Treatment of posterior circulation stroke: acute management and secondary prevention

 My takeaway from this, don't have a posterior circulation stroke, interventions are unproven and uncertain.  Unless you want to be a guinea pig in unregulated research by your doctor.  With a great stroke association we would have a strategy in place to do research to solve this problem. But NO, we have fucking failures of stroke associations doing nothing to solve stroke.

Treatment of posterior circulation stroke: acute management and secondary prevention

Hugh S Markus, Patrik Michel

First Published June 6, 2022 Research Article 

https://doi.org/10.1177/17474930221107500

Article information

Abstract

One fifth of strokes occur in the territory of the posterior circulation but their management, particularly acute reperfusion therapy and neurointervention procedures for secondary prevention, have received much less attention than similar interventions for the anterior circulation. In this review we overview treatment of posterior circulation stroke, including both interventions in the acute setting and, secondary prevention. We focus on areas in which management of posterior circulation stroke differs from that of stroke in general, and highlight recent advances.

Effectiveness of acute revascularisation of posterior circulation strokes remains in large parts unproven. Thrombolysis seems to have similar benefits and lower haemorrhage risks than in the anterior circulation. The recent ATTENTION and BAOCHE trials have demonstrated that thrombectomy benefits strokes with basilar artery occlusion, but its effect on other posterior occlusion sites remains uncertain. Ischaemic and haemorrhagic space-occupying cerebellar strokes can benefit from decompressive craniectomy

Secondary prevention of posterior circulation strokes includes aggressive treatment of cerebrovascular risk factors with both drugs and lifestyle interventions, and short term dual antiplatelet therapy. Randomised controlled trial (RCT) data suggest basilar artery stenosis is better treated with medical therapy than stenting, which has a high peri-procedural risk. Limited data from RCTs in stenting for vertebral stenosis suggest intracranial stenosis is currently best treated with medical therapy alone; the situation for extracranial stenosis is less clear where stenting for symptomatic stenosis is an option, particularly for recurrent symptoms; larger RCTs are required in this area.

Keywords

Stenting, Prevention, vertebral, posterior circulation, basilar, Acute stroke therapy, Vertebrobasilar

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The effect of time spent in rehabilitation on activity limitation and impairment after stroke

The time spent in rehab right now is unknown because there are NO  PROTCOLS specifying exact repetitions and time required. Without that, every piece of rehab you do is total guesswork. Hope you are ok being guinea pigs in unregistered experiments. 

The effect of time spent in rehabilitation on activity limitation and impairment after stroke

Beth Clark  ¹ , Jill Whitall  ² , Gert Kwakkel  ³ , Jan Mehrholz  ⁴ , Sean Ewings  ⁵ , Jane Burridge  ⁶

Affiliations

• PMID: 34695300
• PMCID: PMC8545241 (available on 2022-10-25)
• DOI: 10.1002/14651858.CD012612.pub2

Abstract

Background: Stroke affects millions of people every year and is a leading cause of disability, resulting in significant financial cost and reduction in quality of life. Rehabilitation after stroke aims to reduce disability by facilitating recovery of impairment, activity, or participation. One aspect of stroke rehabilitation that may affect outcomes is the amount of time spent in rehabilitation, including minutes provided, frequency (i.e. days per week of rehabilitation), and duration (i.e. time period over which rehabilitation is provided). Effect of time spent in rehabilitation after stroke has been explored extensively in the literature, but findings are inconsistent. Previous systematic reviews with meta-analyses have included studies that differ not only in the amount provided, but also type of rehabilitation.

Objectives: To assess the effect of 1. more time spent in the same type of rehabilitation on activity measures in people with stroke; 2. difference in total rehabilitation time (in minutes) on recovery of activity in people with stroke; and 3. rehabilitation schedule on activity in terms of: a. average time (minutes) per week undergoing rehabilitation, b. frequency (number of sessions per week) of rehabilitation, and c. total duration of rehabilitation.

Search methods: We searched the Cochrane Stroke Group trials register, CENTRAL, MEDLINE, Embase, eight other databases, and five trials registers to June 2021. We searched reference lists of identified studies, contacted key authors, and undertook reference searching using Web of Science Cited Reference Search.

Selection criteria: We included randomised controlled trials (RCTs) of adults with stroke that compared different amounts of time spent, greater than zero, in rehabilitation (any non-pharmacological, non-surgical intervention aimed to improve activity after stroke). Studies varied only in the amount of time in rehabilitation between experimental and control conditions. Primary outcome was activities of daily living (ADLs); secondary outcomes were activity measures of upper and lower limbs, motor impairment measures of upper and lower limbs, and serious adverse events (SAE)/death.

Data collection and analysis: Two review authors independently screened studies, extracted data, assessed methodological quality using the Cochrane RoB 2 tool, and assessed certainty of the evidence using GRADE. For continuous outcomes using different scales, we calculated pooled standardised mean difference (SMDs) and 95% confidence intervals (CIs). We expressed dichotomous outcomes as risk ratios (RR) with 95% CIs.

Main results: The quantitative synthesis of this review comprised 21 parallel RCTs, involving analysed data from 1412 participants. Time in rehabilitation varied between studies. Minutes provided per week were 90 to 1288. Days per week of rehabilitation were three to seven. Duration of rehabilitation was two weeks to six months. Thirteen studies provided upper limb rehabilitation, five general rehabilitation, two mobilisation training, and one lower limb training. Sixteen studies examined participants in the first six months following stroke; the remaining five included participants more than six months poststroke. Comparison of stroke severity or level of impairment was limited due to variations in measurement. The risk of bias assessment suggests there were issues with the methodological quality of the included studies. There were 76 outcome-level risk of bias assessments: 15 low risk, 37 some concerns, and 24 high risk. When comparing groups that spent more time versus less time in rehabilitation immediately after intervention, we found no difference in rehabilitation for ADL outcomes (SMD 0.13, 95% CI -0.02 to 0.28; P = 0.09; I² = 7%; 14 studies, 864 participants; very low-certainty evidence), activity measures of the upper limb (SMD 0.09, 95% CI -0.11 to 0.29; P = 0.36; I² = 0%; 12 studies, 426 participants; very low-certainty evidence), and activity measures of the lower limb (SMD 0.25, 95% CI -0.03 to 0.53; P = 0.08; I² = 48%; 5 studies, 425 participants; very low-certainty evidence). We found an effect in favour of more time in rehabilitation for motor impairment measures of the upper limb (SMD 0.32, 95% CI 0.06 to 0.58; P = 0.01; I² = 10%; 9 studies, 287 participants; low-certainty evidence) and of the lower limb (SMD 0.71, 95% CI 0.15 to 1.28; P = 0.01; 1 study, 51 participants; very low-certainty evidence). There were no intervention-related SAEs. More time in rehabilitation did not affect the risk of SAEs/death (RR 1.20, 95% CI 0.51 to 2.85; P = 0.68; I² = 0%; 2 studies, 379 participants; low-certainty evidence), but few studies measured these outcomes. Predefined subgroup analyses comparing studies with a larger difference of total time spent in rehabilitation between intervention groups to studies with a smaller difference found greater improvements for studies with a larger difference. This was statistically significant for ADL outcomes (P = 0.02) and activity measures of the upper limb (P = 0.04), but not for activity measures of the lower limb (P = 0.41) or motor impairment measures of the upper limb (P = 0.06).

