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:

Tuesday, June 27, 2017

New method could take a snapshot of the whole brain in action

Cool, could be used to find neuroplasticity and neurogenesis in action. But we don't have anyone smart in the stroke medical world to follow this up with stroke recovery experiments.

New method could take a snapshot of the whole brain in action 

Monday, June 26, 2017

Neurology congress in Amsterdam: Outcomes measurements are becoming ever more important

I've been screaming about results for years.
25 June 2017 B&K Kommunikation
How effective is a treatment, does it lead to the expected improvement and how can all this be measured in an objective manner? Outcomes measurements are increasingly important in neurology. Participants at the Congress of the European Academy of Neurology in Amsterdam are discussing latest development in the field of outcomes research and how patients benefit from these activities.
Outcomes measurements are increasingly important in neurology from the perspective of practitioners as well as patients or the payers of health services. How can one objectively determine and plausibly prove whether a given therapy brings about the desired improvement, makes a useful clinical difference or delays the progression of a disease? Is the treatment in reasonable proportion to the patient benefits involved and to the financial cost? The 3rd Congress of the European Academy of Neurology (EAN) in Amsterdam is focused on this overarching focal theme, discussing it in several scientific sessions.

For EAN Programme Committee Chairman Prof Paul Boon (Ghent University, Belgium and Kempenhaeghe, The Netherlands), the possible advantages for patients have priority when it comes to outcomes in neurology: “Of course, the clinical explanation of the disease mechanism revealed through such indicators is very important but patients obviously focus on other aspects.” After being diagnosed with epilepsy or migraine, they are usually keen to know the following: Will the therapy work? Will my seizures or headache attacks stop? Do the medications have undesirable side effects? How many pills do I need to take and when in order to achieve an optimum effect? “Outcomes measurements enable us to answer questions like these. In the process, we can find out how the disease will affect the patient in the future and see how our treatment is working,” explained Prof Dr Bernard Uitdehaag (VUmc MS Center Amsterdam), chair of the local organizing committee of the congress and chair of one of the EAN sessions on this topic.

Progress in measurement methods

Progress is being made in neurology in the development of assessment methods that are easy to handle, and can contribute to objective and precise outcomes measures. This is, however, not yet the case for all diseases. For slowly progressing neuromuscular diseases, for instance, existing outcomes measurements are still cumbersome and burdensome with regard to the patients’ restriction of motion and quality of life. By contrast, there have long been outcomes measurements for common diseases such as epilepsy and migraine. For example, the number of seizures or headache attacks is recorded. Prof Boon: “Recently, the measurements have become more differentiated. For example, we record days free of complaints. For patients, this metric is more meaningful than the total number of seizures.” With epilepsy, outcomes measurements are also assessed with EEG, which is then analysed using special software. Prof Boon: “This approach lets us detect certain indicators much more effectively than with customary methods.”

For instance, in order to measure a possible decline of the condition of multiple sclerosis patients, a simple test has been established as a standard procedure: patients are asked to insert pegs in a board with nine holes and subsequently take them out one by one. If they need 20 per cent longer than last time, this difference proves that the disease has deteriorated clinically.

Measuring outcomes for dementia

Researchers from Amsterdam have developed a questionnaire for Alzheimer’s patients which helps to detect dementia at an early stage. Further outcomes measurements for Alzheimer’s can be done with an amyloid PET scan. In this procedure, a low-radiation substance is injected, enabling amyloid plaques in the brain to be seen.  This protein is a typical biomarker for Alzheimer’s. Examinations of cerebrospinal fluid can also allow conclusions to be drawn about the progression of neurodegeneration in dementia.

Combined methods yield more information

A combination of examination methods is increasingly relied upon in outcomes measurements. Prof Uitdehaag advised to use multidimensional outcomes measurements for heterogeneous diseases such as multiple sclerosis. “It is very revealing to harness the patient’s perspective together with e.g. imaging methods. An MRI scan can indicate a stable condition even though the patient is complaining about a change for the worse. Conversely, the patient can feel great while the MRI result indicates that problems are likely to occur in the near future.” 

