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:

Tuesday, June 27, 2017

Stroke care improving: study - Ontario

Meaningless puffery. It says only one thing about results - 30-day deaths. Fucking lazy bastards. They should be keel hauled for doing almost nothing.
The Quinte region and southeastern Ontario are showing significant improvement in the treatment of stroke patients, a new report shows.

The report was released this month by the Institute for Clinical Evaluative Sciences (ICES) and the Ontario Stroke Network. It showed improvements to provincial stroke care in general while also emphasizing a need for more work.
The report found the Belleville area – with regional stroke care based at Belleville General Hospital – made the greatest improvement of any Ontario community.
The South East Local Health Integration Network (LHIN) had Ontario’s biggest improvement in 30-day mortality rate following an acute stroke. That rate dropped to 11.6 per cent in 2015-2016 from 14.2 per cent in the previous three years, the report noted, calling the decrease “unprecedented.”
That decrease can be measured in lives, said Dr. Andrew Samis.
“It’s between 25 and 30 less people dying in our region,” said Samis, an intensive care doctor with Quinte Health Care and the corporation’s “physician stroke champion.” He was instrumental in QHC’s 2014 implementation of its new stroke protocol.
Samis said there has been an “amazing” improvement in local care in recent years.
But he also said those improvements are “all for naught if someone chooses not to call 911.”
Samis said it’s essential anyone noticing the signs of a stroke call 911 immediately before doing anything else. That call, he explained, allows the stroke team crucial minutes to prepare. And in stroke care, minutes count.
That preparation means “your chance of dying goes down.”
The Heart and Stroke Foundation uses the acronym FAST to teach the signs of stroke:
• Face: Is it drooping?
• Arms: Can you raise both?
• Speech: Is it slurred or jumbled?
• Time to call 911 right away.
Access to care in an acute stroke unit in the South East LHIN was found to be 72.6 per cent and climbing. It was second only to the 80.6 per cent in the Waterloo Wellington LHIN.
“The results of this report highlight the great work being done throughout our region,” South East LHIN chief executive officer Paul Huras said in a press release.
“The rural nature of the South East region has often played a role in how patients access specialized stroke care,” Dr. Albert Jin, a Kingston stroke neurologist and medical director for the Regional Stroke Network of Southeastern Ontario, said in the release.
“By creating specialized stroke units in Belleville, Brockville and Kingston we have been able to ensure that patients across the region can quickly access teams of stroke experts,” he said. “This has played a significant role in improving the mortality rate across our LHIN.”
The region was also one of two top performers in providing home-based community rehabilitation, and hospital readmission rates for stroke survivors have been declining steadily. The region was third with a readmission rate of 6.7 per cent. The Ontario average was 7.1 per cent.
There were also improvements in other categories, including emergency department referrals to stroke prevention clinics.
Provincially, the report found the proportion of stroke patients treated in stroke units increased by nearly 11 per cent in 2015-2016.
The time from acute stroke to admission into inpatient rehabilitation dropped by one day from a median of nine days one year ago, the report found.
Yet 57 per cent of Ontario patients did not have access to stroke unit care and the average of inpatient rehabilitation therapy was 63 minutes per day compared to the target of 180 minutes.
“It is exciting and encouraging to see ongoing improvements in stroke care across Ontario,” said Linda Kelloway, the Ontario Stroke Network’s director of best practices, in a joint release with ICES. “More patients are getting to stroke units and wait time for admission to inpatient rehabilitation has decreased.
“However, we need to continue to move the bar up so that improvements continue and Ontarians will benefit.”

Extra virgin olive oil protects memory and helps prevent Alzheimer’s in mice

Useless for us, no translation of amounts needed for mice to human body size.  Unlikely to be followed up by human clinical trials to help anyone alive today.
Extra virgin oil is part of the much purported Mediterranean diet that is known to be good for the brain as well as the heart. The Mediterranean diet is also known to reduce the risk of dementia development.
Extra Virgin Olive - Image Credit: Lempoyang Photo Art / Shutterstock
A new study by a research team at the Lewis Katz School of Medicine at Temple University (LKSOM) has linked extra-virgin olive oil to a reduction of risk for Alzheimer’s disease. This oil has been shown to prevent cognitive decline. Their study was published in Annals of Clinical and Translational Neurology, where the researchers have shown that consuming extra-virgin olive oil protects memory and preserves the ability to learn. It also stops the formation of the amyloid-beta plaques and neurofibrillary tangles within the brain. These two are the classic hallmarks or Alzheimer's disease.
Domenico Praticò, MD, Professor in the Departments of Pharmacology and Microbiology and the Center for Translational Medicine at LKSOM, a senior investigator of this team of researchers explained that underlying mechanisms by which this oil could help was also identified.
For the study the researchers took a mouse model of Alzheimer's disease known as the a triple transgenic model. These mice develop three key characteristics of the disease;
  • memory impairment
  • amyloid plagues
  • neurofibrillary tangles
The mice were divided into two groups, where one group received a chow diet rich in extra-virgin olive oil and the other group received chow diet without the oil. The oil was started when the animals were six months old before the actual symptoms of Alzheimer's disease begin to emerge in a usual mouse model.
It was noted that at the age of 9 and 12 months, mice on the extra virgin olive oil rich diets did better at the tests that looked at their working memory, spatial memory, and tested their learning abilities.
At end of the study the mice were sacrificed. The brains were significantly different say researchers. The brains of the mice on the oil showed “synaptic integrity” said Praticò. Synapses he explained, are connections between the nerve cells of the brain. This integrity was lacking in those without the olive oil diet. A process called autophagy too was higher among the mice on the olive oil diet.
Praticò explained that there is a process called autophagy by which the cells break down and clean the toxins and the resultant debris including the amyloid plaques and the tau tangles that are characteristic of Alzheimer’s disease. In their experiment when the mice were fed extra virgin olive oil rich diets, the levels of autophagy rose he explained. This reduces the levels of amyloid plaques and phosphorylated tau significantly. Phosphorylated tau leads to formation of neurofibrillary tangles and this leads to nerve cell dysfunction and memory symptoms related to Alzheimer’s disease. Reducing phosphorylated tau could thus be protective.
Dr. Praticò said that the benefits of Mediterranean diet has been studied previously in details but this is the first time that it was found that rather than the fruits and vegetables component of that diet, it the olive oil that is benefitting the brain health more. It is a monounsaturated vegetable fat and is better than saturated animal fats.
As a next step to their study, the team plans to introduce the extra virgin olive oil at the age of 12 months in the mice. This is the age when the mice have already developed that characteristic brain markers of Alzheimer’s disease including plaques and tangles. This is parallel to a person who has begun to show the features of dementia at the onset of the disease. Dr. Praticò explained that they would like to investigate if diet change after the onset of the disease could stop, reverse or slow its progress.