Authors' conclusions: An increase in time spent in the same type of rehabilitation after stroke results in little to no difference in meaningful activities such as activities of daily living and activities of the upper and lower limb but a small benefit in measures of motor impairment (low- to very low-certainty evidence for all findings). If the increase in time spent in rehabilitation exceeds a threshold, this may lead to improved outcomes. There is currently insufficient evidence to recommend a minimum beneficial daily amount in clinical practice. The findings of this study are limited by a lack of studies with a significant contrast in amount of additional rehabilitation provided between control and intervention groups. Large, well-designed, high-quality RCTs that measure time spent in all rehabilitation activities (not just interventional) and provide a large contrast (minimum of 1000 minutes) in amount of rehabilitation between groups would provide further evidence for effect of time spent in rehabilitation.

Trial registration: ClinicalTrials.gov NCT02980796 NCT03259932 NCT01694992 NCT02507466 NCT03230370 NCT00369668 NCT01767480 NCT03168360.

Copyright © 2021 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

 

ESO-WSO 2020 Virtual Conference

Useless for survivors, you had to pay to attend and be able to access this. Which tells you precisely what survivors are thought of. Guinea pigs that allow them to stay employed. In fact it is better for them if they never work on or solve 100% recovery.

ESO-WSO 2020 Virtual Conference

Training Conditions Influence Walking Kinematics and Self-Selected Walking Speed in Patients with Neurological Impairments

In the past nine years have we made ANY PROGRESS TOWARDS GETTING WALKING PROTOCOLS? Or are we still in the dark ages where every stroke patient is a guinea pig in an unregistered one person clinical trial?  THIS is why a hell of a lot of people in stroke need to be fired, they aren't solving stroke, just going thru the motions from their university training.

Training Conditions Influence Walking Kinematics and Self-Selected Walking Speed in Patients with Neurological Impairments

Journal of Neurotrauma, 2011

 Gavin Williams,1
Ross Clark,2
Anthony Schache,3
Natalie A. Fini,4
Liz Moore,5
Meg E. Morris,2
and Paul R. McCrory6

Abstract

Gait training is a major focus of rehabilitation for many people with neurological disorders, yet systematic reviews have failed to identify the most effective form of gait training. The main objective of this study was to compare conditions for gait training for people with acquired brain injury (ABI). Seventeen people who had sustained an ABI and were unable to walk without assistance were recruited as a sample. Each participant was exposed to seven alternative gait training conditions in a randomized order. These were: (1) therapist manual facilitation; (2) the use of a gait-assistive device; (3) unsupported treadmill walking; and (4) four variations of  body weight support treadmill training (BWSTT). Quantitative gait analysis was performed and Gait ProfileScores (GPS) were generated for each participant to determine which condition most closely resembled normal walking. BWSTT without additional therapist or self-support of the upper limbs was associated with more severe gait abnormality [Wilks’ lambda=0.20, F(6, 6)=3.99, p=0.047]. With the exception of therapist facilitation, the gait training conditions that achieved the closest approximation of normal walking required self-support of the upper limbs. When participants held on to a stable handrail, self-selected gait speeds were up to three times higher than the speeds obtained for over-ground walking [Wilks’ lambda=0.17, F(6, 7)=5.85, p<0.05]. The provision of stable upper-limb support was associated with high self-selected gait speeds that were not sustained when walking over ground. BWSTT protocols may need to prioritize reduction in self-support of the upper limbs, instead of increasing treadmill speed and reducing body weight support, in order to improve training outcomes.
 

Gait impairment in neurological disorders: a new technological approach

Notice that 'improve' and not yet sufficient are what you get from gait rehab. So you are a one person guinea pig in an unregistered clinical trial. This times 10 million yearly stroke survivors.   And our fucking failures of stroke associations, along with your stroke doctors and stroke hospital are OK with doing nothing to solve that.  That is the tyranny of low expectations you have to fight against. Screaming may be required.

Gait impairment in neurological disorders: a new technological approach

 Roberta Semprini,MD
a
Patrizio Sale, MD
a1
Calogero Foti,MD
b
Massimo Fini,MD
a
Marco Franceschini MD
a
a
IRCCS San Raffaele Pisana, Rome, Italy
b
Physical and Rehabilitation Medicine, Public HealthDepartment, Tor Vergata University, Rome, ItalyCorresponding author:Marco FranceschiniIRCCS San Raffaele Pisana Via della Pisana, 235Rome, ItalyE-mail: marco.franceschini@sanraffaele.it

Summary

Gait recovery is considered one of the main objectives of rehabilitation interventions in neurological disabilities, as restricted movement can significantly reduce an individualʼs ability to take part in normal activities of daily living. Locomotor training has been shown to improve gait rehabilitation. Studies have recently been published on the use of robots and other devices in patients with gait disabilities, particularly in the rehabilitation of the lower limbs. However, analysis of the recent literature reveals a relative paucity of strong methodological studies. The evidence that is available, while strong, is not yet sufficient to allow definite conclusions to be drawn regarding the efficacy of these devices. From these considerations, it is clear that validated and standardized methods need to be adopted for each of the different systems available. This would help to clarify the indications for and correct use of robotic devices in the different neurological disorders.

