Machine learning-based identification of a minimal wearable sensor for gait assessment in vestibular schwannoma

 Does your competent? doctor even have an OBJECTIVE gait monitoring device so EXACT REHAB PROTOCOLS  can be assigned to fix the gait disability?  One of my therapists was so bad they thought demonstrating; 'Walk this way' was appropriate!

NO? So, PURE INCOMPETENCE? 

Why haven't you fired the board of directors for not having correct performance objectives for staff?

Many possibilities out there and your incompetent? doctor has done nothing! 

wearable sensors(34 posts to January 2018)

Machine learning-based identification of a minimal wearable sensor for gait assessment in vestibular schwannoma

• Lou C. Kohler Voinov,
• Sergio Sanchez-Manso,
• Raabeae Aryan,
• Jennifer L. Millar,
• Michael C. Schubert &
• Kathleen E. Cullen 

We’re sharing this article early to provide faster access to peer-reviewed, accepted research. It is citable and carries a permanent DOI. This version is subject to further edits and will be replaced automatically by the final Version of Record. All legal disclaimers apply.

Abstract

Background

Vestibular schwannoma (VS) impairs balance and gait, often leading to substantial functional limitations that are incompletely captured by standard clinical assessments. While wearable inertial sensors and machine learning offer promise for objective gait analysis, clinical translation is limited by uncertainty regarding optimal sensor placement, task selection, and interpretability.

Methods

We recorded six-dimensional kinematics from 32 individuals with unilateral vestibular schwannoma and 32 age-matched healthy controls as they performed the ten tasks of the Functional Gait Assessment (FGA). Adapting a previously developed deep learning framework, we systematically evaluated all combinations of ten gait tasks and six sensor locations, yielding 60 task–sensor models. Models were trained and tested using subject-level leave-one-out cross-validation. To support clinical interpretation, we derived a continuous kinematic score reflecting the similarity of an individual’s gait patterns to those observed in vestibular pathology.

Results

Model performance depended strongly on task and sensor selection. Gait with eyes closed (FGA8) emerged as the most informative task, and wrist-mounted sensors consistently outperformed head and trunk sensors across tasks. A wrist-worn sensor during gait with eyes closed provided discrimination between VS and control participants with overall accuracies ranging from 60 to 83%, while substantially reducing instrumentation burden. The resulting kinematic score significantly differentiated groups, and model accuracies correlated with established clinical measures including the Dizziness Handicap Inventory.

Conclusions

These findings demonstrate that machine learning can be used not only to classify gait pathology, but to identify a minimal, clinically deployable wearable configuration for objective gait assessment in vestibular schwannoma. The proposed wrist-based kinematic score offers a continuous, interpretable metric that complements existing clinical assessments and supports longitudinal monitoring across in-clinic and remote rehabilitation settings. This work advances the development of quantitative, scalable digital biomarkers for precision rehabilitation in vestibular disorders.

Enhancing Value and Well-Being The Basket of Motivators Framework for Aligning Neurology Clinical Practices With Performance Outcomes

You can easily have your neurologists produce quality outcomes if you create EXACT DAMAGE DIAGNOSES and then follow that up with EXACT REHAB PROTOCOLS! Your neurologists won't be second guessing themselves all the time and wondering how their work will be measured.

Enhancing Value and Well-Being The Basket of Motivators Framework for Aligning Neurology Clinical Practices With Performance Outcomes

Peter N. Hadar, MD, MS https://orcid.org/0000-0002-1681-4717, Susanna Gallani, PhD, MBA https://orcid.org/0000-0001-6242-3031, and Lidia Moura, MD, PhD, MPH https://orcid.org/0000-0002-1191-1315Authors Info & Affiliations

June 2024 issue

14 (3)

https://doi.org/10.1212/CPJ.0000000000200280

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Abstract

Purpose of Review

Physician burnout, which is prevalent in neurology, has accelerated in recent years. While multifactorial, a major contributing factor to burnout is a payment model that rewards volume over quality, leaving physicians overburdened and unfulfilled. The aim of this review was to investigate ways of reducing burnout while improving quality-based outcomes in a value-based health care model.

