Six rules to regain movements after stroke

Yes, we can help the brain to recover movements after a stroke.

Yes, for best results, it should happen in the first six months – that is what expert recommendation is.

This post summarises the expert recommendations to regain movements after stroke into six rules.

The six rules are;

  1. Move early
  2. Follow up with an intense activity and exercise program
  3. Choose activities that are meaningful, engaging, task-specific, and goal-oriented
  4. Repeat the chosen activities incrementally and consistently
  5. Add aerobic and muscle-strengthening exercises
  6. Set goals

1. Move early

The first is to move out of bed as early as possible. How early?


Help to sit out of bed, stand, or walk 24 hours after the incident”*

NICE Guidelines, (2019)1;
*only after the attending physician decides they are clinically stable to do so.

With regard to the 24-hour timeline;

The Australian Clinical Guidelines2 strongly recommend not to start intense out-of-bed activities within 24 hours of the incident but to start such activities within 24 – 48 hours of the event.

2. Follow up with an intense activity and exercise program

Make every effort to create an intense and regular exercise program for at least three months.

However, before embarking on an exercise program, a qualified health professional should screen and prescribe suitable exercises.

3. Choose meaningful and engaging tasks

The exercise program should focus on meaningful and engaging tasks.

These typically should be the activities of daily living – the activities necessary to become independent in daily tasks.

Let us consider one example: Sit-to-stand.

  • This is a meaningful and engaging activity.
  • And, it is task-specific. One has to stand before walking.

It should also include the activities meaningful to the affected such as work-related skills and even a hobby.

There are specific recommendations that apply to regain movements of arm and hands as well as walking ability.


“how to regain arm and hand movements”

“how to regain walking ability”.


Research reveals that the training benefit may last six months after the completion of the training4. This is critically important. The Stroke Rehabilitation Clinician Handbook says such activities help reorganize new neurons and make changes last long5.

4. Repeat the chosen activities consistently

How many repititions?

How frequently one should engage in rehab exercises to gain a desirable effect? Janice Eng, a UBC physiotherapist6 has responded to this question. More specifically, the question was this:

How many arm and hand movements repetitions per day can positively change the brain after stroke?

Quoting findings from earlier researchers (Nudo et al. 1996; Murata et al. 2007), she said it would be between 600- 1000 successful reach and grasp repetitions per day. The successful means that the number of reach and grasps without any droppings. These findings were based on research work using monkey brains after a stroke lesion to the motor cortex. The research has shown that hand representation in the undamaged primary motor cortex has regained. This is pretty impressive. The improvements have even progressed to precision finger grips.

Does this happen even in the best rehab centers? It is not. Not even close to it. In 2009 Lang C. et al.7 found that it was about 32 per session (day). Later research8 that analyzed metadata showed the more the better.

And, the 2021 Australian Guidelines9 recommend encouraging the affected to practice outside the scheduled treatment sessions.

Consistency

Consistency is the most important requirement for success but is difficult to adhere to.

Exercise and physical activities become effective if those are done consistently.

Stroke Journal, 20143

5. Add aerobic and muscle-strengthening exercises

The Heart and Stroke Foundation10 emphasizes four types of exercises to recover movements after stroke. Those are;

  • Endurance (aerobic)
  • Strength
  • Balance
  • Stretching

The American Heart and Stroke Association statement3 recommends that people with stroke perform aerobic exercises 3-7 days a week and other types – strengthening, flexibility, and neuromuscular 2-3 days a week for life. Having a sufficient dose or intensity is essential to recover movements after stroke.

6. Set goals

The 2021 Australian Guidelines strongly recommend setting goals for each activity in consultation with the affected and stroke caregivers2.

One caveat

Two factors interfere with the extent of recovery of movements:

  • Stroke severety at the begining – the extent of regaining the lost function become lesser with the severity.
  • Age – the extent of the recovery become lesser with advancing age.

Next, read also

References

  1. National Institute for Health and Care Excellence (NICE) Guidelines 2019): Stroke and Transient Ischemic Attack in over 16s: Diagnosis and Initial Management, published on May 1, 2019. accessed on May 27, 2021.
  2. Australian Clinical Guidelines for Stroke Management: Chapter 5 of 8. Rehabilitation. accessed June 5, 2021.
  3. American Heart Association/American Stroke Association (2014): Physical activity and exercise recommendations for stroke survivors. Stroke Journal, 2014. Accessed on June 6, 2021.
  4. French B, Thomas LH, Coupe J, McMahon NE, Connell L, Harrison J, Sutton CJ, Tishkovskaya S, Watkins CL.Repetitive task training for improving functional ability after stroke.Cochrane Database of Systematic Reviews2016, Issue 11. Art. No.: CD006073.DOI: 10.1002/14651858.CD006073.pub3.www.cochranelibrary.com repetitive task training for improving functional ability after stroke (Review)Copyright © 2016 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
  5. Teasle R. et al. (2020): Stroke Rehabilitation Clinicians Handbook (2020): Lower extremity Motor and Mobility Rehabilitation. accessed May 27, 2021.
  6. Janice Eng (2013): Strategies to increase upper and lower extremity physical activity after stroke. CPSR lecture. 2013. Youtube presentation. Accessed on June 6, 2021.
  7. Lang C. et al. (2009): Observation of amount of movement practice during stroke rehabilitation. Arch Phy Med Rehab. Accessed on June 6, 2021.
  8. Lohse K.R. et l. (2014): Is more better? Stroke. Accessed on June 6, 2021.
  9. Australian Clinical Guidelines for Stroke Management (2021): Amount of rehabilitation. Accessed on June 6, 2021.
  10. Heart and Stroke Foundation: Exercise after stroke. accessed May 25, 2021.

Read more…

Additional resources

Exercises after stroke: An excellent but simple resource guide from the Stroke Foundation, New Zealand

It is rare to find online materials without copyright issues. However, I found an excellent open-access resource published by Margot Andrew, Margaret Hoessly, and Kate Hedges. It is under the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original author and source are credited.

Physical activities and exercise, and wellness videos for people with mobility challenges

A team of physiotherapists and occupational therapists from the University Health Network have published a list of exercises and wellness videos for people with mobility challenges. It includes an excellent collection of YouTube video clips. Here are some relevant ones. One should keep in mind that these resources do not replace the exercise regimen prescribed by your healthcare professional.

Three-part series of the “it’s Your Choice” project:

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Author: Prasantha De Silva

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