Use the labels in the right column to find what you want. Or you can go thru them one by one, there are only 34,264 posts. Searching is done in the search box in upper left corner. I blog on anything to do with stroke. DO NOT DO ANYTHING SUGGESTED HERE AS I AM NOT MEDICALLY TRAINED, YOUR DOCTOR IS, LISTEN TO THEM. BUT I BET THEY DON'T KNOW HOW TO GET YOU 100% RECOVERED. I DON'T EITHER BUT HAVE PLENTY OF QUESTIONS FOR YOUR DOCTOR TO ANSWER.
Changing stroke rehab and research worldwide now.Time is Brain!trillions and trillions of neuronsthatDIEeach day because there areNOeffective hyperacute therapies besides tPA(only 12% effective). I have 523 posts on hyperacute therapy, enough for researchers to spend decades proving them out. These are my personal ideas and blog on stroke rehabilitation and stroke research. Do not attempt any of these without checking with your medical provider. Unless you join me in agitating, when you need these therapies they won't be there.
What this blog is for:
My blog is not to help survivors recover, it is to have the 10 million yearly stroke survivors light fires underneath their doctors, stroke hospitals and stroke researchers to get stroke solved. 100% recovery. The stroke medical world is completely failing at that goal, they don't even have it as a goal. Shortly after getting out of the hospital and getting NO information on the process or protocols of stroke rehabilitation and recovery I started searching on the internet and found that no other survivor received useful information. This is an attempt to cover all stroke rehabilitation information that should be readily available to survivors so they can talk with informed knowledge to their medical staff. It lays out what needs to be done to get stroke survivors closer to 100% recovery. It's quite disgusting that this information is not available from every stroke association and doctors group.
Showing posts with label tyranny of low expectations. Show all posts
Showing posts with label tyranny of low expectations. Show all posts
Acknowledging A COMPLETE FUCKING FAILURE by not getting to 100% recovery! For that tyranny of low expectations; you're all fired! Even rock star stroke researchers like Steven C. Cramer aren't getting this right!
Let's check how long your doctor and hospital have been incompetent in not having ENTF!
ENTF(6 posts to October 2025) Almost a year and those involved should be keel hauled!
Electromagnetic network-targeted field (ENTF) brain stimulation therapy is a promising approach to reduce poststroke disability. Two pilot, randomized, sham-controlled trials showed safety and signals of efficacy. The aim of this study was to perform a pooled analysis with greater statistical power to characterize with precision the effect of ENTF in promoting recovery and reducing disability.
METHODS:
We pooled individual patient-level data from 2 double-blind, randomized, sham-controlled studies, BQ3 (BrainQ3 Trial; Unique identifier: NCT04039178) and EMAGINE 1 (Electromagnetic Field Ischemic Stroke-Novel Subacute Treatment Trial; NCT05044507). Key entry criteria in both trials were (1) 4 to 21 days post-ischemic stroke and (2) Fugl-Meyer assessment-upper extremity score of 10 to 45. For EMAGINE 1, an additional criterion was a study entry modified Rankin Scale (mRS) score of 3 to 4. The primary outcome for this pooled analysis was freedom-from-disability (mRS score, 0–1) at 8 to 12 weeks. Secondary outcomes were level of disability (ordinal mRS score distribution), disability change (delta mRS score) change from entry to 8 to 12 weeks, and 2 focused upper extremity motor end points.
RESULTS:
Altogether, 124 patients were included (active n=65; sham n=59). The mean age was 58.2±13.1 years, 31% were female, the study entry Fugl-Meyer assessment-upper extremity score was 25.3 (±10.6), and the therapy started 14.5 (±4.9) days poststroke. The study entry mRS score was 3.9 (±0.36), and 123/124 (99.2%) had a study entry mRS score of 3 to 4. Study entry features were well-balanced across treatment groups. At 8 to 12 weeks, freedom-from-disability was higher with active ENTF than sham stimulation (33.8% versus 11.9%; P=0.005). Ordinal shift across 3 disability strata (mRS score, 0–1, 2, and >2) also favored ENTF (P=0.009). Focused upper extremity motor end points nonsignificantly favored ENTF. Safety analyses showed no device- or procedure-related serious adverse events.
CONCLUSIONS:
In pooled data from 2 randomized, sham-controlled trials, treatment with ENTF compared with sham for patients with subacute ischemic stroke with moderate-severe study entry disability yielded increased(NOT RECOVERY!) achieved freedom-from-disability, greater disability improvement from study entry, and reduced(NOT RECOVERY!)final disability level. These findings, together with an attractive safety profile, support ENTF as a promising therapy for stroke recovery.(Which means you are accepting failure as Ok; survivors don't accept that!)
