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Acta Neurol Scand 2011: 123: 147159 DOI: 10.1111/j.1600-0404.2010.01417.

x  2010 John Wiley & Sons A S


ACTA NEUROLOGICA
SCANDINAVICA

Review Article
Current trends in stroke rehabilitation.
A review with focus on brain plasticity
Johansson BB. Current trends in stroke rehabilitation. A review with B. B. Johansson
focus on brain plasticity. Department of Clinical Neuroscience, Wallenberg
Acta Neurol Scand: 2011: 123: 147159. Neuroscience Center, Lund University, Lund, Sweden
 2010 John Wiley & Sons A S.

Current understanding of brain plasticity has lead to new approaches


in ischemic stroke rehabilitation. Stroke units that combine good
medical and nursing care with task-oriented intense training in an
environment that provides condence, stimulation and motivation
signicantly improve outcome. Repetitive trans-cranial magnetic
stimulation (rTMS), and trans-cranial direct current stimulation
(tDCS) are applied in rehabilitation of motor function. The long-term
eect, optimal way of stimulation and possibly ecacy in cognitive
rehabilitation need evaluation. Methods based on multisensory
integration of motor, cognitive, and perceptual processes including
action observation, mental training, and virtual reality are being tested.
Dierent approaches of intensive aphasia training are described.
Key words: aphasia; cognition; hemispheric
Recent data on intensive melodic intonation therapy indicate that even sub-specialization; plasticity; multisensory integration;
patients with very severe non-uent aphasia can regain speech through music; stroke units
homotopic white matter tract plasticity. Music therapy is applied in
Barbro B. Johansson, Department of Clinical Neuro-
motor and cognitive rehabilitation. To avoid the confounding eect of science, Wallenberg Neuroscience Center, BMC A13, SE
spontaneous improvement, most trials are preformed 3 months post 221 84 Lund, Sweden
stroke. Randomized controlled trials starting earlier after strokes are Tel.: +46 462 220621
needed. More attention should be given to stroke heterogeneity, Fax: +46 462 220615
cognitive rehabilitation, and social adjustment and to genetic e-mail: barbro.johansson@med.lu.se
dierences, including the role of BDNF polymorphism in brain
plasticity. Accepted for publication July 14, 2010

have an impact on future design and choice of


Introduction
rehabilitation methods for individual patients.
Brain plasticity is a broad term for the property of
the human brain to adapt to environmental
The value of stroke units
pressure, experiences, and challenges including
brain damage (15). It occurs at many levels Key principles of stroke rehabilitation include a
from molecules to cortical reorganization. The functional approach targeted at specic activities,
advances in technologies enabling non-invasive frequent and intense practice, and start in the rst
exploration of the human brain have increased days or weeks after stroke (18). These general
our understanding of brain reorganization after principles are applied in stroke units where multi-
ischemic stroke (613). The time after stroke, the disciplinary teams stress the importance of active
lesion location, and the integrity of cortico-spinal participation of the patients in the rehabilitation
tracts and cortical and subcortical connections are process. Stroke unit care is the only treatment that
factors that inuence outcome. Diffusion tensor has so far been shown to have a major impact on
imaging tractography is a recent technique that the outcome after stroke (19). More patients can
enables non-invasive visualization of ber tracts in return home early, and the need for institutional
the human brain in vivo (1417), which is likely to care is reduced. It is highly cost-effective when

