Update on the TWIST

One of the most common symptoms of stroke is weakness on one side of the body (hemiplegia). Many people with leg weakness are unable to walk early after stroke and require a period of rehabilitation to get back on their feet again. This is a stressful and worrying time for patients and their whānau, as they come to terms with what the future might hold.

Patients frequently ask their doctors “Will I be able to walk again?” or “How long will it take for me to be walking by myself?” Being able to predict whether and when someone will walk again is difficult to do accurately yet having this information early after stroke is hugely important for patients as they make plans for getting out of hospital. Some patients need to consider how long they might be off work or whether their partner will need to look after them. Other patients who live alone need to think about whether they need a family member to live with them or whether it’s necessary for them to move to a residential care facility. Knowing how long it will be until a patient is likely to achieve independent walking may also help the clinical team (physiotherapists, occupational therapists, doctors, nurses) plan a patient’s rehabilitation programme and start making plans for discharge from hospital.

The TWIST study aims to identify, within the first week of stroke, what assessments are required to predict whether and when a patient will regain the ability to walk by themselves within the first six months after stroke.

The TWIST algorithm was originally developed using a group of 41 patients from Auckland City Hospital as part of my PhD studies.

The latest phase of the study includes more potential predictors and looks at improving the precision of the prediction timeframes. Patients are asked to complete some simple clinical tests of strength, balance, sensation, memory and thinking. We also do a test of the motor pathways from their brain to their legs (transcranial magnetic stimulation) and complete an MRI scan to establish how much damage the stroke has done to their movement pathways and whether these might be important predictors for how long it takes someone to walk independently after stroke. All participants are followed up for six months after their stroke to see if and when they achieve independent walking.

If the TWIST algorithm is validated in this study, we will also be investigating ways to make this a useful tool for clinicians in their everyday practice. The end-goal is that all patients with stroke have access to important information about their likely recovery as early as possible.

As part of the study, we are asking physiotherapists to tell us, at one week after stroke, whether they think their patient is likely to walk by themselves again and when they will achieve this. We also ask them how confident they are in their predictions. Understanding how accurate physiotherapists’ predictions are will help us to establish the benefit of using something like the TWIST algorithm in clinical practice.

To date, we have found that physiotherapists find it difficult at one week after stroke to make accurate predictions about the time frame for recovering independent walking. This suggests that clinical experience and intuition alone are not enough to make accurate predictions for patients.

The TWIST study is led by Professor Cathy Stinear and Professor Barber provides clinical oversight for the study. He ensures that patients are safe to participate in the testing of the motor pathways from their brain to their legs (transcranial magnetic stimulation). We could not engage in this research without the fantastic collaborative support we receive from the clinicians on the stroke unit.