Brain Evolved to Need Exercise

How is your doctor and therapists making sure you get enough exercise to have your brain have similar connections as runners do? Do they even know how much exercise that is? What heart rate and length of time?

Summary: While much research has shown that exercise can be good for our brains, the link between how physical activity benefits the brain is not clearly understood. In a new study, researchers suggest the link between brain health and exercise could be a product of our evolutionary history and our hunter-gatherer past.
Source: University of Arizona.
Mounting scientific evidence shows that exercise is good not only for our bodies, but for our brains. Yet, exactly why physical activity benefits the brain is not well understood.
In a new article published in the journal Trends in Neurosciences, University of Arizona researchers suggest that the link between exercise and the brain is a product of our evolutionary history and our past as hunter-gatherers.
UA anthropologist David Raichlen and UA psychologist Gene Alexander, who together run a research program on exercise and the brain, propose an “adaptive capacity model” for understanding, from an evolutionary neuroscience perspective, how physical activity impacts brain structure and function.
Their argument: As humans transitioned from a relatively sedentary apelike existence to a more physically demanding hunter-gatherer lifestyle, starting around 2 million years ago, we began to engage in complex foraging tasks that were simultaneously physically and mentally demanding, and that may explain how physical activity and the brain came to be so connected.
“We think our physiology evolved to respond to those increases in physical activity levels, and those physiological adaptations go from your bones and your muscles, apparently all the way to your brain,” said Raichlen, an associate professor in the UA School of Anthropology in the College of Social and Behavioral Sciences.
“It’s very odd to think that moving your body should affect your brain in this way — that exercise should have some beneficial impact on brain structure and function — but if you start thinking about it from an evolutionary perspective, you can start to piece together why that system would adaptively respond to exercise challenges and stresses,” he said.
Having this underlying understanding of the exercise-brain connection could help researchers come up with ways to enhance the benefits of exercise even further, and to develop effective interventions for age-related cognitive decline or even neurodegenerative diseases such as Alzheimer’s.
Notably, the parts of the brain most taxed during a complex activity such as foraging — areas that play a key role in memory and executive functions such as problem solving and planning — are the same areas that seem to benefit from exercise in studies.
“Foraging is an incredibly complex cognitive behavior,” Raichlen said. “You’re moving on a landscape, you’re using memory not only to know where to go but also to navigate your way back, you’re paying attention to your surroundings. You’re multitasking the entire time because you’re making decisions while you’re paying attention to the environment, while you are also monitoring your motor systems over complex terrain. Putting all that together creates a very complex multitasking effort.”
The adaptive capacity model could help explain research findings such as those published by Raichlen and Alexander last year showing that runners’ brains appear to be more connected than brains of non-runners.
The model also could help inform interventions for the cognitive decline that often accompanies aging — in a period in life when physical activity levels tend to decline as well.
“What we’re proposing is, if you’re not sufficiently engaged in this kind of cognitively challenging aerobic activity, then this may be responsible for what we often see as healthy brain aging, where people start to show some diminished cognitive abilities,” said Alexander, a UA professor of psychology, psychiatry, neuroscience and physiological sciences. “So the natural aging process might really be part of a reduced capacity in response to not being engaged enough.”
Reduced capacity refers to what can happen in organ systems throughout the body when they are deprived of exercise.
“Our organ systems adapt to the stresses they undergo,” said Raichlen, an avid runner and expert on running. “For example, if you engage in exercise, your cardiovascular system has to adapt to expand capacity, be it through enlarging your heart or increasing your vasculature, and that takes energy. So if you’re not challenging it in that way — if you’re not engaging in aerobic exercise — to save energy, your body simply reduces that capacity.”
In the case of the brain, if it is not being stressed enough it may begin to atrophy. This may be especially concerning, considering how much more sedentary humans’ lifestyles have become.
“Our evolutionary history suggests that we are, fundamentally, cognitively engaged endurance athletes, and that if we don’t remain active we’re going to have this loss of capacity in response to that,” said Alexander, who studies brain aging and Alzheimer’s disease as a member of the UA’s Evelyn F. McKnight Brain Institute. “So there really may be a mismatch between our relatively sedentary lifestyles of today and how we evolved.”
Alexander and Raichlen say future research should look at how different levels of exercise intensity, as well as different types of exercise, or exercise paired specifically with cognitive tasks, affect the brain.
For example, exercising in a novel environment that poses a new mental challenge, may prove to be especially beneficial, Raichlen said.

