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So, what’s the point of task-specific practice and why should you do it? Dutch researchers (Kollen, Kwakkel & Lindeman) way back in 2006 reviewed ALL available published clinical stroke rehabilitation trials, of which at the time of writing there existed 735. They selected 151 studies including 123 randomised controlled trials and 28 controlled trials. In their consideration, the rest either did not meet the inclusion criteria or lacked statistical and internal validity, reflecting the poorer methodological quality of many of the clinical intervention studies under consideration. The Dutch researchers concluded in their analysis that traditional treatment approaches induce improvements that are confined to impairment level only and do not generalise to a functional improvement level. In contrast, they concluded that evidence existed that: ‘more recently developed treatment strategies that incorporate compensation strategies with a strong emphasis on functional training, may hold the key to optimal stroke rehabilitation’.

In summing up their findings, they reported that ‘intensity and task-specific exercise therapy are important components of such an approach’. I have found that there is a strong case for implementing and balancing both into an Approach, with the addition of strength training. It’s what I did (and still do) to retrain, manage and ‘negate’ my own physical limitations. And it is how so many others are being taught how to get some significant results in terms of upper limb capacity AND performance (in ADLs).

Although still under investigation for strong evidence of efficacy for stroke rehabilitation, task-specific practice can be said to be one of the best weapons we have to help retrain the brain. It means simply to train the action to be performed in a natural environment. For example, if you wanted to lift a mug and drink from it, you should take a mug and practice lifting and drinking from it, over and over again … and attempt to improve progressively and consistently. The retraining that you are going to do holds this method up as a very BEST paradigm to be following, and one around which lots of other improvement interventions can be introduced/tried, from active orthotics to technology and drugs.

Functional task-practice must not only reinforce recovery milestones, such as sitting balance, standing upright and the ability to walk but also tackle behaviours that are introduced after stroke. You need to be doing the task you want to do. So, for those with significant spasticity in the upper limb, to retrain the ability to open a glasses case to get your specs, for instance… you practise opening up a glasses case.

Get a ‘How-To’ Video. This online DVD about Real-life Upper Limb Self-rehab will show you lots of ways for people who are retraining at home to ‘retrain’ for normal tasks which involve reaching, grasping and releasing.

Task training is critical because it will ‘force’ you to practice using your more-affected limb. This is why the Evidence-Based Review of Stroke Rehabilitation (EBRSR) concludes that constraint induced movement therapy (CIMT) in clinical settings, for those who meet the qualifying criteria, shows strong evidence of benefit in comparison to traditional therapies in the chronic stage of stroke. CIMT is a great example of task training for the upper-limb. 30 to 66 % of stroke survivors report no longer being able to use the affected arm despite trying to rehabilitate and are in danger of avoiding using it (‘learned non-use’ or inattention/ neglect of the limb). Several factors might explain this phenomenon. First, you may see no reason to try and use your bad arm and therefore remain ignorant of underlying motor potential. Second, you may not know how to use any emerging isolated movement for functional performance.

In fact, emerging movement often overlooked: it is considered non-functional. But this is wrong. You actually need to try and regain an increase in active range of motion (AROM) in as many planes and pivots as possible.  Increase in non-functional AROM increases strength and muscle bulk, encourages muscular activity which promotes vascular return, decreases the potential for soft-tissue shortening, and damage with resultant pain and stiffness – and increases osteoblastic activity on the affected and often osteoporetic) side.

What you need to know is that now, eclectic therapists are seeking to fight on two fronts: teaching compensatory strategies for the sake of function and training the affected side to re-establish cortical control over the affected extremities by the ‘original’ neurons. This means that actually, compensatory strategies are not ‘bad’. Rather, they are now being recognised as critical to recovery.

Indeed, as action control is incrementally unmasked on the affected side, emerging movement should be recognised, celebrated, encouraged and built upon. The trick is making sure that compensations & recovery are both worked on, although the work will be separate in the short-term. In the long-term they will meld indistinguishably.

So, try to do MORE with your more-affected upper limb by yourself each day (ie work towards a new goal, and check retention during your ADLs constantly afterwards (because you can lose ability, just like strength (which is shockingly easy to lose). Repeated attempts to use your affected limbs in training creates a form of practice that can potentially lead to further improvement in performance. The ideal is to find oneself in a ‘virtuous circle’, in which spontaneous limb use and motor performance will reinforce each other and re-teach your body to control the position of an affected limb.

