Transcript
Speaker: Welcome to the NeuroPowerHour. I'm your host and neurological navigator, Dr. Michael Powers, physical therapist, board certified in neurologic physical therapy and clinical electrophysiology.
Speaker: Let's get started. Today is the fourth and final of the multi-part series on stroke, and we'll be talking about evidence-based interventions for stroke. In this, similar to the approach to examination of last episode, might be a little bit different than what you're expecting.
Speaker: I'm not going to be providing cookie cutter approaches towards treatment and stroke. Rather, I'm going to talk about the evidence in the overall approach. Specifically, we're going to talk about the task oriented approach and how that's aligned with best current evidence.
Speaker: and how it taps into neuroplasticity. And then I'm going to highlight two clinical practice guidelines, including the improving locomotor function, CPG, and the use of AFO and functional electrical stimulation after stroke as well.
Speaker: After this episode, then, you should feel that you're equipped with the best current evidence in terms of approaching interventions in stroke. How you actually go about with the details of your interventions will be up to you, but I'm providing the scaffolding in the background of how to apply the evidence in your stroke treatments.
Speaker: Let's start by talking about the task-oriented approach. This is an approach that places movement at the intersection of the individual, the task, and the environment. And you know me, I love a good Venn diagram. So here we've got movement in the center, and our three circles creating that Venn diagram are going to be the individual, the task, and the environment.
Speaker: And the reason that task-oriented approach is so powerful is that it's consistent with best current evidence for individuals with acute movement disorders following neurologic injury, and that includes stroke. In order to tap into neuroplasticity or to maximize neuroplasticity, we really want high specificity, amount, and intensity of task practice. We don't want to give someone who's had a stroke three sets of 10 of long arc quads or short arc quads. It's really irrelevant to the nervous system.
Speaker: What we do want to do is if someone said, it's really important for me to be able to stand at my kitchen counter and put away the dishes. That's salient, that's important.
Speaker: The brain is gonna latch onto that and that helps drive neuroplasticity. The other important consideration is we're engaged in the task-oriented approach is we want to continually increase the task difficulty and induce errors.
Speaker: So the nervous system learns by correcting errors and not by having the therapist necessarily or someone external constantly telling someone they're doing it wrong. We learn best when we perceive errors and are able to safely self-correct them. So a key part of this task-oriented approach is understanding the task being performed in ways that we can improve the task difficulty.
Speaker: Let's break down some of the components then of the task-oriented approach. I mentioned it includes the individual, the task, and the environment. And we can break each of these down into smaller pieces.
Speaker: And sometimes in the classroom, I've talked about this as almost a recipe. So think about as you're maybe setting up a treatment plan, you're engaging in the task-oriented approach, maybe you dial up some areas a little bit more, dial other areas down, you've got this tremendous recipe that you can choose from in terms of what aspects you want to manipulate or control or change as part of your treatment plan.
Speaker: At the individual level, these are really going to be your body function and structure that you've already examined during your examination. But these are going to impact the overall movement that you see from the patient.
Speaker: And here we have three main areas, and I think they're pretty straightforward and easy to remember. So we've got the motor action function. That's what the individual is bringing into the task-oriented approach.
Speaker: What is the motor and action function? Then we have the sensory and perceptual function. And these two are linked. We can think about can the patient sense and perceive needed information that's coming in? And can they produce an output via the motor action function? Then the third key consideration on the individual level is going to be cognitive function.
Speaker: To recap then, on the individual level, we're really interested in motor action function, sensory perceptual function, and cognitive function.
Speaker: Now let's talk about the task, and we could probably spend a whole episode, and I likely will, talking about task analysis and how to change aspects of tasks. But I want you to know some of the key variables that you can be looking at as you're setting up your treatment plan relating to performance of tasks.
Speaker: The first is going to be, is the task discrete, continuous, or serial. A discrete task has a clear beginning and end and can't really be broken down into parts.