Side effects count as part of the overall outcomes

In the treatment of neurological diseases, certain medications can provoke side effects such as difficulties in concentration or memory loss. Until a few years ago, these side effects were simply put up with, especially by older patients. Prof Boon emphasized that these attitudes are changing more and more, adding: “Side effects are recorded and taken seriously as part of outcomes measurements.” To an increasing extent, therapies are individually tailored to patients so outcomes, too, must be subject to a differentiated analysis. Prof Uitdehaag: “It no longer suffices to compare patient groups with each other in sweeping ways. Even if many people do respond to a certain treatment, it may not be effective for a given individual.” As therapies become more individualized, the challenge grows to record exactly what is being done, what benefits this action has and whether the treatment is beneficial for this specific patient. 

Cost-benefit analysis

As cost pressure on public health care budgets mounts, the field of neurology is also increasingly confronted with demands to give evidence of therapy outcomes so the costs of a given treatment can be weighed against its benefits. Prof Boon: “Payers in the European healthcare systems are showing an increasing interest in outcomes-related reimbursement concepts. In other words, they are willing to assume costs if the effectiveness of a treatment can be verified. In the process, new therapies are compared against conventional ones to find out which ones are worth the price being charged. The more varied the possible treatment options for a disease, the more relevant outcomes measurement becomes,” the expert concluded.

Sources: van Munster CE, Uitdehaag BM. Outcome Measures in Clinical Trials for Multiple Sclerosis. CNS Drugs. 2017 Mar;31(3):217-236; Feys P, Lamers I, Francis G: The Nine-Hole Peg Test as a manual dexterity performance measure for multiple sclerosis,; Sikkes SA,de Lange-de Klerk ES, Pijnenburg YA, Gillissen F, Romkes R, Knol DL, Uitdehaag BM, Scheltens P. A new informant-based questionnaire for instrumental activities of daily living in dementia. Alzheimers Dement. 2012 Nov;8(6):536-43; Sikkes SA , Knol DL, Pijnenburg YA, de Lange-de Klerk ES, Uitdehaag BM, Scheltens P:Validation of the Amsterdam IADL Questionnaire©, a new tool to measure instrumental activities of daily living in dementia. Neuroepidemiology.2013;41(1):35-41.

The effect of water-based exercises on balance in persons post-stroke: a randomized controlled trial

The therapy pool at my hospital had closed years before I needed it.

Pages 228-235 | Published online: 03 Nov 2016

Objective: Water-based exercises have been used in the rehabilitation of people with stroke, but little is known about the impact of this treatment on balance. This study examined the effect of water-based exercises compared to land-based exercises on the balance of people with sub-acute stroke.
Methods: In this single-blind randomized controlled study, 32 patients with first-time stroke discharged from inpatient rehabilitation at West Park Healthcare Centre were recruited. Participants were randomized into W (water-based + land; n = 17) or L (land only; n = 15) exercise groups. Both groups attended therapy two times per week for six weeks. Initial and progression protocols for the water-based exercises (a combination of balance, stretching, and strengthening and endurance training) and land therapy (balance, strength, transfer, gait, and stair training) were devised. Outcomes included the Berg Balance Score, Community Balance and Mobility Score, Timed Up and Go Test, and 2 Minute Walk Test.
Results: Baseline characteristics of groups W and L were similar in age, side of stroke, time since stroke, and wait time between inpatient discharge and outpatient therapy on all four outcomes. Pooled change scores from all outcomes showed that significantly greater number of patients in the W-group showed improvement post-training compared to the L-group (p < 0.05). More patients in W-group showed change scores exceeding the published minimal detectable change scores.
Discussion: A combination of water- and land-based exercises has potential for improving balance. The results of this study extend the work showing benefit of water-based exercise in chronic and less-impaired stroke groups to patients with sub-acute stroke.

Determining the potential benefits of yoga in chronic stroke care: a systematic review and meta-analysis

Is yoga or Tai Chi better for recovery?