Recent Findings

Burnout affects researchers, educators, clinicians, and administrators in all fields and tracks, but neurologists experience some of the worst burnout rates among specialties. Transitioning to a value-based health care model, which rewards quality and outcomes(Yeah, you reward 100% recovery! That would be quality!) over volume, may contribute to reversing the burnout trend. However, this requires that physicians feel valued in the workplace in ways corresponding to their preferences. We propose to stratify neurologists using the “basket of motivators” framework, which operates multiple individual-based and team-based motivators including balance among work responsibilities, work-life balance, institutional pride, self-actualization at work, work environment, and finances. By tailoring individual-based and team-based financial and nonfinancial incentives, neurologists are empowered to work at the top of their license to provide high-impact clinical care while combating the most prominent causes of burnout.

Summary

To address the neurologist burnout epidemic, a transition to value-based health care is needed that rewards quality-based performance outcomes through both individual-based and team-based approaches that apply financial and nonfinancial incentives. Understanding the underlying motivations behind neurologists' drives to work can inform tailored incentives that allow neurologists to provide value to their patients and feel valued by their organizations.

 

 

 

 

 

 

 

 

 

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HFAP-Certified Stroke Centers Met or Exceeded Industry Standards, Per Report

Well then those fucking standards are wrong. They don't refer to recovery results, just processes completed. These people all need to be keel hauled and removed from the stroke medical world. We need stroke leadership, NOT this lazy crapola. If you were my employee and came to me with this as your performance goal results I would have you fired.
http://www.ptproductsonline.com/2018/07/hfap-certified-stroke-centers-met-exceeded-industry-standards-per-report/

According to a recently released benchmarking report, Healthcare Facilities Accreditation Program (HFAP)-certified primary stroke centers met or exceeded benchmarks identified for the majority of performance measures set by the American Heart Association.

Reportedly the first of its kind, the external benchmarking resource identifies target goals and compares results achieved by individual centers.

“We designed the benchmarking report as a tool for both certified and non-certified stroke centers to use for education and training to ensure their programs are meeting specific thresholds,” says Marci Ramahi, director, accreditation and certification operations, per a media release from HFAP.

“Stroke coordinators at certified centers can also share the information in this report within their organizations to demonstrate the quality of their stroke care program or areas for improvement to key stakeholders.”

The HFAP benchmarking report analyzed data from July to December 2017 to determine whether benchmarks identified for each performance measure were achieved. The data represent patients 18 years and older who arrived in the emergency department or who experienced onset of symptoms while in the hospital for another diagnosis.

On average, participating stroke centers surpassed industry standards in key areas including:(None of these are recovery results, 100% recovery is the only goal. GET THERE!)

• Stroke Team Arrival: Stroke teams responded to 96% of patients’ bedside within 15 minutes of arrival in ED or, for inpatients, of onset of symptoms. Benchmark at 85%.
• Thrombolytic Therapy: Stroke teams initiated IV tPA to 96% of acute ischemic stroke patients within three hours of time last known well. Benchmark at 85%.
• Antithrombotic Therapy: Stroke teams administered the first dose of antithrombotic therapy by the end of hospital day two to 97% of all eligible ischemic stroke patients. Benchmark at 85%.
• Anticoagulation Therapy for AF/Flutter: Stroke teams provided prescriptions for anticoagulants at the time of discharge to 99% of eligible ischemic stroke patients. Benchmark at 85%.
• Stroke Education: Stroke teams equipped 96% of ischemic or hemorrhagic stroke patients or their caregivers with educational materials on stroke care during their stay. Benchmark at 85%.
• Assessed for Rehabilitation: Stroke teams conducted a physical rehabilitation evaluation for 98% of eligible patients. Benchmark at 85%.