Mechanism shown to reverse disease in arteries

This would seem to make much more sense than treating for cholesterol.
A certain immune reaction is the key, not to slowing atherosclerosis like cholesterol-lowering drugs do, but instead to reversing a disease that gradually blocks arteries to cause heart attacks and strokes.
This is the finding of a study in mice led by researchers at NYU Langone Medical Center and published online June 26 in the Journal of Clinical Investigation.
The study focuses on reversing the effects of "bad ," which is deposited into the walls lining blood vessels in levels influenced by both genetics and a person's diet. By the fourth decade of life, and thanks to the chronic reaction to cholesterol, most people have inflamed "wounds" in their called plaques, which when severe enough can rupture to cause blood clots that block arteries.
"Even the latest, most potent cholesterol-lowering drugs, PCSK9 inhibitors, let alone widely used statins, cannot fully reverse damage done to arteries over time, and so they can't prevent roughly 500,000 heart attacks per year in the United States," says lead study author Edward Fisher, MD, PhD, director of the Marc and Ruti Bell Vascular Biology and Disease Program at NYU Langone.
"We need the next generation of drugs to go beyond cholesterol lowering to address the immune reaction to accumulated cholesterol, and to dismantle plaques as part of reversing or regressing mature disease," says Fisher, the Leon H. Charney Professor of Cardiovascular Medicine at NYU Langone.
In years of painstaking research, the NYU Langone-led research team has zeroed in on the molecular events that occur in arteries when regression of atherosclerotic plaques is underway.
Once deposited into arteries, - known to physicians as low density lipoprotein - triggers the body's immune system, which is meant to destroy invading microbes but can drive inflammatory disease in the wrong context. Immune cells in the bloodstream called swarm to cholesterol deposits, and become either inflammatory or healing cell types based on signals there.
In situations where disease is worsening in a , past studies have shown that monocytes become M1 macrophages that amplify immune responses, increase inflammation, and secrete enzymes that gnaw at plaques until they rupture. The current study confirmed that monocytes arriving in plaques where disease is regressing instead become M2 "healing" macrophages, which dampen inflammation and prevent the ruptures that precede clotting.
When mice were engineered to lose the ability of monocytes to become M2 macrophages, they could no longer achieve normal disease regression, say the authors.
By surgically transplanting plaques from diseased mice into the arteries of healthy mice, the research team brought about dramatic drops in cholesterol levels. This drop has been shown to trigger a second benefit in mice, where monocytes automatically become M2 instead of M1 macrophages as plaques rapidly regress.
It is not known whether cholesterol lowering alone triggers this M2 switch in humans. But new imaging techniques may soon be able to detect changes in the type and number of macrophages in plaques. In the meantime, if researchers learn how to boost the M2 switch, a number of clinical applications may become possible just as methods arrive that can measure their success.
"A race is underway to develop treatments that enhance the decision of human monocytes to become M2 macrophages in cases where the disease has not yet caused clot formation, at which point it becomes irreversible," says Fisher.
Specifically, the current study found that the same blood-borne Ly6Chigh monocytes, once thought of only as precursors to "inflammation-prone" M1 macrophages, instead become anti-inflammatory M2 cells when they arrive in a regressing plaque. Having found the class of cells from which M2 macrophages arise, the team is now seeking to identify the local signals that tell monocytes to become M2.
Among the candidates are the immune signaling proteins interleukin-4 and interleukin-13, which have been linked by past studies to the M2 decision. These interleukins are known to turn on the STAT6 pathway, which sends this protein to the nucleus where it turns on genes that direct a monocyte to become a M2 macrophage. Researchers confirmed that blocking the action of STAT6 reduced the number of M2 macrophages in regressing plaques.
Fisher's team is already experimenting with nanoparticles based on the structure of "good cholesterol," which is known to take cholesterol of out of plaques and deliver it to the liver for destruction. One version of their nanoparticle delivers interleukin 4 to plaques as well. A next step for the work would be a study of nanoparticles in pigs, a model where success can set the stage for human trials.

New method could take a snapshot of the whole brain in action

Cool, could be used to find neuroplasticity and neurogenesis in action. But we don't have anyone smart in the stroke medical world to follow this up with stroke recovery experiments.

New method could take a snapshot of the whole brain in action 

Monday, June 26, 2017

Neurology congress in Amsterdam: Outcomes measurements are becoming ever more important

I've been screaming about results for years.
25 June 2017 B&K Kommunikation
How effective is a treatment, does it lead to the expected improvement and how can all this be measured in an objective manner? Outcomes measurements are increasingly important in neurology. Participants at the Congress of the European Academy of Neurology in Amsterdam are discussing latest development in the field of outcomes research and how patients benefit from these activities.
Outcomes measurements are increasingly important in neurology from the perspective of practitioners as well as patients or the payers of health services. How can one objectively determine and plausibly prove whether a given therapy brings about the desired improvement, makes a useful clinical difference or delays the progression of a disease? Is the treatment in reasonable proportion to the patient benefits involved and to the financial cost? The 3rd Congress of the European Academy of Neurology (EAN) in Amsterdam is focused on this overarching focal theme, discussing it in several scientific sessions.

