|Year : 2017 | Volume
| Issue : 1 | Page : 46-48
Effect of motor relearning program poststem cell therapy in chronic stroke
Jorida Fernandes, Sanjiv Kumar
Department of Neurophysiotherapy, KLEU Institute of Physiotherapy, Belagavi, Karnataka, India
|Date of Web Publication||20-Mar-2017|
KLEU Institute of Physiotherapy, JNMC Campus, Nehru Nagar, Belagavi - 590 010, Karnataka
Source of Support: None, Conflict of Interest: None
A 59-year-old male, with chronic hemiplegia, received the first dose of stem cell therapy 1 year back. Physiotherapy was started immediately. The patient was evaluated using Fugl-Meyer assessment scale and functional independence measure before and after physiotherapy. After 6 months of physiotherapy intervention using motor relearning program, improvements were observed in the motor outcome with significant changes in the upper extremity, especially the hand component.
Keywords: Motor relearning program, stem cell, stroke
|How to cite this article:|
Fernandes J, Kumar S. Effect of motor relearning program poststem cell therapy in chronic stroke. J Sci Soc 2017;44:46-8
| Introduction|| |
Stroke is the second most frequent cause of death after coronary artery disease. In India, stroke is an important cause of premature death and disability. Diagnosis can be done by laboratory tests and brain imaging followed by appropriate medical treatment. In the present day, stem cell therapy has been used in the treatment of stroke. Evidence suggests that hematopoietic stem cells improve functional outcome after ischemic brain injury.
The aim of rehabilitation is to maximize the functional capabilities of an individual. Experimental evidence suggests that physiotherapy techniques are associated with changes in the activity of brain areas. These techniques also improve transmission in the corticospinal pathways. Motor training results in performance improvements that are associated with re-organization. Motor relearning program (MRP) can be started as soon as the patient is medically stable. Research regarding the outcomes of physiotherapy with stem cell therapy in patients with chronic stroke is lacking, and the potential of physiotherapy along with stem cell therapy in these patients is not fully explored.
Hence, the objective of undertaking this case report is to describe the treatment and outcomes associated with physiotherapy following stem cell therapy in a patient with chronic stroke.
| Case Report|| |
The patient is a 59-year-old male, who was 55 at the time of stroke 4 years back. He received physiotherapy and other alternative therapies prior to stem cell therapy with which he was able to walk independently but with poor gait pattern. In 2014, he received stem cell therapy and started physiotherapy within 20 days. Examination of the patient was done using Fugl-Meyer assessment scale and functional independence measure (FIM) before starting physiotherapy.
The patient had mixed synergy pattern in the upper limb and predominantly extensor synergy in the lower limb. Grade 2 spasticity (according to modified Ashworth scale) was present in most of the muscles in the right upper limb and lower limb. Loss of superficial and deep sensations was illustrated in the right side. Poor balance reactions were noted. The patient walked with a typical circumductory gait with reduced stance phase and increased swing phase.
The patient received physiotherapy for 6 months, six times a week, twice a day, and each session lasting for 1 h. MRP was used for rehabilitation. The therapy sessions focused on upper limb functions, functions performed in sitting and standing, walking, oro-motor functions, and giving a sustained stretch to the spastic muscles (3 sets × 30 s hold).
At the end of 1 month, improvements were seen in hand and arm function. The patient was able to bring the affected hand to the mouth and feed himself, and put on and remove his footwear. Within 3 months, he was able to dress himself. He started bathing and toileting activities independently. During the initial 3 months, recovery was rapid, followed by slow improvement. He can do independent stair climbing.
| Results|| |
The Fugl-Meyer assessment of physical performance and FIM were assessed at the beginning of the session, end of 3rd month, and end of 6th month. Changes were mostly noted in the upper extremity function. Sensory part of the Fugl-Meyer did not show any change at the end of 6 months [Table 1]. The self-care component of FIMs showed changes along with social cognition [Table 2].
| Discussion|| |
After MRP, improvements were observed in the motor outcome of patient with chronic stroke. Changes were seen in the upper extremity component, especially the hand.
Long-term effects of mesenchymal stem cell therapy were positively reflected on functional outcome and survival. Reason stated for the improvement was due to mesenchymal stem cell therapy-induced neurogenesis poststroke. The patient in the present study could have shown good results because of neurogenesis poststem cell therapy.
