More Canadian stroke patients could get clot-grabbing treatment

They may have saved your life doing this but they left you with no way to get 100% recovered. That is the ONLY stroke goal.
http://www.cbc.ca/news/health/stroke-guidelines-blood-clot-treatment-1.4753969

People in remote areas or who suffer a stroke while sleeping could benefit from new 24-hour window

Nicole Ireland · CBC News · Posted: Jul 19, 2018 9:54 PM ET | Last Updated: July 19

Endovascular thrombectomy, a procedure in which doctors pull a blood clot out of a stroke patient's artery to restore blood flow to the brain, could benefit more Canadian patients than previously thought, the Heart and Stroke Foundation says. (Akkalak Aiempradit/Shutterstock )

A procedure that allows doctors to pull stroke-causing blood clots out of patients' arteries could now save more lives and prevent more disabilities in Canada, the Heart and Stroke Foundation says.
The procedure, endovascular thrombectomy (EVT), was previously OK'd for use up to only six hours after a stroke. But on Thursday, the foundation announced it had changed its guidelines, extending that window to 24 hours.
New research suggests EVT could benefit one in five Canadian stroke patients, said Patrice Lindsay, stroke director for the Heart and Stroke Foundation. Previously, experts thought the treatment was only viable for 10 to 15 per cent of patients.

How a thrombectomy works

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Watch how a clot in the brain of a person having a stroke is cleared with a device 0:22

Last February, when the American Heart Association announced it was changing its maximum timeline for EVT (also called mechanical thrombectomy) to 24 hours, the foundation confirmed it was also planning to change the guidelines in Canada. The results of the new studies, which were announced at a European conference in May, offered compelling evidence that even more patients could benefit from EVT many hours after having a stroke, Lindsay said.

• New stroke guidelines mean more patients could get life-changing treatment

During the procedure, physicians insert a stent into the patient's groin and thread it up through the blood vessels to reach a clot — that is blocking a major artery supplying blood to the brain — and pull it out.
EVT is only useful in cases of ischemic strokes (strokes caused by a blood clot), as opposed to those caused by a bleed in the brain. Health-care providers assess whether to use EVT on a case-by-case basis, using an advanced CT scan to see exactly where the clot is and whether it can be removed with minimal risk of causing additional damage.
Doctors also use CT imaging to see how much brain tissue has died in the area where the stroke occurred, and how much can be saved. It was previously thought that after six hours, there wasn't enough surviving tissue left to justify doing an EVT —  but there's now evidence to the contrary, prompting the extension to 24 hours.

'Catastrophic' strokes 

The extension will especially affect people who live in remote and rural communities, Lindsay said.
Because EVT is a highly specialized procedure, it is only performed in 23 hospitals across Canada. That means many stroke victims who live far from an urban centre, and who had to be transferred, "would never have made the six-hour time window," she said.
That's been a worry for Dr. Ayman Hassan, a neurologist at Thunder Bay Regional Health Sciences Centre in northern Ontario.
The hospital has one neurosurgeon who does EVT, but if he's not there, patients who need the procedure have to be transferred to Winnipeg or to health-care centres in southern Ontario. Stroke patients also come to Thunder Bay from remote communities.
In the past, some patients who would have been eligible for EVT have run out of time before being able to get the treatment, Hassan said. With the new 24-hour time frame, he expects about 30 patients a year at his hospital will escape the "catastrophic" disability or death that this type of stroke brings.

• More women die after stroke than men, Heart & Stroke says

The neurologist has seen the difference EVT can make, recalling a patient in his 60s who suffered a "significant stroke" last spring.
"He was able to walk on his own and no residual weakness, no residual visual change, no residual sensory dysfunction," Hassan said. "So he almost recovered like it was a minor, non-disabling stroke."
Had that patient not had the treatment, he likely would have been left with serious disabilities, including trouble walking, speaking and swallowing, he said.
The new time frame for EVT will also affect patients who have an ischemic stroke while sleeping.
"We now have opportunity for people who went to bed feeling fine and at whatever time they woke up, they were showing stroke symptoms, but there was no way of pinpointing exactly when that stroke occurred," Lindsay said.

• New emergency brain procedure saving stroke patients

But the Heart and Stroke Foundation acknowledges the new guidelines have implications for Canada's already stressed health-care system.
It's been working with provincial and territorial health ministries to prepare, Lindsay said, noting that screening more stroke patients to see if EVT is appropriate for them means an increased demand for immediate CT scans.
"All of the sudden everybody in that [24-hour] time window is critically urgent because we still have a chance to do something," she said.
Although that extra time is "great" in circumstances in which delays getting treatment are unavoidable, Lindsay emphasized that "sooner is still better" when it comes to stroke.
"We still lose 1.9 million brain cells a minute [after a stroke], and the longer you wait, the more harm and damage and less positive recovery," she said.

Rehabilitation unit opens at Aiken Regional Medical Centers - Aiken, South Carolina

If that goal to 'get them home' applies to stroke that needs to be changed immediately. You need to call that hospital and DEMAND stroke goals of 100% recovery. Don't let them dumb down the goals.
http://www.aikenstandard.com/news/rehabilitation-unit-opens-at-aiken-regional-medical-centers/article_52717348-bf37-11e7-a908-23fb9aa92aba.html