Effects of bodyweight support and guidance force on muscle activation during Lokomat walking in people with stroke: a cross-sectional study

So we obviously have NO PROTOCOLS on any type of BWSTT. Hope you are OK with being a guinea pig in an unregistered one person clinical trial(YOU). 

Effects of bodyweight support and guidance force on muscle activation during Lokomat walking in people with stroke: a cross-sectional study

• Jianhua Lin,
• Guojiong Hu,
• Jun Ran,
• Linyu Chen,
• Xian Zhang &
• Yanxin Zhang 

Journal of NeuroEngineering and Rehabilitation volume 17, Article number: 5 (2020) Cite this article

Abstract

Background

Locomat(sic) is a robotic exoskeleton providing guidance force and bodyweight support to facilitate intensive walking training for people with stroke. Although the Locomat has been reported to be effective in improving walking performance, the effects of training parameters on the neuromuscular control remain unclear. This study aimed to compare the muscle activities between Locomat walking and treadmill walking at a normal speed, as well as to investigate the effects of varying bodyweight support and guidance force on muscle activation patterns during Locomat walking in people with stroke.

Methods

A cross-sectional study design was employed. Participants first performed an unrestrained walking on a treadmill and then walked in the Locomat with different levels of bodyweight support (30% or 50%) and guidance force (40% or 70%) at the same speed (1.2 m/s). Surface electromyography (sEMG) of seven muscles of the affected leg was recorded. The sEMG envelope was time-normalised and averaged over gait cycles. Mean sEMG amplitude was then calculated by normalising the sEMG amplitude with respect to the peak amplitude during treadmill walking for statistical analysis. A series of Non-parametric test and post hoc analysis were performed with a significance level of 0.05.

Results

Fourteen participants with stroke were recruited at the Yangzhi Affiliated Rehabilitation Hospital of Tongji University (female n = 1; mean age 46.1 ± 11.1 years). Only the mean sEMG amplitude of vastus medialis oblique during Locomat walking (50% bodyweight support and 70% guidance force) was significantly lower than that during treadmill walking. Reducing both bodyweight and guidance increased muscle activity of gluteus medius and tibialis anterior. Activity of vastus medialis oblique muscle increased as bodyweight support reduced, while that of rectus femoris increased as guidance force decreased.

Conclusions

The effects of Locomat on reducing muscle activity in people with stroke were minimized when walking at a normal speed. Reducing bodyweight support and guidance force increased the activity of specific muscles during Locomat walking. Effects of bodyweight support, guidance force and speed should be taken into account when developing individualized Locomat training protocols for clients with stroke.

Training Conditions Influence Walking Kinematics and Self-Selected Walking Speed in Patients with Neurological Impairments

So your doctor and therapists still have absolutely no clue how to get you walking properly yet.  Hope you like being a guinea pig in an unregistered single person clinical trial. Did you sign a release form? 

Training Conditions Influence Walking Kinematics and Self-Selected Walking Speed in Patients with Neurological Impairments

 Gavin Williams,
1
Ross Clark,
2
Anthony Schache,
3
Natalie A. Fini,
4
Liz Moore,
5
Meg E. Morris,
2
and Paul R. McCrory
6

Abstract

Gait training is a major focus of rehabilitation for many people with neurological disorders, yet systematic reviews have failed to identify the most effective form of gait training. The main objective of this study was to compare conditions for gait training for people with acquired brain injury (ABI). Seventeen people who had sustained an ABI and were unable to walk without assistance were recruited as a sample. Each participant was exposed to seven alternative gait training conditions in a randomized order. These were: (1) therapist manual facilitation; (2) the use of a gait-assistive device; (3) unsupported treadmill walking; and (4) four variations of  body weight support treadmill training (BWSTT). Quantitative gait analysis was performed and Gait ProfileScores (GPS) were generated for each participant to determine which condition most closely resembled normalwalking. BWSTT without additional therapist or self-support of the upper limbs was associated with moresevere gait abnormality [Wilks’ lambda = 0.20,  F (6, 6) ¼ 3.99,  p ¼ 0.047].With the exception of therapist facilitation, the gait training conditions that achieved the closest approximation of normal walking required self-support of the upper limbs. When participants held on to a stable handrail, self-selected gait speeds were up to three times higher than the speeds obtained for over-ground walking [[Wilks’ lambda = 0.17,  F (6, 7) ¼ 5.85,  p < 0.05]. The provision of stable upper-limb support was associated with high self-selected gait speeds that were not sustained when walking over ground. BWSTT protocols may need to prioritize reduction in self-support of the upper limbs, instead of increasing treadmill speed and reducing body weight support, in order to improve training outcomes.

Oral Anticoagulant Choice Matters in Bone Health, Study Finds

So ask your doctor VERY SPECIFICALLY  why your anticoagulant was chosen. I just got rat poison(warfarin) because that was the only thing available at the time except for a couple of lovenox shots. 

So good to know your doctors know nothing specific about this and are just guessing in the dark.(suggest, propose, theory) Aren't you happy that there seems to be NO PROTOCOLS anywhere in stroke?  Stroke survivors are just guinea pigs in unregulated experiments.  And you are paying your doctor for that privilege.

Oral Anticoagulant Choice Matters in Bone Health, Study Finds

Investigators compare direct oral anticoagulants with vitamin K antagonists

Did your doctor do anything with this from November 2013 regarding prescribing intravenous bisphosphonates?

Falls, Fractures, and Osteoporosis After Stroke

 

• by Nicole Lou, Contributing Writer, MedPage Today October 21, 2019

Bone fractures are a risk to be considered when choosing the oral anticoagulant for a patient with non-valvular atrial fibrillation (Afib), a study suggested.
The risk of poor osteoporotic outcomes was significantly lower with direct oral anticoagulant (DOAC) compared with vitamin K antagonist (VKA) therapy, as follows:

• Any fracture: 3.09% vs 3.77% (adjusted HR 0.85, 95% CI 0.74-0.97)

• Major osteoporotic fractures: 2.29% vs 2.82% (adjusted HR 0.85, 95% CI 0.72-0.99)

• Initiation of  medication: 2.44% vs 3.14% (adjusted HR 0.82, 95% CI 0.71-0.95)

• Any fracture or starting osteoporosis medication: 5.21% vs 6.43% (adjusted HR 0.84, 95% CI 0.76-0.93)