For EAN Programme Committee Chairman Prof Paul Boon (Ghent University, Belgium and Kempenhaeghe, The Netherlands), the possible advantages for patients have priority when it comes to outcomes in neurology: “Of course, the clinical explanation of the disease mechanism revealed through such indicators is very important but patients obviously focus on other aspects.” After being diagnosed with epilepsy or migraine, they are usually keen to know the following: Will the therapy work? Will my seizures or headache attacks stop? Do the medications have undesirable side effects? How many pills do I need to take and when in order to achieve an optimum effect? “Outcomes measurements enable us to answer questions like these. In the process, we can find out how the disease will affect the patient in the future and see how our treatment is working,” explained Prof Dr Bernard Uitdehaag (VUmc MS Center Amsterdam), chair of the local organizing committee of the congress and chair of one of the EAN sessions on this topic.

Progress in measurement methods

Progress is being made in neurology in the development of assessment methods that are easy to handle, and can contribute to objective and precise outcomes measures. This is, however, not yet the case for all diseases. For slowly progressing neuromuscular diseases, for instance, existing outcomes measurements are still cumbersome and burdensome with regard to the patients’ restriction of motion and quality of life. By contrast, there have long been outcomes measurements for common diseases such as epilepsy and migraine. For example, the number of seizures or headache attacks is recorded. Prof Boon: “Recently, the measurements have become more differentiated. For example, we record days free of complaints. For patients, this metric is more meaningful than the total number of seizures.” With epilepsy, outcomes measurements are also assessed with EEG, which is then analysed using special software. Prof Boon: “This approach lets us detect certain indicators much more effectively than with customary methods.”

For instance, in order to measure a possible decline of the condition of multiple sclerosis patients, a simple test has been established as a standard procedure: patients are asked to insert pegs in a board with nine holes and subsequently take them out one by one. If they need 20 per cent longer than last time, this difference proves that the disease has deteriorated clinically.

Measuring outcomes for dementia

Researchers from Amsterdam have developed a questionnaire for Alzheimer’s patients which helps to detect dementia at an early stage. Further outcomes measurements for Alzheimer’s can be done with an amyloid PET scan. In this procedure, a low-radiation substance is injected, enabling amyloid plaques in the brain to be seen.  This protein is a typical biomarker for Alzheimer’s. Examinations of cerebrospinal fluid can also allow conclusions to be drawn about the progression of neurodegeneration in dementia.

Combined methods yield more information

A combination of examination methods is increasingly relied upon in outcomes measurements. Prof Uitdehaag advised to use multidimensional outcomes measurements for heterogeneous diseases such as multiple sclerosis. “It is very revealing to harness the patient’s perspective together with e.g. imaging methods. An MRI scan can indicate a stable condition even though the patient is complaining about a change for the worse. Conversely, the patient can feel great while the MRI result indicates that problems are likely to occur in the near future.” 

Side effects count as part of the overall outcomes

In the treatment of neurological diseases, certain medications can provoke side effects such as difficulties in concentration or memory loss. Until a few years ago, these side effects were simply put up with, especially by older patients. Prof Boon emphasized that these attitudes are changing more and more, adding: “Side effects are recorded and taken seriously as part of outcomes measurements.” To an increasing extent, therapies are individually tailored to patients so outcomes, too, must be subject to a differentiated analysis. Prof Uitdehaag: “It no longer suffices to compare patient groups with each other in sweeping ways. Even if many people do respond to a certain treatment, it may not be effective for a given individual.” As therapies become more individualized, the challenge grows to record exactly what is being done, what benefits this action has and whether the treatment is beneficial for this specific patient. 

Cost-benefit analysis

As cost pressure on public health care budgets mounts, the field of neurology is also increasingly confronted with demands to give evidence of therapy outcomes so the costs of a given treatment can be weighed against its benefits. Prof Boon: “Payers in the European healthcare systems are showing an increasing interest in outcomes-related reimbursement concepts. In other words, they are willing to assume costs if the effectiveness of a treatment can be verified. In the process, new therapies are compared against conventional ones to find out which ones are worth the price being charged. The more varied the possible treatment options for a disease, the more relevant outcomes measurement becomes,” the expert concluded.

Sources: van Munster CE, Uitdehaag BM. Outcome Measures in Clinical Trials for Multiple Sclerosis. CNS Drugs. 2017 Mar;31(3):217-236; Feys P, Lamers I, Francis G: The Nine-Hole Peg Test as a manual dexterity performance measure for multiple sclerosis,; Sikkes SA,de Lange-de Klerk ES, Pijnenburg YA, Gillissen F, Romkes R, Knol DL, Uitdehaag BM, Scheltens P. A new informant-based questionnaire for instrumental activities of daily living in dementia. Alzheimers Dement. 2012 Nov;8(6):536-43; Sikkes SA , Knol DL, Pijnenburg YA, de Lange-de Klerk ES, Uitdehaag BM, Scheltens P:Validation of the Amsterdam IADL Questionnaire©, a new tool to measure instrumental activities of daily living in dementia. Neuroepidemiology.2013;41(1):35-41.

