Once Daily, 10 Minute Rehab Maybe Be Enough in Mild Stroke

 WRONG, WRONG, WRONG!

Your endpoints are wrong, 100% recovery is the only goal in stroke and you blithering idiots are leaving persons disabled!

Comeuppance is going to be a real bitch for you when you are the 1 in 4 per WHO that has a stroke!

Once Daily, 10 Minute Rehab Maybe Be Enough in Mild Stroke

A new clinical trial has produced the most reliable information to date on the optimum level of early rehabilitation appropriate for patients with acute stroke.

The AVERT DOSE trial has suggested that in the initial days after an acute stroke, just 10 minutes of active training per day is sufficient for patients with mild stroke, while patients with moderate stroke could benefit from slightly higher levels of exercise training split into two separate sessions.

“The AVERT DOSE trial, while underpowered, provides current best available evidence to guide early training after an acute stroke,” said lead investigator, professor Julie Bernhardt, PhD, The Florey Institute, Melbourne, Australia.

“Our trial shows that the protocolized training tested can feasibly be delivered in multiple settings and is safe,” she added.

Article Key Points

The AVERT DOSE trial suggests that 10 minutes of daily active training may suffice for mild stroke patients, while moderate stroke patients benefit from two 10-minute sessions. The interventions are safe and adaptable across various settings.

The findings suggest that for patients with mild stroke (National Institutes of Health Stroke Scale [NIHSS] 0-7), a single 10-minute session of active, task-specific training supported by nurses during upright daily activities may be sufficient for most patients, with no clear evidence that higher-intensity training provides additional benefit, Bernhardt said.

For patients with moderate stroke severity (NIHSS, 8-16), the findings suggest that two separate 10-minute sessions of active, task-specific training supported by nurses during upright daily activities provided clinically meaningful benefits compared with a single session.

In both cases the 10 minutes of active training refers to only the active practice time and does not include preparation or rest periods in between activity, so the session itself would take significantly longer than 10 minutes.

The trial results were presented on May 6 at the European Stroke Organization Conference (ESOC) 2026.

A Vital Early Poststroke Goal

Bernhardt explained that regaining movement is a vital early goal after stroke, but important questions remain about how soon rehabilitation should begin and how much training is beneficial. Those uncertainties have persisted since the first AVERT trial, reported in 2015, showed that very early intensive mobilization — initiated within 24 hours of stroke onset — worsened outcomes compared with lower-dose usual care, with the greatest adverse effects seen in patients with intracerebral hemorrhage (ICH) and severe stroke.

“This very early intensive therapy appeared to be too much, too soon and but there has remained a lack of clear evidence on the optimal timing and intensity for rehabilitation training,” Bernhardt noted 

To address this issue the researchers conducted the AVERT DOSE trial.

For the study, the researchers analyzed data from the original AVERT trial to identify intervention doses with the most favorable safety and efficacy profiles, then evaluated those dosing strategies in the new trial that excluded patients with ICH and severe stroke.

The study enrolled 1000 patients across 50 hospitals in seven countries, including Australia, Brazil, India, Ireland, Malaysia, Singapore, and the UK.

Participants were stratified by stroke severity, with 631 patients in the mild stroke group and 366 in the moderate stroke group and randomly assigned to one of four mobility training regimens.

All interventions were initiated within 48 hours of stroke onset (mean, 38 hours) and continued for 14 days or until hospital discharge. The interventions focused on functional, task-specific upright movement tailored to each patient and delivered by trained physiotherapists.

Participants were stratified by stroke severity, with 631 patients in the mild stroke group and 366 in the moderate stroke group and randomized to one of four mobility training regimens. All interventions were initiated within 48 hours of stroke onset (mean, 38 hours) and continued for 14 days or until hospital discharge.

Optimal Exercise Dose

The interventions emphasized functional, task-specific upright movement tailored to each patient and delivered by trained physiotherapists.

The groups differed by time (10-40 mins) and session frequency (1-4 sessions/d), with varying activity types and intensity as patients progressed. These protocols replaced usual care.

“There was no usual care alone group as usual care is so varied it is difficult to document what it actually is and makes clinical trial results very difficult to interpret,” said Bernhardt.

