Advances in post stroke neurorehabilitation - From neuro fundamentals to evidence based medicine

Abstract

Previous years have seen substantial effort to understand brain functioning and how to enhance endogenous neuromodulation and neurorehabilitation in general, by using a broad spectrum of instruments: imaging techniques (functional magnetic resonance imaging, positron emission tomography, diffusion-tensor imaging), quantitative electroencephalogram, magnetoencephalography, eye tracking, optogenetics, brain stimulation and brain-computer interfaces. Together, these technologies provide valuable information about the structure-function relationship of resting-state networks, as well as the dynamic interaction between networks and aberrations in functional connectivity. The first part of this presentation aims to highlight the limitations of the classic models in brain protection and recovery. The new principles related to anticorrelated processes may explain and account for the complexity of brain function and open avenues to new therapeutic interventions. Ischemic brain damage affects all three levels of structural and functional organization (cellular and molecular, circuitries and dynamic network levels), launching an endogenous continuous brain defense response which consists of neuroprotection (the immediate response) and neurorecovery (a later response). At the circuitries and dynamic network levels, it is expressed by the tendency to rebalance the functional connectivity in resting-state networks. Currently, there is no widely accepted therapy for acute ischemic stroke, except for thrombolytic therapy and thrombectomy in the acute phase. Existing data shows that even if highest standards of care are applied, up to 60% of stroke patients still have adverse outcomes. Rehabilitation plays a vital role in stroke care, as immobilization-related complications cause over 50% of stroke patients' deaths. Spontaneous recovery may occur after IS but is incomplete for a majority of patients. The resulting individual and societal burden of the disease is enhanced by debilitating complications that strongly impact both physical and mental functions. The recovery of neurological functions is a dynamic, multifactorial process, which differs for each patient. Neuroplasticity, as a consequence of neurorehabilitation, can be exogenously stimulated using a tailored approach, combining multimodal drugs with non-pharmacological interventions, such as physical activity, cortical stimulation, mental health, and psychosocial support. Initiating recovery immediately after IS is of paramount importance to reach full potential for outcome improvement. The second part of the presentation will showcase the latest evidence in neurorehabilitation after ischemic stroke (IS), a complex and heterogeneous disease, that occurs as a result of several risk factors and comorbidities.