Early intervention neurophysiotherapy can be vital in maximising outcomes for patients after stroke, new research has found.
Following ischaemic stroke, researchers found that the capacity of the human brain to recover and rewire itself peaks after around two weeks.
And it is during those crucial early stages, when the brain has a greater capacity to modify its neural connections and its plasticity is increased, when neurophysiotherapy can deliver optimum impact.
“It is during this early period after stroke that any physiotherapy is going to be most effective because the brain is more responsive to treatment,” says Dr Brenton Hordacre, lead author of a study conducted in London and Australia.
“Earlier experiments with rats showed that within five days of an ischaemic stroke, they were able to repair damaged limbs and neural connections more easily than if therapy was delayed until 30 days post stroke.”
In the new study, published in Neurorehabilitation and Neural Repair, the recovery of 60 stroke patients was charted up to one year after post-stroke. Brain scans were carried out as they recovered during the 12 month period.
The research team report that they found, in the initial days following an ischaemic stroke, the brain has a greater capacity to modify its neural connections and its plasticity is increased.
Dr Hordacre, of the University of Southern Australia in Adelaide, says that the two week peak post-stroke for the brain to recover was demonstrated in their findings.
“Earlier animal studies suggested this was the case, but this is the first time we have conclusively demonstrated this phenomenon exists in humans,” he says.
The researchers used continuous transcranial magnetic stimulation (cTBS) repetitively, to activate different hemispheres of the motor cortex.
According to researchers: “This initiates early stages of synaptic plasticity that temporarily reduces cortical excitability and motor-evoked potential amplitude. Thus, the greater the effect of cTBS on the motor-evoked potential, the greater the inferred level of synaptic plasticity.”
Separate measurements were taken from each cohort. The Adelaide laboratory tested the stroke damaged motor cortex, while the London laboratory tested the non-stroke damaged hemisphere.
Dr Hordacre says: “Our assessments showed that plasticity was strongest around two weeks after stroke in the non-damaged motor cortex. Contrary to what we expected, there was no change in the damaged hemisphere in response to cTBS.
“The next step is to identify techniques which prolong or even re-open a period of increased brain plasticity, so we can maximise recovery.”
Rehab specialist invests £500,000 in expansion
A rehabilitation specialist is expanding its offering through the opening of the first intensive neurotherapy centre in the south of England.
Hobbs Rehabilitation has invested £500,000 in its new Intensive Neurotherapy Centre in Bristol, which has given 2,000sq ft of space to more than double its level of technology available at its previous Bristol clinic.
It also gives the potential to deliver a six-fold increase in the intensity of treatment, all backed by data to chart patient progress and outcomes.
Through the creation of its new centre, Hobbs Rehabilitation Bristol is expanding its services beyond its core upper limb therapy to bring in lower limb specialism, with plans in place to develop an additional intensive speech and language therapy (SLT) service for aphasia patients.
A move into paediatric work is also being considered, as part of its ongoing development.
Four new people have already been added to the team based at the Intensive Neurotherapy Centre – two physiotherapists, one occupational therapist and a rehab assistant – with more set to be recruited as the centre continues to grow.
While its traditional client base has been mainly people with neurological conditions, such as stroke, the new centre is enabling it to work with growing numbers of spinal cord injury patients – with Ed Jackson, a former rugby union player who sustained such an injury in 2017, being one of its clients.
Bristol is the first Hobbs Rehabilitation centre with the entire Tyrosolution suite from Tyromotion, including the LEXO robotic gait trainer, having increased its provision from three to seven pieces of the high-tech equipment.
It is also the first independent provider in the UK to combine bespoke high-dosage physiotherapy, occupational therapy and speech and language therapy alongside the complete Tyrosolution and other assistive technologies such as the MyoPro.
“This new centre is a big expansion and investment and we plan to continue with this development of our services going forward,” says Ali Gomes da Silva, clinical lead at Hobbs Rehabilitation Bristol.
“We are looking to develop an SLT service with a specialist who used to work in aphasia rehab in Spain, and we are also looking to add a paediatrics service.