Statistically significant improvements is STILL COMPLETE FAILURE; NOT 100% RECOVERY! Don't you dare use the tyranny of low expectations on stroke survivors! You'll rue the day when you become the1 in 4 per WHO that has a stroke! I really hope comeuppance hits you hard with not recovering. You deserve it.
Brain-Computer Interface (BCI) has emerged as a promising intervention, facilitating recovery of upper limb motor function, enhancing associated neurophysiological markers, and improving activities of daily living (ADL) performance, which is measured using the Modified Barthel Index (MBI). Nevertheless, most existing research has centered on individual outcome domains, and thus critical questions remain unanswered. These questions include heterogeneity in treatment efficacy across different post-stroke phases, in addition to the consistency of BCI’s effects across specific functional assessment scales, such as the Fugl-Meyer Upper Extremity Scale (FMA-UE) and the Action Research Arm Test (ARAT)—and on neurophysiological markers.
Objective
To perform a systematic review and meta-analysis of the effects of BCI-mediated rehabilitation versus conventional rehabilitation on upper limb motor function, functional activities, neurophysiological markers, and MBI performance in patients with stroke.
Methods
Systematic searches were performed in 7 databases for this study: PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI), Wan Fang Data, and China Biology Medicine Database (CBM). Inclusion criteria were randomized controlled trials (RCTs) comparing BCI-mediated rehabilitation with conventional rehabilitation in patients with upper limb dysfunction following stroke. The primary outcome measure was FMA-UE scores. Secondary outcome measures included functional activity levels as assessed by ARAT, neurophysiological markers (e.g., motor evoked potentials, MEPs, electroencephalography, EEG indices), and MBI scores. The methodological quality of the included studies was assessed using the validated evidence-based Cochrane Collaboration’s RoB 2.0. In the meta-analysis, if the results of the heterogeneity test were less than 25%, the fixed-effect model was employed; otherwise, the random-effects model was used. For each outcome measure, the mean difference (MD) or standardized mean difference (SMD), together with their corresponding 95% confidence intervals (95% CI), were calculated.
Results
After screening against the inclusion and exclusion criteria, 16 eligible randomized controlled trials (RCTs) were ultimately included, encompassing a total of 1761 patients. Compared with conventional rehabilitation interventions, BCI rehabilitation interventions exert a certain effect on improving patients ‘upper limb motor function (SMD = 0.49, 95%CI;0.26–0.73, p = 0.037).Additionally, significant improvements were observed in ARAT scores (SMD = 0.53, 95% CI: 0.14–0.91, p = 0.035),neurophysiological markers(SMD = 0.53, 95% CI;0.08–0.98, p < 0.05)and MBI scores(SMD = 0.85, 95% CI;0.55–1.14, p < 0.001).Subgroup analyses of BCI-mediated rehabilitation interventions for upper limb motor function recovery in stroke patients demonstrated certain subgroup-specific disparities in the magnitude of therapeutic effects across different subgroups. With respect to stroke staging, BCI-mediated rehabilitation interventions conferred superior efficacy for motor function recovery in patients with subacute stroke, a finding plausibly attributable to the temporal course of post-stroke neural remodeling. Subgroup analyses stratified by intervention dosage demonstrated that both 10–15 and 20–30 sessions of BCI-mediated rehabilitation interventions resulted in clinically meaningful improvements in patients’ upper limb function. No statistically significant difference was detected between these two treatment regimens, yet the 20-30-session protocol was associated with a relatively larger effect size. Furthermore, subgroup analyses stratified by intervention modality demonstrated that no statistically significant differences emerged across the distinct intervention approaches, and this observation plausibly suggests the rehabilitative benefits of divergent BCI paradigms in patients are uniformly mediated through neural circuit remodeling.
Conclusion
BCI emerges as a promising therapeutic modality for stroke rehabilitation, delivering substantial, statistically significant improvements across multiple key outcomes, including FMA-UE, ARAT, neurophysiological markers, and MBI scores with consistent statistical significance observed across all aforementioned domains.
Do you really think anyone in stroke is competent enough to get stroke testing going? I don't, everything in stroke IS A COMPLETE FUCKING FAILURE!
Prove me wrong; failure is defined as not getting to 100% recovery!
Don't try your tyranny of low expectations on me. Here;
oc1dean@gmail.com, I'll print it verbatim with my reply. Have at it, or
are you afraid to engage with a stroke-addled survivor?