In formal retraining situations it is important to advance quickly toward practice of whole tasks with as much of ordinary environment context made available as possible. For example, say, a goal of yours is to improve the action control of your paretic foot for being able to cope whilst walking outside on the pavement, unsupervised and with no supports. The best retraining you can get is to ask a trainer or friend to plan a route for you to go with him or her, so that you can trial it safely and under careful supervision. You can work on leaving your stick and/or supports behind or using/wearing them according to your current levels of ability.

Many stroke survivors can be assisted to retrain by advising them to have one place and a set amount of times per week in which they devote time to their retraining. I tend to promote the importance of setting up a small matted ‘training area’ in your house, which needs only to be a few square metres wide. You also need a chair and a small table with a task-board, more advanced challenge board and other small items on it.

You need to finding your own task specifics, according to your goals. You also need to work on ‘close-simulations’. Even though simulations are probably not as effective for motor learning as performing the actual task, and remember, we are after significant performance improvement via task practice, you can see that this approach gives you some great advantages. It keeps you in the training area, keeps you working on-task and keeps you safe. And then outside of the training area, you need to make an effort to practice the tasks (or the components of them that you can manage), as part of your ADLs, noting changes when you can.

One great example: I created ‘DJ-Therapy’ to get my upper limb working again. I basically made up a hugely successful paradigm which was suitable for me. How I did it is all listed in The Successful Stroke Survivor.

You can read how I started it ‘off-decks’, then used the decks themselves to absolutely superb effect – ‘training’ 5 or so hours per day. It was never ‘training’ per se, for me, however.

Making training ‘not training’ is one of the biggest secrets to getting optimal success with upper limb function. I wish more people would have a go at this idea. Have a think about what might be suitable for YOU to keep YOU practising and interested.

Messages from this post are:

• Get clued up to understand how to set up a training methodology (a good number shown on these DVDs, for example)
• Get some help from a physio, OT or trainer.
• Perform as many specific, whole tasks of your choice inside a safe training area as you can.
• Work on the ‘edges of your current ability’
• If the task is not appropriate to perform in your training area, you should try and to practise for it using close simulations in your training area first.
• Progress on task performance must consistently be checked outside your training area.
• If you can, you should try and pinpoint new action control in your ADLs to something you are doing in retraining
• And repeat! Many many many times. And have fun with it. Make things. Create.

• Investigate to see if you can find any appropriate technology for stroke rehab.
• For upper limb problems, if in England, see if you can be referred into the Queen Square Upper Limb service in London for an intervention (this requires a referral from your GP).
• Also for upper limb problems, get assessed to see if any anti-spasticity medications are appropriate and could help.

On October 13^th 2017, the ARNI Institute for Stroke Rehabilitation and the Institute for Sport, Exercise and Health combined forces to run the ‘Recovery after Brain Injury – State of the Art’ Conference at the Royal Society of Medicine. Chaired by Professor Alan Roberts OBE, Professor Hugh Montgomery, Professor Helen Dawes and Dr Tom Balchin, the Formal Welcome was given by the Rt Hon, the Lord Lingfield, DL, Kt., and the Address was given by HRH Princess Katarina of Yugoslavia. The theme was recovery from acquired brain injury: stroke in particular.

Professor of Stroke Medicine at the University of Leicester, Thompson Robinson, noted the many strides forward in acute ischaemic and haemorrhagic stroke treatment over the past 10 years, which has contributed to a reduction in mortality from 25% to 12%. He stated that the most significant factor leading to better survival has been the introduction of specialist stroke units. He warned that with the number of people registered as hypertensive consistently increasing since 2005, that there could be up to another 6.8 million people in the UK with undiagnosed high blood pressure.

Professor of Stroke Medicine at Keele University, Christine Roffe, reported that early treatment with aspirin following the IST study has undoubtedly been a significant factor. Pneumonia, caused by aspiration of saliva and vomit, remains the most common cause of death after stroke, and there is good evidence that early screening for swallowing problems lowers the risk. Maintenance of normal physiological parameters, such as blood pressure, body temperature, oxygen levels, and blood sugar have also been shown to be important for better outcomes.

Professor of Neurological Rehabilitation at the University of Newcastle upon Tyne, Mike Barnes, spoke about the impact of brain injury. He noted that while there is now good evidence of the efficacy of multidisciplinary rehabilitation, the lack of appropriate rehabilitation facilities means that many people have less than adequate rehabilitation and thus do not meet their full potential. Specific rehabilitation problems were outlined, including the management of pressure sores, urinary continence, spasticity and nutrition.

