Except that successful rehabilitation only occurs 10% of the time. To get better at that you're going to have to stop the 5 causes of the neuronal cascade of death in
the first days, saving millions to billions of neurons. That might allow your rehab to actually work. What you call successful is the tyranny of low expectations that your survivors don't want. They want 100% recovery. GET THERE!
A cohesive, person-centric evidence-based model for successful rehabilitation after stroke and other disabling conditions
Professor Derick Wade, in his valedictory editorial for Clinical Rehabilitation
after 27 years in the editor's chair, makes many important observations
about the changing understanding of rehabilitation during his
professional life and reflects on his phenomenal contribution to the
field.1 Most importantly, he states that ‘rehabilitation is
much broader than traditional medical practice’ and that ‘psychology,
sociology and other behavioural sciences’ are relevant to its practice.
He champions the Biopsychosocial model of wellness and despairs of the
‘biomedical approach’ to much of non-rehabilitation medicine. He
concludes that he has ‘developed a reasonably cohesive model of what
rehabilitation is’.2 We think he could go further and, in
this article, using a much broader time horizon and evidence from large,
randomised trials, we propose a cohesive model for rehabilitation with
the evidence mainly from the field of stroke, arguing that successful
rehabilitation depends most on the person, not the health professionals
who may be involved.(WRONG, WRONG, WRONG! The health professional is required to provide EXACT REHAB PROTOCOLS LEADING TO 100% RECOVERY! Anything less is incompetence.) This key idea requires us to rethink current
rehabilitation dogma, including the pre-eminence of the health
professional team, the belief that success is fundamentally about
rehabilitation ‘dose’ and the use of ‘SMART’ (Specific Measurable
Achievable Realistic Timed) and similar goal-setting strategies.
In
1972, Dr Howard Rusk, often credited as the ‘father’ of modern
comprehensive rehabilitation, proposed two principles for successful
rehabilitation outcomes.3 The first was that ‘the whole person needed rehabilitation, not just the part of him that had been damaged’ and the second that ‘Ultimately, the success of all rehabilitation depends on the patient himself’. Even earlier, Abraham Maslow, one of the great pioneers of modern psychology, proposed that ‘the integrated wholeness of the organism must be one of the foundation stones of motivation theory’.4
Few
rehabilitation clinicians today would argue with these statements, as
they express the ideas that formed the ‘Biopsychosocial model of
wellness’5,6
which remains a core part of modern rehabilitation teaching. Yet, in
the intervening 50 years, the actual practice of rehabilitation has
focussed more and more on the ‘damaged part’ and less and less on the
‘whole person’. We argue here that the theory of a balanced
Biopsychosocial model has become distorted in clinical practice to a
biomedical-dominant idea of what successful rehabilitation is,
particularly in the belief that ‘more therapy improves outcomes’ (Figure 1).
With the focus on delivery of therapy, the balance in the therapeutic
relationship between the person and the rehabilitation team has changed
from the theoretical ideal of an equal partnership to one where the
rehabilitation team dominates.
A
recent Cochrane review found no convincing evidence that more
rehabilitation therapy leads to better outcomes for people with stroke.7
Evidence from large, randomised trials in stroke, not included in the
Cochrane review, have also failed to demonstrate a benefit for various
types and doses of extra rehabilitation therapy, as we detail below.
This evidence raises two important questions: (1) Is there a fundamental
problem with the current dominant rehabilitation approach? And (2) Is
there evidence to support an alternative? We think the answer to both
these questions is ‘Yes’.
In the following
paragraphs, we chart the rise of the ‘more therapy is better’ approach
interrogating the evidence; propose an alternative and more
Biopsychosocial approach applied in a person-centric manner with
supportive evidence from randomised trials; and suggest the next steps
for rehabilitation practice, practitioner training and research.
The rise of the ‘more therapy leads to better outcomes’ hypothesis
Supporters
of a narrow biomedical approach to stroke rehabilitation point to a
combination of ideas and evidence. The main ideas are that increased
amounts of physical activity should enhance neuroplasticity in people
with brain damage from stroke and that – just as increases in practice
work for athletes who want to run further or faster or lift heavier
weights – the same should apply to people recovering from a stroke.
