Stroke and Other Cerebrovascular Disorders Part Two: Rehabilitation Management and Treatments

Hopefully your doctor is well versed in everything here. Nothing here tells you the effectiveness of these treatments so I can only assume they barely work!  If they worked they would be shouting it from the rooftops!

Stroke and Other Cerebrovascular Disorders Part Two: Rehabilitation Management and Treatments

Author(s): Sarah Hunton, MD, Rani Gardner, MD, Suzanne Abou-Diab, MD, Bilal Ahsan

Originally published: October 3, 2012 Last updated: January 3, 2024

Jump to: Disease/disorderEssentials of AssessmentCutting Edge/emerging and Unique Concepts and PracticeRehabilitation Management and TreatmentsGaps in the Evidence-Based KnowledgeReferences

Disease/disorder

See Cerebrovascular Disorders Part 1.

Essentials of Assessment

See Cerebrovascular Disorders Part 1.

Cutting Edge/emerging and Unique Concepts and Practice

Constraint-induced movement therapy (CIMT)^1,2

Traditional CIMT involves restraint of the unaffected limb for 90% of the waking hours for 14 days while intensively training the use of the affected arm during 4-6 hour sessions. A modified version exists (mCIMT) during which the unaffected arm is only restrained for 5-6 hours per day; it is less time consuming and a more appealing option for patients and therapy team members. A number of studies have shown that CIMT induces a use-dependent increase in cortical reorganization of the areas of the brain controlling the more affected limb.^3,4 Studies have demonstrated significant improvements in motor and functional outcomes, although there have been mixed results. CIMT is shown to be effective in patients who have active wrist extension (at least 20 degrees), active finger extension (at least 10 degrees), good cognition, limited spasticity, and preserved balance. CIMT has shown effectiveness in improving motor function in both the acute and chronic phases of stroke recovery, but studies have been limited by small sample sizes.  High volume CIMT combined with electrical stimulation with task-specific training and strength training have been shown to be the most effective interventions in improving upper limb motor function in individuals with stroke. ⁵

Bilateral upper extremity training

This training is a stroke rehabilitation technique that has been applied to patients in both acute and chronic post-stroke phases. Investigators have recommended that patients in the chronic phase poststroke who retain at least a minimal degree of corticospinal integrity (as reflected by, e.g., active finger movements) should receive unilateral training, and those with little or no distal movement might benefit more from bilateral training. For those stroke patients without corticospinal tract integrity, targeting the contralesional hemisphere using bilateral training is expected to be more appropriate, although the functional gains are expected to be small.⁶

Body-weight-supported (BWS) therapy⁷

This modality allows stroke patients to safely participate in task-specific gait training. A harness provides support of body weight over a treadmill or other surface, while a therapist can observe and correct any unwanted gait pattern. BWS treadmill training can be done with or without visual feedback however no significant difference in functional improvements have been found with the presence or absence of visual biofeedback.⁸ BWS gait training has been shown to improve ambulation in hemiparetic stroke patients producing a more symmetric, efficient hemiparetic gait pattern. However, superiority of BWS therapy over conventional post-stroke gait training therapies has not been established.

Robotics⁹

Robotic devices are ideal for the repetitive exercises that are often used to facilitate motor relearning and strengthening after stroke. Used for both upper and lower limb rehabilitation, newer robotic software makes previously tedious and repetitive tasks more engaging by incorporating gaming and other challenges. Many newer robotic devices have the added benefit of being able to collect data for the rehabilitation team. Similar to most emerging therapies, there are barriers to use which include limited studies supporting benefit, high cost, and limited knowledge of using the technology.

Brain-computer interface (BCI)^10–12

BCI’s have evolved from assistive technologies allowing those with severe motor impairments (e.g., locked-in syndrome, stroke, amyotrophic lateral sclerosis) avenues to control devices for mobility and communication to newer neurorehabilitation tools allowing patients with severe motor deficits to participate in the rehabilitation process. BCI involves developing neuroprosthetic devices and technologies to bypass damaged brain tissue via adaptive neuroplasticity of uninvolved distal brain areas. Parts of the nervous system not involved in specific tasks can be harnessed to reconstruct the neural substrate that interacts with a BCI-driven devices. A brain-machine interface uses brain signals to drive external devices without the use of peripheral physiologic activities. Barriers to use are high cost and unreliable technology.

Noninvasive Brain Stimulation (NIBS) – Transcranial magnetic and direct current stimulation^13-15

This therapy involves applying mild magnetic or electric stimulation to the scalp. The benefit is thought to be achieved by neuromodulation of plasticity and cortical excitability. A growing number of studies support its therapeutic potential and safety in stroke rehabilitation and have shown to improve motor function, gait, language (aphasia) and cognitive (neglect) deficits, and mood. A meta-analysis reported that even though there are gait, balance, and lower limb function improvements across NIBS, the results vary based on the type of stimulation technique, the location of stimulated area, as well as the protocol used, warranting further in-depth research.¹⁵

Mental Practice (MP)/Motor Imagery¹³

This refers to mental rehearsal of a movement. Imaging studies have shown that this motor imagery stimulates overlapping cortical areas as the actual movements. Most studies have shown a positive effect on upper extremity function. A recent Cochrane Review found MP in combination with routine rehabilitation is more effective in restoring arm function compared to rehabilitation alone.¹⁷ A recent systematic review concluded that MP/MI used on its own is not effective, but it is shown to be effective in recovering upper limb motor movements, speed and coordination of such movements when used in conjunction with conventional and non-conventional therapies. There is still further research needed to establish assessment tools to analyze the efficacy of this therapy as well as to quantify the progress being made when used on its own.¹⁸

Mirror Therapy^13,19

Initially applied to amputation patients, this therapy involves placing a mirror in the mid-sagittal plane, allowing the patient to visualize the reflection of the non-paretic limb as if it were the paretic limb. The underlying theory is that there is cortical activation of the injured region of the brain from the perception of movement via interhemispheric communication.  Though there are studies have showing gains in motor function, there is limited evidence in the stroke population prompting routine use.¹⁶

Virtual reality (VR)²⁰

Virtual environments and objects provide the user with visual feedback and repetitive skills practice. The interface may be through a head-mounted device, projection systems, or involving sensations of hearing, touch, movement, balance, or smell. The user interacts with the environment by devices, such as a mouse or joystick, or more complex systems using cameras, sensors, or haptic feedback devices. A 2017 Cochrane review²⁰ found evidence that VR and interactive video gaming may be beneficial in improving upper limb function and ADL function as an adjunctive therapy or when compared with the same amount of standard therapy. There was insufficient evidence to make conclusions about the effect on grip strength, gait speed or global motor function. A randomized control trial observed a significant improvement in cognitive flexibility and shifting skills, selective attention/visual research, and quality of life with regard to perception of mental and physical state in stroke patients when VR and robotic exoskeleton were used in combination.²¹

Rehabilitation Management and Treatments

Current treatment guidelines(Survivors don't want useless guidelines! They want EXACT PROTOCOLS THAT DELIVER 100% RECOVERY! GET THERE!)