“One of our new additions to the team joined us from Glavic Clinic in Zagreb and has worked extensively in this area, so combined with the expertise we already have in the team and the equipment we now have, paediatrics is an area we are looking to expand into.
“We have added a number of people to our team already, and we’ll continue to recruit against the workload.”
While ongoing COVID-19 restrictions mean the centre can accommodate four people at one time currently, that will be raised to six in the near future as lockdown lifts, with more to be added in time.
And already the demand for such time is significant, says Ali, with referrals coming from therapists, case managers and patients themselves.
“We have done a lot of work with stroke patients to date through our upper limb service, but I think our huge increase in SCI is in large part through Ed Jackson being so vocal on social media,” she says.
“He’s been absolutely blown over by the advances in therapy practice we’ve made and how we can supply the data to support that.
“Through our new technology and equipment, we have made really good advances in both lower limb and upper limb, so are now even more able to support people with their therapy.
“We’ve fulfilled all the plans we had in place initially, but the expansion will continue as we go.”
Community neurorehab gym continues to expand
A community therapy centre which enables neuro patients access to the physio-led exercise which can support their recovery continues to expand in response to demand for its services.
West Berkshire Therapy Centre was opened in 2014 to bridge the gap in existing community resources, and initially opened for 20 hours a week with ten items of equipment.
Since that time, the Thatcham centre has expanded into premises twice the size of its initial home, and now has 17 items of equipment which clients can access 35 hours each week.
While the centre has been forced to close during lockdown periods, the investment in its offering has continued, with a further £17,500 being spent to upgrade equipment.
In addition to its regular clientele of around 260 people, around 200 more will be referred to the centre from the Berkshire Long COVID Integrated Service, led by Dr Deepak Ravindran, who has worked closely with the centre for several years.
As well as the anecdotal evidence from clients who attest the positive effect West Berkshire Therapy Centre has, the centre’s work has been proven to improve client mobility by an average of ten per cent, psychological outlook by 15 per cent and weight loss by three per cent.
All clients are assessed by the centre’s physio before being prescribed an individual exercise programme. The centre prides itself on its client-centred approach and some of the equipment in the gym has been designed and built specifically in response to what clients said were important to them.
West Berkshire Therapy Centre was created by the West Berkshire Neurological Alliance, a group of 23 local neuro charities, which recognised the need for greater specialist provision for people living with neurological conditions in the area.
John Holt was instrumental to the creation of both the Alliance and the Centre. Having supported his wife in living with MS for over 40 years, he took the lead on ensuring greater provision and support was there for those who needed it.
“I’m not from a medical background, I’m a food technologist, and while I was chair of a trade association during my career, I was used to working with competitors and business enemies, that was just what happened for the greater good of us all,” he says.
“So I was rather shocked when I got involved with the local voluntary sector and found that wasn’t the case. I was very proactive in all of our charities working together as I know the importance of working as one alliance.
“People who were living with neurological conditions were often having to fend for themselves when it came to community rehab, and that’s why we wanted to create the West Berkshire Therapy Centre.”
Having been established on the back of £145,000 in fundraising, five years later the demand for its services was such it had to expand into larger premises and invest in more equipment.
The centre – which is funded by voluntary contributions for sessions and through fundraising – now has eight part-time staff and a core of volunteers to support clients with whatever rehabilitation issues they have.
While most clients have neurological conditions – including stroke, Parkinson’s, MS and Post-Polio Syndrome – the centre has broadened its reach to include large numbers of people with arthritis, heart and lung conditions, sight impairments as well as amputees.
“We’re completely pan-disability and will support anyone who needs us. Our clients talk to us and we listen and adapt,” says John.
“I think many clients come to us because we are a safe place for them and they’re among people who understand the challenges they face.
“It is very important that we talk about things openly. For example, we talk about how hard it is when you can’t get to the bathroom in time and you wet yourself.
“When you face issues like that, it can be the start of a spiral downhill, you might then stop going to work or stop leaving the house, but we share these kinds of things.
