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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