“The data used to generate the benchmarking report are key clinical performance metrics primary stroke programs must track and submit quarterly to be certified,” Ramahi says.

“In addition, centers use these measures for internal benchmarking of their care and processes. We compiled this report to help our stroke center partners and other stroke programs develop data-driven quality improvement initiatives and improve clinical outcomes.”

For more information, visit HFAP.

[Source: HFAP]

Should older doctors be examined, tested or forced to retire?

My doctor probably  hadn't read a single stroke research article since he graduated from medical school, maybe 30 years prior.
I would say yes, except it has nothing to do with being old, it has to do with keeping up with research. Your stroke hospital should have goals and objectives for that for their doctors and therapists.  Fireable for cause for not keeping up. I should never know more than any stroke doctor out there. Every single one should be able to run rings around me. 

Should older doctors be examined, tested or forced to retire?

Reuters Health News

At 81, Dr. Frank Stockdale continues to see breast cancer patients and believes he offers them the wisdom and knowledge from his more than 50 years of oncology practice.
But a new review of the literature on aging physicians questions the competency to practice of older physicians like Stockdale. The report in JAMA Surgery, online July 19, recommends that healthcare organizations develop protocols for testing doctors of a certain–though undetermined–age for health and competence.
“This is clearly a discriminatory policy if you pick an age to test,” said Stockdale, professor, Stanford University School of Medicine, Stanford, CA, who was not involved in the review.
Lead author Dr. E. Patchen Dellinger, professor of surgery, University of Washington, Seattle, WA, does not know what age is the right age to begin testing doctors, he said. But the 73–year–old surgeon believes he and other doctors should willingly submit to physical examinations and cognitive testing. And he has.
The medical community has grappled with the question of whether to test aging physicians, particularly surgeons, for two decades, if not longer. But the graying of the nation’s physicians has energized the debate over their health and competence.
During the past four decades, the number of practicing US doctors who were at least 65 years old more than quadrupled. By 2015, nearly one in four physicians were 65 or older, the authors write.
Dr. Paul Schenarts, a trauma surgeon and professor, University of Nebraska College of Medicine, Omaha, NB, agrees with the authors of the review that a program for testing aging physicians should be implemented.
“Something new and different should be done,” Schenarts, who was not involved with the review, said in an email. “It is a well–known paradox that the surgeon with the greatest experience may be the one putting patients at the greatest risk.”
Though federal law prohibits age discrimination, commercial pilots are required to retire before 65, and starting at 40, they must submit to more–frequent medical examinations than younger pilots.
Previous studies of a possible link between doctors’ ages and clinical performance found mixed results. While some showed patients more likely to die from cardiovascular procedures performed by older surgeons, others showed patients were more vulnerable at the hands of younger surgeons.
Using a cognition test called a MicroCog, one prior study examined doctors alongside people outside the profession. Doctors scored better than others, but cognition scores for everyone in the study declined with age. Researchers found significant variability in older physicians’ scores, with some demonstrating fully intact cognitive ability and others showing dramatic declines.
Stockdale discounted the MicroCog as incapable of judging a physician’s ability to practice and said he knew of no test that could appropriately examine a doctor’s cognitive ability to practice medicine.
“The major problem is what is the test for cognition,” he said. “You have to have an instrument that’s been shown to correlate with our work task.”
In 2012, Stanford, where Stockdale practices, proposed cognitive testing for doctors 74.5 years and older. Stockdale protested the policy, which was tabled.
But that doesn’t mean Stanford isn’t monitoring its physicians, he said. They, along with physicians in hospitals throughout the nation, are evaluated every 6 to 9 months and constantly subjected to the scrutiny of their coworkers, patients and oversight committees, he said.
“If If I were demented, I can tell you I’d last about a week before every nurse and medical student noticed,” Stockdale said.
“Physicians of all ages are injuring patients,” he said. “We should be testing everybody at all ages for their competence. It shouldn’t be because you’re 65.”

