Continuum Audio
Stroke Rehabilitation and Motor Recovery (Cerebrovascular Disease April 2023)
April 01, 2023.Michael W. O'Dell, MD, .
Educational Objectives
The goal of this program is to improve management of stroke. After hearing and assimilating this program, the clinician will be better able to:
- Involve rehabilitation health care professionals in the care of stroke patients.
- Recognize the nuances of long-term stroke recovery and the roles played by therapists and nursing staff.
- Employ new, evidence-based technologies to assist in stroke recovery and rehabilitation.
Summary
Stroke Rehabilitation and Motor Recovery (Cerebrovascular Disease April 2023)
Dr Smith: This is Dr Gordon Smith with Continuum Audio. Today I’ve got the great pleasure of interviewing Dr Michael O’Dell on stroke rehabilitation and recovery, which is part of an issue on cerebrovascular disease. Dr O’Dell is Professor Emeritus of Clinical Rehabilitation Medicine in the Department of Rehabilitation Medicine at Weill Cornell Medicine in New York City. Dr O’Dell, thanks so much for joining me today on Continuum Audio.
Dr O’Dell: Thank you, Dr Smith. It’s an absolute pleasure to be with you today.
Dr Smith: Well, thanks. You know, I always tell our residents that this is the exciting side of stroke. Thrombolytics is super exciting, and neuroprotection is exciting. But at the end of the day, I think most of the future advances we’re going to see are going to be in recovery. So, I’ve been really looking forward to talking to you. And I wonder if maybe you can begin by framing the conversation inside the scope of the problem. You know, about 800,000 Americans have a stroke each year, about 150,000 die from their strokes. I think this makes it the fifth most common cause of death, you’ll correct me if I’m wrong. Tell us about the importance of stroke rehabilitation and recovery in determining long-term stroke outcomes.
Dr O’Dell: Well, you know, I tell my residents something similar as well. It’s terribly important to correct somebody’s low potassium as well, but it’s far more exciting to have somebody that comes to see you or starts their rehab process in a wheelchair and actually walks at the end of that process. It’s a much more palpable end point. Rehab is an incredibly important process in stroke recovery. And it really is a process, not an event, and it involves so many different, incredibly talented professionals on the rehab team — starts in acute care through, for many people, an inpatient experience, either in an inpatient rehab facility or subacute care, and on through the outpatient process. And it may involve specialized equipment or technology — sometimes involves medications — but it involves a great deal of education as well. And it’s not only we rehab professionals using our skill set for a patient, but our educating the patient and family on stuff that they can do with the patient themselves or their family member. So, part of what I love about the rehab process is it’s so collaborative. We can’t do rehab “to” someone, we have to do rehab “with” someone. And because of that, it makes it a very satisfying experience.
Dr Smith: That’s a great description. I’m just remembering a dinner once many years ago with a good friend of mine, who’s a pediatrician, who introduced me to a friend of hers, who was a physiatrist, who upon hearing what I did, said, “oh, you’re acute PM&R.” And so, I think a lot of the things you said sound a lot like what we do in acute management as well. Maybe we can begin by talking a little bit about what you mean by recovery. In the article, you highlight the difference between motor recovery, which is what I think most neurologists focus on in most strokes, versus functional recovery. Can you tell us about these and the differences between them?
Dr O’Dell: Sure. Interestingly enough, as a physiatrist — as a rehabilitation medicine physician — I’m not real thrilled with the word “functional.” It’s not one of my favorite words in my repertoire, in my professional lexicon. I like “performance” a lot better. I think performance really describes the essence of what we mean by function. Motor recovery is when we refer to the actual movement becoming better after a stroke. And that could be due to very passive processes — natural recovery — or it could be due to the interventions that we provide as rehab professionals. And I don’t mean just physiatry, I mean the terrific therapists that I have the privilege of working with — occupational, physical, speech pathologists — so, as a result of active interventions that we make. Functional recovery, or an improvement in performance, absolutely could be due to any degree of improvement in the actual movement, the motor recovery. But remember, we have also the concept of compensation as well. There are different strategies that we can use in rehabilitation medicine to improve performance that may or may not have any impact or be completely not dependent on motor recovery at all. We can teach somebody to essentially perform better by using those systems that aren’t effective, we can use different kinds of bracing strategies, or even functional electrical stimulation to allow certain parts of the body affected by the stroke to work better. We can even alter the environment to allow somebody to perform better. All these things allow a greater degree of function, of performance, in one’s environment, but do not depend in any way on motor recovery. And I think this is something that perhaps your field in neurology has really taught us a lot in rehab medicine, particularly in the research realm, about being much more careful about separating those concepts of motor recovery and functional recovery when we look at outcomes in clinical trials. And I think this is something that we in rehab pay a lot more attention now to, just in the last, perhaps, decade than we did before. So, we are really looking very carefully and teasing apart, what are we doing that actually is impacting the natural history of the motor recover, versus what are we doing perhaps behaviorally to facilitate compensatory strategies — what’s remedial versus what’s compensatory. And we’re paying a lot of attention to the underlying strategies that we’re using to really facilitate either one of those categories.
