Stroke Clinical Guidelines

For this month’s journal club, I’ve chosen to feature the Australian Stroke Foundation’s Clinical Guidelines (2017) which were released in September. Clinical guidelines play a very important role in clinical practice and they are increasingly seen by the general public as what should and should not be doing as healthcare professionals.

When we have a question about clinical practice, rather than having to work through all the most recent evidence for ourselves, we can be thankful that an army of colleagues have already done this work for us. I disclose that I was involved in one of the sections relating to activities of daily living, but this does not result in any financial gains. Many countries have their own clinical guidelines, so keep in mind that the ones being featured here in the October Journal Club, are specific to the Australian context.

If you’re a health professional working with people directly affected by stroke, then you should be familiar with the clinical guidelines that are most relevant to your work place. For “humble opinion”, please go do this month’s Journal Club page.

Caregivers and Stroke

September 2017: Krieger et al. (2017) Developing a complex intervention program for informal caregivers of stroke survivors: The Caregivers’ Guide. Scandinavian Journal of Caring Sciences, 31(1), 146-156. DOI 10.1111/scs.12344

Yet again, I had the honour of presenting to therapists on stroke recovery; this time in Sydney. One of the questions we discussed at some length was the answer to the following question: “Whose stroke is it?” This is something I’ve been thinking a lot about in recent years. The processes of documenting stroke in health facilities clearly identifies the stroke as “belonging” to the facility, and yet, the actual stroke leaves the facility inside the head of the survivor. In fact, the long-term impact of stroke eventually falls almost entirely to the survivors and their families and carers. They are the people who carry the burden, who grieve the loss and who live with the stroke’s consequences and complications. As I say, “Whose stroke is it?”

I’ve selected this month’s journal article because these authors are reporting evidence about the impact of stroke on families and the benefits of well organised support framework for families and carers. You’ll find the article’s abstract and “Humble Opinion” in its usual place under this topic on the 2017 Journal Club page. This article is freely available at http://onlinelibrary.wiley.com/doi/10.1111/scs.12344/full

Changing Stroke book

It is my very great pleasure to let you know that my new book titled: Changing Stroke: Radical Rethink of Recovery, is now available!

The book costs AUD$45 and, for Australian customers, this includes GST. Please note, there are additional costs for packaging and postage which are dependent on where you live. To purchase it online, go to: http://www.cpdlife.com/changing-stroke-book/

I tried to write a book that wasn’t too long or too technical. I hope I’ve achieved this, and I hope you enjoy reading it. Regards, Isobel

“Changing Stroke is a must-read for clinicians who work with stroke survivors and who want to make a real difference. It is an essential read for clinicians passionate about optimising stroke recovery using evidence-based therapy, and doing so with empathy.”

Dr Heidi Janssen

Nordic Walking After Stroke

August 2017:  Kang et al., (2016). Six-week Nordic Treadmill Training compared with Treadmill Training on balance, gait, and activities of daily living for stroke patients: A randomized controlled trial. Journal of Stroke and Cerebrovascular Diseases25(4), 848-856. doi:10.1016/j.jstrokecerebrovasdis.2015.11.037

This month’s Journal Club is a first!! It’s the very first time that someone else has written the JC post and “humble opinion”. If you’d like to be next, please contact me via the CPDLife® contact page. My thanks to Mandy Shintani and Gabriella De Nino who nominated the article and wrote the following post. They have also added their comments (humble opinion) to the August 2017 journal club page. Thanks Mandy and Gabriella.

Post authored by Mandy and Gabriella: While awareness is increasing among therapists of the potential benefits of Nordic Walking (NW) for gait and balance retraining, there appears to be limited use of this treatment approach for those recovering from stroke, which may be attributed in part to the lack of research in this population.  To date, NW has been well researched with more than 200 studies posted on PubMed regarding other conditions affecting balance, including Parkinson’s disease. Based on these studies, which found significant improvements in balance, gait speed, posture, stride length and Activities of Daily Living (ADL), the researchers hypothesize that Nordic Treadmill Training (NTT) could be tremendously effective for gait retraining after stroke.  Kang et al (2016) are the first to demonstrate the benefits of NTT in terms of balance, gait and activities of daily living for participants with hemiparesis. They present results demonstrating the benefits of NTT when compared to regular treadmill training (TT).  However, it is important to note that their study used a modified technique of simulating NW with the constant assistance of a therapist.

The findings of Kang et al (2016) are well worth reading. They highlight the importance of arm swing and contralateral leg movement for balance and gait. This study will hopefully pave the way for further research on regular NW which in my opinion may be safer for independent use than NTT and more cost effective in a clinical setting. NW is an exciting new treatment approach that has the potential to promote active living for those on the road to recovery. For the abstract and my comments, go to Journal Club 2017. You can access this article at https://www.ncbi.nlm.nih.gov/pubmed/26796052

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.