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Johansson

compared with general medical ward care (2022). has attained much media interest after a signicant
Also cognitively impaired stroke patients do ben- effect was obtained in a randomized study with a
et from admission to an acute stroke unit (23). 2-week program of CIMT applied to 222 stroke
These data have been supported by a large study patients mostly with mild to moderate impairment
including 105,043 patients with acute stroke 39 months after stroke (33). A follow-up
reported to the Swedish Stroke Register during 24 months after the ischemic event showed a
the years 2001 through 2005 that were followed persistent benet (34). Some limitations with the
until January 2007 (24). Stroke unit care was study include that the controls received usual and
associated with reduced risk for death and institu- customary care that involved less motor training
tional living at 3 months after stroke onset, and than that delivered to the CIMT group. Further-
with better long-term survival in all subgroups more, the separate effects of higher dose of motor
(age, sex, stroke subtypes, and level of conscious- training and immobilization cannot be evaluated.
ness). The benet of stroke units compared to The study included rather few patients with severe
general wards is most likely a combination of impairments, and the participating patients may
optimal medical and nursing care, task oriented, have represented a minority of patients with
and for the individual meaningful training in an chronic stroke (35). A remaining question is
environment that gives them condence, stimula- whether it is superior to other treatment of
tion, and motivation (25). Mere admittance to a comparable intensity.
stroke unit with specially trained staff encouraging There is no evidence that CIMT is of benet in
active participation in the rehabilitation process early stroke rehabilitation. No signicant dier-
and more information to patients and relatives ences were noted in patients randomized within
may increase the motivation and expectation of the 2 weeks after stroke either to 2 weeks of CIMT or
patients. Animal studies have demonstrated that to traditional therapy at an equal frequency of up
environmental enrichment has many functional to 3 h day. The groups were well balanced for
and biological effects and signicantly enhance the frequency, duration, and intensity of the treatment,
effect of other interventions (2, 5, 26, 27). and the results did not show any signicant
dierences between the groups (36). In another
study, patients were randomized within 28 days of
Motor rehabilitation
admission into three groups. Control treatment
Tactile sensibility of the hand is essential for consisted of 1 h of activity of daily living retraining
identifying objects and for motor performance. and 1 h of bilateral training 5 days a week during
When sensory perception is aected in stroke, 2 weeks, The standard CIMT group received 2 h of
rehabilitation of motor skills is more dicult to shaping therapy and wore a mitten 6 h a day; and
achieve (28). Aging is associated with reduced high intensity CIMT underwent 3 h of shaping
tactile discrimination and deterioration of ne therapy and mitten 90% of waking hours. Stan-
manipulative movements and handling of tools. dard CIMT was equally effective but not superior
Sensory stimulation by means of tactile co- to an equal dose of traditional therapy (37), and
activation of ngertips successfully improves tactile the higher intensity CIMT resulted in less improve-
acuity in elderly individuals and, in contrast to ment at 90 days. These two studies on early CIMT
motor training, it does not require active partic- emphasize the need for control groups that match
ipation or attention of the subjects. This lead to therapy intensity and dose in clinical trials.
the suggesting that it might be a useful therapeu- A meta-analysis based on 10 studies of robot-
tic intervention to improve the activity of daily assisted therapy on motor and functional recovery
living in stroke patients with impaired sensory in patients with stroke involving 218 patients
motor abilities (29, 30). A preliminary study on showed a signicant eect on motor recovery of
four individual post-stroke showed that all the upper paretic limb but no signicant eect on
improved in sensory tasks and motor perfor- functional ability. The recommendation was that
mance, effects that remained 4 weeks post treat- future research on the eect should distinguish
ment (31). If those data can be conrmed in between upper and lower robotics arm training and
larger studies, it may have a considerable impact concentrate on kinematic analysis to dierentiate
in stroke rehabilitation. between genuine upper limb motor recovery and
Constraint-induced movement therapy (CIMT) functional recovery owing to compensation strat-
is a method in which a splint is applied to the intact egies by proximal control of the trunk and upper
hand 90% of the day to force the use of the paretic limb (38). Similarly, a Cochrane report based on 11
hand, and combined with shaping by which the trials with 328 participants found no signicant
tasks are made progressively more difcult (32). It improvement in activities of daily although arm

