Dear Gauthier, this is an interesting question and I suppose depends on the particular intervention and what effect (short/long term) you would expect from reading the previous literature or from what your hypothesis (prediction) would expect. We carry out clinical RCT's on new interventions for stroke patients in our Neuroplasticity Research Group (see attached papers) and we have included a follow up of 3-6 months. It may also depend if you are designing a pilot RCT or a full RCT.

Can i also send some additional information regarding my belief on the future of stroke rehabilitation. I have just finished Malcolm Gladwell's excellent book 'Outliers' (2011) for probably the 4th time and would like to recommend such a tremendous and inspiring book to any clinical therapist or anyone working in the neuroplasticity field. I have read all Malcolm's books and in fact his most recent'Talking To Strangers' was also excellent because of the important issues it raises (I can assure everyone I am not related to Malcolm or have no vested interest in promoting his work but it introduces some really interesting psychological concepts, although as far as I'm aware Malcolm never mentions how these could possibly be applied in the clinical setting). I am interesting in getting a discussion started because I believe that there needs to be a fundamental shift in our approach to rehabilitating patients (especially neurology) towards achieving greater successful outcomes. I believe that the same psychological principles mentioned in outliers can apply to clinical rehabilitation and I would be very interested to develop this over the coming years. I have already started writing focus and editorials for journals based on his work.

As a Physical Therapist (Physiotherapist in Ireland) and now researcher who is very interested in developing and improving clinical rehabilitation post stroke etc, I would like to consider outliers in this context and would be interested if you agree. I firmly believe that a new approach to rehabilitation is required and the current 'passiveness' that takes place needs to be replaced with 'psychological education' to equip patients with the confidence for success. For me all physiotherapy is 70% psychology (partly placebo effect) and 30% physical interventions.

I believe that a lot of the psychological approaches mentioned in Malcolm's book could be applied to clinical rehabilitation and would indeed improve current outcomes. Regarding 'Outliers' can I make some observations please;

Introduction: I believe that patients rehabilitating from home rather than in a rehabilitation setting can benefit from a similar 'Rosetto Effect'.

Chapter 1 & 2: We can apply the principle of the 10,000 hour rule to rehabilitation. Success in rehabilitation is also the result of 'Cumulative Advantage' (availability of home-based rehab equipment, access to professional supervision, means of receiving real-time feedback) but in order to achieve this we need to find a way to motivate patients to do the '10,000 hours of meaningful rehabilitation'. After 30 years of experience I truly believe that almost all patients can get a successful recovery if they are willing to work really really really hard.

Chapters 3 & 4: In a similar fashion to practical intelligence that is gained from rich parents, stroke patients need to take control of their therapy and if they start to steer their therapy then they will create a neuroplasticity in their brains that will result in improved success. I believe there is an element of stereotyping that exists in elderly patients who accept 'their lot' and don't have the confidence to fight hard enough to make a full recovery.

Chapters 5 & 6: Again, emphasises the concept that hard work or 'grit' will make us successful. Same principle can be applied to rehabilitation. The ability of a patient to question their therapist/consultant and to guide treatment is probably a result of their cultural background and again this type of disadvantage can lead to poor results.

Chapters 7 & 8: The concept of Power Distance Index again fits with patient potential in rehabilitation. Medicine is general is a passive process, where the patient waits to be told what to take/do. I believe that patients need to be educated to improve confidence and realise that rehab techniques will be more successful if initiated by the patient themselves. Lets give them a menu of therapies and let the patient decide which is best suited to them. We need more of a personal approach. Again, hard work and effort important for good results.

Chapters 9 & 10: Could a new form of KIPP School be created for rehabilitation excellence where the emphasis is 70% education/psychological approach and 30% physical interventions. I believe the reverse is happening unsuccessfully at present.

Its recommended to stand on the shoulders of giants and none are greater than Malcolm Gladwells. I would be very interested in your opinion to these comments (whether you agree or disagree) and this book has inspired me so much, brought great enjoyment to my life and has been inspirational to hundreds of people like me. I think a change is needed!!

Thanks Ken

Dear Dr Monaghan,

I read with interest your answer and I have to admit that your analogy between post-stroke/neuro-rehabilitation and Malcolm Gladwells issues is quite relevant. Indeed, you make here very interesting comments about improving physiotherapy through a psychological approach.

Stroke rehabilitation is a patient-centered approach and should therefore be adapted to each patient regarding his needs. Education about pathology and rehabilitation process is certainly one of the most important things to do when meeting the patient for the first time. I do agree that adding a psychological education would help patients to better recover. Indeed, teaching them to think positive and to develop the habits of working hard would probably lead to improved results.

I would also like to add that patient's motivation could be easily enhanced by giving him the opportunity to self-rehabilitate. In fact, with the development of new technologies such as robot-assisted therapy and virtual reality, self-rehabilitation becomes very interesting. More importantly, thanks to serious games, these technologies offer a good opportunity to enhance patient's adherence to rehabilitation. Indeed, a serious game is an interactive game specifically designed for rehabilitation whose difficulty is constantly adapted to the patient. These games help to make rehabilitation more playful.

Other neurorehabilitation principles described in the review of Maier et al., in 2019

("Effect of Specific Over Nonspecific VR-Based Rehabilitation on Poststroke Motor Recovery: A Systematic Meta-analysis") are also a good way to enhance patient's motivation and outcomes. These principles are: “a massed practice (training with repetitive tasks), dosage (intensive training), a structured practice (training that includes resting times), a task-specific practice (functional training), a variable practice (training that includes different types of task), a multisensory stimulation (training that provides at least two sensorial feedbacks such as visual, auditive or haptic feedback), an increasing difficulty, an explicit feedback (training that provides information about the patient’s task results), an implicit feedback (training that delivers information about the performance such as real time visualization of movement properties), an avatar representation (embodied training), and promoting the use of the paretic limb.”

I also think that stroke rehabilitation could be improved by collaborating between technology developers and the various experts involved in stroke rehabilitation, including physical medicine, neuropsychology, speech and language therapy and occupational therapy. Indeed, neuropsychological disorders are common after stroke and should more often be considered during motor relearning. Cognitive processes are important for the motor function as they spearhead voluntary actions, such as selective attention to select the object for interaction, selection of the response limb effector, planning action to the object and execution, including the inhibition and avoidance of distractors.

Lastly, as described by Stinear et al., in 2020 ("Advances and challenges in stroke rehabilitation"), we also have to improve the way of conducting experimental researches in order to better understand what is efficient or not in stroke motor rehabilitation.

Best regards,

Gauthier