Dr Smith: You know, you’re really great at packaging complex concepts into sound bites, like that “rehabilitation is a process not an event,” and “performance more than function,” which I really appreciate. And I think your points about clinical trials are lessons that we’re all learning right now. You spoke a little bit about different rehab strategies, and you also bring up a categorization-spanning remedial-to-compensatory strategies. Can you define these, maybe give some examples and tell us about their importance over time?
Dr O’Dell: So, really, remedial strategy equals exercise, in my way of thinking when it comes to stroke rehabilitation. We certainly have any number of different strategies that — and this is a very hot area of research at the moment looking at pharmacology or technology or biologics, any number of ways — that we try to facilitate the recovery process following stroke. But when it comes down to it, with very, very few exceptions, all these strategies are really meant to augment the process of exercise. That’s what we really mean when we talk about remediation. And I think, Dr Smith, we really have to consider that exercise in this area is sort of in its infancy. We really only have some basic directions on the dosing and the timing of exercise following stroke. So, any of these technological or pharmacologic or biologic interventions, they’re really here to augment the process of exercise following stroke. That’s the remediation. Again, the compensation has to do with either altering the person, altering the environment, or teaching a patient to use those systems that have not been affected by the stroke to perform those tasks, those activities, that they need to perform to function in their everyday life, to perform in their everyday life. That’s kind of the distinction that we make between a remedial strategy and a compensatory strategy.
Dr Smith: Dr O’Dell, thanks, this has all been great foundation. Maybe we can now get into the meat of it. And I thought we could kind of start with the acute-care phase for stroke patients, and then over the next few moments kind of work our way down the care pathway, if you will. So starting with care for patients right after their acute stroke, what do our listeners, who are mainly neurologists, need to know about how their acute treatments impact prospects for long-term recovery, beyond the standard stuff that we do in terms of medical and neurological care — for instance, medications that we may want to avoid because they negatively impact long-term recovery or other issues such as that.
Dr O’Dell: So, when we talk about the interventions acutely, in the first hours to days, even though the prospect of adding medications or having a pill to enhance the recovery after stroke is very appealing, it’s a very sexy proposition to have a single pill to improve recovery after stroke, probably far more important is avoiding detrimental medications. And there are 4 classes of medications that are, I think, particularly important to avoid — certainly, the first-generation antipsychotic medications, that really aren’t used all that often anymore. Benzodiazepines, the class in general. Centrally acting antihypertensive medications, clonidine being the primary one in that category. Among the antiseizure agents, 2 in particular — phenytoin as well as phenobarbital, phenobarbital not being used very often anymore, phenytoin is used occasionally. And so, avoiding these medications, certainly in the first few days following stroke, probably is a greater contribution to facilitating better long-term recovery than adding any medication. When to start therapy, acute OT, PT, speech, following a stroke, is somewhat controversial, but I think the recent guidelines, as well as data from the AVERT trial — the initial study and subsequent studies published over the last 10 years or so — would suggest that waiting about 24 hours after the acute stroke is appropriate. And then having a team of therapists at your acute-care hospital that are thoughtful, that are well trained, having protocols set within your hospital, that will gradually mobilize your patient with stroke, obviously taking frequent vital signs, listening to what the patients are telling you, and having a thoughtful protocol for mobilization of the patients after that 24-hour period of time. Really, what we’re trying to achieve within those first few days after stroke is preventing the complications of bed rest, making sure that we don’t develop contracture or other musculoskeletal complications, and minimizing the detrimental cardiopulmonary complications of extended bed rest. This is really the primary goals of what we’re trying to accomplish in those first few days following stroke.