Pages 279-287 | Received 03 Oct 2016, Accepted 24 Dec 2016, Published online: 19 Jan 2017

Background: Survivors of stroke have long-term physical and psychological consequences that impact their quality of life. Few interventions are available in the community to address these problems. Yoga, a type of mindfulness-based intervention, is shown to be effective in people with other chronic illnesses and may have the potential to address many of the problems reported by survivors of stroke.
Objectives: To date only narrative reviews have been published. We sought to perform, the first systematic review with meta-analyses of randomized controlled trials (RCTs) that investigated yoga for its potential benefit for chronic survivors of stroke.
Methods: Ovid Medline, CINHAL plus, AMED, PubMed, PsychINFO, PeDro, Cochrane database, Sport Discuss, and Google Scholar were searched for papers published between January 1950 and August 2016. Reference lists of included papers, review articles and OpenGrey for Grey literature were also searched. We used a modified Cochrane tool to evaluate risk of bias. The methodological quality of RCTs was assessed using the GRADE approach, results were collated, and random effects meta-analyses performed where appropriate.
Results: The search yielded five eligible papers from four RCTs with small sample sizes (n = 17–47). Quality of RCTs was rated as low to moderate. Yoga is beneficial in reducing state anxiety symptoms and depression in the intervention group compared to the control group (mean differences for state anxiety 6.05, 95% CI:−0.02 to 12.12; p = 0.05 and standardized mean differences for depression: 0.50, 95% CI:−0.01 to 1.02; p = 0.05). Consistent but nonsignificant improvements were demonstrated for balance, trait anxiety, and overall quality of life.
Conclusions: Yoga may be effective for ameliorating some of the long-term consequences of stroke. Large well-designed RCTs are needed to confirm these findings.

Vagus nerve stimulation shows stroke recovery promise

Just when the fuck will this become a standard protocol? I've written 21 posts on this back to July 2012. 
With ANY competency anywhere in the stroke medical world this would have been a protocol years ago. But we have NO stroke leadership and NO stroke strategy causing survivors to still be disabled. Your stroke medical 'professional' has not been inconvenienced one bit by doing nothing to help stroke survivors.

  • Mitchel L. Zoler
  • Clinical Neurology News 

    – Stroke patients with arm weakness had a clinically significant boost in arm function after about 19 weeks on a rehabilitation program that combined vagus nerve stimulation with rehabilitation training sessions in a multicenter, randomized, and sham-controlled proof-of-concept study with 17 patients.
    This promising result follows a prior 21-patient study with a similar design and results (Stroke. 2016 Jan;47[1]:143-50), making the next step a pivotal trial with about 120 randomized patients that should start in 2017, Jesse Dawson, MD, said at the International Stroke Conference sponsored by the American Heart Association.
    Dr. Jesse Dawson Mitchel L. Zoler/Frontline Medical News
    Dr. Jesse Dawson
    “We feel this is promising, but more work needs to be done,” said Dr. Dawson, a stroke researcher at the University of Glasgow (Scotland).

    Results in the new study showed that eight poststroke patients with arm weakness who received a prolonged course of vagus nerve stimulation (VNS) and rehabilitation training had an average boost from baseline in their upper-extremity Fugl-Meyer score of 9.5 points measured 132 days after the start of the regimen, compared with an average 3.8-point rise among nine similar patients who underwent the same rehabilitation training but without VNS. A rise of 4-7 points on the upper-extremity Fugl-Meyer score is considered clinically significant for chronic stroke patients (J Physiotherapy. 2017 Jan;63[1]:53). The difference in mean scores between the VNS and control groups after 132 days was statistically significant for a secondary endpoint of the study.

    The study’s primary endpoint, the difference between the control and VNS patients in mean upper-extremity Fugl-Meyer scores at the end of the initial phase of the study – a 6-week supervised training period – was 7.6 points in the VNS recipients and 5.3 points for the control patients, a difference that was not statistically significant.