The effect of water-based exercises on balance in persons post-stroke: a randomized controlled trial

The therapy pool at my hospital had closed years before I needed it.

Pages 228-235 | Published online: 03 Nov 2016

Objective: Water-based exercises have been used in the rehabilitation of people with stroke, but little is known about the impact of this treatment on balance. This study examined the effect of water-based exercises compared to land-based exercises on the balance of people with sub-acute stroke.
Methods: In this single-blind randomized controlled study, 32 patients with first-time stroke discharged from inpatient rehabilitation at West Park Healthcare Centre were recruited. Participants were randomized into W (water-based + land; n = 17) or L (land only; n = 15) exercise groups. Both groups attended therapy two times per week for six weeks. Initial and progression protocols for the water-based exercises (a combination of balance, stretching, and strengthening and endurance training) and land therapy (balance, strength, transfer, gait, and stair training) were devised. Outcomes included the Berg Balance Score, Community Balance and Mobility Score, Timed Up and Go Test, and 2 Minute Walk Test.
Results: Baseline characteristics of groups W and L were similar in age, side of stroke, time since stroke, and wait time between inpatient discharge and outpatient therapy on all four outcomes. Pooled change scores from all outcomes showed that significantly greater number of patients in the W-group showed improvement post-training compared to the L-group (p < 0.05). More patients in W-group showed change scores exceeding the published minimal detectable change scores.
Discussion: A combination of water- and land-based exercises has potential for improving balance. The results of this study extend the work showing benefit of water-based exercise in chronic and less-impaired stroke groups to patients with sub-acute stroke.

Determining the potential benefits of yoga in chronic stroke care: a systematic review and meta-analysis

Is yoga or Tai Chi better for recovery?

Pages 279-287 | Received 03 Oct 2016, Accepted 24 Dec 2016, Published online: 19 Jan 2017

Background: Survivors of stroke have long-term physical and psychological consequences that impact their quality of life. Few interventions are available in the community to address these problems. Yoga, a type of mindfulness-based intervention, is shown to be effective in people with other chronic illnesses and may have the potential to address many of the problems reported by survivors of stroke.
Objectives: To date only narrative reviews have been published. We sought to perform, the first systematic review with meta-analyses of randomized controlled trials (RCTs) that investigated yoga for its potential benefit for chronic survivors of stroke.
Methods: Ovid Medline, CINHAL plus, AMED, PubMed, PsychINFO, PeDro, Cochrane database, Sport Discuss, and Google Scholar were searched for papers published between January 1950 and August 2016. Reference lists of included papers, review articles and OpenGrey for Grey literature were also searched. We used a modified Cochrane tool to evaluate risk of bias. The methodological quality of RCTs was assessed using the GRADE approach, results were collated, and random effects meta-analyses performed where appropriate.
Results: The search yielded five eligible papers from four RCTs with small sample sizes (n = 17–47). Quality of RCTs was rated as low to moderate. Yoga is beneficial in reducing state anxiety symptoms and depression in the intervention group compared to the control group (mean differences for state anxiety 6.05, 95% CI:−0.02 to 12.12; p = 0.05 and standardized mean differences for depression: 0.50, 95% CI:−0.01 to 1.02; p = 0.05). Consistent but nonsignificant improvements were demonstrated for balance, trait anxiety, and overall quality of life.
Conclusions: Yoga may be effective for ameliorating some of the long-term consequences of stroke. Large well-designed RCTs are needed to confirm these findings.

Vagus nerve stimulation shows stroke recovery promise

Just when the fuck will this become a standard protocol? I've written 21 posts on this back to July 2012. 
With ANY competency anywhere in the stroke medical world this would have been a protocol years ago. But we have NO stroke leadership and NO stroke strategy causing survivors to still be disabled. Your stroke medical 'professional' has not been inconvenienced one bit by doing nothing to help stroke survivors.

  • Mitchel L. Zoler
  • Clinical Neurology News 

    – Stroke patients with arm weakness had a clinically significant boost in arm function after about 19 weeks on a rehabilitation program that combined vagus nerve stimulation with rehabilitation training sessions in a multicenter, randomized, and sham-controlled proof-of-concept study with 17 patients.
    This promising result follows a prior 21-patient study with a similar design and results (Stroke. 2016 Jan;47[1]:143-50), making the next step a pivotal trial with about 120 randomized patients that should start in 2017, Jesse Dawson, MD, said at the International Stroke Conference sponsored by the American Heart Association.
    Dr. Jesse Dawson Mitchel L. Zoler/Frontline Medical News
    Dr. Jesse Dawson
    “We feel this is promising, but more work needs to be done,” said Dr. Dawson, a stroke researcher at the University of Glasgow (Scotland).

    Results in the new study showed that eight poststroke patients with arm weakness who received a prolonged course of vagus nerve stimulation (VNS) and rehabilitation training had an average boost from baseline in their upper-extremity Fugl-Meyer score of 9.5 points measured 132 days after the start of the regimen, compared with an average 3.8-point rise among nine similar patients who underwent the same rehabilitation training but without VNS. A rise of 4-7 points on the upper-extremity Fugl-Meyer score is considered clinically significant for chronic stroke patients (J Physiotherapy. 2017 Jan;63[1]:53). The difference in mean scores between the VNS and control groups after 132 days was statistically significant for a secondary endpoint of the study.

