Deans' stroke musings

Changing stroke rehab and research worldwide now.Time is Brain!Just think of all the trillions and trillions of neurons that DIE each day because there are NO effective hyperacute therapies besides tPA(only 12% effective). I have 493 posts on hyperacute therapy, enough for researchers to spend decades proving them out. These are my personal ideas and blog on stroke rehabilitation and stroke research. Do not attempt any of these without checking with your medical provider. Unless you join me in agitating, when you need these therapies they won't be there.

What this blog is for:

Shortly after getting out of the hospital and getting NO information on the process or protocols of stroke rehabilitation and recovery I started searching on the internet and found that no other survivor received useful information. This is an attempt to cover all stroke rehabilitation information that should be readily available to survivors so they can talk with informed knowledge to their medical staff. It's quite disgusting that this information is not available from every stroke association and doctors group.
My back ground story is here:

Monday, March 19, 2018

Quantification of upper limb position sense using an exoskeleton and a virtual reality display

This is really about the only proprioception intervention I have heard of.
  • Anne Deblock-Bellamy,
  • Charles Sebiyo Batcho,
  • Catherine Mercier and
  • Andreanne K. BlanchetteEmail author
Journal of NeuroEngineering and Rehabilitation201815:24
Received: 10 April 2017
Accepted: 6 March 2018
Published: 16 March 2018



Proprioceptive sense plays a significant role in the generation and correction of skilled movements and, consequently, in most activities of daily living. We developed a new proprioception assessment protocol that enables the quantification of elbow position sense without using the opposite arm, involving active movement of the evaluated limb or relying on working memory. The aims of this descriptive study were to validate this assessment protocol by quantifying the elbow position sense of healthy adults, before using it in individuals who sustained a stroke, and to investigate its test-retest reliability.


Elbow joint position sense was quantified using a robotic device and a virtual reality system. Two assessments were performed, by the same evaluator, with a one-week interval. While the participant’s arms and hands were occluded from vision, the exoskeleton passively moved the dominant arm from an initial to a target position. Then, a virtual arm representation was projected on a screen placed over the participant’s arm. This virtual representation and the real arm were not perfectly superimposed, however. Participants had to indicate verbally the relative position of their arm (more flexed or more extended; two-alternative forced choice paradigm) compared to the virtual representation. Each participant completed a total of 136 trials, distributed in three phases. The angular differences between the participant’s arm and the virtual representation ranged from 1° to 27° and changed pseudo-randomly across trials. No feedback about results was provided to the participants during the task. A discrimination threshold was statistically extracted from a sigmoid curve fit representing the relationship between the angular difference and the percentage of successful trials. Test-retest reliability was evaluated with 3 different complementary approaches, i.e. a Bland-Altman analysis, an intraclass correlation coefficient (ICC) and a standard error of measurement (SEm).


Thirty participants (24.6 years old; 17 males, 25 right-handed) completed both assessments. The mean discrimination thresholds were 7.0 ± 2.4 (mean ± standard deviation) and 5.9 ± 2.1 degrees for the first and the second assessment session, respectively. This small difference between assessments was significant (− 1.1 ± 2.2 degrees), however. The assessment protocol was characterized by a fair to good test-retest reliability (ICC = 0.47).


This study demonstrated the potential of this assessment protocol to objectively quantify elbow position sense in healthy individuals. Futures studies will validate this protocol in older adults and in individuals who sustained a stroke.