Dr Smith: Thanks, that’s very helpful. I wonder if we could now move to sort of the last phase of our care before sending patients off for their acute rehabilitation therapy, and that is often patients and their families saying, “What does the future hold for me?” “What’s my recovery going to look like?” “Can you prognosticate?” And I struggle with this, because oftentimes — and this is particularly true of our trainees — we don’t see those patients back for a while. And some of them, if you’re a neurohospitalist, you may not see them a year later and know how they recover. Do you have any words of wisdom about how to approach talking about prognosis for long-term stroke recovery?
Dr O’Dell: Well, and I guess I’m speaking on behalf of those of us in the specialties that are inheriting these folks, I guess, downstream from the emergency department personnel and neurologists and neurosurgeons. Just be cautious. I would ask you to please be cautious, and perhaps not be overly optimistic nor overly pessimistic. Because (
Dr Smith: So, I wonder, as we’re talking about inpatient rehabilitation, maybe we can just talk about the different options that are available. And I think we often think of these in very simplistic ways in the acute care setting, the differences between inpatient, inpatient rehabilitation facility, or a subacute nursing facility, or subacute rehabilitation facility. I wonder if you could just talk us through the differences in these and maybe some pearls and pitfalls for this, particularly for our trainees or people that are early in their career thinking about it.
Dr O’Dell: If there’s anything today that I would really like for your listeners to take away from this chat, this would probably be it. And that’s understanding the difference between the rehab that’s provided in a skilled nursing facility versus an inpatient rehab facility. And that’s whether it’s embedded within an acute-care hospital or a freestanding inpatient rehab facility. There are substantial differences between those experiences, both qualitatively and quantitatively. The qualitative differences are really in terms of how that experience is structured. In terms of the leadership, the requirement in an inpatient rehab facility that a physiatrist or other similarly qualified physician lead that team, that the cadre of therapists that is put together, the incredibly important role of rehabilitation nursing that is required to be present in a rehab facility, the skilled therapy and nursing interventions that are required to be provided in an inpatient rehab facility — these are substantially different than what’s provided in a skilled nursing facility. The second is really quantitative. In an inpatient rehab facility, it is required by government regulation that at least 3 hours a day, 5 days a week (and honestly, most inpatient rehab facilities this day and age provide that kind of treatment 6 days a week), it’s required by regulations that 3 hours a day, we provide at least 5 days a week. That’s not required in a skilled nursing facility. And so, I think it’s important for the neurologists and residents in training who are listening to this to realize that there are both qualitative and quantitative differences between those experiences. A recent article that was just published in JAMA by Hong et al, was really a tremendous demonstration of this. Just quickly, this was a study that looked at almost 100,000 Medicare recipients that went to both skilled nursing facilities and inpatient rehab. And doing a very sophisticated statistical analysis, using propensity analysis, found that the outcomes were almost twice as good from a functional standpoint in those patients with stroke that went to inpatient rehab facilities as those who went to skilled nursing facilities. And so, understanding that those differences are there, I would really ask that the neurologists who care for persons with stroke make sure that at the end of that acute hospitalization, if your patient is not able to return to home, and that there is a inpatient rehabilitation facility available in your area — and quite frankly, that’s not the case in all places in the United States, particularly in more rural areas — to seek an evaluation by the rehabilitation team at your facility and at least have an evaluation to see if your patient is appropriate for that facility. And by the way, not everybody is appropriate for an inpatient rehab experience, it’s quite exhausting. It’s a very intense experience. And there are going to be those individuals, either by virtue of underlying medical conditions or concomitant orthopedic or other conditions who simply cannot tolerate that 3 hours a day. Those are folks that are perfectly appropriate to complete their rehab in a subacute facility. But for everyone else, I think it is absolutely appropriate, and in fact, standard of care that they be evaluated for an admission to an inpatient rehab facility.
