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, May 31, 2016

Efficacy of Constraint-Induced Movement Therapy in Early Stroke Rehabilitation

The reason you don't do early CIMT is that there is no way to posit whether spontaneous recovery caused the changes or CIMT. Thus this research is practically useless.

A Randomized Controlled Multisite Trial

  1. Gyrd Thrane, MSc1,2
  2. Torunn Askim, PhD3,4
  3. Roland Stock, MSc5
  4. Bent Indredavik, MD, PhD5
  5. Ragna Gjone, MSc6
  6. Anne Erichsen, MSc7
  7. Audny Anke, MD, PhD1,2
  1. 1UiT The Arctic University of Norway, Tromsø, Norway
  2. 2University Hospital of North Norway, Tromsø, Norway
  3. 3Norwegian University of Science and Technology, Trondheim, Norway
  4. 4Sør-Trøndelag University College, Trondheim, Norway
  5. 5Trondheim University Hospital, Norway
  6. 6Vestfold Hospital Trust, Norway
  7. 7Oslo University Hospital, Norway
  1. Gyrd Thrane, MSc, Department of Health and Care Sciences, University of Tromsø, Faculty of Health Sciences, NO-9037 Tromsø, Norway. Email:


Background. There is limited evidence for the effects of constraint-induced movement therapy (CIMT) in the early stages of stroke recovery.  
Objective. To evaluate the effect of a modified CIMT within 4 weeks poststroke.  
Methods. This single-blinded randomized multisite trial investigated the effects of CIMT in 47 individuals who had experienced a stroke in the preceding 26 days. Patients were allocated to a CIMT or a usual care (control) group. The CIMT program was 3 h/d over 10 consecutive working days, with mitt use on the unaffected arm for up to 90% of waking hours. The follow-up time was 6 months. The primary outcome was the Wolf Motor Function test (WMFT) score. Secondary outcomes were the Fugl-Meyer upper-extremity motor score, Nine-Hole Peg test (NHPT) score, the arm use ratio, and the Stroke Impact Scale. Analyses of covariance with adjustment for baseline values were used to assess differences between the groups. Results. After treatment, the mean timed WMFT score was significantly better in the CIMT group compared with the control group. Moreover, posttreatment dexterity, as tested with the NHPT, was significantly better in the CIMT group, whereas the other test results were similar in both the groups. At the 6-month follow-up, the 2 groups showed no significant difference in arm impairment, function, or use in daily activities.  
Conclusions. Despite a favorable effect of CIMT on timed movement measures immediately after treatment, significant effects were not found after 6 months.


Constraint-induced movement therapy (CIMT) is designed to improve upper-extremity motor function after stroke and consists of 3 key components: (1) repetitive, task-oriented training; (2) adherence-enhancing behavioral strategies (transfer package); and (3) constraining the use of the less-affected arm, usually by wearing a mitt.1,2 The original protocol was developed for patients with chronic stroke and included 10 days of therapy for 6 h/d and constraining the less-affected arm during 90% of the time awake.3
There is a critical window for neuroplasticity and ability to relearn impaired activities within the first weeks after stroke.4,5 Modified forms of CIMT have already been tested in the early stages of stroke rehabilitation (<10 weeks).5 In 2000, Dromerick et al6 published the results from a small-scale trial of 23 patients and reported that a 2-hour/10-day CIMT program was associated with less arm impairment at the end of treatment. Another study of 23 patients by Boake et al7 reported trends favoring a 3-hour/10-day CIMT program over standard therapy of equal duration. However, their only significant finding was improved Fugl-Meyer assessment scores immediately after treatment; no long-term effects were found. In the VECTORS study,8 3 groups of stroke patients received 10 days of treatment within 4 weeks after stroke. The low-intensity CIMT group (2 h/d, 6-hour constraint) had significantly better improvement in the Action Research Arm test (ARAT), whereas the high-intensity CIMT group (3 h/d, 90% constraint) scored significantly worse than the control group. Yet another modification of CIMT was reported by Page et al,9 who reported increased use of the affected arm and improved motor impairment after 0.5 hours of training, 3 d/wk for 10 weeks of CIMT in a sample of 10 patients. In summary, the existing evidence on the effect of CIMT in the early stages of rehabilitation is limited to 5 trials that included 64 CIMT patients and 41 controls.10 These 5 trials included at least 3 different protocols and reported wide confidence intervals and large variations in treatment effects. Of particular concern are the negative results of the VECTORS trial.8 Because of the limited data and diversity of the results between previous trials, the effect of CIMT in the early stroke rehabilitation is still uncertain.
The aim of the present study was to assess the effect of a modified CIMT protocol in the early phase of rehabilitation after stroke. The primary hypothesis was that patients who completed a modified CIMT protocol in the early phase after stroke would have better arm motor function measured with the Wolf Motor Function test (WMFT) 6 months after the intervention compared with patients who received the usual care. The secondary aims were to evaluate the effect of CIMT on arm motor impairment, dexterity, arm use in daily activities, and overall health status after stroke. 

More at link.

Neural Substrates of Motor Recovery in Severely Impaired Stroke Patients With Hand Paralysis

Do these fucking idiots not even comprehend that there has to be different interventions for dead brain vs. damaged brain. They talk but never tell us anything useful. They excluded primary motor cortex damage, cherry picking at its' worst.