    The 9.5-point boost in average scores with more prolonged treatment and follow-up in the VNS patients is “highly likely to be clinically significant,” Dr. Dawson said. “We would like to see an effect earlier, with clinically important effects after 6 weeks of treatment. That would make the intervention easier to translate into clinical practice.”

    The study ran at three U.S. centers and in Glasgow and enrolled patients who were 4 months to 5 years out from their index stroke and had moderate to severe arm weakness based on an upper-extremity Fugl-Meyer score of 20-50. The average age of the 17 patients in the study was 60 years. They were an average of 1.5 years removed from their index stroke.

    All of the patients received an implanted device to produce VNS. The eight patients in the active arm received VNS during their 2-hour, thrice-weekly rehabilitation training sessions for the first 6 weeks of the study, with about 400 individual stimulations delivered during each training session. The nine controls received brief VNS to aid blinding, but had no meaningful VNS while they replicated the rehabilitation training regimen of the intervention group. At the end of 6 weeks, no training or VNS was done for 30 days. Then for the next 60 days, all patients did a daily program of unsupervised home rehabilitation exercises and patients in the intervention arm also self-administered 30 minutes of VNS daily.

    The 17 patients who received a VNS device implant had three serious adverse events, Dr. Dawson reported: one infection, one episode of dyspnea, and one episode of vocal cord paralysis. None of the adverse events were judged definitely or likely linked to the stimulator, and all three effects were in control patients. In several patients in both arms, nonserious adverse effects occurred that are expected for the surgery used, including bruising, pain, swelling, and scarring. When the study ended, patients originally randomized to the sham group underwent active intervention with VNS and subsequently had an average 13-point increase on their upper extremity Fugl-Meyer score.

    MicroTransponder, the company developing the vagus nerve stimulation device, funded the study. Dr. Dawson has received travel and meeting cost reimbursements from MicroTransponder, and several coauthors are employees of the company.
  • Slower Runners Live Longer—Here’s Why

    My running is non-existent so I should be good in this.

    Here’s some food for thought: the slower you run, the longer you live.
    That’s a finding from a new study published in the Journal of the American College of Cardiology, which concluded that people who run on a regular basis—consistently, but slowly—have a longer lifespan than those who are out pushing it to the line every time. The people who executed the research used around 1,100 joggers and 4,000 non-joggers. Everyone, men and women, were various ages, and all were relatively healthy. For the study, those who identified as “non-joggers” by definition did not participate in any strenuous activity regularly.
    Fast forward more than 10 years later, and the researchers checked in on the death rates of the people involved. People who identified as joggers were split into three main groups: light joggers, moderate joggers and “strenuous joggers” based on the information regarding frequency, how many miles and pace they provided at the beginning of the study. The results? Duh—joggers had a longer lifespan or life expectancy than non-joggers.
    Related: Why Running Slow Doesn’t Matter
    But wait, what about the sub-groups? The light joggers had the lowest rate of death, followed by the moderate joggers. And newsflash (sorry speedsters)–the strenuous ones tied with the non-joggers with highest mortality. What’s even more shocking? Their life expectancy, statistically speaking, matched that of a sedentary person. What?!
    In short, the ideal sweet spot for jogging and gaining full benefit was 2 to 3 times per week. The optimal speed was slow, and the optimal weekly distance? 1 to 2.4 miles!
    Take what you want from this study, but we found it interesting and somewhat surprising! Although we are all pretty confident we will continue to train for marathons, but perhaps a more leisurely pace. Because, if you run slow, who cares?

    Sunday, June 25, 2017

    What the Latest Research Says About Alcohol and Your Brain

    More negative results on alcohol, while I look at all these positives. But listen to your negative Nellie doctor instead of me. Your choice.

    Alcohol for these 12 reasons.

    A little daily alcohol may cut stroke risk

    An occasional drink doesn't hurt coronary arteries

    Six healthy reasons to drink more beer   Red wine benefits are in this one also.

