The Best Time For Rehabilitation After A Stroke Might Actually Be 2 To 3 Months Later

Sep 20, 2021
Originally published on September 21, 2021 12:20 am

People who have had a stroke appear to regain more hand and arm function if intensive rehabilitation starts two to three months after the injury to their brain.

A study of 72 stroke patients suggests this is a "critical period," when the brain has the greatest capacity to rewire, a team reports in this week's journal PNAS.

The finding challenges the current practice of beginning rehabilitation as soon as possible after a stroke and suggests intensive rehabilitation should go on longer than most insurance coverage allows, says Elissa Newport, a co-author of the study and director of the Center for Brain Plasticity and Recovery at Georgetown University Medical Center.

"Two to three months after a stroke is when people are at home," Newport notes. "That's not when most people are having their rehabilitation."

Newport was speaking 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 with 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, N.Y., who was not involved in the research.

The study involved patients treated at Medstar National Rehabilitation Hospital in Washington, D.C., most in their 50s and 60s. One of the study participants was Anthony McEachern, who was 45 when he had a stroke in 2017.

"My ability to move was diminishing in front of my eyes"

Just a few hours earlier, McEachern had been imitating Michael Jackson dance moves with his kids. But at home that night he found himself unable stand up.

"My ability to move was diminishing in front of my eyes," says McEachern, who is now a professor of visual and performing arts at North Carolina Agricultural and Technical State University.

After the stroke, McEachern spent a week in the hospital getting treatment and more than a month in a rehabilitation center. He slowly regained the ability to walk. But after returning home, he still had trouble with basic tasks involving his right arm and hand.

"Normally I could jump in the shower and 20 minutes [later] I'm showered, dressed and out," he says. After the stroke, it took him two hours.

The study was inspired by earlier research on the rehabilitation of animals who have had a stroke.

When rehabilitation begins too quickly, "you can often make a stroke bigger and worse," Newport says. When rehab therapy was delayed briefly, "you got very good success. And then as you got farther off from the stroke you didn't get any success anymore."

In the study of stroke patients, participants were randomly assigned to receive an extra 20 hours of intensive training that started during one of three time periods: less than 30 days after the event, 60 to 90 days after, or at least six months after. The training might involve reaching or grasping exercises, with the precise regimen tailored to each patient.

A critical period for optimal recovery

"What we found is that the best recovery was the people who received their intensive training at two to three months after their stroke," Newport says.

The treatment isn't a cure-all, she notes. "There is a measurable, noticeable amount" of improvement in tasks such as reaching and grasping, she says, "but they don't recover fully."

McEachern's intensive training started before the optimal period. Even so, he thinks the extra therapy, and its intensity, helped him regain some use of his right hand.

"I can carry a toothbrush. I can carry bottles. I can use one hand to hold the bottle, while I use the other hand to open it," he says. "None of this stuff was possible immediately after I had the stroke and probably not even imaginable."

Brain scientists say the study's finding is likely to stimulate a new round of debate about when to start intensive rehabilitation for stroke patients.

"It's a good start to help identify what is the optimal time or sensitive period to begin intensive motor training," Zhao says. But the study was relatively small and limited to one treatment center.

The idea that there is a critical period when the brain is most able to recover is "something we've suspected all along, based on the animal models," says Dr. Jin-Moo Lee, chair of neurology at Washington University in St. Louis. "But this is really the first human evidence that there's a period in which rehab therapies are most effective in improving recovery."

Lee says right after a stroke, the brain is in survival mode, trying to "clean up the mess" caused by an injury. Eventually, though, the brain enters an interim period in which an injury gradually becomes a scar.

"And probably in the interim period there are also changes that allow the brain to become more plastic," he says. That period is a bit like early childhood, he says, when the brain is able to learn and rewire very rapidly.

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People who've had a stroke appear to recover more fully if intensive rehabilitation starts two to three months after the event. That's the conclusion of a study suggesting there is a critical period in which an injured brain is best able to rewire. The finding challenges the current practice of starting rehabilitation within a few days. NPR's Jon Hamilton has more.

JON HAMILTON, BYLINE: The day before Tony McEachern's stroke in 2017, he was doing Michael Jackson dance moves with his kids. A few hours later, he couldn't stand up.

TONY MCEACHERN: My ability to move was diminishing in front of my eyes.

HAMILTON: McEachern, who was then 45 and a professor at Howard University, lost control of the right side of his body. He would spend a week in the hospital and more than a month in a rehabilitation center, but he still had trouble with basic tasks.

MCEACHERN: Whereas normally I could jump in the shower - 20 minutes, I'm showered, dressed and out. Coming from the stroke, it took me two hours - took me a long time.

HAMILTON: McEachern kept improving, though, perhaps because he was part of a study on when intensive rehabilitation is best able to restore a person's use of their arm and hand. Elissa Newport of Georgetown University Medical Center says the study was inspired by what scientists had learned about rehabilitation in animals.

ELISSA NEWPORT: Very, very early, you can often make a stroke bigger and worse. Moderately early, you got very good success. And then as you got farther out of the stroke, you didn't get any success anymore.

HAMILTON: So Newport and a team of researchers studied 72 stroke patients at the MedStar National Rehabilitation Hospital in Washington, D.C. She says participants were randomly assigned to receive an extra 20 hours of intensive training during one of three time periods.

NEWPORT: And what we found is that the best recovery was the people who received their intensive training at two to three months after their stroke.

HAMILTON: The results, published in the journal PNAS, found that earlier training wasn't as good, while training that started more than six months after a stroke showed no benefit. And Newport says even rehabilitation at the ideal time produced only a modest improvement in patients' ability to do things like reach and grasp.

NEWPORT: This is a measurable, noticeable amount, but they don't recover fully.

HAMILTON: Newport says it will take a larger study to confirm the finding, but she says it appears that intensive rehabilitation should go on longer than most insurance coverage allows.

NEWPORT: Two to three months after stroke is when people are at home. That's not when most people are having their rehabilitation.

HAMILTON: Tony McEachern's intensive training started before the optimal period. Even so, he thinks the extra therapy helped him regain some use of his right hand.

MCEACHERN: I can carry a toothbrush. I can carry bottles. I can use one hand to hold the bottle while I use the other hand to open it. None of this stuff was possible immediately after I had the stroke and probably not even imaginable.

HAMILTON: Stroke experts say the study's finding is likely to stoke debate about when to start intensive rehabilitation for stroke patients. Dr. Jin-Moo Lee is the chair of neurology at Washington University in St. Louis.

JIN-MOO LEE: It's something that we've suspected all along based on the animal models, but this is really the first human evidence that there is a critical period in which rehab therapies are most effective in improving recovery.

HAMILTON: Lee says right after a stroke, the brain is in survival mode. Cells are dying. There's inflammation. Eventually, though, he says it enters an interim period in which injuries become a scar.

LEE: And probably in that interim period, there's also changes that allow the brain to become more plastic.

HAMILTON: Lee says the brain seems to enter a mode similar to childhood, when rewiring and relearning can happen very rapidly.

Jon Hamilton, NPR News.

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