The primary endpoint — favorable functional outcome(You never do talk to survivors about their definition of favorable, do you?), defined as a modified Rankin Scale score of 0-2 at 3 months — showed no significant differences between the lowest-dose reference group (one 10-minute session daily) and the higher-dose training regimens.

However, a prespecified analysis of clinically meaningful benefit found more than 90% confidence that higher training doses were not clinically meaningfully better than the lowest reference dose — 10 minutes once per day — for patients with mild stroke.

In the moderate stroke group, there was 96% confidence that two 10-minute regimens at different times of day was better than the lowest dose reference arm, and 84% confidence that this difference was clinically meaningful.

A Safe Intervention

Safety results showed no significant differences in deaths or serious adverse events between lowest reference dose and the higher dose regimens.

“Our primary message is that these interventions are safe. We had low rates of death and serious adverse events, and that was across all of the different dose arms in both the mild and moderate groups. That is a very important finding given that the previous AVERT trial had shown harm,” Bernhardt said.

“We’ve also shown that these interventions can be delivered in multiple settings across the world, including in low- and middle-income countries,” she added.

She explained that the 10 minutes of task specific training took place within a longer overall sessions and the exercises were done in bursts, with rest times not included in the exercise times.

“The training was individualized to the patient depending on their deficit but could be something like repeatedly standing up from a chair. It is trying to build control, stamina, and strength. Patients have to be active, and they have to be working to improve their mobility.”

As part of the study publication, the researchers plan to fully characterize the interventions and how they evolved over time, and the protocols will be made publicly available.

“This is the first time we’ve been able to provide any documented rehabilitation strategy for these patients. The strength of this trial is that we have used consistent protocols, and although we didn’t finish the trial as we planned because of the pandemic, this 1000 patient-strong data set is the best we have,” Bernhardt concluded.

‘An Amazing Achievement’

Commenting on the trial, Peter Kelly, MD, clinical professor of neurology at University College Dublin, Dublin, Ireland, said it was “an amazing achievement.”

“This is the best designed and best conducted trial in rehabilitation that we have ever seen. The though that went into eliminating variability was very impressive and the findings are very useful,” he noted.

Kelly added that the lack of any safety concerns was “very reassuring” and “the lessons from AVERT-DOSE trial that will inform the next steps in rehabilitation studies were outstanding.”

The AVERT DOSE trial was funded by the National Health & Medical Research Council of Australia.

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VASCage project ACTpatient: Mild stroke – difficult life afterwards

Well that is blindingly obvious to anyone with more than two functioning neurons. All because your stroke medical 'professionals' completely failed at getting you 100% recovered.

 VASCage project ACTpatient: Mild stroke – difficult life afterwards

Surprising results are delivered by a scientific pilot project, which was carried out by stroke patients themselves: What the medical classification only defines as a “light” stroke is perceived by many patients as a quite severe limitation in their daily life.

As part of the VASCage research project ACTpatient, stroke patients and their relatives designed questionnaires on the topics of aftercare and clinical research. They then provided these to 75 other patients. These were people who had suffered a stroke a year ago and whose condition was assessed as good, i.e. only slightly limited, according to the usual medical classification. The results of the survey are now available. They show that many of those affected and their families feel a heavy burden. For example, about one third of the respondents said they could not accept the consequences of the stroke. The reasons they gave were that they could no longer do what they used to before the stroke and that they “want their old life back”. They feel that independence, work, social life and “having hope” are particularly affected. Three quarters are supported by partners or children in their daily life at home, a quarter of the respondents would have needed more support, one in ten missed information on reintegration at home.

ACTpatient advisory board member Karin Flatz, whose father had a stroke, reports: “The questionnaire was created by stroke patients and their relatives. It makes a big difference whether the right questions are asked and whether they are formulated in an understandable way. I think it’s very important that we affected people can participate ourselves and get the feeling of being heard.”  And Prof. Michael Knoflach, clinical stroke researcher at VASCage and head of the stroke division at the Medical University of Innsbruck, sums up: “These results are quite astonishing when you consider that they come from those who have actually come out of treatment well.” He adds: “VASCage is conducting numerous clinical studies, including the Stroke Card Registry study with more than 1200 patients currently enrolled in post-stroke care. ACTpatient gives us important impulses for even further improved aftercare, especially by supporting the relatives.”