Dalfampridine Improves Cognitive Impairment in Multiple Sclerosis

Would this help post-stroke? It seemed to fail in walking post-stroke. Since I have never been able to find out if stroke demyelinates nerves in the brain, that answer may tell us whether this would work for stroke. So ask your doctor that question, 'Does stroke demyelinate nerves in the brain?'  A neurologist I saw once tried to tell me that was the case but I think he was just blowing smoke out his ass, trying to pull the stunt that I(the doctor) know more than you, so just shut up about questions.

Acorda ditches dalfampridine poststroke walking studies

Ask your doctor for help in getting this clinically tested in stroke patients, you shouldn't have to ask, it should already be part of their goals and objectives. Assuming the stroke department head is competent and actually wants to solve all the problems in stroke.

Dalfampridine Improves Cognitive Impairment in Multiple Sclerosis

By Alex Morrisson
BOSTON -- May 2, 2017 -- Treatment with dalfampridine appears to improve cognitive impairment and some cognitive functioning tasks among patients diagnosed with multiple sclerosis (MS), according to clinical trial results presented at the 2017 Annual Meeting of the American Academy of Neurology (AAN).
“Dalfampridine should be considered as an effective treatment option for cognitive impairment in multiple sclerosis,” said lead author Laura De Giglio, MD, PhD, Sapienza University, Rome, Italy, speaking here on April 26.
Dr. De Giglio and colleagues randomised subjects in a 2:1 fashion to receive either 10-mg dalfampridine twice daily or placebo for 12 weeks.
Baseline score in the Symbol Digit Modalities Test (SDMT) was a mean of 30 seconds. The primary endpoint of the study was the improvement of processing speed measured with SDMT. Four weeks after the end of treatment, evaluable patients treated with dalfampridine (n = 70) achieved a scoring increase of 9.89 seconds on the Symbol Digit Modalities Test (SDMT) compared with evaluable patients on placebo (n = 37) who achieved a scoring increase of 4.89 seconds (P = .001).
In all, 76.1% of subjects treated with dalfampridine achieved at least a 20% improvement in the SDMT compared with 41.4% of the subjects receiving placebo (P = .001).
On a variety of secondary measures, subjects taking dalfampridine also showed some improvement on spatial memory, cognitive fatigue, and the overall Multiple Sclerosis Functional Composite.
Most subjects were in their mid-to-late 40s; about 60% were female. Subjects had a diagnosis of multiple sclerosis for about 15 years.
“Thirty-five to sixty percent of multiple sclerosis patients are believed to have some cognitive dysfunction, but results of treatment for this aspect of the disease have been limited or inconsistent,” noted Dr. De Giglio.
Dalfampridine, approved in the United States to improve walking difficulty in patients with MS, is a selective neuronal potassium-channel blocker that is designed to improve conduction of action potential in demyelinated nerve fibers. The drug is believed to increase the release of neurotransmitters in synapses and at the neuromuscular junctions.
Funding for this study was provided by Biogen, Cambridge, Massachusetts.
[Presentation title: Dalfampridine Improves Cognitive Impairment in Multiple Sclerosis (MS): Results From a Randomised, Double-blind, Placebo-controlled Trial.]

Altering the Rehabilitation Environment to Improve Stroke Survivor Activity (AREISSA): A Phase II Trial

All this seems like followup to enriched environment as talked about by Dr. Dale Corbett in 2011

Has your doctor done one fucking thing about enriched environment since 2011? Call the hospital president and ask what the goals and objectives are for stroke doctors. If there is nothing on staying current with research or updating stroke protocols you need to have a lot of people fired.

In a March 2015 report patients undertook a mean of 61 minutes (SD = 39) of activity per day.

Ask your doctor how much structured stroke rehab activity occurs on a daily basis. If  not close to 12-14 hours ask why the hell not.