• BY STACIE LANDRUM slandrum@hotmail.com

Patients in need of physical rehabilitation won't have to far now that Aiken Regional Medical Centers has opened its new 14-bed rehabilitation wing.
Tours of the new rehabilitation center followed a ribbon-cutting ceremony Wednesday afternoon, allowing interested parties to take a look at the new wing before it fills with patients.
“It’s a beautiful unit,” said hospital CEO Vance Reynolds, who thanked everyone who made the addition possible.
“We stayed local,” said Reynolds. “Everything in here has been done by local providers and people in the community. All the pictures are also local pictures of Aiken or somewhere in Aiken County. We want this to be home.”
Reynolds took note that a typical rehabilitation patient may stay in rehab for 21 to 28 days, adding that for those patients it was important to make their surroundings comfortable.
“The ultimate goal is that we be taking patients who are typically coming straight from the hospital from an acute episode, disability or catastrophic event who are typically in need of a higher physical therapy level,” said Heather Raynack, director of rehab services. “Our goal is to get them home so that they can have better outcomes, have more success and be able to return to their families."
Raynack said patients who have had a catastrophic accident or injury may need time to adjust. The rehabilitation training is as much for the family as it is for the patient, saying the family will be the support the patient goes to once he or she is able to leave the hospital.
“We hope to get people back to home independently and not have them be re-admitted,” said Raynack. “We have an Activities Daily Living suite which has a full kitchen, washer and dryer. A lot of patients that may have suffered a  or something like, once they go back home still need to be able to prepare meals so this will be a part of that."
The unit also has a dayroom where patients will be encouraged to mingle and socialize with not only their family, but other patients as well. Families are encouraged to be with the patients to give them and be trained in the same physical therapy the patient learns. Each room with a patient bed has a chair and sofa as well.
“It very much makes a sense of community for the patients,” said Raynack.
Opening the unit also means patients who would otherwise need to go another area for treatment can stay home close to their families.
“It allows patients that have to go to a rehab hospital to stay local,” said Reynolds. “Instead of having to go to Columbia or Augusta … they can actually stay here so that when they are discharged from the hospital and need rehab, they can now stay here and it’s easier on family and loved ones.”
He also pointed out a convenience factor, stating that expending a hospital is better for the community surrounding it by making that form of health care more accessible.
“There are two things that can make a Chamber president really happy,” said J. David Jamerson, president and CEO of the Aiken Chamber of Commerce. “One is a new company coming in with new investment in our community. The other is someone that’s been around for a long, long time and continues to invest because it’s a continuing statement that they believe in our community and want to continue to grow with our community, and that’s what this represents today.”
Mayor Rick Osbon also took a moment to thank everyone involved in the opening of the rehab unit.
“Thank you for being such a great community partner,” said Osbon of the hospital. “It really is astounding, the way this campus steps up to meet the needs of our city. This is a service that will touch the lives of our citizens and means so much to the city, we just say thank you for all you do.”
The rehabilitation services are designed to help a patient through events such as a stroke, brain injury, neurological condition, amputation, major trauma or medical reconditioning and other disabling conditions, according to a brochure provided by Aiken Regional Medical Centers.

The Necessity of Striving for Unattainable Goals

Not directly stroke related but it should be. The unattainable goal of 100% recovery for all will never occur under current stroke leadership. They all need to die. Too bad. They had their chance and totally blew it, don't feel sorry for them.

The Necessity of Striving for Unattainable Goals

We can't eliminate all errors. But we have to keep trying

• by Fred N. Pelzman, MD November 02, 2017

Walking into the office very early this morning, before the 8:00 seminar I was scheduled to give for the interns on ambulatory block rotation, I happened to look up and notice this safety cone, which stays curled up in a gray plastic container on the wall of our practice, right where it has been for quite a few years.
It is one of those "In the Event of a Spill" devices, an intervention that is supposed to protect our staff and our patients from trips and falls should liquid spills end up in the hallways of our practice.
Pull down and it pops open, a little hazard-yellow tripod, meant to stand guard and protect.
They're scattered at various points throughout the practice, tucked up in the corner on the walls, available should anyone notice anything spilled on the floor, be it water, coffee, urine, vomit, blood, or pretty much any other fluid one might encounter in a medical practice. It's meant to be a temporary thing, a warning, a "watch your step", something to tide us over until the appropriate cleanup can occur.
Now obviously, when I spill a cup of water, instead of putting a cone on it marking it as a potential hazard, I should probably just grab some paper towels and wipe it up.
But if a chemical hazard spill occurs, or a body fluid that needs safer and more effective cleanup, it makes sense that we warn patients and staff not to step in it, while we wait for appropriately armed personnel to arrive to safely eradicate the problem.
Unfortunately, this reminds me a little bit of institutional quality and patient safety efforts.
Across healthcare institutions, including our own, there are multiple committees and groups that get together to review quality improvement efforts and patient safety efforts, tracking errors in the practice, focusing on efforts to prevent, improve, and correct these by getting to the heart of the matter.
Every year, each practice is required to present, to each of these committees, a compilation of our quality improvement and patient safety efforts throughout the past year.
This includes a description of our practice and leadership structure (as if they do not already know who we are), and a compilation of the quality and patient safety team showing how reporting is done, essentially who does what, and then a long list of things that have been noted and responded to over the past year.
We have an electronic system in which safety issues can be reported, for errors and near-harm events, including such things as falls, mislabeled specimens, and other bad outcomes.
We have another system that collects patient complaints and grievances, which come to our practice from multiple sources, including individual providers, our administrators, and Patient Services.
And then we have a long list of projects we have done, things we have been working on over the past year meant to improve our performance on measures that we have either deemed important to our practice, areas where we have been found lacking, processes that have been analyzed and found to be fraught with errors or risk thereof, and regulatory requirements that necessitate the collection of data and the implementation of further practice improvement.
We also have extensive quality improvement education and curriculum within our practice, for the faculty and residents and medical students, which has in-itself led to quite a few successful projects that improve the way we take care of patients.
Those doing the work and seeing the errors are often best in a place to figure out a better way to do things. And sometimes you need a fresh pair of eyes to move us away from "we do it this way since this is how we have always done it".
But as our systems continue to evolve, I hope we move away from the collecting of data in all these small incremental steps aimed at improving quality and safety.
We're never going to be 100% error-free.
In a practice where we have many patients with many significant comorbidities, and gravity is in play, people are going to fall.
We have a water cooler in our waiting room, there will be spills.
Three to four hundred patients make their way through so many different interactions when they visit our practice, from registration to medical technician to provider to nurse to phlebotomist means nearly overwhelming opportunities to miss something or trip up on some minor detail.
But our staff has done an incredible job of identifying many of these problems, both environmental and structural, within our practice, as well as with the procedures we do and how we handle our patients, which have led to significant interventions to prevent slips, falls, and medical errors from happening.
One would think that in the 21st-century that it would be impossible to draw a patient's blood into a tube labeled with someone else's medical record number, but it happens.
Surgeons sign their sites, not because anyone thinks they are just operating willy-nilly, but because it is a chaotic storm of stuff we are working in, and we all need all the help we can get.
We can have endless meetings and endless discussions about what works in the airline industry or what worked for Toyota long ago, but as long as there are humans involved, there will always be errors.
I can only hope that as we continue to evolve and improve these processes, we're not just putting up a pop-up cone over a spill, and hoping no one slips and falls.
So we'll keep going to meetings, we'll keep reporting, we'll keep participating in all of these quality improvement and patient safety initiatives, but we need to make sure it's not just lip-service. Everyone needs to be fully engaged and the people in power need to make sure that we all have all the tools we need, that we're not rushed, that we're not burned-out, that we always treat each of our patients exactly as we would want one of our own family members to be treated.
When we do that, quality will improve, and patients will be safer, to the limits which we are able to get them to.

