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Lorie Gage Richards: Motor Recovery and Neural Reorganization After Stroke
Thomas Pearl
SUNY Downstate

ALWAYS JUSTIFY YOUR PAPER ….AS IN THE ALIGNMENT … NOT LEFT
Over 750,000 strokes occur annually in the United States alone. The majority of those suffering a stroke have ongoing reductions in contralateral arm and hand functions that interfere with accomplishing goal oriented activities and vocational needs (Richards, Stewart, Woodbury, Senesac, & Cauraugh, 2008a). Knowing the best methods to promote motor recovery in arm and hand functioning is therefore critical in stroke rehabilitation. Lori Gage Richards, (PhD, OTR/L) is an active researcher and educator seeking to uncover which therapies drive neural reorganization after a stroke, and what are the most effective strategies leading to improvements is UE function.
Richards is currently Associate Professor and Chair of the Occupational Therapy Department at the University of Utah. She was recently appointed editor-in-chief of the American Journal of Occupational Therapy and serves as Chair of the Nursing and Rehabilitation Committee-Stroke Council, of the American Heart Association. Additionally at the American Heart Association, she is a member of both the Leadership Council - Stroke Council and the Stroke Rehabilitation and Recovery Committee - Stroke Council. Her current professional affiliations include the American Occupational Therapy Association (AOTA), Society for Neuroscience, and the American Congress of Rehabilitation Medicine.
Motor rehabilitation is premised on the belief that behavior (e.g., practice and motor-based intervention) forces neuroplastic changes in the central nervous system (CNS) which lead to better motor function. According to Richards, Hanson, Wellborn, & Sethi (2008b) the current evidence supports that "repetitive behavior that produces motor skill acquisition does change neural structure and function" (p.397) . In Driving Motor Recovery After a Stroke, the authors reviewed and compiled numerous sources and levels of evidence to support these findings. Additionally, motor practice can improve motor skills even with individuals who have very chronic stroke (> 1 year). This last point in particular is very important to how funding, insurance coverage, and legislation will affect treatment options. Many individuals are released from subacute facilities as soon as they are deemed able and then do not maintain gains or reach the further gains that are possible. Clear evidence showing neural changes beyond one year of stroke occurrence will be an important part of changing this practice and helping patients get the most motor function recovery possible.
While the evidence supports that neural changes occur with motor-based interventions, there is still an evolving consensus on what is the best method to achieve these changes, and what aspects of these interventions are really the cause of the change. For example, should a clinician use Constraint Induced Motor Therapy (CIMT) over bilateral arm training? According to Hayner, Gibson, & Giles (2010) in a small Level I study, there is no difference in functional gains between the two when intensity and duration are controlled for. Another area needing clarification involves implicit learning strategies versus explicit ones. Pohl, McDowd, Filion, Richards, & Steirs (2001) look at lesion location and how that affects learning. Do patients learn and practice better with an implicit approach? Once again the evidence for the best treatment method is evolving and no set rule is available. Which is the more effective approach that a therapist should take?
Beginning therapists and clinicians seeking the best treatments should not be daunted. This apparent lack of consensus should not be viewed as an impediment to treatment. Research by Richards et al. (2008a) in their systematic review and meta-analysis of neural changes following UE therapy, conclude that there is clear support that increased UE function, resulting from movement based stroke rehabilitation, causes plastic changes in the lesioned hemisphere. Importantly, these changes occurred primarily in individuals who were more than one-year post stroke, and fully support the conclusion that behavioral movement challenges and experiences are effective stroke interventions immediately following stroke and in the later chronic phase as well.
Significantly supporting behavioral (i.e. activity-dependent) interventions are meaningful advances in neuroscience and the ability to measure and view brain scans. Richards’ PhD in Psychology and her work as an Associate Scientist at the Center on Aging, University of Kansas Medical Center, gave her important competence in this area. TMS and fMRI data show higher engagement of the lesioned hemisphere upon conclusion of an UE rehabilitation program. Damage to neurons from stroke, necessitates the brain to create alternate functional ensembles with neurons that are still viable. It is thought that spared neurons in the lesioned hemisphere and unaffected neurons in the intact hemisphere may be recruited to control the performance of movements after stroke (Richards et al., 2008a).
UE motor function and control are vital when trying to achieve independence in ADLs and IADLs. Certainly adaptations and environmental modifications can help augment UE motor challenges, but there are a vast number of tasks humans perform that require control of the arms and hands. Reaching for a coffee mug, gripping the handle, and lifting the mug to the lips all require motor skills delineated in the Occupational Therapy Practice Framework (OTPF) (American Association of Occupational Therapy, 2014). The client factors involved in lifting a mug are muscle power and tone, motor reflexes, control of voluntary movement, structure of the nervous system, and joint mobility/stability. There are a multitude of UE motor skill combinations needed to be independent. Richards started her professional work as an OT. While the exact parameters of the OTPF had not been laid out when she began her career, Richards certainly understood the need for participation, independence and task based interventions.
The ecological models within occupational therapy provide another important pathway towards understanding which activities provide the best types of motor practice. The ecological models understand that the environment affects performance. Engaging in functional tasks in different environmental contexts will provide novel challenges and adaptations to new environmental demands. CIMT, recognized as a highly effective motor rehabilitation intervention (Management of Stroke Rehabilitation Working, 2010) incorporates an individual's actual environment. The ongoing challenges that constantly occur in the changing environment are seen as important in getting the needed intensity to drive neural reorganization. As stated earlier, other motor-task based training methods produce gains. To highlight once more: intensity is a critical component along with varied motor practice. Changing environments can be another option used to increase the task demands.
Stroke risk does increase with age, however 34% of hospital admissions were for people under 65 years. This is a ten percent increase from 1989. Younger people are having strokes in higher numbers and this coupled with seniors living longer may keep stroke rates steady or cause them to increase. The average age of stroke patients is 70-71 years and comorbidities include diabetes, hypertension, and atrial fibrillation. At least one comorbidity is seen with 94% of strokes according to Hall, Levant, & DeFrances, (2012). Motor skill training clearly would be beneficial to those suffering stroke.
Richard’s work has important implications for both patients and clinicians. Stroke is seen as a static event, it is not considered a progressive illness. And while greatest motor recovery gains are seen within the first few months, (Richards et al., 2008b), appropriate motor practice, well into the chronic stage, will maximize motor skill gains. Richards stresses this point repeatedly in her recent work. She has steadily built the evidence base to make the case for continued interventions with stroke patients who would normally no longer qualify for services because they’ve either met near-term targets, or there are no longer any additional gains being documented. Medicare is starting to realize the benefits of continued therapy that patients and clinicians have already known (Jaffee, 2013). While Richards may not have had a direct impact on these reimbursement changes, her work will certainly provide a pillar of evidence to hopefully prod other insurers to start and continue paying for ongoing therapy services. The benefits to patients could be far reaching and highly impactful. Stroke survivors, like many others, want to age-in-place and live independently. Showing that there is a potential to improve and maintain motor skills deep into stroke’s chronic phase will be needed to do this.
The impact of Richard's’ work on OT clinicians and researchers is likely to be considerable. From the standpoint of what task interventions to use, clinicians are provided with much needed clarity when sifting through the many different treatment options. Clear guidelines are now in place to guide the best way to achieve UE motor skill. From a research perspective, her view is to stop quibbling about what type of motor intervention should be utilized and to design clinical trials that focus on the amount of intensity to produce the greatest gains (Richards et al., 2008b). Additionally, research to match clients to protocols is needed. Occupational therapists, clinicians, and researches will continue to be impacted by Richards into the foreseeable future. As the newly appointed Editor-in-Chief of the American Journal of Occupational Therapy, Richards will be influencing publishing decisions at a leading research publication of the OT profession.
Richard’s first clinical research work was in stroke rehabilitation. While it is not explicitly stated, this likely framed the trajectory of her research work. The advances in neuroscience, her background in psychology, and her grounding as an OT educator placed her with a very wide but focused skill set to uncover the questions of how the brain reacts to motor rehabilitation. With developing technologies coming into existence to image the brain in new ways, greater possibilities for basic science research emerged. Richards was fortunately well placed to add to the emerging research while at the same time holding her OT heritage.