Professor of Clinical Neurology and Neurorehabilitation at UCL, Nick Ward, noted that stroke appears to induce the critical period plasticity that supports recovery. Further, that we should seek evidence of this in humans to justify early and intensive therapy/training. He stated that the evidence shows that the window for plasticity may return to ‘normal’ levels after a few months, but it does not shut. Importantly, drugs (e.g. fluoxetine) are available to increase the potential for plasticity right now, but in order to know who and when to treat, he highlights the need for biomarkers of plasticity mechanisms in humans.

Professor of Cognitive Neuroscience at Oxford University, Heidi Johansen-Berg  confirmed how non-invasive brain imaging techniques can be used to detect systems-level structural and functional plasticity in the human brain. She stressed that although imaging is useful to detect such adaptations, many imaging measures are non-specific and do not allow us to pinpoint the underlying cellular changes that are driving observed effects. She predicted that in the future, imaging could be used to guide individually targeted brain stimulation to enhance adaptive brain plasticity.

Professor of Neurorehabilitation at the University of East Anglia, Val Pomeroy, reported on the creation of a free app called ‘Viatherapy’. This is designed to enhance the ability of clinicians to be current in their use of evidence-based stroke rehabilitation interventions for the upper limb. Through answering a series of questions that the app poses, the therapist is guided to the current best treatment options based on the motor impairment characteristics of each individual after stroke. These options can then be refined by considering other aspects of the individual’s clinical presentation such time after stroke and whether apraxia is present.

Professor in Cognitive Neuroscience at UCL, Cathy Price, spoke about how people recover the power of speech after stroke. She confirmed that not being able to speak to family and friends is one of the most devastating consequences of stroke. Patients desperately want to know if they will recover but currently, clinicians can’t provide accurate predictions. Cathy and her PLORAS team are predicting recovery based on which parts of the brain have been damaged by the stroke. The results are proving to be much more useful than previous methods. The goal is to improve the quality of life for as many stroke patients as possible.

Consultant in Stroke Medicine at Imperial College Healthcare NHS Trust, Soma Banerjee, informed Conference about a stroke therapy using stem cells extracted from patients’ bone marrow which has shown promising results in the first trial of its kind in humans.  She noted that the study showed that the treatment appears to be safe and that it is feasible to treat patients early when they might be more likely to benefit. She noted that it is currently too early to draw definitive conclusions about the effectiveness of the therapy.

Associate Professor in Psychology Applied to Rehabilitation and Health at Exeter University, Sarah Dean, spoke about the evaluate the clinical effectiveness and cost effectiveness of the ARNI Programme (the ReTrain Trial). ARNI (Action for Rehabilitation from Neurological Injury) Institute Charity was set up in 2001 by Dr Tom Balchin. It provides a community-integration and support network for survivors by matching them with its therapists and instructors. These specialists teach its intensive and creative programme which features innovative techniques such as a rotational technique to get off the floor without assistance, and the use of implement-challenge boards to train the reach, grasp and release components of the upper limb.

Professor of Restorative Neuroscience & Rehabilitation at the University of East London, Duncan Turner, presented the results from some patients who had taken part in the RATULS (Robotic Assisted Training for the Upper Limb after Stroke) Trial so far. He charted the improvement in fine movement control in these patients before and after the intervention and stated that noted that robots, which can carry out 1,000 repetitions an hour, can dramatically augment the therapist’s power to deliver clinically-meaningful input volume.

Key emergent themes from the event were that early intervention, repetitive practice, meaningful tasks and intensity are primary drivers for successful recoveries after stroke. Our grateful thanks to guest speaker Michael Lynagh, and Advances in Clinical Neuroscience and Rehabilitation (ACNR) Editor, Rachael Hansford, who donated a box of the latest issues for delegates.

Download page report, published March 2018, from ACNR

The stroke rehabilitation literature suggests that the first three to six months are typically when most spontaneous functional motor recovery will occur. This first recovery mechanism is essentially a resolution of harmful local factors, which generally account for early spontaneous improvement after stroke. These processes include resolution of local edema, resorption of local toxins, improvement of local circulation, and recovery of partially damaged ischemic neurons.

So, mu advice is that it is useful to wave goodbye to the naysayers. Forget about any 1-year rule. Forget a 3-year rule. In fact, time to forget ‘the rules’, ok? Very limiting things, rules… because we tend to follow them blindly without asking why they are there or who made them up. Recovery can continue over a long period of time if you have partial return of voluntary movement, especially in the upper limb.  A systematic review of 58 studies confirms the most important predictive factor for upper limb recovery following stroke is the initial severity of motor impairment or function.