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motor function and arm motor strength improved However, the anesthetic procedure is not easy,
(39). Rehabilitation program may require different which explains why this intervention has not been
therapy protocols and equipment in acute and much used.
chronic stages of recovery (40, 41). Adding virtual Another approach is based on the concept of
reality to robot-based gate training (42) and arm interhemispheric inhibition. The cortical sensory
(43) training may have benecial effects as will be and motor representation of the hand exerts
discussed later. inhibitory inuences on the homonymous repre-
Bilateral coordination is important in daily life. sentation in the opposite hemisphere (50), an
Bilateral arm training (BAT) may be of value interhemispheric inhibition that is thought to
particular for stroke patients with severe func- contribute to skilled motor performance. Short-
tional decits (44). In a randomized controlled term ischemic nerve block to the hand leads to
trial 667 months after stroke onset, BAT functional reorganization in the de-afferented
improved the spatiotemporal control of the motor cortex, and also to functional changes in
affected arm in both bilateral and unilateral homotopic motor regions in the contra-lateral
tasks and reduced motor impairment (45). Com- cortex (51, 52). Based on the observation of an
paring CIMT, BAT, and a control intervention of abnormally high interhemispheric inhibitory drive
equally intense but less specic therapy for from the motor cortex of the intact hemisphere to
2 hours a day 5 days a week for 3 weeks, both the injured hemisphere during a voluntary move-
CIMT and bilateral arm training resulted in better ment of the paretic hand in patients with sub-
performance than the control intervention. BAT cortical infarcts, it was hypothesized that this
exhibited greater gains in the proximal upper limb abnormality might adversely inuence motor
than the other two groups on motor performance, recovery (53). Different neurophysiologic strate-
and CIMT produced greater functional gains in gies to increase the activity of the injured area
hand functions in patients with mild to moderate have been proposed mainly using transcranial
chronic hemiparesis (46). It has been proposed magnetic stimulation, TMS (54, 55), and trans-
that bilateral training is a necessary adjunct to cranial direct current stimulation, tDCS (56).
unilateral training and that individuals at all level Lower frequencies of repetitive TMS (rTMS = a
of severity can benet from bilateral training train of TMS pulses of the same intensity) in the
although not all approaches are effective at all range 1 Hz range suppress excitability of the
severity levels (47). Specic training approaches motor cortex, while 20 Hz lead to a temporary
need to be matched to the individual case increase in cortical excitability (57). With tDCS, a
characteristics. To achieve bilateral skills impor- weak polarizing electrical current is delivered to
tant in daily life training should not be either the cortex, and the effect depends on the polarity
unilateral or bilateral but both. In a systematic (56). An excitatory effect is obtained with the
review based on 56 studies 19792008, the authors anode placed over the motor cortex, and inhibi-
concluded that the current evaluation scales are tion is induced with the cathode over motor
not optimal for exploring changes in real life of cortex. tDCS is easier to apply and less expensive
the patients and that there is a need for the than TMS, and a feasibility study demonstrated
development of direct measures of arm use in that the participants could not distinguish tDCS
real-life environments (48). from sham stimulation, making it suitable for
larger double-blinded, sham-controlled random-
ized trials (58).
Electrical brain stimulation
Two main approaches to alter the hemispheric
After a cortical lesion, the surrounding intact tissue dominance have been used in clinical studies. 1)
has an inhibitory action on the damaged area, an Reducing the cortical activity on the intact side by
intra-hemispheric inhibition. Most patients with low frequency rTMS (5961) or by reducing the
stroke have better function in the upper arm than somatosensory input to the intact hemisphere (62,
in the hand, and it was postulated that intracortical 63); 2) Enhancing the activity in the damaged
competition from surrounding areas had an inhib- hemisphere by high-frequency rTMS (64), anodal
itory eect on the hand muscles. When the upper tDCS (58, 65), or increasing the sensory input by
part of the brachial plexus was anaesthetized, electrical stimulation of the peripheral nerves in the
intense training of the paretic hand signicantly paretic hand (6668). These manipulations have
enhanced motor function, and the improvement shown 1030% signicant effects in behavioral test
was associated with an increase in TMS-evoked in these pilot studies. Combining peripheral nerve
motor output to the practiced hand muscles. The stimulation with tDCS can facilitate the benecial
eect remained at follow-up 2 weeks later (49). effects motor performance beyond levels reached

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with each intervention alone with 41% increase