The American Heart Association (AHA) & American Stroke Association have published guidelines for the management and rehabilitation of stroke.^22–25

Acute stroke management

• Emergency noncontrast computerized tomography (CT) scan of the head is performed to differentiate between ischemic and hemorrhagic stroke.
• Intravenous thrombolysis with recombinant tissue plasminogen activator (rTPA) is indicated for adults with diagnosis of ischemic stroke in the absence of contraindications, provided it can be administered within 4.5 hours of symptom onset.^23,26
• Endovascular techniques (e.g., thrombectomy or intra-arterial fibrinolysis) are recommended for selected patients within 16-24 hours for those with large vessel occlusion in the anterior circulation > 6 hours.^13,23,26 rTPA should still be administered in eligible patients.^1,7 Intracranial vascular imaging (CT angiogram or MR angiogram) is recommended if endovascular therapy is contemplated.²⁷
• Initiation of aspirin within 24-48 hours is indicated for ischemic strokes.²³ Patients with acute ischemic stroke who are allergic to or intolerant of aspirin should be given an alternative antiplatelet agent (e.g. clopidogrel).
• Initial management of intracerebral hemorrhage (ICH) includes reversal of any identified coagulopathy and monitoring/lowering of intracranial pressure, if increased. Surgical evacuation is generally not indicated for supratentorial hemorrhage but is recommended for cerebellar ICH with brainstem compression or hydrocephalus.²⁶
• Comprehensive stroke centers and stroke systems of care(NOT RESULTS OR RECOVERY! So useless!) improve(NOT GOOD ENOUGH!) outcomes through prevention and treatment of stroke, as well as post-stroke rehabilitation.^23,24,26

Acute and post-acute stroke management and rehabilitation^16,24

Early initiation of rehabilitation after acute stroke is associated with shorter rehabilitation length of stays and improved functional outcomes.²⁴

The goals of rehabilitation include prevention of complications, minimizing functional impairments, and maximizing function recovery. Initial rehabilitation efforts should start as soon as possible in the acute care setting then transition to the inpatient rehabilitation setting. Other levels of post-acute care include sub-acute inpatient rehabilitation, day rehabilitation programs, outpatient programs, and home therapy programs.

Rehabilitation involves a multidisciplinary team that is often led by a rehabilitation physician. Depending on functional impairments and patient needs, the team often includes:

• Physical therapy: evaluation and rehabilitation of mobility including stretching, range of motion, strengthening, balance, endurance, transfers, standing, and ambulation
• Occupational therapy: evaluation and rehabilitation of self-care skills including treatment of impairments related to activities of daily living and upper extremity impairments
• Speech and language pathology: evaluation and rehabilitation of cognitive, language, and swallowing impairments
• Neuropsychology: Psychological support and cognitive assessment and interventions
• Nursing: Assistance with bed mobility and positioning, bowel and bladder management, skin care, education
• Recreational therapy: community integration, functional cognitive tasks (games, music, social interaction, etc.)
• Social work/Case management: Discharge planning, resource and benefits counseling, and guidance/education
• Other disciplines: vocational rehabilitation specialist, dietician, pharmacist

The rehabilitation physician and team play a significant role in minimizing complications

• Early mobilization: Minimizing deconditioning and its associated effects on fatigue, orthostatic hypotension, and endurance.
• Evaluation and treatment of dysphagia: Dysphagia is common and increases risk of pneumonia. A formal swallowing assessment is standard of care for determination of the safest diet consistency/texture to minimize risk of aspiration; aspiration is missed on bedside swallow study in 40-60% of patients. Screening should be performed before any oral intake. Dynamic instrumental assessment with a videofluoroscopy swallowing study (VFSS) or fiberoptic endoscopic evaluation of swallowing (FEES) can help guide rehabilitative techniques.
• Nutrition status: Adequate nutritional status, including adequate hydration, should be ensured by monitoring intake (consider formal calorie counts), body weight, and laboratory tests (e.g., albumin or prealbumin).
• Blood glucose levels: Monitor for at least 72 hours post-stroke. Hyperglycemia or hypoglycemia should be treated adequately. Blood glucose should be maintained between 140-180 mg/dl.
• Blood pressure management:^{25,26,29–31} There is controversy about optimal blood pressure levels in the acute stage and concern about adverse effect on collateral circulation in the brain with rapid lowering of blood pressure. It is reasonable to restart or initiate antihypertensives during acute hospitalization with pressures greater than 140/90mmg HG once neurologically stable and it is suggested that lowering blood pressure no more than 15% during the first 24 hours is reasonable when values are significantly elevated (greater than or equal to 220/120mmHG).
• Spasticity: Prevention and early detection are important. Prevention measures include early mobilization, range of motion, proper positioning, and use of braces, if needed. Medications include tizanidine, dantrolene, and baclofen.  Botulinum toxin or intrathecal baclofen should be considered for selected patients. Contractures can be treated using splinting, serial casting, or surgical correction. Diazepam and other benzodiazepines should be avoided during the stroke recovery period because they may delay recovery. Those who have spasticity in their upper or lower limbs after stroke should not be treated with electrical stimulation to reduce spasticity unless after botulinum toxin injection to wrist or fingers as an adjunct to splinting.³²
• Deep vein thrombosis (DVT) prophylaxis: Preventative measures include early mobilization, pharmacological prophylaxis with subcutaneous heparin or low molecular weight heparin (unless contraindicated), and pneumatic compression devices or graduated compression stockings. An inferior vena cava filter may be considered in patients at risk for pulmonary embolism if anticoagulation is contraindicated.
• Shoulder pain: Prevention of post-stroke shoulder pain and subluxation is done through careful monitoring, proper positioning, hemiplegic limb support including use of wheelchair arm trough, shoulder harness/sling or taping, trauma prevention, avoidance of uncontrolled abduction and overhead pulley use, and precautions during transfers. Shoulder subluxation and pain may be treated with oral medications, intra-articular steroid injections, shoulder support, arm trough or lap tray, stretching, thermal modalities, functional electrical stimulus, spasticity management, or referral for suprascapular nerve block.³³
• Bladder management: Urinary incontinence is a common post-stroke complication but often resolves over time. Urinary retention can be assessed with use of a bladder scanner or an in-and-out catheterization. Timed voids and temporary use of external or intermittent catheterization may be helpful. Indwelling catheters increase risk of urinary infection and prolonged use should be avoided whenever feasible.
• Bowel management: Incontinence is less common than constipation or fecal impaction. Discussion regarding improved diet, fluid intake and exercise as well as medication review for constipating medications is encouraged. A bowel regimen involving the use of laxatives, stool softeners, and bowel training should be initiated.
• Skin: Skin integrity should be assessed on admission and monitored daily. Skin breakdown risk may be assessed with standardized tools, such as the Braden Scale. Preventative interventions include special mattresses, frequent turning, proper positioning, transfers, lubricants, barrier sprays and ointments, spasticity management when appropriate and protective dressings.
• Medication considerations: Central nervous system (CNS) depressants, such as neuroleptics, benzodiazepines, and barbiturates, may be associated with poorer outcomes and should be avoided whenever feasible.
• Post-stroke depression: Up to 1/3^rd of all stroke patients will experience depression during their recovery process. Early diagnosis and treatment is recommended as stroke outcomes have been shown to be negatively affected and may even increase risk of recurrent stroke.³¹ Depression may be related to neurotransmitter depletion from stroke lesions and/or psychological response to physical/personal losses associated with stroke. Selective serotonin reuptake inhibitors are the preferred medication when appropriate and should not be given routinely for prevention of depression without evidence of increased risk due to increased potential of adverse effects.³⁴ Several studies suggest neural mechanisms of recovery may be facilitated by certain antidepressants.²⁸ Other emerging treatment approaches include electroconvulsive therapy, acupuncture, music therapy, and nutraceuticals.²⁹ Further studies are needed in these emerging areas.
• Fall risk: Fall risk should be assessed using established tools and prevention strategies utilized. Strategies include low beds, bed alarms, wheelchair belts, and patient/caregiver education.
• Infection: Fever should be reduced promptly. Pneumonia and urinary tract infections should be prevented and promptly identified and treated if they occur.
• Specific rehabilitation interventions: Rehabilitation interventions are based on comprehensive, standardized assessments for impairments (motor, sensory, cognitive, communication, swallowing, psychological, and safety awareness) and prior/current functional status.
  • Motor assessment should be at both the impairment and functional level. Components should include strength, active and passive range of motion, tone, gross and fine motor coordination, balance, apraxia, and mobility. Motor function is addressed with strengthening, balance and gait training, orthoses, transcutaneous electrical nerve stimulation (TENS), robot-assisted movement therapy, constraint-induced movement therapy, and body-weight-supported treadmill training, and upper extremity interventions in order to improve activities of daily living.⁶ Functional electrical stimulation may help facilitate movement or compensate for lack of voluntary movement.
  • Sensory assessment should include an evaluation of different sensations (sharp/dull, temperature, light touch, vibratory and position), a vision exam, and a hearing exam if hearing impairment is suspected. Compensatory techniques for sensory impairments should be included in the stroke patient’s individualized rehabilitation program.
  • Cognitive assessment should address arousal, attention, visual neglect, learning, memory, executive function, and problem solving.
  • Psychosocial assessments should be made of psychological factors (e.g., pre-morbid personality, level of insight, loss of identity concerns, sexuality), psychiatric illnesses, available resources, social support, patient goals, life situation, and social roles. A home assessment may be needed.
  • Management of dysphagia includes postural changes, increased sensory input, modified swallowing maneuvers, active exercise programs, and diet modifications. Non-oral feeding may be required in some instances, including consideration of percutaneous endoscopic gastrostomy feeding.
  • Aphasia management includes early recognition and development of a multidisciplinary focused treatment plan to increase gains during spontaneous recovery and use of compensatory techniques for persistent communication problems. Dysarthria treatments include interventions to improve articulation, fluency, resonance, and phonation, compensatory techniques, and use of alternate/augmentative communication (AAC) devices. Personalized, telerehabilitation programs as supplementation to in person rehabilitation as shown to be beneficial for those limited by insurance, transportation or limited providers.³⁵
  • Cognitive deficits are common and can include impaired memory, concentration and executive function. Deficits can be managed through patient, family, and staff education of deficits, teaching compensatory strategies and structured feedback.
  • Measures to address visual and spatial neglect should be integrated with other therapies, and may include prism glasses, increased awareness of deficits, and compensatory techniques.
  • Neuropsychiatric sequalae should be identified and treated. Acetylcholinesterase inhibitors or the NMDA receptor inhibitor, Memantine, can be considered for patients with vascular dementia or vascular cognitive impairment.²⁷ Amphetamines are not recommended to enhance motor recovery.²⁷
  • Patient, family, and caregiver education is an integral part of rehabilitation, as are appropriate advocacy and identification and help with securing of available support and resources. Assessment findings and expected outcomes should be discussed with the patient and family/caregivers.