In addition to stem cell therapy, MRP has led to better skill acquisition and retention. The task was broken down into simpler components. The patient was made to practice individual components repeatedly. At the end of the session, the task was combined into a whole and the activity was practiced. Pandian et al. compared Brunnstrom therapy and MRP in hemiparetic hand. Brunnstrom proved better than MRP. However, in the present study, hand function has showed a significant change after 3 months. The reason could be due to repeated practice in MRP. William James postulated that increments in synaptic efficacy occur during learning when firing of one neuron repeatedly produces firing in another neuron to which it is connected. The reason may be attributed to collateral sprouting. During collateral sprouting, adjacent to the destroyed neural tissue, there will be new growth in a healthy neuron. Synaptic effectiveness is enhanced due to sprouting. This may be due to dynamic synaptogenesis. This continually occurs under normal circumstances. These synaptic changes may be the underlying physiological mechanism for relearning which is responsible for recovery.
The type of feedback plays a major role in motor improvement. Patients constantly receive feedback from the therapist while performing the activities initially. In the later stages of intervention, feedback was given after completing the task. This type of feedback may help to improve performance in the initial stages but later leads to retention of the skill.
Speed of walking changed postintervention significantly. In a cross-sectional study, improvements in step length symmetry at the end of locomotor training were associated with improved walking speed at the end of 6 months. Our results do suggest that training with MRP targeting lower limb kinematics results in improvement in walking speed or function. All improvements persisted 2 months postintervention. It may be due to distributed type of practice that was used. In this, the patient was given rest time equal to that of the time spent on a task. This type of practice is used when superior performance is required leading to better motor outcome. In our study, in addition, blocked practice order was used during performing each task. This may have led to improved skill acquisition and performance. The patient showed changes that can be attributed to stem cell therapy which were accelerated by the repeated practice of physiotherapy.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
GBD Mortality and Causes of Death Collaborators. Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: A systematic analysis for the global burden of disease study 2013. Lancet 2015;385:117-71.
Pandian JD, Sudhan P. Stroke epidemiology and stroke care services in India. J Stroke 2013;15:128-34.
Haas S, Weidner N, Winkler J. Adult stem cell therapy in stroke. Curr Opin Neurol 2005;18:59-64.
Liepert J, Bauder H, Wolfgang HR, Miltner WH, Taub E, Weiller C. Treatment-induced cortical reorganization after stroke in humans. Stroke 2000;31:1210-6.
Langhammer B, Stanghelle JK. Can physiotherapy after stroke based on the Bobath concept result in improved quality of movement compared to the motor relearning programme. Physiother Res Int 2011;16:69-80.
Lee JS, Hong JM, Moon GJ, Lee PH, Ahn YH, Bang OY; Starting collaborators. A long-term follow-up study of intravenous autologous mesenchymal stem cell transplantation in patients with ischemic stroke. Stem Cells 2010;28:1099-106.
Pandian S, Arya KN, Davidson EW. Comparison of Brunnstrom movement therapy and motor relearning program in rehabilitation of post-stroke hemiparetic hand: A randomized trial. J Bodyw Mov Ther 2012;16:330-7.
Rehani P, Kumari R, Midha D. Effectiveness of motor relearning programme and mirror therapy on hand functions in patients with stroke – A randomized clinical trial. Int J Ther Rehabil Res 2015;4:2.
Carr JH, Shepherd RB. A Motor Relearning Programme for Stroke. 2nd
ed. London: Heinemann Physiotherapy, Aspen Publishers; 1987.
Cirstea CM, Ptito A, Levin MF. Feedback and cognition in arm motor skill reacquisition after stroke. Stroke 2006;37:1237-42.
Shumway-Cook A, Woollacott MH. Motor Control: Translating Research into Clinical Practice. 3rd
ed. Philadelphia: Lippincott Williams and Wilkins; 2007.
Reisman D, Kesar T, Perumal R, Roos M, Rudolph K, Higginson J, et al.
Time course of functional and biomechanical improvements during a gait training intervention in persons with chronic stroke. J Neurol Phys Ther 2013;37:159-65.
[Table 1], [Table 2]