Community Transition Program for Stroke Survivors Improves Health, Saves Money - Kentucky

The fact that this is necessary is proof that the hospital is failing stroke survivors, getting them nowhere close to 100% recovery. I don't care about the low goals that stroke medical professionals have set for survivors. Talking about 'care' NOT results.They are completely useless. 100% RECOVERY IS THE ONLY GOAL. GET THERE! 
http://uknow.uky.edu/research/community-transition-program-stroke-survivors-improves-health-saves-money 

HAZARD, Ky. (Oct. 26, 2017) – Kentucky has one of the highest rates of stroke in the nation, and in Eastern Kentucky, the burden of cardiovascular disease is especially severe. An innovative program, though, is improving patient outcomes and saving money in the region by providing intensive, personalized support for stroke survivors and their families.
The Kentucky Care Coordination for Community Transitions program — a partnership between the University of Kentucky Center of Excellence in Rural Health (CERH) in Hazard, Appalachian Regional Healthcare (ARH), and the UK College of Health Sciences — integrates a CERH community health worker with the ARH rehabilitation team to help stroke survivors transition back to their homes and to facilitate a network of community support.
Established in 2014 with pilot funding from the UK Center for Clinical and Translational Science and ARH, the project evolved into a permanent program in 2015. Just past its two-year anniversary, the program has supported nearly 150 individuals, helping them adjust to the new realities of life after a stroke, learn about chronic disease self-management, navigate complex health care and insurance systems, monitor their rehabilitation, and connect with other survivors and caregivers.
The program has markedly improved health and wellbeing for participating stroke survivors, among whom there have been zero 30-day hospital readmissions and only one emergency department visit (which wasn’t stroke related). This is compared to 19 percent and 8 percent, respectively, of the matched control group of stroke survivors who chose not to join the program. The result is not only better health and quality of life for survivors and caregivers, but also a cost savings of more than $1.4 million over two years to the local health care system.
“We’re keeping people healthier and saving a phenomenal amount of money for the health care system,” said Patrick Kitzman, Ph.D., founding director of the program and professor of physical therapy in the UK College of Health Sciences. “But we also concentrate very much on the caregiver and family — we always look at the whole unit with our follow-up education and support.”
In 2016 alone, the program supported 70 individuals, including 512 encounters between the community health worker and participants and more than 1,000 provided services. Half of participants needed assistance obtaining durable medical equipment, 71 percent needed assistance obtaining essential medications, and 35 percent needed assistance obtaining health insurance.
A critical element of the program’s success is the integration of the community health worker, Keisha Hudson, with the stroke rehabilitation team at ARH. Hudson, who is from the local community, participates in the discharge planning for participating stroke patients so that she can establish a relationship with them and their families while they’re still in the hospital and get a head start on arranging for anything they might need when they get home — shower chairs, wheelchair ramps, medical equipment, etc.
Hudson then visits patients at their home within a week of discharge and provides weekly face-to-face meetings or phone follow-up calls which tapers to bi-weekly or monthly check-ins as patients improve. Some patients, however, have stayed with the program since its beginning.
 As she works with patients and families, Hudson provides health education and tracks compliance with medical visits and medication; when she notices that a patient has missed an appointment or medication, she figures out why. Sometimes the problem can be as simple as the patient lacking transportation, in which case Hudson can help them make arrangements to get to the clinic or pharmacy.
Such attention and regular communication allows Hudson to develop a personal relationship with patients and their families to the extent that she can often sense when something is “off” and intervene before a serious problem develops. While none of the patients in the transition program have been readmitted to the hospital for stroke complications within 30 days of discharge, Hudson’s attentive care has led to life-saving interventions related to patients’ other health issues; nearly 60 percent of participants have five or more co-morbid health conditions. Once, while speaking with a patient over the phone, Hudson recognized that the woman’s breathing sounded especially labored, and she told the patient to go to the hospital immediately. It turned out the woman had a dangerous level of fluid on her lungs and needed urgent treatment. While making a routine visit to check on a different patient, Hudson arrived to find them in a diabetic coma. With yet another patient, she caught an infected surgical site that required immediate attention.
Hudson also hosts a monthly stroke survivor and caregiver support group. It meets at the hospital, which allows currently hospitalized stroke survivors or their caregivers to come downstairs from the care unit and connect with the group before they go home.
“The program has evolved in the community because we’ve built trust as people hear about us through word of mouth. Some patients and caregivers have become really big advocates for us. One of the patients we’ve worked with for a while has had people in his community who’ve had strokes and he himself has referred them to us. We’ve proven to our community that we’re here to help and we’re here to stay and when we say we’re going to do something, we do it — that’s helped a lot,” Hudson said.
Dr. James Hammock, who runs the stroke rehabilitation program at ARH, sees the community transition program as essential in ensuring continued care for his patients after they leave the hospital, which can be especially challenging in a rural area plagued by an elevated prevalence of stroke and co-morbidities and limited access to health care. From his perspective, the benefits of the program have been “innumerable,” including improved patient compliance, patient education, community integration and interdisciplinary communication.
“I came to this region to help improve patient care for disabled persons, and one key component of a well-rounded program is ensuring optimal care throughout the entire spectrum of care. The community transition program allows me to worry just a little less about my patients when they return home," he said. "Patients prefer to stay close to home for healthcare, and a partnership such as the one between ARH and UK allows them to do just that while staying within the confines of medical care. Medical literature has demonstrated time and again that a patient and family who are bolstered by a program such as this are less likely to return to the hospital in the short-term and more likely to be successful both medically and functionally in the long-term.”
Hammock recognizes the necessity to provide support and education to a patients’ caregivers, who play a pivotal role in recovery and can ultimately be the deciding factor between success and failure.
“Caregivers must know how important they truly are, and programs such as this will allow us to shift our focus to the caregiver for a moment,” he said.
For Tonya Kincaid, whose husband Mark had a stroke eight years ago at age 42, Hudson, Kitzman and the Community Transition program have provided life-changing support, both logistically and personally. Kincaid is her husband’s primary caregiver, and before they were referred to the program almost two years ago, she felt like she was fighting every battle single-handedly.
“I just did it alone. It was so frustrating because sometimes it takes a professional title, or someone who has the energy not to take no for an answer, and sometimes I’d just get worn down. I didn’t have anyone as a back-up then, and no support group, and now I do,” Kincaid said. “Anything we ask of Keisha, she helps us with. I’m constantly fighting Medicare and Anthem over therapy and equipment. I go at it for anything that Mark needs. And I hit roadblocks sometimes. Once I told Keisha, ‘I’m always researching and fighting Medicare, and sometimes I just get really tired.’ And she said, ‘Well, let me tell you what. You’ve been your husband’s voice for six years now. Why don’t you take a rest and let me do some of the fighting for you.’ And that just meant the world to me, because she really meant it. She takes a lot off of me. She helps us get appointments, equipment, if we need paper work faxed from the doctor — all we have to do is call her and she takes care of it immediately. She will go to the doctor’s office herself and pick it up if she needs to. She just doesn’t take no for an answer. She really is a true advocate for us, and for everyone in the group.”
In addition to providing important health education from visiting speakers each month, the support group meetings have also helped the Kincaids develop strong friendships with other families who have experienced a stroke.
“The meetings are wonderful because we’ve just made such good friends. If you’ve not been through this, you just don’t understand it. So it’s nice to have a meal and talk about what you’re going through with people who have been there. One couple came in recently and they were so happy because the husband, who’d had a stroke, could cut his own finger nails now. To most people, that’s not a big deal at all. But to us, we’re like ‘Yay!’ because it’s such a big milestone.”
The program has connected the Kincaids with other opportunities as well, including clinical trial opportunities for stroke survivors and treatment options at Cardinal Hill Rehabilitation Hospital in Lexington.
Building upon the successful model established over the last two years, the program will soon expand to support individuals recovering from traumatic brain injury. Hudson has also expanded her capacity to support participants by becoming trained to provide the Stanford Chronic Disease Self-Management program, in addition to her training in diabetes and mental health management. The program was recently listed with the National Stroke Association, and the program team is currently exploring options for sustainable funding via partnerships, sponsorships, and reimbursement for services.
“We’ve invested in this area, and this program and these people have become a small family where everybody is checking on everybody else,” Hudson said. “I had big dreams for this program anyway, but it’s been more successful than I ever imagined it could be. It just takes a whole team.”
Perry County Stroke Support meetings are co-hosted each month by the UK CERH and ARH. They are held the fourth Wednesday of each month at 5 p.m. at Appalachian Regional Healthcare Regional Medical Center in Hazard. Anyone from the community can join the Community Transition program, and new members are always welcome. For more information contact Keisha Hudson at the UK Center of Excellence in Rural Health at 606-439-557 or keisha.hudson@uky.edu.

