Over 400,000 Canadians live with long-term disability from stroke. Stroke survivors say regaining walking ability is a top priority; but, poor cognition, or thinking abilities, can limit walking in the community. How much walking recovery someone achieves likely stems from the brain's ability to dual-task (DT), like walking while talking. In fact, almost 80% of stroke survivors struggle with some aspect of cognition limiting full walking recovery after stroke. The complex demands of community mobility after stroke can be studied in laboratory settings using DT, where walking is done with a cognitive task.
Using DT, studies have found the brain is crucial for DT, and that altered levels of brain activity affect DT ability. But, little research probes if stroke survivors could produce brain recovery with DT training, as neuroimaging methods like functional MRI, cannot collect data during standing and walking. Functional near-infrared spectroscopy (fNIRS) is an ideal imaging tool to assess walking without physical limits, but its utility to detect if DT training can drive the brain to recover walking has not been tested in stroke survivors. So, the goal of our clinical trial is to test if DT training can help the brain recover and allow for better DT ability. DT training may drive brain recovery by addressing cognitive and motor difficulties at the same time, maximizing rehabilitation efforts, and improve walking ability in the community after stroke.
Stroke is the leading cause of disability in Canada with more than 400,000 Canadians living with long-term disorders due to stroke. Hence, whilst challenging, it is critical to restore mobility to these individuals such as independent walking; the most frequently stated goal of individuals post-stroke. However, achieving this goal is hindered by motor impairments, including muscle weakness and spasticity, yet we still do not understand how these impairments influence walking post-stroke. This lessens the efficacy of emerging innovative treatments such as the use of botulinum toxin or Botox to suppress spasticity and improve walking. Computer simulations are powerful tools to uncover how muscles coordinate movement and predict the functional gains following a personalised treatment plan.
This research aims to develop diagnostic tools that can be used in clinical practice to identify movement deficiencies during walking post-stroke and associate them with clinical measures of function and spasticity before and after an intervention. These tools will facilitate greater use of personalised therapies, one of the primary goals of stroke recovery in Canada, and ultimately give people with strokes the ability to walk independently.
Up to 73% of people who are able to walk post-stroke suffer a fall, commonly within the first few months after discharge home. Optimizing the approach to rehabilitation of walking balance remains vital to long-term outcomes post-stroke. A fall poses a significant risk of injury and erodes confidence. The loss in confidence alone can lead to decreased activity levels, loss of independence and social isolation that affect quality of life and overall health, even hastening death.
After stroke, much of the focus of rehabilitation is on improving balance and walking. However, no objective measures are available to assist clinicians in making important treatment decisions such as walking balance task type or intensity of the challenge. Unlike retraining of walking endurance that uses established measures such as heart rate to monitor and plan progression of walking endurance, there are no objective measures to guide progression of rehabilitation of walking balance.
To address this issue I am working with clinicians and people with stroke to:
- develop clinically useful balance measurement technology for use during rehabilitation;
- better understand the interaction between physical ability and confidence during rehabilitation of walking post-stroke; and
- incorporate this new technology together with algorithms that model rates of change to personalize the level of challenge of walking interventions and assure the best outcome for each individual with stroke.
Throughout the history of medicine, patients who had a disease that was poorly understood were advised to rest. As scientists and doctors learned more, early mobilization and active therapies (e.g., exercise) gradually replaced rest as the conventional treatment for a variety of medical conditions, such as chronic fatigue, whiplash, stroke, low back pain, and cardiac arrest. We have now reached this same juncture for concussion care. The proposed project aims to figure out how to support doctors in implementing new science-informed return to activity guidelines for concussion.
By way of background, concussions (also known as mild traumatic brain injuries) are very common, affecting more than 20,000 people each year in British Columbia's lower mainland alone. Concussions have been historically treated with rest. An explosion of concussion research over the past decade has led to several important insights. One such insight is that resting for more than a few days does not speed up recovery, and in fact, may cause harm (for example, lead to social isolation and depression). There is also emerging evidence that exercise is an effective treatment. Guidelines for clinical care prepared by Canadian and international concussion experts now emphasize that patients should gradually return to activity (e.g., school, work, recreation) soon after injury, as tolerated. Nevertheless, rest remains the most common treatment prescribed by doctors. It is promoted in pamphlets and websites designed to educate patients about their injury.
The goal of the proposed research is to bridge the gap between concussion science and clinical care, and study how effective this knowledge translation effort is. We focus on family doctors because they are best positioned to counsel patients about returning to activity after concussion. We have assembled a package of knowledge translation strategies based on behaviour change theory, prior research on how to best implement new clinical care guidelines, and input from the kind of doctors and patients who could most benefit from this knowledge. The study plan involves learning about doctors' behaviour through an online survey tool each time they see a patient with a concussion, and measuring patient outcomes through telephone-based assessments. We will measure changes in how doctors manage concussions and whether those changes result in corresponding improvements in how quickly patients recover from a concussion.
