Deans' stroke musings

Changing stroke rehab and research worldwide now.Time is Brain!Just think of all the trillions and trillions of neurons that DIE each day because there are NO effective hyperacute therapies besides tPA(only 12% effective). I have 493 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:

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's quite disgusting that this information is not available from every stroke association and doctors group.
My back ground story is here:http://oc1dean.blogspot.com/2010/11/my-background-story_8.html

Sunday, September 25, 2016

Pediatric stroke rehabilitation: A review of techniques facilitating motor recovery

 

Pediatric stroke rehabilitation: A review of techniques facilitating motor recovery

Abstract

Objective

Paediatric stroke is a relatively rare medical condition, but it often leads to long lasting motor and cognitive impairments. Rehabilitation of motor impairments has been widely studied, with most studies performed in children with cerebral palsy (CP). However, CP covers a variety of medical conditions, including brain lesions due to paediatric stroke occurring early in life, but not stroke occurring later on during childhood. The specificity of rehabilitation after paediatric stroke remains understudied. This paper aims to present current motor rehabilitation practices (from birth to age 18) and examine which of these techniques are applicable and efficient for paediatric stroke.

Materials/Patients and methods

We first conducted searches using Ovid Database, for motor rehabilitation techniques used in childhood hemiplegia and/or CP. As a second step, a systematic search was conducted up to March 2016, combining the therapies retrieved in the first search AND key words referring to paediatric stroke. Separate searches were conducted for each rehabilitation technique previously identified, namely: constraint induced movement therapy (CIMT), hand arm bimanual training (HABIT), occupational therapy combined with botulinum toxin injections, non-invasive brain stimulation, virtual reality, robotics, action-observation therapy, functional electric stimulation and prismatic or mirror adaptations.

Results

In paediatric stroke, studies on rehabilitation of lower limb present low or insufficient evidence, whereas most studies refer to rehabilitation of upper-limb disabilities. CIMT presents moderate to strong evidence, sometimes coupled with imaging studies examining the associated brain changes. Individual case studies propose CIMT for toddlers or infants, both for motor rehabilitation or unilateral spatial neglect. Contrary to CP literature, there is no available evidence on bimanual training or botulinum toxin injections, whereas there is a growing body of research on non-invasive brain stimulation, (tDCS or TMS) providing preliminary evidence on the efficacy, as well as safety and feasibility of such methods for older children. Novel approaches such as functional electric stimulation, robotic therapy, virtual reality and action–observation therapy present low or insufficient evidence, but may be promising for more severe upper limb deficits or early intervention.

Discussion/Conclusion

Rehabilitation of motor deficits following paediatric stroke remains understudied, but a number of promising therapies are emerging.

 

 

Asking New Questions with Old Data: The Centralized Open-Access Rehabilitation Database for Stroke

With this amount of knowledge it should be damned easy to come up with a strategy to solve all the problems in stroke.
http://journal.frontiersin.org/article/10.3389/fneur.2016.00153/full
  • 1School of Kinesiology, Auburn University, Auburn, AL, USA
  • 2School of Biological and Health Systems Engineering, Arizona State University, Tempe, AZ, USA
  • 3Department of Health, Physical Education and Recreation, Utah State University, Logan, UT, USA
  • 4Department of Physical Therapy, University of British Columbia, Vancouver, BC, Canada
  • 5Program in Physical Therapy, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
  • 6Program in Occupational Therapy, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
  • 7Department of Neurology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
Background: This paper introduces a tool for streamlining data integration in rehabilitation science, the Centralized Open-Access Rehabilitation database for Stroke (SCOAR), which allows researchers to quickly visualize relationships among variables, efficiently share data, generate hypotheses, and enhance clinical trial design.
Methods: Bibliographic databases were searched according to inclusion criteria leaving 2,892 titles that were further screened to 514 manuscripts to be screened by full text, leaving 215 randomized controlled trials (RCTs) in the database (489 independent groups representing 12,847 patients). Demographic, methodological, and statistical data were extracted by independent coders and entered into SCOAR.
Results: Trial data came from 114 locations in 27 different countries and represented patients with a wide range of ages, 62 year [41; 85] [shown as median (range)] and at various stages of recovery following their stroke, 141 days [1; 3372]. There was considerable variation in the dose of therapy that patients received, 20 h [0; 221], over interventions of different durations, 28 days [10; 365]. There was also a lack of common data elements (CDEs) across trials, but this lack of CDEs was most pronounced for baseline assessments of patient impairment and severity of stroke.
Conclusion: Data integration across hundreds of RCTs allows clinicians and researchers to quickly visualize data from the history of the field and lays the foundation for making SCOAR a living database to which researchers can upload new data as trial results are published. SCOAR is a useful tool for clinicians and researchers that will facilitate data visualization, data sharing, the finding of relevant past studies, and the design of clinical trials by enabling more accurate and comprehensive power analyses. Furthermore, these data speak to the need for CDEs specific to stroke rehabilitation in randomized controlled trials.
PROSPERO 2014:CRD42014009010