Hemispheric subspecialization in motor activities
compared to sham (69). The differences were
maintained 6 days after the end of the training Studies on motor lateralization have revealed a
with no further follow-up. consistent dierence in the control strategies of the
Most of the above-mentioned studies have been dominant and non-dominant hand; the perfor-
performed on patients with chronic stroke from mance with the dominant arm hand is most
several months up to 4 years after stroke. How- accurate when reaching from one xed starting
ever, in one study patients were randomized position to multiple targets, whereas performance
57 days after stroke to receive high-frequency with the non-dominant hand is most accurate when
rTMS to enhance neuronal activity on the lesion reaching toward a single target from multiple start
side once a day for 10 days or to a standard locations (77). Studies on patients with stroke have
treatment group (64). Compared to the standard demonstrated deciencies that reect these distinc-
therapy group, the study group had better scores in tions (78), data that may help to explain why
all tests used, and the gains remained at 10 days patients with stroke may have some difculties also
after the end of treatment. The same group has with the hand corresponding to the intact hemi-
reported benecial effects of rTMS on dysphagia in sphere. The subspecialization and function of the
the subacute stage (70). The rst study on long-term ipsilateral hand may be of importance particularly
follow-up of patients treated 515 days after stroke for patients with severe motor dysfunction that
with 5 daily stimulations and followed for 1 year must relay on the ipsilateral intact hand for some
demonstrated a lasting benet (71). Although activities of daily living (79). The side of lesion
stroke leads to changes in the brain tissue that inuences the degree of bilateral activation in
potentially could alter the electrical response prop- chronic post-stroke hemiparesis (80). In healthy
erties, no adverse effects have been reported in the individuals, the interhemispheric inhibition is
studies with rTMS and tDCS after stroke. Thirty- stronger from the dominant to the non-dominant
six authorities in the eld have published a consen- side than in the opposite direction (81). Simulta-
sus statement on safety and ethical considerations neously applying cathodal tDCS over the dominant
together with an application guideline for the use of motor cortex and anodal tDCS over the non-
TMS in clinical practice and research (72). dominant motor cortex produced an additive effect
Epidural cortical stimulation is an invasive that facilitates motor performance in the non-
technique that improves motor rehabilitation in dominant hand (82). Modulation of excitability in
experimental animals. In a preliminary report from the dominant motor cortex signicantly affected
a planned multi-center non-blinded trial, patients performance for the contra-lateral and ipsi-lateral
with stroke were randomized to surgery or to a hands, whereas modulating excitability in the non-
control group at least 4 months after stroke. dominant motor cortex only had a signicant
Subdural electrodes were implanted in the cortex impact for the contra-lateral hand (83). The
of the treatment groups, and both groups under- evidence for a hemispheric asymmetry in the ipsi-
went rehabilitation for 3 weeks after which the lateral effect of modulating excitability in the
electrodes in the treatment group were removed. motor cortex may be important for clinical research
Stimulation plus rehabilitation improved function on motor recovery. The arm use after left or right
in the upper extremity signicantly more then hemiparesis is inuenced by hand preference.
rehabilitation alone, and the eect remained at Although both groups used their ipsi-lesional
12 weeks after the stimulation (73). A multicenter intact arm more than the contra-lesional paretic
feasibility study of safety and efcacy was also arm, the right hemisphere-damaged group used the
promising (74). However, in a phase III study intact arm four times more frequently and the left
based on 146 patients with hemispheric stroke, the hemisphere damaged two times more frequently
outcome of the stimulated group was not better than their paretic arm (84). If this observation was
than in the group that received only rehabilitation related to the frequency of hemi-neglect after right-
(75). hemisphere lesions was not studied. Recent data
Considering many reports on the importance of that successful recovery of motor skills after
cortico-spinal tract integrity for functional recov- hemiparetic stroke involves participation of
ery (7, 8, 10, 17) future studies on motor outcome contra-lesional cortical networks support that we
after stroke should take that into consideration. A need to pay attention to both hemispheres (85).
recent study indicates different effects of rTMS on Whether the hemispheric subspecialization is of the
the ipsi-lesional primary motor cortex in cortical magnitude that it could signicantly inuence the
and subcortical chronic middle cerebral artery rehabilitation strategies in left and right hemi-
stroke (76). spheric stroke remains to be investigated.

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enhanced the effect of training alone on rehabilita-