"Because of a more favorable skeletal health profile, DOAC treatment could be preferred to VKA in patients with Afib with strong risk factors for osteoporotic fractures," said Casper Binding, BMedSc, of Copenhagen University Hospital Herlev and Gentofte in Denmark, and colleagues.
As the team noted in the study online in the Journal of the American College of Cardiology, VKAs like warfarin (Coumadin) have been widely used for stroke prophylaxis for decades. The newer DOACs have been shown to have efficacy similar to that of warfarin in preventing stroke in Afib and do not require international normalized ratio (INR) monitoring, Binding and colleagues explained.
Using data from the Danish National Patient Register, the investigators identified 37,350 people with non-valvular Afib as having had no prior use of osteoporosis medication and having undergone 180 days of oral anticoagulation with a VKA or a DOAC, including dabigatran, rivaroxaban, apixaban, or edoxaban.
Two-thirds of the cohort received DOAC rather than VKA treatment. The DOAC group was significantly older; included more women; and were more often on hormone-replacement therapy and to have had previous fractures, stroke, or a diagnosis of alcohol abuse.
"Studies suggest a link between warfarin and undercarboxylated osteocalcin, which is associated with low bone mineral density," the researchers wrote. "These results correlate with findings that propose a connection between warfarin and an increased risk of osteoporotic fractures."
Then there is the theory that dietary restrictions around VKA treatment could lead to low folic acid intake and a resulting risk of hyperhomocysteinemia, which can reduce bone strength, the researchers continued, adding that in the end, the main results are in line with those of a smaller study of Chinese patients.
"The results of our study not only support what other studies have suggested, but also more importantly they show that the risk reductions apply to nationwide data from a Western society and persist when all DOACs are analyzed and compared with VKA," the investigators said.
They noted that their analysis may be subject to residual confounding from unmeasured variables such as INR, body mass index (BMI), hemoglobin, and renal function.
Writing in an accompanying editorial, Brian Gage, MD, MSc, of Washington University in St. Louis, Missouri, said: "Because patients with low creatinine clearance or low BMI are both more likely to have an osteoporotic fracture and to be prescribed a VKA rather than a DOAC, residual confounding could have exaggerated the association between VKA and fracture."
"Thus, at least for patients who have Afib and no prior osteoporotic fracture (the population studied), the decision to prescribe a VKA or a DOAC should depend on the risks of ischemic stroke, hemorrhage, need for monitoring, and affordability rather than on the risk of osteoporotic fracture," Gage argued.
In summary, he said, the researchers "had a strong biochemical basis to search for a link between VKAs and osteoporotic fracture. Their well-done observational study provides additional evidence of this link, but residual confounding may have exaggerated the association."

The study was funded by an institutional scholarship awarded to Binding.
Binding and Gage disclosed no conflicts.

• Primary Source

  Journal of the American College of Cardiology

  Source Reference: Binding C, et al "Osteoporotic fractures in patients with atrial fibrillation treated with conventional versus direct anticoagulants" J Am Coll Cardiol 2019; DOI: 10.1016/j.jacc.2019.08.1025.

• Secondary Source

  Journal of the American College of Cardiology

  Source Reference: Gage BF "Warfarin-induced fractures in atrial fibrillation?" J Am Coll Cardiol 2019; DOI: 10.1016/j.jacc.2019.08.1026.

 

Occupational Therapy for Stroke Patients: A Systematic Review * Occupational Therapy for Stroke Patients: When, Where, and How?

Very importantly you will notice they don't point to any rehab protocols.  My takeaway from this is that you are still a one person guinea pig in an uncontrolled clinical study.  Hope you are ok with that.  How long before your hospital discontinues splinting, 7 years after research came out ? 

Hand splinting for poststroke spasticity: A randomized controlled trial

November 2012

The latest here:

Occupational Therapy for Stroke Patients: A Systematic Review * Occupational Therapy for Stroke Patients: When, Where, and How?

 Esther M.J. Steultjens, MA; Joost Dekker, PhD; Lex M. Bouter, PhD; Jos C.M. van de Nes, MD;Edith H.C. Cup, MSc; Cornelia H.M. van den Ende, PhD
 Background and Purpose
—Occupational therapy (OT) is an important aspect of stroke rehabilitation. The objective of thisstudy was to determine from the available literature whether OT interventions improve outcome for stroke patients.
 Methods
—An extensive search in MEDLINE, CINAHL, EMBASE, AMED, and SCISEARCH was performed. Studieswith controlled and uncontrolled designs were included. Seven intervention categories were distinguished and separatelyanalyzed. If a quantitative approach (meta-analysis) of data analysis was not appropriate, a qualitative approach(best-evidence synthesis), based on the type of design, methodological quality, and significant findings of outcomeand/or process measures, was performed.
 Results
—Thirty-two studies were included in this review, of which 18 were randomized controlled trials. Ten randomized controlled trials had a high methodological quality. For the comprehensive OT intervention, the pooled standardized mean difference for primary activities of daily living (ADL) (0.46; CI, 0.04 to 0.88), extended ADL (0.32; CI, 0.00 to0.64), and social participation (0.33; CI, 0.03 to 0.62) favored treatment. For the training of skills intervention, some evidence for improvement in primary ADL was found. Insufficient evidence was found to indicate that the provision of splints is effective in decreasing muscle tone.
Conclusions
—This review identified small but significant effect sizes for the efficacy of comprehensive OT on primaryADL, extended ADL, and social participation. These results correspond to the outcome of a systematic review of intensified rehabilitation for stroke patients. The amount of evidence with respect to specific interventions, however, islimited. More research is needed to enable evidence-based OT for stroke patients.
 (Stroke. 2003;34:676-687.)

Dosage Matters A Phase IIb Randomized Controlled Trial of Motor Therapy in the Chronic Phase After Stroke

This in a nutshell is the whole problem with stroke rehab. No one knows anything specific. We just get crappy guidelines when we need EXACT protocols.  Until we get stroke survivors in charge this crapola will not change.

Dosage Matters - A Phase IIb Randomized Controlled Trial of Motor Therapy in the Chronic Phase After Stroke

 

Carolee Winstein

,

Bokkyu Kim

,

Sujin Kim

,

Clarisa Martinez

,

Nicolas Schweighofer

Originally publishedhttps://doi.org/10.1161/STROKEAHA.118.023603Stroke. ;0

Abstract

Background and Purpose—

For stroke rehabilitation, task-specific training in animal models and human rehabilitation trials is considered important to modulate neuroplasticity, promote motor learning, and functional recovery. Little is known about what constitutes an effective dosage of therapy. (So every stroke patient is a one person guinea pig in an unregistered clinical trial. Did you sign a consent form for that?)

