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• Recovery or maintenace?
  Birgitta Langhammer
  Published on: 18 April 2011

• Published on: 18 April 2011

  Recovery or maintenace?

  • Birgitta Langhammer, Associate professor
  • Other Contributors:
    • Iris Brunner Research Fellow, MSc

  We read with interest the meta-analysis with the focus on physiotherapy interventions late after stroke and we would like to thank the authors for their effort to shed light on this subject. Interventions late after stroke are an important area of rehabilitation that has been neglected. There most certainly is a need for rehabilitation and exercise tailored for stroke survivors late after onset. As the authors point out...

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  We read with interest the meta-analysis with the focus on physiotherapy interventions late after stroke and we would like to thank the authors for their effort to shed light on this subject. Interventions late after stroke are an important area of rehabilitation that has been neglected. There most certainly is a need for rehabilitation and exercise tailored for stroke survivors late after onset. As the authors point out the disabling process after stroke is complex and resources to maintain physical functions, after the first months of primary rehabilitation are scarce. It is not an area prioritized by administrators and health politicians in any country and we applaud the authors' genuine wish to forward this need of maintenance and need for exercise late after stroke. However, the authors do not distinguish between the different underlying mechanisms in early and late motor function recovery in this meta- analysis. Most studies are either in the acute scenario OR, as the ones presented in this meta-analysis late after stroke. Several studies provided evidence that patients with stroke reach a plateau after 3-6 months and functional improvements seem to stabilize on a "peak performance" (1-3).

  So, the early rehabilitation seems to be very important in regaining as much function as possible. How successful this is depends on many factors. But, if treated in a stroke unit with multidisciplinary care and with proper early rehabilitation all stroke survivors get a functional profit to some degree. Some of the stroke survivors perform on a higher level and some on lower levels in accordance with the initial lesion and the damage that was imposed. Basically, one can speak of a therapeutic window up till approximately 6 months to regain the function of the lost bodily motor functions. This does by no means indicate that rehabilitation after 6 months is futile. For one thing can patients with stroke at any later stage learn to exploit their obtained motor potential to a larger extent, and for another thing can patients with stroke like everybody else gain strength and endurance with the help of training. There are few studies that have followed stroke patients continuously from the acute to the chronic stages, with or without interventions. However, the few that exist indicate an interesting development: If treatment and exercise is abandoned functions deteriorate, but if treatment and exercise persist, functions are maintained(4-7). In the acute early stage of rehabilitation focus is on regaining bodily functions. After 3-6 months, it seems, you will not see any significant difference in the RECOVERY of function, as to less paresis, but if maintained they will be preserved at that level. Some patients may even be able to improve functional abilities due to practice, but usually on the basis of the motor function regained early after stroke (8). However, if this new and improved function is not maintained with exercise or physical activity the motor functions may and will deteriorate...and rapidly so. And many stroke survivors are less active and sometimes overprotected by their kind relatives so performance often DOES deteriorate (9). So people with stroke, like the general population, have a need for maintenance of capacity and function (10). And this is we would like to argue, that these studies in this meta- analysis have focused on: maintenance of capacity. So the beauty of it all is that stroke patients can enhance their capacity like endurance and strength and thereby their functioning in daily life activities, on line with healthy people BUT nevertheless seems genuine motor recovery to be limited to the first 3 - 6 months post stroke. Thank you once again for bringing this topic to attention!

  Birgitta Langhammer, Associate Professor, PhD, Oslo University College, Norway

  Iris Brunner, Research Fellow, MSc, University of Bergen, Norway

  References

  1. Kwakkel G, van Peppen R, Wagenaar RC, Wood Dauphinee S, Richards C, Ashburn A, Miller K, Lincoln N, Partridge C, Wellwood I, Langhorne P. Effects of augmented exercise therapy time after stroke: a meta-analysis. Stroke 2004;35(11):2529-39.

  2. Kollen B, van de Port I, Lindeman E, Twisk J, Kwakkel G.Predicting improvement in gait after stroke: a longitudinal prospective study. Stroke 2005;36(12):2676-80.

  3. Verheyden G, Nieuwboer A, De Wit L, Thijs V, Dobbelaere J, Devos H, Severijns D, Vanbeveren S, De Weerdt W. Time course of trunk, arm, leg, and functional recovery after ischemic stroke. Neurorehabilitation And Neural Repair 2008;22(2):173-9.

  4. Van de Port IG, Kwakkel G, van Wijk I, Lindeman E. Susceptibility to deterioration of mobility long-term after stroke: a prospective cohort study. Stroke 2006 Jan;37(1):167-71.

  5. Langhammer B, Stanghelle JK, Lindmark B.An evaluation of two different exercise regimes during the first year following stroke: a randomised controlled trial. Physiotherapy Theory And Practice 2009;25(2):55-68.

  6. Langhammer B, Stanghelle JK, Lindmark B. Exercise and health- related quality of life during the first year following acute stroke. A randomized controlled trial. Brain Injury 2008;22(2):135-45.

  7. Langhammer B, Lindmark B, Stanghelle JK. Stroke patients and long- term training: is it worthwhile? A randomized comparison of two different training strategies after rehabilitation. Clinical Rehabilitation 2007;21(6):495-510.

  8. Langhammer B, Stanghelle JK. Exercise on a treadmill or walking outdoors? A randomized controlled trial comparing effectiveness of two walking exercise programmes late after stroke.Clinical Rehabilitation 2010;24(1):46-54.

  9. Michael KM, Allen JK, Macko RF. Reduced ambulatory activity after stroke: the role of balance, gait, and cardiovascular fitness.Archives Of Physical Medicine And Rehabilitation 2005;86(8):1552-6.

  10. Pang MY, Eng JJ, Dawson AS, Gylfad?ttir S. The use of aerobic exercise training in improving aerobic capacity in individuals with stroke: a meta-analysis.Clinical Rehabilitation 2006; 20(2):97-111.

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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