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PHYS THER
Vol. 87, No. 11, November 2007, p. 1560
DOI: 10.2522/ptj.2007.87.11.1560
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Letters and Responses

On "Modified constraint-induced therapy..." Page and Levine. Phys Ther. 2007;87:872–878.


Advances in neuroscience, particularly in the area of physiologic responses to acute brain injury from either trauma or stroke, have led to a major paradigm shift in our understanding of therapeutic efficacy. Nudo and Dancause1 describe how cortical injury sets off a cascade of acute, subacute, and chronic molecular and cellular events that characterize the presumed mechanisms of recovery over the hours, days, weeks, months, and years after brain injury. As rehabilitation clinicians or researchers, we need to be aware of these various and distinct phases, because the mechanisms associated with rehabilitation intervention effectiveness are either interactive with the spontaneous physiologic events that are triggered by the brain injury during the acute and subacute phases or are independent of these processes in the chronic phases.

Due to a better understanding of the pathophysiology of stroke, there have been major advances in both medical and rehabilitative management of survivors of stroke. Due to individual variability, it is a challenge to define specific parameters for each event that is triggered by an acute stroke. However, there is general agreement in the stroke literature about time frames that are related to the various phases of poststroke recovery.

The "hyperacute period" represents the time from stroke symptom onset up to 6 hours poststroke that includes arrival at the emergency department and therapy such as intravenous recombinant tissue plasminogen activator (rtPA).2 The "acute period" is the time frame within the first 24 hours poststroke to approximately 7 days poststroke when most pathophysiologic responses related to ischemia have resolved and the patient after stroke is considered "medically stable."2 The "subacute phase" is the period of rapid neurologic and functional recovery that occurs from 1 week to 3 or 4 months.3 This is typically the time of transfer to acute inpatient rehabilitation and most likely reflects rapid recovery due to both spontaneous recovery as well as the effects of therapeutic interventions.4 The "chronic phase" refers to any time along the recovery continuum that is beyond this 3- or 4-month time poststroke and can refer to individuals who are years poststroke. Changes in the "chronic phase" are most likely attributable to adaptive cortical plasticity1 in response either to compensatory movement patterns or to reacquisition of more normal movement patterns.5

It is not only accurate but an important qualifier that Page and Levine6 described their patients as individuals with chronic stroke. They report on 4 individuals ranging from 15 to 73 months poststroke who responded favorably to a modified constraint-induced outpatient therapy program. Clearly, these individuals are beyond the acute and subacute phases poststroke when physiologic changes related to spontaneous recovery could contribute to therapeutic results. Therefore, studies on individuals who are 4 months or more poststroke are referred to as studies of "chronic stroke." This is not "jargon" but in fact reflects a time point on the poststroke recovery continuum where behavioral interventions such as high-intensity, task-specific therapies are effective, most likely due to usedependent changes in neuroplasticity and not resolution of acute or subacute poststroke physiologic events.

Katherine J Sullivan

KJ Sullivan, PT, PhD, is Associate Professor at the University of Southern California


  Footnotes
 
This letter was posted as a Rapid Response on September 17, 2007, at www.ptjournal.org.

References

  1. Nudo RJ, Dancause N. Neuroscientific basis for occupational and physical therapy interventions. In: Zasler ND, Katz DI, Zafonte RD, eds. Brain Injury Medicine: Principles and Practice. New York, NY: Demos Publishing LLC; 2007:913–928.
  2. Bader MK, Palmer S. What's the "hyper" in hyperacute stroke? Strategies to improve outcomes in ischemic stroke patients presenting within 6 hours. AACN Adv Crit Care. 2006;17:194–214.[Medline]
  3. Kalra L, Langhorne P. Facilitating recovery: evidence for organized stroke care. J Rehabil Med. 2007;39:97–102.[CrossRef][Web of Science][Medline]
  4. DeJong G, Horn SD, Conroy B, et al. Opening the black box of post-stroke rehabilitation: stroke rehabilitation patients, processes, and outcomes. Arch Phys Med Rehabil. 2005;86(12 suppl 2):S1–S7.
  5. Fisher BE, Sullivan KJ. Activity-dependent factors affecting poststroke functional outcomes. Top Stroke Rehabil. 2001;8:31–44.[Medline]
  6. Page SJ, Levine P. Modified constraint-induced therapy in patients with chronic stroke exhibiting minimal movement ability in the affected arm. Phys Ther. 2007;87:872–878.[Abstract/Free Full Text]

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This article has been cited by other articles:


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[Abstract] [Full Text] [PDF]

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Right arrow Adaptive/Assistive Devices
Right arrow Stroke (Neurology)
Right arrow Stroke (Geriatrics)
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