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The human brain is a wonderful organ with amazing flexibility. Learn more about recovery.
For most family members, life is not the same after TBI. We want you to know that you are not alone in what you are feeling. While everyone’s situation is a bit different, there are some common problems that many family members experience such as less time for yourself, financial difficulties, role changes of family members, problems with communication, and lack of support from other family members and friends. These are just some of the problems that family members may face after injury. Sometimes these problems can seem too much and you may become overwhelmed, not seeing any way out. Family members have commonly reported feeling sad, anxious, angry, guilty, and frustrated.[…]
Up to 70% of individuals experience difficulties using their upper limb (UL, arm and hand) to perform meaningful activities after stroke . There is an assumption that when a stroke survivor demonstrates a change in activity, it is underpinned by an improvement in their capacity (i.e., what a person can do in the clinical environment) and performance (i.e., does a person actually use their UL in real world environments outside of the clinic) . However, UL recovery post-stroke is unlikely to be this simplistic . Understanding how capacity and performance change over years post-stroke might help to identify which patients to target and when during their recovery.
Previous research has noted distinct recovery profiles during inpatient ,  and outpatient  rehabilitation. Firstly, survivors may demonstrate improvements in both capacity and performance after stroke. Secondly, survivors may demonstrate an improvement in capacity but not performance. Lastly, survivors may demonstrate little or no change in both capacity and performance. An improvement in performance but not capacity has not been documented in the literature. Combined, these profiles support our rationale that UL capacity and performance are interrelated, yet are different constructs that must be measured separately.
Stroke recovery is a long-term goal. It is important to complete observational studies that track recovery to establish whether there is a discrepancy between capacity and performance in the long-term. To date, longitudinal tracking of recovery has largely lacked investigation of natural recovery from an acute time point post-stroke (first 7- to 14-days), long-term follow up of patients beyond 3- to 6-months post-stroke, and characterisation of stroke variables such as lesion type and location that may modify or interact with observed recovery profiles .
In this exploratory study our objectives were to determine 1) whether UL capacity and performance improve over the first 24-months after stroke; and 2) if there is a window of greatest improvement in UL capacity and performance. This information is important to develop an understanding of the longterm timecourse of recovery after stroke to support evidence-based clinical practice guidelines to inform upper limb rehabilitation services.
In 2008, it was proposed that the magnitude of recovery from nonsevere upper limb motor impairment over the first 3 to 6 months after stroke, measured with the Fugl-Meyer Assessment (FMA), is approximately 0.7 times the initial impairment (“proportional recovery”). In contrast to patients with nonsevere hemiparesis, about 30% of patients with an initial severe paresis do not show such recovery (“nonrecoverers”). Hence it was suggested that the proportional recovery rule (PRR) was a manifestation of a spontaneous mechanism that is present in all patients with mild-to-moderate paresis but only in some with severe paresis. Since the introduction of the PRR, it has subsequently been applied to other motor and nonmotor impairments. This more general investigation of the PRR has led to inconsistencies in its formulation and application, making it difficult to draw conclusions across studies and precipitating some cogent criticism. Here, we conduct a detailed comparison of the different studies reporting proportional recovery and, where appropriate, critique statistical methodology. On balance, we conclude that existing data in aggregate are largely consistent with the PRR as a population-level model for upper limb motor recovery; recent reports of its demise are exaggerated, as these excessively focus on the less conclusive issue of individual subject-level predictions. Moving forward, we suggest that methodological caution and new analytical approaches will be needed to confirm (or refute) a systematic character to spontaneous recovery from motor and other poststroke impairments, which can be captured by a mathematical rule either at the population or at the subject level.
