The yin and yang of safety and risk: a content analysis and critical narrative synthesis exploring the conceptualisation of risk in the stroke rehabilitation literature

My risk taking started my first day release from the hospital; went to watch a whitewater slalom race with a quarter mile rough path to get to the banks. Nurses found out about it and I got a stern visit from one of my doctors highly recommending against it. I totally ignored her since she obviously knew nothing about my risk taking. I was damn good at OC1 and OC2 slaloms and wasn't going to miss it.

The trophies are from the Buttercup series of whitewater slalom races(6 races in Wisconsin and Minnesota).

Left is 1rst place OC1(Open Canoe 1 person) 2004

Middle is 2nd place OC1(Open Canoe 1 person) 2003

Right is 3rd place OC1(Open Canoe 1 person) 2005, stroke was in May 2006

Missing are the two first place finishes in OC2(Open Canoe 2 person) in consecutive years with different paddling partners, they have the trophies.

One of my main reasons for my excellent balance is this: Don't follow me, I'm not medically trained, is your doctor?

bar stool rehab (3 posts to January 2014)

 The yin and yang of safety and risk: a content analysis and critical narrative synthesis exploring the conceptualisation of risk in the stroke rehabilitation literature

Sharon Jackson

,

Sara Demain

,

Francine O’Malley

 &

Dorit Kunkel

Received 04 Oct 2024, Accepted 11 Jul 2025, Published online: 25 Jul 2025

• Cite this article
 
• https://doi.org/10.1080/13698575.2025.2535973
 
• CrossMark

(open in a new window)

Abstract

Many people feel unprepared for life following discharge from stroke services. Rehabilitation occurs within a harm-reduction framework, but evidence suggests risk-taking is crucial for recovery. The aims of this review study were to explore how risk is conceptualised in the stroke rehabilitation literature and to develop a critical narrative synthesis of articles exploring and challenging dominant conceptualisations of risk, in the context of post-stroke identity and engagement in valued activities. We undertook a literature search (including Embase, PubMed, CINHAL and PsycINFO), including qualitative, quantitative and mixed-methods studies in post-stroke adults > 18 years. Phase 1 involved a content analysis, with 1420 articles screened and 246 included. Most (n = 233) were described by the theme ‘Safety first’, divided into sub-themes: i) Physical safety; ii) Societal and organisational protection; and iii) Cognitive, affective and communication risks. Remaining articles were described by Theme 2: ‘Taking risks as necessary and subjective’. Critical narrative synthesis in Phase 2 included fifteen articles, demonstrating the imposition of ‘rules’ for safety, despite risk-taking being important. The predominant narrative prioritised safety and harm-reduction during stroke rehabilitation, overlooking unintended consequences for post-stroke identity and engagement in valued activities. The voice of people post-stroke was largely absent(So, not listening to the experts in the field.) in decision-making around risk prioritisation and management, which often failed to acknowledge the inherent uncertainties and sociocultural factors influencing beliefs and behaviours in relation to risk. Further qualitative research is needed to understand the experiences of people post-stroke and to inform service co-design and shared decision-making in relation to risk in stroke rehabilitation.

Impact of Physical Activity Before Stroke

Well, the week before my stroke I was on a whitewater canoe trip in Canada, class III+. Dog River, Ontario(23 miles and dropping 1050 feet with a 1.5 mile portage around a 120 ft. waterfall). We only portaged 5 times. 3 years post-stroke at a physical I had a resting heart rate of 54 at age 53, meaning I had the cardiovascular fitness of an athlete, even with doing no exercise for 3 years. I was in shape.

That fitness allowed me to go on a an extended wilderness canoe trip 3 years post-stroke. In 2009 this was my 'vacation'. A 21 day canoe trip on the Eagle, Bell and Porcupine rivers in the Yukon and Alaska with Wilderness Inquiry. I wouldn't call it a vacation because we paddled every day and I was quite fatigued every day. I ended up being the only disabled person on the trip.