Introduction

The information architecture in rehabilitation science is poor (1). For example, randomized controlled trials (RCTs) are the basic “unit” of information that guide clinical practice. Yet when clinicians and scientists want to ask a very basic question of these data, they are published: (1) across a wide spectrum of journals and formats that often have limited access (e.g., payment required for access); (2) embedded potentially in text, tables, figures, or even supplemental materials; and (3) with very few common data elements (CDEs) reported across studies (2, 3). Thus, despite the tremendous time and financial burdens associated with even a single RCT, the resultant data lack a consistent structure. This lack of structure is an unnecessary barrier to integration in future scientific and clinical practice. Efforts to streamline data integration should increase the transparency and visibility of comprehensive bodies of evidence, rather than a single study, to better inform clinically relevant questions such as, “How do therapy outcomes change with increased time in therapy?” or “How variable are outcomes, historically, for specific parameters of therapy?”
We now introduce one such tool for streamlining data integration: the Centralized Open-Access Rehabilitation database for Stroke (SCOAR). In short, SCOAR is a central repository for summary statistics from RCTs. SCOAR currently contains data from a systematic review and extraction of papers from 1981 to early 2014 (described in detail below), but the goal of SCOAR is much bigger: to create a “living” database where new data can be added as clinical trials are completed. Imposing such an architecture (4) on clinical trial data would allow basic and clinical scientists to (1) quickly and easily visualize relationships among variables, (2) efficiently share data, (3) generate hypotheses based on noticeable patterns or even “gaps” in the current data, (4) search the current literature from the data up (rather than key-terms down), and (5) improve clinical trial design through more accurate and comprehensive power analyses.
Generally speaking, the goal of SCOAR is to improve the design of future clinical trials by giving researchers fast and easy access to the historical range of effect-sizes, based on thousands of stroke patients who received therapies of different types, different doses, at different times, and were measured on different outcomes. From our perspective, the effort associated with the design, implementation, and dissemination of randomized clinical trials deserves an information architecture that supports and increases their visibility. In the current paper, we (1) explain the systematic search and data extraction that led to the creation of SCOAR; (2) present summary statistics for the major variables in SCOAR, including the geographical reach, to understand how SCOAR data represent research in stroke rehabilitation; and (3) based on the lack of CDEs we find across many variables, we argue for a consistent set of CDEs in rehabilitation trials (CDEs to describe participants, methodology, and outcomes). SCOAR lays the foundation for an information architecture that captures some of the complex and multivariate nature of neurorehabilitation. Most importantly, this information architecture is scalable, making it easy to add new data as new trials are published.