Furthermore, who says that you cannot be the exception to the ‘rule’? Potential is a difficult word. I personally have the potential to be astronaut. Probably won’t happen! But recovery potential? Don’t let anyone tell you that you aren’t going to make as good a recovery as possible. The reason is that there is ALWAYS something you can do to try to improve your lot. If all else fails, you’ll at least be keeping the ‘plastic template’ open and available for applications of current or future cutting-edge innovations. That’s why every repetition you do counts. More on this in a later post. For now, I can tell you for certain that time-rules and the ‘nay-sayers’ can be ignored.

The current UK National Stroke Strategy emphasises the need for long-term, therapy-based rehabilitation for stroke patients. Yet at the same time, there is insufficient evidence to support the development of more therapy-based rehabilitation, which is currently such an accepted part of stroke management.

Wider afield, in Florida, internationally respected stroke therapy expert Professor Pamela Duncan suggested that there is an urgent need to make additional strides in stroke rehabilitation research for such reasons, arguing that we still know little about how the characteristics (timing, intensity, or duration) of traditional therapies really work in comparison to others.

She was, and is still, right! This lack of data is also down to the fact that it has been felt over the years to be unethical not to ‘treat’ a large cohort of patients as part of a control group to test dominant therapies. Whilst the experts figure it out and continue to add to the growing body of high quality studies for the evidence base, I suggest that YOU (when you’re ready), start incrementally to make the rules for yourself, as I did.

To help you on your journey, you can use the complete system shown in the Successful Stroke Survivor manual  and there IS a lot of other help around – you just need to know where and how to look. You can be much more informed than I ever was 2o years ago at the time of my own stroke. You have absolutely nothing to lose. Who knows what you can achieve if you have no set boundaries? There’s absolutely no reason why you can’t ‘Do It Yourself’ to a large extent, after you reach some significant functional milestones, avoiding spending thousands of expensive clinical neurophysiotherapy in the process.

Importantly, you can significantly increase your ability to perform activities of daily life from ANY point in time after your injury. I’ll show you how. Not only that, but I can show you what you have to do to keep, and add to, your gains year on year. Make sure to tune in to further posts!

“If we could put exercise into a drug, it would be one of the most effective medications to  prevent vascular disease and treat patients with cardiovascular and cerebrovascular diseases including stroke.” Yep. And this statement is reinforced by the finding that exercise interventions are significantly more effective than drug treatments in both rehabilitation and reducing the odds of mortality among stroke survivors.

Chronic inactivity related to stroke basically has a whole load of physiological consequences that result in cardiovascular deconditioning, increased cardiovascular risk and increased mortality and morbidity risk.

The majority of survivors are cardiovascularly unfit. It has been found that due to the effects of stroke, you can even be rendered half as cardiovascularly fit compared to someone who has not had a stroke.

This can be worsened by a pre-existing cardiovascular condition, such as hypertension, congestive heart failure, peripheral vascular disease, or pulmonary and metabolic diseases. This is the bad news. The good news is that the evidence now also suggests that your exercise train-ability may be comparable, in many ways, to that of your age-matched healthy counterparts.

Despite the fact that the energy expenditure required for you to perform routine walking varies with the degree of weakness, spasticity, training, and AFO usage.. and is elevated by one and a half to two times that of non-stroke subjects…you can increase your cardiovascular fitness by a magnitude that is similar to that of healthy adults who engage in endurance training programmes. Improving aerobic fitness may allow you to carry out everyday activities with less effort and for longer periods.

So you’ve got to be active, right? There’s another crucial factor you need to know. There is growing evidence that exercise promotes brain neuroplasticity. Neuroplasticity mediates cognition and the relearning of motor skills and other skills after stroke. Brains learn what they do. Remember, the brain loves repetition. Cardiovascular exercise is repetition.

And for such adaptation to happen optimally, you must be prepared to do some focused work with whatever movement you possess (with some caveats, to be explained shortly), even if you believe you have none at all. Over and over again, with as much attention to detail as you can muster.

We’ll have a look at programming for cardiovascular fitness in further posts (watch out for my tips and hints coming shortly!).