The
evidence underpinning this argument comes from three main sources. The
first was a highly influential study by Kwakkel et al., and accompanying
editorial published in The Lancet in 1999.8,9
This small (n = 101, around 3% of all people screened) randomised
controlled trial (RCT) with three arms compared significantly disabled
patients with middle cerebral artery stroke receiving a baseline of 4
hours/week of usual rehabilitation therapy plus the use of an
immobilising splint on their paretic arm and leg for 30 minutes five
times a week for 20 weeks (the control group) against an additional 30
minutes five times a week of either arm therapy or leg therapy instead
of the splint. The authors point to statistically significant
differences in Barthel Index (BI) at 26 weeks after stroke as evidence
that more exercise leads to more functional gains. The accompanying
editorial said that ‘this study shows how great an effect a small
quantity of a specific input may achieve’ and that ‘Few pharmaceutical
or surgical interventions are so powerful’.9
The
main problem with these conclusions was the significant imbalance of
groups at baseline and associated failure to consider the natural
recovery pathway for different types of ischaemic stroke when using a
fixed assessment time point. The control group had more patients with
total anterior circulation infarcts (TACIs), that is, large carotid
territory strokes (control 68% vs. arm training 58% vs. leg training
55%) reflected in better baseline scores for activities of daily living
and walking ability in the leg training group.10
The rate of gain in BI points over time for patients with TACIs is only
32–43% that of other (smaller) types of anterior circulation strokes.11
At 26 weeks, we would expect the best BI scores in the group with the
lowest proportion of TACIs, that is, the leg training group, which this
study confirmed.
This interpretation is supported by the 1-year follow-up results12
which show more of the control group patients improving and many fewer
deteriorating between six months and 12 months than the two ‘active’
groups on BI score, walking speed, walking ability and hand dexterity.
At 12 months, there was no difference between the three groups on any of
the primary outcome measures. In summary, the additional therapy in
this study made no difference to outcomes at the level of impairment or
activity at 12 months.
The second strand of
evidence comes from the Stroke Unit trials. These trials compared
variable forms of organised inpatient stroke care (OISC) (either
specialist stroke wards, mixed acute and rehabilitation stroke units or
mobile stroke teams) with care on general medical wards with patients
randomised and transferred to OISC any time from very early after stroke
to a few weeks later.13
Key publications between 1993 and 1997 combined the results of several
studies, conclusively showing a reduction in mortality for people with
stroke managed in an OISC setting compared to a general medical ward
with less clear improvements in the prospects of returning home and
regaining independence in usual activities.14
The
authors of the 1997 collaboration (19 trials, >3000 participants)
used the features that were more common in OISC settings and less common
in general ward settings to describe and recommend implementation of
the ‘distinctive features’ of OISC: viz. organisation (coordinated
multidisciplinary team care, nursing integration with multidisciplinary
care and involvement of carers in the rehabilitation process),
specialisation (medical and nursing interest and expertise in stroke and
rehabilitation) and education (education and training programmes for
staff, patients and carers).14
Only
half (9/17, 53%) of OISC settings provided more physiotherapy or
occupational therapy and a third provided earlier therapy intervention
(7/20, 35%) than the general medical ward comparators. The authors
concluded that ‘the benefits of organised stroke unit care, as opposed
to conventional care, are not clearly due to … staff mix, or the amount
of medical, nursing, and therapy input available’.14
Nevertheless, over time, the idea that more intensive, earlier therapy
was the key to better outcomes gained ground. With this has come the
rise of clinician experts, working in teams, determining the type and
dose of rehabilitation for the person, linked to a goal-setting strategy
– dominated by SMART goals – that can have the effect of reinforcing
clinician power over patient autonomy.15,16
Third, and most compelling at face value, are systematic reviews and modelling studies which, until the recent Cochrane review,7 provide strong conclusions supporting the idea that more therapy leads to better outcomes. Three of these reviews,17,19 detailed in Table 1,
form the basis for the strong recommendation ‘to provide as much
therapy as possible’ in the Australasian stroke rehabilitation
guidelines,20 the most recently revised international guidelines. However, the more recent systematic review7
concludes the opposite – that ‘An increase in time spent in the same
type of rehabilitation after stroke results in little to no difference
in meaningful activities such as activities of daily living and
activities of the upper and lower limb’. They point to the possibility
that a much bigger dose (almost 17 extra hours) may produce a
significant difference in the outcome, but the size of the effect would
be small and ‘unlikely to represent a clinically meaningful change to a
stroke survivor’.7
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