Speaker: One example would be turning on a light switch. You flick the switch and it's on. That's a discrete task. A continuous task is one that's repeated over and over There's no clear beginning and end or the beginning and end is really decided by the person.
Speaker: An example of this would be swimming in a pool. That's a repetition of, let's say someone's doing the breaststroke. You just keep going until the person decides to stop. That's a continuous task. A serial task has a series of stages. A great example of this would be a sliding board transfer.
Speaker: You position the wheelchair, get the armrests out of the way, position the sliding board, and perform the transfer. The reason consideration of whether a task is discrete, continuous, or serial is important is in terms of thinking about, well, if we're training or working on a task, can it be broken down into pieces?
Speaker: If you're really working towards, let's say, walking, which is more of a continuous task, if you're walking without an assistive device, you don't want to break that down into pieces because that's no longer a walking task.
Speaker: But if you're working on a sliding board transfer, you may decide, you know what, I'm going to work on just removing the armrests, and then I'm going to work on positioning the board. You can work on pieces of the task.
Speaker: Another key consideration for the task is whether it's a stability task or a mobility task. And here in the classroom, there's usually some confusion because we in physical therapy use the term stable and mobile interchangeably in a lot of areas.
Speaker: When I'm talking about a task, whether it's stable or mobile, really comes back to the consideration of, is the base of support moving?
Speaker: Base of support is the area of the body that's in contact with the support surface. So for our purposes and task analysis here, if the base of support does not move, it's a stable task.
Speaker: Now, you could be reaching, the body could be moving, and you could have what's called a dynamic stability task, but the base of support's not changing.
Speaker: And generally speaking, a stable task is thought to be easier or less difficult than a mobility task. Let's say then that I'm standing and reaching.
Speaker: That's a stability task. Now, let's say that I'm walking. That would be a mobility task. And again, generally speaking, mobility is a little more challenging because the person's having to respond and be dynamic in managing their center of mass within their base of support. So that's stability versus mobility.
Speaker: And as you're setting up your treatment plan, you can change whether you're working on stable or mobile tasks, depending on the task difficulty you want, and depending on the task that you're working on.
Speaker: Another key task consideration is whether use of the upper extremity is needed for the task. That's manipulation. If the arm is not needed, that's not manipulation or no manipulation Generally speaking, manipulation tasks are going to be a little more difficult because it requires coordination and cognitive awareness of using the arm.
Speaker: So manipulation versus no manipulation. Then finally, if you're doing repetitions or repeats of a task, if there is no variability between the trials, that's going to be a little bit easier.
Speaker: versus if there's variability between the trials. So maybe you're working on a sit-to-stand task and you're having or asking the patient to stand from the same chair each time. That's no inter-trial variability.
Speaker: And then maybe you're doing sit-to-stands from a couch and then chair with armrests and then a low stool. That would be intertrial variability and that's going to be more challenging. To recap then on the task, we can consider whether it's discrete, continuous, or serial, whether it's a stable or mobile task, whether we need to use the arms in the task, so whether there's manipulation involved,
Speaker: and whether there is intertrial variability or no intertrial variability. Finally, let's talk about the environment. And this one I think is really fun and something that we don't always consider unless we really take a big picture view and recognize that our environment absolutely shapes and informs our movement.
Speaker: The big one that's particularly relevant in neurologic therapy is going to be as the environment closed or open. Reason that's so important is an open environment where there's a lot of distractions.
Speaker: It's a dynamic environment. I typically use the example, think about a crowded store, lot of noise, a lot of people moving randomly. Seems like people are always stopping right in front of you and you have to all of a sudden hit your brakes so you don't fall, that's a very challenging environment for able-bodied individuals.
Speaker: And then you lay on someone who's had a stroke or if there's cognitive issues or they have balance concerns, that open environment is really going to be more cognitively demanding.