Methods—

This is a parallel group, 4 arms, single-blind, phase IIb, randomized controlled trial of 4 dosages of arm therapy delivered in an outpatient setting chronically after stroke. Participants were randomized into groups that varied in duration of scheduled therapy (ie, 0, 15, 30, or 60 hours). Forty-one participants completed the study. Planned primary analyses used linear mixed effects regression to model changes from baseline to postintervention in the Motor Activity Log-Quality of Movement rating and the Wolf Motor Function Test time score over 3 weeks of training as a function of therapy dosage.

Results—

We observed a dose response for the Motor Activity Log-Quality of Movement: the model that included dose and dose by week interaction significantly better fit the data than the model that included week only (log-likelihood test, P=0.0026). In addition, the greater the dosage of training, the greater the change in Motor Activity Log-Quality of Movement, with the dose by week interaction parameter equal to 0.0045 (P=0.0016; 95% CI, 0.0018–0.0071). Over the 3 weeks of therapy, there was a gain of 0.92 in Motor Activity Log-Quality of Movement for the 60-hour group compared to the 0-hour group. There was no dose response for the Wolf Motor Function Test.

Conclusions—

For mild-to-moderately impaired stroke survivors, the dosage of patient-centered, task-specific practice systematically influences the gain in quality of arm use but not functional capacity. We caution that we may have been underpowered for the functional capacity outcome. These findings highlight the importance of recovery outcomes that capture arm use in the natural environment.

Clinical Trial Registration—

URL: https://www.clinicaltrials.gov. Unique identifier: NCT01749358.

Development, Implementation, and Clinician Adherence to a Standardized Assessment Toolkit for Sensorimotor Rehabilitation after Stroke

Until you get to a protocol, stuff like this is worthless.  You need a protocol with exact steps mapped to an objective diagnosis that will deliver an x% efficacy. Until that occurs stroke survivors will continue to be one person stroke research subjects as unregulated guinea pigs.

Development, Implementation, and Clinician Adherence to a Standardized Assessment Toolkit for Sensorimotor Rehabilitation after Stroke 

Carol L. Richards , BScPT, PhDRelated information

*Centre intégré universitaire de santé et de services sociaux (CIUSSS) de la Capitale-Nationale, Quebec City;

†Centre interdisciplinaire de recherche en réadaptation et intégration sociale;

‡Département de réadaptation, Université Laval, Laval, Que.

; Francine Malouin , BScPT, PhDRelated information

*Centre intégré universitaire de santé et de services sociaux (CIUSSS) de la Capitale-Nationale, Quebec City;

†Centre interdisciplinaire de recherche en réadaptation et intégration sociale;

‡Département de réadaptation, Université Laval, Laval, Que.

; Sylvie Nadeau , BScPT, PhDRelated information

§Institut de réadaptation Gingras-Lindsay de Montréal, CIUSSS Centre-Sud-de-l’Île-de-Montréal;

¶Centre interdisciplinaire de recherche en réadaptation;

**École de réadaptation, Université de Montréal;

; Joyce Fung , BScPT, PhDRelated information

¶Centre interdisciplinaire de recherche en réadaptation;

††Jewish Rehabilitation Hospital, Centre intégré de santé et de services sociaux de Laval;

‡‡School of Physical and Occupational Therapy, McGill University, Montreal;

; Line D’Amours , BScOT, MBARelated information

*Centre intégré universitaire de santé et de services sociaux (CIUSSS) de la Capitale-Nationale, Quebec City;

; Claire Perez , BScPT, MScRelated information

¶Centre interdisciplinaire de recherche en réadaptation;

††Jewish Rehabilitation Hospital, Centre intégré de santé et de services sociaux de Laval;

‡‡School of Physical and Occupational Therapy, McGill University, Montreal;

; Anne Durand , BScPT, PhDRelated information

*Centre intégré universitaire de santé et de services sociaux (CIUSSS) de la Capitale-Nationale, Quebec City;

From the:

*Centre intégré universitaire de santé et de services sociaux (CIUSSS) de la Capitale-Nationale, Quebec City;

§Institut de réadaptation Gingras-Lindsay de Montréal, CIUSSS Centre-Sud-de-l’Île-de-Montréal;

¶Centre interdisciplinaire de recherche en réadaptation;

**École de réadaptation, Université de Montréal;

‡‡School of Physical and Occupational Therapy, McGill University, Montreal;

††Jewish Rehabilitation Hospital, Centre intégré de santé et de services sociaux de Laval;

†Centre interdisciplinaire de recherche en réadaptation et intégration sociale;

‡Département de réadaptation, Université Laval, Laval, Que.

Correspondence to: Dr. Carol L. Richards, Centre interdisciplinaire de recherche en réadaptation et intégration sociale (CIRRIS), 525 Boul. Wilfrid-Hamel Est, Québec, QC G1M 2S8; carol.richards@fmed.ulaval.ca.

https://doi.org/10.3138/ptc.2017-41

Published Online: January 04, 2019

• Abstract
• PDF

Abstract

Purpose: This study describes the development of a standardized assessment toolkit (SAT) and associated clinical database focusing on sensorimotor rehabilitation in three stroke rehabilitation units (SRUs). Implementation of the SAT was confirmed using objective measures of clinician adherence while exploring reasons for varied adherence.  
Method: Participants were patients post-stroke admitted for inpatient rehabilitation and clinicians from the three SRUs. A collaborative and iterative process was used to develop the SAT. Implementation was measured by clinician adherence, which was charted by means of assessment entries in patient records and transferred to the clinical database. Reasons for lower adherence were interpreted from therapist data logs at one SRU.  
Results: The SAT consisted of 25 assessment tools. Clinician adherence to a subset of the tools ranged from 33% to 99% at admission and from 28% to 94% at discharge. At one site, lower adherence among the tools was explained by patient-related factors (1%–36%) and protocol or logistical reasons (0%–7%) at admission; missing data ranged from 0% to 3%, except for the Montreal Cognitive Assessment (17%).  
Conclusions: In this pragmatic study, objective measures of clinician adherence demonstrated the feasibility of implementing an SAT in daily practice. Moreover, the reasons for lower adherence rates may be related to the patients, protocol, and logistics, all of which may vary with the assessment tool, rather than clinician compliance.