  1. Michelle L. Harris-Love, PhD1,2
  2. Evan Chan, MS2
  3. Alexander W. Dromerick, MD1,2,3
  4. Leonardo G. Cohen, MD4
  1. 1Georgetown University Medical Center, Washington, DC, USA
  2. 2MedStar National Rehabilitation Hospital, Washington, DC, USA
  3. 3District of Columbia VA Medical Center, Washington, DC, USA
  4. 4Human Cortical Physiology and Neurorehabilitation Section, NINDS, NIH, Bethesda, MD, USA
  1. Michelle L. Harris-Love, PhD, 102 Irving Street NW, Room 1058, Washington, DC 20010, USA. Email:


In well-recovered stroke patients with preserved hand movement, motor dysfunction relates to interhemispheric and intracortical inhibition in affected hand muscles. In less fully recovered patients unable to move their hand, the neural substrates of recovered arm movements, crucial for performance of daily living tasks, are not well understood. Here, we evaluated interhemispheric and intracortical inhibition in paretic arm muscles of patients with no recovery of hand movement (n = 16, upper extremity Fugl-Meyer Assessment = 27.0 ± 8.6). We recorded silent periods (contralateral and ipsilateral) induced by transcranial magnetic stimulation during voluntary isometric contraction of the paretic biceps and triceps brachii muscles (correlates of intracortical and interhemispheric inhibition, respectively) and investigated links between the silent periods and motor recovery, an issue that has not been previously explored. We report that interhemispheric inhibition, stronger in the paretic triceps than biceps brachii muscles, significantly correlated with the magnitude of residual impairment (lower Fugl-Meyer scores). In contrast, intracortical inhibition in the paretic biceps brachii, but not in the triceps, correlated positively with motor recovery (Fugl-Meyer scores) and negatively with spasticity (lower Modified Ashworth scores). Our results suggest that interhemispheric inhibition and intracortical inhibition of paretic upper arm muscles relate to motor recovery in different ways. While interhemispheric inhibition may contribute to poorer recovery, muscle-specific intracortical inhibition may relate to successful motor recovery and lesser spasticity.


Over the past nearly 2 decades, there has been a great deal of investigation into mechanisms of impairment and recovery of hand movement after human stroke.(But no protocols) This work has demonstrated that limitations in recovery of functional hand movements poststroke are often linked to abnormalities in intracortical and interhemispheric inhibition. These findings have provided insight into the mechanisms of behavioral rehabilitation approaches, such as constraint-induced movement therapy,1-5 and have informed the development of cortical stimulation paradigms to improve hand recovery.6-9

Previous studies have used transcranial magnetic stimulation (TMS) to investigate intracortical inhibition of primary motor cortex (M1) hand representations in well-recovered stroke patients with at least partial recovery of hand function. Paired-pulse measurements of short-interval intracortical inhibition (SICI),10 associated with GABAA-mediated intracortical inhibition,11 have shown abnormally decreased levels of intracortical inhibition targeting the paretic hand.1,2,12-15 In contrast, intracortical inhibition reflected by the contralateral silent period (cSP), associated with GABAB receptor–mediated inhibition,11 is reported to be abnormally increased in the paretic hand1,15-19 and to decrease with recovery.16 Thus, it appears that SICI, reflecting GABAA-mediated intracortical inhibition, is abnormally decreased while cSP, reflecting GABAB receptor–mediated inhibition, is abnormally increased in the paretic hand post-stroke.

In addition to intracortical inhibition, interhemispheric inhibition between M1 hand representations in stroke patients with hand recovery has also been widely studied, and like intracortical inhibition, it has been studied using both paired-pulse and silent period TMS techniques. Paired-pulse measurements have shown that interhemispheric inhibition targeting the affected hemisphere (ie, paretic hand) is stronger than that targeting the unaffected hemisphere20-22 and abnormally persistent during paretic finger movement preparation,23,24 particularly in those with poorer hand recovery. Ipsilateral silent period measurements have provided further support for the notion that interhemispheric inhibition targeting the paretic hand is stronger than that targeting the nonparetic hand15,25 and that measured in controls.26

Mechanisms of upper arm motor recovery in stroke patients unable to use their hands, however, are not well understood. To examine interhemispheric and intracortical inhibition in paretic elbow flexors and extensors, we evaluated silent periods during voluntary isometric contractions of paretic arm biceps (flexor) or triceps (extensor) brachii and measured the correlation between these measures and clinical and behavioral tests of motor ability, reaching performance, and spasticity. Recognizing that specific electrophysiological measurements, such as silent periods, reflect only a portion of the larger processes of intracortical and interhemispheric inhibition, we emphasize that when we refer to intracortical and interhemispheric inhibition we are referring only to that reflected by the contralateral and ipsilateral silent periods, respectively.

Given that many patients have particular difficulty deactivating elbow flexors, we postulated that inhibition targeting an elbow flexor muscle (biceps brachii) would be less than that targeting an elbow extensor (triceps brachii) and that biceps inhibition would correlate negatively with motor impairment. We report that interhemispheric inhibition and intracortical inhibition of these paretic upper arm muscles relate to paretic arm motor recovery differently in this population. 

More at link.

Reflections on Mirror Therapy A Systematic Review of the Effect of Mirror Visual Feedback on the Brain

How many more research articles repeating the same things on this subject need to be written before our stroke leaderships steps up and declares that there already is a written protocol on this and to stop writing on this. Well never, since we have NO stroke leadership and NO stroke rehabilitation protocols. You are fucking screwed and what stroke leadership there is doesn't care.
Mirror training has been considered useful since at least 1999. I've written 30 posts on mirror therapy since 2012. But since nobody is listening to me, nothing has been done about writing a fucking simple stroke protocol on this. Do not do this on your own, way too dangerous.

