Motivation Is More Important Than Physical Therapy In Stroke Rehabilitation

The editorial, ‘https://journals.sagepub.com/eprint/BP92VZWUUBAEYGTZXEDD/full', published this week in Clinical Rehabilitation, argues the need for rehabilitation medicine to move away from its standard physical therapy-intensive approach by incorporating a patient-centred model informed by individual circumstances and motivations.

More than 8,000 people survive a new stroke in Aotearoa New Zealand every year. Only 10% of those say they are ‘fully recovered’ 3 months after the stroke. For the remaining 90%, stroke rehabilitation that improves important outcomes is vital.

If you had a stroke and were asked what would make the most difference to your outcome, you might reasonably say ‘loads of therapy’ from physiotherapists, occupational therapists, and speech language therapists, experienced in looking after people with stroke. And guideline writers agree, with the Australasian Stroke Rehabilitation Guideline strongly recommending ‘as much therapy as possible.’

However, in a provocative editorial in the international journal Clinical Rehabilitation, Dr Harry McNaughton, Stroke/Rehabilitation Research Programme lead at Medical Research Institute of New Zealand (MRINZ), and colleagues, assert that there is limited evidence supporting the ‘more physical therapy’ approach and strong evidence that even large amounts of extra therapy make no difference to outcomes for people with stroke. For example, in a randomised trial of over 2,000 participants, an Australian research team showed that an intervention made up of earlier, more frequent, and longer mobilisation in hospital, resulted in greater harm compared to people receiving ‘usual therapy’.

Dr McNaughton and colleagues argue that the most important part of rehabilitation is to put the person with stroke first.

“The current strong recommendations for a specific ‘dose’ of rehabilitation therapy or simply ‘more therapy’ are wrong and should be changed,” says Dr McNaughton. “In the editorial we provide evidence that the two most important components of successful rehabilitation are engaging with the whole person, not just their ‘damaged part,’ and improving motivation.” Dr McNaughton states that rehabilitation clinicians have always known that motivation is important but attempts to increase it by external encouragement, rewards and watching inspirational videos of other people with stroke have not worked.

“The good news is that now we have a simple tool that helps people with stroke and other conditions motivate themselves.’ This tool – called ‘Take Charge’ — has been shown to be effective in addition to usual rehabilitation and puts people in charge of their own recovery and life after stroke.”

Using the Take Charge approach for stroke rehabilitation in conjunction with standard therapy, two large studies led by the MRINZ, involving a total of 572 Māori, Pacific people and Pākehā with stroke, found that there is significant benefit for patient outcomes. When compared to standard care, health-related quality of life and independence outcomes were improved 12 months after the stroke in participants who had received the Take Charge intervention.

Take Charge is a patient-centred, ‘whole person’ rehabilitation approach involving simple images and prompts. It focuses on an individual’s thoughts, goals, support network and strategies for success, rather than being directed and overly influenced by health professionals. Using this approach, patients are encouraged to think positively about their future and allow the patient to feel in control of their own recovery.

Applicable to not just stroke and able to be used alongside conventional therapy, the Take Charge approach returns the focus of rehabilitation to the patient and their individual circumstances to help produce improved outcomes. Take Charge is also cost-efficient as it is free and easily accessible online for both clinicians and individuals.

“People with stroke – not health professionals – know best what works for them. We – the health professionals – need to learn to properly listen to them and Take Charge can help that happen.” says Dr McNaughton.

Take Charge is available free to download at www.mrinz.ac.nz/programmes/stroke . It is currently available in five languages. The tool has also been adapted for people with conditions other than stroke.

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