The science of stroke rehabilitation: part three

In my previous two articles, I explained the principles of stroke rehabilitation and synaptic repair. In this last part of my series on this topic, I focus on the importance of environmental management and functional therapies to repurpose redundant cells. We also consider what new therapies the future may bring.

Stroke rehabilitation is tied intrinsically to the promotion of synaptic regeneration. It is subdivided into different categories which are managed by specialist teams, including motor, sensory, cognition, visual and emotion. Specific teams include doctors, nurses, psychiatrists, occupational and physical therapists and speech and language therapists. These teams work together with the patient in goal-directed therapies. Appreciation of the environment and simple modifications to facilitate interaction are symbiotic in improving outcomes. For now, we will focus exercise-based stimulation of synaptic regeneration.

Evidence shows that repeated stimulation of a brain region, through either social or physical activity, promotes the formation and consolidation of complex synaptic networks designed to perfect a function. Stimulation promotes synaptic plasticity, restructuring and increased concentrations of cell promoting molecules. This is as true for all brain regions. Current guidelines encourage early mobilisation and rehabilitation, which has been suggested through evidence to increase dendritic activity, promote growth factors and increase synaptic activity. Simply put, early encouragement gets the neurons talking again and practice cements their lines. It is perhaps interesting that stimulatory therapy mirrors the functional impetus for brain evolution itself.

How therapists can retrain brains

Through emulation of function the brain is inspired to repurpose cells. Therapists exploit this natural ability to retrain the brain. Within rehab therapy this treatment is as simple as moving the affected limb, applying sensory stimulus or exercises in speech or writing. The brain's intrinsic learning pathways and propensity to utilise redundant systems will go some way to developing new ways of performing old tasks. This is more effective if performed early in stimulating environments and national guidance champions early therapy in specialist centres.

Although these adaptions may not be perfect, by manipulating the local environment we can compensate. For example, an occupational therapist may suggest using large-grip cutlery, or try using communication tools. Speech and language therapists will help patients develop simple strategies to improve speech and swallowing, and psychiatrists will use pharmacological or cognitive techniques to rewire thinking. In each case, we see the understanding of biology and evolution of the brain systems paramount in delivering excellent treatment. Emphasis is placed on teamwork to compliment the brain's own abilities.

We must remember that although the brain is a wonderful machine, there are limitations to its recovery. Stroke is a serious problem and, even with the prolonged and integrated work of multiple teams, it is rare to regain full function. Rehabilitation is planned to provide recovery to the highest standard possible, and research may bring new therapies in future. Stroke prevention is first and foremost.

What the future may bring: the next chapter

Regardless of the science, the jury is still out on how to best practise rehabilitation. We know that early repetitive exercises tailored to specific patients in high stimulus environments provide better outcomes, but specific timing and duration is unclear. Future research will focus on perfecting these regimens by using electric and magnetic stimulation to message the brain and help it rewire. Stem cell therapy is in its infancy and presents exciting opportunities to replace dead cells. Finally, the integration of new neural technology may lead to mind-controlled prosthesis. The future is ripe with promise.

In the end it all comes down to the patient. Prevention is better than treatment, but by understanding the brain, its science and its processes we can design treatments to help patients return to a quality of life they will accept. We are a long way from perfection, but like the evolution of the brain, changes are slow. To find out more or make a donation to stroke research, visit the Stroke Association.

Ben is a young NHS doctor in the Southwest. His interests include neurology, health communication, and medical ethics. He is also an avid advocate of compassionate care and quality improvement, running a project in the Southwest around medical humanities. Please follow and support: Dr Janaway on Facebook Dr Janaway on Twitter

The opinions expressed in this article are the author's alone and do not reflect those of the NHS or associated agencies. All facts are based on the best available evidence. The author is happy to receive questions. There are no conflicts of interest and due consideration has been given to the consequence of conclusion or interpretation.