Interview with Critical Care Neurologist David Lin, MD: Addressing Issues in Stroke Recovery

David J. Lin, MD is a critical care neurologist and neurorehabilitation specialist at Massachusetts General Hospital (MGH). He is an attending physician in the MGH Neurosciences Intensive Care Unit and directs the MGH NeuroRecovery Clinic. We spoke to him this Spring about issues he sees in the stroke recovery journey and potential ways to address them. Below are the questions we asked in the interview followed by his answers.

Q: What do you see as the major stages of stroke recovery?

A: Stroke recovery has traditionally been divided into acute (1 week), subacute (1 week to 6 months), and chronic (> 6 months) phases. These phases correspond to the major types of biological processes that are occurring in patients’ brains after stroke. We used to think that the vast majority of recovery was only possible in the acute / subacute phases but more recent research has shown that substantial recovery is possible even in chronic phases of stroke recovery.

Patients come to acute stroke centers for acute stroke treatments: these therapies are focused on lysis and retrieval of the clot to save dying brain tissue. After about a week in the acute stroke hospital, a time that is focused primarily on diagnosis and workup for the causes of stroke, patients are then usually discharged to inpatient rehabilitation facilities. Here patients receive inpatient rehabilitation, which is focused on patients re-learning how to function with brain that has survived the stroke. The goal of rehabilitation is to maximize functional independence. After a few weeks spent in inpatient rehabilitation (average approximately 2-3 weeks in the US), stroke survivors either transition home or to longer-term care facilities.

Q: What are the important questions for a patient or their family to ask their provider during their stroke recovery journey?

A: In the acute stage: “What caused my stroke?” “What are my deficits?” “What is the projected recovery for each of my deficits?”

In the subacute stage: “What therapies can be offered beyond 1 hour per day of rehabilitation that may help me recover more fully in the long run?” “What do I need to plan for in the next phase of recovery (i.e. when I return home)?” “Who will continue to support my recovery when I go home?”

In the chronic stage: “What therapies can I do to help me to recover more fully?”

Q: What are the most exaggerated myths within each stage of stroke recovery?

A: In the acute stage: “There is no possibility of recovery” – All patients with stroke have the possibility of recovery, especially early on after stroke. And all stroke patients will undergo some degree of recovery. Furthermore, despite substantial progress in research, we, as a field, are not good at prognosis. Some patients can be quite severe in the first days to a week after acute stroke and then recover nearly full function.

In the subacute stage: “3 hours per day is the maximum amount of therapy that a patient can tolerate” – The amount of therapy that a patient can tolerate is very patient-specific. Some patients can tolerate a huge amount of therapy each day (i.e. young, highly motivated patients without significant comorbidities). Others need relatively small amounts due to age/deconditioning. Also, there are different types of rehabilitation, some are physical while others cognitive/language-based. The amount of therapy that a patient can tolerate will depend on both patient factors and therapy factors.

In the chronic stage: “Continued high dose therapy does not improve impairment” – In the chronic stroke phase, converging evidence points to the fact that continued gains are dependent on high-dose, goal-oriented practice. I make an analogy to playing a sport or a musical instrument. Coaching is important, especially in the chronic stages. Patients in the chronic stroke recovery phase can continue to make improvements with enough and the right type of practice.

Q: Does Constant Therapy fit into the stroke recovery journey?

A: Yes, a digital-based therapeutic like Constant Therapy that can significantly increase the dose of therapy outside of regular therapy hours undoubtedly has a place in the patient journey – and perhaps in all phases of the stroke recovery journey. 

Q: Where do you see gaps in the way that our health system supports stroke recovery?

A: In 2021, we hosted a multidisciplinary and interactive workshop to discuss challenges facing patients recovering from stroke. Our research was published in the Archives of Physical Medicine and Rehabilitation and found that systems for stroke rehabilitation and recovery are variable and fragmented, and stroke survivors often experience gaps in care with detrimental effects on their recovery. Qualitative analysis revealed 6 major challenges for patients including: 

• Knowledge gaps in understanding of mechanisms and treatments
• Access to resources and care team
• Standardized outcomes measures
• Lack of support for patients (social, psychological, spiritual) 
• Health insurance barriers

Q: A recurrent theme that continues to come up is the need for health navigators that help patients across phases of care – does anyone try to play this role now in stroke recovery? 

A: This person is likely a combination of a lot of people – an MD, an RN, a social worker, a physical, occupational, or speech therapist, a clinical psychologist, a personal coach, etc etc. My intuition is that the reason the healthcare system has yet to find and formalize this role is that the person required to fill the gaps would need to span lots of different roles. We have started to re-imagine what a health system to support stroke recovery might look like at Mass General with the MGH NeuroRecovery Clinic which brings multidisciplinary expertise ranging from neurology to rehabilitation therapy to patients recovering from a stroke. 

Q: Are there any solutions for the gaps in the stroke recovery journey?

A: During the 2021 workshop noted above, our research team and participants brainstormed solutions to these gaps. Eleven unique solutions were proposed that centered around new technologies, health care system changes, and the creation of new support roles. Analysis of the alignment between the challenges and solutions revealed that the one solution that solved the most identified challenges was a “comprehensive stroke clinic with follow-up programs, cutting edge treatments, patient advocation and research.” And this is what we are striving to do at the MGH NeuroRecovery Clinic, with the goal of collaborating across disciplines, ranging from physiatrists, neurosurgeons, psychiatrists, psychologists, physical / occupational / speech therapists, pharmacists, nurses, and social workers, to harness our complementary expertise to provide the best care for our patients recovering from acute neurologic illness.

Reference:
Julie A DiCarlo, Galina Gheihman, David J Lin, and 2019 Northeast Cerebrovascular Consortium Conference Stroke Recovery Workshop Participants: Archives of Physical Medicine & Rehabilitation, Reimagining Stroke Rehabilitation and Recovery Across the Care Continuum: Results From a Design-Thinking Workshop to Identify Challenges and Propose Solutions, Aug 2021.

David J. Lin, MD is a critical care neurologist and neurorehabilitation specialist at Massachusetts General Hospital. He attends in the MGH Neurosciences Intensive Care Unit and directs the MGH NeuroRecovery Clinic. Dr. Lin’s interdisciplinary research program focuses on understanding systems neuroscience mechanisms of recovery from stroke in order to inform new treatments. He received his B.S. with honors in Mathematics and Computational Science from Stanford University, graduated Magna Cum Laude from the Harvard-MIT Health Sciences and Technology Pathway at Harvard Medical School, and completed clinical training in Neurology, Neurocritical Care, and Neurorecovery at Massachusetts General Hospital.