Dr Smith: So that’s great. And I think very helpful because a lot of us, I think, don’t have a lot of experience — neurologists working on inpatient rehab facilities, or they haven’t done it in a very long time. So, it’s really great to have that clarity and take-home message. Let’s shift a little bit to outpatient setting. Or maybe we can think of the sort of long-term arc of rehabilitation and recovery. I was interested to learn that there are — you’ve talked about a couple of principles already — but you cited one reference that there are 15 principles of neurorehabilitation after stroke, which is a lot of principles. We don’t have time to talk about 15, but I wonder if you could highlight one or two of the most important principles for our listeners to be aware of.
Dr O’Dell: Yeah, this was taken from a recent article published by Martina Maier, which is a really, really nice summary. And these principles are actually general principles that are used in motor learning. In general, these are the same principles, quite frankly, that we use to learn to play a new sport or learn for any kind of motor activity that we might be involved in life. The two principles, in terms of exercise, that seemed to be most important are repetition and task-specific activity. After a stroke, if we need for our patient’s hand to work better, than we have to exercise the hand, not the elbow, not the shoulder, and it needs to be done a whole bunch of times — repetition and task-specific activity. And then there are other aspects of exercise that seem to be really, really important. For example, that the activities, whatever the exercise is, it needs to be varied in terms of the types of exercise, both within a given exercise session and over time — that, if we can use multiple sensory systems to be stimulated along with the exercise, that’s great as well. This is where robotics actually can be very helpful, because we can have visual stimulation, auditory stimulation, and in some cases, even haptic stimulation that goes along with the robotics treatment. So, the more sensory systems that are stimulated, the more efficient the motor learning. And then all these things come together with this social interaction between the therapist and the patient. And I have to tell you, this is one of the areas where I just have an undying admiration for my colleagues in physical, and occupational, and speech therapy. That interaction between a therapist and a patient with stroke — how the therapists can take a person with stroke through a series of exercise, and motivate them each step of the way, provide just enough assistance that an exercise can be completed, but not so much that the patient isn’t sort of working and providing the maximum amount of effort that they possibly can without getting frustrated — this is really the art of rehab. And it’s something that I certainly would not have the patience to do myself. And it’s a constant source of admiration I have for my therapy colleagues. I also think it’s something that we really underestimate in terms of not only clinical, but in clinical trials, as we look at stroke rehabilitation and recovery clinical trials, I think we underestimate that interaction between the therapist and the case participant in the clinical trial. How do we quantify that magical (almost) relationship between the therapist and the participant, and how do we quantify that? And perhaps even more important, how do we replicate that social interaction between the therapist and the participant so that is not a confounding factor in the clinical trials? But there are a number of different parameters in terms of the exercises after stroke rehab — a lot of them really do fall into the category, in the control, of a really, really good therapist that’s providing that therapy.
Dr Smith: So, listening to you talk about this, Dr O’Dell, and having read the article, I’m impressed, albeit not terribly surprised, at how important patient engagement is for the recovery process, and hearing you talk about repetitions. It’s like learning a new skill or sporting skill. That engagement is super important. And I wonder if you can talk about a related concept that was new to me, which is that of “learned nonuse,” which, it sounds like, poses a significant challenge for many patients during recovery. And it’s sort of the opposite of what you’re talking about. Can you talk a little bit about this and what role our listeners have in combating this problem?
