Rehabilitation is Initiated Early After Stroke, but Most Motor Rehabilitation Trials Are Not: A Systematic Review

It is good for you to know that absolutely nothing in stroke recovery is known.  Your doctor and therapists only know guidelines.  So start planning your own recovery protocols Then ask your doctor why you are paying them for ignorance. 

Rehabilitation is Initiated Early After Stroke, but Most Motor Rehabilitation Trials Are Not: A Systematic Review

 

1 Stroke is the third most common cause of death and the most common cause of acquired adult disability in developed countries.1 Motor impairment is common after stroke, and a critical factor influencing the patient’s ability to live independently.2,3 The neurobiological mechanisms of plasticity and spontaneous recovery during the initial days and weeks after stroke have been reasonably well characterized using animal models.4,5 These mechanisms include cell genesis, functional plasticity, and structural adaptations, such as axonal sprouting and synaptogenesis. The nature and time course of these mechanisms map onto the trajectory of motor recovery observed in human patients, most of whom reach their recovery plateau within 3 months of stroke.6,7 Rehabilitation is primarily delivered in this time period, to capitalize on the unique physiological conditions that prevail, and shape the spontaneous recovery process for the patient’s benefit. Recovery of function is likely to be enhanced by novel treatments that interact with and facilitate the underlying mechanisms of spontaneous recovery.A variety of neurorehabilitation techniques aimed at improving motor recovery after stroke have been developed and trialed over the past 3 decades. These include repetitive task training, biofeedback, constraint-induced movement therapy, robotics, virtual reality, motor imagery, noninvasive brain stimulation, and pharmacological agents.8,9 However, despite almost 1000 randomized control trials (RCTs) in stroke rehabilitation,10 there is very little translation of this evidence base into clinical practice.11,12 Research efforts to develop the evidence base are challenged by difficulties in recruiting patients, resulting in small sample sizes; the heterogeneity of impairments after stroke and the complexity of their interactions with factors affecting recovery; and limited collaboration between scientists, clinicians, patient groups, and industry.11(So you want to give up just because research is hard? Try recovering from a stroke with NO useful medical guidance.) Even when the research evidence base supports the development of clinical guidelines, significant barriers to implementation remain.10,13Reviews of stroke rehabilitation commonly identify the need to perform research in real-world clinical settings9,11; however, they do not routinely report the timing of RCTs with respect to stroke onset. Similarly, Cochrane reviews typically draw conclusions about the efficacy of an intervention based on RCTs performed at any time after stroke.14–19 These conclusions are then used to develop guidelines that recommend initiating rehabilitation as soon as safely possible after stroke.20–24 A misalignment between the timing of RCTs and the real-world delivery of stroke rehabilitation may be an important aspect of the evidence base that limits its translation to clinical practice.The first 30 days after stroke represent a critical time period for treatment initiation.25 Delays in RCT initiation may reduce the efficacy of the new treatment being tested, in the same way that delays in initiating rehabilitation lead to worse outcomes.26–28 The evidence base for new treatments initiated within the first month after stroke has not been evaluated. Rehabilitation of motor function is a common goal after stroke, and RCTs in this area are likely to be fairly representative of the stroke rehabilitation evidence base. The aim of this review was to determine the percentage of motor rehabilitation RCTs initiated within 30 days of stroke, and characterize these studies.