I’m currently in Sydney at the Annual Scientific Meeting of my original tribe. The session I went to this morning were my first look back at the state of stroke rehabilitation for nearly a decade.
Things had changed a bit!
The surge of neuroscience research that has occurred in that time has had a huge impact on stroke rehabilitation. When I was a trainee, it was often said that there was nothing new in stroke. Many GPs, general physicians and even some neurologists felt that attempting to restore function to a brain and body that had been so brutally disconnected was largely a waste of time. The picture now couldn’t be more different.
There is evidence now that there can be both structural and functional plasticity in the brain, both for good and ill. Structural plasticity refers to the ability of nerve cells in the brain to form new connections or repair themselves after injury. Functional plasticity refers to reorganization of existing but not used connections between cells. This is referred to in the trade as your ‘connectome’. Given the staggering complexity of he brain, and its capacity to be shaped by both external and internal events, it can be reasonably said that 'you’ are your connectome. If a stroke robs you of parts of your brain tissue, neurorehabilitationists are not very far away from being able to help you string up the wires to compensate for it. The understanding of the processes that brain cells go through has come such as long way, that stimulation of critical pathways to help preserve neural function post stroke may mean that we can come up with a ‘stroke first aid’ process which can start outside the hospital even before the diagnosis is confirmed.
Once you hit the hospital with your stroke-like symptoms though, you won’t be able to rest. A massive international trial based in Melbourne called the AVERT project, aims to see whether starting rehabilitation efforts from within the first 24 hours can result in better outcomes for survivors. Even unconscious patients in the ICU may have their sedation lightened to enable some useful therapy to take place so that not a day is wasted. The volume of repetition that is required means there will be no rest for the patient from day one. Restoring motor patterns properly demands hundreds of rehearsal movements every day. Therapy will only pause for sleep!
The evidence is building that not only should rehabilitation begin earlier than we are used to, but it can be effective out to a much longer time frame that we ever thought as well. Understanding maladaptive plasticity may allow us to work out how to reverse abnormal movement patterns that have been around for years. Stroke survivors often have sensory loss as well as motor loss, and improvements in lost sensation can now be induced years after the stroke, when conventional experience was that it was irretrievable.
All this will come at a cost, but the good news is that the cost for many of these provably effective interventions is not as much as you might fear. Most of them are relatively low-tech, non-pharmacological modalities. The issue with providing them will be having appropriately trained and available therapists to deliver the care. Some of the hypothetical drugs under development will have to be preserved for younger patients with higher abilities pre-stroke, as older, more unwell stroke sufferers may not tolerate them or benefit enough to be worth the cost.
In many ways, given how much new hope there is for stroke patients, these are not bad discussions to be having. A decade ago there was nothing new to even be worried about.