Neuroplasticity After Stroke

July 2017: Livingston-Thomas et al. (2016) Exercise and environmental enrichment of task-specific neuroplasticity and stroke recovery. Neurotherapeutics, 13, 395-402. DOI 10.1007/s13311-016-0423-9

Earlier this week I was in Melbourne running a 2-Day Neuroplasticity workshop. My thanks to all those who attended – such an enervating and inspiring group of therapists. Two of the issues we discussed were firstly, the fact that neuroplasticity is an “umbrella term” that includes both brain reorganization and neurogenesis; and secondly, the fact that some of the neuroplasticity literature can be really difficult to read and comprehend. Its important that we don’t allow this difficulty to prevent us from understanding neuroplasticity because, after the first few hours post-stroke, it is foundational to all recovery in all people diagnosed with all strokes.

This article explores neuroplasticity from more of a neurogenesis perspective. Sure, it is hard to read, but not impossible to understand. What I reckon these authors give us, is an intriguing review of the literature relating to two of the most contemporary issues in stroke recovery; physical activity and an enriched environment. This is well worth reading, and yes, it may take some extra concentration! You’ll find “Humble Opinion” in its usual place under this topic on the 2017 Journal Club page.

Just to give you the “heads-up”, I reckon my book will be released in August. It’s titled (surprise, surprise!!) Changing Stroke: Radical Rethink of Recovery.

Robotics & Upper Limb Outcomes

June 2017: Veerbeek et al (2017) Effects of robot-assisted therapy for upper limb after stroke: A systematic review and meta-analysis. Neurorehabilitation and Neural Repair, 3(230, 107-121. DOI: 10.1177/1545968316666957

Do we employ technology in patients with stroke after there is evidence that it is effective, or do we employ it on the basis of theory, for example, it increases the amount of repetitions in task-specific training? It’s a tricky question, but keep in mind that much of what we used to do in stroke rehabilitation was never clinically proven before we employed it! In fact, in some instances, for example splinting after stroke, evidence has since demonstrated that it is ineffective, and now we have the challenge of convincing some health professionals to NOT use it in therapy!! It is a chicken-and-the-egg situation, isn’t it? Which comes first?

To add to this tricky’ness is the issue of what to do when evidence, even high-level evidence like a systematic review and meta-analysis, does not clearly indicate either way. This is the result of Veerbeek et al’s study. In their conclusion they state: “RT-UL [robotic-assisted therapy for the paretic upper limb] allows patients to increase the number of repetitions and hence intensity of practice poststroke, and appears to be a safe therapy. Effects on motor control are small and specific to the joints targeted by RT-UL, whereas no generalization is found to improvements in upper limb capacity”.

It’s very easy to wish for a more definitive result, but this is what the researchers found. Still well worth reading. You’ll find “Humble Opinion” in its usual place under this topic on the 2017 Journal Club page.

Predicting Recovery

May 2017: Stinear et al (2017 In Press) Predicting recovery potential for individual stroke patients increases rehabilitation efficiency. Stroke, https://doi.org/10.1161/STROKEAHA.116.015790

This is a topic that I have been thinking so much about in recent years. The evidence indicating a strong association between severity of upper limb dysfunction and long-term functional outcomes is compelling, and some of the principal contributors to this evidence are Drs Cathy Stinear, Winston Byblow and Alan Barber. All three live and work in the North Island of beautiful New Zealand. For many years now, they have headed up a team of researchers who continue to publish in health journals with high scientific integrity.

This article is yet another in their PREP series: Predicting Recovery Potential. However, what sets it apart is that it tests the PREP algorithm in the clinical workplace. It comes as no surprise that they have been able to demonstrate that the “PREP algorithm predictions modify therapy content and increase rehabilitation efficiency after stroke without compromising clinical outcome”. My congratulations go to these three amazing researchers. This article is well worth reading. You’ll find “Humble Opinion” in its usual place under this topic on the 2017 Journal Club page.