Multisensory interaction; Training with a mirror, action
tion of motor decits (96). Brocas area is one of the
observation, motor imagery or mental practice, virtual
cortical areas activated by hand mouth action
reality
observation, and it has been reported that patients
Perception, attention, memory, language and other with frontal aphasia are specically impaired in
cognitive functions consist of distributed inter- their capability to correctly encode observed
active and overlapping networks. The healthy human actions (97).
human brain has a large capacity for automatic Imaging performance of a motor action requires
simultaneous processing and integration of sensory conscious activation of brain regions involved in
information, and multisensory inuences are inte- movement preparation and execution. Mental
gral to primary as well as higher-order cortical training can improve motor function and alter
operations. Multisensory-training protocols can cortical representation areas (4, 91, 98). In a
better approximate natural settings and are more placebo-controlled trial on patients with stroke
eective for learning in healthy individuals (86, 87). with a mean post-stroke time of 3.6 years, mental
Cortical lesions interrupt cortical and cortico- practice induced a signicant effect on motor
subcortical networks, and the capacity for auto- outcome (99). One advantage is that it is not
matic and simultaneous processing of incoming dependent on the ability to execute a movement
stimuli is reduced. Current data indicate that and can thus start early in rehabilitation even in
relearning and compensation for lost functions severely paretic patients with little motor activity
benet from multisensory stimulation. Multisen- and that it can be combined with other treatments.
sory approaches to motor, somatosensory, and However, some patients with left parietal or left
cognitive rehabilitation include action observation, lateral prefrontal lesions may have problem with
mental training, and training in a virtual reality mental imagery (98).
and music-related therapies. Virtual reality (VR) technologies provide multi-
In training with a mirror, the patients aected modal, interactive, and realistic 3-D environments
arm is hidden behind a mirror. While moving the with a high level of control of the parameters and
unaected arm, the patient watches its mirror applications that can be adjusted for each user
image as if it were the aected arm (88). Some pilot (100, 101). VR can enhance velocity and walking
studies have been published, indicting that it might distance in robot-based gate training (42), and VR
be useful in patients with stroke, and two random- games improves attention, speed, precision, and
ized controlled trials have been published with timing in robot-based hand training (43). A virtual
positive results lasting at least 6 months after supermarket provides opportunity for practicing
training (89, 90). The mirror-training patients functional tasks in everyday life (102). Unilateral
regained more distal hand function than control spatial neglect that is present in almost 50% of
patients. Interestingly, across all patients, mirror patients with right-hemisphere stroke has a nega-
training patients improved recovery of surface tive impact on functional recovery (103). VR has
sensibility, and it stimulated recovery from hemi- been successfully used both for assessment and
neglect, suggesting that training with a mirror may treatment of neglect. (104107). A three-dimen-
induce multisensory interactions and be related to sional virtual street crossing program has been
action observation that activates motor and pre- developed for assessment and training extra-per-
motor areas (91). Neurons in the regions that sonal neglect and enable outdoor mobilization
discharge both in association with performance of (108). Computerized VR interfaced with robots,
a motor task and with observation of another movement tracking, and sensing glove systems can
individual performing the same action are named further be coupled to fMRI images providing
mirror neuron and are thought to contribute to modied visual feedback (109). VR spatial brain
imitation and to be important for our understand- processing differs from brain fMRI activation in
ing of other individuals intensions (9294). Four reality. Thus, in evaluation of possible restoration
weeks of action observation signicantly enhanced effects caused by VR training it is important to
motor function with a signicant rise in activity in integrate information about the brain activation
the bilateral ventral premotor cortex, the supple- networks elicited by the training (110). Tele-reha-
mentary motor area, bilateral superior temporal bilitation that allows a therapist to conduct inter-
gyrus, and some other areas in fMRI. The func- active VE treatment sessions with a patient who is
tional improvement remained at 8 weeks after the located at home has shown highly signicant
end of the intervention (95). Combining observa- results in three standard clinical tests after 30 l-h
tion of daily actions concomitant with physical sessions, maintained at 4- month follow-up (111).
training of the same movements signicantly Data from training activities of daily living in a