Reflections on Mirror Therapy A Systematic Review of the Effect of Mirror Visual Feedback on the Brain

  1. Frederik J. A. Deconinck, PhD1,2
  2. Ana R. P. Smorenburg, PhD3
  3. Alex Benham, PhD4
  4. Annick Ledebt, PhD5
  5. Max G. Feltham, PhD6
  6. Geert J. P. Savelsbergh, PhD5
  1. 1Ghent University, Ghent, Belgium
  2. 2Manchester Metropolitan University, Manchester, UK
  3. 3Burke-Cornell Medical Research Institute, White Plains, NY, USA
  4. 4Bradford Institute for Health Research, Bradford, UK
  5. 5VU University, Amsterdam, Netherlands
  6. 6University of Birmingham, Birmingham, UK
  1. Frederik J. A. Deconinck, Ghent University, Faculty of Medicine and Health Sciences, Department of Movement and Sports Sciences, Watersportlaan 2, Gent 9000, Belgium. Email:


Background. Mirror visual feedback (MVF), a phenomenon where movement of one limb is perceived as movement of the other limb, has the capacity to alleviate phantom limb pain or promote motor recovery of the upper limbs after stroke. The tool has received great interest from health professionals; however, a clear understanding of the mechanisms underlying the neural recovery owing to MVF is lacking.  
Objective. We performed a systematic review to assess the effect of MVF on brain activation during a motor task. Methods. We searched PubMed, CINAHL, and EMBASE databases for neuroimaging studies investigating the effect of MVF on the brain. Key details for each study regarding participants, imaging methods, and results were extracted.  
Results. The database search yielded 347 article, of which we identified 33 suitable for inclusion. Compared with a control condition, MVF increases neural activity in areas involved with allocation of attention and cognitive control (dorsolateral prefrontal cortex, posterior cingulate cortex, S1 and S2, precuneus). Apart from activation in the superior temporal gyrus and premotor cortex, there is little evidence that MVF activates the mirror neuron system. MVF increases the excitability of the ipsilateral primary motor cortex (M1) that projects to the “untrained” hand/arm. There is also evidence for ipsilateral projections from the contralateral M1 to the untrained/affected hand as a consequence of training with MVF.  
Conclusion. MVF can exert a strong influence on the motor network, mainly through increased cognitive penetration in action control, though the variance in methodology and the lack of studies that shed light on the functional connectivity between areas still limit insight into the actual underlying mechanisms.


Often a source of fascination, or perhaps frustration, optical illusions have captivated people since ancient times. For instance, curved surfaces and the absence of right angles in archaic Greek temples suggest that its architects attempted to optically correct the illusion of slanted columns or curved tympanums; however, others believe these features may serve engineering purposes or reflect aesthetic preference.1 As much as they are a source of excitement, for neuroscientists optical illusions are considered a backdoor into people’s mind and provide an excellent way to study the neural mechanisms underlying perception and action.2
Interestingly, although optical illusions are known to deceive the individual, the false reality may fool the brain, such that the outcome is beneficial. One such an illusion is the mirror illusion, which has been found to have therapeutic benefits over the past 2 decades. When a mirror is placed, along the midsagittal plane in between the 2 limbs, the reflection of the limb in front of the mirror is superimposed on the contralateral limb. Any motion of the limb in front of the mirror induces the illusion of 2 synchronously moving limbs. After Ramachandran and his colleagues found that this illusion could alleviate phantom pain in a proportion of the patients,3 mirror visual feedback (MVF) was introduced as a neurorehabilitation tool to treat other unilateral pain disorders, such as complex regional pain syndrome (CRPS). In addition, the paradigm is now used to promote motor recovery (eg, in hemiparetic patients or after hand surgery).
Despite its widespread use in neurorehabilitation and the claims that MVF therapy would lead to neuroplastic changes, there is no consensus about the underlying mechanism and speculation often lacks the neuroscientific proof. The aim of this review is therefore to bring together current knowledge on the effect of MVF on the brain as has been described in neuroimaging studies, in order to explore potential processes underlying the beneficial clinical effects of MVF. To acquaint the reader with MVF and its current applications, we will first revisit Ramachandran’s rationale for MVF, followed by a narrative review of the clinical neurorehabilitation research that followed in his footsteps. At the end of this section, we introduce 3 hypotheses that have been proposed to explain the positive effects related to MVF. Part 2 provides a systematic review and discussion of studies that examined the effect of MVF on brain activation patterns using neuroimaging or electrophysiological techniques. Finally, in Part 3 we discuss the findings of the systematic review in relation to the hypotheses introduced in Part 1 and we identify where further research is required.

Velano Vascular needle-free blood draw device

How long before your hospital get this for those damned INR draws? Will you be able to sleep thru the 7am blood draws with this? 