Dr O’Dell: This is a fascinating concept. This was originally described by Ed Taub at the University of Alabama, and it’s actually the theoretical basis upon which constraint-induced motor therapy is based. This is the concept that with time, someone with stroke actually learns not to use their affected extremity. And it actually doesn’t take long interacting with someone with a stroke to just see the frustration that comes with trying to utilize an arm or a leg that just doesn’t work right. It’s terribly frustrating, you can see the, almost, anger and frustration in their eyes. It’s palpable. With time, a patient will actually learn, quite frankly, that it’s just quicker and easier and less frustrating to use the “good side” rather than using the affected side. Again, we go back to this principle of repetition and task-specific activity. Exercise is everything in terms of the process of stroke recovery. So, this process of learned nonuse really flies in the face of the basic principles of recovery. One of the things that constraint-induced motor therapy, and again, this is one of the very few interventions, remedial interventions, that’s been shown to be effective in stroke rehabilitation, where the good extremity is actually restrained over a 2-week period of time and the affected extremity is forced to be used up to 6 hours a day, and the good extremity is restrained up to 23 hours a day over a 2-week period of time, and that, that affected extremity is truly forced to be used a great deal of time over a 2-week period of time. It’s terribly frustrating for the patient to go through this, but actually, it’s been shown to improve use and movement of the arm even up to 2 years later. Again, it’s not something that has been implemented very widely, partly because of the intensity of the therapy (and our payment systems just aren’t set up to do this), but also because it takes a huge amount of motivation on the part of the patient to go through such a treatment. So, part of what we can do, certainly as practitioners — both neurologists and physiatrists, and quite frankly, internists and family practice physicians who are taking care of our patients as well — and family members, is to encourage our patients with stroke to use that extremity whenever possible. To look at everyday activities as exercise in and of itself — even if it takes just a little bit longer, even if it brings with it a degree of frustration, having someone get dressed on their own to the degree that they can, walk even short distances to the degree that they can, eat, shower, do other activities of daily living to the best of their ability — is great exercise in and of itself. And encouraging our patients to do that to the greatest possible degree is probably going to minimize that learned nonuse to a certain degree. I don’t know that it’s going to eliminate it, but it will minimize it to the greatest possible degree. This also brings up this whole concept of participation as well. The exercise is great, but it is an active process, you have to have somebody do the exercise for it to facilitate recovery. And one of the things I beat into my residents’ heads, especially during inpatient rehab, but also outpatient process as well, is that our job as physiatrists is to keep our patients medically stable enough, nondepressed enough, and pain-free enough that they can do what they need to do in OT, PT, and speech. Because that’s really the essence of what needs to be done. It’s the work that’s done during those therapy sessions that is really required — it’s the magic of the recovery process. So, our job as physicians is to make sure that our patients are able to participate in those therapy sessions, really, by any means necessary.
Dr Smith: Well, I certainly hope our health care system in the future does a better job of really valuing this kind of care. I think it’s something that physiatrists and neurologists come across time and again, that we tend to do a good job of medicines and technology, but not such a good job of preventative care, or perhaps the softer skills that are critically important. So, I really appreciate that summary. But I wonder if we might finish by talking some more about technology. And I know this is something you could talk about for a very long time. You already talked a little bit about robotics, and maybe there are a couple of other points you want to make about that. Another area in which I was interested, based on reading your article, was that of neuromodulation. So maybe a few highlights of the role, particularly in the future, for technology, robotics, neuromodulation, or other modalities.
Dr O’Dell: I think, in a limited amount of time, the one that I would want to mention is vagal nerve stimulation. And point of disclosure is that I was involved in the clinical trial that I’m going to talk about at the moment. So, I just want to make that clear to the listeners. And the reason I mention that is that we don’t have that many interventions, remedial interventions, that have been shown to be effective. And so, the recent publication in The Lancet of the vagal nerve stimulation trial is important. This is a trial that was completed with about 100 participants, a nicely designed, randomized sham-controlled trial, that demonstrated the effectiveness of vagal nerve stimulation. And this was a trial that looked at upper-extremity recovery. And the primary outcome measures using the Fugl-Meyer scale, which is essentially a scale that looks at movement of the upper extremity, and the Wolf motor function test, which is a test that looks at functional movement of the task. And after about 6 weeks of stimulation and a very, very intense occupational therapy program, 18 hours, which would be a far more intense program than what we would provide in a clinical setting, in a nonresearch setting, those two combined actually led to this very, very impressive improvement. Looking at the two groups, about twice as many folks in the VNS group had a clinically meaningful improvement in the Fugl-Meyer scores, and about three times as many in the Wolf motor function tests. So, among the technologies, certainly, the vagal nerve stimulation most recently has some of the best data. There are other technologies that have been explored as well. Transcranial electrical direct current stimulation, transcranial magnetic stimulation, robotics you had mentioned. Robotics are very frequently offered at rehab hospitals across the country. There may be a benefit in lower-extremity robotics, particularly in more severe strokes. When you look at the meta-analyses that have been published in the data, it’s unclear whether robotics provide a great deal more benefit than dose-matched exercise alone. So, I think we still are a little bit unclear what the ultimate benefit of robotics are, but it’s something that’s offered quite frequently at rehab hospitals across the country. Again, we talked about pharmacologic interventions, of which there really is not a whole lot of data to support at this point in the game. And then sort of the whole area of biologic and stem cells, we’re just now starting to get initial data back. Looks promising, but certainly not at the point that this is at a stage for clinical implementation yet. So, the whole area of motor recovery is an active area of research at the moment. It’s really quite exciting, and I think that we’re living in a time that over the next decade, I really am hopeful that we’re going to see some substantial progress forward. And it’s an exciting time to be in this area.