Chronic stroke management

• Rehabilitation team members should provide adequate support as the patient transitions from inpatient rehabilitation to home. Team can provide assistance with ordering appropriate durable medical equipment (DME), instructions for home rehabilitation programs, arranging for home health or outpatient therapy services, scheduling follow up medical appointments, and providing information on local stroke support groups.
• Ongoing management may include a regular exercise program, walking aids and/or wheelchair, adaptive devices for activities of daily living, home modifications, addressing return to work, driving, management of sexual dysfunction, and ongoing evaluation and management of stroke risk factors and comorbid conditions. Appropriate safety measures (e.g., fall prevention) should be instituted.⁴
• Secondary prevention of stroke:³⁰ Appropriate treatment of hypertension, anticoagulation for atrial fibrillation thrombo-embolic prophylaxis, use of antiplatelet therapy in cerebral ischemia, prevention of coronary heart disease, lipid lowering therapy, exercise, and smoking cessation are all important. Blood sugar maintenance of near-normoglycemic levels (80-140 mg/dl) is recommended for long-term prevention of microvascular and macrovascular complications.

Coordination of care

Coordination of treatment care plans should include all involved medical specialists-including the primary care physician, home care services, outpatient therapists, and the patient and their care givers. A multidisciplinary team is essential for success.

Patient & family education

Education must focus on management of risk factors, maintenance of rehabilitation gains, preventing complications, community support and resources, home modifications, and community reintegration.

Key topics for stroke prevention education (also see “Secondary prevention of stroke” section above):

• Modifiable risk factors include hypertension, heart disease, diabetes, obesity or being overweight.
• Recommend: smoking cessation, avoiding excess alcohol consumption, having a balanced diet, and exercise participation.

Key topics for post stroke complication education and prevention

• Maintain regular follow up with a primary care physician to prevent and monitor for complications.
• Monitor for signs and symptoms of post stroke complications: depression, spasticity or contractures, shoulder pain/subluxation, DVTs, pressure ulcers, pneumonias, seizures, osteoporosis, UTIs and/or bladder control.
• The following treatment or preventative techniques may be employed:
  • Counseling, psychotherapy, local stroke support groups, and antidepressant medications may be utilized for depression.
  • Range of motion exercises and physical therapies can help prevent limb contractures and shoulder pain.
  • Good nutrition and frequent pressure relief, including turning while in bed, will help prevent pressure ulcers.
  • Swallowing exercises and precautions, deep breathing exercises, and respiratory therapy can minimize risk of pneumonia.
  • Bladder training programs may be helpful for poor bladder function control.

Outcome measures

Functional status, discharge disposition (i.e., home versus facility), hospital readmissions, and mortality are important indicators to measure in the post-discharge period.

Common scales

• Functional Independence Measure Scale (FIM): Assesses physical and cognitive function focusing on burden of care. There are a total of 13 motor items and 5 social-cognitive items. Each item is scored from 1-7, with 7 indicating complete independence.
• Modified Rankin Scale: A global outcome scale that runs from 0-6, with 0 being perfect health without symptoms, and 6 being death. It is commonly used for measuring the degree of disability, or dependence, and has become a widely used clinical outcome measure for stroke clinical trials.