But the take-home from this post is that I want you now to think of yourself as a CREATIVE stroke survivor. Take walking. Repetitions are required but ALSO you need to set goals and targets (actually, like me, you’ll find these are fast-moving targets): to get away from supports like wheelchairs, frames and sticks as soon as possible, to go further, to go for set distances, to feel less tired each time, to ramp up the quality of your walking by focusing on how you walk, to walk over different surfaces, to walk with an AFO and without, to tackle stairs, etc. etc.

Time to make a move! Get professional help if you need or ‘go-it-alone’. If you are setting up to ‘retrain’ by yourself, when attempting walking practice, dependent on your presentation, at least collar a young and strong family member or friend to help you. No-one will mind, especially when they see you making a darned good effort. The world is yours.

Even you have hired the help of a trainer or a therapist to get you started (advised), you must have input towards your own rehabilitation and the way you want to go. Knowledge is power. My aim is to show you exactly how to achieve 6 things:

1. Correct balance, co-ordination and posture over time
2. Increase muscular, tendon and ligament strength and fitness over time
3. Decrease spasticity and increase specific functional movement return over time
4. Increase confidence and remove fear of the consequences of exercising
5. Become progressively more self-sufficient
6. Become productive in an occupation and be happy with life

Can you take up the challenge? These can all be achieved by you to a certain degree, however old you are, if you want them badly enough and are prepared to sacrifice some time and effort. Can a generic programme be created? For example, is there one ‘programme’ that will fit everyone? It would be much easier that way, right?

The simple answer is ‘no’. But there are many things that all stroke survivors must do, and many things that most will need to do. You will start with basic tasks that you need to master in order that you can work towards more complex tasks. Everything you do will rewire your brain: by doing more, you will develop more motor control and gain strength. You will ‘get nothing by doing nothing’.

Please understand that the degree to which brain repair, neural rewiring and neurogenesis happens can be influenced very significantly long after the short therapeutic window after stroke may close.

So, I hope to emphasise to you with this post that the regain of functional movement with control, strength, flexibility, stability and essential physical coping strategies are highly individual, relying as they do on your own genetics, status of accompanying medical problems, attitude (drive, persistence, desire and motivation) and so very many other factors.

The longer you’re a stroke survivor, the more you’ll notice that you can ‘win’ or control (manage) many of these but others will have to be accepted. And, I have to tell you, that re-training efforts can never stop, throughout the rest of your life. Sounds like bad news?! Not so… I’ll show why, in a forthcoming post.

Long term stroke survivors reading this will be nodding to themselves. New stroke survivors will get to understand what I mean (just read my next posts. The good news? ‘Retraining’ can very soon phase into an enjoyable and social physical activity wherein you are actively rehabilitating. So encouragingly, it seems that ‘formal training’ is finite… but it must be done right so you can phase into a maintaining status quo in some areas and regularly improve in others (usually micro-improvements).

Stroke is the commonest cause of physical disability in the world and although there are many excellent services to help stroke survivors, there is no doubt that the continuation of practice and exercise programmes is invaluable in enhancing recovery.

This is important because neuroimaging studies tell us that the brain is a plastic organ. In other words the brain’s structure, the way it is organised, and the way it functions can be influenced by practice and learning. This is the basis for at least some of the recovery that occurs after stroke. A major problem often encountered is that stroke survivors are not sure what exercises they can usefully or safely perform.

The secret is that ‘re-training’ rather than ‘therapy’ is the zone you need to think about now.

Did you know that what we call ‘task-oriented’ exercise programmes are the most promising? If not, you’ll get to love the effects of task-related training IF YOU CAN PROVIDE ENOUGH DOSAGE. By this I mean ‘time on task’… targeted repetition… drives plastic change by strengthening connections. Each rep you do counts.

Enhancing upper limb function is often an essential component of rehabilitation. Weakness in upper-limb musculature could impair stabilisation of proximal arm segments, limit reaching ability, confine hand usage, and affect upper-limb control and coordination. These factors have a direct effect on the use of the paretic (weaker) upper limb in daily activities, supporting the importance of paretic upper-limb strength.

Low grip strength in the stroke population can and should be corrected via strength training since grip strength is also a predictor of disability and mortality in older adults. This is why ARNI has, since inception 17 years ago, concentrated on task-training, strength training and the appropriate development of physical coping skills. We’ve done the same thing ever since.

The evidence base right now supports these THREE components that form of backbone of ARNI type training over all others – principles which training can be based around. In a post further on down the line I’ll show you what kinds of ‘interventions’ (those that operate concurrently with an effective dialled-in training programme) hold the most promise too, and that you should explore. It’s the best time in history to be a stroke survivor!