It has been appreciated since Hippocrates that the strongest predictor of final motor impairment after stroke is initial impairment (Aphorisms of Hippocrates, Section 2: 42). A prominent poststroke motor impairment in humans is the intrusion of unwanted synergies, with synergy referring to a systematic pattern of either joint co-articulation or muscle co-activation. The Fugl-Meyer Assessment (FMA) was explicitly developed to track progression of recovery from such synergies. A seminal study tracking the recovery of patients using the upper extremity subscale of the Fugl-Meyer Assessment (FMA-UE) demonstrated that more severely affected patients saw greater recovery in this outcome, on average, than more mildly affected patients in the immediate poststroke recovery period1; however, the average final score of the FMA-UE among the severly affected still trailed behind the mildly affected. The authors of this study stated, “The most dramatic recovery in motor function occurred over the first 30 days, regardless of the initial severity of the stroke.” On the basis of this study and other considerations, Krakauer et al2 sought to investigate the nature of this FMA-UE change early after stroke; work that led to the formulation of the proportional recovery rule (PRR).2 The PRR states that patients recover approximately 70% of their maximal potential reduction in impairment as measured by the FMA.2
Since it was introduced, the PRR has been applied in a broad range of studies that involve recovery from stroke, both for FMA-UE and for other outcomes. Claims related to the PRR have been made for upper and lower limb impairment measured by the FMA,3–10 aphasia measured with the Western Aphasia Battery (WAB),11 the resting motor threshold (RMT) of the extensor carpi radialis,6 and visuospatial neglect measured with the Letter Cancellation Test (LCT),12 among others. Applications of the PRR typically distinguish between two distinct subgroups of patients, referred to as “recoverers” and “nonrecoverers”: the former subgroup is composed of patients who recover a significant amount of lost function, and the latter is composed of those who do not. The PRR is thought to usefully characterize the recovery process among recoverers only. Although the methods by which the PRR was applied and evaluated have differed substantially across publications, many authors have argued that their findings are evidence for a PRR that accurately describes an underlying biological process that arises across neurolocical domains. Recently, however, the PRR has been the subject of criticism related to the validity of the statistical methods underlying its implementation and to the degree to which data are consistent with claims in support of the PRR.13,14 Much of the critique on the PRR articulated by these articles was focused on specific statements associated with the PRR followed by a general dismissal of all findings.
Our goal in this work is to provide a critical reexamination of the literature pertaining to the PRR. We focus first on the interpretation and implementation of PRR as a statistical model, and on data-driven concerns about the use of the PRR in studies of recovery. We then reexamine data reported in the literature and the extent to which past studies provide evidence for the PRR with these considerations in mind. Our hope is that this will serve as an instructive overview of issues that can arise in the application of the PRR to studies of recovery, aiming to improve future investigations into the PRR. Although our primary purpose is not to provide direct response to recent critiques,13,14 we are mindful of the concerns raised and address these directly in the Discussion section.
The breadth of work on the PRR introduces a commensurate range of methodological concerns one might consider. We attempt to be complete in our discussion but prefer to focus on overarching concerns regarding the statistical validity of the PRR instead of point-by-point inspections of the existing literature. Two themes we will revisit while pursuing the main goals of this paper are the identification of recoverers and the distinction between describing biological mechanisms and making patient-level predictions. The manner in which nonrecoverers are identified is a point of legitimate concern, as some statistical approaches can artifactually create evidence for the PRR. The PRR was originally intended to describe biological mechanisms at the population level, although implicitly it is expected that the PRR may be useful for predicting recovery of individual patients. Both of these are related to recent concerns regarding the PRR.
The next section provides an overview of the statistical formulation of the PRR and introduces three simulated datasets to illustrate scenarios over which the PRR shows varying degrees of validity. Subsequent sections conduct a selective review of the literature, reevaluating specific articles in the light of the three scenarios, comment on recent criticisms of the PRR, and end with our current view on the veracity of the PRR.
Continue —> What the Proportional Recovery Rule Is (and Is Not): Methodological and Statistical Considerations – Robinson Kundert, Jeff Goldsmith, Janne M. Veerbeek, John W. Krakauer, Andreas R. Luft,
Neuroplasticity is a natural process occurring in the brain for entire life. Stroke is the leading cause of long term disability and huge medical and financial problem throughout the world. Research conducted over the past decade focused mainly on neuroprotection in the acute phase of stroke while very little studies targets chronic stage. Recovery after stroke depends on the ability of our brain to reestablish structural and functional organization of neurovascular networks. Combining adjuvant therapies and drugs may enhance the repair processes and restore impaired brain functions. Currently, there are some drugs and rehabilitative strategies that can facilitate brain repair and improve clinical effect even years after stroke onset. Moreover, some of compounds such as citicoline, fluoxetine, niacin, levodopa etc. are already in clinical use or are being trial in clinical issues. Many studies testing also cell therapies, in our review we will focused on studies where cells have been implemented at the early stage of stroke. Next, we discuss pharmaceutical interventions. In this section selected methods of cognitive, behavioral and physical rehabilitation as well as adjuvant interventions for neuroprotection including non invasive brain stimulation and extremely low frequency electromagnetic field. The modern rehabilitation represents new model of physical interventions with limited therapeutic window up to six months after stroke. However, last studies suggest, that time window for stroke recovery is much longer than previous thought. This review attempts to present the progress in neuroprotective strategies, both pharmacological and non-pharmacological that can stimulate the endogenous neuroplasticity in post stroke patients.
