Stroke Rehabilitation in the Modern Era

By Tina Zabehi

Image 1. A CT scan demonstrating an ischemic stroke via brain imaging.

One day, you find yourself on the field, track, rink, or court, listening to others applaud your ability, performance, and physical strength as an athlete. The next day, you find yourself exerting ten times as much effort in the hope of regaining just a fraction of your former strength. This unfortunate scenario is similar to what many survivors face in their daily lives following the  event of a stroke. A stroke, also known as a "brain attack," is a condition in which the blood  supply to the brain is blocked, resulting in a lack of oxygen. The brain relies on oxygen on a neurochemical level since brain energy is primarily derived from glucose and oxygen for the manufacture of energy in the form of adenosine triphosphate (ATP).  Since the brain requires oxygen to function, a lack of oxygen supply, known as cerebral hypoxia, can cause certain brain cells to die very quickly. This is why, in the case of a stroke, time is of the essence, and acting quickly can potentially save a life.

Strokes are classified as either ischemic or hemorrhagic. Ischemic stroke occurs when a  blood vessel carrying blood to a specific region of the brain becomes obstructed. This type of  stroke is frequently caused by thrombosis (blood clot), an embolism (artery blockage), or  hypoperfusion (reduced blood flow). However, the exact cause of an ischemic stroke is unknown  in many cases. In contrast, hemorrhagic stroke, on the other hand, is caused by a blood vessel  rupture and an excess of blood flow into a specific region of the brain. Hemorrhagic strokes are  frequently caused by uncontrollable hypertension (high blood pressure) or aneurysms. Both types  of stroke can cause brain damage, disability, or even death. In fact, stroke is one of the leading  causes of death in the United States and around the world. Its negative effects on physical and  mental health are a major source of concern in today's society.

Image 2. A comparison of MRI and CT scans for hemorrhagic stroke. 

The effects of a stroke on the body extend beyond the brain. Since the brain is often  referred to as the body's control center, it is easy to see how cell death as a result of stroke could  affect the rest of the body. Patients may experience impairment with several bodily functions  depending on the location of the damage in the brain caused by a stroke. Stroke patients may  experience impairments in cognitive abilities, motor skills, emotional capacities, memory, vision,  and speech, among other areas. These disabilities make life difficult for stroke survivors and  have a significant impact on their quality of life and mental wellbeing. 

Image 3. A diagram of how TMS would look for a stroke patient.

The rehabilitation and recovery period following a stroke varies from person to person,  but rehabilitation through therapy is especially important during this time. Physical therapy,  speech therapy, and occupational therapy have been shown to help patients return to premorbid  functioning to the greatest extent possible. The importance of family and psychological/psychiatric support in maintaining the patient's mental health cannot be overstated.  The brain has its own intrinsic ability to repair itself and miraculous recoveries have been  observed following stroke. The remarkable case of the stroke in the Broca's area on the left side  of the brain is an example of these recoveries. This region is primarily in charge of speech function. When a stroke damages this area of the brain (Broca's aphasia), patients may struggle to form intelligible words and sentences. Interestingly, research has discovered that therapy (Melodic Intonation Therapy in this case) can provide an alternative method for speech recovery.  MIT works by interacting with language areas on the right side of the brain that are involved in singing. Instead of speaking, patients can communicate by singing, and they may eventually be able to train their brain to speak rather than sing. Neuroplasticity, or the brain's inherent ability to reorganize and adapt to new conditions in response to various stimuli or injury, is largely responsible for this. As more is learned about the brain and its healing abilities, intriguing scenarios like this one provide hope for breakthroughs in stroke recovery. 

While a neurosurgeon's role in stroke has traditionally been focused on hemorrhagic strokes and their treatment, compelling evidence has shown that innovative methods may change this trajectory. According to new research, regenerative surgery may hold promise for the future of stroke recovery. Enhancing neurogenesis through stem-cell therapies has received particular attention. Non-invasive brain stimulation techniques such as transcranial magnetic stimulation (TMS) for rehabilitation and stimulation of brain structures impacted by stroke have also been discussed. In recent years, researchers and neurosurgeons have paid increased attention to these methods. 

Image 4. BrainGate BCI implantation shows promise for quadriplegic man.

In addition, new developments in stroke rehabilitation are now emerging in the medical community. Brain-computer interfaces (BCIs) represent a popular and growing modality in recent times. BCIs employ brain activity to control external devices, which may then improve or restore the brain's natural neural output and stimulate neuroplasticity. As a result, impaired individuals, such as those who have been paralyzed by a stroke, can interact with their surroundings more freely. Several studies have indicated that sustained use of BCIs can promote neurological healing and improve motor performance. BrainGate and Elon Musk's Neuralink are the two widely recognized invasive BCI technologies currently being studied. If these mechanisms become more widely used, a new era in medicine may dawn, bringing hope to those suffering from the long-term effects and disabilities caused by stroke.

