I don't know what you mean when you say "intense" upper extremity (UE) neurorehabilitation.
You don't either.
During my postdoc, NIH held a workshop on the optimal #intensity and #duration of #strokerehabilitation and - of all things - hip fracture (fodder for another blog). Meanwhile, "top scientists" were churning out trials whose results touted the provision of "intense" #strokerehabilitation. Even today, many scientists hang their hats on programs of "intensive" rehabilitation.
Yet, a glaring issue persists: the concept of upper extremity rehabilitative intensity is poorly (or not at all) defined. This ambiguity hinders the development of standardized protocols, creates variability in clinical practice, and ultimately affects patient outcomes.
What Does "Intensity" Really Mean for UE Neurorehab?
Outside of neurorehabilitation, "intensity" is synonymous with the effort that an individual puts forth during an exercise - usually measured through self assessment or biological metrics such as heart rate. The "FIT" principles (Frequency Intensity and Time/duration) and the oft-cited ACSM Guide to Exercise Prescription in which these principles are operationalized - have guided both exercise and rehabilitation practitioners literally for generations. With regard to the latter, the Borg ratings of perceived exertion (RPE) are frequently used in rehabilitative environments to describe the intensity that patients are putting forth during a given exercise.
What we do in neurorehabilitation is not that far removed from exercise prescription and therapeutic exercise. Yet, progenitors of "intense" stroke rehabilitation got it all wrong. Repeatedly.
Some (including authors in the above mentioned NIH workshop) conflated "intensity" with duration. For instance, a recent article on pediatric constraint induced therapy used the term “intensity” or “intensive” 8 times and asserted that pCIMT was a “…high-intensity therapy for the more impaired UE (≥3 hr/day, many days per week, for multiple weeks);” an example of conflating the vague term of “intensity” with both duration and frequency (ie, session length; the number of intervention days per week; the number of weeks comprising the intervention period).
Others have gone so far as calling interventions “intense” or “intensive” in their study titles. Yet, they didn't specify how they determined that their interventions were “intense.” Evidently, saying something is "intense" passes for science nowadays.
The lack of clarity around #upperextremity intensity has real-world consequences.
For one thing, without a clear definition, therapists may vary widely in how they structure therapy sessions, leading to inconsistencies in care delivery. After all, how do I know if I'm providing sufficiently "intense" therapy, when the so-called experts haven't even measured - let alone defined - this construct? Are my colleagues who are routinely using RPE and heart rate apps - established methods for measuring intensity that are advocated by our professional organizations - now getting it wrong? And as a clinician, what am I supposed to do with the "intensive" approaches that companies and researchers advocate when their "intense" ingredients are not articulated or even measured?
The absence of a standardized measure of intensity also complicates the design and comparison of clinical trials, slowing the development of evidence-based guidelines. Controlled clinical trials are not so "controlled" and comparison of outcomes is obfuscated when participants are exerting varied, unchecked intensity levels from study to study. Check out our treatise on this topic from 2012 here.
To address these challenges, the rehabilitation community needs to take deliberate steps to refine the concept of upper extremity intensity. These should include:
identifying and validating measurable indicators of intensity for the upper extremity and, as needed, for specific upper extremity tasks.
Wearable sensors and artificial intelligence can also provide objective data on effort and engagement, offering a more nuanced understanding of intensity.
Most importantly, collaborations among researchers, clinicians, and policymakers can lead to the development of standardized protocols and guidelines, ensuring consistency in "intense" therapy delivery.
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