AssessmentProprioceptionRoboticStrokeSensoryVirtual realityUpper limb


Proprioception is defined as the ability to perceive body segment positions and movements in space [1]. Sensory receptors involved in proprioception are mostly located in muscle [2, 3, 4], joint [5, 6] and skin [3, 7]. Proprioceptive sense is known to play a significant role in motor control [8, 9, 10, 11] and learning [8, 12], particularly in the absence of vision. The importance of proprioceptive inputs has been demonstrated while studying individuals who presented lack of proprioception due to large-fiber sensory neuropathy [11, 12]. Despite an intact motor system, somatosensory deafferentation may lead to limitations in several activities involving motor skills, such as eating or dressing [12]. These disabilities may also be observed in individuals with proprioceptive impairments due to a stroke. Indeed, approximately half of the individuals who sustained a stroke present proprioceptive impairments in contralesional upper limb [13]. After a stroke, proprioception is known to be related to recovery of functional mobility and independence in activities of daily living (ADL; [14]). Fewer individuals with significant proprioceptive and motor losses (25%) were independent in ADL than individuals with motor deficits alone (78%). Moreover, fewer individuals with proprioceptive deficits (60%) after a stroke are discharged from the hospital directly to home compared to those without proprioceptive deficits (92%) [15].
Although the negative impact of proprioceptive impairments on motor and functional recovery is known, a large proportion of clinicians (70%) report not using standardised assessment to evaluate somatosensory deficits in patients with a stroke [16]. In clinical and research settings, proprioception is most frequently assessed with limb-matching tasks. Two types of matching tasks have commonly been used: the ipsilateral remembered matching task and the contralateral concurrent matching task [17]. In an ipsilateral remembered matching task, the evaluator or robotic device brings the patient’s limb to a target joint position, when the patient’s eyes are closed, keeps the limb in this position for several seconds, and then moves back the limb to the initial position. The patient needs to memorize the reference position and replicate it with the same (ipsilateral) limb. This task cannot, however, be used to evaluate proprioception in individuals with working memory issues, which represent around 25% of individuals who sustained a stroke [18]. In such cases, the matching error observed could reflect memory deficits, rather than proprioceptive impairments. Moreover, upper limb paresis affects 76% of individuals who sustained a stroke [19], making the task’s execution difficult or impossible. Assessing proprioception with the less affected arm as the indicator arm is therefore frequently considered in patients with hemiparesis. Indeed, in a contralateral concurrent matching task, the patient has to reproduce a mirror image of the evaluated limb position with the opposite (contralateral) limb [17]. However, considering that 20% of individuals who sustained a stroke also presents proprioceptive impairment on the ipsilateral side of the lesion [13], it would be difficult to ascertain whether the error is due to deficits in the evaluated arm, the opposite arm or both. In addition, interhemispheric communication is required in a contralateral concurrent matching task. Individuals with asymmetric stroke or with transcallosal degeneration would therefore be particularly disadvantaged while being assessed with a contralateral concurrent matching task [17].
In order to study proprioception in individuals who sustained a stroke, we developed an assessment protocol, that combines the use of an exoskeleton and a virtual reality system, enabling the quantification of position sense without using the opposite arm, involving active movement of the evaluated limb or relying on working memory. The primary objective of the present study was to validate the assessment protocol by quantifying the elbow joint position sense of healthy adults, before using this protocol with individuals who sustained a stroke. As a secondary objective, test-retest reliability of the assessment protocol was investigated.

More at link. 

Emergency Medicine Pharmacist Impact on Door-to-Needle Time in Patients With Acute Ischemic Stroke

The tyranny of low expectations raises its ugly head once again. Talking about door to needle time rather than negative time, treatment in the ambulance. Quite possible to get there with these diagnosis tools.

Hats off to Helmet of Hope - stroke diagnosis in 30 seconds


Microwave Imaging for Brain Stroke Detection and Monitoring using High Performance Computing in 94 seconds


New Device Quickly Assesses Brain Bleeding in Head Injuries - 5-10 minutes


Noninvasive Cerebral Oximetry May Help Detect LAO Stroke - 1-2 minutes

FDA approves a visor to detect strokes - Cerebrotech, 30 seconds

  If your hospital does not know of them they are completely fucking incompetent.

Decreased door-to-needle (DTN) time with tissue plasminogen activator (tPA) for acute ischemic stroke is associated with improved patient outcomes. Emergency medicine pharmacists (EMPs) can expedite the administration of tPA by assessing patients for contraindications, preparing, and administering tPA. The purpose of this study was to determine the impact of EMPs on DTN times and clinical outcomes in patients with acute ischemic stroke who receive tPA in the emergency department.

A retrospective, single-center, cohort study of patients who received tPA between August 1, 2012, and August 30, 2014, was conducted to compare DTN times with or without EMP involvement in stroke care. Secondary outcomes included changes in neurological status as measured by the National Institutes of Health Stroke Scale (NIHSS), length of hospital stay, discharge disposition, symptomatic intracranial hemorrhage, and in-hospital all-cause mortality.