    The study’s primary endpoint, the difference between the control and VNS patients in mean upper-extremity Fugl-Meyer scores at the end of the initial phase of the study – a 6-week supervised training period – was 7.6 points in the VNS recipients and 5.3 points for the control patients, a difference that was not statistically significant.

    The 9.5-point boost in average scores with more prolonged treatment and follow-up in the VNS patients is “highly likely to be clinically significant,” Dr. Dawson said. “We would like to see an effect earlier, with clinically important effects after 6 weeks of treatment. That would make the intervention easier to translate into clinical practice.”

    The study ran at three U.S. centers and in Glasgow and enrolled patients who were 4 months to 5 years out from their index stroke and had moderate to severe arm weakness based on an upper-extremity Fugl-Meyer score of 20-50. The average age of the 17 patients in the study was 60 years. They were an average of 1.5 years removed from their index stroke.

    All of the patients received an implanted device to produce VNS. The eight patients in the active arm received VNS during their 2-hour, thrice-weekly rehabilitation training sessions for the first 6 weeks of the study, with about 400 individual stimulations delivered during each training session. The nine controls received brief VNS to aid blinding, but had no meaningful VNS while they replicated the rehabilitation training regimen of the intervention group. At the end of 6 weeks, no training or VNS was done for 30 days. Then for the next 60 days, all patients did a daily program of unsupervised home rehabilitation exercises and patients in the intervention arm also self-administered 30 minutes of VNS daily.

    The 17 patients who received a VNS device implant had three serious adverse events, Dr. Dawson reported: one infection, one episode of dyspnea, and one episode of vocal cord paralysis. None of the adverse events were judged definitely or likely linked to the stimulator, and all three effects were in control patients. In several patients in both arms, nonserious adverse effects occurred that are expected for the surgery used, including bruising, pain, swelling, and scarring. When the study ended, patients originally randomized to the sham group underwent active intervention with VNS and subsequently had an average 13-point increase on their upper extremity Fugl-Meyer score.

    MicroTransponder, the company developing the vagus nerve stimulation device, funded the study. Dr. Dawson has received travel and meeting cost reimbursements from MicroTransponder, and several coauthors are employees of the company.
  • Slower Runners Live Longer—Here’s Why

    My running is non-existent so I should be good in this.

    Here’s some food for thought: the slower you run, the longer you live.
    That’s a finding from a new study published in the Journal of the American College of Cardiology, which concluded that people who run on a regular basis—consistently, but slowly—have a longer lifespan than those who are out pushing it to the line every time. The people who executed the research used around 1,100 joggers and 4,000 non-joggers. Everyone, men and women, were various ages, and all were relatively healthy. For the study, those who identified as “non-joggers” by definition did not participate in any strenuous activity regularly.
    Fast forward more than 10 years later, and the researchers checked in on the death rates of the people involved. People who identified as joggers were split into three main groups: light joggers, moderate joggers and “strenuous joggers” based on the information regarding frequency, how many miles and pace they provided at the beginning of the study. The results? Duh—joggers had a longer lifespan or life expectancy than non-joggers.
    Related: Why Running Slow Doesn’t Matter
    But wait, what about the sub-groups? The light joggers had the lowest rate of death, followed by the moderate joggers. And newsflash (sorry speedsters)–the strenuous ones tied with the non-joggers with highest mortality. What’s even more shocking? Their life expectancy, statistically speaking, matched that of a sedentary person. What?!
    In short, the ideal sweet spot for jogging and gaining full benefit was 2 to 3 times per week. The optimal speed was slow, and the optimal weekly distance? 1 to 2.4 miles!
    Take what you want from this study, but we found it interesting and somewhat surprising! Although we are all pretty confident we will continue to train for marathons, but perhaps a more leisurely pace. Because, if you run slow, who cares?

    Sunday, June 25, 2017

    What the Latest Research Says About Alcohol and Your Brain

    More negative results on alcohol, while I look at all these positives. But listen to your negative Nellie doctor instead of me. Your choice.

    Alcohol for these 12 reasons.

    A little daily alcohol may cut stroke risk

    An occasional drink doesn't hurt coronary arteries

    Six healthy reasons to drink more beer   Red wine benefits are in this one also.

    10 Health Benefits of Whiskey

    More negative stuff here:

    What the Latest Research Says About Alcohol and Your Brain  

    Chapter 5; Pain in the Stroke Rehabilitation Patient

    Have at it.

    Pain in the Stroke Rehabilitation Patient

    Hospital based program launched to improve outcomes for stroke patients in China to impact world's largest population

    You want results not lazy guidelines and best practices and care.
    Big fucking whoopee.
    PR Newswire
    BEIJING, June 24, 2017
    BEIJING, June 24, 2017 /PRNewswire/ -- Delivering big, positive stroke outcomes for the world's largest population is the aim of the American Stroke Association (ASA) and Chinese Stroke Association (CSA) with the launch of a quality improvement program adapted from the American Heart Association's guidelines-based program called Get With The Guidelines®.