How Neurons Talk to Each Other

Will this help your doctor get you to 100% recovery?
http://neurosciencenews.com/neurons-synapses-neuroscience-5119/
Summary: A new paper offers an overview as to how neurons ‘communicate’ with one another.
Source: Max Planck Institute.
Neurons are connected to each other through synapses, sites where signals are transmitted in the form of chemical messengers. Reinhard Jahn, Director at the Max Planck Institute for Biophysical Chemistry in Göttingen, has investigated precisely how the process works.
Our nervous system consists of about 100 billion interlinked neurons that are capable of carrying out complex computations. Each neuron has an antenna zone comprising the cell body and its extensions (dendrites). It is here that it receives signals from other neurons.
One cell talks, the other listens
The signals are then computed and forwarded by a “cable”, the axon, in the form of electrical impulses. In the emitter region, the axon branches to form contact sites, known as synapses, where the signals are transmitted to other neurons. At the synapse, electrical impulses arriving from the axon are converted into chemical signals. The information then flows in only one direction: one cell talks, the other listens. The number of synapses that a single neuron can develop varies considerably. Depending on its type, a neuron can have anything from just one to more than 100,000 synapses. On average, each neuron has around 1,000 synapses.
Synapses – elementary units of neuronal information transmission
Synapses consist of:
  • the nerve ending of the transmitting (presynaptic) neuron,
  • the synaptic cleft separating the transmitting and receiving neurons and
  • the membrane of the receiving (postsynaptic) neuron.
The presynaptic nerve endings contain signal molecules known as neurotransmitters, which are stored in small membrane-enclosed vesicles. Each nerve ending in the central nervous system contains an average of several hundred synaptic vesicles. However, synapses vary significantly. For example, some specialist synapses contain more than 100,000 vesicles. They include the synapses that control our muscles. At each synapse some vesicles are always in the starting position, “lurking”, as it were, on the presynaptic plasma membrane to which they have docked.
Molecular machines at work
An electrical signal arriving at the nerve ending activates calcium channels in the plasma membrane. Calcium ions from outside then flow through the channels into the interior of the synapse. There, the inflowing calcium ions encounter and activate a molecular machine located between the vesicle membrane and the plasma membrane. This machine causes the membranes of the vesicles in the starting position to fuse with the plasma membrane and release the neurotransmitters contained in the vesicles into the synaptic cleft.
Illustration of a neuron (left) and a synapse (right). NeuroscienceNews.com image is credited to MPI for Biophysical Chemistry.

On the other side of the synaptic cleft, the neurotransmitters come into contact with docking sites on the membrane of the receiving neuron which regulate the electrical properties of that membrane. This alters the electrical resistance of the membrane. The receiving cell is able to process the resulting potential change rapidly. Only around one thousandth of a second elapses between the arrival of an impulse and the potential change on the other side of the synaptic cleft. In fact, synaptic transmission is one of the fastest biological processes known. Nevertheless, it is positively sluggish in comparison to a transistor.
Synaptic vesicles: not just storage organelles
A synaptic vesicle is not just a kind of membrane-bound “storage tank” for neurotransmitters. Its membrane contains a whole series of proteins that have barely changed over millions of years of evolution. A group of these proteins, the neurotransmitter transporters, are responsible for pumping neurotransmitters from the cytoplasm into the vesicles, where they accumulate. This process requires a great deal of energy, which is provided by another protein molecule, proton ATPase (V-ATPase), that pumps protons into the vesicles – a process that is fuelled by adenosine triphosphate (ATP). The pumps, in turn, use the resulting concentration gradient for the uptake of neurotransmitters.
In addition to these proteins required for “replenishing”, the membranes of synaptic vesicles contain other components that enable the vesicles to fuse with the plasma membrane (including the SNARE protein synaptobrevin and the calcium sensor synaptotagmin). Once membrane fusion has occurred, they are transported back into the nerve ending. The synaptic vesicles are then recycled back into the nerve ending via several intermediate steps and are refilled with neurotransmitters. This process is repeated again and again, thousands of times in the life cycle of a vesicle.
The process by which synaptic vesicles function at the molecular level is intricate. Several years ago, we created a comprehensive inventory of all vesicle components. Because vesicles are tiny and complex in composition, this undertaking was not easy. Several teams from Germany, Japan, Switzerland and the United States collaborated for years in order to identify the protein and fat components of vesicles and develop a quantitative molecular model of a standard vesicle.
First, problems had to be solved that were not as straightforward as one might suppose, for example counting the number of vesicles in a solution and determining the quantities of proteins and membrane lipids present. The results were surprising even for experts. It turned out that the structure of a biological transport vesicle is shaped to a far greater extent by proteins than was previously thought: If the vesicle model is looked at from the outside, the lipid membrane (yellow) can barely be seen for the sheer number of proteins. Yet the model only contains around 70 percent of the total quantity of protein present.