Because of my fitness and my superior balance I take risks no survivor should try to follow.

So my read on this research is that YOUR pretreatment for stroke requires you to be very physically fit. This allows your doctor to not have to do one goddamn thing about your recovery after your stroke. Like maybe solving these  5 causes of neuronal cascade of death in the first week

Impact of Physical Activity Before Stroke

Research has suggested that people who have higher levels of physical activity before a stroke have better outcomes after the stroke has occurred, but scientists have yet to understand the underlying mechanisms.¹

Now a study has found that increased physical activity before a stroke may increase levels of vascular endothelial growth factor (VEGF). The study further found that higher levels of physical activity as well as higher levels of VEGF were linked to improved stroke outcomes and smaller infarct size. Results were published online in the Journal of Stroke and Cardiovascular Diseases.²
“In the present study we have observed that a high level of self-reported physical activity prior to stroke was associated with greater VEGF expression in the first days after ischemic stroke. Likewise, this increment in VEGF levels was independently associated with a reduction in final infarct volume and with improvement of functional outcome at 3 months,” wrote first author Elena Lopez-Cancio, MD, PhD, of the Universidad Autónoma Barcelona (UAB) (Barcelona, Spain), and colleagues.
The study was part of the AFRICA (Prestroke Physical Activity and Functional Recovery in patients with Ischemic stroke and Arterial Occlusion) study. Participants were included if they had experienced an acute ischemic event in the anterior large artery, and were admitted to a single tertiary care stroke center in Barcelona, Spain between June 2008 and January 2011.
Using a validated questionnaire, participants self-reported their physical activity in the past week before the stroke. They also provided blood samples for evaluation of circulating VEGF, granulocyte colony-stimulating factor (G-CSF), and brain-derived neurotrophic factor (BDNF). Levels of these angiogenic and neurogenic factors were evaluated upon admission, at 7 days, and three months post-stroke.
The analysis included 83 patients, with a mean age of 69.6 years.
Key results:
• VEGF increased from baseline to day 7

♦ This increase was significantly higher in those with higher pre-stroke physical activity vs lower activity (mean increase 30.1 pg/mL versus 14.4 pg/mL, P<0.05)

♦ This increase was linked to significantly better NIHSS stroke severity scores at admission (−031, P=0.004) and at day 7 (−.65, P<0.001)

• Higher prestroke physical activity was linked to smaller infarct volume 30 days post-stroke and better functional outcome at 3 months
• Higher serum VEGF at day 7 was independently linked to smaller infarct volume at 30 days, and improved functional outcome at 3 months
• G-CSF and BDNF were not linked to prestroke physical activity or stroke outcomes
The authors provided several explanations for these results. Past studies have suggested that physical activity may increase VEGF expression. In turn, animal studies have suggested that VEGF may play a role in neuroprotection, neurogenesis, nitric oxide-induced angiogenesis and repair of the postischemic brain. Animals studies have also suggested that VEGF expression in parts of the brain increases after an ischemic event, and this increase has been linked to smaller infarct volume.
If VEGF is neuroprotective, administering it after stroke may improve outcomes, they suggested. Unfortunately, studies that have evaluated post-stroke VEGF delivery show positive but also negative effects, including blood-brain barrier leakage and brain edema. The authors propose that physical activity may be a safe way to increase VEGF production, rather than delivering exogenous VEGF.
“Although there are probably more molecular mechanisms by which physical activity exerts its beneficial effects in stroke outcomes, our observation regarding the potential role of VEGF is plausible and in line with previous experimental studies. Further research in this field is needed,” they concluded.
Take-home Points
• A study in Spain found that VEGF increases from baseline to day 7 in patients with ischemic stroke.
• Patients with higher levels of pre-stroke physical activity had greater increases in VEGF than those with lower levels of pre-stroke physical activity.
• Higher increases in VEGF and higher levels of pre-stroke activity were linked to improved functional outcomes at three months, and smaller infarct size at 30 days.
• Physical activity may be one way to increase synthesis of VEGF, which may be neuroprotective in stroke.
• Further studies are needed.
This study was partially supported by the Instituto de Salud Carlos III, the Spanish Research Network on Cerebrovascular Diseases, and the European Union program FEDER. Drs. Campos and Sobrino have received research contracts from Miguel Servet Program of Instituto de Salud Carlos III. Dr. López-Cancio has received a research contract from Juan Rodés program of Instituto de Salud Carlos III.

