Rehabilitation and recovery after stroke

Functional brain imaging - evidence of brain plasticity after stroke in adults - statement

Despite extensive experimental research in animals, the precise mechanisms underlying recovery after stroke in adults are still largely unknown. Recently introduced functional imaging techniques such as PET and fMRI now allow assessment of brain plasticity directly in the human. Taking recovery of motor functions as a model, both cross-sectional and longitudinal studies have demonstrated plasticity of the damaged adult brain. Rather than substitution of function, the main mechanisms involve enhanced activity in pre-existing networks, including the disconnected motor cortex in subcortical stroke and the infarct rim after partial cortical stroke, as well as non-motor areas and contralesional motor areas. One emerging notion is that the greater the involvement of the ipsilesional motor network the better the recovery. This is further supported by the observation that intensive motor training and some acute pharmacological interventions enhance the activity of the ipsilesional primary motor cortex in parallel with improved motor function. There are now robust data showing clear-cut evidence of brain plasticity after stroke in adult as revealed by functional brain imaging such as PET and fMRI.  

Amphetamines and stroke recovery - statement

Amphetamines are sympathomimetic agents that release and block the reuptake of catecholamines in the nervous system. Amphetamines have been found to improve outcome in experimental models of stroke and other brain injuries. The neural mechanisms underlying the facilitation of brain recovery after amphetamine treatment are still relatively unknown. Clinically, 7 RCT’s including 172 post-stroke (mainly infarct) patients have reported on amphetamine intervention. The following trends were observed: a better motor and language recovery but a tendency to a higher case fatality. The latter may reflect imbalancies in baseline prognostic factors. 

Further RCT’s are on-going and more data are warranted. There is a need for more dose finding studies and comparison of different dosing paradigms, e.g. continuous versus intermittent dosing. It will be necessary to further clarify potential sympathomimetic CNS and cardiovascular side effects. Amphetamine is considered as one out of several possible agents to facilitate brain recovery after stroke.

There are several definitions of a stroke unit. Based on the Stroke Unit Trialists Collaboration (SUTC) and the European Stroke Intitiative (EUSI), one merged definition is as follows:

·        A stroke unit is an organized inpatient area that exclusively or near exclusively takes care of stroke patients and is managed by a multi-disciplinary team of specialists who are knowledgeable about stroke care.

The Cochrane review by the Stroke Units Trialists’ Collaboration summarises data from 25 randomised or quasi-randomised trials including 4,911 stroke patients receiving organised and dedicated in-patient stroke unit or conventional care in general wards. These trials have convincingly shown that

stroke patients managed in organised stroke units have

·        a lower case-fatality and disability, and are

·        more likely to return home, as compared with those managed in general wards.

This favorable outcome was shown to be

·        independent of the patients’ age, sex and stroke severity, and was

·        most apparent in stroke units based in a discrete ward.

Most of the data summariszed in the Cochrane stroke units review comes either from acute admission units with combined dedicated non-intensive acute care and early active rehabilitation, or delayed admission to dedicated rehabilitation stroke units, compared with conventional care in general wards. However, the role of care in an intensive/acute care without rehabilitation and with ultra short time of stay (typically a couple of days) is unproven and needs further study.

Stroke units consist of a complex package of care, provided at various times after onset. Although many of the factors and their interactions in the stroke unit generate a ‘black box’, certain features appear to improve outcome, including:

(i)                  structured program for acute evaluation, physiological monitoring and medical treatment;

(ii)                immediate start of mobilisation and early rehabilitation;

(iii)               multidisciplinary team of medical, nursing, physiotherapy, occupational therapy, speech therapy and social worker staff coordinated at regular meetings;

(iv)              a coordinator of the team;

(v)                educational program for the staff;

(vi)              involvement of the patient and the family in the care and rehabilitation process.

In order to implement good clinical practice and maintain equitable care and consistency, stroke units should be regularly assessed and evaluated by use of quality assurance programs (e.g. the Swedish National Stroke Registry (Riksstroke), SITS-MOST, UK Royal College of Physicians audit system and the German audit system).  The stroke unit is ideally suited for research trials, e.g., novel and promising, but unproven, interventions such as body cooling.

In summary,

·        all acute stroke patients should have access to stroke unit care

·        the units should have the characteristics present in the units evaluated in randomised trials.

·        There is no reason why proven treatments such as hyperacute thrombolysis cannot be implemented in all hospitals caring for acute stroke within the confines of an acute non-intensive stroke unit with appropriate expertise and experience.