Gaps in the Evidence-Based Knowledge

• Although several different forms of rehabilitation techniques have been proven effective, these studies often involve small and highly selective populations and are not generalizable to the stroke population.
• Further studies are needed to develop optimal treatment protocols evaluating for ideal patient population(No survivor should be left behind, they all want 100% recovery! Why the hell isn't that your goal?), ease of treatment program, and combined modalities for many of the therapies, including constraint-induced movement therapy, indirect brain stimulation, and mirror therapy.
• Blood pressure management during early stroke management continues to be an area of conflict. Larger trials with well-defined criteria are needed and appear to be forthcoming. Current guidelines should be followed until such time.²⁵
• The most recent AHA guidelines suggest further study is needed in specific areas of early acute ischemic stroke management, including in intravenous fibrinolysis, endovascular interventions, anticoagulants, antiplatelet agents, and induced hypertension.²⁶
• The use of complementary and alternative medicine (CAM) in cardiovascular disease and stroke patients has gained in popularity over recent years and appears common. These include biological therapies such as dietary supplements, herbal medicine, and aromatherapy; mind-body therapies such as deep breathing, meditation, yoga, tai chi, and praying; manipulative and body-based therapies such acupressure, chiropractic manipulation, massage, osteopathic manipulation, and reflexology; whole medical systems which include acupuncture, Ayurveda, homeopathy, and naturopathy; and finally energy medicine which includes healing touch, light therapy, magnetic therapy, Reiki, and sound energy therapy. Biologic, mind-body therapies, and acupuncture (especially among stroke patients) are the most commonly used. Potential interactions and adverse effects may exist for biological CAM therapies. Further studies are needed, especially in regard to effects of CAM therapies on clinical outcomes and safety, particularly in stroke patients.^31,36
  

References at link.

AI-driven Stroke Rehabilitation Systems and Assessment: A Systematic Review.

Since only 10% of survivors get to full recovery, there is NO therapy department in the world that is effective. That is how stroke survivors rate effectiveness, they don't use the tyranny of low expectations to declare success. Stroke survivors have only 1 question to answer: Am I 100% recovered? Y/N? If yes, you may have an effective stroke department.

AI-driven Stroke Rehabilitation Systems and Assessment: A Systematic Review.

Rahman S,

Sarker S,

Nadimul Haque AKM,

Uttsha MM,

Islam MF,

Deb S

IEEE Transactions on Neural Systems and Rehabilitation Engineering : a Publication of the IEEE Engineering in Medicine and Biology Society, 03 Nov 2022, PP
DOI: 10.1109/tnsre.2022.3219085 PMID: 36327176 

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Abstract 

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Post-stroke therapy restores lost skills. Traditionally, patients are supported by skilled therapists who monitor their progress and evaluate the program's effectiveness. Due to a shortage of qualified therapists, rehabilitation facilities are both expensive and inadequate. Furthermore, evaluations may be subjective and prone to errors. These limitations motivate the researchers to devise automated systems with minimal human intervention, therapist-like assessment, and broader outreach. This article reviews seminal works from 2013 onwards, qualitatively and quantitatively adapting the PRISMA approach to examine the potential of robot-assisted, virtual reality-based rehabilitation and automated assessments through data-driven learning. Extensive experimentation on KIMORE and UI-PRMD datasets reveal high agreement between automated methods and therapists. Our investigation shows that deep learning with spatio-temporal skeleton data and dynamic attention outperforms others, with an RMSE as low as 0.55. Fully automated rehabilitation is still in development, but, being an active research topic, it could hasten objective assessment and improve outreach.

Full text links

Clinical effectiveness of endovascular stroke treatment in the early and extended time windows

You obviously have the wrong definition of efficacy and effectiveness. 100% recovery  is the only goal in stroke and you're not even measuring that.

Clinical effectiveness of endovascular stroke treatment in the early and extended time windows

Show all authors

Raul G Nogueira, Diogo C Haussen, David S Liebeskind, ...

First Published April 20, 2021 Research Article Find in PubMed 

https://doi.org/10.1177/17474930211005740

Article information

 

Abstract

Background

The clinical efficacy of mechanical thrombectomy has been unequivocally demonstrated in multiple randomized clinical trials. However, these studies were performed in carefully selected centers and utilized strict inclusion criteria.

Aim

We aimed to assess the clinical effectiveness of mechanical thrombectomy in a prospective registry.

Methods

A total of 2008 patients from 76 sites across 12 countries were enrolled in a prospective open-label mechanical thrombectomy registry. Patients were categorized into the corresponding cohorts of the SWIFT-Prime, DAWN, and DEFUSE 3 trials according to the basic demographic and clinical criteria without considering specific parenchymal imaging findings. Baseline and outcome variables were compared across the corresponding groups.

Results

As compared to the treated patients in the actual trials, registry-derived patients tended to be younger and had lower baseline ASPECTS. In addition, time to treatment was earlier and the use of intravenous tissue plasminogen activator (IV-tPA) and general anesthesia were higher in DAWN- and DEFUSE-3 registry derived patients versus their corresponding trials. Reperfusion rates were higher in the registry patients. The rates of 90-day good outcome (mRS0-2) in registry-derived patients were comparable to those of the patients treated in the corresponding randomized clinical trials (SWIFT-Prime, 64.5% vs. 60.2%; DAWN, 50.4% vs. 48.6%; Beyond-DAWN: 52.4% vs. 48.6%; DEFUSE 3, 52% vs. 44.6%, respectively; all P > 0.05). Registry-derived patients had significant less disability(So you think your tyranny of low expectation is OK for your patients? Talk to them sometimes.) than the corresponding randomized clinical trial controls (ordinal modified Rankin Scale (mRS) shift odds ratio (OR), P < 0.05 for all).

Conclusion

Our study provides favorable generalizability data for the safety and efficacy of thrombectomy in the “real-world” setting and supports that patients may be safely treated outside the constraints of randomized clinical trials.

Keywords Stroke, thrombectomy, registry

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Effectiveness of a multidisciplinary approach in the rehabilitation treatment of post-stroke patients at the outpatient stage of medical rehabilitation

Multidisciplinary is a useless big word used to disguise the fact your stroke team KNOWS ABSOLUTELY NOTHING ABOUT 100% STROKE RECOVERY.

Hope your doctor knows Russian.

Effectiveness of a multidisciplinary approach in the rehabilitation treatment of post-stroke patients at the outpatient stage of medical rehabilitation

• Authors: Fakhretdinov V.V.¹, Brynza N.S.¹, Kurmangulov A.A.¹
• Affiliations:
  1. Tyumen State Medical University
• Issue: Vol 26, No 1 (2020)
• Pages: 4-9
• Section: Health care organization and public health
• URL: https://journals.eco-vector.com/0869-2106/article/view/25848
• DOI: https://doi.org/10.18821/0869-2106-2020-26-1-4-9
• Cite item

(Russian)

Abstract

Background. Current approaches to the rehabilitation of stroke patients are based on the early start of rehabilitation measures, a certain sequence, duration, and, of course, the active participation of the patient and their environment. Recently, the scientific medical community has engaged in a serious discussion on the organization of rehabilitation from the perspective of a multidisciplinary approach.
Aim. To assess the impact of the multidisciplinary approach to the outpatient rehabilitation phase on the main health components in stroke patients.
Materials and methods. An experimental, longitudinal, open study included 60 patients with stroke in the late residual period. The studied patients were classified into groups using stratification randomization: Group 1 – 30 (50%) patients with high rehabilitation potential, as well as a high degree of personal interest in undergoing the outpatient phase of medical rehabilitation; Group 2 – 30 (50%) patients who had rehabilitation potential but were, for several reasons, forced to refrain from undergoing the outpatient phase of medical rehabilitation. The duration of the outpatient rehabilitation phase was 14 days: the course of rehabilitation treatment included 10 visits to the rehabilitation department, which operates on the principles of lean manufacturing and a quality management system; 2 days of medical leave; and 2 days of independent work by patients. The multidisciplinary team included a neurologist, physiotherapy physiologist, physical therapy instructor, speech therapist, psychologist, occupational therapist, and a social worker who received special training in medical rehabilitation. As the criteria for assessing the effectiveness of rehabilitation measures during the course of this study, we identified 11 key indicators that allowed us to assess the recovery of neurological deficit, motor functions, possible risk of patients falling, psycho-emotional state, cognitive functions, level of disability, frequency of repeated strokes, number of visits to the clinic place of residence, level of independence, and quality of life of the patient.
Results. When we compared these groups in response to the course of rehabilitation treatment, the patients who passed the outpatient stage achieved a positive result of 91% (a positive response to 10/11 criteria for evaluating effectiveness(Did the effectiveness questions ask about 100% recovery? If not, you didn't ask the correct questions.), while the percentage of response to treatment in the second group was 18% (positive answer for 2/11 criteria for evaluating effectiveness).
Conclusion. To achieve the rehabilitation goals and objectives set for the patient in the late recovery period, it is advisable to conduct the outpatient phase of medical rehabilitation.

