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 Recovery & Rehab


October 2019: Bernhardt, Borshmann, Kwakkel et al (2019) Setting the scene for the second stroke recovery and rehabilitation roundtable. International Journal of Stroke, 4(5), 450-456, DOI ttps://

It’s hugely, hugely encouraging to hear about the work of international collaboratives like this one. I’ve been involved in one of the sub-groups and again, this is also hugely encouraging and energising. After all, why not approach stroke recovery from an international perspective; taking what is done best in one country and applying it in another, and learning lessons from the less effective practices and models of care? When it comes to improving outcomes for those directly affected by stroke, an international “team” approach should be underpinning the clinical practices of every local team. To stay up-to-date on what is happening at an international level, this is the team to follow.

As the authors rightly state, this team includes those who are working with people recovering from stroke right through to researchers like Andrew Clarkson, who are investigating animal models of stroke. This broader perspective and collective provides a richer source of what is, and is not, the very best practice that we can deliver to those directly affected. It also provides the broadest platform on which future research and change can occur. If you have a professional and/or personal interest in stroke recovery and rehabilitation, I commend the work and output of this group to you. If we liken stroke recovery to a ship sailing international waters, this group acts as the rudder mechanisms directing and plotting its course.

This article is freely available. Although it is not reporting original research, it is nevertheless an important publication for those with an interest in stroke recovery.

Sitting, Upper Limb Impairment and Falls

April 2019: Hanna et al (2019) Participation, Fear of Falling, and Upper Limb Impairment are Associated with High Sitting Time in People with Stroke, Occupational Therapy In Health Care, DOI: 10.1080/07380577.2019.1587675

OK, so I best confess that I’ve selected this article on the basis of the fact that it’s written by some of my closest colleagues, who I most admire, and it’s about topics that I’m very interested in! So, put that all together, and you have, in my humble opinion, a most engaging article. The investigators and their research questions exemplify the type of new knowledge that can be generated when the line between researcher, scientist and therapist, is so blurred, as to be indistinguishable.

This article is not publicly available, but you can always contact the corresponding author and request a copy. This study is an exploratory study only, but raises important questions and provides provisional answers. As always, you’ll find the abstract under Journal Club 2019 and “humble opinion” as a comment to this post.

Falls and Acute Stroke

March 2019: Westerlind et al (In Press) Drug treatment, postural control and falls: An observational cohort study of 504 patients with acute stroke, the fall study of Gothenburg. Archives of Physical Medicine and Rehabilitation.

As some of you might know, I have fairly strong opinions about our approaches to reducing the risk of falls, generally, and more specifically, reducing risk in those recovering from stroke. I challenge the applying of a zero tolerance to falls, because it assumes that risk-reduction is a unilateral approach; however, in those recovering from stroke, there is the competing demand of the benefits of getting up and about! Rarely are the two issues discussed in tandem. In those recovering from stroke, we already have a cohort known to have a higher-than-average risk of falls. So, does this mean we go all out to reduce the risk of falls? Yes, but only if consideration is given to the physical, cognitive and emotional benefits of getting up-and-out and about! So, to assist us in this, let’s better understand who is most at risk and why.

In this month’s Journal Club, Westerlind et al (In press) report on their investigation of the risk of falls in acute stroke, with a particular focus on its association with postural control, and in turn, the impact of drug treatment. In my humble opinion, their findings make for very interesting reading.

This article is not publicly available; but you can always contact the corresponding author for a copy if your library doesn’t have access to the APHR journal. To find the abstract, go to Journal Club 2019 tab and select Falls and Acute Stroke from the drop-down menu. “Humble Opinion” is added as comment to this post.

Stroke & Horse Riding

Pohl et al (2018) A qualitative exploration of post-acute stroke participants’ experiences of a multimodal intervention incorporating horse riding. PLOS One,

This is the final Journal Club entry for 2018. When it comes to stroke recovery, a collective “light bulb” moment has been the realisation that the average stroke recovery environment is bereft of stimuli, interest, reasons to participate and requirements to be involved in…well, almost anything and everything. So, here’s a stroke intervention that’s completely “out of the box”! It’s yet to be proven to be clinically effective, but for the 18 participants in the horse-riding group, the experience was transformative! I’m not sure we’d have ever considered rehabilitation could be transformative. They’re powerful words indeed. To find the abstract, go to the Journal Club page and to find “Humble Opinion”, go to the attached comment.

I hope 2018 has been a transformative year for you, in the smaller and/or greater experiences of life. For me, 2018 started with great sadness, but it’s finishing with gladness as I look towards a 2019 that’s heralding change. I wish you a hugely rewarding 2019 and here’s hoping you can enjoy some relaxing time over the Christmas/New Year break, with those precious to you.

A huge thank you to all my Changing Stroke followers and to those who have participated as learners and/or educators in my CPDLife® courses. I look forward to more Journal Clubs postings in 2019, but please note that these won’t re-start until February.

Walking After Stroke

Berg Balance Scale Predicts Walking

Louie DR & Eng JJ (2018) Berg Balance Scale score at admission can predict walking suitable for community ambulation at discharge from inpatient stroke rehabilitation. Journal of Rehabilitation Medicine, 50 (1), 37-44, DOI:

One of my very favourite academic researchers is Janice Eng and I’m so excited, because, guess what; she’s a keynote speaker at the Stroke 2018 conference in Sydney next week. If you-re going, let’s try and catch up! Although I do realise this is a hugely challenging thing to do at scientific conferences.

Two of my very favourite topics, as CS followers will already know, are using standardised assessments to measure recovery after stroke and predicting recovery potential on the basis of stroke assessments.

So, in my humble opinion, this article is a hit for three very good reasons!

Why don’t we do this more? Why don’t we measure function at baseline or on admission to our services, and then, when we can, use that data to predict what is most likely to occur in most patients? We do this in almost every other aspect of our personal and professional lives. For example, when we calculate a housing loan with the bank, or put in the time and effort to apply for a job on the basis of our estimates on the chances we have of success. There’s more and more reason to do this in those recovering from stroke! These researchers have demonstrated you can use admission Berg Balance Scale data to predict mobility at discharge from inpatient rehabilitation.

This article is freely available. You can find the abstract in the 2018 Journal Club, and I’ve posted “humble opinion” below.  If you’re in Sydney next week, why not attend the Stroke 2018 conference? Hopefully I’ll see some of you there!

Quality of Life and Disability

June 2018: Rangaraju et al (2017) Comparison of 3-month stroke disability and quality of life across modified Rankin Scale categories. Interventional Neurology, 6, 36-41.

One of the issues that continues to concern me is that we fail to consistently and routinely measure outcomes across a survivor’s recovery journey after stroke. If I were to experience a stroke here in Australia, would I have my own baseline data and/or measures across time documenting my recovery or otherwise? It’s highly, highly unlikely! Why is this the case, and in turn, how can we expect health funders to support what’s happening in facilities that support those affected by stroke?

Often health professionals will argue that the reason they’re not doing it is because of time: it just takes too much time to use standardised assessments! They may also argue that its better to spend time on interventions, not assessments! Whatever the excuse, here’s an article that has investigated a standardised assessment that takes just a split-second to reliably measure disability after stroke! The modified Rankin score (mRS), a very raw score, could be your “for starters” choice! Rangaraju et al (2017) investigated its association with quality of life. To find out what an mRS of 3 means, read what they found!

The article is freely available at Please find my “humble opinion” below, or under the Journal Club 2018 pages with the same title.

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

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.