Of course your competent? doctor can inform these researchers of earlier protocols they already created on these.
The combined function of 3D-printed collagen/silk fibroin (3D-CS) scaffolds with injury-preconditioned exosomes obtained from human umbilical cord mesenchymal stem cells (hUCMSCs) in traumatic brain injury repair remains unclear. Here, we demonstrate that exosomes produced from hUCMSCs preconditioned with brain trauma extracts have a neuroprotective effect on a craniocerebral trauma model in beagles. Notably, injury-preconditioned exosomes generated by hUCMSCs combined with 3D-CS scaffolds markedly promoted neuroregeneration and angiogenesis after TBI. Injury-preconditioned exosomes combined with 3D-CS scaffolds also alleviated both the proinflammatory factor-induced apoptosis and nerve apoptosis induced by injury in vivo. We further showed that the joint action of injury-preconditioned exosomes combined with 3D-C/S scaffold-induced neurorepair ultimately promoted the recovery of neurological dysfunction after traumatic brain injury. In summary, this study reveals the cofunction of injury-preconditioned exosomes and 3D-CS scaffolds in response to traumatic brain injury and suggests a potential therapeutic strategy.
Visual Abstract
The combined function of 3D-printed collagen/silk fibroin (3D-CS) scaffolds with injury-preconditioned exosomes obtained from human umbilical cord mesenchymal stem cells (hUCMSCs) in traumatic brain injury repair remains unclear. Here, we...
Only in the rose colored glasses of the tyranny of low expectations can this be considered positive! Measured against the only goal in stroke(100% RECOVERY!) This was a complete failure! You blithering idiots have the wrong goal! You'll want 100% recovery when you are the 1 in 4 per WHO that has a stroke
The TESLA trial tested the concept of stroke
thrombectomy on large-core infarcts with a noncontrast CT-alone
selection paradigm to lower the barrier for imaging and patient
selection.
While primary results at 90 days did not meet
statistical superiority, extended follow-up to 1 year did significantly
favor endovascular therapy over medical management alone for functional
outcomes.
The investigators suggested that the between-group
difference is related to the severe natural history of untreated
large-core tissue decay, hence the diverging recovery or decline
trajectories.
In the TESLA trial, stroke outcomes took a turn
for the better following swift mechanical thrombectomy for large
anterior circulation infarcts identified without advanced imaging.
In an extended analysis of the trial at 1 year, patients treated with
CT-selected endovascular therapy (EVT) for large-core infarcts had
improved functional outcomes compared with those treated with medical
management alone, as measured by mean utility-weighted modified Rankin
Scale (mRS) scores (3.65 vs 2.78, bayesian adjusted mean difference 1.18
points, 95% credible interval 0.42-1.93; posterior probability of
superiority P=0.999).
Patients
receiving EVT versus medical management alone also had a higher
likelihood of functional independence (mRS score 0-2; 23.6% vs 6.8%, P<0.001) and independent ambulation (mRS score 0-3; 35.4% vs 18.0%, P<0.001) at 1 year, reported Albert Yoo, MD, PhD, of California Neurointerventional Surgeons in Riverside, and colleagues.
"Although functional independence in the IAT [intra-arterial
thrombectomy] group numerically increased between 90 days and 1 year, it
declined in the MM [medical management] group, which may reflect the
severe natural history of untreated large-core tissue decay, delayed
deconditioning, unmeasured rehabilitation intensity difference between
groups, or baseline imbalances, such as age," they wrote in a research
letter in JAMA.
"These exploratory observations complement the 12-month data reported in the SELECT2 and TENSION
trials, supporting that early large-core reperfusion may facilitate
prolonged neuroplastic remodeling up to 1 year post stroke," they added.
The favorable 1-year results of TESLA put the study more in line with these other trials, after its main analysis had indicated neutral results for EVT in the short term.
TESLA
stands alone as the only EVT trial to extend the enrollment window to
24 hours while requiring only noncontrast CT for infarct size estimation
and CT angiography for diagnosis of target vessel occlusion without
more advanced imaging techniques to identify eligible patients with
large-core strokes. Of note, with the more pragmatic entry criteria,
there was a relatively long median of 11.5 hours from stroke onset to
randomization in this study.
The open-label trial was conducted across 47 U.S. stroke centers and
included adults presenting within 24 hours of last known well with an
NIH Stroke Scale score of 6 or higher, internal carotid artery or middle
cerebral artery occlusion, an Alberta Stroke Program Early Computed
Tomography Score of 2 to 5 on baseline CT, and a premorbid mRS score of 0
to 1.