    10 Health Benefits of Whiskey

    More negative stuff here:

    What the Latest Research Says About Alcohol and Your Brain  

    Chapter 5; Pain in the Stroke Rehabilitation Patient

    Have at it.

    Pain in the Stroke Rehabilitation Patient

    Hospital based program launched to improve outcomes for stroke patients in China to impact world's largest population

    You want results not lazy guidelines and best practices and care.
    Big fucking whoopee.
    PR Newswire
    BEIJING, June 24, 2017
    BEIJING, June 24, 2017 /PRNewswire/ -- Delivering big, positive stroke outcomes for the world's largest population is the aim of the American Stroke Association (ASA) and Chinese Stroke Association (CSA) with the launch of a quality improvement program adapted from the American Heart Association's guidelines-based program called Get With The Guidelines®.

    The program works to improve treatment for, and prevention of, cardiovascular and stroke events by helping hospitals and providers consistently adhere to the latest scientific treatment guidelines. In the last 15 years, Get With The Guidelines has transformed patient care for heart and stroke patients in the U.S., helping hospitals and providers learn the correct treatment and translate guidelines into practice. This program has saved lives and resulted in more than 400 scientific publications that advance heart and brain health around the world.
    The adapted Get With The Guidelines program, designed through a collaboration of the ASA and the CSA, endorsed by the China National Health and Family Planning Commission, and supported by Medtronic, is a set of "best practices" that aim to continuously improve treatment, enhance the quality of care, and prevent future stroke events in China.
    While several evidence-based, highly effective, guideline-recommended therapies are known, adherence to guidelines for stroke care remains incomplete and highly variable from region to region, and country to country.
    This effort aims to solve for that in China. Specifically, this program addresses the need for:
    1.     Enhanced education for EMS and pre-hospital caregivers, especially since analysis shows only 13 percent of Chinese stroke patients arrive at the hospital by EMS, versus 50 percent in the U.S.
    2.     A reduction in "door-to-needle" times for patients to receive the clot-busting drug tPA. To-date, analysis for rates of compliance with evidenced based therapies notes significant gaps in timeliness to tPA treatment.
    3.     Increased awareness and application of mechanical endovascular reperfusion therapies in appropriate patients.
    4.     Increased awareness and application of secondary prevention in appropriate stroke patients to fill significant gaps in venous thromboembolism (VTE) prophylaxis, lipid lowering therapy, anticoagulation for atrial fibrillation and rehabilitation assessment in Chinese patients.
    With a population of 1.4 billion, stroke is the leading killer and claims the lives of 1.6 million Chinese people annually. Today, China faces cardiovascular and stroke risk factors similar to those in Western nations. Among risk factors, hypertension remains the most important for all types of strokes.[1] Additionally, the concept of a "stroke belt" in China has emerged which identifies specific geographic regions where the mortality associated with stroke is 50 percent higher than that of other regions in the country. Currently, the areas with higher mortality are the northeast and the western/southwestern.[2]
    In 2007, the Ministry of Health -- now National Health and Family Planning Commission -- sponsored the Chinese National Stroke Registry and a five-year plan to increase comprehensive stroke centers in China. Establishing the registry also led to creating the Stroke Screening, Prevention and Treatment Project in 2009, and more recently the National Center of Stroke Care Quality Control in 2011.