Speaker: Closed environments going to be not a lot of distractions, good lighting. Think about a ah pretty typical therapy environment unless ah the environment's really crowded. But a typical therapy gym is going to be a more closed environment versus when the client or patient's out in the community, that's a more open environment.
Speaker: So we can think as we're setting up our practice schedule and our treatments that we may be starting someone in a more closed environment. decreasing distractions, letting the person have some success early, letting them focus on the movement, then progressing to an open environment because that's going to be a bigger challenge. Along the similar lines there, we can also consider the regulatory features of the environment.
Speaker: These shape the movement versus the non-regulatory features. An example of a regulatory feature might be the height of a chair in performing sit to stand.
Speaker: That shapes the movement. You have no choice. If ah the chair is 15 inches, you need to be able to have the power to stand up from a 15 inch chair. Non-regulatory feature might be the background noise. Maybe there's some loud music that might impact the movement, but it doesn't define the movement.
Speaker: So for environment, we've got closed versus open. and regulatory and non-regulatory features. To recap then the task-oriented approach, we are considering that movement is the intersection between the individual, the task, and the environment.
Speaker: As you're thinking about setting up your treatment plan for the individual who's had a stroke, you'll want to consider, okay, at the individual level, what is their motor action function?
Speaker: What is their sensory perceptual function? What is their cognitive function? You're going to consider all the things that the individual bringing to the movement. Then you think about the task. So maybe we're thinking about a sit to stand task.
Speaker: And if we're only training the part where the person is sitting at the edge of the chair to standing up, we would consider that a discrete task. There's no series of steps.
Speaker: It's not a continuous task. So we're going to work on that aspect. If we think of sit to stand includes scooting forward in the chair and then standing, that would be a serial task and we may work on stages of that as part of our treatment.
Speaker: And you have the freedom to choose that, that's up to you. So that would be part of our task considerations is that discrete, continuous, or serial. A sit to stand task then would be considered a mobility task because the base of support changes from having the feet on the ground and the legs and the bottom on the chair towards only having the feet on the ground and standing. So it's a difficult task in terms of when we look at is it stable or mobile, a sit to stand task is going to be a mobile task. This could be a manipulation task if the person has to push up from the chair, that would be manipulation. If they're able to do it without pushing up, that wouldn't be manipulation.
Speaker: And it may also be manipulation if the person's using an assistive device and they need to hold on when they're standing. Then the final task consideration is their intertrial variability versus not.
Speaker: If we're initially training a sit to stand, we're probably standing from the same surface. So there's probably not intertrial variability. When we wanted to increase the difficulty, we could add some variability to the task.
Speaker: Finally, then the environment, and I'll keep using the sit to stand task as my example. Are we performing this in a relatively quiet area, good lighting, no distractions?
Speaker: That would be a closed environment. If we are then moving out into the community, maybe we're doing an outing or maybe the person's out at a shopping mall, that's going to be an open environment.
Speaker: Regulatory feature if for the sit-to-stand task would be the height of the chair. Are there armrests? Non-regulatory would be lighting, amount of background noise, etc. So that is the task-oriented approach. We're going to use this approach across neurologic physical therapy.
Speaker: It's really pertinent, however, in stroke to really drive that neuroplasticity. We want to employ this model, high intensity, high repetition, keep cranking up the difficulty, induce movement errors, because that's how the patient's going to learn best.
Speaker: Let's move to the first of our two clinical practice guidelines we're going to be covering today. And this is the Improving Locomotor Function CPG or Clinical Practice Guideline.
Speaker: This was published by Hornby et al. in 2020. This is a systematic review and additional work's been done since then, adding on a little bit to it. And this is looking at populations that include persons greater than six months after acute onset central nervous system injury. So this includes patients who have sustained a stroke, incomplete spinal cord injury, and or traumatic brain injury who are ambulatory.