New device reduces risks, anxiety associated with blood draws

Velano Vascular —
Velano Vascular needle-free blood draw device
The FDA has granted clearance to a modified version of Velano Vascular’s novel, needle-free blood draw device, which is designed to reduce blood draw-related discomfort and anxiety for hospital inpatients, provide a safer work environment for healthcare providers, and standardize today’s fragmented approaches to inpatient blood draws. This second FDA clearance of the device includes two modifications designed to enhance the product’s usability for inpatient blood draws, one of the most common medical procedures performed today: The addition of a clamp for use with syringe draws, a frequent practice in pediatric patients, and a refinement to the Indication for Use (IFU). The Velano device is attached to a peripheral IV catheter to draw blood directly into a vacuum tube or a syringe; the revised IFU removes a limitation in the earlier clearance that specified when the device could be used with in-dwelling peripheral IV catheters. Roughly 760 inpatient blood draws are conducted every minute in the United States alone. Despite their ubiquity, blood draws create tremendous disruption for patients and clinicians alike, and are associated with significant direct and indirect costs. Twenty-eight percent of adult venipunctures and 44 percent of pediatric venipunctures require more than one stick to successfully draw blood, and around 10 percent of children aged 3 to 10 years old must be physically restrained to endure a needle-based blood draw. Published data suggest that U.S. healthcare professionals endure an average of 200 needle-related injuries each day. Aside from the significant physical and emotional toll of these injuries and any related seroconversion, studies suggest that accidental needle sticks cost hospitals upwards of $50 million per year.

Recent progress in tracking the viability of transplanted stem cells in vivo

If the stem cell company or researchers you are following don't mention tracking of stem cells then they have NO fucking clue if they survive or not. You can attribute that to laziness or fraud, but regardless not doing so is incompetent.
Noninvasive cell-tracking methods are indispensable for assessing the safety and efficacy of stem-cell based therapy. Thus, the research of noninvasive cell-tracking methods for determining in vivo the translocation and long-term viability of the transplanted stem cells have received considerable attention. A recent review article summarized the recent progress in tracking the viability of the transplanted stem cells in vivo.

In the article coauthored with S. Lin, G. Chen, D. Huang, C. Meng, and Q. Wang, scholars at Suzhou Institute of Nano-Tech and Nano-Bionics, Chinese Academy of Sciences, and College of Biological Science and Technology, Fuzhou University summarized the current methods for tracking the viability of the transplanted stem cells in vivo, including reporter-gene based methods, exogenous contrast label-based methods and multimodel imaging methods.

In recent decades, stem cell-based regenerative medicine has attracted intense attention and extraordinary expectation due to its potentials in the treatment of numerous major diseases, such as hepatic, cardiac, pulmonary, renal and neurological diseases.

Knowing the viability, distribution and differentiation of the transplanted stem cells in vivo is a prerequisite for better understanding the role of stem cells playing in the therapeutic process, in which the survival report of the transplanted stem cells in vivo is particularly crucial in determining the success of stem cell-based regenerative medicine. Therefore, the development of non-invasive imaging methods that can monitor the viability of the transplanted stem cells in situ is urgently needed.

In this article, the authors summarized the development history of stem cell-tracking imaging techniques, explained the imaging principles, pros and cons underlying these techniques, and provided an overview of the applications of these techniques in animal models or humans. Furthermore, this review provided a guideline for researchers to select the right tracking method for the right study. Finally, this review discussed the current challenges in tracking the viability of transplanted stem cells, and emphasized the promise of the combined NIR-II fluorescence imaging/BLI method and MRI/PET method for further applications in high-throughput cell therapy screening in animal models and safe imaging in clinical trials, respectively.

Explore further: Researchers track neural stem cells by coloring chicken eggs from the inside

More information: SuYing LIN et al. Progress of tracking the viability of transplanted stem cells, Chinese Science Bulletin (Chinese Version) (2016). DOI: 10.1360/N972015-01404

Image at link.

Noninvasive cell-tracking methods are indispensable for assessing the safety and efficacy of stem-cell based therapy. Thus, the research of noninvasive cell-tracking methods for determining in vivo the translocation and long-term viability of the transplanted stem cells have received considerable attention. A recent review article summarized the recent progress in tracking the viability of the transplanted stem cells in vivo.
In the article coauthored with S. Lin, G. Chen, D. Huang, C. Meng, and Q. Wang, scholars at Suzhou Institute of Nano-Tech and Nano-Bionics, Chinese Academy of Sciences, and College of Biological Science and Technology, Fuzhou University summarized the current methods for tracking the of the in vivo, including reporter-gene based methods, exogenous contrast label-based methods and multimodel imaging methods.
In recent decades, stem cell-based regenerative medicine has attracted intense attention and extraordinary expectation due to its potentials in the treatment of numerous major diseases, such as hepatic, cardiac, pulmonary, renal and neurological diseases.
Knowing the viability, distribution and differentiation of the transplanted stem cells in vivo is a prerequisite for better understanding the role of stem cells playing in the therapeutic process, in which the survival report of the transplanted stem cells in vivo is particularly crucial in determining the success of stem cell-based regenerative medicine. Therefore, the development of non-invasive imaging methods that can monitor the viability of the transplanted stem cells in situ is urgently needed.
In this article, the authors summarized the development history of stem cell-tracking imaging techniques, explained the imaging principles, pros and cons underlying these techniques, and provided an overview of the applications of these techniques in animal models or humans. Furthermore, this review provided a guideline for researchers to select the right tracking method for the right study. Finally, this review discussed the current challenges in tracking the viability of transplanted , and emphasized the promise of the combined NIR-II fluorescence imaging/BLI method and MRI/PET method for further applications in high-throughput cell therapy screening in animal models and safe imaging in clinical trials, respectively.
More information: SuYing LIN et al. Progress of tracking the viability of transplanted stem cells, Chinese Science Bulletin (Chinese Version) (2016). DOI: 10.1360/N972015-01404

Read more at:

Predicting activities after stroke: what is clinically relevant?