    "The American Stroke Association is deeply committed to having a transformative impact on healthcare systems and patients worldwide by working alongside countries, governments and international cardiovascular and cerebrovascular societies to facilitate the application of the tools and knowledge of our quality programs," said Ying Xian, M.D., Ph.D, American Stroke Association spokesperson and Assistant Professor of Neurology and Medicine at the Duke University Medical Center and Duke Clinical Research Institute. "The U.S. marketplace has given us a road map to develop scalable and sustainable models for international quality improvement initiatives. Now, with our consult, the Chinese Stroke Association aims to adopt those models to achieve better outcomes for stroke patients in China."
    "It is with great excitement that we announce the launch of this collaborative stroke quality improvement project between the CSA and ASA to further enhance cooperation on clinical research, education, and the impact of acute stroke science," said Jizong Zhao, President, CSA. "I congratulate both organizations' dedication to improving stroke outcomes in China."
    Reaching healthcare providers with the Get With The Guidelines program at Chinese secondary and tertiary hospitals -- and at all stages of the chain of survival, from pre-hospital advanced medical care (also known as EMS or emergency medical services) to neurologists to even hospital administrators -- is the priority.
    "Medtronic is a leading stroke care solution provider in stent retriever therapy with more than 20 years of experience in China. We provide clinical education and training systems for Chinese physicians and, together with medical societies, we consistently promote a hierarchical treatment system, raise public awareness, and speed up patient admission and treatment to ensure the proper care for patients," said Chris Lee, President, Medtronic Greater China. "We are very proud to collaborate with both the CSA and ASA, and we will continuously work together to improve China's stroke care quality."
    Stroke has also had a significant impact on healthcare expenditures and the Chinese economy. The cost for stroke care by the government-funded hospitals was 1.17 billion RMB (approx. $170M USD) in 2003 and 8.19 billion RMB (approx. $1.3B USD) in 2009, a 117 percent increase annually. Now, the annual cost of stroke care in China is approximately 40 billion RMB ($5.8B USD).[3]

    Markerless motion capture systems as training device in neurological rehabilitation: a systematic review of their use, application, target population and efficacy

    It is impossible to even attempt to figure out any stroke rehab if you don't even have an objective measurement of what is wrong and can objectively see improvements. This is long overdue. Your therapists and doctors have been flying completely blind about stroke rehab since forever.
    • Els KnippenbergEmail author,
    • Jonas Verbrugghe,
    • Ilse Lamers,
    • Steven Palmaers,
    • Annick Timmermans and
    • Annemie Spooren
    Journal of NeuroEngineering and Rehabilitation201714:61
    DOI: 10.1186/s12984-017-0270-x
    Received: 26 August 2016
    Accepted: 5 June 2017
    Published: 24 June 2017



    Client-centred task-oriented training is important in neurological rehabilitation but is time consuming and costly in clinical practice. The use of technology, especially motion capture systems (MCS) which are low cost and easy to apply in clinical practice, may be used to support this kind of training, but knowledge and evidence of their use for training is scarce. The present review aims to investigate 1) which motion capture systems are used as training devices in neurological rehabilitation, 2) how they are applied, 3) in which target population, 4) what the content of the training and 5) efficacy of training with MCS is.


    A computerised systematic literature review was conducted in four databases (PubMed, Cinahl, Cochrane Database and IEEE). The following MeSH terms and key words were used: Motion, Movement, Detection, Capture, Kinect, Rehabilitation, Nervous System Diseases, Multiple Sclerosis, Stroke, Spinal Cord, Parkinson Disease, Cerebral Palsy and Traumatic Brain Injury. The Van Tulder’s Quality assessment was used to score the methodological quality of the selected studies. The descriptive analysis is reported by MCS, target population, training parameters and training efficacy.


    Eighteen studies were selected (mean Van Tulder score = 8.06 ± 3.67). Based on methodological quality, six studies were selected for analysis of training efficacy. Most commonly used MCS was Microsoft Kinect, training was mostly conducted in upper limb stroke rehabilitation. Training programs varied in intensity, frequency and content. None of the studies reported an individualised training program based on client-centred approach.


    Motion capture systems are training devices with potential in neurological rehabilitation to increase the motivation during training and may assist improvement on one or more International Classification of Functioning, Disability and Health (ICF) levels. Although client-centred task-oriented training is important in neurological rehabilitation, the client-centred approach was not included. Future technological developments should take up the challenge to combine MCS with the principles of a client-centred task-oriented approach and prove efficacy using randomised controlled trials with long-term follow-up.

    Trial registration

    Prospero registration number 42016035582.

    The Diagnosis and Management of Mild Cognitive Impairment

    You will need this for your doctor to baseline your cognition.