References
American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl. 1-48)). doi:10.5014/ajot.2014.682006
Hall, M. J., Levant, S., & DeFrances, C. J. (2012). Hospitalization for stroke in US hospitals,
1989–2009. Diabetes, 18(23), 23.
Hayner, K., Gibson, G., & Giles, G. M. (2010). Comparison of constraint-induced movement therapy and bilateral treatment of equal intensity in people with chronic upper-extremity dysfunction after cerebrovascular accident. American Journal of Occupational Therapy, 64(4), 528-539. doi: doi:10.5014/ajot.2010.08027
Jaffe, S. (2013). Therapy plateau no longer ends coverage. The New York Times. Retrieved from http://newoldage.blogs.nytimes.com/2013/02/04/therapy-plateau-no-longer-ends-coverage/?_r=1
Management of Stroke Rehabilitation Working Group. (2010). VA/DOD Clinical practice guideline for the management of stroke rehabilitation. Journal of rehabilitation research and development, 47(9), 1.
Pohl, P. S., McDowd, J. M., Filion, D., Richards, L. G., & Stiers, W. (2006). Implicit learning of a motor skill after mild and moderate stroke. Clin Rehabil, 20(3), 246-253.
Richards, L., Hanson, C., Wellborn, M., & Sethi, A. (2008). Driving motor recovery after stroke. Topics in stroke rehabilitation, 15(5), 397-411.
Richards, L. G., Stewart, K. C., Woodbury, M. L., Senesac, C., & Cauraugh, J. H. (2008).
Movement-dependent stroke recovery: a systematic review and meta-analysis of TMS and fMRI evidence. Neuropsychologia, 46(1), 3-11. doi: 10.1016/j.neuropsychologia.2007.08.013
Brown, C. (2013). From ecological models in occupational therapy. In Schell, B. A., Gillen,
G., Scaffa, M., & Cohn, E. S. (Eds.), Willard and Spackman's Occupational Therapy, Twelfth Edition (pp.494-504). Baltimore: Lippincott Williams & Wilkins.

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