I'd have to say that the National Institutes of Health Stroke Scale is not objective or really useful in predicting recovery. This research is pretty useless with the Barthel scales also being subjective. Isn't anyone ever going to start using objective 3d scans of damage and location to determine stroke severity and recovery possibilities?

  1. G. Kwakkel1,2,3,* and
  2. B. J. Kollen4
Version of Record online: 24 DEC 2012
DOI: 10.1111/j.1747-4949.2012.00967.x
International Journal of Stroke

International Journal of Stroke

Volume 8, Issue 1, pages 25–32, January 2013

  1. Conflict of interest: None declared.



  • activities;
  • prognosis;
  • stroke


Knowledge about factors that determine the final outcome after stroke is important for early stroke management, rehabilitation goals, and discharge planning. This narrative review provides an overview of current knowledge about the prediction of activities after stroke. We reviewed the pattern of stroke recovery for functions and activities, the impact of spontaneous recovery on activities, and the measurement of improvement in general. We explored the activities profiles during the chronic phase and predictors for activities of daily living independence after stroke, and finally, we discussed where to from here? Mathematical regularities explain the nonlinear patterns of recovery, making the outcome of activities of daily living highly predictable. Initial severity of disability and extent of improvement observed within the first weeks poststroke are important indicators of the outcome at six-months. The sequence of progress in activities is almost fixed in time. Studies showed that most motor recovery is almost completed within 10 weeks poststroke. On average, stroke recovery plateaus three- to six-months after onset. Strong evidence was found that age and scores on scales assessing severity of neurological deficits in the early poststroke phase are strongly associated with the final basic activities of daily living outcome after three-months poststroke. The validated prediction models using simple algorithms, such as National Institutes of Health Stroke Scale or Barthel Index, need to be implemented in rehabilitation services and used for stratifying stroke patients in trials. Future studies should investigate the accuracy of dynamic models that includes time poststroke to optimize the application of prediction rules in individuals with stroke.

When EBP meets neurological therapy

You need to read this to see of your therapist is following these. I probably have these scattered in my 10000 posts. With no database of stroke protocols you will have to rely on other survivors and a few forward thinking therapists to recover.

Interventions for improving community ambulation in individuals with stroke

Once again, more research needed that will never occur with NO stroke leadership or strategy. I don't see how this walking would not improve stroke recovery.



Community ambulation refers to the ability of a person to walk in their own community, outside of their home and also indoors in private or public locations. Some people choose to walk for exercise or leisure and may walk with others as an important aspect of social functioning. Community ambulation is therefore an important skill for stroke survivors living in the community whose walking ability has been affected.


To determine: (1) whether interventions improve community ambulation for stroke survivors, and (2) if any specific intervention method improves community ambulation more than other interventions.


We searched the Cochrane Stroke Group Trials Register (September 2014), the Cochrane Central Register of Controlled Trials (CENTRAL) (November 2013), PubMed (1946 to November 2013), EMBASE (1980 to November 2013), CINAHL (1982 to November 2013), PsycINFO (1887 to November 2013), Scopus (1960 to November 2013), Web of Science (1900 to November 2013), SPORTDiscus (1975 to November 2013), and PEDro, CIRRIE and REHABDATA (November 2013). We also searched ongoing trials registers (November 2013) and reference lists, and performed a cited reference search.


Selection criteria included parallel-group randomised controlled trials (RCTs) and cross-over RCTs, studies in which participants are adult (aged 18 years or more) stroke survivors, and interventions that were aimed at improving community ambulation. We defined the primary outcome as participation; secondary outcomes included activity level outcomes related to gait and self-efficacy.


One review author independently screened titles. Two review authors screened abstracts and full text articles, with a third review author was available to resolve any disagreements. Two review authors extracted data and assessed risk of bias. All outcomes were continuous. The analysis for the primary outcome used the generic inverse variance methods for meta-analysis, using the standardised mean difference (SMD) and standard error (SE) from the participation outcomes. Analyses for secondary outcomes all used SMD or mean difference (MD). We completed analyses for each outcome with all studies, and by type of community ambulation intervention (community or outdoor ambulation practice, virtual practice, and imagery practice). We considered trials for each outcome to be of low quality due to some trial design considerations, such as who knew what group the participants were in, and the number of people who dropped out of the studies.


We included five studies involving 266 participants (136 intervention; 130 control). All participants were adult stroke survivors, living in the community or a care home. Programmes to improve community ambulation consisted of walking practice in a variety of settings and environments in the community, or an indoor activity that mimicked community walking (including virtual reality or mental imagery). Three studies were funded by government agencies, and two had no funding.From two studies of 198 people there was low quality evidence for the effect of intervention on participation compared with control (SMD, 0.08, 95% confidence interval (CI) -0.20 to 0.35 (using inverse variance). The CI for the effect of the intervention on gait speed was wide and does not exclude no difference (MD 0.12, 95% CI -0.01 to 0.24; four studies, 98 participants, low quality evidence). We considered the quality of the evidence to be low for all the remaining outcomes in our review: Community Walk Test (MD -6.35, 95% CI -21.59 to 8.88); Walking Ability Questionnaire (MD 0.53, 95% CI -5.59 to 6.66); Six-Minute Walk Test (MD 39.62 metres, 95% CI -8.26 to 87.51) and self-efficacy (SMD 0.32, 95% CI -0.09 to 0.72). We downgraded the quality of the evidence because of a high risk of bias and imprecision.