Yoo and team randomized 302 patients to medical management with or
without intra-arterial thrombectomy; ultimately, 300 were included in
the intention-to-treat analysis. Complete 1-year functional data were
available for 277 people, among whom baseline profiles were balanced
between groups, though the EVT group was slightly younger (median age 66
vs 68) and more likely to have diabetes (28.5% vs 16.8%).
As
part of the exploratory analyses, the study authors also found that
patient-reported quality of life was better in the EVT group at 1 year,
as measured by the 100-point European Quality of Life 5 Dimensions, 5
Levels (EQ-5D-5L) health questionnaire (average score 60.3 vs 49.3, P=0.003).
All-cause mortality rates were not significantly different between groups (43.1% vs 46.6%, P=0.42).
As for potential harm, EVT had been associated with excess
symptomatic intracranial hemorrhage at 24 hours, as previously reported
(4.0% vs 1.3%).
Yoo and colleagues stressed that the present report covered
exploratory analysis and may have been biased by unblinded
postprocedural rehabilitation intensity and asymmetric 1-year attrition,
as follow-up was complete for 144 patients in the EVT group and 133
controls. External validity to lower-resource regions remains
unestablished, they added.
"Nevertheless, these descriptive data suggest longer-term benefit
associated with thrombectomy in large-core stroke, indicating that a
[noncontrast] CT-alone selection paradigm warrants further study as a
lower-barrier strategy for global stroke systems," the investigators
concluded.
Do you really think anyone in stroke is competent enough to get human testing going? I don't, everything in stroke IS A COMPLETE FUCKING FAILURE! Prove me wrong; failure is defined as not getting to 100% recovery! Don't try your tyranny of low expectations on me. Here; oc1dean@gmail.com, I'll print it verbatim with my reply. Have at it, or are you afraid to engage with a stroke-addled survivor?
Of course your competent? doctor can inform these researchers of earlier work.
When someone has a stroke caused by a blood clot, doctors can quickly restore blood flow. However, they can’t easily replace the brain tissue that gets lost. Recovering this tissue usually means relying on rehab to help the remaining brain circuits adapt.
A team of biomedical engineers at Duke University has built an injectable biomaterial that could change stroke recovery.
Rebuilding the Brain’s Neighborhood
The research team isn’t attempting to rebuild the brain directly. Instead, they are setting up a scaffolding system to let the body do the work for them. They achieve this system using tiny hydrogel microparticles called MAPS. When the material is injected into the cavity caused by a stroke, it creates a porous structure for cells to grow on.
“Once brain tissue has been lost, restoring blood flow is no longer enough,” said Tatiana Segura, the Robert Plonsey Distinguished Professor of Biomedical Engineering at Duke. “Our goal is to engineer the injured space so that immune, vascular, and neural repair processes can begin to work together.”
The team attached specific signals to these particles so that the body’s immune cells could help. These signals come from astrocytes, which are star-shaped cells in the brain.
“We are not simply placing a material into the brain,” Segura added. “We are engineering a local environment that can coordinate several parts of the repair response.”
Surprising Helpers
The team found that certain signaling molecules attracted helpful immune cells, including the most common type of white blood cell: neutrophils. Usually, neutrophils cause inflammation right after a stroke. However, that wasn’t the case in this scenario.
“This result changes how we think about neutrophils after stroke,” said Shangjing Xin, lead scientist of the study and a postdoctoral fellow in the Segura Laboratory. “Their role appears to depend on when they arrive, where they are located, and the signals they receive from their surroundings. Our study demonstrates a potential engineering strategy to recruit and retain these cells at the right time.”
In mouse tests, this treated scaffold helped grow new blood vessels and improved movement. By eight weeks, the mice performed like healthy controls on a coordination test.
Right now, the work is still preclinical. The team is looking at using human cells next to make it scalable.
“You do not restore an ecosystem simply by containing the initial damage. You have to create the conditions that allow life to return. That is how we think about the stroke cavity,” Segura said. “The material is not intended to reproduce the brain itself, but to create an environment where the body’s own cells can enter, communicate and participate in rebuilding vascularized tissue.”
Useless! Where is the RECOVERY CERTIFICATION that survivors want? Since you're not doing anything survivors want, just turn it over to survivors so recovery protocols can be created!