Behavioural Domains

April 2017: Ramsey et al (2017) Behavioural clusters and predictors of performance during recovery from stroke. Nature Human Behaviour, Early Online, DOI: 10.1038/s41562-016-0038

Although this may be a difficult “read”, its this month’s journal article because it challenges the way we think about stroke recovery and particular impairments or areas of dysfunction. To date, our understanding of the impact of stroke is usually in terms of differentiating between impairments. Different therapists see patients with different impairments based on their professional expertise . For example, speech pathologists manage patients with language impairments. However, what Ramsey et al found challenges this approach. In relation to recovery in the first 12 months after first-ever stroke, they have found a clustering of impairments and two behavioural domains: 1) motor and attention; and 2) language and memory. This means we may need to re-think our differentiation and management of impairments after stroke.

This article is freely available and is well worth reading. To find the abstract and “humble opinion”, go to Journal Club 2017 and select: Behavioural Domains.

Self-Assessment After Stroke

March 2017: Törnbom et al  (2017) Self-Assessed Physical, Cognitive, and Emotional Impact of Stroke at 1 Month: The Importance of Stroke Severity and Participation. Journal of stroke and Cerebrovascular Diseases, 26(1), 57-63, http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2016.08.029

The last journal article I posted about on CS in December 2016, reported the prevalence of impairments after stroke; so this article seemed like a useful “other side of the coin” article to review for February 2017. In contrast to Lawrence et al, Törnbom et al give voice to the people directly affected by stroke. In the words of the authors, the “aims of this study were to describe the self-assessed physical, emotional, and cognitive impact of stroke. and to investigate associations with participation and stroke severity at 1 month poststroke”.

What is the actual experience of those who are recovering from stroke, and more particularly, those with a stroke-affected upper limb? Good question! Also, do the early self-assessments of their own experiences, have any association with what actually occurs one month down the track? If you want to know more, this article is well worth reading!

The PdF is freely available at: http://www.strokejournal.org/article/S1052-3057(16)30301-9/pdf To find the full reference, abstract and “humble opinion”, go to Journal Club 2017 and Self-Assessment After Stroke.

Active Brain | Active Body

Here’s wishing you all the very best for 2017! As I’ve done in previous years, I’m going to start this year off with a Changing Stroke project. Journal Club and “humble opinion” will kick off in February.

Are you looking for an interesting Quality Improvement project for 2017? If so, what about joining others in the Active Brain | Active Body project? It’s something I developed for an acute stroke unit in New South Wales Australia, and, considering it’s applicability, I’m thinking, “why not share it” so others can do the same.

To find out more, select the Active Brain | Active Body tab under the CS Project tab. Here’s hoping the attachment on the project’s page gives you a useful starting point, but of course you’ll need to modify the project to your own clinical context.

Let me know what you think about the project and let me know if you have other ideas that could bridge the practice-evidence gap in people recovering from stroke.

Thanks again to the faithful followers of my blog. I look forward to another interesting year as we journey together.

 

Impairments after Stroke

December 2016: Lawrence et al (2001) Estimates of the prevalence of acute stroke impairments and disability in a multiethnic population. Stroke, 32, 1279-1284 http://dx.doi.org/10.1161/01.STR.32.6.1279

OK, so this is a bit weird! I’m reviewing an article that was published 6 years ago!! What are you doing Isobel? Isn’t one of your aims to make sure you only ever review recently-published evidence?

True, but this time I’m going to make an exception. I’m currently in the process of writing a book!! It’s titled “Stroke and the Upper Limb: A practical guide for therapists”. I’m aiming to launch it mid-way through next year. Whilst researching the evidence about predicting upper limb recovery, I wanted to find out how prevalent upper limb dysfunction was and where it ranked on the prevalence “hierarchy”. I probably shouldn’t have been surprised, but Lawrence et al (2001) report that upper limb motor dysfunction has the highest prevalence in patients 3 months post-stroke. At 77% of all patients, it comes in just in front of lower limb motor dysfunction. No wonder we see so many patients with motor dysfunction!

This article is a really interesting “read” if you’d like to know more about the prevalence hierarchy of impairments early after stroke. I also thought this was a good place to conclude this year’s Journal Club. Our aim is to reduce the impact of stroke and this article is a useful summary of the oh-so-many impairments that patients experience after stroke. The article is publicly available at: http://stroke.ahajournals.org/content/32/6/1279.short

To find the full reference, abstract and “humble opinion”, go to Journal Club 2016 and Impairments After Stroke.