    A Clinical Review

    JAMA. 2014;312(23):2551-2561. doi:10.1001/jama.2014.13806

    Importance  Cognitive decline is a common and feared aspect of aging. Mild cognitive impairment (MCI) is defined as the symptomatic predementia stage on the continuum of cognitive decline, characterized by objective impairment in cognition that is not severe enough to require help with usual activities of daily living.
    Objective  To present evidence on the diagnosis, treatment, and prognosis of MCI and to provide physicians with an evidence-based framework for caring for older patients with MCI and their caregivers.
    Evidence Acquisition  We searched PubMed for English-language articles in peer-reviewed journals and the Cochrane Library database from inception through July 2014. Relevant references from retrieved articles were also evaluated.
    Findings  The prevalence of MCI in adults aged 65 years and older is 10% to 20%; risk increases with age and men appear to be at higher risk than women. In older patients with MCI, clinicians should consider depression, polypharmacy, and uncontrolled cardiovascular risk factors, all of which may increase risk for cognitive impairment and other negative outcomes. Currently, no medications have proven effective for MCI; treatments and interventions should be aimed at reducing cardiovascular risk factors and prevention of stroke. Aerobic exercise, mental activity, and social engagement may help decrease risk of further cognitive decline. Although patients with MCI are at greater risk for developing dementia compared with the general population, there is currently substantial variation in risk estimates (from <5% to 20% annual conversion rates), depending on the population studied. Current research targets improving early detection and treatment of MCI, particularly in patients at high risk for progression to dementia.
    Conclusions and Relevance  Cognitive decline and MCI have important implications for patients and their families and will require that primary care clinicians be skilled in identifying and managing this common disorder as the number of older adults increases in coming decades. Current evidence supports aerobic exercise, mental activity, and cardiovascular risk factor control in patients with MCI.

    Multivariate Analyses of Peripheral Blood Leukocyte Transcripts Distinguish Alzheimer’s, Parkinson’s, Control and Those at Risk for Developing Alzheimer’s

    You'll want your doctor to follow this up with for your risk of getting dementia/Alzheimers


    • Peripheral blood leukocyte transcripts can be used as a prognostic marker of progression to the clinical stages of Alzheimer’s disease in unimpaired older adults.
    • Peripheral blood leukocyte transcripts distinguish Parkinson’s disease from Alzheimer’s disease.
    • Peripheral blood leukocyte transcripts distinguish cognitively resilient apoe4 homozygotes.
    • The same peripheral blood leukocyte transcripts used to distinguish probable Alzheimer’s disease in blood samples were also able to distinguish neuropathologically confirmed Alzheimer’s disease in brain samples.


    The need for a reliable, simple and inexpensive blood test for Alzheimer’s disease (AD) suitable for use in a primary care setting is widely recognized. This has led to a large number of publications describing blood tests for AD, which have, for the most part, not been replicable. We have chosen to examine transcripts expressed by the cellular, leukocyte compartment of blood. We have used hypothesis based cDNA arrays and quantitative PCR to quantify expression of selected sets of genes followed by multivariate analyses in multiple independent samples. Rather than one study with no replicates we chose an experimental design in which there were multiple replicates using different platforms and different sample populations. We have divided 177 blood and 27 brain samples into multiple replicates to demonstrate the ability to distinguish early clinical AD (CDR 0.5), Parkinson’s disease (PD), and cognitively unimpaired APOE4 homozygotes, as well as to determine persons at risk for future cognitive impairment with significant accuracy. We assess our methods in a training/test set and also show that the variables we use distinguish AD, PD and control brain. Importantly, we describe variability of the weights assigned to individual transcripts in multivariate analyses in repeated studies and suggest that the variability we describe may be the cause of inability to repeat many prior studies. Our data constitute a proof of principle that multivariate analysis of the transcriptome related to cell stress and inflammation of peripheral blood leukocytes has significant potential as a minimally invasive and inexpensive diagnostic tool for diagnosis and early detection of risk for AD.

