Totally missed the most important option of reducing disability after stroke.
You need to stop the 5 causes of the neuronal cascade of death in the first days saving billions of neurons.
You are so out-of-date that you missed this enriched environment talked about by Dr. Dale Corbett in 2011 and did nothing until now?
THIS is the reason survivors need to be in charge, no one in the stroke medical world is putting it all together with a way to get to 100% recovery. No one seems to be up-to-date.
Reducing disability after stroke
Stroke is the most common cause of long-term neurological disability worldwide.1 Half of all people who survive are left disabled, with a third relying on others to assist with activities of daily living. A number of articles in this month’s issue of International Journal of Stroke (IJS) address important aspects of stroke recovery research.
One obstacle to improved treatments is a lack of understanding of potential pathways which we can target to increase recovery. Genome-wide association (GWAS) genetic studies have proved a powerful technique in identifying mechanisms underlying a whole variety of diseases. They have identified many genetic loci and pathogenic pathways underlying stroke risk.2 A major advantage of the GWAS approach is that it is “agnostic,” that is, it does not depend upon a hypothesis, and therefore associations with completely new genes and mechanistic pathways can be identified. However, applying such techniques to stroke recovery is challenging. Such studies require data from thousands of cases, and data collection and outcomes need to be standardized across these different cohorts.3 An useful framework for design of these studies is presented in a consensus paper from the International Stroke Genetics Consortium in this issue. It makes an important reading for anyone planning to carry out studies in this area.3
A potentially exciting novel treatment approach is environmental enrichment. This has been shown to improve recovery in animal models of stroke, promoting brain plasticity and enhancing sensory motor recovery with the greatest gains made when used in conjunction with motor retraining.4 Such approaches are now being trialed in humans. Janssen and colleagues, in this month’s issue, describe a feasibility study of environmental enrichment using a non-randomized cluster trial design.5 Both individual and communal forms of environmental enrichment were provided, for the duration of stay in the rehabilitation unit. The experimental group spent 7% less time inactive and 9% more time physically and 6% more time socially active than the control group. There was a trend toward better mobility in the experimental group but no other differences in outcome measures. The authors concluded that the increase in activity was modest and the lack of benefit in clinical outcome 3 months after stroke does not provide evidence for an efficacy trial. Perhaps further work is required to develop enrichment interventions that increase activity further. It is also likely that much larger sample sizes will be required to definitively identify treatment effects.
Another concern, and potential treatment opportunity, during rehabilitation is the use of commonly used prescription drugs. It has been suggested that a number of these influence motor recovery following a brain lesion. Experimental findings indicate that selective serotonin reuptake inhibitors (SSRIs) may boost practice-dependent motor improvements, although large clinical randomized controlled trials showed no effect on outcome.6 It has been suggested that activation of gamma-aminobutyric acid (GABA) receptors may be detrimental to motor recovery. In this issue, Johnstone and colleagues determined whether common central nervous system–acting drugs altered outcomes in an intensive upper limb rehabilitation program. Previously in the Queen’s Square Upper Limb Recovery Programme, they have demonstrated that specific high-dose training in chronic stroke patients can result in clinically significant improvements in upper limb function.7 In a careful retrospective study in 277 stroke or brain injury patients, studied at a mean time since event of 20 months, they determined the effect of prescriptions on outcome.8 There was no evidence that patients prescribed GABA agonists performed worse on high-intensity rehabilitation. Patients on antidepressants, however, performed poorer than expected. The vast majority (about 80%) of antidepressants were selective serotonin reuptake inhibitors (SSRIs), so this was an unexpected observation.
Finally, this issue includes a review on an important emerging area on health services research particularly in the elderly, namely, frailty. Frailty describes a distinctive health state in which the ability of older people to cope with acute stressors is compromised by in increased vulnerability brought about by age-associated declines in physiological reserve and function across multiple organ systems. Although closely associated with age, multimorbidity, and disability, frailty is a discrete syndrome and is independently associated with poorer outcomes across a range of medical conditions. It has been reported to occur in about a fifth of all stroke patients, has been independently associated with stroke severity, and may influence stroke outcome although the authors highlight that more work is required in this area. Certainly an area for future research.
University of Cambridge, UK
Email: hsm32@medschl.cam.ac.uk
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