Predicting Recovery After Stroke

April 2020 Journal Club

Reference: Stinear et al (2019) Prediction tools for stroke rehabilitation, Stroke 50(11), 3314-3322 DOI: 10.1161/STROKEAHA.119.025696

Humble Opinion: I know! I’m back on one of my favourite topics again! Please forgive me – but, as these authors rightly point out:

“Clinicians rate the patient’s prognosis for functional recovery as the most important factor when considering discharge destination from the acute setting.”

I’ve often presented on the need to be able to predict recovery potential after stroke, and sometimes at my own peril! As those of you who have followed me for some time will know, its one of the reasons I’ve always kept a close eye on the publications of Cathy Stinear and Winston Byblow. The other reason is that both of them, alongside many others researchers, have focussed much of their academic careers investigating recovery after stroke. This publication is not research, but a narrative review. However, I think many of you will find it very interesting indeed. Not only do the authors work their way through many areas of potential dysfunction after stroke, they also explain, along the way, the nuances of what predicting recovery potential is, and is not, about. As is usually the case, the authors keep their discussion firmly set in the “real world” of clinicians, therapy, and most importantly, the people directly affected by stroke. Answers to the “so what” question is an ever-present thread in their discussion.

This review synthesises the evidence related to predicting recovery in independence and disability, upper limb function, walking, independent walking, community ambulation and swallowing. As the authors rightly point out, there’s not enough evidence yet, to review communication, cognition, depression, return to work and driving. If you’re interested in how best to predict recovery after stroke, then this is an article well worth reading in my humble opinion. At the very least, it will point you in the right direction. The article is not publicly available; therefore, if you can’t gain access via other means you may need to purchase it or contact the corresponding author. Because there’s no abstract, you’ll find the opening paragraph of the article posted under the Journal Club 2020 tab.

Stroke and Infectious Diseases

Journal Club March 2020: Blackburn et al (2018) Laboratory-confirmed respiratory infections as predictors of hospital admission for myocardial infarction and stroke: Time-series analysis of English data for 2004-2015. Clinical Infectious Diseases, 67(1), 8-17, https://academic.oup.com/cid/article/67/1/8/4791948

Comment: I’ve never asked myself this before, but, as concern about, and infections from, COVID-19 start to spread globally, I wondered: Is there an association between respiratory infections and stroke? I’m certainly not meaning to be alarmist, or cause any offence by even giving this some consideration, but yes, is there any association? Obviously, it’s far, far too early to know if “respiratory infections” includes COVID-19.

Before I tell you about what I found, can I quickly extol the incredible contribution of clinical epidemiologists and biostatisticians at times like these. Together, their expertise maps patterns across populations, with particular focus on cause and effect. When a totally new disease “arrives”, like COVID-19, the role of these experts come to the fore. Without them, we’re unable to map, explore, understand, respond to, and/or learn from, the impact of diseases on our communities, societies and world-wide. Many of my colleagues are clinical epidemiologists and biostatisticians. Their work is mainly viewed within the context of journal publications and conference presentations, but at times like these, we do well to appreciate their significant contribution to our ability to overcome global diseases like COVID-19.

So, back to my question. Blackburn et al (2018) found an association between increases in hospital admissions for respiratory diseases and increases in hospital admissions for stroke, but that association was limited to certain diagnoses and it was only present in the elderly. It will, of course, be some years before we know if this association includes COVID-19 or not.  As always, this is just my humble opinion. Please read this article for yourself before you make up your own mind. To find the abstract, go to Journal Club 2020 and select Stroke and Infections Diseases.

Predicting Upper Limb Recovery

van der Vliet et al (Accepted manuscript) Predicting upper limb motor impairment recovery after stroke: a mixture model. Annals of Neurology, https://onlinelibrary.wiley.com/doi/abs/10.1002/ana.25679

This is the first time I’ve referenced an article that’s still being edited! Be assured it’s been accepted by the journal, but it’s sooo.. recent, that it’s not even “in press” yet!

Acknowledging that this article comes out of Gert Kwakkel’s research team, it’s yet more confirmation that upper limb recovery after stroke can be predicted in most affected people, most of the time. And that’s what evidence is all about – it’s about predicting patterns across populations. Sure, there’ll always be the exceptions, but it’s still important to understand what’s most likely to occur in most patients, most of the time; even if they indicate no improvement in some.

When I read this article, I thought “phew”! As a health professional who’s been presenting evidence on this for some years now, I’ve copped my share of criticism and disbelief. And that’s OK. Essentially, as scientific communities, it’s very important that we’re always prepared to question, challenge and discuss current clinical practice. However, there’s now ample evidence that, most of the time, it’s possible to accurately predict upper limb recovery after stroke in most people, based on data collected in the first week post-event.

As I argue in my Changing Stroke book, accepting this evidence means presenting it to those directly affected, and in turn, offering them interventions influenced by the early data. What I refer to as a stratified approach. Not accepting this evidence means leaving those directly affected, ill-informed, and, by applying a one-size-fits-all approach, potentially spending time engaged in interventions that are highly unlikely to be effective. Were I to have recently experienced a stroke-affected upper limb, I’d want to know what is most likely to occur, and, as with most events in my life, prepare for the worst and hope for the best.

As always, this is just my humble opinion, and you’ll find the full reference and abstract under Journal Club 2020. It’s important to read this article for yourself. Although challenging to read, it’s worth it; particularly the figures which at present, are on the final page of the PdF. Once published, these will be embedded in the article’s results.