ESJ Comment: Secondary prevention of stroke

Obviously there are NO PROTOCOLS for these patients. You are just a guinea pig. 'Can be' and 80% is not good enough.  We don't want 'care', we want results.

ESJ Comment: Secondary prevention of stroke

Original research article: “Availability of secondary prevention services after stroke in Europe: An ESO/SAFE survey of national scientific societies and stroke experts” European Stroke Journal DOI: 10.1177/2396987318816136   https://journals.sagepub.com/doi/full/10.1177/2396987318816136

Secondary prevention of stroke: never too late

Comment by Linxin Li
Stroke is the second most common cause of death and the leading cause of long-term disability in Europe.¹ Recurrent stroke is associated with physical disability, cognitive decline, mood disturbances and poor quality of life. However, early recurrent stroke can be reduced in up to 80% of cases with the implementation of optimal secondary prevention of stroke.² Although all countries across Europe agree that appropriate secondary preventive measures are important, information is lacking regarding the provision of secondary prevention services in different countries.

Acute stroke care in Europe

Following the recent publication of the ESO/SAFE/ESMINT/EAN survey on provision of Acute Stroke Care across Europe,³ in this issue of the ESJ, the ESO-SAFE Secondary Prevention Survey Steering Group reported their results of a survey on the availability of secondary prevention services after stroke in Europe.
Methodology of this survey is similar to the previous survey on acute stroke care, where consensus responses were sought from panels of three experts in each country, coordinated by national stroke society chairs, or an ESO-nominated expert where there was no national society. National or local stroke registries were identified where possible and in the absence of such information, the coordinator and experts were asked to perform best estimates by consensus.
Of all 50 countries, data were available from 46 countries. 71% countries reported access to some registry data and 54% identified national strategies including secondary stroke prevention. Overall provision of secondary prevention varied between countries of different GDPs, with gaps in care prevalent particularly in lower income countries. Highlights of the results are listed below

• Acute assessment: more than 60% of patients with a TIA were assessed by stroke specialists in high income countries, whilst 4 countries in the lowest tertile of GDP assessed >60% of patients in general medical clinics, and 3 countries in the lower two tertiles still deferred assessment of >20% patients to primary care. Even in high income countries, less than one third of them had >60% of the patients assessed on the same day, one of which took more than one week to see most patients.
• Investigation and interventions: prolonged cardiac monitoring was routinely performed for AF screening in only half of the countries. Blood pressure monitoring is standardly deferred to primary care with only a third of countries offering out-of-office monitoring. Significant delays until carotid intervention remain common across all countries, especially in lower income countries. 5 lower income countries reported that >60% of patients are not operated within one month.
• Management of risk factors: The commonest follow-up method was primary care (51%) and only 10% of the countries offered specialist-led follow-up clinics for most patients. Combined lifestyle management programmes are commonly available only in half of the countries. In contrast, the majority of patients across all countries receive antiplatelet and antihypertensive treatment at initial assessment. Statins are however less commonly prescribed in lower income countries. Moreover excellent compliance to secondary prevention medication in >60% of patients is only achieved in less than 60% of countries.

The authors concluded that, “despite significant advances in secondary stroke prevention over the past decade, many gaps in the provision of routine, cost-effective, evidence-based interventions across Europe remain”. The gaps identified in this survey also echoed with the Action Plan for Stroke in Europe,⁴ which identified 4 targets for 2030 in the area of secondary prevention, including incorporating secondary prevention in national stroke plans, ensuring that at least 90% of the stroke population is seen by a stroke specialist, and ensuring access to key investigations as well as key preventative strategies.
So, for secondary prevention of stroke, there is still many to do but it is never too late!
The full paper can be found on the ESJ website.

References

1. Feigin VL, Forouzanfar MH, Krishnamurthi R, et al. Global and regional burden of stroke during 1990–2010: findings from the Global Burden of Disease Study 2010. Lancet 2014; 383: 245–254.
2. Rothwell PM, Giles MF, Chandratheva A, et al. Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study): a prospective population-based sequential comparison. Lancet 2007; 370: 1432–1442.
3. Aguiar de Sousa D, von Martial R, Abilleira S, et al. Access to and delivery of acute ischaemic stroke treatments: A survey of national scientific societies and stroke experts in 44 European countries. Eur Stroke J 2018; DOI: 10.1177/2396987318786023
4. Bo Norrving, Jon Barrick, Antoni Davalos, et al. Action Plan for Stroke in Europe 2018–2030. Eur Stroke J 2018; DOI: 10.1177/2396987318808719

Virtual reality experiences, embodiment, videogames and their dimensions in neurorehabilitation

So we can't conclude any efficacy of using virtual reality for stroke rehab yet. You are a guinea pig if you get this for therapy.

Virtual reality experiences, embodiment, videogames and their dimensions in neurorehabilitation

• Daniel Perez-MarcosEmail authorView ORCID ID profile

Journal of NeuroEngineering and Rehabilitation201815:113

https://doi.org/10.1186/s12984-018-0461-0

©  The Author(s). 2018

• Received: 11 June 2018
• Accepted: 12 November 2018
• Published: 26 November 2018

Abstract

Background

In the context of stroke rehabilitation, new training approaches mediated by virtual reality and videogames are usually discussed and evaluated together in reviews and meta-analyses. This represents a serious confounding factor that is leading to misleading, inconclusive outcomes in the interest of validating these new solutions.

Main body

Extending existing definitions of virtual reality, in this paper I put forward the concept of virtual reality experience (VRE), generated by virtual reality systems (VRS; i.e. a group of variable technologies employed to create a VRE). Then, I review the main components composing a VRE, and how they may purposely affect the mind and body of participants in the context of neurorehabilitation. In turn, VRS are not anymore exclusive from VREs but are currently used in videogames and other human-computer interaction applications in different domains. Often, these other applications receive the name of virtual reality applications as they use VRS. However, they do not necessarily create a VRE. I put emphasis on exposing fundamental similarities and differences between VREs and videogames for neurorehabilitation. I also recommend describing and evaluating the specific features encompassing the intervention rather than evaluating virtual reality or videogames as a whole.