    The program works to improve treatment for, and prevention of, cardiovascular and stroke events by helping hospitals and providers consistently adhere to the latest scientific treatment guidelines. In the last 15 years, Get With The Guidelines has transformed patient care for heart and stroke patients in the U.S., helping hospitals and providers learn the correct treatment and translate guidelines into practice. This program has saved lives and resulted in more than 400 scientific publications that advance heart and brain health around the world.
    The adapted Get With The Guidelines program, designed through a collaboration of the ASA and the CSA, endorsed by the China National Health and Family Planning Commission, and supported by Medtronic, is a set of "best practices" that aim to continuously improve treatment, enhance the quality of care, and prevent future stroke events in China.
    While several evidence-based, highly effective, guideline-recommended therapies are known, adherence to guidelines for stroke care remains incomplete and highly variable from region to region, and country to country.
    This effort aims to solve for that in China. Specifically, this program addresses the need for:
    1.     Enhanced education for EMS and pre-hospital caregivers, especially since analysis shows only 13 percent of Chinese stroke patients arrive at the hospital by EMS, versus 50 percent in the U.S.
    2.     A reduction in "door-to-needle" times for patients to receive the clot-busting drug tPA. To-date, analysis for rates of compliance with evidenced based therapies notes significant gaps in timeliness to tPA treatment.
    3.     Increased awareness and application of mechanical endovascular reperfusion therapies in appropriate patients.
    4.     Increased awareness and application of secondary prevention in appropriate stroke patients to fill significant gaps in venous thromboembolism (VTE) prophylaxis, lipid lowering therapy, anticoagulation for atrial fibrillation and rehabilitation assessment in Chinese patients.
    With a population of 1.4 billion, stroke is the leading killer and claims the lives of 1.6 million Chinese people annually. Today, China faces cardiovascular and stroke risk factors similar to those in Western nations. Among risk factors, hypertension remains the most important for all types of strokes.[1] Additionally, the concept of a "stroke belt" in China has emerged which identifies specific geographic regions where the mortality associated with stroke is 50 percent higher than that of other regions in the country. Currently, the areas with higher mortality are the northeast and the western/southwestern.[2]
    In 2007, the Ministry of Health -- now National Health and Family Planning Commission -- sponsored the Chinese National Stroke Registry and a five-year plan to increase comprehensive stroke centers in China. Establishing the registry also led to creating the Stroke Screening, Prevention and Treatment Project in 2009, and more recently the National Center of Stroke Care Quality Control in 2011.

    "The American Stroke Association is deeply committed to having a transformative impact on healthcare systems and patients worldwide by working alongside countries, governments and international cardiovascular and cerebrovascular societies to facilitate the application of the tools and knowledge of our quality programs," said Ying Xian, M.D., Ph.D, American Stroke Association spokesperson and Assistant Professor of Neurology and Medicine at the Duke University Medical Center and Duke Clinical Research Institute. "The U.S. marketplace has given us a road map to develop scalable and sustainable models for international quality improvement initiatives. Now, with our consult, the Chinese Stroke Association aims to adopt those models to achieve better outcomes for stroke patients in China."
    "It is with great excitement that we announce the launch of this collaborative stroke quality improvement project between the CSA and ASA to further enhance cooperation on clinical research, education, and the impact of acute stroke science," said Jizong Zhao, President, CSA. "I congratulate both organizations' dedication to improving stroke outcomes in China."
    Reaching healthcare providers with the Get With The Guidelines program at Chinese secondary and tertiary hospitals -- and at all stages of the chain of survival, from pre-hospital advanced medical care (also known as EMS or emergency medical services) to neurologists to even hospital administrators -- is the priority.
    "Medtronic is a leading stroke care solution provider in stent retriever therapy with more than 20 years of experience in China. We provide clinical education and training systems for Chinese physicians and, together with medical societies, we consistently promote a hierarchical treatment system, raise public awareness, and speed up patient admission and treatment to ensure the proper care for patients," said Chris Lee, President, Medtronic Greater China. "We are very proud to collaborate with both the CSA and ASA, and we will continuously work together to improve China's stroke care quality."
    Stroke has also had a significant impact on healthcare expenditures and the Chinese economy. The cost for stroke care by the government-funded hospitals was 1.17 billion RMB (approx. $170M USD) in 2003 and 8.19 billion RMB (approx. $1.3B USD) in 2009, a 117 percent increase annually. Now, the annual cost of stroke care in China is approximately 40 billion RMB ($5.8B USD).[3]

    Markerless motion capture systems as training device in neurological rehabilitation: a systematic review of their use, application, target population and efficacy

    It is impossible to even attempt to figure out any stroke rehab if you don't even have an objective measurement of what is wrong and can objectively see improvements. This is long overdue. Your therapists and doctors have been flying completely blind about stroke rehab since forever.
    • Els KnippenbergEmail author,
    • Jonas Verbrugghe,
    • Ilse Lamers,
    • Steven Palmaers,
    • Annick Timmermans and
    • Annemie Spooren
    Journal of NeuroEngineering and Rehabilitation201714:61
    DOI: 10.1186/s12984-017-0270-x
    Received: 26 August 2016
    Accepted: 5 June 2017
    Published: 24 June 2017



    Client-centred task-oriented training is important in neurological rehabilitation but is time consuming and costly in clinical practice. The use of technology, especially motion capture systems (MCS) which are low cost and easy to apply in clinical practice, may be used to support this kind of training, but knowledge and evidence of their use for training is scarce. The present review aims to investigate 1) which motion capture systems are used as training devices in neurological rehabilitation, 2) how they are applied, 3) in which target population, 4) what the content of the training and 5) efficacy of training with MCS is.