Temple scientists use hydrogen sulfide to restore stem cell-mediated blood flow in ischemic limbs of diabetic mice

Not that this directly helps stroke survivors but shit hydrogen sulfide research back to 2013 proved helpful for survivors. 7 posts on it here.  But shit once again nothing seems to have been done that might actually help stroke survivors. I blame our fucking failures of stroke associations, great at doing nothing for survivors.
http://www.mdlinx.com/internal-medicine/top-medical-news/article/2016/09/23/6

Temple Health
Hydrogen sulfide is a noxious gas, but in the human body it serves important functions as a gaseous signaling molecule. Among those functions is to protect the tone and cell function of blood vessels, which according to scientists at the Lewis Katz School of Medicine at Temple University (LKSOM) could prove critical in preventing limb amputation in patients with diabetes, a major complication of which is a painful reduction in limb blood flow known as critical limb ischemia (CLI). In a new study, the researchers are the first to show in diabetic animals that induced hydrogen sulfide production in bone marrow stem cells can effectively repair vessel tone and limb circulation. The study was published online September 22 in the journal Circulation. To determine whether hydrogen sulfide deficiency predisposed diabetic stem cells to abnormalities that undermine their function, Dr. Kishore and colleagues isolated bone marrow cells from nondiabetic and diabetic mice and examined the cells for differences in levels of hydrogen sulfide–synthesizing enzymes. They found that protein levels of an enzyme known as cystathionine gamma–lyase (CSE) were significantly decreased in diabetic bone marrow cells, accounting for the animals' hydrogen sulfide deficiency. The researchers then introduced the CSE gene into bone marrow cells isolated from diabetic mice to induce CSE overexpression and injected the cells back into the animals. The treatment resulted in dramatic improvements in blood vessel formation and blood flow. Remarkably, simple dietary supplementation with a hydrogen sulfide donor compound likewise restored hydrogen sulfide levels and improved limb circulation, enabling partial limb rescue. Blood flow was further increased when the special diet was combined with conventional stem cell therapy for CLI.

