DOCUMENT

Headlines 5 “ It’s quite hard for even experienced clinicians to be able to confidently tell a patient and their family what to expect for walking recovery. A week after stroke, some people are doing really well and recover quickly, and others aren’t doing well. Weeks later, even with their best efforts and lots of intensive therapy, some patients still aren’t able to walk. ” Being able to put a time frame around the ability to walk independently again is helpful for everybody involved with stroke recovery – the clinicians, physiotherapists, friends and family. And of course, it’s hugely helpful for the patient, especially if they’re still in paid work. Walking unassisted is pivotal for regaining independence following stroke. “When doctors and therapists are able to confidently predict a patient’s ability to walk unaided again, families and friends can make better plans for support. For example, if they don’t live in the same city as the patient, they can decide when their visit would be most helpful. Bigger decisions are aided too, such as whether to change the patient’s living arrangements or organise home help. “I can think of a man who's young by stroke standards, in his late 40s. Immediately following stroke he had no muscle activity in his weak leg. But TWIST predicted he’d be able to walk safely on his own in six weeks. As it turned out, he was there within a month. The knowledge that it was highly likely he’d walk again soon energised the patient, his therapy team and his family.” Final patient recruitment is underway for TWIST, and then the study will have just six months to run. At that time, data will be carefully considered and analysed, then Cathy and her teamwill release the results. “We developed the algorithmwith a sample of just 40 patients, however funding from the Neurological Foundation has allowed us to expand the study to 120 patients. We only have five more to recruit. Once we have them on board, we’ll follow their progress for six months and then wrap up the study.” With the end in sight for phase one of TWIST, Cathy is preparing a much larger study that will validate the final algorithm. This study will discover what happens when TWIST information is available to patients and clinical teams, including measuring any potentially negative consequences that result from patients knowing if or when they will walk again. “We need to understand the patient experience and what it’s like to receive the information that TWIST provides. Then we can be more confident with how to put TWIST into practice. If there’s potential for negative impacts, we can think about how to mitigate those risks.” FRAMBOISE: Fluoxetine, recovery and motor biomarkers in stroke Finding pharmaceutical ways to aid stroke recovery is part of the holistic approach to treatment and rehabilitation. Phoebe Ross, one of the PhD students in Cathy’s group, is working on a study called FRAMBOISE: Fluoxetine, Recovery, And Motor BiOmarkers In StrokE. Her work is funded by the Neurological Foundation. “Phoebe’s research is looking at whether a commonly prescribed antidepressant, fluoxetine, might help patients who have the worst prognosis for their hand and arm after stroke. It uses biomarkers to identify which patients are most likely to benefit.” The results of this research could lead to new approaches in stroke rehabilitation clinical practice, and improvements in recovery and quality of life for the thousands of New Zealanders who experience a stroke each year. “There have been some issues with the studies that have been done to date. The main one is that they haven't used a key biomarker, which we use here, to select patients for the study. We’re going to look at patients who have the worst outlook based on this biomarker and, therefore, potentially the most to gain. Fluoxetine does a couple of things that promote neuroplasticity, which could be useful for somebody recovering after a stroke.” PREP2 VIP: Checking the accuracy of the PREP2 algorithm in clinical practice Developed by Cathy and her team, PREP2 is an algorithm for predicting hand and arm function after stroke. It involves a combination of assessments within days of stroke to predict how well a patient will be using their affected hand and armwithin the next three months. PREP2 is now routine clinical care at Auckland DHB and other DHBs are following suit. To see how real-life use of the algorithm is going, senior physiotherapist Olivia Norrie is working on PREP2-VIP (validation in practice), which focuses on checking that the algorithm remains accurate when the clinicians are using it. “Our research showed that PREP2 runs at about 75% accuracy, so we’re watching to see if that holds up when clinicians are using it. Olivia’s work will include collecting more data, including measures of patients’ vision and apraxia, which is a movement disorder. She’s going to see if we should add this data in, to further improve the accuracy of PREP2.” Overall mission: Personalising stroke rehabilitation The common thread with Cathy’s team’s work is the mission to personalise stroke rehabilitation and treatment using biomarkers and predictive tools. “The work we’re doing is in the real world. We’re very privileged to be working with people within a day or two of their stroke while they’re here in the hospital. We’re now able to carefully identify patients and target their treatments more appropriately. Personalised medicine is the new frontier for stroke recovery. Thanks to funding from the Neurological Foundation, we’re doing it right here and now in Auckland.”