UK is the University for Kentucky. At UK, we are educating more students, treating more patients with complex illnesses and conducting more research and service than at any time in our 150-year history. To read more about the UK story and how you can support continued investment in your university and the Commonwealth, go to: uky.edu/uk4ky. #uk4ky #seeblue

One-Stop Management of Acute Stroke Patients Minimizing Door-to-Reperfusion Times

Still not fast enough. I expect stroke patients to be treated with tPA prior to getting to the hospital. Your goal is wrong.
http://stroke.ahajournals.org/content/48/11/3152?etoc=

Marios-Nikos Psychogios, Daniel Behme, Katharina Schregel, Ioannis Tsogkas, Ilko L. Maier, Johanna Rosemarie Leyhe, Antonia Zapf, Julia Tran, Mathias Bähr, Jan Liman, Michael Knauth

https://doi.org/10.1161/STROKEAHA.117.018077 Originally published October 10, 2017

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Abstract

Background and Purpose—Intrahospital time delays significantly affect the neurological outcome of stroke patients with large-vessel occlusion. This study was conducted to determine whether a one-stop management can reduce intrahospital times of patients with acute large-vessel occlusion.

Methods—In this observational study, we report the first 30 consecutive stroke patients imaged and treated in the same room. As part of our protocol, we transported patients with a National Institutes of Health Stroke Scale score of ≥10 directly to the angio suite, bypassing multidetector computed tomography (CT). Preinterventional imaging consisted of noncontrast flat detector CT and flat detector CT angiography, acquired with an angiography system. Patients with large-vessel occlusions remained on the angio table and were treated with mechanical thrombectomy; patients with small artery occlusions were treated with intravenous thrombolysis, whereas patients with an intracranial hemorrhage and stroke mimics were treated as per guidelines. Door-to-groin puncture times were recorded and compared with our past results.

Results—Thirty patients were transferred directly to our angio suite from June to December 2016. The time from symptom onset to admission was 105 minutes. Ischemic stroke was diagnosed in 22 of 30 (73%) patients, 4 of 30 (13.5%) had an intracranial hemorrhage, and 4 of 30 (13.5) were diagnosed with a Todd’s paresis. Time from admission to groin puncture was 20.5 minutes. Compared with 44 patients imaged with multidetector CT in the first 6 months of 2016, door-to-groin times were significantly reduced (54.5 minutes [95% confidence interval, 47–61] versus 20.5 minutes [95% confidence interval, 17–26]).

Conclusions—In this small series, a one-stop management protocol of selected stroke patients using latest generation flat detector CT led to a significant reduction of intrahospital times.

New acute stroke unit opens to patients after major investment - Royal Lancaster Infirmary, North Lancashire and South Cumbria

YOU will need to ask what the goals are for this stroke unit, it can't be left to the medical staff, they will just use dumbed down goals. Talking about 'care' and 'services' are not good enough, that is just being lazy. The goal is 100% recovery, NON-NEGOTIABLE, survivors don't give a shit how difficult that is for their providers, figure out a way to get there.
http://www.cumbriacrack.com/2017/09/11/new-acute-stroke-unit-opens-patients-major-investment/
Patients in North Lancashire and South Cumbria will now benefit from a brand new stroke unit at the Royal Lancaster Infirmary (RLI), thanks to a major investment of over £1m.
The Huggett Suite, which opened today, will be based in the Centenary Building, and will provide the RLI with six acute stroke beds and an assessment bay.
In addition to the opening of the new unit, clinicians from University Hospitals of Morecambe Bay NHS Foundation NHS Trust (UHMBT) and from across the bay have come together to try and reduce the number of people in the area that suffer strokes, and improve the services for those who have a stroke.
Patients suffering a stroke will now come into the Emergency Department (ED) at the RLI to be assessed for eligibility for clot busting treatment in the department before being transferred to the new suite. There, they will be monitored by staff specially trained to care for patients immediately after a stroke.
The suite is equipped with ceiling hoists to make lifting safer for patients and staff, continuous heart monitoring equipment, a patient gym and a therapy kitchen.

