HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

Rapid Responses to:

Research Report: Stephen J Page and Peter Levine Modified Constraint-Induced Therapy in Patients With Chronic Stroke Exhibiting Minimal Movement Ability in the Affected Arm PHYS THER 2007; 0: ptj.20060202v1-0 [Abstract] [PDF]

Rapid Responses: Submit a response to this article

Rapid Responses published:

Acute, subacute, and chronic phases of stroke recovery

Katherine J Sullivan   (17 September 2007)

Use of "Chronic Stroke"

Ellen A Hillegass   (6 September 2007)

Acute, subacute, and chronic phases of stroke recovery 17 September 2007
Katherine J Sullivan, Associate Professor University of Southern California Send rapid response to journal: Re: Acute, subacute, and chronic phases of stroke recovery kasulliv{at}usc.edu Katherine J Sullivan	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 Dancause(1) 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, as 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 timeframes that are related to the various phases of poststroke recovery. The “hyperacute period” represents the time from stroke symptom onset up to 6 hours post stroke that includes arrival at the emergency department and therapy such as intravenous recombinant tissue plasminogen activator (rtPA).(2) The “acute period” is the timeframe within the first 24 hours post stroke to approximately 7 days post stroke 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 post stroke and can refer to individuals who are years post stroke. Changes in the “chronic phase” are most likely attributable to adaptive cortical plasticity(1) 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 Levine(6) described their patients as individuals with chronic stroke. They report on 4 individuals who ranged from 15 to 73 months post stroke who responded favorably to a modified constraint-induced outpatient therapy program. Clearly, these individuals are beyond the acute and subacute phases post stroke where physiologic changes related to spontaneous recovery could contribute to therapeutic results. Therefore, studies on individuals who are 4 months or more post stroke 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 use-dependent changes in neuroplasticity and not resolution of acute or subacute poststroke physiologic events. 1 Nudo RJ, Dancause N. Neuroscientific basis for occupational and physical therapy interventions. In: ND Zasler DK, RD Zafonte, 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 Apr-Jun;17(2):194-214. Review. 3 Kalra L, Langhorne P. Facilitating recovery: evidence for organized stroke care. J Rehab Med. 2007;39:97-102. 4 DeJong G, Horn SD, Conroy B, et al. Opening the black box of post-stroke rehabilitation: stroke rehabilitation patients, processes, and outcomes.[see comment]. Arch Phys Med Rehab. 2005;86(12 Suppl 2):S1-S7. 5 Fisher BE, Sullivan KJ. Activity-dependent factors affecting poststroke functional outcomes. Top Stroke Rehabil. 2001;8(3):31-44. 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.
Use of "Chronic Stroke" 6 September 2007
Ellen A Hillegass, PT Send rapid response to journal: Re: Use of "Chronic Stroke" ezhillegass{at}mindspring.com Ellen A Hillegass	I would like to compliment the authors on a well-written article providing modifications of a technique that has proven to be instrumental in the rehabilitation of individuals who have suffered hemiparesis following a cerebral vascular accident. However, I am concerned about the choice of words of "chronic stroke" to define the population. My first encounter with this "term" occurred when a graduate student presented it in her thesis. At this time I discussed my concerns and the inappropriate use of this term, as to my knowledge chronic stroke has never been operationally defined and universally accepted. Your article came out weeks after I recommended changing the term from chronic stroke to something that can be understood and is more descriptive of the population. However, I note you have used this term in the past [and that it has been used] Archives of Physical Medicine and Rehabilitation as well. I'm unaware how many others use this term besides yourselves. I may possibly be the only individual with this concern, but I feel that we should not be creating our own "jargon"; instead we should be using terms that are more universally accepted and that actually describe our population. Chronic stroke concerns me, as it is not descriptive. Stroke is the actual accident... and chronic does not give me a time frame. My concern is that I want physical therapists to be able to communicate with other professionals, and if I don't understand what chronic stroke is, how could I expect others outside our profession to understand it? Developing our own jargon isolates us from other professionals.