Rehabilitation(NOT RECOVERY! That is how fucking incompetent the WSO is!) has been identified by the World Stroke Organization (WSO) as a key priority to reduce the global burden of stroke. Global access to rehabilitation('Access is useless if you don't have recovery protocols! Or are you OK with your tyranny of low expectations? Survivors aren't!) is inconsistent and is particularly limited in low-and-middle-income countries. Progress in rehabilitation has not been as well evidenced as progress in acute care(NOT RECOVERY!). The WSO certification program, which commenced in 2021, focuses on acute interventions. A rehabilitation certification program, applicable in both inpatient and outpatient rehabilitation settings, has been developed to complement the acute certification program to address global implementation of evidence-based stroke care(NOT RECOVERY!).
Aim:
To develop globally applicable, evidence-based, stroke rehabilitation recommendations and performance metrics for use in a stroke rehabilitation certification program.
Methods:
Strong recommendations were extracted from high-quality stroke rehabilitation Clinical Practice Guidelines, systematic reviews and syntheses of clinical practice guidelines, and from the defining criteria of the International Stroke Recovery and Rehabilitation Alliance (ISRRA) Centers of Clinical Excellence. The WSO Rehabilitation Implementation Committee led the development of the recommendations and invited input from three international, multidisciplinary consultation groups. Group 1 compared strong recommendations from the Australia/New Zealand Living Guidelines with other international guidelines to identify consistent, high-quality recommendations. Group 2 mapped recommendations from global guideline syntheses against the Australia/New Zealand Living Guidelines. Group 3 reviewed and adapted the ISRRA Center of Clinical Excellence recommendations. Recommendations were consolidated through consensus meetings involving representatives from each workgroup, including people from high, upper-middle, and lower-middle-income countries. Strong recommendations that were consistent across teams, alongside additional recommendations based on certainty of evidence, anticipated risk versus benefit, and relevance across settings, were included as patient-level recommendations in the implementation certification program. Service-level recommendations were generated through consensus or derived from existing guidelines. An implementation manual, outlining “what,” “who,” and “how,” as well as indicators to demonstrate performance of each recommendation, was developed to support clinical implementation and to facilitate assessment for certification. The criteria were piloted between November 2024 and September 2025 at 15 centers in six upper- and lower-middle-income countries (three continents) and subsequently refined. Expectations (mandatory or recommended) for each level of certification (Minimal, Essential and Advanced) were set post-pilot through rating strength of evidence, a series of group discussions and review of pilot data.
Results
Fifty-five recommendations were included. Nine recommendations address service-level indicators, and 46 address patient-level indicators. Service-level indicators address defining features of rehabilitation services that are not apparent in individual patient medical record audits. Patient-level indicators address management of swallowing impairment, nutrition and hydration, information provision and goal setting, amount and timing of rehabilitation, exercise and motor rehabilitation, visual function, communication, mood and cognition, management of complications, and discharge planning and support. An implementation manual complements the recommendations to guide clinical care(NOT RECOVERY!) and consistent assessment.
Conclusions
The WSO rehabilitation recommendations and performance metrics incorporate the most current evidence and have been refined following pilot-testing. The recommendations are globally relevant and support both resource-limited and high-income settings in participating in the rehabilitation certification program to advance international stroke rehabilitation delivery.
Learn what spasticity really is, why it happens after stroke, and what you can do at home to help manage it.
Spasticity can feel confusing, frustrating, and unpredictable. One day your arm, hand, leg, or foot may feel loose. The next day it may feel tight, stiff, or difficult to move.
In this free webinar, licensed neuro physical therapist Rachel Higdon will explain what spasticity is, why it starts in the brain, and how daily tools like slow stretching, breathing, positioning, rhythmic movement, and weight bearing may help calm the nervous system.
You’ll also learn when it may be time to talk with a medical provider about options like medication, Botox, splinting, orthotics, or other treatments.
What You’ll Learn (THAT THEY KNOW NOTHING ABOUT CURING IT! That's the takeaway!)
• The difference between normal muscle tone, tightness, and spasticity
• Why spasticity happens after stroke or neurological injury
• Common triggers that can make spasticity worse, including stress, pain, fatigue, poor sleep, cold, and fast movements
• Gentle home strategies that may help reduce reflex overactivity
• How positioning, stretching, and weight bearing can support better movement
• When to ask your care team about medical treatment options
In my 16 years writing this blog, I SEE NOTHING THAT SUGGESTS ANY GUARANTEED WAY TO GET RECOVERY! Hope is NOT GOOD ENOUGH! Do the work that delivers recovery!