Works Cited

Burke, E., & Cramer, S. C. (2013). Biomarkers and predictors of restorative therapy effects after  stroke. Current Neurology and Neuroscience Reports, 13(329), 1-10.  https://doi.org/10.1007/s11910-012-0329-9 

Carey, L., Walsh, A., Adikari, A., Goodin, P., Alahakoon, D., De Silva, D., Ong, K., Nilsson,  M., & Boyd, L. (2019). Finding the intersection of neuroplasticity, stroke recovery, and  learning: Scope and contributions to stroke rehabilitation. Neural Plasticity, 2019, 1-15.  https://doi.org/10.1155/2019/5232374 

Cervera, M. A., Soekadar, S. R., Ushiba, J., Millán, J. D. R., Liu, M., Birbaumer, N., & Garipelli, G. (2018). Brain‐computer interfaces for post‐stroke motor rehabilitation: a meta‐analysis. Annals of clinical and translational neurology, 5(5), 651-663.

Cuartero, M. I., García-Culebras, A., Torres-López, C., Medina, V., Fraga, E., Vázquez-Reyes, S., Jareño-Flores, T., García-Segura, J. M., Lizasoain, I., & Moro M. Á. (2021). Post stroke neurogenesis: Friend or foe? Frontiers in Cell and Developmental Biology,  9(657846), 1-14. doi: 10.3389/fcell.2021.657846 

[CT and MRI scans of hemorrhagic stroke]. (n.d.). [Photograph]. Retrieved February 1, 2024. University  of Wisconsin-Madison. https://news.wisc.edu/mr-guidance-next-frontier-in-hemorrhagic-stroke/.

Dempsey, R. J., & Bowman, K. (2020). The past, present, and future of neurosurgery’s role in  stroke. Journal of Neurosurgery, 133(1), 260-266. doi: 10.3171/2020.1.JNS193043. Koh, SH., & Park, HH. (2017). Neurogenesis in stroke recovery. Translational Stroke Research, 8, 3–13. https://doi.org/10.1007/s12975-016-0460-z 

Gaillard, F. (2009). Hyperdense middle cerebral artery sign [Photograph]. Radiopaedia.org, https://doi.org/10.53347/rID-7150.

Kubis, N. (2016). Non-invasive brain stimulation to enhance post-stroke recovery. Frontiers in  Neural Circuits, 10(56), 1-10. doi: 10.3389/fncir.2016.00056 

Mane, R., Wu, Z., & Wang, D. (2022). Poststroke motor, cognitive and speech rehabilitation with brain–computer interface: a perspective review. Stroke and vascular neurology, svn-2022.

[Taking a bite with BrainGate implantation]. (n.d.). [Photograph]. Retrieved February 1, 2024. Brown University. https://www.brown.edu/news/2017-03-28/braingatefes.

Penev, Y. P., Beneke, A., Root, K. T., Meisel, E., Kwak, S., Diaz, M. J., ... & Lucke-Wold, B. (2023). Therapeutic Effectiveness of Brain Computer Interfaces in Stroke Patients: A Systematic Review. Journal of experimental neurology, 4(3), 87.

Prevalence of stroke--United States, 2006-2010. (2012). Morbidity and Mortality Weekly Report, 61(20), 379–382. 

Shlaug, G., Marchina, S., & Norton, A. (2008). From singing to speaking: Why singing may lead to recovery of expressive language function in patients with Broca’s aphasia. Music  Perception, 25 (4), 315-323. https://doi.org/10.1525/mp.2008.25.4.315

[TMS diagram]. (n.d.). [Digital Art]. Retrieved February 1, 2024. Medicalxpress. https://medicalxpress.com/news/2020-12-movement-recovery-cerebral-cortex-spinal.html

Whitehead, S., & Baalbergen, E. (2019). Post-stroke rehabilitation. South African Medical  Journal, 109 (2), 81-83. doi:10.7196/SAMJ.2019.v109i2.00011 

Zhao, L. R., & Willing A. (2018). Enhancing endogenous capacity to repair a stroke-damaged  brain: An evolving field for stroke research. Progress in Neurobiology, 163-164, 5-26.  https://doi.org/10.1016/j.pneurobio.2018.01.004

Zhu, X. H., Lu, M., & Chen, W. (2018). Quantitative imaging of brain energy metabolisms and neuroenergetics using in vivo X-nuclear 2H, 17O and 31P MRS at ultra-high field. Journal of Magnetic Resonance, 292, 155-170.