Keywords

stroke, rehabilitation, multidisciplinary approach, multidisciplinary team, drop, depression, anxiety, quality of life.

Full Text

Актуальность исследования

Инсульт является одной из самых актуальных медико-социальных и экономических проблем современного общества, продолжая занимать лидирующее место среди всех цереброваскулярных заболеваний по распространенности, смертности и стойкой инвалидизации среди взрослого населения [1, 2]. Современные подходы к реабилитации пациентов, перенесших мозговой инсульт, основаны на раннем начале реабилитационных мероприятий, определенной последовательности, длительности и, конечно, активном участии самого пациента и его окружения [3]. При этом в поздний восстановительный период (6 мес –2 года) инсульта особо возрастает значимость решения задач по поддержанию и совершенствованию когнитивных функций и речи, активному перемещению пациентов с помощью средств дополнительной опоры, совершенствованию ходьбы и навыков самообслуживания [4]. В последнее время в научном медицинском сообществе серьезно обсуждается организация реабилитации с позиции мультидисциплинарного подхода [5, 6]. Объединение специалистов в мультидисциплинарную бригаду, оказывающую помощь в лечении и реабилитации пациентов и работающих как единая команда (бригада) с четкой согласованностью и координированностью действий, открывает новые возможности в реализации задач реабилитации. С этой связи целью настоящего исследования явилась оценка влияния мультидисциплинарного подхода этапа амбулаторной реабилитации на основные компоненты здоровья у пациентов, перенесших инсульт.

Материал и методы

В экспериментальное продольное открытое исследование были включены 60 пациентов с инсультом в позднем восстановительном периоде. Критериями включения в исследование – верифицированный диагноз ишемический инсульт давностью от 6 месяцев до 2-х лет; значения по шкале реабилитационной маршрутизации (ШРМ) 2-3 балла; возможность продуктивного контакта с самим пациентом и его близкими; подписание добровольного информированного согласия на исследование и использование современных методов реабилитации. Критериями исключения из исследования – давность инсульта более 2 лет и менее 6 месяцев; возраст менее 40 и более 80 лет; тяжелая сопутствующая соматическая патология; высокие риски несоблюдения протокола исследования и др.
Исследуемые пациенты были определены в группы методом стратификационной рандомизации: 1 группа – 30(50%) пациентов, имеющих высокий реабилитационный потенциал, а также высокую степень личной заинтересованности прохождения амбулаторного этапа медицинской реабилитации; 2 группа – 30(50%) пациентов, имеющих реабилитационный потенциал, но в силу ряда причин отказавшиеся от прохождения амбулаторного этапа медицинской реабилитации. Достоверные различия групп по возрасту, полу и стадиям заболевания отсутствовали.
Длительность амбулаторного этапа реабилитации составила 14 дней. Курс восстановительного лечения включал в себя 2 дня лечебного отпуска; 2 дня самостоятельной работы пациентов, 10 посещений отделения реабилитации, функционирующего на принципах бережливого производства и системы менеджмента качества. В основе бережливого подхода устанавливалось снижение основных и дополнительных потерь со стороны пациента (прием в одном помещении, снижение трансакционных издержек, организация приема по принципу «точно-вовремя», сокращение ненужной транспортировки медицинских документов) и со стороны медицинских сотрудников отделения (организация рабочего пространства по методу 5S, визуализация данных, внедрения метода всеобщего обслуживания оборудования) [7, 8]. В состав мультидисциплинарной бригады входили прошедший специальную подготовку по вопросам медицинской реабилитации врач-невролог, врач лечебной физкультуры, инструктор лечебной физической культуры, нейропсихолог-логопед, психолог, эрготерапевт, социальный работник. В данном составе бригада разрабатывала индивидуальный план медицинской реабилитации с учетом выраженности неврологического дефицита, а также функциональных нарушений пациента. Для адекватного отражения изменений в состоянии пациента, проделанной медицинским и педагогическим персоналом работы и повышения мотивации к процессу реабилитации использовались клинические шкалы, отражающие патологический процесс, изменения в различных системах. В процессе проведения восстановительного лечения в ежедневном режиме проводилась повторная оценка состояния пациента и корректировался ход восстановительных занятий в зависимости от результатов оценки, что позволило снизить неэффективное использование ресурсов и повысить качество восстановительно лечения.
В качестве критериев для оценки эффективности реабилитационных мероприятий в ходе настоящего исследования были определены 11 основных показателей, позволяющих оценить восстановление неврологического дефицита, моторные функции, возможные риски падения пациентов, психоэмоциональное состояние, когнитивные функции, уровень самостоятельности и качества жизни пациента.
Полученные данные были обработаны статистически в программном пакете Statistica 10.0. Нормальность распределения значений параметров оценивали с использованием критерия Шапиро–Уилка. Данные были представлены в виде среднего арифметического ± стандартное отклонение. Для дальнейших расчетов использовали методы параметрической статистики: для количественных признаков в сравнении групп – критерий Стьюдента, для сравнения показателей внутри одной группы в разные моменты времени – парный критерий Стьюдента. Критический уровень значимости (p-value) при проверке статистических гипотез принимали равным 0,05.

Результаты и обсуждение

Двухнедельная динамика показателей физического компонента здоровья пациентов, перенесших инсульт, оказалась более выраженной в четырех из пяти анализируемых показателей у пациентов, которые находились на амбулаторной реабилитации (табл. 1).

Таблица 1
Динамика показателей физического компонента здоровья пациентов, перенесших инсульт, на фоне амбулаторной реабилитации
№	Показатель		1 группа	2 группа	Уровень достоверности (p)
					1-2*	1**	2***
1	ШРМ, баллы	исх.	2,53±0,5	2,40±0,5	0,309	<0,05	0,528
2		2 нед	2,20±0,5	2,33±0,5	0,251
3	Индекс Ривермид, баллы	исх.	13,40±0,7	13,53±0,6	0,432	<0,01	0,735
4		2 нед	13,97±0,8	13,57±0,6	<0,05
5	Шкала Рэнкин, баллы	исх.	2,57±0,5	2,60±0,5	0,798	<0,01	0,262
6		2 нед	2,17±0,5	2,47±0,5	<0,05
7	ВАШ, баллы	исх.	3,23±1,1	3,03±0,9	0,427	<0,05	&lt0,05
8		2 нед	2,33±0,5	2,40±0,5	0,599
9	Коэффициент падений, баллы	исх.	2,53±0,7	2,90±0,9	0,085	<0,05	0,182
10		2 нед	2,23±0,6	2,70±0,7	<0,01
Примечание. * – различия между 1 и 2 группой; ** – различия 1 группы в динамике; *** – различия 2 группы в динамике.