Michelle Andersen, Ward Manager, Sue Gormley, Domestic for the Stroke Unit, Linda Dunn, Clinical Lead for Stroke, Eva Bannister, Lead Stroke Physiotherapist, and Liz Newsham, Registered Acute Stroke Nurse

Linda Dunn, Clinical Lead for Stroke, UHMBT, said: “A designated unit, with staff skilled in the management of acute stroke, will allow us to offer our patients the very best chance of recovery. Direct access to this type of unit with close monitoring and early intervention from a multi-disciplinary team is associated with a reduction in disability, death and a reduced length of stay in hospital.
“To ensure that we have the right staff in the unit, the Trust has recruited registered nursing, physiotherapy, occupational therapy and speech and language therapy staff.
“It is an exciting time for us as a team. Before the suite opened, patients who had a stroke would come into ED and then go up to the Lancaster Suite, a general medical ward which houses stroke beds, before being transferred to Ward 23 for rehabilitation. Now patients will come straight to a dedicated acute stroke bed on the Huggett Suite where they can be cared for by our specialist stroke team.”
Across the UK there are around 100,000 strokes a year. In 2015, there were 605 strokes in Morecambe Bay with the total healthcare and social care costs for this local group of patients being £13.4 million in 2015/16 – rising to £27.4 million over five years.
Michelle Andersen, Ward Manager for the Huggert Suite, UHMBT, said: “It is nice to see the project come to fruition. We have a fantastic team on board who are passionate about giving the very best care to patients who suffer from a stroke.”
Ward 23 in Medical Unit 2 at the RLI will remain as a rehabilitation facility for stroke patients who need longer term rehabilitation.
The Huggett Suite was given its name in recognition of the contribution that consultant Dr Isabel Huggett has made to stroke and elderly medicine at the RLI. Dr Huggett retired from the Trust in 2014. An official opening is planned for later in the year.
Stroke is a medical emergency that occurs when the blood supply to the brain is interrupted by either a blockage or rupture of an artery in the brain. The lack of blood supply starves the brain cells of oxygen and nutrients, causing brain cells to become damaged or die. This damage can have different effects, depending on where it happens in your brain.
Sue Smith, Executive Chief Nurse, UHMBT, said: “I am delighted to see the Huggett Suite is now open to patients and look forward to the official opening later in the year. The new suite will support our staff and help us to provide outstanding care to patients for years to come.”
There are a lot of myths surrounding stroke such as it only affects elderly people. This is incorrect; around a quarter of strokes happen in people of working age. There are over 400 childhood strokes a year in the UK. Around a quarter of these are in children under a year old, half are in children aged 1-10 and a quarter are in children aged 11 and over. The average age of stroke has also decreased in recent years.
Bay Health and Care Partners which is made up of 10 health and care organisations in Cumbria and North Lancashire has committed to using a ‘population health’ approach to tackle stroke in Morecambe Bay.
You could save your own or someone else’s life, or help limit the long-term effects of stroke, by learning to think and Act F.A.S.T.
F.A.S.T. or Face-Arms-Speech-Time is easy to remember and will help you to recognise if you or someone else is having a stroke.

• Face – has their face fallen on one side? Can they smile?
• Arms – can they raise both arms and keep them there?
• Speech – is their speech slurred?
• Time to call 999 if you see any single one of these signs of a stroke

You can find out more about strokes at https://www.stroke.org.uk/what-stroke or http://www.nhs.uk/conditions/Stroke/Pages/Introduction.aspx

National Stroke Center to be established in Mulleriyawa hospital - Sri Lanka

Time to contact them and DEMAND  that the goal of the hospital is 100% recovery for all stroke survivors. Anything less and they aren't even trying for the best interests of their stroke patients.  Dumbed down goals for the doctors and hospital are not to be tolerated. YOU have to be in charge of the goals not the self serving interests of the stroke medical professionals.
National Stroke Center to be established in Mulleriyawa hospital

Aug 23, Colombo: Sri Lanka's Minister of Health, Nutrition and Indigenous Medicine, Dr. Rajitha Senaratne has said that measures have been taken to establish the National Stroke Center in the Mulleriyawa hospital.
Minister Senaratne has disclosed this participating as the Chief Guest in an event held to launch the register of stroke patients in Sri Lanka recently at the Colombo National Hospital.
Speaking at the event, the Minister said that steps have been taken to establish stroke centers throughout the country.
The Minister of Health further said stroke has been identified as a major cause of paralysis among adults and care must be taken to eliminate the cause of strokes and the government has taken several steps.
According to the Health reports prevalence of stroke in Sri Lanka is 10 per 1000 people and is a leading cause of disability and death.
The Minister said the impact of stroke on the economy and families is very powerful, therefore, the hospital facilities have been upgraded for stroke patients.
"We must also focus on the rehabilitation of the patients after stroke. It is also important to educate the general public about the actions that need to be taken to curb the disease. That includes lifestyle changes and emergency management," the Minister said.
Director General of Health Services Dr. Jayasundera Bandara, Deputy Director General Dr. Champika Wickramasinghe, Colombo National Hospital Director Dr. Anil Jasinghe and a team of specialist doctors were present at the occasion.

What do stroke patients and their carers want from community services?

You wouldn't have these secondary problems to solve if you solved the primary problem of getting all stroke survivors 100% recovered. If that isn't your doctors', therapists' and hospitals' goal then you have lazy bastards in charge of your rehab.  So why are you settling for incompetency? Fire them all.
https://academic.oup.com/fampra/article/23/1/131/554650/What-do-stroke-patients-and-their-carers-want-from

R Hare H Rogers H Lester RJ McManus J Mant

Family Practice, Volume 23, Issue 1, 1 February 2006, Pages 131–136, https://doi.org/10.1093/fampra/cmi098

Published:

24 November 2005

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Abstract

Background. Previous research has focused on the longer term needs of ‘new’ stroke patients at fixed time intervals after the event, but neglected those of stroke patients who may have had the event many years earlier.
Objective. To identify the long-term support needs of patients with prevalent stroke, and their carers identified from practice stroke registers.
Design of study. Patients and their carers were invited to attend focus groups at the university, a nursing home or in the community.
Setting. Seven practices in South Birmingham. Adults (18+) with a validated record of stroke.
Methods. Focus groups were audio-taped and data analysed using a constant comparison method.
Results. Twenty-seven patients and six carers participated in the study. Three major themes emerged: emotional and psychological problems; lack of information available for patients and their families; the importance of Primary Care as the first point of contact for information or problems, even if these were non medical.
Conclusions. Better methods of providing information for long-term survivors of stroke, and for addressing their emotional and psychological needs are required. Primary care could be a key setting for helping to provide more inclusive services for both patient and carer.