There is currently insufficient evidence to establish the effect of community ambulation interventions or to support a change in clinical practice. More research is needed to determine if practicing outdoor or community walking will improve participation and community ambulation skills for stroke survivors living in the community.

What people say about travelling outdoors after their stroke: a qualitative study

We absolutely need outdoor experiences post-stroke. Demand you get some. A doctor was insistent that I not watch an outdoor whitewater slalom race during a weekend pass due to the possibility of falling and bleeds due to warfarin use. I ignored her.

Glancing at greenery can boost concentration levels


Residential exposure to visible blue space (but not green space) associated with lower psychological distress in a capital city



Reduced walking ability and loss of confidence are common after stroke. Many people cannot drive or use public transport, which can restrict participation. This qualitative study aimed to explore the experiences and attitudes of people following stroke to travelling outdoors early after hospital discharge.


Two semi-structured interviews were conducted with 19 people post-stroke, all of whom were receiving rehabilitation to increase outdoor travel. Mean age was 68.6 years (SD 11.7years). Eight significant others also participated. Interviews were conducted at home (median 21 days post-discharge), with a second interview three months later. Questions focussed on common destinations, modes of travel including driving when relevant and factors that influenced outdoor travel. Qualitative data were analysed using constant comparative (grounded theory) methods, resulting in themes and categories.


People with stroke were categorised as either a hesitant or confident explorer, in relation to walking, catching public transport and driving. Factors influencing outdoor travel included their emotional disposition, having meaningful destinations, expectations of recovery and the sphere of influence, including family and therapists. These factors could have an enabling or restricting effect. A pre-stroke walking habit also positively contributed to outdoor travel. Gate-keeping by therapists, general practitioners and family members seemed to adversely affect travel.


This emerging theory offers insights into the experiences and attitudes to outdoor travel of people who were ambulant and participating in community rehabilitation following a stroke. Future research could explore the experiences of people with more severe mobility, cognitive and communication problems.
© 2011 The Authors. Australian Occupational Therapy Journal © 2011 Occupational Therapy Australia.

A behavior change program to increase outings delivered during therapy to stroke survivors by community rehabilitation teams: The Out-and-About trial

With no place to publicly put stroke protocols, nothing will ever get better.

J'accuse the stroke associations of failing to provide even this minimal help to stroke survivors.



Australian guidelines recommend that outdoor mobility be addressed to increase participation after stroke.


To investigate the efficacy of the Out-and-About program at increasing outings delivered during therapy by community teams, and outings taken by stroke survivors in real life.


Cluster-randomized trial involving 22 community teams providing stroke rehabilitation. Experimental teams received the Out-and-About program (a behavior change program comprising a training workshop with barrier identification and booster session, printed educational materials, audit, and feedback). Control teams received printed clinical guidelines only. The primary outcome was the percentage of stroke survivors receiving four or more outings during therapy. Secondary outcomes included the number of outings received by stroke survivors during therapy and undertaken in real life.


At 12 months after implementation of the behavior change program, 9% of audited experimental group stroke survivors received four or more outings during therapy compared with 5% in the control group (adjusted risk difference 4%, 95% CI - 9 to 17, p = 0.54). They received 1.1 (SD 0.9) outings during therapy compared with 0.6 (SD 1.0) in the control group (adjusted mean difference 0.5, 95% CI - 0.4 to 1.4; p = 0.26). After six months of rehabilitation, observed experimental group stroke survivors took 9.0 (SD 3.0) outings per week in real life compared with 7.4 (SD 4.0) in the control group (adjusted mean difference 0.5, 95% CI - 1.8 to 2.8; p = 0.63).


The Out-and-About program did not change team or stroke survivor behavior.


Pericyte-targeting drug delivery and tissue engineering

How is your doctor going to use this in collaboration with researchers to solve  Capillaries that don't open due to pericytes in the neuronal cascade of death? I bet nothing will happen, your doctor won't step up to the plate because they don't have the correct goals and objectives to actually solve all the problems in stroke. Their goal is to bring in money for the stroke department, not to solve your stroke problems. You should be able to figure out why the signaling doesn't open the capillaries.
Authors Kang E, Shin JW
Received 28 January 2016
Accepted for publication 2 April 2016
Published 27 May 2016 Volume 2016:11 Pages 2397—2406
Checked for plagiarism Yes
Review by Single-blind
Peer reviewers approved by Dr Lakshmi Kiran Chelluri
Peer reviewer comments 3
Editor who approved publication: Dr Thomas Webster
Eunah Kang,1 Jong Wook Shin2

1School of Chemical Engineering and Material Science, 2Division of Allergic and Pulmonary Medicine, Department of Internal Medicine, College of Medicine, Chung-Ang University, Dongjak-Gu, Seoul, South Korea

Abstract: Pericytes are contractile mural cells that wrap around the endothelial cells of capillaries and venules. Depending on the triggers by cellular signals, pericytes have specific functionality in tumor microenvironments, properties of potent stem cells, and plasticity in cellular pathology. These features of pericytes can be activated for the promotion or reduction of angiogenesis. Frontier studies have exploited pericyte-targeting drug delivery, using pericyte-specific peptides, small molecules, and DNA in tumor therapy. Moreover, the communication between pericytes and endothelial cells has been applied to the induction of vessel neoformation in tissue engineering. Pericytes may prove to be a novel target for tumor therapy and tissue engineering. The present paper specifically reviews pericyte-specific drug delivery and tissue engineering, allowing insight into the emerging research targeting pericytes.