Conclusion

This disambiguation between VREs, VRS and videogames should help reduce confusion in the field. This is important for databases searches when looking for specific studies or building metareviews that aim at evaluating the efficacy of technology-mediated interventions.

A new study in @StrokeAHA_ASA compares adverse risks of #NOACs and #warfarin for AF patients. Tell us if the #ARISTOPHANES study results will affect your practice > http://spr.ly/6015EBEGN

What incredible lack of professionalism. There should never be a question about what to do. You have an objective diagnosis, that leads directly to a stroke protocol.  But I must be missing a hell of a lot, probably that there is NO objective diagnosis for anything in stroke. With nothing objective, every single stroke patient is a guinea pig in an unregulated and unregistered stroke research trial of one person.
https://twitter.com/StrokeAHA_ASA?cn=ZmxleGlibGVfcmVjc18y&refsrc=email

Intravenous Thrombolytic Therapy Remains the Basis and Mainstay of Revascularizing Therapy!

WHY! WHAT ARE THE RECOVERY RESULTS FROM SUCH THERAPY? BETTER THAN THE 88% FAILURE RATE OF tPA?
https://www.ahajournals.org/doi/10.1161/STROKEAHA.118.022620?platform=hootsuite 
You can read the two pages yourself, our stroke medical professionals still have NO PROTOCOLS on use of IVT vs. EVT. So all stroke patients are still guinea pigs in unregulated clinical trials. 

Long-Term Consequences of Worsened Poststroke Status in Patients With Premorbid Disability

You better hope like hell you have a stroke that matches the clinical trials so your doctors know exactly what to do.  Otherwise you get to be a guinea pig in 'winging it'. I expect 100% recovery for all. No survivor left behind.

Long-Term Consequences of Worsened Poststroke Status in Patients With Premorbid Disability 

Implications for Treatment

Aravind Ganesh

,

Ramon Luengo-Fernandez

,

Sarah T. Pendlebury

,

Peter M. Rothwell

and on behalf of the Oxford Vascular Study

Originally published10 Sep 2018Stroke. 2018;0:STROKEAHA.118.022416

Abstract

Background and Purpose—

Patients with premorbid disability, generally defined as modified Rankin Scale (mRS) score ≥2, are often excluded from trials of acute stroke therapies. However, increased disability in such patients will adversely affect long-term outcomes if treatments are withheld in routine practice. We assessed the extent to which increased disability poststroke influences 5-year mortality, institutionalization, and costs in premorbidly disabled patients.

Methods—

In a population-based, prospective cohort of patients with ischemic stroke (OXVASC [Oxford Vascular Study], 2002–2014), we tracked mortality, institutionalization, and healthcare/social-care costs during follow-up. We compared 5-year mortality and poststroke institutionalization (Cox regressions) and 5-year healthcare/social-care costs (generalized linear model) in 3-month survivors with premorbid mRS of 2 to 4 (excluding extreme disability, mRS=5), based on the degree of change in mRS(ΔmRS) from prestroke to 3 months poststroke, adjusting analyses for age/sex/initial National Institutes of Health Stroke Scale.

Results—

Among 1607 patients, 530 (33.0%) had premorbid mRS of 2 to 4. Only 2 premorbidly disabled patients received thrombolysis, but 421 (79.4%) were alive at 3 months. ΔmRS was independently associated with 5-year mortality/institutionalization (adjusted hazard ratio for ΔmRS=1 versus 0: 1.59; 95% CI, 1.20–2.11; ΔmRS=2: 2.39; 95% CI, 1.62–3.53; ΔmRS=3: 4.12; 95% CI, 1.98–8.60; P<0.001) and costs (margin for ΔmRS ≥2 versus 0: $30 011, 95% CI, $4222–55 801; P=0.023). Results were similar on examining patients with premorbid mRS of 2, 3, and 4 separately (eg, 5-year mortality/institutionalization adjusted hazard ratio for premorbid mRS=3 with ΔmRS=1 versus 0: 1.60; 95% CI, 1.06–2.42; P=0.027; ΔmRS=2: 3.20; 95% CI, 1.85–5.54; P<0.001).

Conclusions—

Patients with stroke with premorbid disability have higher mortality, institutionalization, and costs if they accumulate additional disability because of the stroke. These findings highlight the long-term outcomes expected if acute interventions are routinely withheld in patients with mild-moderate premorbid disability and suggest that trials/registries should include such patients.

Time, Flow, and Location Key to Lytic Sufficiency for Stroke

By using the word triage this means that we still don't have protocols on how stroke should be treated in the first hours. You better hope like hell you have a stroke that matches the clinical trials so your doctors know exactly what to do.  Otherwise you get to be a guinea pig in 'winging it'.  We still have no clue how fast tPA needs to be delivered to get full recovery from it.

Time, Flow, and Location Key to Lytic Sufficiency for Stroke

Recanalization factors pinned down in prospective analysis

• by Nicole Lou, Reporter, MedPage Today/CRTonline.org September 11, 2018

How responsive an intracranial thrombus is to alteplase (Activase) depends on certain factors that could help inform how patients with acute ischemic stroke should be triaged, according to a global prospective cohort study.
IV alteplase was associated with higher odds of successful recanalization, at 30.4% versus 13.3% for non-recipients (difference 17.1%, 95% CI 10.2%-25.8%) among the 575 stroke patients with intracranial occlusions observed on CT angiography in the INTERRSeCT study, reported online in JAMA by Andrew Demchuk, MD, of University of Calgary in Alberta, and collaborators.
Among those getting alteplase, the factors associated with recanalization of the arterial occlusion were:

• Time from treatment start to recanalization assessment: OR 1.28 for every 30-minute interval (95% CI 1.18-1.38)
• More distal thrombus location: OR 5.61 (95% CI 2.38-13.26)
• Greater residual flow: OR 7.03 (95% CI 3.32-14.87)

