Deans' stroke musings

Changing stroke rehab and research worldwide now.Time is Brain!Just think of all the trillions and trillions of neurons that DIE each day because there are NO effective hyperacute therapies besides tPA(only 12% effective). I have 493 posts on hyperacute therapy, enough for researchers to spend decades proving them out. These are my personal ideas and blog on stroke rehabilitation and stroke research. Do not attempt any of these without checking with your medical provider. Unless you join me in agitating, when you need these therapies they won't be there.

What this blog is for:

Shortly after getting out of the hospital and getting NO information on the process or protocols of stroke rehabilitation and recovery I started searching on the internet and found that no other survivor received useful information. This is an attempt to cover all stroke rehabilitation information that should be readily available to survivors so they can talk with informed knowledge to their medical staff. It's quite disgusting that this information is not available from every stroke association and doctors group.
My back ground story is here:

Friday, December 9, 2016

Resources for evidence based neurological physiotherapy

From Sarah Tyson, Professor of Rehabilitation at the University of Manchester, neurological physiotherapist and enthusiast for improving outcomes for people neurological conditions using research and other evidence. Something like this should be published and promoted by our fucking failures of stroke associations, but it isn't which is why they are so fucking incompetent.  But it has no action observation or environment enrichment or mirror therapy or thermal therapy or mental imagery. Less than complete.

We all know (or at least I hope we do!) that exercise and functional task practice are the most effective interventions to promote physical recovery and thus should be the mainstay of physiotherapy practice. We also know that the intensity of the exercise and functional task practice (let’s call it FTP for short!) is crucial  – the more the better and the sooner the better. But most stroke patients spend most of their time inactive and alone and receive insufficient therapy to maximise recovery. So we need to find ways to increase the amount of practice/ exercise/ therapy.
Here are some resources that I have collected together which give the details of how to deliver good quality, effective exercise and intensive tasks specific practice. Many thanks to the folk who have contributed their work:  Professors Janice Eng, Jan Merholz, Louise Ada, Coralie English, Susan Hillier and Lisa Harvey, plus Bex Townley of Laterlife Training and Annie Merhag for the CIMT links.  Most are free and will tell you exactly what to do and how to do it. You just need to work out which are the appropriate bits for your patient – that’s where the clinical skill comes in!
Please let me, and everyone else know how you get on via the blog – what are your experiences of using them? Your top tips and handy hints? Also please add any additional resources that you have found useful and would be willing to share with others

GRASP (upper limb) and FAME (lower limb/ mobility) are evidence based exercise and functional practice programmes developed by Janice Eng and team at University of BC in Vancouver with strong evidence that they improve impairments and activity/ disability levels. They can be used in hospital, out-patient or community settings.  The manuals and relevant papers can be downloaded here.

LATER LIFE TRAINING  have produced effective exercise programmes focussing on mobility and falls prevention. There are best practice guidelines for exercise for stroke here with all the details about how to set up and deliver an exercise group. They also run courses about how to run exercise programmes for people with stroke and to become a certified instructor. There are also courses for postural stability; the Otago Falls programme and chair based exercise. Laterlife are a non-profit making organisation and all profits are ploughed back into the developing the programmes

PHYIOTHERAPY EXERCISES is a free website of exercises for people with disabilities and injuries. There are 100’s of exercises!! And there are specific collections for people with stroke, TBI, SCI, MS and other conditions and one can also select exercises according to exercise type and difficulty, equipment used, patients’ age,  and /or body part  so it’s straight forward to select and then download/ print out the simple line drawing and instructions for whatever suits individual patients. They were developed by physiotherapists working in Sydney and NSW, led by Lisa Harvey.

The treatment manual from Coralie English and Susan Hillier trial of circuit classes during in-patient stroke rehabilitation. English C, Hillier S et al Circuit class therapy versus individual therapy sessions during inpatient stroke rehabilitation. A controlled trial” Archives of Physical Medicine and Rehabilitation 2007;88:955-63 is available for purchase (for $AU45) from this link

I have recently come across a good book – How to do Constraint Induced Movement Therapy: A practical guide, written by one of my former MSc students, Annie Mehag (not that I’m name dropping or anything) and Jill Kings about how they deliver CIMT in the UK. It is full of evidence, experience and good sense. It only costs £24. They also run courses on how to do CIMT, not that I know anything about those or can vouch for them, one way or the other. The book can be ordered from

improves mobility, walking speed and fitness for ambulant stroke survivors. But which type of treadmill to use? The difficulty is that many treadmills don’t go slow enough to accommodate the most disabled and nervous patients, you really need one that starts of 0.1m/s and most only start at 0.5 m/s, which is too fast for many neurological patients. The only one I have come across in the UK which goes slow enough is supplied by Biodex, they also produce a gantry/ bodyweight support ( but there may be others.
Treadmill training is most effective if patients practise walking as fast as they can. How to deliver this? Here is the treatment protocol that Prof Jan Merholz (author of many Cochrane reviews!) uses in his practice, Klinik Bavaria (
Speed dependent treadmill training protocol
  • Warm-up on the treadmill (5-minutes)
  • Step 1 (maximum over ground walking speed, work this out before the session starts). Over 1 – 2 minutes increase the belt speed, in communication with the patient, to the highest speed at which the patient can walk safely and without stumbling. (hold Step 1 for 10 seconds) followed by a recovery period
  • Step 2 Increase speed by 10% during the next attempt = (step 1 + 10%)
  • Step 3 Increase speed by 10% during the next attempt = (Step 2 + 10%)
  • Step 4 Increase speed by 10% during the next attempt = (Step 3 + 10%)
  • Step 5 Increase speed by 10% during the next attempt = (Step 4 + 10%)
  • Cool down for the rest of the session
  • At the next session start at the speed used in Step 5 and increase as above, as tolerated by the patient.
  • Repeat three times a week for at least 4 weeks (e.g. Monday, Wednesday, Friday)
Pohl M, Mehrholz J, Ritschel C, Ruckriem S. Speed-dependent treadmill training in ambulatory hemiparetic stroke patients: a randomized controlled trial. Stroke 2002; 33: 553-558.
So treadmill training (as above) will sort out gait rehab for those who can walk. But what about those who can’t walk? Well, the most effective option seems to be robotic gait training AKA ‘electromechanical gait training’ (let’s call it elec-mech gait training for short). In fact the Cochrane review suggests that using an elec-mech training could increase the number of stroke survivors who regain independent mobility by ~20% How good is that??!!! Can you imagine what a difference that would make if you could get 20% more people walking out of your hospital / clinic??
Mehrholz J, Elsner B, Werner C, Kugler J, Pohl M. Electromechanical-assisted training for walking after stroke: updated evidence. Cochrane Database Syst Rev. 2013 Jul 25;7:CD006185. doi: 10.1002/14651858.CD006185.pub3. .
But very people have access to an elec-mech gait trainer as they are very large and eye-wateringly expensive. Just to plug my work, keep your eyes peeled for the Morow mobility robot which I am developing (with clever colleagues, obvs) which is clinical-sized and trains sit-to-stand and walking, inexpensively. We putting the finishing touches to the final prototype before starting clinical testing.
In the meantime …… BODY-WEIGHT SUPPOR

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