“By having this interaction, it becomes a place people aren’t afraid to open up.”
With the centre having been closed for much of the past year, John and the team are ready to welcome back regular and new clients, including the many who are recovering from Long COVID.
“Many of our clients won’t have exercised for several months, but we hear very often that people have waited 20 years for a centre like this, so a few months hasn’t been long in comparison,” says John.
“But we are very much looking forward to re-opening and supporting our clients in regaining any progress and fitness they may have lost. Hopefully we are on the right track now after three lockdowns and clients can come back to us regularly.
“Long COVID is a new condition for us, as it has only come into being in the past few months, but we are ready to support people with their symptoms and in them using exercise as part of their recovery.”
New at-home tech aids virtual rehab
Neurophysio patients are receiving personalised virtual rehabilitation through the adoption of new technology.
Hobbs Rehabilitation is supporting chronic stroke patients by enabling them to use the EvolvRehab platform for at-home therapy, with exergames playing a central role in the rehab approach.
The use of EvolvRehab will be subject to a year-long study – funded by the Seedcorn funding program of the NIHR Brain Injury MedTech Co-operative (MIC) based in Cambridge, with researchers from the University of Winchester – to measure the level of effectiveness, as well as acceptance by patients.
Initial feedback from the first two stroke survivors to begin using the newly-launched Evolv RehabKit has been described as “extremely positive” with three-month programmes involving the use of prescribed exergames designed around their individual needs.
The integration of Microsoft Teams into the EvolvRehab platform means that patients can maintain direct contact with their therapists with periodic video meetings.
Hobbs are also using Teams to provide the patients with their weekly questionnaire that will be used in the study.
Hannah Woods-Hier, the therapist supervising the project for Hobbs, is overseeing the personalisation of the exergames for each of the patients, as well as following their adherence to treatment and performance results.
“We are enabling an engaging programme of exercises for patients that can be tailored by their therapist to their needs to be completed at home,” says Hannah.
“I find that patients are more compliant with the programme as they are having fun while doing it and perhaps completing more exercise than they think, as they are engaged in the games as opposed to the number of repetitions they are completing as in traditional home exercise programmes.
“Patients are able to see how they are moving through the avatar on screen, which provides prompts to them to monitor the quality of their movement rather than just achieving it, which is always a difficult monitor through a traditional home exercise programme.
“This gives the patients greater awareness of their own movement patterns.”
And while patients are engaged in the games, therapists are monitoring their progress remotely, says Hannah.
“This lets me know how the patient is adhering to the programme, as well as the length of time each session takes and how many repetitions they are completing,” continues Hannah.
“This lets me personalise their programme further to ensure they are working at the correct level and intensity, progressing them as needed.”
The use of the RehabKit in patients’ homes is part of the developing relationship between the tech business and Hobbs Rehabilitation.
“We’ve been using the EvolvRehab solution at Hobbs for years now, and we’ve worked closely with the Evolv team to provide them with clinical feedback on their products,” says Nicky Ellis, co-founder of Hobbs Rehabilitation.
“The NIHR Seedcorn project gave both of us an excellent opportunity to test their new RehabKit directly in patients’ homes.
“The project start was delayed because of the COVID lockdown here in the UK, and the pandemic has greatly reduced the possibility of patients to receive one-on-one or group therapy in clinics, which makes this telerehabilitation project even more relevant.
“Now that we have EvolvRehab up and running with patients, we’re looking forward to seeing the results.”
David Fried, CEO of Evolv, says of the project with Hobbs: “This collaboration with Hobbs marks an important milestone in terms of promoting telerehabilitation for stroke patients in the UK. This NIHR Brain MIC funded-project demonstrates the clear interest in seeking ways of providing greater access to specialised rehabilitation directly in the home.
“Judging by the early response from patients, they’re also very keen to do more rehabilitation in their own time with the aim of improving their quality of life. People are really enjoying using our RehabKits with EvolvRehab personalised exergames as a way of increasing intensity and dose of therapeutic activity, which is so important in helping improve outcomes for stroke survivors.”
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