Post-Stroke Rehabilitation
Dr Alex Leff
Senior Lecturer Institute of Neurology
Honorary Consultant Neurologist NHNN
Plan
1. Neuro-rehabilitation process
2. Evidence base (speech therapy)
3. Evidence from expert human performance
Practicing the right thing, often enough, with
feedback
Where is rehabilitation on the
treatment path?
1 Prevention
Acute
Therapy
2 Prevention
Rehabilitation
Neuro-rehabilitation
iterative process
•
•
•
•
•
•
•
Avoid complications
Assessment
Measurement
Planning
Treatment
Evaluation
Reassessment
Contractures
Neuro-rehabilitation
iterative process
•
•
•
•
•
•
•
Avoid complications
Assessment
Measurement
Planning
Treatment
Evaluation
Reassessment
Planning – Goal setting
• A process of discussion and negotiation in which the
patient and staff determine the key priorities for
rehabilitation for that individual, and agree the
performance level to be attained by the patient for
defined activities within a specified time frame.
• A key element in the rehabilitation process.
• Commonly employed as a technique to actively
engage patients in their rehabilitation programme.
• Occupational/organisational literature 1970s
Short term goals
• To wash my face and clean my teeth standing at the
sink with an upright posture
• To wash myself in sitting, reaching down to my feet
• To dress my top half, following written prompts
• To move independently from sitting to lying in the
gym
Long term goal
To return home able to
• Walk indoors with my frame feeling more confident
• Participate in personal care and light domestic tasks
incorporating standing
• Able to turn myself in bed
• Able to complete car transfers independently
With advice on:
• Exercise programme
• Bladder and bowel management
• Standing programme/tone management
Who should be referred?
• In-patient or out-patient
• Patients
–
–
–
–
who are medically stable (-ish)
with multiple interacting problems
who need input from two or more disciplines
with potential to make functional gains
• Before you refer identify any previous input
and its outcome
Speech therapy
Important issue?
Does it work?
Dose?
Intensity?
Is it ever too late?
Assumption
Therapy is a form of learning; learning takes
time, repetition (and money)
Important issue
• Aphasia more prevalent than MS or PD 1x106 US
• 80,000 additional per year from stroke alone
Prof. Martin L. Albert
Stroke 2003;34:992-9930
Does it work ?
Does it work - Dose
Problem: average amount of out-patient speech therapy ~ 12 hours
Does it work - Intensity
Problem: confounding
Does it work - Intensity
Case unproven
When is it too late?
When is it too late?
MPC = maximum possible change
When is it too late?
Never
Practice makes perfect!
In sum, our empirical investigations and
extensive reviews show that the development
of expert performance will be primarily
constrained by individuals’ engagement in
deliberate practice and the quality of the
available training resources.
Ericsson Ann. N.Y. Acad. Sci. 1172: 199–217 (2009).
popularized by Gladwell “Outliers”
World experts, how do they do it?
Hours
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Old people, can they learn?
Yes
Nola Ochs: MSc in liberal studies from Fort Hays State University in August 2007
She is the oldest recipient of a master's degree at age 98
Park D. et al., Models of visuospatial and verbal memory across the
lifespan. Psychol Aging. 2002;17(2):299-320
Specificity?
Free
throws
distance
Keetch et al. Journal of Sport and Exercise Psychology, 2008
Free throws - jump
Role of attention?
SALT dose Bhogal revisited
Aphasic patients’ response to therapy, dose effect:
Average improvement for low (n=574) and high (n=259) dose studies
20
Therapy-induced
change in score:
PICA battery
15
10
5
0
?
NHS
45 Hours
100 Hours
Web app for hemianopic alexia
Yean-Hoon
Ong
Maurice
Brown
Web app for visual search