Epilepsy, multiple sclerosis, Parkinson's and other neurological disorders impair sexuality

Is your doctor accommodating this? For these reasons:

Sexual Frequency Predicts Greater Well-Being, But More is Not Always Better

Sex after stroke

Sex linked to better brain power in older age

Good News About Sex- It Doesn't Cause a Stroke

Sex Does Not Increase Heart Attack Risk - What about stroke?

Frequent orgasms may protect against heart attacks

An orgasm a day keeps the doctor away!


Sexuality Within Stroke Rehabilitation


Neurological disorders can impair sexuality on a much more massive scale than frequently assumed, leaving loss of desire, erection problems and infertility in their wake. Both men and women are affected. A person's self-esteem, love life and relationship with a significant other can all suffer. But as Prof David B. Vodušek from the University of Ljubljana, Slovenia, pointed out at the Second Congress of the European Academy of Neurology (EAN) in Copenhagen, people do not have to simply acquiesce to this situation: "There are ways of helping affected individuals, provided neurologists actively address possible problems with the patient's intimate private life. Many patients have the impression that this aspect is given too little attention," the Chairman of the EAN Liaison Committee noted.
Neurological problems affect a person's love life
Prof Vodušek explained: "Erectile dysfunction in men and orgasm dysfunction in women are the most frequent sexual consequences of neurological deficits." Hypothalamo-pituitary disorders reduce in men whereas in women the complaints are usually amenorrhea and infertility, a lack of sexual desire, a decrease in vaginal lubrication, and orgasm dysfunction. Particularly lesions of the frontal and temporal lobes seem to lead to sexual dysfunction in with serious neurological disorders, for instance after a stroke. Epileptic patients have complex sexual problems, which can include hypersexuality but mostly decreased sexual arousability. Male patients with Parkinson's often report erectile dysfunction and problems with orgasm and ejaculation. Women and men both complain of very weak sexual desire as a result of Parkinson's disease – notwithstanding the detrimental effect that their limited mobility has on passion. Multiple sclerosis can result in similar sexual dysfunctions as with Parkinson's as well as in genital sensory dysfunction. In male diabetic patients erectile dysfunction is common, and retrograde ejaculation may occur (seminal discharge in the bladder). Women with polyneuropathy may have greater difficulty with sexual arousal and vaginal lubrication.
From examination to potency enhancing drugs – the factors that bring back sex
Prof Vodušek explained: "The dedicated neurologist can treat typical and simple sexual problems in his patient and reserve urological consultation for the more complex issues and for dysfunctions that prove refractory." Clinical screening is most important for determining neurogenic sexual dysfunction. Even if the treatment is initially aimed at improving neurological symptoms, the patient's current quality of life must also be considered, including the person's sex life. Prof Vodušek: "A sexual consultation is a must in this context. The person's partner should definitely become involved in these consultations. Whether genital pain or panic about the next attempt of sexual intercourse, the expert said on a positive note: "Solutions can be found for many problems. Lubricants help against vaginal dryness, for instance, and oral drugs help to counter erectile dysfunction, especially those based on cGMP phosphodiesterase type 5 inhibitors." If oral therapy fails, an injection in the penis may help this organ do its duty despite neurogenic . Patients with Parkinson's benefit from dopamine treatment in that it helps them to normalise their sexual desire.
Never omit questions about sex life
Prof Vodušek: "Compassionate, respectful consultations that consider the patient holistically instead of focusing on individual body parts are among the best means of getting a sexual problem under control. They do much to sensitize the patients about certain phenomena that might occur in the course of the disease. If certain dysfunctions do end up actually occurring, the patient will have any easier time addressing them."

Big improvements in performance follow changes to Gwent stroke services

Absolutely nothing on results, this article told you nothing about how good this hospital is getting you to full recovery. Improvements in care mean nothing if results don't improve. Are you even measuring results? This is what incompetent/mediocre organizations focus on; processes, not results.
CHANGES to the way stroke services are provided in Gwent are delivering big improvements in the care of patients in hospital and after discharge, early figures show.
A new stroke care pathway for patients was launched in January and a single hyper-acute stroke unit - at the Royal Gwent Hospital - began admitting new patients from across Gwent.
And stroke service performance has since improved against a range of UK standards measuring factors such as the time it takes for patients to be admitted, to receive a CT scan, and to be assessed by stroke consultants and nurses.
Lengths of stay in hospital, either in the hyper-acute unit, or in a specialist acute stroke rehab ward are also falling, with the work of a new community neuro-rehab service helping patients cope at home.
New figures indicate that direct admission to a stroke unit within four hours was achieved for 66 per cent of patients in Gwent in March - up from less than 20 per cent in November - and the figures for April and May are above 70 per cent.
Close to 95 per cent of stroke patients in May will have received a CT scan within 12 hours, up from 71.4 per cent in April.
At the Royal Gwent, during the past 12 months, 72 per cent of patients have been assessed by a consultant within 24 hours. But during January-March this year, performance has been at 99 per cent, the best in Wales.
Assessments by a stroke nurse within 24 hours are currently running at 100 per cent.
Lead stroke physician Dr Yaqoob Bhat is delighted with the improvements and believes there is more to come.
"Providing a uniform service for everyone is vital, and we now have one hyper-acute stroke unit and a seven-day service," he said.
"It is very hard work, very challenging, but we are heading in the right direction, improving the service."(Are you improving the results?)
He added that having a stroke specialist in the emergency department means assessments can be made quickly, speeding up the pathway for procedures such as scans and reviews.
If patients are considered medically stable enough to be discharged from the hyper-acute unit or a stroke rehab ward, they come under the care of the community neuro-rehab service.
This can involve input from physiotherapy, occupational therapy, dietetics, speech and language therapy, nursing and psychology.
After 74- year-old Jean McCook, of Alway, Newport, had a stroke last December, she could not initially move her legs and arms, and was affected down her left side.
"Jean was quite severely affected and when she came home she was having to sleep downstairs," said Adele Griffiths, acting clinical manager for the service.
"We can come in on a daily basis or once or twice a week. It's about working with people to reconstruct meaningful lives."
Mrs McCook said the team has helped her get her mobility back more quickly, and helped her confidence too.
"They've been fantastic," she said.