A total of 100 patients were included. The EMPs were involved in the care of 49 patients. The EMP involvement was associated with a significant improvement in DTN time (median 46 [interquartile range IQR: 34.5-67] vs 58 [IQR: 45-79] minutes; P = .019) and with receiving tPA within 45 minutes of arrival (49% vs 25%, odds ratio [OR]: 2.81 [95% confidence interval [CI]: 1.21-6.52]). National Institutes of Health Stroke Scale scores were significantly improved at 24 hours post-tPA in favor of the EMP group (median NIHSS 1 [IQR: 0-4] vs 2 [IQR: 1-9.25]; P = .047).

The EMP involvement in initial stroke care was associated with a significant improvement in DTN time.

Feasibility of incorporating functionally relevant virtual rehabilitation in sub-acute stroke care: perception of patients and clinicians

I don't care that this is successful in a test against standard therapy. What we need to know and never will find out is it better than action observation or mirror therapy?
Received 01 May 2017, Accepted 03 Mar 2018, Published online: 11 Mar 2018

Purpose: To determine user satisfaction and safety of incorporating a low-cost virtual rehabilitation intervention as an adjunctive therapeutic option for cognitive-motor upper limb rehabilitation in individuals with sub-acute stroke.
Methods: A low-cost upper limb virtual rehabilitation application incorporating realistic functionally-relevant unimanual and bimanual tasks, specifically designed for cognitive-motor rehabilitation was developed for patients with sub-acute stroke. Clinicians and individuals with stroke interacted with the intervention for 15–20 or 20–45 minutes, respectively. The study had a mixed-methods convergent parallel design that included a focus group interview with clinicians working in a stroke program and semi-structured interviews and standardized assessments (Borg Perceived Exertion Scale, Short Feedback Questionnaire) for participants with sub-acute stroke undergoing rehabilitation. The occurrence of adverse events was also noted.
Results: Three main themes emerged from the clinician focus group and patient interviews: Perceived usefulness in rehabilitation, satisfaction with the virtual reality intervention and aspects to improve. All clinicians and the majority of participants with stroke were highly satisfied with the intervention and perceived its usefulness to decrease arm motor impairment during functional tasks. No participants experienced major adverse events.
Conclusions: Incorporation of this type of functional activity game-based virtual reality intervention in the sub-acute phase of rehabilitation represents a way to transfer skills learned early in the clinical setting to real world situations. This type of intervention may lead to better integration of the upper limb into everyday activities.
  • Implications for Rehabilitation
  • • Use of a cognitive-motor low-cost virtual reality intervention designed to remediate arm motor impairments in sub-acute stroke is feasible, safe and perceived as useful by therapists and patients for stroke rehabilitation.

  •    • Input from end-users (therapists and individuals with stroke) is critical for the development and implementation of a virtual reality intervention.
  • High Cardiovascular Fitness May Fend Off Dementia

    You are quite likely to get dementia.

    Your chances of getting dementia.

    1. A documented 33% dementia chance post-stroke from an Australian study?   May 2012.
    2. Then this study came out and seems to have a range from 17-66%. December 2013.
    3. A 20% chance in this research.   July 2013.

    What the fuck are your doctors' protocols such that you can exercise to such a fitness state?

    High Cardiovascular Fitness May Fend Off Dementia

    Very fit women had 90% lower dementia risk decades later

    • by Contributing Writer, MedPage Today

    Action Points

    • High cardiovascular fitness in midlife was associated with a markedly decreased risk of dementia decades later, but causality could not be determined, in a prospective study of Swedish women.
    • Note that fitness is a measure of cardiovascular function, strongly determined by genetics, age, sex, and body size, and influenced by lifestyle behaviors such as physical activity, meaning a person may be very fit because of factors other than physical activity affecting fitness.
    Highly fit women in midlife were nearly 90% less likely to have dementia decades later, a prospective study in Sweden found.
    Over 44 years of follow-up, the adjusted hazard ratio for dementia was 0.12 for women with high cardiovascular fitness and 1.41 for low-fitness women, compared with women of medium fitness, reported Helena Horder, PhD, of the University of Gothenburg and colleagues.
    And when highly fit women did develop dementia, it was 11 years later than for women who were moderately fit, the team wrote online in Neurology
    "The most exciting result is that so few in the group with highest fitness developed dementia -- namely two persons, or 5%," Horder told
    While many observational studies have linked physical activity to preserved cognitive function, few have assessed cardiovascular fitness objectively, Horder and colleagues noted. Even fewer (the Cooper Center Longitudinal Study is one) have follow-up periods that span decades.