References

1. Ricciardi AC, et al. Prestroke physical activity is associated with good functional outcome and arterial recanalization after stroke due to a large vessel occlusion. Cerebrovasc Dis. 2014;37:304-311.
2. López-Cancio E, et al. Reported prestroke physical activity is associated with vascular endothelial growth factor expression and good outcomes after stroke. J Stroke Cerebrovasc Dis. 2016 Oct 28.

This happens in our mind when we take a gamble

So would damage in this area explain who is willing to take the challenges/risks necessary to recover better?
http://www.futurity.org/risk-decisions-1213152-2/
Scientists have located a region of the brain that kicks into gear when we make decisions that we’re not completely sure about.
The discovery could lead to treatments for psychological and psychiatric disorders that involve misjudging risk, such as problem gambling and anxiety disorders.
“We know from human imaging studies that certain parts of the brain are more or less active in risk-seeking people, but the neural circuits involved are largely unknown,” says Ilya Monosov, assistant professor of neuroscience at Washington University in St. Louis. “We found a population of value-coding neurons that are specifically suppressed when animals make a risky choice.”
Value-coding neurons are cells whose activity reflects the value of a stimulus—in this study, the more juice that was offered to a monkey, the bigger the neurons’ response. However, shortly before the subject made a risky choice, these neurons became suppressed.

A single brain connection predicts risky gambling

The researchers also found a separate group of neurons that signal information about uncertainty after the choice but before the risky outcome. Their findings appear in the Journal of Neuroscience.

“It makes sense that choosing an uncertain option is an important part of learning.”

As they go about their everyday lives, people often must choose between a safe option and a better, but riskier, option. Do you stay in a secure job or quit to start your own business? Do you keep $2 in your pocket or use the money to buy a lottery ticket?
When the system of evaluating risk goes awry, it can have a severe impact on people’s lives. Maladaptive risky behaviors are a feature of compulsive gambling, bipolar disorder, and attention deficit hyperactivity disorder. People with anxiety, on the other hand, err too far on the side of caution.
To study the neuronal circuits of risk-taking, researchers gave rhesus monkeys—whose brains are structured very similarly to humans—a choice between a small amount of juice or a 50-50 chance of receiving either double that amount of juice or nothing at all. Over time, the amount of juice received under either condition would be the same, but one option was safe and the other risky.

Living on the edge

It turns out rhesus monkeys like to live on the edge. The monkeys chose the risky option more often than the safe option. Moreover, a group of value-coding neurons in a part of the brain called the ventral pallidum were selectively suppressed when monkeys chose a risky option over a safe one.
The ventral pallidum plays an important role in controlling levels of dopamine—a molecule that transmits signals between neurons and makes us feel good.
“The ventral pallidum inhibits dopamine neurons, and suppression of this area during risky behavior may increase dopamine release,” says Monosov, who is also an adjunct professor of biomedical engineering.
The results of the study may fit with observations showing an increase in risky behavior among people who take drugs that increase dopamine—such as methamphetamine users and Parkinson’s disease patients treated with L-dopa.

Can brain scans predict risky sex and drinking?