Family, community support key in stroke recovery

Notice that there is nothing listed in here for the doctor or therapist to be doing for your recovery.
Published: 4:00 AM, May 31, 2016
I was 30 and working as an assistant head at the Economic Development Board when I had a stroke in 2011. One Sunday morning, as I was washing my motorcycle, I felt a sudden pressure in my head and collapsed in the car park. That was where the security guard on duty found me and immediately called for an ambulance.
I had suffered a sudden haemorrhage in the brain from an arteriovenous malformation — an abnormal tangle of blood vessels — that had, until then, shown no symptoms. The bleeding occurred within the parietal lobe of the right hemisphere of my brain, severely affecting movement and sensation on the left and dominant side of my body.
In my journey through the medical establishment since, I have had many opportunities to talk to doctors, therapists and fellow stroke patients. But one particular conversation has stuck with me.
An occupational therapist from the wonderful team at Tan Tock Seng Hospital explained to me that in his professional experience, disability was seldom a purely physical phenomenon. Much depended on the patients’ own reactions to their new physical realities and their willingness to participate in rehabilitation and to devise coping strategies.
Looking back, my fellow patients who approached their rehabilitation journey with positive attitudes had one thing in common. They were optimistic about their future at the same time that they accepted their new physical disabilities.
Later on, I discovered that there is a psychological term for this sense of optimism tempered by realism. It is called the “Stockdale Paradox”, named after Admiral James Stockdale, who was the highest-ranking American soldier to be held prisoner during the Vietnam War.
He and his fellow prisoners of war who survived kept each other going, while maintaining a realistic assessment of their chances of rescue.
Faced with a challenge or trauma, the Stockdale Paradox defines those who are willing to accept the realities of their situations and yet are confident enough to believe that they will somehow prevail.
Although attitude and effort may make the greatest difference in how stroke patients approach rehabilitation, family and community support are vital in reinforcing this.
Trauma can be just as hard for family members and loved ones to come to terms with as it is for those directly affected. But mutual understanding and encouragement can keep everyone grounded and positive.
Family members need to be prepared to be flexible to help patients regain a sense of normalcy. Being able to regain some independence in daily routines early on can be a huge boost to self-esteem and encourages further effort.
While family members should provide help where needed, the line between being supportive and being patronising needs to be constantly negotiated.
One of the hardest things for both patients and their immediate relatives to cope with may be negative moods and emotions, which may be a direct cause of the brain injury itself as much as a normal psychological reaction to trauma.
For me, one of the most noticeable mood changes after my stroke was a quicker temper. In the years since, I have learnt to cope by detecting early signs of anger and quickly acting to calm myself down.
Even if both patients and their families are invested in the rehabilitation process, the larger social support and healthcare infrastructure must facilitate the journey.
A 2012 study by the National University of Singapore showed that adherence to post-discharge therapy in Singapore was dismal, at less than 40 per cent.
The direct cost of therapy aside, even those with access to subsidies often find the cost of transport prohibitive, especially specialised transport such as ambulances, which can cost many times the therapy itself.
Recent initiatives such as the launch of a new Wellness Centre by the Stroke Support Station (S3) this month by Minister for Health Gan Kim Yong are important in improving community access to therapy.
Mr Gan recognised the importance of such community-based efforts in helping stroke survivors “re-integrate into society and return to their normal activities as soon as possible”. However, in my opinion, still more can be done to address “last-mile” issues such as travel to and from therapy.
In the United Kingdom, where the National Health Service pays for both post-discharge rehabilitation as well as ambulance transport, therapy adherence rate is around 90 per cent, more than twice that in Singapore.
It is imperative that Singapore improves on its rehabilitation adherence rate as our population ages. Already, there are more than 10,000 new stroke patients every year, two-thirds of whom suffer moderate to severe physical disabilities.
Community support can help patients take advantage of the crucial one-year recovery window, and stop them from getting trapped in a self-reinforcing cycle of reduced mobility and exclusion from society.
In fact, faster social re-integration may help the country save on long-term healthcare costs by reducing associated chronic illnesses.
Dealing with trauma is never easy, but a positive attitude, encouragement from family and friends, and support from the wider community can greatly ease the road to recovery.
Five years after my stroke, I still cannot move my left hand much or walk without aid.
But if you ask me if I would trade what I have gained since then in terms of new friendships and life experiences for the ability to move normally again, I would be really hard pressed to give you an answer.
Hawyee Auyong is the founder of the Rehabilitation Assistance to Cure Heal and Enable Lives (RACHEL) Fund administered by Tan Tock Seng Hospital Community Charity Fund that provides assistance to low-income families for stroke rehabilitation therapy. He is also a Research Associate at the Lee Kuan Yuan School of Public Policy.