ШРМ (шкала реабилитационной маршрутизации) чувствительна для оценки реабилитационного потенциала пациентов, перенёсших инсульт. При сравнении эффективности восстановительного лечения при исходно одинаковых значениях в обеих группах (2-3 балла) только пациенты с амбулаторным этапом реабилитации показали статистически значимую положительную динамику (13,0%) снижения значений ШРМ. Быстрое снижение неврологического дефицита, оценённое по ШРМ, в данной группе способствует в дальнейшем более благоприятному исходу инсульта.
Уровень мобильности, оцененный по индексу мобильности Ривермид, статистически значимо увеличился (p<0,01) на 4,3% у пациентов 1 группы. В то же время пациенты 2 группы по способности перемещать собственное тело не продемонстрировали динамику через 2 недели (p>0,05).
Степень нарушенных функций и самостоятельности в повседневной жизни при исходно одинаковых значениях (p>0,05) в обеих группах статистически значимо (p<0,01) снизилась на 18,4% у пациентов, прошедших двухнедельную амбулаторную реабилитацию. При этом значение шкалы Рэнкин во 2 группе снизилось только на 5,3%, что оказалось статистически не значимо (p>0,05).
Болевой синдром статистически значимо (p<0,05) уменьшился в обеих группах вне зависимости от формы проводимого восстановительного лечения. При этом значения Визуальной аналоговой шкалы (ВАШ) в обеих группах в динамики оказались сопоставимы (p>0,05). Полученные результаты коррелируют с многочисленными литературными данными [3, 9, 10]. Большинство отечественных и зарубежных исследователей данной проблемы отмечают снижение болевого синдрома у пациентов, перенёсших инсульт, в позднем восстановительном периоде независимо от лечебной и реабилитационной тактики, в том числе и в случаях ее полного отсутствия. Вероятнее всего, в основе данного эффекта лежит активация естественных собственных адаптационных и восстановительных механизмов организма человека [9].
У пациентов 2 группы, по сравнению с группой на амбулаторной реабилитации, установлены более частые случаи травматизма, вызванные частыми падениями пациентов как исходно (+14,6%), так и в процессе двухнедельного наблюдения (+14,6%). При опросе самих пациентов и/или их близких установлено, что у 39% (12/30 человек) отмечались ежедневные падения с высоты собственного роста. В то же время у пациентов 1 группы указанный показатель был значительно ниже – 20% (6/30 человек). Данное осложнение инсульта влияет как на высокий показатель травматизма пациентов 2 группы, так и на выбор тактики восстановительного лечения. 1% (3/10 человек) пациентов 2 группы в течение позднего восстановительного периода имели серьезные повреждения: перелом бедра на стороне пареза – 1 человек, перелом таза – 1 человек, перелом запястья – 1 человек. В 1 группе риск падений был ниже, серьезных травм, полученных при падениях, зафиксировано не было, это могло опосредованно повлиять на активное желание посещения отделения медицинской реабилитации.
Двухнедельная динамика показателей психического компонента здоровья пациентов, перенесших инсульт, оказалась более выраженной по одному из трех анализируемых показателей у пациентов, которые находились на амбулаторной реабилитации (табл. 2).

Таблица 2
Динамика показателей психического компонента здоровья пациентов, перенесших инсульт, на фоне амбулаторной реабилитации
№	Показатель		1 группа	2 группа	Уровень достоверности (p)
					1-2*	1**	2***
1	Когнитивные нарушения, баллы	исх.	24,73±1,3	24,30±1,7	0,274	<0,01	0,320
2		2 нед	25,63±1,8	24,70±1,6	0,036
3	Уровень тревоги, баллы	исх.	4,60±1,5	4,17±1,1	0,209	<0,05	<0,05
4		2 нед	3,93±1,1	3,60±1,0	0,228
5	Уровень депрессии, баллы	исх.	8,77±1,9	8,47±1,8	0,526	<0,05	0,321
6		2 нед	7,93±2,0	8,13±2,4	0,726
Примечание. * – различия между 1 и 2 группой; ** – различия 1 группы в динамике; *** – различия 2 группы в динамике.

При оценке когнитивных нарушений в обеих группах при одинаково низком исходном значении по Монреальской шкале, указывающей на снижение когнитивных функций (внимание и концентрация, исполнительные функции, память, речь, абстрактное мышление, счет и ориентация), в 1 группе отмечена положительная динамика на фоне восстановительного лечения (+3,5%, p<0,01), в то время как во 2 группе динамика анализируемого показателя оказалась статистически не значимой (p>0,05).
Исходно уровень тревожных расстройств пациентов обеих групп соответствовал нормативному показателю и не превышал 7 баллов по Госпитальной школе тревоги и депрессии. Через 2 недели как в 1 группе, так и во 2 группе отмечено снижение показателя тревожности в 1,1 раза (p<0,05). Наличие или отсутствие амбулаторного этапа реабилитации не повлияло на итоговые значения уровня тревоги. Вероятнее всего, подобная динамика объясняется психологической адаптацией к сложившейся ситуации пациентов; завершением острой стадии стрессовой ситуации, вызванной основным заболеванием; принятием собственной личности и окружающего пространства в сложившейся новой реальности необходимости существования с проявлением заболевания, его осложнений и последствий.
В то же время наличие амбулаторного этапа восстановительного лечения, включающего в свой арсенал индивидуальные и групповые занятия с медицинским психологом, отразилось в статистически значимом (p<0,05) снижении уровня депрессии на 10,6% по сравнению с исходными данными. Пациенты 2 группы не показали динамики результатов (p>0,05). При этом динамическое наблюдение данной группы показало увеличение коэффициента вариации показателей с 21% до 30%, что свидетельствует о расширении разброса значений данного признака спустя 2 недели.
Социальная дезадаптация человека является одной из острейших проблем реабилитации постинсультных больных как для системы здравоохранения, так и для общества, в целом. Двухнедельная динамика показателей социального компонента здоровья пациентов, перенесших инсульт, оказалась более выраженной во всех анализируемых показателях у пациентов, которые находились на амбулаторной реабилитации (табл. 3).

Таблица 3
Динамика показателей социального компонента здоровья пациентов, перенесших инсульт, на фоне амбулаторной реабилитации
№	Показатель		1 группа		Уровень достоверности (p)
					1-2*	1**	2***
1	Степень зависимости от близких, баллы	исх.	2,23±0,7	2,17±0,7	0,719	0,107	0,201
2		2 нед	1,97±0,5	2,40±0,6	<0,01
3	Уровень социализации, баллы	исх.	2,20±0,4	2,03±0,6	0,190	<0,05	0,320
4		2 нед	2,53±0,5	2,20±0,6	<0,05
5	Уровень приверженности к лечению, баллы	исх.	2,10±0,4	1,87±0,6	0,073	<0,01	0,203
6		2 нед	2,47±0,6	1,70±0,5	<0,001
Примечание. * – различия между 1 и 2 группой; ** – различия 1 группы в динамике; *** – различия 2 группы в динамике.