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virtual reality setting are promising. The patients able to sing the text of a song while they are unable to
have to be positive to VR training, continued speak the same text. When allowed to sing and speak
contact with a therapist is essential, and it needs to along with an auditory model, aphasics repeat and
be further evaluated for long-term gains. A low recall more words when singing than when speaking
cost multiple users VR environment system has (131). The intelligibility and naturalness of the
been developed for rehabilitation of patients with speech improved after vocal exercises and singing
stroke (112). training in patients with non-uent aphasia after
stroke or trauma (132).
Intensive melodic intonation therapy for aphasia
Speech and language rehabilitation
is an old method that has been systematically
The brain organization for language involves a applied and evaluated in recent years (133, 134).
combination of cortical structures and white The method includes three important components:
matter tracts, some of which are unilateral and melodic intonation, intense training 1.5 h d 5 days
other bilateral. A dorsal stream, sound to action a week, and simultaneous tapping with the left
(non-uent or Brocas aphasia), is essentially left hand to prime the sensorimotor and premotor
oriented in most persons, and a ventral stream, cortices on the right side for articulation. Melodic
from sound to meaning (semantic aphasia), is to intonation therapy delivered at high intensity to
a considerable extent bilateral (113, 114). The patients with chronic severe Brocas aphasia leads
degree of language lateralization determines sus- to remodeling of the right arcuate fasciculus, a
ceptibility to unilateral brain lesions (115). ber bundle that combines the anterior and pos-
Aphasia or dysphasia can be caused by cortical terior language area in the left hemisphere demon-
lesions and or to damage to white matter tracts strating that plasticity can be induced in the
connecting dierent language areas. Decreased contra-lateral homolog tract (135).
fMRI activation was observed in the remaining Constraint-induced aphasia therapy (CIAT) is a
language area during the rst days after stroke dierent approach. Based on the concept of
(acute phase followed 10 days later by an activa- constraint-induced therapy for motor therapy, it
tion of homolog regions in the right hemisphere. In was hypothesized that gestures and other types of
the chronic phase (about a year later), the activity non-speech communication should be prevented,
had reappeared in the remaining left language and patients forced to use speech while a therapist
areas in patients with good recovery (116). How- is playing language games with two or three
ever, there is a large variability of language aphasic patients. The picture cards and the hands
recovery after rst-ever stroke, and a follow-up are hidden for other players to prevent visual
study 90 days after stroke onset failed to identify input, and all communication, mainly questions
any prognostic factors (117). Several studies indi- and answers, have to be performed by spoken
cate that both hemispheres can be involved in the words and sentences. The game is getting more
recovery process. dicult in small steps and reinforcement is pro-
Language and actions are closely linked in the vided. Extensive training 3 h a day resulted in
brain (118120), and Brocas area, traditionally signicant eect compared to standard training
looked upon an exclusive language area, is now one hour a day during an extended period adding
thought to detect and represent complex hierar- up to the same total amount of training, thus the
chical dependencies regardless of modalities and same training time spread over a longer time (136).
use including gesture, action and music (121124). In a study when all aphasia patients were trained
Listening to speech specically modulates the with CIAT over a 2-week period 19 years after
tongue muscles (125) and language perception stroke, half of the patients received additional
activates the hand motor cortex (126). Integrating training in everyday communication with the
observed facial movements into the speech percep- assistance of family members. Language tests
tion process involves a network of multimodal improved after training in both CIAT groups. No
brain regions associated with speech production alterative treatment group was included. However,
that contribute less to speech perception when only only the patients who were encouraged by their
auditory signals are present (127). Gestures may relatives to be more active verbally during the
facilitate word retrieval in aphasia (128). 2- week training period exhibited more communi-
There is a bihemispheric network for vocal cative activity than before treatment when
production regardless of whether the words re-examined after 6 months (137), demonstrating
phrases are intoned or spoken (129), and words that environmental encouragement is essential
and melody are intertwined in singing (130), which for transforming the effects observed in language
may explain why some patients with aphasia are tests into useful verbal communication. For en