In contrast, the sole predictor of recanalization without IV alteplase was male sex.
"Patients with factors associated with thrombus responsiveness to alteplase (e.g., thrombus permeability) may not require transfer because they will recanalize with IV alteplase," Demchuk's group suggested.
The stroke patients in the study -- from 12 centers across North America, Europe, and East Asia -- had a median 114 minutes elapse from the last time they were known to be well to baseline CT angiography, 19 minutes between baseline CT angiography to the start of alteplase administration, and then another 132.5 minutes to recanalization assessment.
"The results of this study suggest that recanalization with IV alteplase is a continuous process over time," the authors said. "With a plasma half-life of 6 to 7 minutes, alteplase is not likely to be biologically active at 6 hours following administration. However, it is possible that the early thrombus debulking effects of alteplase translate to less overall thrombus, allowing endogenous tissue plasminogen activator [tPA] to complete the remaining lysis required."
The INTERRSeCT findings may be relevant in deciding where to send stroke patients who are potential candidates for endovascular therapy, the investigators suggested.
"When transport times are several hours longer to a comprehensive stroke center compared with a primary stroke center, evaluation at a primary stroke center for initial treatment with IV alteplase is likely the better option based on reasonable recanalization rates with alteplase over several hours," they said.
This is the most important message of this study, according to Brian Silver, MD, of UMass Memorial Health Care in Worcester, Massachusetts.
"What the actual distance or time duration should be is not clear at this time, but anything over 60 minutes probably does not warrant diversion to a comprehensive stroke center because of potential negative implications for the patient," he said in an interview.
On the other hand, Tudor Jovin, MD, of the University of Pittsburgh Medical Center, wasn't completely on board.
"This is another piece in the puzzle but it doesn't solve the puzzle [of how to triage patients]," he told MedPage Today. "By the time patients get to CT angiography to determine the level and characteristics of the occlusion, the patient is already at the primary stroke center."
The "holy grail" would be to have this information in the field, before hospital arrival, Jovin said. This may be possible with mobile stroke units (which have yet to prove their cost-effectiveness, he noted) or the use of transcranial ultrasound in ambulances.
Another issue is the need for more refined predictive capabilities: "Even if you identify some patients who have, say, a 70% chance of opening up with IV tPA, is that enough to send them to a non-thrombectomy place? None of these methods detect the chance of recanalization with tPA to a level where we are actually comfortable taking a patient to a non-thrombectomy center," cautioned Jovin.
Nevertheless, he called Demchuk's study "very important," because it confirms with prospective data what other retrospective studies had previously suggested about recanalization rates. "We can now put more reliable numbers when we plan trials and things like that -- the recanalization rate of tPA in someone with internal carotid artery occlusion [for example] ... We now have better numbers to quote."
One caveat to the study, Demchuk and colleagues acknowledged, was that patients were enrolled in 2010-2016, during a period of significant evolution in stroke care. Additionally, the sample was relatively small and precluded subset analyses by occlusion site.
Study participants were a median 72 years old and 51.5% men. Treatments provided were alteplase only (47.8%), alteplase plus endovascular thrombectomy (33.9%), thrombectomy alone (8.3%), and conservative treatment (9.9%).

Demchuk reported receiving honoraria for CME events from Medtronic.
Jovin and Silver disclosed no conflicts of interest.

• Primary Source

  JAMA

  Source Reference: Menon BK, et al “Association of clinical, imaging, and thrombus characteristics with recanalization of visible intracranial occlusion in patients with acute ischemic stroke” JAMA 2018; DOI: 10.1001/jama.2018.12498.

Construct validity of the NIH toolbox cognition battery in individuals with stroke

So prior to this our medical teams were completely blind in cognitive testing post stroke. Aren't you glad you were a guinea pig in your doctors unregistered research? I bet your doctor provided your results to no one.
https://search.naric.com/research/rehab/redesign_record.cfm?search=2&type=all&criteria=J77631&phrase=no&rec=135597&article_source=Rehab&international=0&international_language=&international_location=
Rehabilitation Psychology , Volume 62(4) , Pgs. 443-454.

NARIC Accession Number: J77631.  What's this?
ISSN: 0090-5550.
Author(s): Carlozzi, Noelle E; Tulsky, David S.; Wolf, Timothy J.; Goodnight, Siera.; Heaton, Robert K.; Casaletto, Kaitlin B.; Wong, Alex W. K; Baum, Carolyn; Gershon, Richard C.; Heinemann, Allen W..
Project Number: 90RT5008 (formerly H133B090024).
Publication Year: 2017.
Number of Pages: 12.
Abstract: Study evaluated the construct validity of the National Institutes of Health (NIH) Toolbox (NIHTB) for the Assessment of Behavior and Neurological Function Cognition Battery (NIHTB-CB) in individuals with stroke. The NIHTB-CB provides a brief assessment (approximately 30 minutes) of key components of cognition. A total of 131 individuals with stroke (71 with mild stroke; 60 with moderate/severe stroke) completed the NIHTB-CB. Univariate analyses were conducted to examine the cognitive profiles of the two different stroke groups (mild versus moderate/severe stroke) on NIHTB-CB measures and composite scores. Pearson correlations were computed to evaluate relationships between NIHTB-CB and established measures to examine convergent and discriminant validity. Effect sizes and clinical impairment rates for the different NIHTB-CB measures and composite scores were also examined. Participants experiencing moderate-to-severe stroke had poorer performance than did individuals with mild stroke on several of the NIHTB cognition measures. Evidence of convergent validity was provided by moderate-to-strong correlations between the NIHTB measures and the corresponding standard neuropsychological test (Pearson correlation coefficients ranged from 0.31 to 0.88). Evidence of discriminant validity was provided by smaller correlations between different cognitive domains than correlations of measures within the same domain. Effect sizes for composite and subtest scores regarding stroke severity were generally moderate-to-large. In addition, 42 percent of the sample were exhibiting mild cognitive impairment (i.e., ≥2 low scores on fluid tests). Findings provide support for the construct validity of the NIHTB-CB in individuals with stroke.
Descriptor Terms: COGNITION, MEASUREMENTS, OUTCOMES, PERFORMANCE STANDARDS, PROGRAM EVALUATION, STROKE.


Can this document be ordered through NARIC's document delivery service*?: Y.

Citation: Carlozzi, Noelle E, Tulsky, David S., Wolf, Timothy J., Goodnight, Siera., Heaton, Robert K., Casaletto, Kaitlin B., Wong, Alex W. K, Baum, Carolyn, Gershon, Richard C., Heinemann, Allen W.. (2017). Construct validity of the NIH toolbox cognition battery in individuals with stroke.  Rehabilitation Psychology , 62(4), Pgs. 443-454. Retrieved 2/21/2018, from REHABDATA database.