Speaker: That's a key consideration here. So if we're in the initial stages of setting up our interventions for someone who's had a stroke, the evidence currently does not necessarily apply. My thought is we're probably going to be seeing evidence coming out that this high-intensity approach applies to individuals with acute stroke. But I do want to point out that currently the evidence is recommending, or the CPG is saying, persons greater than six months after stroke. The outcomes, so the what that we're talking about here, is walking speed and time distance. And I want to make that point that as we're using the evidence, we can't just say, well, the improving locomotor function CPG says high intensity gait improves all aspects of walking. It's not saying that. Our key variables of interest are walking speed and time distance.
Speaker: And these are extremely important. But again, I want and you to think about we're not saying this improves necessarily static balance or it's not saying it improves transferability. or it's not saying necessarily walking independence, although walking speed, we do know the importance of that walking speed in terms of functional outcomes and even overall mortality.
Speaker: So the Academy of Neurologic Physical Therapy has some good clinician handouts, clinician information for implementing the improving locomotor function, CPG, and I'm going to make sure to link that in the show notes. What is the CPG actually recommending? In order to improve locomotor function, the recommended guidelines then are walking practice at moderate to vigorous intensity, 60 80% of heart rate reserve, or to of heart rate max. There's also included in the CPG are might considers and not recommended.
Speaker: So might consider includes strength training, circuit training, cycling, standing balance training with VR-based feedback. Not recommended is static balance training, bodyweight-supported treadmill training with manual assist, robotic-assisted training.
Speaker: And interestingly enough, I saw Hornby present at CSM, I think it was in 2023, His group talked a little bit more about the possible reasons that robotic-assisted training was not as beneficial, and I think he called it the principle of laziness. And if using robotic training or using the bodyweight-supported treadmill training where we're not getting enough intensity, there's just not enough of that high intensity to drive neuroplasticity. there does seem to be a key link between what's considered aerobic exercise or high intensity and neuroplasticity.
Speaker: I'll have a whole episode on neuroplasticity coming up as well. And so if we think about, and I really like that term, the principle of laziness, that there's just not enough intensity if we're using robotic assisted training. So something to consider, we want the person or the patient doing the walking practice at moderate to vigorous intensity. That's really the take-home message from this CPG. couple caveats I want to mention is the CPG is specific to improving gait function. And currently, as I previously mentioned, it's limited to the chronic phase. There is some evidence that body weight supported treadmill training plus manual assist or robotic assist training could have some benefit in subacute stages and or with patients who are non-ambulatory. Remember, this CPG is saying it's appropriate for use for patients who are ambulatory. And when we're using the evidence, we always have to consider, well, is the patient that I'm working with, that patient that's in front of me, does that match the target population in the evidence that I'm using? Here, we've got this specific mention that someone who has a subacute stroke, so that's different than chronic, who's not ambulatory, that's different than the target population in the CPG, could potentially benefit from body weight support treadmill training and or robotic training.
Speaker: And I want to mention that because if you're working with someone who's got a pretty involved stroke and it's early on, you may want to get them up in some fashion. Yes, we're not going to be getting high intensity, but there's also evidence that just being upright can be helpful. And recall from the Sheetz et al. article, we know that we don't have to necessarily go in a developmental pattern. We don't need to have someone who can sit before we get them up in a body weight system or robotic system and start having them walking, there's something about that reciprocal motion of walking, there's something about being upright that also taps into neuroplasticity.
Speaker: So I wanted to make that key distinction and put that caveat in that don't be scared to use body weight, support treadmill training or robotic training. If you've got someone who's not ambulatory and or is in the subacute phase, you're free to do that.
Speaker: They do mention in the initial study or the initial CPG that there's possibly an increased risk of cardiovascular events during higher intensity walking training without appropriate cardiovascular monitoring.
Speaker: The evidence currently doesn't say, though, that we've seen an uptick in cardiovascular events. And it makes sense to me as well. If we think about, well, a stroke is a cardiovascular event, people may have been coming in to the stroke event with suboptimal status in the cardiovascular system.