Степень зависимости пациентов от близких и родственников оказалась на 22% выше во 2 группе (p<0,01) в сравнении с группой прошедших амбулаторный этап. При долгосрочной оценке через 6 месяцев показатель самостоятельности в группе пациентов, прошедших амбулаторный этап в сравнении с пациентами 2 группы показал статистически значимую разницу (p<0,05). Степень зависимости у пациентов 2 группы статистически значимо возросла (p<0,05). Это дает право предположить, что амбулаторный этап медицинской реабилитации способствует формированию самостоятельности пациентов и снижает степень зависимости от посторонних в повседневной жизни.
При исходно одинаковом уровне социальной активности спустя две недели с момента наблюдения у пациентов 1 группы определялось статистически значимое (p<0,05) повышение уровня потребности межличностного общения, участия в социальных процессах и проявлении интересов. В то время как у 13% (4/30) пациентов 2 группы по результатам опроса близких, напротив, была отмечена тенденция к снижению социализации, уровня вербального общения, реакции на окружающие изменения. В процессе долгосрочного наблюдения 17%(5/30) пациентов 2 группы на фоне отрицания проблем начали злоупотреблять алкоголем (более 8 литров алкоголя в год и 3-4 дня полной трезвости в неделю).
Показатель уровня приверженности к лечению у пациентов 1 группы оказался выше (p<0,01), чем у пациентов 2 группы, что соответствует распределению пациентов по анализируемым группам – одним из стратификационных критериев рандомизации стало согласие пациента проходить амбулаторный этап реабилитации. Стоит также отметить, что прохождение амбулаторного этапа, и, по всей видимости, положительный эффект от реабилитации, статистически значимо (p<0,05) повышает комплаентность пациентов к лечению в будущем: пациенты начинают понимать основные цели реабилитационного процесса, появляется интерес к достижению еще большего реабилитационного потенциала, новых результатов.
Амбулаторной этап реабилитации направлен на стабилизацию течения основного сосудистого заболевания, адаптацию к повседневным бытовым нагрузкам, уменьшению выраженности двигательных и других постинсультных нарушений. К задачам мультидисциплинарной бригады в рамках отделения реабилитации МО относится выработка со стороны пациентов заместительных компенсаций, приспособлении к дефекту, ликвидации артралгий, коррекции психопатологических проявлений, полном или частичном восстановлении бытовой активности.

Заключение

Наличие амбулаторного этапа восстановительного лечения положительно сказывается на состоянии физического, психического и социального компонента здоровья пациентов, перенесших инсульт. В то же время, даже отсутствие амбулаторной реабилитации характеризуется постепенным снижением уровня боли и тревоги, что можно объяснить активизацией собственных адаптационных механизмов организма человека.
Для достижения реабилитационных целей и задач, поставленных перед пациентом в позднем восстановительном периоде, целесообразно последовательное проведение амбулаторного этапа медицинской реабилитации. При данном методе восстановительного лечения положительный эффект отмечается на 91% (10/11) основных критериев оценки, не оказывая влияния, в краткосрочный период, на зависимость пациента от близких и родственников.
В условиях непрерывной оптимизации и усовершенствования системы здравоохранения возникает потребность в использовании систем реабилитации с целью обеспечения успешной и непрерывной реабилитации на амбулаторном этапе с учетом места нахождения больного, а также возможностей перемещения пациента к месту занятий. Подобные методы позволят обеспечить персонифицированный непрерывный процесс реабилитационного лечения, способствующий достижению максимально возможного уровня самостоятельности пациента, а также сохранить уже достигнутые результаты восстановительного лечения. Одной из таких систем может стать дистанционный этап медицинской реабилитации.
Финансирование. Исследование не имело спонсорской поддержки.
Конфликт интересов. Авторы заявляют об отсутствии конфликта интересов.

About the authors

Vitaly V. Fakhretdinov

Tyumen State Medical University

Author for correspondence.
Email: fahretdinov_vv@mail.ru
ORCID iD: 0000-0001-8375-8244

Russian Federation, 625023, Tyumen region, Tyumen, Odesskaya st., 54

graduate student of the department of the department of the department of public health care and health ICPD

Natalya S. Brynza

Tyumen State Medical University

Email: brynzans@tyumsmu.ru
ORCID iD: 0000-0001-5985-1780

Russian Federation, 625023, Tyumen region, Tyumen, Odesskaya st., 54

MD, associate professor of the department of public health and health care ICPD

Al’bert A. Kurmangulov

Tyumen State Medical University

Email: kurmangulovaa@tyumsmu.ru
ORCID iD: 0000-0003-0850-3422

Russian Federation, 625023, Tyumen region, Tyumen, Odesskaya st., 54

Ph. D., associate professor of the department of the department of public health care and health ICPD

References

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6. Galyaev I.Y., Barabanova M.A., Timchenko L.V., Zhadan O.N. Staging and continuity in rehabilitation of patients with neurosurgical issues. Innovatsionnaya meditsina Kubani. 2018; (1): 6-11. (in Russian)
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Effectiveness of Home-based rehabilitation in improving physical function of persons with Stroke and other physical disability: A systematic review of randomized controlled trials

I'm quite positive that your definition of effectiveness is completely WRONG, WRONG, WRONG. Effective is 100% recovery, NOTHING LESS. Stop with your tyranny of low expectations. 

Effectiveness of Home-based rehabilitation in improving physical function of persons with Stroke and other physical disability: A systematic review of randomized controlled trials

Author links open overlay panelAsmare YitayehGelawMSc PT*BalamuruganJanakiramanMPT, PGCDE (Diab educator)*

Berihu FissehaGebremeskelMSc PT^†HariharasudhanRavichandranMPT^†

https://doi.org/10.1016/j.jstrokecerebrovasdis.2020.104800Get rights and content

Abstract

Background

A significant number of people with physical disabilities in the world, especially in most developing countries face a lot of impediments. There is a dearth of literature describing the consensus of effectiveness of home-based rehabilitation programs designed specifically for people living with different types of physical disabilities resulting from stroke, Parkinson's and other musculoskeletal conditions.

Objective

To determine if home-based rehabilitation is effective in improving physical function of people with physical disabilities.

Method

A systematic review of randomized controlled trials was done. An electronic search of the literature was done by PubMed, Cochrane Library, the Physiotherapy Evidence Database and Cumulative Index to Nursing and Allied Health Literature from 1990 to March 2018 to identify full text, peer-reviewed randomized controlled trials, Published in English. Selected randomized controlled trials were critically appraised with 11 items Physiotherapy Evidence Database scale scores extracted from the Physiotherapy Evidence Database and studies were included if the cutoff of 5 points was reached on Physiotherapy Evidence Database scale score.

Results

Nine randomized controlled trials met the preset eligibility criteria. This systematic review found that there is the consistency of findings among the included studies which showed that home-based rehabilitation is an effective option for people with physical disabilities.

Conclusion

Home-based rehabilitation is not superior to hospital-based rehabilitation in improving nearly all patient outcomes assessed. However, home-based exercise programs require patient enthusiasm and regular follow-up to yield positive outcomes.

Year-Long Study Shows Brain Stenting Has Long-Term Effectiveness

I don't think a 8.5% stroke and death rate is effective. What would you do if your doctor said you have an 8.5% chance of dying or having another stroke from the stent procedure and 2.6% in the first days? 

Don't listen to me, I'm not medically trained and I don't have a Dr. in front of my name.

