Hi Margaret,

In my opinion and according to my knowledge of stroke rehabilitation, intervention program should start as soon as the patient is found to be stable on the respiratory and circulatory systems. Studies have shown that patients who are started with rehabilitation program earlier shows better prognosis. The intensity of rehabilitation program should be decided according to the condition and severity of stroke.

Hi Priya,

Thanks for your quick response. I do agree with the principles you have put forth. Reading the article I have referenced, one looks at what we have traditionally done like you rightly put it with a critical eye. Reading the article will make you appreciate where my question is coming from. I have also given you the reference review article I had written with my team in line with my question. You can find it here in the data base of Research Gate.

Waiting to hear your views again after reading my references.

Dr. Margaret Mweshi

Berhadt J, Indredavik B, Langhorne P. When should rehabilitation begin? Int J of Stroke, 2013; 8:5–7.

Margaret M. Mweshi, Hastings K. Shula, Loveness A. Nkhata, Brian Chiluba. The Best Time to Start Stroke Rehabilitation: A Review of the Evidence in Resource-Adequate and Resource Constrained Settings. Journal of Preventive and Rehabilitative Medicine. Vol. 1, No. 1, 2016, pp. 7-15. doi: 10.21617/jprm.2016.0101.2

Start when the situation is stable and than on the highest functional level. And What in my opinion so good is on the AVERT program that the frequency kan be high because every member of the team can do an exercise that is necessary. Get in and out the bed, Standing and sutting in the chair , going to the toilet or toiletchair .

When all this events through the day are done on an high level , we have an very intensitif program with high frequency and very Task-specific and that will stimulated the damaged brain to seek for solution and is very ADL - IADL minded

Greetings 

jan van de Rakt

Early stroke rehabilitation at the bedside can be implemented as soon as the patients become medically stable to improve orientation to the environment and encourage functional mobility (eg, reah-to-grasp functional objects)  in order to prevent nonuse of the affected limbs.

Thank you so much for your great contribution. I totally agree with your principles which have been practiced traditionally. Do you have any systematic reviews and meta-analyses on the same topic. Such references will be greatly appreciated

Dear Jan,

It is always exiting to read your contribution on stroke rehabilitation. Your passion and commitment to your work is encouraging. Your contribution was greatly appreciated.

Dr Margaret Mweshi

The question also needs to begin with what does stroke Rehabilitation mean at the earliest stages so it's really how you define the interventions. If we are only talking about say for example physical occupational and speech therapy that is an entirely different conversation than beginning to address bowel and bladder function, DVT prophylaxis, depression,  bed sores, stroke recurrence or risk factors reduction which falls under the idea of prevention which is of course the highest form of Rehabilitation. Then there's an entire conversation about pharmacologic intervention in order to optimize recovery or minimize extension of the damage. Somewhere along there there is the idea of which antiplatelet or anticoagulation to use depending on the origin of the stroke. Also if diabetes is a major factor then there is keeping the blood sugar from going too high and if hypertension as a contributing factor then there are often mistakes made about how tightly to control low blood pressure. Finally we get to the area of using drugs such as Minocycline which may improve stroke outcome by reducing inflammation and other medications such as fluoxetine which has shown to improve recovery. Even more controversial but something in which I am in favor is the use of Methylphenidate. If aphasia is involved there also interventions such as donepezil and memantine as well as methylphenidate bromocriptine Etc. I worry about the overuse of seizure medications and poor choices of which medications. So really there is a very large discussion to be had about acts of omission and act of commission meaning there are many drugs that are used that should not be used because they have been shown to suppress and reduce ultimate outcomes and there are drugs that should be used but often are not used which have been shown to improve outcomes. Once again these discussions occur even before we get to a discussion of which nutritional supplements or nutraceuticals may be used to enhance outcome from stroke with regard to the building blocks of the brain anatomy and the raw material the brain uses for neurotransmitter function as well as combatting the double assault of inflammation and oxidative stress. The brain should also be given supplements that increase mitochondrial production of ATP due to the heightened metabolic needsof  neuro homeostasis

Dear Jonathan,

Thank you so much for your great contribution. I agree with you on the issue of defining what rehabilitation is all about. Your explanation was quite explicit and very helpful. However, the context of the rehabilitation under discussion is as a result of some publication concerning physical rehabilitation with the purpose of improving activities of daily living. Perusing through the paper by Julie attached to my question is what even motivated me to writing a review paper also attached. Therefore my question was based on the aftermath of the AVERT study results with the view of the status quo on the best time after reviewing phase three of the whole trial study. Nonetheless, stroke rehabilitation is complex hence generalization can be quite risky if not controversial.

Dr Margaret Mweshi

Hi Margaret,

As a student of occupational therapy, and a stroke survivor who has made a significant recovery(80% MCA), from my personal experience I believe that starting rehab the 1st month after cortical lesion is best, particularly as this is the time when the brain has highest level of BDNF, to rely on to maximize recovery after most spontaneous recovery has been achieved. Following onset of lesion, the brain usually has less GABA( inhibitory neurotransmitter) which means that the risk of seizures may occur with heavy, intensive exercise. Ive found that 1 or 2 months, when the inflammation after lesion has healed more, will be the best opportunity to start exercise, which will be most effective with patient education so that the stroke survivor knows not to push their limits to induce a seizure.