The neurologist Orlando Swayne doesn’t suggest everyone can recover.(That's the problem in a nutshell, advocating the tyranny of low expectations to dumb down the survivor goals to what can currently be delivered! THAT IS GIVING UP BEFORE THE SURVIVOR EVEN STARTS! 100% recovery is the only goal in stroke! GET THERE!) But he does argue that early, targeted and intense therapy can sometimes bring about life-changing improvements – and we have a moral obligation to provide it
Prefer the Guardian on GoogleThe Guardian’s journalism is independent. We will earn a commission if you buy something through an affiliate link. Learn more.
Claire was in bad shape. She had been brought to the ward on a stretcher and hoisted on to a bed where she lay curled up in a ball. She was unable to speak, her eyes flat and face expressionless. While she could move her right arm a little, her left arm and both legs were immobile.
Life had changed dramatically for Claire, a mother of three in her late 30s, many months earlier, when she collapsed while on a night out with friends. A weakness in an artery at the base of her brain had ruptured, spilling blood around her frontal lobe. She was taken to hospital, where surgeons removed two side plate-sized pieces of bone from her skull to relieve the pressure on her brain. She spent months in intensive care.
Can a patient with such profound impairment improve in any meaningful way, especially so long after the event? That was the question for Orlando Swayne, a consultant neurologist and co-lead of the pioneering neurorehabilitation unit at the National hospital for Neurology and Neurosurgery, a Victorian redbrick building in Queen Square, central London.
(If your doctor doesn't reference
Pedro Bach-y-Rita who recovered fully back in 1958 with only a partial brain! Aren't you smart enough to duplicate that? Then you DON'T have a functioning stroke doctor! Get rid of them!)
It was a few years before the pandemic when Swayne first met Claire on the ward. She made eye contact but showed no other response. He knew from the referring hospital that she could write single-word answers to queries, but these revealed characteristic signs of the brain damage she had sustained. Before leaving her bedside to tend to other patients, Swayne asked if she had any questions. With a pencil clenched in her right hand, she wrote: “Questions, questions, questions,” and then tailed off into a wiggly line. The pathological repetition comes from a failure in the frontal lobe to keep actions moving along in sequence.
“There are some patients who start off, when we first work with them, severely impaired – and I mean very severely impaired,” says Swayne. Claire (not her real name) was one such patient.
If he had trusted only his lectures at medical school, Swayne might have considered Claire beyond help. Dogma held that broken brains didn’t mend. A brief flirtation with neurosurgery did nothing to dispel the view. “You see patients in a really terrible state and you think that’s them for life,” he says, “but you don’t see them for very long.”
You see patients in a really terrible state and you think that’s them for life
Swayne quickly decided against a career in neurosurgery, perhaps for the best. “I’m a bit clumsy,” he says, though this wasn’t the only reason. “Neurosurgery is all about the craft, and I’m not really a craft person. I like the people. I like the relationships and the human aspects, which you don’t get so much in neurosurgery.”
He moved into general medicine, then into neurology and stroke medicine, and over the next 20 years or so started to see patients long after their original admission. “I began to realise that some of these patients were improving. And the ones who were improving were the ones working with therapists,” he says. “I thought: ‘OK, I didn’t realise that was a thing. How does it work?’”
The answer, it seems, is to be found in the brain’s capacity for neuroplasticity, its ability to make new connections and reorganise in the face of changed circumstances. In his new book, How to Use a Fork: Stories of Mending the Broken Brain, Swayne argues that recent discoveries in this area have “profound implications” for patients and the therapy and care we owe them.
Swayne is at the piano murdering Chopin – his words, not mine – when I arrive at his north London home. Our chat clashes with his daughter leaving for gap year travels, a milestone I’d assumed would be infused with chaos, but a calmness prevails. A small black dog bounds over and then scoots away, before finding a spot on the kitchen sofa.
My copy of his book is a mess of folded corners, underlined passages and notes in the margin, but I confess, unfairly in retrospect, that I hadn’t relished reading it. For there is history here. Doctors have written books on neuroplasticity before and some made me deeply uncomfortable. To my mind, they peddled false hope through portrayals of miraculous recoveries. At worst, they seemed to imply that patients with severe brain injuries could rise up from their wheelchairs, speak fluently once again and overcome deep cognitive impairment if only they put their mind to it. I feared more of the same: show me a publisher that wants stories of patients whose lives are destroyed and remain so.
Swayne, it turns out, has read the same books and shares the concern. To be clear, he is not suggesting that everyone who suffers a huge stroke or brain injury can recover. His argument is that early, targeted and intense therapy can bring about life-changing improvements, and that we have a moral obligation, not to mention an economic one, to provide such care. “The perception of brain injury is that it is irreversible and irrecoverable from, and this is a corrective to that view,” he says. “There is hope, but clearly you have to balance that. Some people just don’t recover.”(Discounting
Pedro Bach-y-Rita who recovered fully back in 1958 with only a partial brain!)
