How Clinicians Hold Survivors Back: Debunking Stroke Recovery Myths

As with other fields, persistent myths continue to shape contemporary stroke rehabilitation.

Misconceptions and myths held by clinicians can effectively hold back stroke survivor progress and recovery. And yes; its an AI-generated picture, but I thought it was awesome.

Many #stroke clinicians unknowingly propagate outdated beliefs that effectively limit #strokerecovery. These myths can spread through word of mouth, outdated training, and even well-intentioned but misguided clinical guidelines.

Addressing these misconceptions is critical to improving #strokesurvivor care and maximizing functional outcomes. Below are four of the most common misconceptions, along with the research-backed truths that challenge them.

The "Six Month Myth"

Acute stroke clinicians as well as therapists are often arbiters of misconceptions about "late" recovery, due to outdated training, reliance on anecdotal evidence, and/or overly pessimistic views about #neuroplasticity. Consequently, many #strokesurvivors are told that the improvements that they exhibit in the first 6 months post ictus are the only gains that they will achieve.

This common clinical tenet can dampen participation, as well as reimbursement for rehabilitation after the six month mark. In fact, such information often introduces self-fulfilling prophecies, in which negative, inaccurate, recovery information undermines stroke survivor attitudes, behaviors during therapies, and resulting outcomes (eg, McCabe & Williams, 2019).

While #endogenousrecovery processes demonstrably occur for 3 - 6 months, response to novel rehabilitative strategies is not confined to this same narrow window. In fact, studies show that individuals can make gains well beyond six months, sometimes years after a stroke. Approaches such as modified constraint-induced therapy, transcranial direct current stimulation, mental practice, and other noninvasive techniques have demonstrated efficacy in promoting recovery years post stroke (see my own publications available elsewhere on this website for more information on these effective strategies).

"Brain Rest"

Since at least the 19th century (eg, Hughlings Jackson, 1875) there has been a belief that encouraging survivors to move too aggressively, too soon, elicits cognitive fatigue, confusion, or even further neural damage. To this day, many clinicians still assert that mobilizing a stroke survivor too soon post ictus may exacerbate neurological injury.

In reality, immobility in the days post stroke can lead to muscle atrophy, cardiovascular deconditioning, and a higher risk of secondary complications such as contractures, pneumonia, and deep vein thrombosis. Delaying rehabilitation can also hinder rate of recovery and increase likelihood of long term disability. I've seen (and continue to see) the unfortunate "recipients" of under-dosed physical and occupational therapies. It's unfortunate and avoidable.

In contrast, early rehabilitation encourages the activity of endothelial progenitor cells, which create new blood vessels and support healing. These changes translate to better motor outcomes and quality of life (Bernhardt et al., 2015). In fact, Amin and colleagues (2019) recently demonstrated that rehabilitation in the intensive care unit led to significant improvements in stroke survivors' functional outcomes.

Size Doesn't Matter

Clinicians often assume that the size of the stroke lesion directly determines the extent of functional recovery.

Here are the facts: (a) size doesn't matter; (b) like your realtor says, it's all about location, location, location. Specifically, the location of the damage, the integrity of surrounding tracts, and the individual's pre stroke health contribute most markedly to recovery potential (eg, Page et al., 2016).

Accordingly, a #strokesurvivor displaying a "large" lesion who engages in high quality rehabilitation may regain more function than a survivor with a smaller lesion who receives the same - or even a larger dose - of motor rehabilitation. Reliance on lesion size as a predictor of #strokemotorrecovery is simply not supported by contemporary evidence, oversimplifies the complexity of brain adaptations, and can bring about misleading prognoses.

Lazarus Continues to Have Impairments

In the context of acute ischemic stroke, the term #Lazaruseffect metaphorically describes sudden, dramatic changes in neurological status, drawing on the historical account of Lazarus being restored to life four days after his death (John 11:1-44). This moniker implies a transformation in functional status from moderate/severe impairment to “no” impairment. Because the survivor can "move again" (and, moreso, because he/she scores well or even perfectly on bedside measures such as the NIH Stroke Scale), acute clinicians often assume that the individual has fully recovered. This assumption has grave implications for rehabilitation, not the least of which is under-prescribing much-needed occupational and physical therapies.

Most #strokesurvivors who regain movement quickly still continue to struggle with subtle but clinically-significant deficits. Weakness, poor coordination, and fatigue may persist even if gross movement returns. Additionally, "hidden" impairments such as difficulty with fine motor control, executive dysfunction, balance challenges, high fall risk, or post stroke pain may not be immediately obvious during a brief clinical assessment such as those administered by acute stroke personnel (Cirstea & Levin, 2007).

Stroke survivors who show early recovery still need structured rehabilitation to refine motor control, restore activity tolerance. Assuming that these survivors do not require therapy can lead to missed opportunities for optimizing function. Comprehensive assessments should go beyond physicalities and acute bedside measures, and consider the quality, efficiency, and endurance of a variety of factors.

Breaking the Cycle of Stroke Recovery Misinformation

Encouraging #strokerecovery beyond six months, embracing early rehabilitation, recognizing that lesion size does not dictate outcomes, and ensuring that all survivors receive comprehensive therapy regardless of early recovery patterns are essential steps toward better stroke care.

Moving away from obsolete myths and adopting better clinician, care partner and survivor education practices informed by evidence will result in improved outcomes for stroke survivors.