Friday, September 23, 2016

‘Spokes’-man for stroke survivors

I really hate outliers like this and myself. It gives a totally wrong picture of what normal recovery for a stroke survivor is like. This 'happy talk' will never get us closer to solving all the fucking problems in stroke, it actually makes it less likely because people take the easy way out and just say, 'Look at how much that person recovered, why can't you do that?' That is why you need to be screaming into your doctors face asking why s/he knows NOTHING ABOUT STROKE RECOVERY.  Whew, I feel better now.
http://www.mariettatimes.com/news/2016/09/spokes-man-for-stroke-survivors/
For Dan “Trikeman” Zimmerman, stroke survivor and cyclist, it’s not about the destination, it’s about the journey.
On Wednesday Zimmerman shared his passionate and inspirational message with more than 30 people at Selby General Hospital as a part of his third cross-country trip “Sea to Sea Tour,” totaling 3,814 miles. He uses a trike, a lightweight, three-wheeled vehicle that’s low to the gorund.
Zimmerman’s presentation also served as a kickoff to National Rehabilitation Week.
The 52-year-old Gilbert, Ariz. resident suffered a massive stroke in 2005 (caused by hereditary hemorrhagic telangiectasia), leading doctors to believe he would never walk or talk again.
Zimmerman said he was determined to prove the doctors wrong and take back the life he once had.
Through his recovery, Zimmerman found a love for adaptive cycling, and now he travels the country speaking to other stroke survivors advocating for this type of rehabilitation.
“I want to show that as an alternative recovery mode, trike riding works,” he said. “It got me talking and believing in myself again.”
Zimmerman said he was able to find a new sense of freedom  and comfort through cycling.
“I’ve found freedom, plain and simple,” Zimmerman said. “Plus, nobody knows while I’m riding that I had a stroke. Freedom has inspired me to do this.”
Lise Neer, Zimmerman’s communication manager, said he inspires people to never give up on what they want to do.
“We’ve already had so many people come up to us,” said Neer. “They told us how inspiring and encouraging he was and how positive it is. It’s so great and it’s exactly what we want to happen.”
Lloyd Booth, 69, of Whipple is a stroke survivor and a volunteer for the stroke support group at Selby General Hospital.
Booth heard about Zimmerman through a news article he read and wanted the cyclist to come speak during one of the support group’s gatherings.
“This is such a blessing to enjoy at this time when survivors are realizing their strengths and helping them live through those,” he said.
Booth said Zimmerman’s message is empowering.
“His message teaches us what the human spirit should strive to be,” he said.
Stroke survivor, Lori Jett, 53, of St. Marys said Zimmerman’s message lets her know that anything is possible.
“He’s gone through what we’ve all gone through, and that’s an amazing feeling to know that anything can happen,” she said.
Stroke survivors were also given the opportunity Wednesday to try out four trikes that were made available by Zimmerman.
Zimmerman said it’s always a joy to see the smiles on the faces of the stroke survivors when they try out a trike for the first time.
Neer met Zimmerman a few years ago as he was passing through Denver and decided then that she wanted to be a part of his journey.
“I’m a better person because of this,” she said. “He’s the type of person who knows what he wants and determination is his driving force. He has a strong personality and a lot of that energy is now focused into his mission.”
As a reflection of the cyclist’s personality, he named his trike “Equalizer.”
“I pride myself on being fast,”  Zimmerman said. “My type-A personality never allowed me to consider giving up. Once I decide on something I stick with it till the end.”
In Zimmerman’s presentation he also spoke about his life before the stroke and the struggles he faced during his recovery.
“I watched my diet and lifted weights five times a week, two hours a day, for 10 years,” he said. “After the stroke happened, it’s hard for me to tell you what hopelessness feels like when I was in the hospital, with my entire right side paralyzed and no talking. I lost my ability to spell; screaming and swearing in my head helped me, but I had no words to express myself.”
Before the stroke Zimmerman was constantly outdoors, and through cycling he was able to be out in the environment he so longed for during his recovery.
“I was shut-in for four years,” he said. “I desperately wanted to get outside, but was dependent on others for mobility. On the trike, it’s my decision whether to stop or go, turn left or right.”
Cycling was the gateway to the future of  Zimmerman’s health and through cycling he proved the doctors wrong.
“I was barely talking before I started riding,” he said. “Doctors told me my progress would plateau after one year, so I listened to them for the first four years. I enjoy proving them wrong. I want to open the eyes of therapy professionals to greater possibilities for recovery.”
Through his foundation, Spokes Fighting Strokes founded in 2013, Zimmerman has done a total of three cross-country tours in order to spread awareness about stroke and HHT.
“I picked the Adventure Cycling Association’s Norther Tier Route, which is a total of 3,814 miles to spread awareness about stroke and HHT, with the message of don’t give up. Hope, freedom and recovery is possible through triking. I am a living proof of that.”
HHT is a genetic disorder of the blood vessels, which affects approximately one in 5,000 people, some of those people being Zimmerman’s family members.
“My grandmother and mother both died from HHT,” he said. “My older brother died at the age of 19 from  a brain bleed caused by an AVM (arteriovenous malformation,) due to having HHT. My younger son now has it and I want people to know about it.”
According to Zimmerman, HHT is relatively unknown and gets little research attention or funding.
The “Sea to Sea Tour” team is asking for donations to continue Zimmerman’s awareness plan.
Neer said new equipment is needed, such as another folding trike, a tandem and an enclosed trailer for storage and transport, volunteers and most importantly funding.
“We will be fundraising throughout the winter in Arizona and next summer, while running the Adaptive Cycling program in Denver, as we prepare for our next big tour in 2018, along the east coast, north to south,” said Neer.
Donations to “Spokes Fighting Strokes” can be made through Zimmerman’s website spokesfightingstrokes.org or through mail.