    A computerised systematic literature review was conducted in four databases (PubMed, Cinahl, Cochrane Database and IEEE). The following MeSH terms and key words were used: Motion, Movement, Detection, Capture, Kinect, Rehabilitation, Nervous System Diseases, Multiple Sclerosis, Stroke, Spinal Cord, Parkinson Disease, Cerebral Palsy and Traumatic Brain Injury. The Van Tulder’s Quality assessment was used to score the methodological quality of the selected studies. The descriptive analysis is reported by MCS, target population, training parameters and training efficacy.


    Eighteen studies were selected (mean Van Tulder score = 8.06 ± 3.67). Based on methodological quality, six studies were selected for analysis of training efficacy. Most commonly used MCS was Microsoft Kinect, training was mostly conducted in upper limb stroke rehabilitation. Training programs varied in intensity, frequency and content. None of the studies reported an individualised training program based on client-centred approach.


    Motion capture systems are training devices with potential in neurological rehabilitation to increase the motivation during training and may assist improvement on one or more International Classification of Functioning, Disability and Health (ICF) levels. Although client-centred task-oriented training is important in neurological rehabilitation, the client-centred approach was not included. Future technological developments should take up the challenge to combine MCS with the principles of a client-centred task-oriented approach and prove efficacy using randomised controlled trials with long-term follow-up.

    Trial registration

    Prospero registration number 42016035582.

    The Diagnosis and Management of Mild Cognitive Impairment

    You will need this for your doctor to baseline your cognition.

    A Clinical Review

    JAMA. 2014;312(23):2551-2561. doi:10.1001/jama.2014.13806

    Importance  Cognitive decline is a common and feared aspect of aging. Mild cognitive impairment (MCI) is defined as the symptomatic predementia stage on the continuum of cognitive decline, characterized by objective impairment in cognition that is not severe enough to require help with usual activities of daily living.
    Objective  To present evidence on the diagnosis, treatment, and prognosis of MCI and to provide physicians with an evidence-based framework for caring for older patients with MCI and their caregivers.
    Evidence Acquisition  We searched PubMed for English-language articles in peer-reviewed journals and the Cochrane Library database from inception through July 2014. Relevant references from retrieved articles were also evaluated.
    Findings  The prevalence of MCI in adults aged 65 years and older is 10% to 20%; risk increases with age and men appear to be at higher risk than women. In older patients with MCI, clinicians should consider depression, polypharmacy, and uncontrolled cardiovascular risk factors, all of which may increase risk for cognitive impairment and other negative outcomes. Currently, no medications have proven effective for MCI; treatments and interventions should be aimed at reducing cardiovascular risk factors and prevention of stroke. Aerobic exercise, mental activity, and social engagement may help decrease risk of further cognitive decline. Although patients with MCI are at greater risk for developing dementia compared with the general population, there is currently substantial variation in risk estimates (from <5% to 20% annual conversion rates), depending on the population studied. Current research targets improving early detection and treatment of MCI, particularly in patients at high risk for progression to dementia.
    Conclusions and Relevance  Cognitive decline and MCI have important implications for patients and their families and will require that primary care clinicians be skilled in identifying and managing this common disorder as the number of older adults increases in coming decades. Current evidence supports aerobic exercise, mental activity, and cardiovascular risk factor control in patients with MCI.

    Multivariate Analyses of Peripheral Blood Leukocyte Transcripts Distinguish Alzheimer’s, Parkinson’s, Control and Those at Risk for Developing Alzheimer’s

    You'll want your doctor to follow this up with for your risk of getting dementia/Alzheimers


    • Peripheral blood leukocyte transcripts can be used as a prognostic marker of progression to the clinical stages of Alzheimer’s disease in unimpaired older adults.
    • Peripheral blood leukocyte transcripts distinguish Parkinson’s disease from Alzheimer’s disease.
    • Peripheral blood leukocyte transcripts distinguish cognitively resilient apoe4 homozygotes.
    • The same peripheral blood leukocyte transcripts used to distinguish probable Alzheimer’s disease in blood samples were also able to distinguish neuropathologically confirmed Alzheimer’s disease in brain samples.


    The need for a reliable, simple and inexpensive blood test for Alzheimer’s disease (AD) suitable for use in a primary care setting is widely recognized. This has led to a large number of publications describing blood tests for AD, which have, for the most part, not been replicable. We have chosen to examine transcripts expressed by the cellular, leukocyte compartment of blood. We have used hypothesis based cDNA arrays and quantitative PCR to quantify expression of selected sets of genes followed by multivariate analyses in multiple independent samples. Rather than one study with no replicates we chose an experimental design in which there were multiple replicates using different platforms and different sample populations. We have divided 177 blood and 27 brain samples into multiple replicates to demonstrate the ability to distinguish early clinical AD (CDR 0.5), Parkinson’s disease (PD), and cognitively unimpaired APOE4 homozygotes, as well as to determine persons at risk for future cognitive impairment with significant accuracy. We assess our methods in a training/test set and also show that the variables we use distinguish AD, PD and control brain. Importantly, we describe variability of the weights assigned to individual transcripts in multivariate analyses in repeated studies and suggest that the variability we describe may be the cause of inability to repeat many prior studies. Our data constitute a proof of principle that multivariate analysis of the transcriptome related to cell stress and inflammation of peripheral blood leukocytes has significant potential as a minimally invasive and inexpensive diagnostic tool for diagnosis and early detection of risk for AD.

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