Dr Smith: Well, Dr O’Dell, I think we’re finishing where we began, which is both the huge need, but also the tremendous promise, of recovery-based therapies. And I’ve really enjoyed this conversation. I wonder if we can wrap up and have you just provide what are the most important take-home point or a couple of take-home points for our audience?
Dr O’Dell: I’ve been at this — in this area for 30 years. And I think just pointing out that the model of neurology and rehabilitation professionals working together is an incredibly powerful care model. The diagnostic and anatomical expertise of neurologists, with the symptom management and functional expertise of rehabilitation professionals, I think is an incredibly powerful combination across the entire lifespan of the recovery process, from acute care through rehab into the outpatient setting. And I’m hoping that your residents and neurologists in training will really seek out rehab professionals, physiatrists and therapists both, and understand a little bit more about what the rehab interventions are. We have so much to learn from neurologists, and I think the neurologists have a lot to learn from us as well. And the better we understand each other’s field, I guarantee you, the better care we’re going to be able to provide your patients with strokes.
Dr Smith: Well, Dr O’Dell, thank you so much — couldn’t agree more. And that’s a really great finish to, I think, a really engaging conversation. I’d love to keep talking to you for another half hour or hour, but I think our time is up. So, thank you very much for this conversation, which has been informative, and congratulations on a great article. I encourage everyone listening to Continuum Audio to take a look at it. I think you’ll enjoy it and learn a lot.
Dr O’Dell: Absolute pleasure being with you.
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Readings
O’Dell MW. Stroke rehabilitation and motor recovery. Continuum (Minneap Minn) 2023;29(2, Cerebrovascular Disease).
Dawson J, Liu CY, Francisco GE, et al. Vagus nerve stimulation paired with rehabilitation for upper limb motor function after ischaemic stroke (VNS-REHAB): a randomised, blinded, pivotal, device trial. Lancet. 2021;397(10284):1545-1553. doi:10.1016/S0140-6736(21)00475-X
Hong I, Goodwin JS, Reistetter TA, et al. Comparison of Functional Status Improvements Among Patients With Stroke Receiving Postacute Care in Inpatient Rehabilitation vs Skilled Nursing Facilities. JAMA Netw Open. 2019;2(12):e1916646. Published 2019 Dec 2. doi:10.1001/jamanetworkopen.2019.16646
Maier M, Ballester BR, Verschure PFMJ. Principles of Neurorehabilitation After Stroke Based on Motor Learning and Brain Plasticity Mechanisms. Front Syst Neurosci. 2019;13:74. Published 2019 Dec 17. doi:10.3389/fnsys.2019.00074
Taub E, Uswatte G, Mark VW, Morris DM. The learned nonuse phenomenon: implications for rehabilitation. Eura Medicophys. 2006;42(3):241-256.
Disclosures
For this program, the following relevant financial relationships were disclosed and mitigated to ensure that no commercial bias has been inserted into this content: Dr O’Dell has received personal compensation in the range of $0 to $499 for serving as an officer or member of the board of directors for Franklin College of Indiana, and in the range of $500 to $4999 for serving on a scientific advisory or data safety monitoring board for Merz Pharmaceuticals, LLC.
Unlabeled Use of Products/Investigational Use Disclosure: Dr O’Dell discusses several clinical trials involving the use of investigational drugs, none of which are US Food and Drug Administration (FDA) approved for use in people with stroke.
To view disclosures of planning committee members with relevant financial relationships, visit: legacy.audio-digest.org/continuumaudio/committee. All other members of the planning committee report nothing to disclose.
Acknowledgements
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