Congratulations to Drs, Catherine Boissoneault, Anna Khanna and Janis Daly on the publication of your case report “Feasibility and benefit of long-dose stroke neurorehabilitation which produced and maintained balance and mobility gains throughout cancer surgery and radiation treatment,” in Vascular Diseases and Therapeutics Volume 3(2).
This case study provides quantitative evidence of the feasibility and benefit of a long-dose, 10-month neurorehabilitation program for a chronic stroke survivor who, in the midst of the neurorehabilitation program, underwent surgery and radiation treatment for breast cancer.
The patient was age 60 years, and 6 years post-stroke (left middle cerebral artery stroke), exhibiting impairments in balance, strength, and gait coordination, as well as deficits in functional mobility, and compromised quality of life. Her comprehensive mobility/fitness neurorehabilitation program included aerobics, strength and coordination training, and balance and gait coordination training. Treatment was 1.5 – 2 hours per day, 5 days/week for 6 months, followed by an additional 4 months of treatment 3 days/week. Outcome measures were acquired at entry into the neurorehabilitation program, and at months 2, 4, 6, 8 and 10. Measures included the following: modified Ashworth (mASH, spasticity); Fugl-Meyer (FM; isolated limb joint coordination); 6-minute walk test (6MWT; walking endurance); gait speed; Berg Balance Scale (BBS; static and dynamic balance); Timed Up and Go (TUG; mobility); 10 Meter Walk Test (10MWT; short distance, self-selected and fast walking speed); Functional Gait Assessment (FGA; dynamic balance and postural stability during gait); Functional Independence Measure (FIM; assessment of functional status and disability); Craig Handicap Assessment and Reporting Technique (CHART; quality of life assessment of how patients with disabilities function in the community and at home); 36-Item Short Form Survey (SF36; quality of life measure); and the Stroke Impact Scale (SIS; stroke-specific quality of life measure). Fatigue level was queried during and following radiation therapy.
From baseline through month 4, the patient demonstrated improvements in most outcome measures. For example, she improved from 3 minutes of cycling endurance to 45 minutes, and balance improvement reached the threshold for functional independence. At month 5, she was diagnosed with breast cancer and underwent a partial mastectomy. She underwent radiation treatment, which concluded in month 7. Prior, during, and after the cancer treatment, she continued participation in the neurorehabilitation program. Following the partial mastectomy, she exhibited continued improvement in BBS, 10MWT-normal speed, FGA, CHART, SF-36, and SIS. Notably, the TUG continued to improve significantly by 4.73sec. She showed some decline in values for the 6MWT, gait speed, and 10MWT- fast walking speed. Four weeks following the end of the course of radiation therapy, most measures showed a small decline. But in contrast, by 12 weeks after the end of radiation (which coincided with 10 months of participation in the neurorehabilitation program), the following measures showed a revival in improvement: Fugl-Myer (limb coordination); 6MWT (walking endurance); gait speed; BBS (balance); FIM (functional tasks); subdomains of the CHART quality of life measure (physical independence, cognitive independence); SF-36 subdomain of energy/fatigue; and the SIS (subdomains of strength, memory and thinking, and mobility.
Years after stroke, intensive, long-dose neurorehabilitation can improve lower limb coordination, balance, strength, mobility, activities of daily living/ instrumental activities of daily living (ADL/IADL),, overall function, and quality of life. It was feasible for a severely impaired stroke survivor to participate in an intensive neurorehabilitation program. It was feasible for a stroke survivor to participate in a neurorehabilitation program throughout surgical and radiation treatment for cancer. For a chronic stroke survivor, many aspects of impairment, function, and quality of life were maintained by neurorehabilitation throughout treatment for cancer.