There should be hours upon hours of action observation videos to watch.

Meditation to do.

Tai chi or yoga to do.

Music listening.

Passive movement.

Lucid dreaming to continue stroke rehab during sleep.

Has your doctor thought about any of this stuff?  Or was it just signing ET(Evaluate and Treat) prescriptions to the therapists thus washing their hands of any failures in recovery?

Altering the Rehabilitation Environment to Improve Stroke Survivor Activity (AREISSA): A Phase II Trial

Project team: A/Prof Neil Spratt, Prof Julie Bernhardt, Dr Heidi Janssen, Prof Louise Ada, Prof Michael Nilsson, A/Prof Michael Pollack and Prof Leonid Churilov
Design: Before-after non-randomised controlled trial
Current status: Recruitment ongoing
Site/s:. Bankstown Lidcombe, NSW; St Vincent’s Hospital Sacred Heart Rehabilitation Unit, NSW; Austin Health Royal Talbot, Mellor Unit, VIC, and Monash Health Kingston Centre, VIC
Background:
Despite higher levels of activity being associated with better stroke recovery, stroke patients on most rehabilitation units spend the majority of their day inactive and alone. In animal models, Environmental Enrichment (EE) involves organisation of the environment and provision of equipment to facilitate physical, cognitive and social activity. EE promotes rewiring of the brain after stroke and has been found to significantly enhance functional recovery. Preliminary work on the use of a human model of EE using individual (eg. iPods, & word puzzles) and communal (eg. access to interactive gaming, computer, books/newspapers & jigsaws) enrichment in a rehabilitation unit indicates it encourages stroke patients to be more active. Greater activity during rehabilitation has numerous benefits, the most important of which is achieving better functional recovery and subsequently, greater independence. Altering the Rehabilitation Environment to Improve Stroke Survivor Activity (AREISSA) is a Phase II Trial involving four rehabilitation units, 2 in NSW and 2 in VIC, which seeks to determine the safety, efficacy, feasibility and patient and staff acceptability of this model of EE during stroke rehabilitation. This and the other enrichment projects conducted alongside AREISSA, will be used to inform future larger trials required to determine the effect of EE on stroke survivor recovery and quality of life.
Aims:
To determine the clinical and operational feasibility and safety of Environmental Enrichment (EE)
Methods:
Behavioural mapping, in-depth interview, audit and survey
References:

1. Janssen H, Bernhardt J, Collier JM, Sena ES, McElduff P, Attia J, Pollack M, Howells DW, Nilsson M, Calford MB, Spratt NJ (2010). An enriched environment improves sensorimotor function post-ischemic stroke. Neurorehabil Neural Repair. 24: 802-813.
2. Janssen H, Ada L, Bernhardt J, McElduff P, Pollack M, Nilsson M, Spratt NJ (2014). An enriched environment increases activity in stroke patients undergoing rehabilitation in a mixed rehabilitation unit: a pilot non-randomized controlled trial. Disabil Rehabil. 36: 255-262.
3. White J, Bartley E, Janssen H, Jordan LA and Spratt NJ (2015). Exploring stroke survivor experience of participation in an enriched environment: a qualitative study. Disabil Rehabil. 37(7): 593-600.
4. White JH, Alborough K, Janssen H, Spratt N, Jordan L, Pollack M (2013). Exploring staff experience of an "enriched environment" within stroke rehabilitation: a qualitative sub-study. Disabil Rehabil. 36 (21): 1783-1789.
5. Janssen H, Ada L, Bernhardt J, McElduff P, Pollack M, Nilsson M, Spratt NJ (2014). Physical, cognitive and social activity levels of stroke patients undergoing rehabilitation within a mixed rehabilitation unit. Clin Rehabil. 28: 91-101.

