Peter Hannon, MD
For any of us who have fought with insurance companies to allow for better access to intensive therapies for patients after a stroke, it seems inherent that “more is more” when it comes stroke rehab. A number of studies and review articles have shown evidence to this effect, and in their current article, authors Lohse and colleagues have made the case for a reliable dose-response relationship between the time scheduled for therapy and improvement on clinical measures of function and impairment.
30 RCT articles investigating were included for review, and details of the interventions and time scheduled for interventions were extracted. Regression models were used to predict improvement during therapy as a function of total time scheduled and for therapy and years post stroke. Outcomes were restricted to “validated behavioral measures of function or impairment.” Authors found that overall, treatment groups receiving more therapies improved beyond control groups that received less, and that analysis suggests a “reliable dose-response relationship between time schedule for therapy and a improvement on clinical measures of function and impairment.”
One of the more interesting aspects of this study for me was the lack of interaction between time post stroke and the intensity of interventions, suggesting that even if rehab occurs months or years out, it may still have significant benefit.This study did not clarify stroke type or severity of participants, nor the “validated behavioral measures” utilized as outcomes, and per exclusion criteria, up to 30% of those included may have not had strokes. Authors were limited to using time scheduled as a proxy for rehab intensity, and note that further RCTs would benefit from reporting active time or repetitions of an exercise as a more accurate representation of the dose of therapy received. Studies are ongoing to find the optimal mix of intensity and timing of rehab after stroke, however this study adds weight to the growing evidence that on a broad scope, more really is better when it comes to therapies after stroke.
And if you want less dead and damaged neurons you will figure out a way to stop the neuronal cascade of death as reported by Rockefeller University in 2009. Even though Dr. Michael Tymianski, of the Toronto Western Hospital Research Institute in Canada mentions that more than 1000 drugs aimed at preventing brain damage that have failed to work in people, even though they worked well in mice or rats. This is easily explainable because in 2013 H. Shaw Warren wrote about rodent inflammation is not the same as human inflammation. Putting everything together and solving the 5 problems in the cascade of death will prevent vast amounts of disability and I bet that would mean more than 10% get to full recovery.