Speaker: in implementing high-intensity gait training is actually helping to improve the cardiovascular system. So yes, we're going to be aware that we need to monitor, but I hope that once we've taken the big-picture view, you've done your screening, you're monitoring appropriately, we're not going into this scared.
Speaker: We're actually going into this thinking we could get that highly sought-after two-for-one deal where we're improving two things at once. We could be improving gait ability and also improving the function of the cardiovascular system. So along those lines with risk monitoring, the CPG recommends physician consultation, possibly ECG exercise testing depending on comorbidities and risk.
Speaker: And to date, no studies have found increased risk. But again, we're going to use safety screening. Two key themes on the CPG. Task-specific practice is an essential ingredient.
Speaker: We get a callback here from what I just talked about on the task-oriented approach. And this really should be burned into your brain that the task-oriented approach, performing activities that are specific, intense, and salient is going to drive neuroplasticity. And that should be the hallmark or the bedrock of your neurologic rehab practice is this task-specific training. And then the other key theme with the CPG intensity and repetition are critical dosing parameters.
Speaker: I think back to my own career and when I started out, I think I did a reasonable job, but I myself would see that I would ask patients constantly, are you tired? Are you doing okay?
Speaker: I would see other therapists doing that. I really highly encourage you to think about your patients as athletes. And I'm not saying don't be safe. We're going to monitor vitals. You're going to make sure you're dosing appropriately.
Speaker: But we kind of need to kick their butts a little bit. And I don't mean to be glib when I say that, but we can be pushing a lot harder. And the evidence says that that's going to drive neuroplasticity.
Speaker: And that's really going to be helping our patients out. So I look back on my earlier career and I give myself a little bit of grace. I was working within what we knew at the time. But I don't want you to overly ask your patients, are you tired? do you need a break?
Speaker: Look at the vitals, maybe use perceived exertion as well, but try and operate in that high intensity area because that's what's really going to drive the neuroplasticity. So to recap then with the improving locomotor function CPG, we're going to do high intensity, high repetitions.
Speaker: And that intensity we want at 60% to 80% of heart rate reserve or 70% to 85% of heart rate max. And this is going to improve walking speed and time distance for those patients who have had a chronic stroke. So whose stroke happened more than six months ago.
Speaker: If you're under that timeframe, maybe there's other options available. I would still consider you've got some wiggle room if you've got a patient who's ambulatory, even if the stroke is not chronic. We're not saying that high intensity gait is contraindicated.
Speaker: We just don't have the robust evidence currently. And I do think and hope that that evidence will be coming out soon. The Academy of Neurologic Physical Therapy has a clinician information sheet that asks the question, should therapists focus on normalizing kinematics? And the question there is, should we be working on making sure that our patients look better when they're walking? And they have a compare and contrast across different paradigms. I'll link this in the show notes, looking at impairment-based treatment, NDT, body weight-supported treadmill training and robotic-assisted stepping, and high-intensity gait training.
Speaker: And according to the review of literature, believe it or not, overly emphasizing kinematics does not lead to improved gait. So there's poor and inconsistent carryover of impairment-based treatment into walking function.
Speaker: And the thinking here, as best we can tell, is maybe there's multiple factors at play. And this one's tough because as therapists, we do want to see those kinematics improve.
Speaker: We do want to see someone walking better from a qualitative perspective. But what seems to be happening according to the evidence is that if we implement high-intensity gait training, we've got some specific training that's salient to the patient at high-intensity, high repetitions.
Speaker: Dynamic systems theory kicks in, and the systems learns how to self-organize and improve such that over time we see improved kinematics because we've just gotten such a high level of intensity and repetitions versus if we're doing more of an impairment-based treatment or NDT where we really focus on the kinematics and and we're trying to make things look good, we're lacking the repetitions and we're lacking the intensity needed to drive neuroplasticity. So as hard as it is, I think for many therapists, if we're truly following this high-intensity protocol, we may let the walking look, for lack of a better term, somewhat terrible.
