Tuesday, May 10, 2011

Neuroscience: "Are you listening?"

Most therapists suspect there is a pretty wide disconnect between what research reveals works to aid in stroke recovery and the treatment options that therapists typically do. One of the reasons for this disconnect is the “meet ‘em, greet ‘em, treat ‘em and street ‘em” perspective hoisted on therapists by managed care. Therapists are sensitive to Rule # 1: Get them safe, functional and out the door. If the best therapeutic option means slowing down the process, it will not see the light of day.
But there is another big reason research fails to resonate with therapists. Much of the “bench side to bedside” rift exists because the two groups (researchers and clinicians) simply don't talk. Mostly, PTs talk to PTs and OTs talk to OTs and if we're feeling really radical we go to a talk or read a paper by an SLP. And if we're feeling truly outlandish we'll go to a talk or read a paper by a neurologist or physiatrist. But is physiatry and neurology where the action is? Neurologists have a vital part to play in stroke recovery, but their input is typically limited to the saving as many neurons as possible hyperacutely (the first few hours post stroke). Physiatrists have the responsibility of dealing with co morbidities and sequelae as well as coordinating recovery efforts through the subacute phase. Generally, physiatry is not involved in the process of driving the massive cortical rewiring needed to aid in motor recovery.
That task is left to stroke survivors, guided by therapists.
We could look to psychology and psychiatry. They do know about the brain. And they have a massive advantage when it comes to knowing how to rewire the brain: they've been working on systems to change the brain since Freud. Edward Taub, the developer of constraint induced therapy, a treatment option that has shown promise in many large clinical trials, is a psychologist. So both psychiatry and psychology are disciplines worth listening to.
Clinical researchers from many disciplines are vigorously trying to solve the conundrum that is stroke recovery. This forces therapists into uncomfortable territory; those who wish to remain evidence-based end up having to listen to researchers outside of PT and OT. And these researchers often speak a different language, write in different journals, work with different treatment techniques, and use different outcome measures. And, as you’ll see, they often work with a different sort of “patient”.
Physical and occupational therapy, physiatry, neurology, psychology and psychiatry. Regarding the question of what systems are best suited to rewire the brain for recovery after stroke, all these disciplines have something to add to the discussion. But, more and more with the passage of time, they will pale in comparison to another branch of science: neuroscience.
Most neuroscientists have a near myopic focus on "unpacking" the 100 billion neurons and quadrillion synapses in the brain. Neuroscientists are involved in the development of a full spectrum of systems to drive massive brain rewiring. And systems to drive brain plasticity post-stroke are no exception.
One of the reasons that neuroscience is such a great source of information has to do with the difference in the actual study participants. Let's say you are a researcher and want to do a double-blind placebo-controlled study. You give a little blue pill to participate A, and a little blue pill to participant B. One is the "real" pill and the other is a placebo. You don't know which pill they got, and they don't know which pill they got. The study is double blinded. There is a study coordinator in the back room who knows who got what pill, but both you and the participants are blinded. How do you do that in stroke-specific rehabilitation research? Participants sign informed consent—this is federal law when it comes to using human subjects in research. The informed consent document may say something like "You will either get a treadmill or you won't get a treadmill for training." In that situation you can single-blind; you can blind the person that's doing the testing. But you can't blind the participant. They know whether or not they got a treadmill. There are other problems with human participants as well. Stroke survivors have strokes in different parts of their brain, they have different comorbidities and sequelae, they are of different ages and have different motivation levels—to name just a few confounds. 
Neuroscientists typically use animal models. Animals are easy to blind; they don't know a treadmill from a glass of milk. And animals can all be given their stroke in exactly the same spot.
In any case, PT and OT are tasked with taking what all these branches of science have revealed, making sense of them and making them available for stroke survivors. As insurmountable as that task seems the payoff is a much richer and robust palette of treatment options.


Robert said...

I work in the medical field and fully the struggles and hardship that a stroke can bring not only in my work experience but with friends who have had a stroke. I have found that hyperbaric oxygen therapy can truly help someone with any kind of neurological injury or disease. I have made a strong effort to help people understand and receive the information regarding this therapy. We have a created a free website listing hyperbaric clinics and facilities nationwide. Hyperbaric oxygen therapy truly can help to bring life back to a more normal state and help the brain begin to heal itself. Our site is www.hyperbaricnation.org I hope this can help whoever reads this post.

Peter G Levine said...


According to the HHS...

"Although a large number of studies address HBOT for the treatment of stroke, the evidence is insufficient to determine whether HBOT reduces mortality in any subgroup of stroke patients because no controlled trial assessed was designed to assess mortality.
Among controlled trials, the evidence about morbidity is conflicting. The three best-quality trials found no difference in neurological measures in patients treated with HBOT versus patients treated with pressurized room air.
Two other controlled trials, one randomized and one nonrandomized, found that HBOT improved neurological outcomes on some measures. However, both were rated poor-quality.
Most observational studies reported favorable, and sometimes dramatic, results, but failed to prove that these results can be attributed to HBOT. For example, one retrospective study found better mortality rates in patients who received HBOT than a comparison group of patients from a different hospital who did not. The study did not provide information on mortality rates from other causes in each hospital; this information would have made it easier to judge whether the improved survival was due to HBOT or to differences in overall quality of care at the HBOT hospital.
The observational studies of HBOT provided insufficient evidence to establish a clear relationship between physiologic changes after HBOT sessions and measures of clinical improvement. Few studies established that patients were stable at baseline."


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