Older Age, Low Socioeconomic Status, and Multiple Comorbidities Lower the Probability of Receiving Inpatient Rehabilitation Half a Year After Stroke

All stroke survivors should be able to receive and use stroke protocols that get them to 100% recovery. No stroke survivor left behind. If you can't get behind that goal then get the fuck out of the stroke profession. 
http://www.archives-pmr.org/article/S0003-9993%2816%2930960-1/fulltext#.WZLrX54sH00.twitter

Huan-Jui Yeh, MD

,

Nicole Huang, PhD

,

Yiing-Jenq Chou, PhD

,

Shun-Ping Cheng, MD

,

Wai-Keung Lee, MD

,

Chun-Cho Lai, MD

,

Chi-Chia Cheng, MDCorrespondence information about the author MD Chi-Chia ChengEmail the author MD Chi-Chia Cheng

Older Age, Low Socioeconomic Status, and Multiple Comorbidities Lower the Probability of Receiving Inpatient Rehabilitation Half a Year After Stroke

DOI: http://dx.doi.org/10.1016/j.apmr.2016.08.468

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Article Info

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Abstract

Objective

To determine the predictors of receiving inpatient rehabilitation during 7 to 12 months after stroke.

Design

Retrospective cohort study.

Setting

A nationally representative sample of 1 million National Health Insurance enrollees.

Participants

Patients with new-onset stroke (N=13,828) were included. Studied participants were patients who received inpatient rehabilitation during 4 to 6 months after stroke. Patients who died within 1 year of the stroke event were excluded (n=488).

Interventions

Not applicable.

Main Outcome Measures

The outcome variable of interest was the probability of receiving inpatient rehabilitation during 7 to 12 months after stroke. The characteristics of both patients and medical care providers were investigated to determine their effect on patients receiving inpatient rehabilitation.

Results

Older patients, patients of low socioeconomic status, patients with Charlson Comorbidity Index ≥5, and patients who received outpatient rehabilitation during 4 to 6 months after stroke have a lower rate of receiving inpatient rehabilitation than do their counterparts. In addition, receiving inpatient rehabilitation during 7 to 9 months after stroke is a strong positive predictor of receiving inpatient rehabilitation during 10 to 12 months after stroke (odds ratio, 38.556; P<.0001).

Conclusions

This study revealed that older age, lower socioeconomic status, and multiple comorbidities are negative predictive factors with a cumulative predictive power for the probability of receiving inpatient rehabilitation during 7 to 12 months after stroke.

Getting on With The Rest of Your Life After Stroke

This would be totally unnecessary if we got every stroke survivor 100% recovered. That is the only goal that stroke doctors should be working towards.
http://canadianstrokenetwork.ca/en/service/getting-on-with-the-rest-of-your-life-after-stroke-2/

The Canadian Stroke Network

Getting on With The Rest of Your Life After Stroke

The CSN’s “Getting On With the Rest of Your Life After Stroke” trial analyzed 204 people with strokes to determine the extent to which participation in life’s roles can be optimized through a community-based structured program that provides the opportunity for physical activity, leisure and social interaction. The lessons learned from the study were translated into two editions of a guidebook for people with stroke, their caregivers and health professionals. The latest update, released in the fall of 2011, includes resources for individuals and families coping with aphasia.

Download the booklet here.

Feinstein Institute study finds robotic ankle rehabilitation helps post stroke recovery

More research will be needed to compare this latest one to the earlier 3 posts on anklebots. But that won't occur because we have NO fucking stroke leadership and NO fucking stroke strategy.
We need a damned protocol on what survivors can use this and what exercises they need to do to recover complete ankle function. That is the goal, damn it all. Get there! 
http://www.prnewswire.com/news-releases/feinstein-institute-study-finds-robotic-ankle-rehabilitation-helps-post-stroke-recovery-300499220.html

Stroke patients with high function walking speed had potential to return to normal after rehabilitation

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MANHASSET, N.Y., Aug. 3, 2017 /PRNewswire-USNewswire/ -- A study published in NeuroRehabilitation by Feinstein Institute for Medical Research scientist Bruce T. Volpe, MD and Johanna L. Chang found that isolated ankle training with a robotic therapy device can improve walking speed and balance after a stroke, depending on the severity of the patient's initial impairment. Better understanding of severity-dependent recovery profiles after stroke will help medical professionals determine the best candidates for robotic rehabilitation. 

Strokes happen when a patient's brain does not receive sufficient blood supply due to a blockage or rupture of a blood vessel, which can result in impairment of motor or cognitive function. Patients typically participate in rehabilitation programs that focus on specific enhanced motor activity of their limbs under the direction of physical and occupational therapists.
Robotic devices are effective tools to aid in this recovery of, for example, wrist and arm movement. The devices have been less effective in encouraging recovery of walking speed (also known as gait). Dr. Volpe's study examines whether a robotic-assist device that uses interactive ankle movement in a seated position would improve a patient's walking speed and balance.
"Exercise is one of the main ways for patients who have had a stroke to regain movement," said Ms. Chang, who is the lead author of the study. "The use of robotic assisted-devices can enhance the therapy by increasing the intensity of the motor experience. This interactive robotic device moves the paralyzed arm or leg when the patient cannot and gets out of the way when the patient powers the movement.  In our study, the baseline or initial walking speed prior to therapy was an important factor in predicting the final walking speed."
Twenty-nine study participants with a foot drop and walking speed abnormalities after stroke were treated three times a week for six weeks with robot-assisted ankle training. The patients were separated into three groups: high function (walking speed greater than 3 feet per second), medium function (1 foot per second) and low function (less than 1 foot per second). During a session, patients were seated in front of a video monitor and the ankle robot was attached at the knee and foot. The patient viewed the video screen that had a cursor and used their legs and ankle to move the cursor to reach a particular target.
After 18 sessions, the high and medium function groups demonstrated significant improvements in walking speed, with the high functioning group achieving a speed that is considered normal for ambulating patients in the community (greater than 4 feet per second).  A further exciting result showed that in follow-up three months after the treatment finished, the high function group continued to improve (4.39 feet per second). The low functioning group demonstrated the greatest change in improved balance.
"Much like one medication is not effective for all patients with a certain condition, not all rehabilitation is beneficial to all," said Kevin J. Tracey, MD, president and CEO of the Feinstein Institute. "By understanding who can most benefit from robotic rehabilitation medical professionals can better tailor a program that will result in the highest benefit for patients."
About the Feinstein InstituteThe Feinstein Institute for Medical Research is the research arm of Northwell Health, the largest healthcare provider in New York. Home to 50 research laboratories and to clinical research throughout dozens of hospitals and outpatient facilities, the Feinstein includes 4,000  researchers and staff who are making breakthroughs in molecular medicine, genetics, oncology, brain research, mental health, autoimmunity, and bioelectronic medicine – a new field of science that has the potential to revolutionize medicine. For more information about how we empower imagination and pioneer discovery, visit FeinsteinInstitute.org
Contact: Heather E. Ball 
516-465-7917
hball@northwell.edu