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extensive review on the theory and practice of composite score based on four subtests of
CIAT, see review by Pulvermuller and Berthier NIHSS was almost as good as the MMSE in
(138). detecting severe cognitive impairment (147).
Using MEG (magneto-encephalography) before, Neglect is an important prognostic factor.
direct after and 3 months after the training, three Among 138 patients with stroke aged 7091 ,
patterns of behavioral and neurophysiologic visual neglect was present in 15% 20 months after
response to constraint-induced language therapy, stroke (141). Cognitive impairment was twice as
not described in detail, were observed (139). common in patients with neglect and three times
Patients with initial response who maintained the as common in those with severe neglect, indicating
gains at 3 months exhibited an increase in left that early rehabilitation of neglect might have
temporal activation (responders, n = 8). Patients important long-term effects.
with initial signicant response to the therapy but In a review based on 78 published quantitative
no eect at 3- month follow-up had greater right- and qualitative studies reporting social conse-
hemisphere activation than other patients at all quences after stroke in patients <65 years of age,
MEG sessions (lost-response, n = 4). Those who the proportions for return to work ranged from
did not improve at any time had increased acti- 0% to 100%. A negative impact on family
vation in left parietal areas (non-responders, relationships ranged from 5% to 79% and for
n = 11). deterioration in leisure activities from 15% to
Decits in auditory single word and sentence 79%. The review highlights the need for robust and
comprehension correlate with the degree of dis- consistent methodologies in future studies on the
ruption of left-right anterior-lateral superior tem- prevalence of social problems and of the eect of
poral cortical connectivity and with local interventions to address them (148).
activation in the superior temporal cortex (118). Attention is closely related to cognition and is
Voxel-based lesion-symptom mapping has con- also important for motor skill training. A signif-
rmed the necessary role for the left anterior icant reduction in the attention decit was
temporal lobe in mapping concepts to words (140). observed at 5 weeks and 6 months in a recent
Also aphasia related to frontal lesions can include randomized controlled trial with an attention-
semantic components. More studies that specify training program starting within 2 weeks after
the location and extension of the lesions and the stroke onset (149). The study included 78 patients
related language problems as to speech uency and with stroke identied via neuropsychological
understanding in daily life situations are needed. assessment as having attention decit. If these
results can be conrmed in further studies, they are
likely to have effects both on motor and cognitive
Rehabilitation of other cognitive deficits
rehabilitation and may improve quality of life after
Post-stroke cognitive impairment interferes with stroke.
recovery and is a major problem for social Whether rTMS and tDCS can inuence cogni-
rehabilitation and post-stroke quality of life at tive decits after stroke has so far been little
all ages (141143). Cognitive activation is clearly explored. In healthy individuals, tDCS may
involved in several examples of multisensory improve language learning (150152) and enhance
interactions already referred to including the planning activity (153). There is some evidence that
effect on neglect in VR training. Although early it may improve naming in aphasia (154, 155),
bedside cognitive assessment is possible in most working memory (156), and attention (157) in
cases (144), specic cognitive rehabilitation is often patients with stroke. These are all small studies
neglected in the early stage after stroke. Two week with no long-term follow-up.
after a rst-ever ischemic infarct, 91.5% of 177
patients (mean age 50  16 years) failed in at least
Music therapy
one cognitive domain, predominantly in working
memory, episodic memory, and executive func- Listening to rhythm activates motor and premotor
tions, compared with education and age-matched cortices (158160). Rhythmic auditory stimulation
control subjects (145). Cognitive dysfunction was and musical motor feedback can improve gait
associated with age, low level of education, NIHSS (161163) and arm training after stroke (164, 165).
score at day 15, and middle cerebral artery Music-supported nger and arm training that
infarcts, suggesting that simple criteria may be a signicantly improved function was accompanied
useful tool for designing clinical trials. (146). In by electrophysiological changes, indicating better
another study on 149 stroke patients 70+ were cortical connectivity and improved activation of
investigated after 18 months suggested that a the motor cortex (166).

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Music is a multimodal stimulus with a well- for poor outcome among survivors of aneurismal
established role in cultural and social communica- subarachnoid hemorrhage (177). There are likely
tion and emotional well-being. During the last to be other genetic differences that can inuence
years, a number of studies have demonstrated that outcome.
music listening activates many brain structures
related to sensory processing, attention, and
Concluding remarks
memory and can stimulate complex cognition
and multisensory integration (158, 167). To what Progress of time is an independent covariate that
extent these effects can be transferred to thera- reects spontaneous recovery of functions that
peutic interventions in patients with stroke is occur during the rst months after a stroke. To
currently investigated. Patients with neglect show avoid the confounding eect of time (178), most
enhanced visual awareness associated with studies testing new rehabilitation methods involve
increased fMRI activation of regions related to patients with chronic stroke several months after
emotion and attention while they listen to music stroke onset. Optimal benets for the patients and
they like but not to un-preferred music or silence the society would supposedly be obtained by
(168). Music therapy improves executive function successful interventions in the subacute phase of
and emotional adjustment in traumatic brain stroke as indicated by the benecial effect on
injury rehabilitation (169). It has been reported motor outcome in stroke units. Rehabilitation
to improve attention and verbal memory in program may require different therapy protocols
patients with stroke (170). However, the statistical in acute and chronic stages of recovery, and we
analyses of the data were not adequate, and need to know the optimal time for specic inter-
further studies are needed. Merely listening to ventions. More homogenous groups of patients
music and speech after stroke starting 1 week after need to be studied. Although it has been repeatedly
stroke onset induced long-term plastic changes in shown that the integrity of the corticospinal tracts
early sensory processing that correlated with the is of main importance for a favorable outcome
improvement in verbal memory and focused after stroke (711), the information is lacking in
attention both in music and in speech listening most studies. Cognitive rehabilitation programs
(171). A community-based intervention program starting early after stroke are essential to establish
combining rhythmic music and a specialized reha- whether attention-training, music, and other cog-
bilitation program during 8 weeks resulted in a nitive interventions can lead to better social
wider range of motion and exibility, more adjustment and quality of life post stroke.
positive moods as well as an increased frequency
and quality of interpersonal relationships com-
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