Speaker: And that can be tough if you maybe don't have a lot of experience or people are watching and you're just letting someone go, and their limbs are all akimbo, it looks terrible. And I, again, don't mean to be rude when I'm saying that, but you probably know what I'm talking about. But as long as they're safe, we're getting the intensity, and we're not putting any joints at risk. That's what we're looking at. We just need to keep going, going, going. And it's so hard, and I'm empathetic to how challenging this could be.
Speaker: But I'm putting out here that our best current evidence says high-intensity, high-intensity, task-specific, high repetitions. And if we're overly focused on kinematics, we're not getting those key ingredients that we want to really improve the patient's ability to walk after stroke.
Speaker: We're going to close this episode with another clinical practice guideline. This one also applies to walking for individuals after stroke. And this is the CPG for use of AFO, which is ankle foot orthosis, and f FES, which is functional electrical stimulation. This CPG provides evidence on the effects of AFO or FES on rehabilitation of individuals with acute and chronic stroke. So most of the recommendations I'm going to mention apply to both acute and chronic stroke.
Speaker: I'll link the informational handout in the show notes. And this one's pretty fascinating too, that we can see that using an AFO and or f FES to assist at the ankle really has tremendous benefits, not only in gait, but also in balance and in some areas of participation as well.
Speaker: A common thing that I've encountered over my career is students especially are pretty reluctant to consider using an AFO or an ankle brace in an individual after stroke because they think that to do so means that the patient's ankle will get weaker.
Speaker: They're not allowing for recovery. And they're thinking that that means that we've given up and we've moved towards compensation already. really early. And that's simply not the case. The evidence does not bear that out.
Speaker: And here I would say we also want to take a big picture view. Are we trying to get some ankle dorsiflexion strength back, some motion back versus are we trying to improve the individual's ability to go to the store, to walk, to get back and forth in their home to the kitchen? Which one's more important?
Speaker: And if we we think back to how I recommended we approach the examination in the last episode, we start by looking at participation, work backwards to then tasks and activities, then body function and structure.
Speaker: And if we think about it this way, this is a no-brainer that, sure, we want to see the ankle getting better, but we're not going to inhibit someone's ability to go to church or go to the store because we've kept them from using a brace because we want them to get a little bit of ankle motion back. So don't think about this backwards. And I feel very strongly about this because when you have overwhelming evidence that says use an AFO and then for whatever reason, you decide that your clinical judgment can counteract all the evidence we have, that gets me pretty annoyed. So don't do that. Use the evidence that we have
Speaker: help your patient walk further, have a higher level of participation, have a higher quality of life, and then combine the use of this CPG with our high-intensity gait training.
Speaker: And now you're really at the forefront of best evidence in physical therapy practice, and you're going to get better clinical outcomes. Okay, let me get off my soapbox. I got a little fired up there. Let's go back to who the CPG for the use of AFO and f FES post-stroke applies to.
Speaker: This is going to apply to adults 18 years of age or older, and the CPG includes patients for all genders, races, and ethnicities. So the target population is pretty much anyone you're going to be working with over the age of 18.
Speaker: The CPG was published in 2021 in the Journal of Neurologic Physical Therapy. And the conclusions are that strong evidence supports the use of both AFO and FES for multiple outcomes for individuals with decreased lower extremity motor control. Here a callback to task-oriented approach, motor control, that's that motor action function. That's something that the individual is bringing to movement.
Speaker: So the CPG is applying to individuals with decreased lower extremity motor control due to both acute and chronic post-stroke hemiplegia. They defined acute stroke as anything from onset up to three months, chronic greater than three months.
Speaker: Some limitations of the CPG, they're unable to recommend specific AFO and or f FES, secondary to variability and study designs, And there is limited availability of quality literature that includes individuals in the acute phase of stroke recovery relative to the chronic phase.