SOURCE Feinstein Institute for Medical Research

Agreed definitions and a shared vision for new standards in stroke recovery research: The Stroke Recovery and Rehabilitation Roundtable taskforce

I bet not a single stroke survivor was a SRRR participant. Why would you want to include the most knowledgeable people in the field? Lots of big important stroke research names however so I guess they all know more about stroke recovery than survivors do. I see nothing that suggests writing up stroke protocols is a focus. 100% recovery is not listed as a goal, so this is just chipping at the edges rather than solving the BHAGs(Big Hairy Audacious Goals) problems in stroke.
http://journals.sagepub.com/doi/full/10.1177/1747493017711816

First Published July 12, 2017 Research Article 
Julie Bernhardt 1,2, Kathryn S Hayward1,2,3, Gert Kwakkel4,5,Nick S Ward6,7, Steven L Wolf8,9, Karen Borschmann1,2,John W Krakauer10, Lara A Boyd3,11, S Thomas Carmichael12,Dale Corbett13,14 and Steven C Cramer15

15

 

Download PDF	Article information

Abstract

The first Stroke Recovery and Rehabilitation Roundtable established a game changing set of new standards for stroke recovery research. Common language and definitions were required to develop an agreed framework spanning the four working groups: translation of basic science, biomarkers of stroke recovery, measurement in clinical trials and intervention development and reporting. This paper outlines the working definitions established by our group and an agreed vision for accelerating progress in stroke recovery research. The goal is quite simple to specify - 100% recovery for all survivors, nothing less. If that is not your goal get the hell out and do something easier like basket weaving.

Keywords Stroke, research standards, stroke recovery, rehabilitation, definitions, translation

Introduction

The first Stroke Recovery and Rehabilitation Roundtable (SRRR) was convened with the aim to move rehabilitation research forward.¹ Working collectively across four initial priority areas, we reviewed, discussed, and attempted to achieve consensus on key recommendations in each of the areas of translation of basic science,² biomarkers of stroke recovery,³ measurement in clinical trials⁴ and intervention development and reporting.⁵ Agreed definitions were a priority. Definitions within stroke recovery research are particularly complex given both the extended time window over which research, clinical interventions and recovery take place; and the multi-disciplinary, multi-faceted nature of the field. This paper outlines the working definitions established by our group that underpinned the scope and methodologies of each of the four groups. Agreed priority areas for accelerating progress in stroke recovery research are highlighted as a way forward for the field. These were developed following comprehensive discussions at the first SRRR roundtable meeting convened in Philadelphia, 2016.
A major point of agreement of the SRRR expert group was to focus on progress of stroke recovery research in the next decade and beyond. ‘Rehabilitation’ as a blanket term for all therapy-based interventions post-stroke was considered problematic, vague and an impediment to progress. Rehabilitation reflects a process of care, while recovery reflects the extent to which body structure and functions, as well as activities, have returned to their pre-stroke state. With that, the term ‘recovery’ can be represented in two ways: (1) the change (mostly improvement) of a given outcome that is achieved by an individual between two (or more) timepoints, or (2) the mechanism underlying this improvement in terms of behavioural restitution or compensation strategies.^6,7 We used the definition of rehabilitation developed by the British Society of Rehabilitation Medicine,⁸ “a process of active change by which a person who has become disabled acquires the knowledge and skills needed for optimum physical, psychological and social function.” Stroke rehabilitation is most often delivered by a multidisciplinary team, defined by the World Health Organisation (WHO)⁹ to encompass the coordinated delivery of intervention(s) provided by two or more disciplines in conjunction with medical professionals. This team aims to improve patient symptoms and maximise functional independence and participation (social integration) using a holistic biopsychosocial model, as defined by the International Classification of Functioning Disability (ICF).⁹

Recovery

The motor system has been studied more than any other in stroke recovery research, as such this was the focus of most dialogue within the SRRR. While many of the principles of recovery emerging from research conducted on the motor system likely extend to non-motor systems, differences exist in the organisation of brain systems. In discussing stroke recovery, acknowledging that any improvement in any domain of the ICF can be viewed as a sign of ongoing recovery is important. For research, understanding the processes that underpin how recovery is achieved during stroke rehabilitation is of utmost value. An understanding that distinguishes between behavioural restitution and use of compensation strategies will further direct how we should train stroke patients to regain the ability to complete meaningful tasks and how we should design interventions, including technology applications for stroke such as rehabilitation robotics.

Behavioral restitution or true recovery

Behavioral restitution has been defined as a return towards more normal patterns of motor control with the impaired effector (a body part such as a hand or foot that interacts with an object or the environment) and reflects the process toward “true recovery.”^10,11 True recovery defines the return of some or all of the normal repertoire of behaviors that was available before injury. Neural repair is required for true recovery. Although rarely complete after stroke, some degree of true recovery is nearly always achieved.¹² For the motor system, recovery is best measured with kinematics,⁴ and for the language system, a test of speech or language production may be the optimal measure.¹³ The development of stroke treatments administered after the hyperacute period of early damage and brain cell death that restore normal function, thereby promoting true recovery, remains an aspirational goal yet to be realized across functional domains.

Compensation

A patient’s ability to accomplish a goal through substitution with a new approach rather than using their normal pre-stroke behavioral repertoire constitutes compensation. This behavior does not require neural repair, but may require learning. Compensation may be seen in all functional domains. In the motor domain, compensation strategies employ the use of intact muscles, joints and effectors in the affected limb, to accomplish the desired task or goal.^10,11 In the language system, compensation may refer to the use of an augmentative and alternative communication device, including a communication board. At present, researchers commonly test interventions that allow or promote compensation, rather than behavioral restitution, in order to improve a patient’s safety and quality of life. This approach is compounded by the choice of an outcome measure, which is unable to distinguish between the two, so that the potential mechanism of an intervention remains opaque.

Spontaneous biological recovery

In animals, this term refers to improvements in recovery of behavior in the absence of a specific, targeted treatment and occurs during a time-sensitive window that begins early after stroke and slowly tapers off.^6,11,14 In human stroke survivors, a similar period of heightened recovery of behaviors occur early post-stroke with little or no active treatment^.15 The duration of the window varies across neural systems, e.g. weeks to months post stroke for arm movement,¹⁶ but longer (weeks to years) for other systems, such as language.¹³ There is literature pertaining to motor,^17–20 visuospatial neglect,²¹ and language^22,23 systems; data for other neural systems exist but are sparser, highlighting research priorities for the field. Most stroke survivors exhibit spontaneous recovery, progressing through characteristic stages.²⁴ Proportional recovery rules suggesting that the degree and rate of recovery are strongly predictable post stroke have been proposed in a number of domains (e.g. in upper limb recovery,^19,20 visuospatial neglect²¹ and language functions.^22,25) However, a substantial group of patients do not fit such proportional recovery rules. Our challenge is to study spontaneous recovery, to understand its biological basis, to determine if we can identify recovery phenotypes in order to select patients for interventions,²⁶ and to use this knowledge to guide the development of interventions that boost behavioral recovery beyond that which occurs spontaneously. Additional definitions that are key for the field of stroke rehabilitation and recovery are contained throughout this document and in Appendix 1.

