Monday, July 4, 2016

Early intensive exercise after stroke IS NOT GOOD.

Intensive rehab after stroke. It's not a good idea, but most clinicians think it is. That's what happens when researchers, who don't know how to keep it clear and simple are interviewed by journalists who know nothing about stroke.     By the time the journalist publishes the research is completely misunderstood.

Here's an example...

What a load of crap.  

The real problem? Well meaning therapists take this nonsense to heart and think more intensity of exercise during the acute phase (broadly, the first 7 days) is better.
C'mon everybody!
Let's go to the gym!!
Intensive rehab right after stroke... (all links)
What the heck does "early" mean?
The problem here is poor communication. The truth is, If too much intensity is introduced too soon (again, broadly, during the first 7 days) the brain damage from the stroke can be made worse. Most survivors will tell you that the first few days after stroke they were barely conscious.

What the heck does "intense" mean?
This article suggests that early "intensive" rehab helps. Here's an experiment: Sit back and imagine what "intense rehab" is. Got an image in your head? OK. Now compare that image with what they did in this research. 

In this study "intensive therapy" involved a "skilled prehension task." A grasping task! Oh, yeah, and it was with mice! With a planned, controlled stroke (like yours probably wasn't) and they were trained on the task right up to the day of the stroke, and then continued training after the stroke. AND... They used mice that were "70 to 120 days old." Guess how long mice live? The type of mice they used in this experiment live (conservatively) 365 days! These were young mice with no other illnesses. Which is pretty much nothing like the highly heterogeneous pathology of stroke. Did they have any mice that were the equivalent of 85 years old, that were on dialysis, recovering from a hip replacement and had a history of falls? No. How, based on this research, does the researcher (who is an MD) conclude that rehab should be 'early' and 'intense'? I'm all for learning from animal research for the good of survivors but let's be careful not to get the cart too far ahead of the horse.

In fact, had the researcher and the reporter knew how and what to communicate, it woulda sounded like this... "In studies of young healthy mice that we give a stroke to, repetitive grasping tasks help mice recover the ability to grasp."

Most therapists know this notion that, in the first few days after the stroke "more is always better" is stupid. And its not just stupid because the science says its stupid (which it does). Its stupid because most stroke survivors can't tolerate multiple hours of intensive therapy after their stroke. And therapists often resent MDs who suggest therapists should force the issue. I've heard of massive clinical dust-ups about what should be a simple question with a simple answer: Should a survivor walk in the first 24 hours after stroke? If someone thinks they know the answer to this one, they're lying.


Rebecca Dutton said...

The only way I could tolerate 5 hours of therapy was to fall asleep on top of the covers of my bed during the breaks. For me, a stroke created a crushing level of fatigue that was unlike anything I had ever experienced.

Tamara said...

In the first stage there is still so much physical stress in the body, that your natural repair mechanisms don't work anyway. After that there's a lot of mental stress: WTF happened? Why me? How am I going to pay for……What does my future look like…? In the first year I mainly sat on the couch with a too big sweater inside out and backwards.

oc1dean said...

Maybe watching hours of action observation videos could be considered intensive, although with my level of fatigue there would have had to be major motion picture quality fight scenes included for me to stay awake. I'm with Rebecca, I could fall asleep with only 5 minutes between therapy sessions.

Douglas Einck said...

I find the debate really interesting & thought provoking to say the least. I wrote my own post on the topic here:

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