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.

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.

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.

Shoulder Pain

October 2018 Journal Club: Lindgren et al (In Press) Pain management strategies amount persons with long-term shoulder pain after stroke – a quantitative study. Clinical Rehabilitation, Online early

How do survivors manage persistent shoulder pain after stroke? In 2007 [1], this same research group published findings indicating that 22% of all patients with stroke experienced shoulder pain and of these, at least three-quarters classified it as moderate to severe. One year later, some experienced no pain, but others, who started experiencing shoulder pain further down the track, were added to this cohort. What a complicated issue this is for those experiencing it and for health professionals managing it!

Since 2007, this research group has continued to investigate shoulder pain after stroke and their findings include a 2018 publication [2], which is also worth reading, if this is a topic of interest to you.

The October 2018 Journal Club publication reports the strategies the “experts” use to manage their shoulder pain in the long-term. This article is not freely available; but as I always say, if you contact the “corresponding author”, they’re usually only too happy to send it to you.

To find “humble opinion” see my posted comment and to read the abstract, use the Journal Club 2018 link.

[1] Lindgren et al (2007) Shoulder pain after stroke: A prospective population-based study. Stroke, 38, 343-348. https://www.ahajournals.org/doi/pdf/10.1161/01.STR.0000254598.16739.4e

[2] Lindgren et al (2018) Shoulder pain after stroke: Experiences, consequences in daily life and effects of interventions: a qualitative study. Disability and Rehabilitation, 40(10), 1176-1182. https://www.ncbi.nlm.nih.gov/pubmed/28637154

Future of Upper Limb Therapy

September 2018: Biasiucci et al (2018) Brain-actuated functional electrical stimulation elicits lasting arm motor recovery after stroke. Nature Communications, 2421 https://www.nature.com/articles/s41467-018-04673-z

This is most definitely an article that all those with an interest in upper limb recovery should read. Not only is this because it has been published in “Nature” (a “dream” that every scientist has, but very, very few achieve!), it is also revolutionary! Yes, that’s right. Evidence like this will revolutionise future upper limb management!! This is not an easy article to read or understand, but it will be worth persisting.

At the start of their discussion, the authors claim that: “BCI–FES therapy resulted in a statistically significant, clinically important, and lasting reduction of impairment in chronic moderate-to-severe stroke patients. In particular, the preservation of clinically relevant improvements at least 6 months after end of therapy is remarkable”. This is “watershed” evidence that closes a loop, that to date, had not been closed. I often refer to stroke as a “brain-based problem that needs a brain-based solution”, and, for the first time, we have evidence that closing the feedback loop between the brain and the upper limb is worthwhile. A remarkable finding indeed!

This article is fully available and well worth reading in my humble opinion. Select the Journal Club 2018 page if you want to view the abstract. The rest of my humble opinion is added as a comment to this post.

PT, OT & the Upper Limb

March 2018: de Jong et al (2018) Content of conventional therapy for the severely affected arm during subacute rehabilitation after stroke: An analysis of physiotherapy and occupational therapy practice. Physiotherapy Research International, 23, e1683. https://doi.org/10.1002/pri.1683

I’m back on one of my very favourite topics, upper limb recovery after stroke, but I promise I won’t stay on it for the rest of the year! I’m also reviewing an study authored by one of my very favourite research teams, Frederike van Wijck and her colleagues in the Netherlands, and I certainly won’t promise not to review another of their articles this year – that’s for sure!

These researchers investigated what treatment physiotherapists and occupational therapists prescribe and apply to patients with a severely, stroke-affected upper limb. If you’re interested, this article is freely available from http://onlinelibrary.wiley.com/enhanced/exportCitation/doi/10.1002/pri.1683

To find the abstract and “humble opinion”, select the PT, OT & the Upper Limb option from the articles under Journal Club 2018.

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