Early prediction of functional outcome is important in stroke management to introduce rehabilitation programs with realistic objectives. These objectives should be periodically checked and continuously readapted with the salient clinical aspects of the patient recovery.
Outcome is generally better for deep cerebral hemorrhage than for subarachnoid hemorrhage and ischemic stroke. The influence of the lesion size and side is controversial, but the best predictor for a more negative outcome remains the severity of the deficits at the stroke onset. Most recovery of sensorimotor and cognitive deficits occurs in the first three months and this is undoubtedly the optimal time for intensive inpatient rehabilitation. Recovery continues at a slower pace throughout the first year or up to several years. Low-level functions (sensorimotor deficits processed by primary brain areas) often improve before than cognitive functions (attention, memory, language, and the other faculties processed by integrative or associative areas).
Age, sitting balance, severity of paresis, disability on admission, urinary incontinence, comorbidities, psychotropic drugs, previous stroke, interval before the onset of the rehabilitation treatment, and the adequacy of social support emerged as factors directly and indirectly influencing functional recovery
Cognitive deficits (particularly aphasia, neglect, and executive dysfunction, low Mini-Mental State Examination scores), and mood disturbances have a strong negative impact on the degree of autonomy after stroke.
In the earliest phases, recovery depends on the resolution of edema and reperfusion of the ischemic penumbra. During the following weeks, months and years, recovery is enhanced by the plasticity of the brain.
Mechanisms of brain plasticity are both structural (sprouting of fibers from the surviving neurons with formation of new synapses) and functional (extension of the cortical map, the emergency of alternative pattern of activation within the neural network including the damaged area, unmasking of previously existing but functionally inactive pathways, the use of alternative strategies and brain circuitries to resolve the same task).
All these mechanisms of recovery have been demonstrated in humans and animals and are modulated by experience and training.
Functional neuroimaging studies have provided considerable evidence that the reorganization of the injured brain can be modulated by activity, behavior, and skill acquisition. These studies suggest that combining therapies, foreseeing greater intensities of therapies, and increasing overall afferent inputs may improve stroke outcome.
While there is evidence that recovery of cognitive functions is supported by mechanisms of brain plasticity, the actual challenge is to identify which of the processes identified are important and how they can be enhanced by specific behavioral or pharmacological interventions.
Cognitive therapies for the individual patient should be supported by high quality evidence-based practice. Randomized controlled trials and rigorous meta-analysis studies are widely accepted as the more robust methodology for research into clinical treatments. Nevertheless, neurologic and cognitive rehabilitation is a particularly hostile field for application for this methodology because the great interindividual variability may be often, unfortunately, responsible for significant sampling errors. Unfortunately the available evidence which is low on the specificity of neurorehabilitative programs is at the origin of a great variability of treatments in different hospitals and clinics.
The best cognitive and physical neurorehabilitation programs are only defined by specialists who are able by themselves to perform detailed cognitive and neurologic assessment, who understand the complexity of the issues that are related to the neurologic recovery, and who know well the theoretical basis of neurology and neurorehabilitation..
In the field of neurorehabilitation I encountered some specialists with a very low scientific profile, insufficient clinical skills, limited knowledge of the rehabilitation literature, often proclaiming the good results of therapies which do not have any scientific or empiric evidence.
In this context I would like to quote Leonardo Da Vinci: “He who loves practice without theory is like the sailor who boards ship without a rudder and compass and never knows where he may cast.”
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