    In this study, the researchers tracked a population-based sample of 1,462 women who were evaluated in 1968 when they were 38 to 60 years old. A subsample of 191 women participated in an exercise test and were followed until December 2012 for dementia diagnoses. Women in the exercise test did not differ from the total sample in age or cumulative dementia incidence (23.0% versus 22.1%, P=0.780).
    These women had their cardiovascular fitness assessed through a stepwise-increased ergometer cycling test that was supervised by a physician. They exercised to exhaustion and had their heart rate, electrocardiogram data, blood pressure, respiratory frequency, and perceived exertion recorded.
    Participants were 50 years old on average, and their mean peak workload was 103 watts. Of 191 women, 40 had high fitness (120 watts or higher), 92 had medium fitness, and 59 had low fitness (80 watts or less, or had the test stopped due to high blood pressure, chest pain, or other cardiovascular problems).
    During 44 years of follow-up, 44 women developed dementia. The cumulative incidence of all-cause dementia was 32% for low, 25% for medium, and 5% for high cardiovascular fitness.
    After adjusting for age, body height, triglycerides, smoking, hypertension, wine consumption, physical inactivity, and income, the researchers found that the hazard ratio for all-cause dementia was 0.12 (95% CI 0.03–0.54) among high-fitness women and 1.41 (95% CI 0.72–2.79) among low-fitness women, compared with women of medium fitness.
    Dementia incidence was highest, at 45%, in women who needed to have the exercise test interrupted at sub-maximal workload. This could mean that adverse cardiovascular processes in midlife may increase dementia risk, the researchers suggested.
    "An interesting mechanism that needs to be further investigated is the direct effects of physical activity and high fitness on brain structures, such as the hippocampus," said Hoarder. "Age-related changes in brain structures might be delayed through positive effects on small vessel circulation, inflammatory mechanisms, and growth factors."
    To translate these findings from a clinical perspective, it's important to understand the term fitness, noted Nicole Spartano, PhD, of Boston University School of Medicine, and Tiia Ngandu, MD, PhD, of the National Institute for Health and Welfare in Helsinki, Finland, writing in an accompanying editorial.
    "Fitness is a measure of cardiovascular function, which is strongly determined by genetics, age, sex, and body size, but also is influenced by lifestyle behaviors such as physical activity. In other words, a very fit person may not necessarily be a very active person, and vice versa, because of factors other than physical activity affecting fitness."
    Cardiac output -- which can be increased in training, but has substantial heritability and varies greatly among sedentary individuals -- determines about 70% to 85% of fitness, Spartano and Ngandu noted. While it is likely the combination of cardiovascular function and physical activity drove the associations seen in this study, it is also possible that they are the result of genetic and other influences.
    Study limitations, the researchers noted, included the small sample size, reducing the possibilities for subanalyses, and since the cohort was relatively homogeneous, the results may not apply to other populations. In addition, the 1968 exercise test measured work capacity, not maximal oxygen consumption with expired gas analysis, which is the gold standard for cardio-respiratory fitness, and the women's fitness level was measured only once, so changes in fitness over time were not captured.
    The team added that because the study findings are not causal, future research should focus on whether improved fitness has positive effects on dementia risk and when high cardiovascular fitness is most important during the course of a life.
    The study was supported by the Forte-Centre Aging and Health: Centre for Capability in Ageing (AGECAP).
    Neither the authors nor the editorialists reported having any conflicts.
    • Primary Source
    Source Reference: Horder H, et al "Midlife cardiovascular fitness and dementia" Neurology 2018; DOI: 10.1212/WNL.0000000000005290.

  • Secondary Source

    Source Reference: Spartano N, Ngandu T "Fitness and dementia risk" Neurology 2018; DOI: 10.1212/WNL.0000000000005282.