Teenage stroke survivor calls on Government to adopt national strategy as 43 per cent of North-East victims feel "abandoned"

NO, YOU write the stroke strategy focusing on results. Because if you let the government write it it is going to suggest processes and guidelines. Totally fucking worthless if the government does it.
Results like:
1. 50% of survivors get to full recovery.
2. tPA fully reverses the stroke 50% of the time.
3. Spasticity is cured, not ameliorated.
4. Fatigue is cured, not told to exercise more.
5. Aphasia is cured in 6 months.
6. Dementia is prevented in 100% of stroke cases.
http://www.thenorthernecho.co.uk/news/14736101.Teenage_stroke_survivor_calls_on_the_Government_to_adopt_a_national_strategy_after_hearing_43_per_cent_of_North_East_stroke_victims_feel__quot_abandoned__quot_/
A 14-YEAR-OLD stroke survivor and her family have called for a new national stroke strategy to be adopted by the Government.
Emily Simpson, of Eaglescliffe, was just ten when she had a stroke while walking with a friend but, despite her huge efforts to counter the condition, has only been granted one hour of physiotherapy a fortnight.
Now Emily and her entire family are backing a campaign by the Stroke Association to help other victims which include 16,200 people in the North-East.
Emily's father, Terry, noticed Emily's face had drooped and she was limp down one side when she collapsed near her home.
While still in hospital in Newcastle a week later, Emily had a second stroke. One of the nation's leading stroke specialist doctors was immediately on hand and she had emergency surgery. She was diagnosed with Central Nervous System Vasculitis and was left with an acquired brain injury which has affected her communication and cognitive skills.
The teenager had been receiving weekly hydrotherapy sessions but now receives just one hour of physiotherapy each fortnight.
The Stroke Association’s latest campaign, A New Era for Stroke, urges the Government to commit to a new national stroke strategy. A current scheme, called the National Stroke Strategy for England ,was introduced to improve standards in treatment and support for people affected by the brain malfunction, but is due to end in 2017. The association want a new strategy to now be adopted.
A recent Stroke Association survey found that in the North-East, 43 per cent of stroke survivors felt abandoned when they left hospital. The charity is warning that stroke survivors’ recovery will continue to be put at serious risk unless the Government commits to a new strategy.
Emily’s mother, Carolyn Simpson, said: “When we saw Emily had the symptoms of stroke, we couldn’t believe it as we thought she was far too young. We had no idea a fit and healthy ten-year-old could be affected by the condition. We knew Emily needed the best possible treatment and care if she was going to recover.
“Emily initially had an hour of hydrotherapy each week, and now has just one hour of physiotherapy per fortnight, which isn’t enough. Fortunately she’s been able to go back to school but we still haven’t found a speech and language therapist who can support children with aphasia. That’s why we’re supporting the Stroke Association’s call for a new national stroke strategy in England.”
Alexis Wieroniey, Deputy Director of Policy and Influencing at the Stroke Association, said: “We urgently need as many petition signatures as possible to make sure these voices are heard by the Government, so it’s great to have the support of Emily and her family."
The petition can be found at stroke.org.uk/petition.