But I'd rather my doctor told me how much watermelon juice to drink.

Watermelon juice reverses hardening of the arteries  Nov. 2011

 

 The latest here:

Year-Long Study Shows Brain Stenting Has Long-Term Effectiveness

By Alex Morrisson

LOS ANGELES -- February 24, 2020 -- A long-term follow-up study appears to indicate that the Wingspan brain stent -- aimed at preventing recurrent strokes -- is safe and effective when used on-label, according to a study presented here at the 2020 International Stroke Conference (ISC).

Patients who received the Wingspan stent for intracranial atherosclerotic disease experienced a 1-year stroke and death rate of 8.5%.
“This trial is unique because prior studies included off-label patients,” said Michael J. Alexander, MD, Cedars-Sinai Medical Center, Los Angeles, California. “This is the largest intracranial stent trial for atherosclerotic disease performed according to the FDA [US Food and Drug Administration] indication for the Wingspan stent. The stroke and death rates were substantially lower than the 1-year rate of 20% in the stenting arm of the SAMMPRIS trial and slightly better than the 12.2% stroke and death rate in the medical arm of SAMMPRIS.”

The Stenting and Aggressive Medical Management for the Prevention of Recurrent Ischemic Stroke (SAMMPRIS) was a large multicentre study comparing the 2 methods of stroke prevention. In the follow-up study, the Wingspan One-year Vascular Imaging, Events and Neurologic Outcomes (WOVEN) study showed a low 2.6% stroke and death rate within the first few days of the procedure in patients who received the Wingspan stent.(Not low enough.)

A third study -- WEAVE -- was mandated by the FDA to assess the periprocedural safety of the Wingspan Stent system in the treatment of symptomatic intracranial atherosclerotic disease. It was conducted at 16 US centres and followed 152 patients. Enrolling sites performed chart and image reviews of patients who were stented with Wingspan under its strict on-label usage. Data of subsequent strokes and deaths were collected with respect to time from stenting and medications at the time of the index event. Follow-up imaging was assessed for incidence and severity of in-stent stenosis and the follow-up management of these patients.

At 1-year, the stroke and death rate was 8.5% for patients who received the Wingspan stent.

“The long-term results are important to determine if safer stenting practices and lower complication rates from the treatment itself resulted in improved patient outcomes at 1 year,” said Dr. Alexander. “Intracranial stenting could provide an alternative when medical therapy and other treatments have been unsuccessful.”

The patients in the trials were treated with Wingspan if it was determined that their ischaemic stroke was caused by a blockage of 70% to 99% of an intracranial artery.

ISC is sponsored by the American Heart Association and the American Stroke Association.

[Presentation title: The Woven Study: Wingspan One-Year Vascular Imaging, Events, and Neurologic Outcomes. Abstract LB4]

From virtual reality to videoconferencing: Technology as effective for post-stroke rehabilitation as traditional care, study finds

But they don't tell you how effective it is. Probably because it would show an appalling failure rate. 

From virtual reality to videoconferencing: Technology as effective for post-stroke rehabilitation as traditional care, study finds

 ews provided by Heart and Stroke Foundation

Oct 02, 2019, 07:00 ET

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New approaches urgently needed to address lack of access to therapy, experts say
OTTAWA, Oct. 2, 2019 /CNW/ - A five-year study of six tele-rehabilitation projects involving more than 300 Canadians in 10 cities found that technology can be as effective in delivering post-stroke therapy to people living in rural and remote parts of Canada as traditional care, according to a highly-anticipated review published today in the Journal of Telemedicine and E-Health.
"The key to optimal recovery after stroke lies in the intensity and frequency of rehabilitation therapy," says Dr. Patrice Lindsay, Heart & Stroke's Director of System Change and the Stroke Program.
"Only 19% of all people admitted to acute care with stroke are discharged to inpatient rehabilitation. Research indicates that over 40% need some rehabilitation and over 60% need some assistance with daily activities after they leave hospital," she says. "Telerehabilitation will help those not able to access inpatient or community rehab in their region."
In 2013, researchers in Nova Scotia, P.E.I., Quebec, Ontario, Manitoba and British Columbia received $1.3 million from Heart & Stroke to test innovative ways to provide physical, occupational and speech therapy and lifestyle coaching to people who are recovering at home after a stroke. Funding was administered through the Heart & Stroke Foundation Canadian Partnership for Stroke Recovery.
"Tele-rehabilitation interventions have great potential to increase efficiency and access to post-stroke therapy," says senior author Dr. Robert Teasell of Western University. "Our research highlights that many studies have reported tele-rehabilitation to be comparable or more beneficial over in-person rehab programs."
Among technologies included in the studies were virtual reality, computer gaming, tablet-based software, video-conferencing, the use of wearable activity-monitors, and coaching over the phone. Patients used the technologies at their homes or at a local healthcare facility.
Researchers found:

• Efficacy of tele-rehabilitation is similar to and sometimes better than traditional face-to-face therapy.
• Engagement of caregivers is important.
• Clinicians prefer face-to-face therapy but they will use tele-rehab when other options aren't available.
• Technology must be easy to use for clinicians and patients.

"Heart & Stroke is committed to addressing the gaps, advocating for increased access to therapy, and helping to find new and innovative ways to deliver rehabilitation," says Heart & Stroke CEO Yves Savoie.
Tele-rehabilitation is gaining traction across North America. A recent U.S. clinical trial published in JAMA Neurology (Cramer et al.) found that tele-rehab produced substantial gains in arm function after stroke, regardless of whether it was provided by home-based tele-rehabilitation or traditional in-clinic rehabilitation.
Dr. Teasell said Canadian research "offers rare insights - and a Canadian lens - into the application of tele-rehabilitation. We believe this will be of great value to clinicians and health care institutions alike." He added that this important research provides valuable evidence to inform the Heart & Stroke Canadian Stroke Best Practice guidelines for delivering rehabilitation therapy after stroke.
More than 405,000 Canadians are living with long-term disability from stroke – a number is that is expected to double in the next 20 years because of the aging population and lifestyle factors. At the same time, access to therapy varies greatly from one part of Canada to another and between urban and rural areas.
The use of tele-rehabilitation for stroke therapy will be a focus at the Canadian Stroke Congress in Ottawa, October 3-5, as researchers and policymakers from across the country gather to look at new approaches to the prevention and treatment of stroke, Dr. Lindsay says.

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STROKE FACTS

• A stroke happens when blood stops flowing to a part of the brain or bleeding occurs in the brain, leading to damage to brain cells.
• 62,000 strokes occur in Canada each year – that is one stroke every nine minutes.
• Each year, more than 13,000 Canadians die from stroke.
• 80% of people survive stroke.
• Brain cells die at a rate of 1.9 million per minute after stroke.
• After stroke 60% are left with some disability; 40% require more intense rehabilitation and support.
• More than 400,000 Canadians live with long-term disability from stroke and this will almost double in the next 20 years.
• Stroke can happen at any age. Stroke among people under 65 is increasing and stroke risk factors are increasing for young adults.

The Congress is being held in Ottawa, ON from Oct. 3-5, 2019. Follow us on Twitter @strokecongress, #StrokeCongress.
Statements and conclusions of study authors are solely those of the study authors and do not necessarily reflect H&S or CSC policy or position. Heart & Stroke and the Canadian Stroke Consortium make no representation or warranty as to their accuracy or reliability.