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People who have suffered a stroke appear to regain more hand and arm function when intensive rehabilitation begins two to three months after their brain injury.
A study of 72 stroke patients suggests this is a “critical period” when the brain has its greatest ability to rewire, a team reported in the magazine this week PNAS.
The finding calls into question the current practice of starting rehabilitation as soon as possible after a stroke.
“Two to three months after a stroke, people are at home and most people do not have their rehabilitation,” says Elissa Newport, co-author of the study and director of the Center for Brain Plasticity and Recovery at Georgetown University Medical Center.
Newport spoke in place of the study’s lead author, Dr. Alexander Dromerick, who died after the study was accepted but before it was published.
If the results are confirmed by other, larger studies, “the clinical protocol for the timing of stroke rehabilitation would be changed,” says Li-Ru Zhao, a professor of neurosurgery at Upstate Medical University in Syracuse, who was not involved in the research.
The study enrolled patients in their 50s and 60s who were being treated at Medstar National Rehabilitation Hospital in Washington. One of the study participants was Anthony McEachern, who was 45 years old when he suffered a stroke in 2017.
“My ability to move was decreasing in front of my eyes”
Just hours earlier, McEachern had mimicked Michael Jackson dance moves with his children. But he couldn’t get up that night at home.
“My ability to move was dwindling before my eyes,” says McEachern, who is now a professor of fine and performing arts at North Carolina Agricultural and Technical State University.
After the stroke, McEachern spent a week in the hospital for treatment and more than a month in a rehabilitation center. He slowly regained the ability to walk. But after returning home, he still struggled with basic tasks involving his right arm and right hand.
“Ordinarily, I could jump in the shower and take 20 minutes [later] I’m showered, dressed and out, ”he says. It took him two hours after the stroke.
The study was inspired by previous research into the rehabilitation of animals that have suffered a stroke.
If rehabilitation begins too quickly, “you can often make a stroke bigger and worse,” says Newport. When the rehab therapy was briefly delayed, “you had very good results. And then, as you moved away from the stroke, you no longer had any success.
In the stroke patient study, participants were randomly assigned to additional 20 hours of intensive training that began in one of three time periods: less than 30 days after the event, 60 to 90 days after the event, or at least six months after the event. Training can include grasping or grasping exercises, with the exact program tailored to each patient.
A “critical phase” for optimal recovery
“We found that the best recovery was from people who got their vigorous exercise two to three months after their stroke,” says Newport.
The treatment is not a panacea, she notes. “There’s a measurable, noticeable improvement” in tasks like grasping and grasping, she says, “but they don’t fully recover.”
McEachern’s intense training began before the optimal time. Even so, he believes the additional therapy and its intensity helped him regain some reasonable use of his right hand.
“I can carry a toothbrush. I can carry bottles. I can hold the bottle with one hand and open it with the other, ”he says. “None of this was possible and probably not even imaginable immediately after the stroke.”
Neuroscientists say the outcome of the study is likely to spark a new round of debate about when to begin intensive rehabilitation for stroke patients.
“It’s a good place to start by figuring out what the optimal time or phase is to begin intense motor training,” says Zhao. However, the study was relatively small and limited to one treatment center.
The idea that there is a critical period when the brain can best recover is “something we’ve always suspected based on animal models,” says Dr. Jin-Moo Lee, Chair of Neurology at Washington University in St. .Louis. “But this is truly the first human evidence that there is a time when rehab therapies are most effective at improving recovery.”
Lee says that right after a stroke, the brain is in survival mode, trying to “clean up the chaos” caused by an injury. At some point, however, the brain enters a transitional phase where an injury gradually turns into a scar.
“And in the meantime there are probably also changes that make the brain more plastic,” he says. This time is a bit like early childhood, he says, when the brain can learn and rewire very quickly.