ACTpatient is being conducted by VASCage as a pilot project and is funded by the Open Innovation in Science Center of the Ludwig Boltzmann Society. “From the project we have learned how to design the process in a meaningful way so that patients can participate in clinical research in a more participatory way,” says project leader Eva Nachtschatt. The ACTpatient advisory board, consisting of patients, relatives and doctors, has now set itself the task of developing comprehensible consent forms and creating an explanatory video.

Link to press release (in German)
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Picture 1: Patient-developed questionnaires ask the crucial questions and are easier to understand. (Photo credit: VASCage)
Download press picture 2
Picture 2: The medical examination of bodily functions often paints a too positive picture of a person’s condition. (Photo credit: VASCage)

Prediction-Driven Decision Support for Patients With Mild Stroke: A Model Based on Machine Learning Algorithms

But if you don't tell us the protocols used to recover from a mild stroke. Useless. 

Prediction-Driven Decision Support for Patients With Mild Stroke: A Model Based on Machine Learning Algorithms

Xinping Lin^1,2†, Shiteng Lin^1,2†, XiaoLi Cui^3†, Daizun Zou^1,2, FuPing Jiang⁴, JunShan Zhou⁵, NiHong Chen⁵, Zhihong Zhao^6*, Juan Zhang^3* and Jianjun Zou^2,7*

• ¹School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
• ²Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
• ³Department of Neurology, Nanjing Yuhua Hospital, Yuhua Branch of Nanjing First Hospital, Nanjing Medical University, Nanjing, China
• ⁴Department of Geriatrics, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
• ⁵Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
• ⁶Department of Neurology, The First Affiliated Hospital (People's Hospital of Hunan Province), Hunan Normal University, Changsha, China
• ⁷Department of Clinical Pharmacology, Nanjing First Hospital, China Pharmaceutical University, Nanjing, China

Background and Purpose: Treatment for mild stroke remains an open question.(Well then, solve that problem by creating protocols. We aim to develop a decision support tool based on machine learning (ML) algorithms, called DAMS (Disability After Mild Stroke), to identify mild stroke patients who would be at high risk of post-stroke disability (PSD) if they only received medical therapy and, more importantly, to aid neurologists in making individual clinical decisions in emergency contexts.

Methods: Ischemic stroke patients were prospectively recorded in the National Advanced Stroke Center of Nanjing First Hospital (China) between July 2016 and September 2020. The exclusion criteria were patients who received thrombolytic therapy, age <18 years, lack of 3-month modified Rankin Scale (mRS), disabled before the index stroke, with an admission National Institute of Health stroke scale (NIHSS) > 5. The primary outcome was PSD, corresponding to 3-month mRS ≥ 2. We developed five ML models and assessed the area under curve (AUC) of receiver operating characteristic, calibration curve, and decision curve analysis. The optimal ML model was selected to be DAMS. In addition, SHapley Additive exPlanations (SHAP) approach was introduced to rank the feature importance. Finally, rapid-DAMS (R-DAMS) was constructed for a more urgent situation based on DAMS.

Results: A total of 1,905 mild stroke patients were enrolled in this study, and patients with PSD accounted for 23.4% (447). There was no difference in AUCs between the five models (ranged from 0.691 to 0.823). Although there was similar discriminative performance between ML models, the support vector machine model exhibited higher net benefit and better calibration (Brier score, 0.159, calibration slope, 0.935, calibration intercept, 0.035). Therefore, this model was selected for DAMS. In addition, SHAP approach showed that the most crucial feature was NIHSS on admission. Finally, R-DAMS was constructed and there was similar discriminative performance between R-DAMS and DAMS, but the former performed worse on calibration.

Conclusions: DAMS and R-DAMS, as prediction-driven decision support tools, were designed to aid clinical decision-making for mild stroke patients in emergency contexts. In addition, even within a narrow range of baseline scores, NIHSS on admission is the strongest feature that contributed to the prediction.