Stroke is a leading cause of adult disability in the UK. It happens when a blood vessel, typically an artery, becomes blocked or bursts, and starves the brain of oxygen and nutrients. Within minutes, brain cells in the affected region begin to die. Depending on the location, a stroke can cause paralysis, loss of speech, blindness and other vision problems, impaired thinking, memory loss, personality changes, an inability to swallow, and more. Of the 12 million or so people globally who suffer a stroke each year, one in five dies within 30 days.
Many stroke patients show small improvements in the first few weeks, as swelling and inflammation subside. According to old-school thinking, that was as much as you could hope for. But it’s not the full story. The damage caused by stroke or brain injury drives chemical changes in the brain. These trigger neuronal growth processes that were last active in the developing brain. Surviving neurons are spurred into making new connections and to work around the dead tissue.
Of course, the brain constantly demonstrates some level of neuroplasticity. To learn a foreign language, or how to play a new instrument or fly a helicopter, your brain must forge new connections. The process redraws the functional maps in the brain, the neural territory called upon to perform particular tasks. So it is that black-cab drivers in London have more grey matter in the hippocampus after learning the Knowledge. Likewise, the amount of brain dedicated to using the index finger expands when people learn to read braille with it. But the process is sluggish in adults compared with children and those who have suffered recent stroke or brain injury.
After such events, neuroplasticity ramps up for several months. This is when intense, targeted therapy can have the most impact. “Even though the capacity for plasticity is greatest in the first few months, it doesn’t just switch off,” Swayne says. In one study, intensive therapy improved upper limb movement in patients 18 months after their strokes.
Claire’s early therapy sessions focused on positioning and stretching – to enable her to sit comfortably – and mouth, tongue and voice box exercises. But they were tough, and she quickly became too tired to continue. In time, though, her stamina improved and she engaged more with the therapists. Her gaze began to follow people walking past and she would sometimes move her mouth to speak in response to questions.
Her improvement gathered pace with music therapy. In those sessions, Claire used her stronger right hand to pluck guitar strings and shake maracas. Her therapists noticed more spontaneous facial expressions and she began to point to instruments, choosing, being proactive. Session after session, for four months, she was drilled to make choices, identify objects, to engage her mouth and tongue.
Swayne hadn’t caught up with the therapists in a while, but one day as he headed past Claire’s bay and said hello, she looked up and said: “What happened to your hair?” Swayne stopped dead. “That was an amazing moment,” he says. “If you work with a patient who’s not spoken for a year, and you do an intervention and they start speaking, it’s got to be a response to the therapy.”
Swayne confided in Claire about his disastrous encounter with a barber and later learned from the speech therapist that her language had been coming for a week or so. First it was single words, then phrases and short sentences. She had made progress with her right hand, too. Before long, she was playing Connect 4 with her boys and fellow patients on the ward, though her left side and right leg remained lifeless.
“She started communicating with her kids and with us, and that was enormous,” Swayne says. “Her left side will always remain weak because it’s very badly damaged, but she started using her right arm to do things, like use a phone and use a power chair. We had her cooking, and that was huge. She will always need help, but for quality of life it was transformational.”
There’s plenty still to learn about the brain’s ability to work around dead tissue, but details of some mechanisms are emerging. Delve into the motor cortex in the brain’s frontal lobe and you’ll find specialised neurons that drive limb movement. These are arranged vertically to send their messages to the spinal cord. But they are also linked by a mesh of horizontal connections. Normally, these horizontal connections are suppressed, but in the event of brain damage, the inhibition is relaxed and the connections activate. Surviving neurons can now recruit neighbours to their cause, though they need time and training to learn the new job.
There’s more to neuroplasticity than this, but the mechanism explains some of the stark limitations that doctors and their patients witness. When neural connections are completely lost, it seems no amount of therapy can bring them back. And while the brain can reorganise to some extent, there’s no evidence that a specialised region of the cortex can take on an entirely different role. If a stroke leaves your right arm limp, your visual cortex cannot take control of it any more than your kettle can make the morning toast. That said, movement, language, sensation and vision are not confined to small brain regions: they are distributed across networks that provide for some flexibility. For example, most people do the bulk of their language processing in the left side of the brain, but if it is damaged, there’s evidence that parts of the language network on the right side can take on some of the work.
