Wrong, wrong, wrong you blasted idiots. Physiotherapy is not the solution, go to preventing the cause of the problems. Dead and damaged neurons which would be vastly lessened by stopping the neuronal cascade of death by these 5 causes in the first week.
http://neurophysiotherapy.com.au/latest-news/in-search-of-the-great-discovery-in-stroke-motor-recovery/
The impact of stroke looms large
Stroke rehabilitation is a big deal. The financial and human cost of
stroke looms large, and the pressure building on clinicians, researchers
and funding agencies has surely reached boiling point. There is more
information about stroke rehabilitation than ever before, and keeping up
with the enormous amount of research is just not feasible or even
possible. For those of us interested in recovery after stroke, the
vortex of information can become overwhelming. At some point we really
should stop and check. What direction are we heading in? What do we need
to know before moving on? Do the key stakeholders – ie. stroke
survivors, family, friends, clinicians and researchers have access to
correct and relevant information? What do we need to consider before
continuing with our quest to maximise the quality of rehabilitation
after stroke?
Recovery, Rehabilitation and life transition
Recovery after stroke is a fascinating topic. Understandably, the
first priorities are to survive a stroke, and then minimise the risk of
another. Following this, attention focusses on any interventions that
can enhance the recovery after stroke and maximising independence and
quality of life. While signs and symptoms of stroke present their own
weird and wonderful challenges, it is the parallel themes of spontaneous
biological recovery, activity dependent rehabilitation and coping or
transitioning to life after stroke that makes stroke rehabilitation a
heavy proposition. (Notice absolutely nothing on stopping the neuronal cascade of death in the first week, shows you he knows nothing about stroke at all)
Acute Stroke Care leading the way
Acute stroke care is certainly moving in the right direction, (with
the help of a hefty sum of financial support). Years of disappointment
in the search for neuroprotective agents changed the focus toward a more
proactive view of effective acute multidisciplinary care. Evidence
shows that organised Acute Stroke Units improve both survival and
recovery outcomes after stroke. No singular intervention or health
discipline can claim any superiority in contributing to these favourable
outcomes. This means that the benefits of acute stroke care is the
cumulative effect of rapid assessment, streamlined investigations,
prompt interventions, plus access to a specialised multidisciplinary
team located in a designated space within a hospital. While some
investigations such as access to CT/MRI and interventions such as
thrombolysis remain quite specialised, many other key ingredients that
are likely to contribute to favourable outcomes are wonderfully
pragmatic. Examples of these ingredients include managing fever, blood
sugar levels and ensuring early swallowing assessment (Middleton et al.,
2011). Multiple Stroke Guidelines have been developed over the years
that aim to provide explicit and accessible access to best evidence.
Despite the simplicity of some of these interventions, clinicians and
services still struggle to adhere to best practice – which is a great
source of frustration! There is still on obvious divide between
knowledge and implementation. The other challenge is to ensure best
possible practice in acute care for every stroke patient, even when
there is no access to a designated stroke services. This means more
effective care for stroke in general medical wards, smaller rural health
services and hospitals in lower income countries (Langhorne, de
Villiers, & Pandian, 2012). Access to a multidisciplinary team with
an interest in stroke care also allows for early rehabilitation. Early
rehabilitation can provide several advantages. Prompt action to provide
regular monitoring and interventions can prevent many complications such
as infection, pain and pressure areas. Early intervention may also give
an opportunity for early repair and re-organisation within the central
nervous system. An example of an early interventions that provides a
head start is body weight support treadmill training for non-ambulant
patients, which can lead to more people becoming mobile after stroke,
and improved mobility beyond the acute stage (Ada, Dean, Morris,
Simpson, & Katrak, 2010; Dean et al., 2010).
Stroke Rehab – a mixed bag
Access to ongoing specialised multidisciplinary stroke rehabilitation
improves outcomes, but accessing such services may well come down to
luck (Enderby et al., 2016). Major questions remain how to best provide a
quality service. Effective teamwork for any group of health
professionals does not always come naturally and requires good
leadership from many areas within the rehabilitation team. The
old-school hierarchy medical model still lingers and may not always
encourage the most effective interdisciplinary working. For those stroke
survivors with rapid recovery, early discharge home can mean a quick
shift to a community rehabilitation model which is usually either
fragmented or non-existent. Rapid recovery and early discharge is
obviously preferable, but dealing with any ongoing issues such as
cognitive dysfunction, fatigue or depression can lead to significant
ongoing issues, which can be difficult to manage in a more disjointed
community setting.
Rehabilitation Potential – where is this heading?