The study also found neurons in a nearby brain area called the medial basal forebrain became most active after the monkeys made a risky choice but before they learned the outcome of their choice—juice or no juice. That part of the brain provides inputs to a wide network of cortical brain regions involved in learning and memory.
“It makes sense that choosing an uncertain option is an important part of learning,” Monosov says. “When people are uncertain, they are driven to resolve the uncertainty. They approach the uncertain option, explore it, and learn from the outcome of their actions.” Modulating the medial basal forebrain by uncertainty could promote or influence learning. However, this remains to be tested.
Monosov is now studying whether temporarily turning off the ventral pallidum and the medial basal forebrain with targeted drug treatments affect the monkeys’ risk preferences and the strategies they use to learn.
“There are no anatomically targeted treatments for psychiatric disorders associated with misjudging risk, such as pathological gambling and anxiety,” Monosov says “Now that we know where uncertainty is processed in the brain, we can start looking for ways to modulate it.”
The Edward Mallinckrodt Jr. Foundation and the Brain and Behavior Research Foundation funded the work.
Source: Washington University in St. Louis

Original Study DOI: 10.1523/JNEUROSCI.1123-16.2016

Are You a Risk Taker? Take the Quiz

I'm sure the amount of risk you are willing to take could determine how well your recovery goes. But we would need a great stroke association to research that and see if true or not. Then use those answers to update stroke protocols appropriately. But we are screwed because no one will ever answer that question for us.
I fall into this category; 8
Risk-Taker (7 - 8)
You are more willing to lose a sum of money than most. The average person is willing to take a risk when the amount of money he could potentially win is 1.7 times the amount he could lose. 

Are You a Risk Taker? Take the Quiz

Can Brain Imaging Detect Risk Takers?

I think I have recovered relatively well because I am willing to take risks on the exercise I do and the situations I put myself into. With no challenges you will likely not recover very well. Magic Johnson did not become a great basketball player by practicing layups, he practiced the hard stuff precisely because it was hard. You are going to have to push your therapists to actively give you therapy that is very difficult. My best example of risk taking is considering and using a chainsaw for therapy, a lesser one is walking in the dark with no flashlight or walking on ice or bar stool rehab.
Your doctor should be telling you that stroke rehab will be the hardest thing you ever will have done.
http://brainblogger.com/2014/10/18/can-brain-imaging-detect-risk-takers/

Aging and risk taking: toward an integration of cognitive, emotional, and neurobiological perspectives

I'm sure I'm an outlier, I will take practically any risk for the intellectual and physical challenge. Life is really not living if I'm not doing that. See my earlier quote from Hunter S. Thompson.
http://www.dovepress.com/articles.php?article_id=16552

Authors: Shao R, Lee TMC

Published Date April 2014 Volume 2014:3 Pages 47 - 62

DOI: http://dx.doi.org/10.2147/NAN.S35914

Received:	21 December 2013
Accepted:	07 February 2014
Published:	25 April 2014

Robin Shao,^1,2 Tatia MC Lee<sup>1–3

1</sup>Laboratory of Neuropsychology, ²Laboratory of Social Cognitive Affective Neuroscience, ³The State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Hong Kong

Abstract: In this article, we characterize the relationship between natural aging and risky decision making through an integration of cognitive, emotional, and neurobiological theories on the effects of natural aging. Based on the existing evidence, we propose that the positivity emotional bias in elderly adults steers them away from taking high risks and toward more conservative approaches during decision making as part of their positive emotional regulatory strategies. However, aging is also associated with marked declines in cognitive functioning, such as attention and working memory, as well as impaired reinforcement-based associative learning, which arises from anatomical and functional declines in the dopaminergic transmission systems and in distinct brain regions such as the dorsolateral prefrontal cortex and hippocampus. In consequence, elderly adults may deviate from their usual conservative stance and toward more risk-taking tendencies, as observed in a subset of studies, if the demands of the risk-taking task exceed their cognitive and learning capacities. More empirical investigations are needed to determine the key factors that influence elderly individuals' decision making and behavior in risky situations. Research in this field is likely to have important practical implications for the financial and medical decision making of elderly adults, as well as promoting designated help targeting the elderly population in making important life decisions.