Pericyte-targeting drug delivery and tissue engineering

How is your doctor going to use this in collaboration with researchers to solve  Capillaries that don't open due to pericytes in the neuronal cascade of death? I bet nothing will happen, your doctor won't step up to the plate because they don't have the correct goals and objectives to actually solve all the problems in stroke. Their goal is to bring in money for the stroke department, not to solve your stroke problems. You should be able to figure out why the signaling doesn't open the capillaries.
https://www.dovepress.com/articles.php?article_id=2716

Authors Kang E, Shin JW
Received 28 January 2016
Accepted for publication 2 April 2016
Published 27 May 2016 Volume 2016:11 Pages 2397—2406
DOI https://dx.doi.org/10.2147/IJN.S105274
Checked for plagiarism Yes
Review by Single-blind
Peer reviewers approved by Dr Lakshmi Kiran Chelluri
Peer reviewer comments 3
Editor who approved publication: Dr Thomas Webster

Eunah Kang,¹ Jong Wook Shin<sup>2

1</sup>School of Chemical Engineering and Material Science, ²Division of Allergic and Pulmonary Medicine, Department of Internal Medicine, College of Medicine, Chung-Ang University, Dongjak-Gu, Seoul, South Korea

Abstract: Pericytes are contractile mural cells that wrap around the endothelial cells of capillaries and venules. Depending on the triggers by cellular signals, pericytes have specific functionality in tumor microenvironments, properties of potent stem cells, and plasticity in cellular pathology. These features of pericytes can be activated for the promotion or reduction of angiogenesis. Frontier studies have exploited pericyte-targeting drug delivery, using pericyte-specific peptides, small molecules, and DNA in tumor therapy. Moreover, the communication between pericytes and endothelial cells has been applied to the induction of vessel neoformation in tissue engineering. Pericytes may prove to be a novel target for tumor therapy and tissue engineering. The present paper specifically reviews pericyte-specific drug delivery and tissue engineering, allowing insight into the emerging research targeting pericytes.

Pericytes of the neurovascular unit: key functions and signaling pathways

How is your doctor going to use this in collaboration with researchers to solve  Capillaries that don't open due to pericytes in the neuronal cascade of death? I bet nothing will happen, your doctor won't step up to the plate because they don't have the correct goals and objectives to actually solve all the problems in stroke. Their goal is to bring in money for the stroke department, not to solve your stroke problems. You should be able to figure out why the signaling doesn't open the capillaries.
http://www.nature.com/neuro/journal/v19/n6/abs/nn.4288.html

• Melanie D Sweeney,
• Shiva Ayyadurai
• & Berislav V Zlokovic

• Affiliations

Nature Neuroscience

19,

771–783

(2016)

doi:10.1038/nn.4288

Received

05 October 2015

Accepted

29 February 2016

Published online

26 May 2016

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Abstract

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Pericytes are vascular mural cells embedded in the basement membrane of blood microvessels. They extend their processes along capillaries, pre-capillary arterioles and post-capillary venules. CNS pericytes are uniquely positioned in the neurovascular unit between endothelial cells, astrocytes and neurons. They integrate, coordinate and process signals from their neighboring cells to generate diverse functional responses that are critical for CNS functions in health and disease, including regulation of the blood–brain barrier permeability, angiogenesis, clearance of toxic metabolites, capillary hemodynamic responses, neuroinflammation and stem cell activity. Here we examine the key signaling pathways between pericytes and their neighboring endothelial cells, astrocytes and neurons that control neurovascular functions. We also review the role of pericytes in CNS disorders including rare monogenic diseases and complex neurological disorders such as Alzheimer's disease and brain tumors. Finally, we discuss directions for future studies.

The ethics of performance measurement - Stroke?