Deciding on who would benefit from rehabilitation is becoming
increasingly influenced by resource pressures. Even if a stroke service
does employ quality health professionals who have patient priorities at
heart, it is naive to think that the ‘selection’ for rehabilitation is
not influenced by predicted length of stay and perceived ‘potential’ for
improvement. Predicting rehabilitation ‘potential’ is often viewed as a
dangerous game, as experienced clinicians know all too well that there
are just so many variables to consider. Movement recovery is influenced
by motor, sensory, visuospatial, psychological and other many other
musculoskeletal complications and comorbidities. Predicting recovery is
extremely difficult, no matter how experienced you think you are.
Neuroscientists hope to assist in this process one day, with the
addition of investigations and procedures that can more accurately
measure the integrity of central nervous pathways needed for more
optimal recovery (Stinear, Barber, Petoe, Anwar, & Byblow, 2012).
This kind of research could be be viewed either with a glass half full
or empty. Some hope that the ability to measure ‘potential’ would enable
us to recognize potential in those people who would otherwise miss the
opportunity receive therapy. Others may be concerned with the idea of a
‘self-fulfilling prophecy’ where there is a real belief that improvement
cannot occur. This could lead to sub-optimal therapy, or even no access
to therapy, with no opportunity for stroke survivors to engage in a
process that could provide vital support and care. This is a prime
example where evidence needs to be carefully placed into the context of a
comprehensive, patient-centred rehabilitation model. At present,
recovery research tells a consistent story – those that recovery well
have the capacity respond to therapy – in other words those that recover
better, do better! (Kitago & Krakauer, 2013) Belief mechanisms
within the human psyche is very powerful, and can have an enormous
negative impact on many health conditions such as chronic pain, chronic
disability and depression. All stroke survivors have a right to know
about specialized stroke rehabilitation. Perhaps predictive research
should be complemented by research that examines access to therapy and
true patient centered goal setting (McKenna, Martin, Jones, Gracey,
& Lennon, 2015).
Compensation vs motor recovery – aim high, stay true.
Rehabilitation interventions for a number of stroke impairments
inevitably lead into discussions about ‘recovery’ versus
‘compensation’(Levin, Kleim, & Wolf, 2009). In what circumstance
does a speech therapist decide to move away from strategies to
relearning expressive speech, to start a process that encourages
alternative compensations such gesturing and communication technology?
When does a physiotherapist or occupational therapist move away from
encouraging and practicing arm and hand function recovery in the
affected arm, and encourage an increased use of the unaffected arm for
functional tasks? When does a physiotherapist decide that mobility can
no longer progress to faster, more independent gait, and must remain a
slow and careful gait with a quad stick? Of course goal setting
influences all of these decisions, but the overarching stress of length
of stay and safe discharge is always there. The unfortunate reality is
that health professionals are often syphoned down a service delivery
path where optimal recovery cannot realistically be reached, regardless
of any ‘potential’. Movement quality can be more difficult to research,
but while enhancing movement quality and performance may be preferable,
it may not lead to measurable change. This may be due to a number of
factors. Outcome measures used in research may not distinguish between
new skills in movement performance and compensatory movements (Levin et
al., 2009). In many circumstances, compensatory movements provide the
meaningful functional change at a faster rate, which is often
preferable. Changing movement quality and skill acquisition may take a
little longer, and the challenge is determining reasons to train
movement to another level. A proportion of people after stroke will have
the capacity to change further and some will not. Hitching hips, trunk
leans, major gait asymmetry, stiff hyperextending knees and internally
rotated shoulders may well lead to pain and structural musculoskeletal
changes sooner rather than later. Skilled and experienced therapists
will help stroke survivors work toward preferred movement performance
that fits with their goals and lifestyle – for the rest of their life!