Much of the immediate work with new stroke patients is to identify their impairments and the causes. If they are unable to use a fork, what is stopping them? Can they feel it? Are they too weak on that side? Can they coordinate their movements?
Therapists take impairments and break them down into steps that patients can be drilled on. There is, so far, no shortcut to the gruelling hours put in by the patients described in Swayne’s book. Thomas, a vicar who couldn’t speak after a stroke at the pulpit, had intensive speech therapy to retrain his swallowing and tongue movements. Christian, a mixologist at a swanky London hotel, relearned how to brush his teeth: turn the tap on, get the toothbrush, add the toothpaste. Vikas, a roofer who fell from three storeys up, had sessions in the kitchen to learn how to pay attention and multitask again.
It’s not just the direct damage that therapists have to contend with. The brain can create its own problems. Patricia, a catering assistant, had lost the use of her right arm. When asked to point to it, she would move it out of the way and keep searching among the bedclothes. She later believed the arm was a baby and became inconsolable when she thought it had died.
The therapy a patient receives after stroke is the most important determinant of how well they recover: will they be dependent on others or able to fend for themselves? Yet what most patients receive is grossly inadequate, Swayne says. Every working day, patients at stroke units in the UK should receive 45 minutes each of physio, occupational therapy and speech therapy. In 2020, an audit found that most patients received only 14, 13 and seven minutes per day, respectively.“It’s shocking,” says Swayne.
It is even worse when people leave hospital. Stroke units used to pass patients on to the community therapy team in their local area, but those networks were demolished by austerity economics. “It’s a real postcode lottery. There are some boroughs where you’re relieved you’re discharging the patient to that borough because they’ve actually got a speech therapist, whereas another borough is a desert,” Swayne says. “It’s frustrating, having worked with these patients for months, to then send them into the wilderness.” It’s common for patients to return a year or two later with complications, having had no therapy since leaving hospital.
The argument that proper rehabilitation is a luxury we cannot afford does not add up, Swayne adds. Early intensive therapy pays for itself by reducing the cost of long-term care. This will become ever more important as first-time strokes rise in the coming years. Today, strokes cost the UK economy an estimated £27bn a year, but only £3bn of that is driven by direct hospital care. The rest is lost economic productivity and the invisible costs of care. By 2035, the cost is predicted to more than triple to £75bn.
“People talk about the cost of these interventions, but if you do the maths, an admission might cost something like £40,000,” Swayne says. “That sounds like a lot of money, but if you look at the change in care costs, it isn’t, because it pays itself back pretty quickly.” Swayne did the sums for one patient: during his time in the rehabilitation unit, his care costs fell to £2,640 per week, meaning the cost was offset within four months of him going home, and would save tens or hundreds of thousands of pounds in the longer term.
uble. Care for traumatic brain injury is also badly neglected. Each year, more than 1 million people in England and Wales attend emergency departments for head injuries. Of the 200,000 or so who are admitted to hospital, about 40,000 have evidence of traumatic brain injury.
Many such patients are discharged within a couple of weeks. Superficially, they seem better: they can walk and talk. But often, important problems are simply not spotted. “What we now realise is that a majority of those patients have got cognitive changes that haven’t been picked up,” Swayne says. “You can see them walking down the street and they look fine, but they cannot function normally. There’s an invisible disability. It affects their relationships, their employment and they get into trouble with the police.”
And so, the hidden damage left by brain trauma can lead to lives falling apart. In one 2025 study, researchers found that nearly 90% of adult men in Scottish prisons had experienced severe head injury. That doesn’t mean that brain injury triggered their crimes: violent men experience more violence. But damage to specific brain regions might contribute to criminal behaviour, by making it harder for people to control their impulses, feel empathy and anticipate the consequences of their actions.
Researchers are looking at ways to make therapy more effective and – the holy grail – to reopen the window of enhanced neuroplasticity. New drugs, brain stimulation and virtual reality are all in the mix. If they succeed, patients could receive more beneficial therapy to boost their recovery. But for now, perhaps the best we can do is keep our brain healthy and protected.
“We all know what to do for brain health,” says Swayne. “We should exercise. We should be in a stimulating environment and have social interactions. We shouldn’t smoke or drink too much alcohol. There’s really strong evidence that all these things help with brain maintenance. By looking after your brain you’re giving yourself the best chance of recovery should you need it.”
How to Use a Fork: Stories of Mending the Broken Brain is published by Pan Macmillan on 4 June (£20). To support the Guardian, order a copy from guardianbookshop. Delivery charges may apply
