Stroke rehab- green, amber and red
What to do, try and avoid
Stroke day is upon us. Rehabilitation post stroke is a vital part of PT education and practice. Stroke rehabilitation research has improved and we have got better answers to what is the best practice.
Even though there are many answered questions, these are some of the best practices we should strive towards:
What should be done - the green
these are what we should be doing. Not whining about the patient will not accept.
Repetitive task practice ( aka functional activity practice) should be the choice of treatment. What it means is fairly simple- if you want your patient to walk or sit to stand- make him walk or sit to stand. You don’t have to reduce spasticity, improve strength or sensory (whatever the hell do we do with that) or reduce synergy. I know the question which i have been asked from the time i had hair and it was black- How will i do that when the patient has no strength or spasticity. Well, nothing it will change when your patient start doing things. Then clever skeptic will ask, “what if there no activity”, sorry dear nothing- you can’t do anything- you are not some x-men to move others with your touch or mind.
More practice may be lead to better improvements. As brain is a learning organ it does learn better if we keep on practising. During practice, it's crucial to remember the concept of variable practice. Instead of repeating the same task endlessly, introduce variability. This approach can be valuable for the generalization of learning.
Probably try out- the amber-
There are some intervention we can try out even though the evidence is not clear.
We should probably teach patients caregivers to help patient to practice meaningful tasks. Even though the evidence is not positive, it may be a good idea. more research can point us towards either to do it or discontinue. Please note this does not mean PT is not needed in practice- it is just to augment practice time.
Try out mirror therapy especially if the patient has some perceptual problems
What not to do- the red:
Passive movements, stretching, positioning, reduce synergy and impairment level exercises. Of course it can help while away the time during the therapy session, but doesnt do any thing else. So exercise like bridging to stretching the muscles should be stopped.
Robotics, virtual reality and other expensive toys- well just that. So just don’t bother (refer 1, 2 , 3 ). While certain interventions might be effective for improving walking, they can be challenging to implement due to their cost and limited accessibility, especially in a country with 230 million people living below the poverty line.
CIMT - the treatment which is just dog shit. I hate dogs and shit- so. CIMT is ineffective and unsuitable for clinical practice ( i mean 6 hours or in modified version 1.5 to hours of upper limb practice)
of course this is not a extensive list. There may be many more shite treatment, which you should avoid. Books and approaches written in 60s like Bobath, PNF, Brunstrom can be retired. If you are an expert in any of these you should start reading.
What we don’t know- unknown:
Well in word we don’t know how to enable our patients. Clinical experience and existing literature highlight the difficulty in motivating patients “do” exercise. The process of enabling patients, lacks a solid scientific foundation. Currently, we often rely on ad hoc methods to encourage patients to understand and adhere to exercise routines.
what are the best outcome measures, what’s the outcome is all very unclear.
Implementing these best practices in our clinical approach can be a straightforward and effective way to enhance patient outcomes. By doing so, we have the potential to significantly improve the well-being of our patients.
PS- the underlined words has a hyperlink to cochrane reviews.