I completely disagree with these doctors criticisms of performance measurement. Our stroke doctors have proven the stupidity of assuming that they are working in stroke patients best interests.
1.  No publicly available stroke protocols.
2.  No strategy.
3.  Nothing to fix spasticity.
4.  Nothing to fix fatigue.
5.  Nothing to prevent dementia.
6.  Only 10% full recovery.
7.  Only 12% full recovery with tPA use.
All these are complete failures and I see nothing that even looks like anyone is tackling these problems. Everyone in stroke seems to have their head completely buried up their ass.
If we were to factually measure their performance they would all receive an F and No pay.
The ethics of performance measurement

Defining Optimal Aerobic Exercise Parameters to Affect Complex Motor and Cognitive Outcomes after Stroke: A Systematic Review and Synthesis

Your doctors should be able to concoct a stroke protocol out of this if they are any good at all. But that likely won't occur because doing so is not part of their goals and objectives because the stroke department head and hospital president are not setting up the correct goals. You're screwed unless you contact the incompetent? board of directors of the hospital to accomplish this. A great stroke association president would be contacting every single stroke hospital to make sure appropriate goals exist for the stroke department. This is way too fucking important to leave to non stroke survivors. 

Defining Optimal Aerobic Exercise Parameters to Affect Complex Motor and Cognitive Outcomes after Stroke: A Systematic Review and Synthesis

S. M. Mahmudul Hasan, Samantha N. Rancourt, Mark W. Austin, and Michelle Ploughman

Recovery & Performance Laboratory, Faculty of Medicine, Memorial University, L.A. Miller Centre, Room 400, 100 Forest Road, St. John’s, NL, Canada A1A 1E5

Received 4 October 2015; Revised 27 November 2015; Accepted 29 November 2015

Academic Editor: James M. Wyss

Copyright © 2016 S. M. Mahmudul Hasan et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract

Although poststroke aerobic exercise (AE) increases markers of neuroplasticity and protects perilesional tissue, the degree to which it enhances complex motor or cognitive outcomes is unknown. Previous research suggests that timing and dosage of exercise may be important. We synthesized data from clinical and animal studies in order to determine optimal AE training parameters and recovery outcomes for future research. Using predefined criteria, we included clinical trials of stroke of any type or duration and animal studies employing any established models of stroke. Of the 5,259 titles returned, 52 articles met our criteria, measuring the effects of AE on balance, lower extremity coordination, upper limb motor skills, learning, processing speed, memory, and executive function. We found that early-initiated low-to-moderate intensity AE improved locomotor coordination in rodents. In clinical trials, AE improved balance and lower limb coordination irrespective of intervention modality or parameter. In contrast, fine upper limb recovery was relatively resistant to AE. In terms of cognitive outcomes, poststroke AE in animals improved memory and learning, except when training was too intense. However, in clinical trials, combined training protocols more consistently improved cognition. We noted a paucity of studies examining the benefits of AE on recovery beyond cessation of the intervention.
1. Introduction

Most people admitted to hospital with stroke continue to have enduring motor and cognitive deficits that interfere with their previous roles and quality of life [1]. Very few people admitted with stroke regain functional use of the hemiplegic arm and hand [2] and recent research suggests that there is a limited time window in which to make the greatest gains [3]. During this window of neuroplasticity, the patient must practice therapist-guided task-specific movements, to drive Hebbian plasticity in order to regain function [4]. However, after stroke, cognitive health and the recovery (or relearning) of complex motor skills are intertwined. Relearning of complex movement, which is fundamental to neurorehabilitation, requires most cognitive domains including working memory [5], attention [6], and executive function [7]. Motor learning is impeded by cognitive impairment [8], limiting the ability of the stroke patient to understand, repeat, refine, and analyze recovering movement [9].

Aerobic exercise (AE) is one intervention recommended as part of stroke best practices to improve gait and cardiovascular fitness [10, 11]. Researchers are beginning to explore how AE, by increasing neurotrophins and blood supply to the brain, could also improve other outcomes (unrelated to fitness and gait) such as cognition and relearning of complex skills [12]. Two recent meta-analyses confirmed that AE enhanced cognitive performance, at least in healthy populations [13, 14]. However, based on the findings of two systematic reviews [8, 15], there was limited evidence to support the use of AE to improve cognition in neurorehabilitation practice. More compelling findings have been reported in animal models of stroke, suggesting that rigorous preclinical and clinical trials are still warranted [16].