Handy developments
Upper limb and hand recovery after stroke is great example where the
requirement to tighten resources intersects with accumulating
neuroscientific and clinical evidence. Over the past 15+ years there has
been a growing field of neuroscientific research into the motor
recovery of upper limb function. Functional MRI (Ward, 2015),
Transcranial Magnetic Stimulation (Reis et al., 2008) and
magnetoencephalography (Paggiaro et al., 2016) research is attractive
reading for those of us interested in how the brain reorganizes itself
after stroke. It gives us some useful information about how we can
measure neuroplastic recovery processes. Brain stimulation also has
given glimpses as potential adjunct to enhance active therapy. However,
Its role in exciting or inhibiting areas of the brain with an aim of
enhancing neuroplasticity has shown only small effects for hand
function, although potential for reducing visuospatial neglect still
looks promising (Müri et al., 2013). At the front line however, these
interesting findings are not really having any direct influence on upper
limb therapy, due to inaccessibility, cost and small effects (Ward
& Kitago, 2016). We are still a long way of designing interventions
based on this neuroscientific research, although the SEnse trial to
improve for hand sensory function is a notable exception (Carey,
Macdonell, & Matyas, 2011). Most forms of upper limb therapy are
based on practice based experience, observation, motor control theories
and are almost impossible to categorise and define. Constraint Induced
movement Therapy (CIMT) stemmed from behavioural neuroscience
experiments with macaque monkeys, based on the concept of learned
non-use. Movement analysis reveals that upper limb recovery can be a mix
of compensatory movements as well as relearning some movements again –
both neuroplastic processes. It is disappointing that so many
neurological therapists still show fanatical tendencies, and firmly
plant themselves in quite vague categories or ‘approaches’. Defining a
therapy intervention can be difficult enough, and methodological flaws
in research reflect this. Current evidence suggests these differing
‘approaches’ are no more or less effective when it comes to stroke
rehabilitation (Pollock et al., 2014). More clearly defined therapy
protocols of CIMT and some task specific practice allow for some useful
information to be extrapolated. Even these these protocols involved a
blend of elements may all contribute to recovery – such as forced-use,
repetitive practice, behaviour modification and intensity (Taub et al.,
2013). Mixed approaches using a variety of verbal, tactile, passive and
active movements, or those that intend to encourage motor priming
(Stoykov & Madhavan, 2015) are very difficult to research, and will
require further movement analysis. Movement analysis is any area of
growing research, and is worth following as it may well help in
identifying key therapeutic targets for movement retraining. Gait
analysis has helped us identify key impairments after stroke (Arene
& Hidler, 2015), and more research is needed with regard upper limb
movement kinematics that will help in identifying key movements to aid
upper limb function (more than just reach & grasp!) (Murphy &
Häger, 2015). Despite this, upper limb therapy evidence remains quite
limited. It has been suggested that upper limb and hand recovery after
stroke may be more influenced by spontaneous biological recovery rather
than any activity-dependent therapy intervention! Maybe in many
circumstances therapists are just ‘overseeing and monitoring’ natural
recovery. Of course, this is debateable as many interventions may be
critical to stimulate recovery, enhance body schema and spatial
awareness, coach postural control, encourage arm use and prevent
complication such as contracture in key muscle groups and shoulder pain.
Remember the brain is plastic, but the body is not! Again, people whose
upper limbs recover better, do better! Animal studies indicate that
spontaneous biological recovery is likely limited to a certain period
after stroke, possibly within the first 3 months (Kitago & Krakauer,
2013). Within this, there may even be a critical period where
neuroplastic potential is heightened. Therapy may be able to capitalise
on this period, so further research such as the current collaborative
work currently being undertaken by South Australian and London
researchers will be worth following (McDonnell et al., 2015).
Is timing everything?
Often stroke interventions research include chronic stroke patients
beyond 6 months, to demonstrate that any change is more likely due to
the intervention, rather than spontaneous biological recovery. With the
disappointing results of many stroke rehabilitation interventions that
show small effects, it may well be worth considering interventions that
start earlier that enhance the effects of spontaneous recovery and push
into later subacute periods where rehabilitation progress is often
disrupted by discharge (Stinear, 2016). The AVERT trial is an extremely
impressive example of multicentre research in the acute phase. Results
indicate that very intensive early mobilisation may not be suitable for
many people after stroke (AVERT Trial Collaboration group et al., 2015).
Perhaps the brain in the immediate phase following stroke has certain
limitations and vulnerabilities that need considering. This may also
explain why early, intense CIMT may also lead to less favourable
outcomes (Dromerick et al., 2009). However, the EXCITE trial, another
impressive multicentre trial involving sub-acute patients 3-9 months
post stroke, showed some longer lasting benefits of CIMT for upper limb
function that persist at 12-months (Wolf et al., 2006). Body weight
support treadmill training for non-ambulant acute stroke patients has
some clear benefits leading to more people recovering mobility at 12
months (Dean et al., 2010). Rehabilitation timing is likely to be very
important, and combining interventions at certain times may be worth
careful consideration with future research. There are many factors
influenced by time and include, deconditioning, weakness, fitness,
contracture and length of stay financial pressures.