Introduction

Around half of patients with ischemic stroke have mild neurological symptoms (1), usually with the expectation that such patients will come back to their pre-stroke activities regardless of the treatment. However, over one-third of mild stroke patients present with some degree of post-stroke disability (PSD) (2–4), which may be the result of inadequate acute treatments, early stroke recurrence, serious complications, or other reasons (1, 5). For the acute treatment of mild stroke patients, the guidelines from the American Heart Association/American Stroke Association (AHA/ASA) (6) distinguish disabling from non-disabling stroke and recommend intravenous (IV) alteplase only for the former. Nonetheless, the more certain, but not definitive, concept of “disabling stroke” is subjective and requires interpretation by individual neurologists. On the other hand, there is a trade-off between the benefits of IV alteplase and the risk of symptomatic intracranial hemorrhage (sICH). Therefore, decisions on how to treat mild stroke patients should be made on an individual basis.

3-month modified Rankin Scale (mRS), a valuable instrument for testing therapeutic interventions (7, 8), was used to assess the levels of PSD (5, 8). For mild stroke patients who only received medical therapy but had PSD, such therapy is not enough. Therefore, mild stroke patients who would be at high risk of PSD if they only received medical therapy should be early identified in emergency contexts, and some aggressive treatments, such as IV alteplase or close monitoring preventing worsening, should be taken in time. Unexpectedly, neurologists' overall accuracy for identifying those patients was staggeringly low (16.9%) (9). Each day that such a problem continues to exist means that uncounted mild stroke patients are being left with preventable disability.

However, none of the previously published risk models which were developed to predict the function outcome after stroke are fit to solve this problem. For example, the Totaled Health Risks in Vascular Events (THRIVE) score and the Houston Intra-Arterial Therapy (HIAT) score assign 0 points for National Institute of Health stroke scale (NIHSS) ≤ 5, losing the predictive power of NIHSS in mild stroke patients (10, 11). NIHSS on admission has been proven to be a strong predictor of PSD (5). Thus, despite convenient clinical applicability, these models cannot accurately identify mild stroke patients at high risk of PSD. Such models remain inadequate.

With the increased clinical data gathered for each patient, modern medical decision-making demands accurate, novel, and prediction-driven decision support. Machine learning (ML) algorithm, as a burgeoning statistical approach, is well-suited for that mission. Numerous studies with a considerable number of patients have shown great potential for ML approaches to predict recurrence (12), swallowing recovery (13), or aphasia (14) in patients with stroke. However, a model based on ML algorithms, focusing on the more debatable area of treating MS, has not yet been established.

Here, our goal was to develop and validate a prediction-driven decision support tool based on ML algorithms, called DAMS (Disability After Mild Stroke), to early identify mild stroke patients who would be at high risk of PSD if they only received medical therapy, and more importantly, to assist neurologists to make individual clinical decisions for mild stroke patients.

 

Falling through the cracks: a literature review to understand the reality of mild stroke survivors

Almost every single survivor falls through the cracks, as evidenced by the appalling 10% full recovery rate 
WHOM is patching up those cracks?
http://www.ncbi.nlm.nih.gov/pubmed/20139048

Tellier M¹, Rochette A.

Author information

Abstract

PURPOSE:

To review the existing literature on mild stroke, its consequences for patients and families, and the effectiveness of rehabilitation services targeting mild stroke.

METHOD:

A systematic search was conducted on Ovid (EMBASE and MEDLINE, 1950-2008), PubMed, CINAHL, and Cochrane (to 4th quarter 2008). Articles had to be written in French or English. The term "mild stroke" was combined with a variety of key words. Titles, abstracts, and results sections were screened, and the sample had to be composed of not greater-than 50% mild stroke. Two reviewers were involved in the selection process to ensure the research was reproducible and that all the literature was screened properly.

RESULTS:

Thirteen articles meeting inclusion and exclusion criteria were found. Mild stroke survivors may present impairments that do not interfere with basic activities of daily living but do affect performance of complex tasks. The consequences for families remain unknown. Home interventions were found to help patients maximize their functions and reduce stroke sequelae.

CONCLUSION:

The majority of mild stroke survivors are sent home without referral to rehabilitation services although they present deficits that, if not addressed, can lead to deconditioning and impede community reengagement. The impact of mild stroke on families needs to be studied.