Speaker: So a little bit less certainty in the acute phase. And again, the CPG does not recommend a specific type of AFO and or FES. i think you can consider it more that we're saying, okay, this person needs some assistance.
Speaker: at the ankle, primarily during swing phase of gait. We're going to account for that, and then it'll be your clinical judgment, possibly a multidisciplinary approach in terms of considering what type of AFO and or FES is best.
Speaker: I really like this CPG. There's a one-page kind of handout that outlines different areas along the ICF model where an AFO and or FES could help. So across body structure and function, activity and participation, we find multiple benefits. So let's talk about body structure and function. For strength and muscle activation, the AFO is beneficial in chronic, may be beneficial in acute therapy.
Speaker: For tone and spasticity, we should not be providing an AFO or FES. And this is a whole separate discussion. This flies counter maybe to what some people historically have been used to, but we're not going to be providing an AFO to manage tone. For gait kinematics, you may provide an AFO or FES. For gait speed, yes, we want to provide an AFO or FES.
Speaker: Again, let's think about how well an AFO then combines with the high intensity gait training we just talked about. For gait speed, it's going to help. And this makes sense. They're able to clear their toes. They're able to walk a little faster.
Speaker: We know the high intensity gait training. We're looking at gait speed. We're looking at intensity. So the AFO CPG couples very nicely with high intensity gait training. At the activity level, dynamic balance, yes, an AFO helps.
Speaker: For other mobility, yes, an AFO helps. For walking endurance, an AFO helps. If it's a chronic stroke, it may help for an acute stroke. And then for quality of life, yes, an AFO helps.
Speaker: So again, i come back to my little soapbox from earlier is I understand if there's worries or concerns that, well, if we use an AFO, the person may not be activating. And I put activating in air quotes, their dorsiflexor muscles. But the ability to clear the toes is very it during gait is a highly context-specific activity that And it's not just muscle strength that's happening here. It's coordination. It's motor planning. It's motor control.
Speaker: I've worked with plenty of patients that in a sitting position have dorsiflexor strength that can pull their toes up. But then as they start walking, whether it's because of a synergy pattern, motor control, motor planning issues, they can't do it during gait. And this AFO allows them to improve gait.
Speaker: It improves the task. It improves participation. So if you're really worried about, oh, I might be limiting recovery at the ankle, think about what you can do in terms of a home program.
Speaker: Think about scheduling activities outside of the use for AFO. But again, if you are not using an AFO because you're isolated, worried about what's happening at the ankle, you're leaving all these improvements or benefits along the ICF model, cross-body structure and function activity and participation,
Speaker: You're leaving all of that on the table and you're holding your patient back. To summarize then what we talked about, the biggest, if you remember nothing else, intensity matters during stroke interventions.
Speaker: And building onto intensity, high repetitions, salience, the ability to make errors and to learn from errors is really what's going to drive neuroplasticity.
Speaker: It's a complete 180 from how I was initially trained. Initially, I thought movement had to be perfect. We needed to let people rest. We didn't want to push them too hard. I really encourage you to consider your patients who've had a stroke as athletes.
Speaker: Now, their sport may not be on a basketball court. Maybe their sport is getting out in the community, walking down to the mailbox. But really think about, okay, how can we have high-intensity practice that's task-specific, that's salience, that's getting that aerobic intensity in there really to drive neuroplasticity? We talked about two clinical practice guidelines, the high-intensity gait training to improve walking speed and distance.
Speaker: And remember, that was primarily for individuals in chronic stroke. You've got some wiggle room or the evidence isn't as clear in acute and or subacute stroke. And the other CPG we talked about was the use of AFO, and that improves multiple gait, balance, body function and structure and participation parameters in both acute and chronic stroke.
Speaker: Thanks for listening to the NeuroPowerHour. I'm your host, Dr. Michael Powers, and hope to catch you next time to continue learning.