All the best in 2020

To all my loyal followers. Here’s wishing you a very rewarding, engaging and interesting 2020. I also hope you can find balance between your professional and personal journeys in a way that will bring you some joy in both.

As I grow older, I spend more time with my seven grandchildren, and in turn, more time doing joyous activities for no reason at all, except to spend precious hours together. For example, splashing around at the beach or playing monopoly! Time with grandies has re-affirmed to me the importance of experiencing some joy. Hence the reason I’m wishing you a 2020 that includes some joy!

I originally established this blog as a “record” of my own continuing professional development. It has pressed me to spend time each month searching out, and reviewing a recently published article about recovery after stroke. As my blog testifies, it’s worked a treat!  However, 2020 year will be my last. If any of you would like to take this blog over, please contact me. It’s not hard to do, and if needs be, I’d be more than happy to walk you through it. But if that doesn’t occur, it will cease with no regrets, as it’s achieved what I intended, and more, thanks to my followers.

Aged Care: Neglect!

A couple of weeks back, I attended the community forum in Newcastle, for Australia’s Royal Commission into Aged Care Quality and Safety. I was close to tears as I listened to people’s harrowing stories of their experiences in relation to the aged care sector. So, this month, I can’t go past this particular publication. Sure, it’s not a journal article, but it’s of equal importance, in my humble opinion, particularly to Australians.

The Foreword of the Commission’s Interim Report (2019), titled: Neglect, opens with: “It’s not easy growing old. We avoid thinking and talking about it….The Australian community generally accepts that older people have earned the chance to enjoy their later years…Yet the language of public discourse is not respectful towards older people. Rather, it is about burden, encumbrance, obligation and whether taxpayers can afford to pay for the dependence of older people.” As many of the forum’s speakers stated, once a person is being cared for by the aged care sector, it’s often “out of sight, and out of mind”.

I attended because I’m concerned about my own ageing; because I’ve been troubled about the care given to elderly members of my family; and because of the stories I’ve heard and investigated in the pre-prescribed care many therapists are trained to provide to residents of Aged Care facilities. Understandably, commission may raise more questions than it answers, but, at this celebratory time of the year for many, I leave you with the question the attending Commissioner, Ms Lynelle Briggs AO, asked asked us, in her closing comments: “Where’s the joy?”

Out of interest, I’ve just searched publications in the last 2 years, for evidence relating to older people and joy. Although findings are limited, one study sheds some light on this. Rinnan et al (2019) set out to find “new approaches to increase positive health and well-being” in residents aged care facilities in Norway. The researchers found “joy of living” was associated with “positive relations, a sense of belonging, sources of meaning, moments of feeling well, and acceptance”. I look forward to a day when quality aged care is the norm, and not the exception. I look forward to a day when the concept of Old People’s Home For 4 Year Olds is just one of many examples of quality aged care; again, the norm and not the exception.

It’s not easy growing old. As Commissioner Briggs asked us to do, I ask you to read the Interim Report, tell people about the report, and talk with family and friends about our aged care. Let’s make sure older Australians are not “out of sight, and out of mind”.

Reference: Rinnan E, André B, Drageset J, Garåsen H, Arild Espnes G, Haugan G (2018) Scandinavian Journal of Caring Sciences, 32(4), 1468-1476, https://doi.org/10.1111/scs.12598

Know’vember!

In celebration of five years of successes, CPDLife® is celebrating with its “Know’vember” promotion. During all of November 2019, all Self Directed courses offered through CPDLife® website are at half price! This means that our “flag-ship”, 8 hour courses are only $110! But this promotion only applies during this months, so get in quick as there’s only a couple more weeks to go.

Proprioception after Stroke

November 2019: Semrau et al (In Press) Differential loss of position sense and kinesthesia in sub-acute stroke. Cortex, https://doi.org/10.1016/j.cortex.2019.09.013 https://www.sciencedirect.com/science/article/pii/S0010945219303351

Humble opinion: Its relatively rare to see evidence published relating to position sense and kinesthesia, so this is an article worth reviewing, especially, because these investigators found that more than half of all those recovering from stroke had deficits in both! This places these at far higher clinical significance, than perhaps has been previously appreciated. All 285 participants in this study had recent, first-ever strokes. The methods, measures, tasks and data analyses all point towards a study that has high scientific integrity. Therefore, these findings can be trusted, giving us true, valid and reliable findings. Interestingly, the study recruited many more participants who were male, but the average age of 61 is reflective of a relatively “normal” stroke cohort.

As I inferred before, to find that more than half of people diagnosed with a recent, first-ever stroke experience deficits in position sense and kinesthesia, means that we should certainly be screening for this in all acute stroke patients, because, this is not an easily-observable deficit. What the investigators also found was that most patients with both deficits were diagnosed with right hemispheric lesions in both cortical and sub-cortical regions; so, at the very least, this sub-cohort of patient should be screened. It’s also worth keeping in mind that 22% of participants experienced only one of these deficits; and this was more likely to occur in those with smaller lesions. Unsurprisingly, the findings indicate the two deficits share common neural pathways. The other significant finding is that yes, these deficits do adversely impact a person’s ability to undertake everyday tasks. I suggest this is a very important article to read, but as always, this is just my humble opinion.

To read the abstract, select Journal Club 2019 and Proprioception after Stroke.