have time to devote to extensive hand-function efforts, and by the time further treatment is sought, the task is all the more harder.

The evidence states clearly that initial degree of motor impairment is the best predictor of motor recovery following a stroke. So, functional recovery goals are appropriate for those patients who are expected to achieve a greater amount of motor recovery in the arm and hand. But the evidence also shows that compensatory treatment goals should be pursued if there is an expected outcome of poor motor recovery. We are even uncertain whether task-specific repetitive training improves upper extremity motor function.

It is vital that stroke survivors are shown, in clinic, ways to either train for progressive functionality or physical self-management techniques or/and both. Rather than leaving people to try and work it out for themselves once they reach the community.

Those with more potential can be shown how to radically ramp up the dose of repetitions performed with upper limb during the day, perhaps incorporating modified constraint induced movement therapy (a beneficial treatment approach which can be done at home, for those stroke patients with some active wrist and hand movement). Professor Nick Ward told me that Professor Gert Kwakkel and colleagues noted way back in 2003 that those showing some synergistic movement in the upper limb within 4 weeks after stroke have 90% chance of improving.

We interviewed Professor Nick Ward to find out more about his views about what both therapists and stroke survivors can potentially do to improve upper limb outcomes after stroke:

35 questions stroke survivors ask

Tom Balchin
December 29, 2017
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You may well be interested in reading just some of the questions asked of me by stroke survivors. You may be asking yourself some of these same questions right now. Or may have conquered many of these issues already. These are a sample of meaningful issues drawn from just two places. First, from the sum of a trawl though hundreds of emails to ARNI from stroke survivors from 2007 to 2011. Second, from the sum of a trawl though notes taken next to baseline assessments (Stroke Impact Scale) face to face with stroke survivors. For more information, see the Successful Stroke Survivor manual, published in 2011.

Will I be able to walk properly again?
Will I be able to coordinate my body movement better?
Will I be able to converse properly again?
Will I be able to understand people?
Will I have to compensate or will I recover actual movement?
How weak will I be (muscle loss etc) after discharge?
How much rehabilitation will I need?
Does my type and severity and site of my stroke impact on my recovery potential?
Will my visual problems recede?
Will I be able to write properly again?
Will I stop feeling overwhelmed and fatigued?
Will I be able to drive? Catch a train? Go on holiday?
Will I be able to dress myself properly?
Will my spasticity (in upper limb/lower limb) recede?
Will it be hard to get back to running/being aerobically fit again?
Will I get back my full movement?
What is the timing, intensity, or duration of such activities I need to do?
Will my confidence return?
Will I enjoy life as much again with the things that stroke has left me with?
Will this affect how long I have to live?
How much do I need to rely on being motivated?
Will I have to drive this recovery myself?
At what point will my movement start to come back in my hand/foot?
Will I be able to wear high heels again?
Will I be able to do everyday manual tasks (using a knife and fork, opening jars)?
Will I be able to regain my strength, flexibility, balance & endurance?
Will depression due to loss of ability and abrupt change in life be a factor?
Is it true that there is a cut off point for functional recovery?
Will my sex life be affected?
How long will I need to rehabilitate for?
Will I be able to get back to my job/studying?
Will I be able to regain a high degree of independence?
Will I be able to become progressively more self-sufficient?
What current technology for stroke rehab is worth investing in?
Might I suffer a further stroke?

No consultant, therapist or expert in stroke research would attempt to answer the majority of these without preceding and qualifying the answer with an ‘if’. You are different from anyone else; from injury to the brain and plastic potential to occupational difficulties, demographic details to rate of recovery and lifestyles, making your presentation unique.

So although there are general principles of stroke recovery, and there are some common problems suffered by a majority of stroke survivors, no two stroke survivors ever shares exactly the same experience.

I will tackle all these issues in future posts – sign up now to receive the posts straight after posting.

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Difficulty moving arm/hand after stroke? Neurofeedback

Upper limb after stroke: can we predict recovery?

35 questions stroke survivors ask

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