Timeline of stroke recovery

A further challenge for our field is determining the optimal timing to implement interventions focused on recovery and repair.^1,6,27,28 As a first step, we needed to agree on a common framework—underpinned by what we know about the biology of recovery— for defining what is meant by “acute,” “sub-acute,” and “chronic.”^6,29 These terms are often used in recovery research without adequate definition. Building on previous work by Dobkin and Carmichael,²⁸ we developed the framework shown in Figure 1. The framework is strongly informed by pre-clinical research in animal models of stroke,^30–33 as well as individuals with stroke,^18,27,34 particularly from studies of the motor system. This framework should be updated as more knowledge is acquired. Figure 1 outlines the timing (hours, days, months) of several important biological processes in ischaemic³⁵ and haemorrhagic³⁶ stroke, as well as the temporal terms (hyper-acute, acute, early and late sub-acute, chronic) across the first six months post-stroke and beyond. The possibility for behavioral changes even years post-stroke is recognized. However, the current understanding of brain repair processes suggests that the majority of behavioral recovery, and the rapid changes occur in the first weeks-to-months post stroke for most people. This time perspective represents an important treatment target to maximize the potential of restorative interventions.

Figure 1. Framework that encapsulates definitions of critical timepoints post stroke that link to the currently known biology of recovery.

The convention proposed for recovery research is that treatments commenced within a week of stroke onset should be classed as “acute.” Relatively, few recovery trials have initiated restorative treatments within this post-stroke phase (for reviews see^37,38). The first week until the first month post-stroke (acute and early sub-acute) is a critical time for neural plasticity^6,30,39 and should be a target for recovery trials, with some uncertainty about how early and how intensively to start training.^37,40 Importantly, we strongly recommend that in all recovery and rehabilitation research, the time from stroke onset is gathered and reported. The start and end of any intervention(s), experimental or standard of care, as well as timing of outcome and follow-up assessment should also be reported. Using this framework, the SRRR groups provide recommendations, e.g. the measurement group recommend core measures to be included in every trial of stroke recovery and rehabilitation;⁴ the biomarker group provide recommendations about the timing and type of data acquisition.³

The way forward

As the body of research in stroke recovery and rehabilitation continues to grow, we will increasingly see interventions specifically developed with the aspiration to target true recovery rather than compensation. Finding breakthrough treatments is critical and has the potential to set the stroke recovery research field on a radically new path. One only needs to look at the transformational effect of thrombolysis(12% full recovery using tPA is failure by any measure) and endovascular thrombectomy on acute stroke outcomes, research funding in this area, and importantly, on health service delivery, to understand the importance of breakthrough treatments in recovery. A number of key themes for future research and collaboration emerged from the SRRR discussions are briefly outlined below.

• Improved understanding of the natural history of recovery and stratification in trials. Applying repeated measurements at set time points (Figure 1) that start early and continue well into the chronic phase in larger cohorts of patients will help to establish the natural history of recovery in specific functional domains. We need better prognostic models of long-term outcome after stroke that are informed by behavioral, neurophysiological and neuroimaging data. Crucially, we need to better stratify patients in clinical trials that target restitution based on recovery potential.⁴¹ Most proof-of-concept trials to date that have started early after stroke are heavily underpowered by lack of proper stratification; leading often to prognostically unbalanced groups at baseline.⁴² Neurophysiology or neuroimaging approaches for stratification are only just emerging⁴³; areas where there is sufficient evidence to support their use in recovery research are outlined in our biomarkers paper.³ Informed by such data, trials of promising new treatments would have a higher likelihood of identifying a true treatment effect if there is one.
• Better understanding of the neurobiology of spontaneous and treatment-induced recovery in human subjects. Animal studies have provided insights into the cellular and molecular events that underlie stroke recovery; this must continue; however, a pressing need exists to achieve this level of understanding in human subjects. Such an understanding will require an overhaul of many current approaches and the development of biomarkers that best reflect important stroke plasticity mechanisms. The resulting insights can be expected to identify a series of biological targets that could translate into improved application of post-stroke therapies in humans and provide a biological basis for testing novel stroke recovery interventions.⁴⁴
• Characterizing different stroke recovery phenotypes. In clinical trials, we consistently identify the presence of responder and non-responder groups to a given treatment, but little is known regarding the underlying biological group differences. We need pre-clinical and clinical researchers to consistently measure neural injury and function and apply outcome measures that can distinguish behavioral restitution from compensation. This distinction will help us characterize and ultimately predict those most likely from those least likely to respond to a given intervention. An effort to understand recovery phenotypes will help target efficacious treatments towards responders and create renewed focus to develop better treatments for non-responders.
• Training new researchers. Given these priorities, an emphasis on cross-disciplinary training of new researchers will build capacity and linkages, while concurrently breaking down the silos that have historically divided basic and clinical researchers. This training should also include standardized training in core outcome assessment and biomarker acquisition for use in stroke recovery research in both animals and humans.
• Development of a network of clinical centers of excellence in stroke recovery. These centers would represent a place where clinicians understand, advocate and importantly, apply treatments at the right time and the right dose according to current best knowledge. Research would also be embedded in these centers.
• A radical new aim. We believe a new dialogue and a collective collaborative investment are needed to work towards a radical new goal of restitution and brain repair. Much of the thinking in this field is currently pragmatic, investigating interventions that could be delivered in existing health care settings. However, we urgently need to know what is possible in terms of recovery and restitution of function after stroke. This knowledge will only come about through aspirational research which seeks to achieve the largest effect size for the benefit of stroke survivors.^45,46 We need to look no further than the first thrombolysis trials for inspiration, as they had little or no chance of implementation on a wide scale within acute stroke services as they were then set up. The early thrombolysis trials drove changes in the way acute (and hyperacute) services were delivered around the world. The field of restorative therapy after stroke requires the same sense of purpose and resolve.

As a group, the SRRR participants are committed to progressing these themes. We hope that researchers, clinicians and academics working or interested in the field of stroke recovery, together with funding bodies and journal editors, will join us in pursuing and promoting the goals outlined here and in our recommendation papers.^2–5