We can all relate to being guilty of spinning around in the dizzying comparison trap. Whether it’s love, family, career, financial, fashion, weight or cosmetic, somewhere along the line, we have compared ourselves to others. With the presence of social media, this trap has become even more intrusive.
From the moment we received the life-changing news of Aaron and Steven’s car accident, the comparison trap began. Aaron didn’t survive the accident that left Steven with a severe Traumatic Brain Injury (TBI). While the comparison trap from the loss of Aaron would set in later, it immediately bombarded us during Steven’s recovery.
Of all comparisons we thought we would face as parents, nothing prepared our ears to absorb the speech that began: don’t compare your child’s TBI progress to another survivor. A wonderful physician, who is now a friend, spoke those words to us. He then proceeded to inform us, “In a line-up of 10 TBI survivors, you would witness 10 different outcomes.” I did not want my son in a TBI line up or any part of the TBI community. All I wanted was to be able to turn back the calendar to August 13, 2012, and plan a totally different Sunday for our intact family of 4, a day close to home, together.
During Steven’s roller-coaster recovery, we were reminded often, felt like hourly, that with the severity of Steven’s injuries the recovery road was long, we should not get our hopes up. Really? Telling parents not to get their hopes up about their child’s survival was the same as telling us not to take our next breath! Of course, we were going to hope, pray, and never give up.
We admit, despite celebrating Steven’s recovery, we did fall into the dismal comparison trap.
Why is Steven’s rehab roommate already walking?
His accident was as severe as Steven’s; how did he escape a craniectomy and the helmet?
How did she escape the epilepsy curse?
These comparisons led me to wonder if I tapped into all available resources for Steven’s recovery?
As shock eventually lifted, we realize that some of our justifications for comparing were due to our lack of knowledge about TBI. How could we not compare? And while we have heard every lecture on not asking why, it’s human nature to ask, “Why?”
As my heart began to absorb the reality of Aaron’s death, I was faced with new comparisons. When it comes to Aaron’s life, it’s not all about comparisons; it’s more about mynatural mom instinct wondering what Aaron’s life would look like today, a mother’s shattered heart longing for what should have been.
Would Aaron be married?
Would we be grandparents?
Where would Aaron be in his career?
What would Aaron’s big trophy be this hunting season?
While I acknowledge that people mean well, and do not know what to say, the comparison that continues to leave me speechless is comparing child loss to losing a parent or a grandparent. Trust me, I have also experienced those deep losses, but it’s unequivocally not the same, it’s just not.
When I find myself being drawn in as a pawn in the comparison game, I don’t beat myself up, I just say no! I refuse to stay in the game. After all, it’s not about comparisons, it’s about living for the ones I love and for those that need and love me. Instead of evaluating those in my life; past and present, I will celebrate them. I refuse to get lost in others idealizedlives, I will focus on being grateful for my life; right here, right now; a priceless lesson that Aaron taught me and one that I and the two men in my life attempt to remind each other of daily.
Unilateral motor weakness is one of the most common deficits resulting
from stroke and one of the main causes of disability. Stroke rehabilitation is
multidisciplinary and the aim of physiotherapy should be to promote activation
and stabilisation of the remaining innervation and functions of the damaged
central nervous system. Scientific evidence demonstrating the values of
specific rehabilitation interventions after stroke is limited. It is still unclear, which
physiotherapeutic approaches in stroke rehabilitation are most effective. Modern
approaches follow the idea that functional improvement to a large extent relies
on the use of compensatory movement strategies, enabling patients to learn
to cope with their deficits. The Vojta therapy is based on a completely different
approach: the reflex locomotion. Vojta described inborn movement sequences
of reflex locomotion that are retrievable at all times. The therapist stimulates
these innate patterns of movement by applying pressure to defined zones. The
therapeutic use of reflex locomotion enables elementary patterns of movement
in patients with impaired locomotor system, for example due to brain damage
caused by stroke, to be restored once more, assuming that repeated stimulation
of these “reflex-like” movements can lead to something like “new networking”
within functionally blocked neuronal networks. After Vojta treatment, these
patterns are more spontaneously available to the patient. Clinical experience
shows, that Vojta therapy improves postural control, uprighting against gravity
and goal-directed movements. We will discuss implementation of Votja therapy
in stroke rehabilitation and introduce a first ever randomized controlled trial for
this approach in stroke rehabilitation.[…]
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