The ability to translate cutting-edge research into advanced clinical care has reopened possibilities for a young patient who is recovering from an idiopathic stroke. A multimodal rehabilitation plan that includes innovative muscle training and music therapy has enabled her to play music again.
The 9-year-old girl was in otherwise good health, attending a summer music camp in July 2018 to hone her skills as a violinist and pianist. After falling ill on the playground, she was rushed to the emergency room where doctors diagnosed a hemorrhagic stroke with severe right-sided weakness.
She was transferred to NYU Langone Health for a neurosurgical evaluation, and though the patient’s stroke etiology remained unclear, neurosurgeons ruled out surgery. With close monitoring and anti-seizure medication, the girl’s condition was stabilized until she could be transferred to inpatient rehabilitative care at Rusk Rehabilitation.
“At first it was a fight for survival, and then it shifted to a fight for what mattered most to her: making music. When I first saw her, she had no movement or sensation; the entire right side was completely limp,” recalls Preeti Raghavan, MD, Howard A. Rusk associate professor of rehabilitation research, vice chair for research, and director of the Division of Motor Recovery.
Early Rehabilitation is Critical
The interdisciplinary care team faced a daunting challenge as the dense hemiparesis on the patient’s right side had significantly reduced her prospects of playing the violin again.
For patients with right-sided weakness, occupational therapy typically involves teaching them compensatory strategies, so they can perform daily activities independently, as well as write with their left hands.
Restoring fine motor skills such as playing the piano or violin with both hands can be less realistic. “But we know that the early period is critical, as the brain tries to repair itself, so we gave it our best shot,” Dr. Raghavan says.
Enhancing Motivation with Music
Louis Roi Oliver Dizon, MD, a clinical instructor in rehabilitation medicine, arranged for a music therapist to bring in a keyboard so the young patient could begin playing it with her unaffected left hand. It was also critical to have the patient move her right arm frequently to stimulate neurological connections and restore natural motion.
Innovative Approach Accelerates Patient Progress
The patient’s rehabilitation plan also includes using an innovative device: the m2 Bimanual Arm Trainer. Renat R. Sukhov, MD, clinical associate professor of rehabilitation medicine and interim medical director of Pediatric Rehabilitation Services, is the principal investigator of a study that provides the Bimanual Arm Trainer for children to use at home after school.
Co-invented by Dr. Raghavan and neurophysiologist Donald J. Weisz, PhD, the device, which has a video game built into it, allows a patient’s affected arm to mirror their unaffected arm. “With the device, the two arms are connected so the affected arm moves with the unaffected arm. So the patient can get lots of movement training for the affected arm outside her therapy sessions with very little setup, and the video game keeps the training engaging,” Dr. Raghavan explains.
Dr. Sukhov arranged for the young patient to use the m2 Bimanual Arm Trainer in the inpatient unit. Each day the young patient used the device, her parents noticed how she began to regain feeling in her affected side, which enabled her therapists to advance their work with her.
Multimodal Rehabilitative Care Yields Rapid Recovery
The regimen elicited dramatic improvement in one month. “At first, this patient couldn’t move the device with her affected arm or tolerate it for more than 10 minutes,” Dr. Raghavan says. “By the time she was discharged, she had independent movement at her affected shoulder and elbow, and sensation in her upper arm.” Soon, she began to move her violin bow with the aid of a prosthesis attached to her forearm.
The team continued working with the young patient on an outpatient basis. She walked with a brace and received intensive therapy on a Lokomat® body weight–supported treadmill. She also continued using the m2 Bimanual Arm Trainer to rehabilitate her arms. However, her muscles were becoming stiff at the wrist and fingers, which prevented her from holding the violin bow in her affected hand.
To help relieve the muscle stiffness in the patient’s wrist and fingers, Dr. Raghavan administered hyaluronidase, a viscosity-decreasing enzyme, as an off-label treatment. The very same day, the patient held her violin bow in her right hand for the first time since her stroke.
Today, the patient continues to rebuild and refine her skills at the violin and piano and is knitting with both hands to improve dexterity. “This patient’s remarkable progress since her initial presentation is an example of neuroplasticity and what is possible with advanced rehabilitative care,” adds Dr. Raghavan.
Disclosures: Preeti Raghavan, MD, is cofounder of Mirrored Motion Works, Inc., and Movease, Inc. NYU Langone Health has filed a patent on use of hyaluronidase for muscle stiffness. The use of hyaluronidase for muscle stiffness is an off-label clinical treatment.