Overdosed on evidence
While some say ‘timing is everything’, the biggest theme more
recently has been ‘more is better’ (Lang et al., 2016). An intensive
dose of practice is considered by many to be a necessary requirement for
neuroplastic change. Constraint induced protocols for speech and upper
limb function are very intensive programs that provide the strongest
evidence to date. One of the main criticisms of the original CIMT upper
limb protocol was the feasibility of such an intense 6-hour a day
program. Intensity and ‘dose’ however are not the one in the same. The
dose of task specific practice within CIMT is likely to be quite
important, but the almost relentless daily reflection of upper limb use
appears to be an effective form of behaviour modification, to increase
upper limb use (Taub et al., 2013). Recent investigation investigating
the dose of task specific practice suggests that the dose effect for
this form of therapy will plateaux, which reminds that type and
intensity of therapy may need to be examined further (Lang et al.,
2016). It is not all about repetitions! We now must consider more
innovative ways to ‘intensify’ task specific practice. Increasing
sensorimotor feedback combined with attention, shaping and task specific
tasks may further enhance plasticity. Sensory stimulation, facilitation
techniques, robotics, supports, electrical stimulation, brain
stimulation, virtual reality, imaging techniques, aerobic training,
strength training and even pharmacological assistance with SSRIs (Mead
et al., 2013) have the potential to prime the brain and gain more
benefit from therapy. Most of these techniques complement each other and
can be quite easily combined with part or whole task specific practice.
What is certain – something must change (Bernhardt et al., 2016;
Stinear, 2016)! In addition, many of these methods may provide some
alternative for the majority of people with more severely affected upper
limbs who cannot undertake many of the currently recommended task
specific protocols.
Where to from here?
It is hard to predict where stroke rehabilitation will be in the next
few decades. There are certainly some priorities to look at;
Education – practice is not following the evidence,
particularly best practice guidelines. This is a fact. Something should
change in the educational sector to ensure therapists are confident and
equipped to perform adequate therapy. Perhaps less lectures and more
practical sessions to run through a checklist of competencies? Many
experienced therapists find themselves as managers or even academics,
where paperwork takes over. Structured mentorship and clinical
supervision should be mandatory. An audit feedback process is important,
and guidelines may need to be more specific (and less vague!) (Janzen,
McIntyre, Richardson, Britt, & Teasell, 2016).
Rehabilitation priorities – combining interventions,
starting earlier and lasting longer (Stinear, 2016). What are the best
outcomes to measure for people with more severe disabilities? How can we
prevent these people from missing out on important care? We need to
push and promote neurorehab, especially aspects such as
cost-effectiveness (Turner-Stokes, Williams, Bill, Bassett, &
Sephton, 2016).
Technology – we have an appetite for technology and its
potential is enormous! Are robots cost-effective and useful? Does
Virtual Reality improve motivation and create and environment for
enhanced learning? How do we research or purchase new technology, even
though it changes so fast? Staff training required? Maintenance costs?
Safe to use at home? Does it need to be prescribed? So many questions!
Tele rehabilitation needs more research, but could be a game changer
(Laver et al., 2013). One thing is for sure – we will be using
technology more, and it will change practice.
Living with stroke – once you survive a stroke, it is the
transition to living with a disability for many years that may be the
real priority (Crichton, Bray, McKevitt, Rudd, & Wolfe, 2016).
Community rehabilitation must get creative to evolve and survive
(Teasell et al., 2012). Long term health issues (Towfighi, Markovic,
& Ovbiagele, 2012), complications and shifting priorities over time
means that self-management (McKenna et al., 2015), goals setting,
accessibility and support will need to be available from multiple
services in the community (Rimmer, 2012). Community rehabilitation is
the next frontier!
Stroke motor recovery research is moving in many directions. Let’s
keep up the pressure and steer research and service delivery in the
right direction to ensure a better life for those people who survive a
stroke.
Associate Professor James McLoughlin
BAppSc (Physio), MSc (Clinical Neuroscience), PhD
James is an experienced neurological physiotherapist, and has been
lecturer in stroke rehabilitation at Flinders University for over 10
years. He also Director at neurophysiotherapy.com.au
Use the labels in the right column to find what you want. Or you can go thru them one by one, there are only 28,983 posts. Searching is done in the search box in upper left corner. I blog on anything to do with stroke.DO NOT DO ANYTHING SUGGESTED HERE AS I AM NOT MEDICALLY TRAINED, YOUR DOCTOR IS, LISTEN TO THEM. BUT I BET THEY DON'T KNOW HOW TO GET YOU 100% RECOVERED. I DON'T EITHER, BUT HAVE PLENTY OF QUESTIONS FOR YOUR DOCTOR TO ANSWER.
Changing stroke rehab and research worldwide now.Time is Brain! trillions and trillions of neurons that DIE each day because there are NO effective hyperacute therapies besides tPA(only 12% effective). I have 523 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:
My blog is not to help survivors recover, it is to have the 10 million yearly stroke survivors light fires underneath their doctors, stroke hospitals and stroke researchers to get stroke solved. 100% recovery. The stroke medical world is completely failing at that goal, they don't even have it as a goal. 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 lays out what needs to be done to get stroke survivors closer to 100% recovery. It's quite disgusting that this information is not available from every stroke association and doctors group.
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