AE is defined as “planned, structured repetitive physical activity for extended periods and at sufficient intensity to improve or maintain physical fitness” [11]. To improve physical fitness it is recommended that AE be instituted most days of the week at gradually increasing intensity for at least 8 weeks [11]. Whether the AE parameters to improve physical fitness are the same as those to improve cognition and relearning of complex skills after stroke is not known. In two previous reviews examining mechanistic effects of AE on the brain, we reported that, in animal models, moderately intense forced AE, instituted soon after stroke (24–48 hours), enhances neurotrophins, synaptogenesis, and dendritic branching and protects perilesional tissue against oxidative damage [69, 70]. Whether these training parameters translate into improved cognition and relearning of complex motor skills (in animal models or clinical trials) is not known, important information in order to design future clinical and preclinical studies. Researchers would be concerned about AE parameters: frequency, intensity, duration, mode (i.e., treadmill, swimming, or bicycling), and the timing of exercise onset after stroke. In addition to optimizing parameters, scientists must also target outcomes responsive to AE since AE may not affect all cognitive and motor domains in the same way, if at all.

We undertook this review to consolidate potentially important findings in both animal models and clinical trials testing the effects of AE on cognitive and complex motor performance after stroke. We hoped to gain methodological insights to inform future preclinical and clinical studies investigating this potentially promising area of neurorehabilitation.

Much more at link.

Neurovascular coupling, cerebral white matter integrity, and response to cocoa in older people

I bet your doctor can't put two and two together to have hot cocoa added to your daily diet protocol in the hospital.  Failure to do that is worth a call to the president asking what the hell the performance goals are for stroke doctors.
http://www.neurology.org/content/81/10/904

1. Farzaneh A. Sorond, MD, PhD,
2. Shelley Hurwitz, PhD,
3. David H. Salat, PhD,
4. Douglas N. Greve, PhD and
5. Naomi D.L. Fisher, MD

+Show Affiliations

| + Show Full Disclosures

1. Correspondence to Dr. Sorond: fsorond@partners.org

1. Published online before print August 7, 2013, doi: http:/​/​dx.​doi.​org/​10.​1212/​WNL.​0b013e3182a351aa Neurology September 3, 2013 vol. 81 no. 10 904-909

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Abstract

Objective: To investigate the relationship between neurovascular coupling and cognitive function in elderly individuals with vascular risk factors and to determine whether neurovascular coupling could be modified by cocoa consumption.

Methods: Sixty older people (aged 72.9 ± 5.4 years) were studied in a parallel-arm, double-blind clinical trial of neurovascular coupling and cognition in response to 24 hours and 30 days of cocoa consumption. Cognitive measures included Mini-Mental State Examination and Trail Making Test A and B. Neurovascular coupling was measured from the beat-to-beat blood flow velocity responses in the middle cerebral arteries to the N-Back Task. In a subset of MRI-eligible participants, cerebral white matter structural integrity was also measured.

Results: Neurovascular coupling was associated with Trails B scores (p = 0.002) and performance on the 2-Back Task. Higher neurovascular coupling was also associated with significantly higher fractional anisotropy in cerebral white matter hyperintensities (p = 0.02). Finally, 30 days of cocoa consumption was associated with increased neurovascular coupling (5.6% ± 7.2% vs −2.4% ± 4.8%; p = 0.001) and improved Trails B times (116 ± 78 seconds vs 167 ± 110 seconds; p = 0.007) in those with impaired neurovascular coupling at baseline.

Conclusion: There is a strong correlation between neurovascular coupling and cognitive function, and both can be improved by regular cocoa consumption in individuals with baseline impairments. Better neurovascular coupling is also associated with greater white matter structural integrity.