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    Designing for diversity: Atablet-based ePRO system to assist stroke rehabilitation

     Hopefully you can track this down yourself. 

    Designing for diversity: Atablet-based ePRO system to assist stroke rehabilitation

    Factors predicting falls and mobility outcomes in patients with stroke returning home after rehabilitation who are at risk of falling

    It would be much better to come up with fall prevention protocols than this piece of laziness.



    To identify factors predicting falls and limited mobility in people with stroke at 12 months after returning home from rehabilitation.


    Observational cohort study with 12 month follow-up.




    People with stroke (n=144) and increased falls risk discharged home from rehabilitation.


    Not applicable.

    Main Outcome Measures

    Falls were measured using monthly calendars completed by participants, and mobility was assessed using gait speed over five metres (high mobility (>0.8m/s) versus low mobility (≤0.8m/s). Both measures were assessed at 12 months post-discharge. Demographics and functional measures including balance, strength, visual or spatial deficits, disability, physical activity level, executive function, functional independence and falls risk were analysed to determine factors significantly predicting falls and mobility levels after 12 months.


    Those assessed as being at high falls risk (Falls Risk for Older People in the Community (FROP-Com) score ≥19) were 4.5 times more likely to fall by 12 months (OR:4.506, 95% CI:1.71-11.86, p-value:0.002). Factors significantly associated with lower usual gait speed (<0.8m/s) at 12 months in the multivariable analysis were age (OR:1.07, 95% CI=1.01–1.14, p-value=0.033), physical activity (OR:1.09, 95% CI =1.03-1.17, p-value=0.007) and functional mobility (OR:0.83, 95% CI =0.75-0.93, p-value=0.001).


    Several factors predicted falls and limited mobility for patients with stroke 12 months after rehabilitation discharge. These results suggest that clinicians should include assessment of falls risk (FROP-Com), physical activity, and dual task Timed Up and Go during rehabilitation to identify those most at risk of falling and experiencing limited mobility outcomes at 12 months, and target these areas during in-patient and out-patient rehabilitation to optimise long term outcomes.

    Neuroplasticity and functional recovery after intensive language therapy in chronic post stroke aphasia: Which factors are relevant?

    Maybe you can get something out of this since no one seems to want to  make this useable to stroke survivors that need it.  On your own once again.
    • 1Department of Psychiatry, Campus Benjamin Franklin, Charite University Medical School, Germany
    The relevance of neuroscience-based treatment for post stroke aphasia

    Neuroscience-based interventions for aphasia are among the most promising approaches towards successful language rehabilitation. Associated therapeutic techniques are highly effective in reducing cognitive-behavioural difficulties resulting from brain damage and can induce neuroplasticity (Taub et al., 2002; Berthier & Pulvermüller, 2011). However, it is still not clear how language recovery and reorganisation of language is reflected by functional changes manifest in human brain activity. In aphasia research, previous studies addressed the role of the left (LH) and right (RH) hemisphere across the entire recovery phase. It has been suggested that brain reorganization in aphasia is a dynamic process, in which the involvement of perilesional LH regions and RH areas (e.g. Broca-homologue or RH superior temporal cortex, Musso et al., 1999) is dependent on the specific phase of language recovery (Saur et al., 2006). These data highlight the importance to control for time post stroke when investigating treatment-related changes to avoid the influence of spontaneous remission.
    To date, only few studies have addressed therapy-induced neuroplasticity in patients with post stroke aphasia (PSA), and findings are rather inconsistent. The reasons for the heterogeneity of previous results may be attributed to patient-specific variables such as lesion size and site, symptom severity, etc. (Crosson et al., 2005). While patient-specific variables seem to influence functional recovery, the specific impact of non-patient factors (e.g. neuroimaging method, language task, therapy method, - intensity, - amount and – duration) has rarely been addressed. However, to maximize therapy outcome, it is important to systematically investigate all possible factors and to identify neurophysiological predictors of recovery. Focussing on intensive, clinically effective, and short-term interventions and on suitable language tasks seems promising to achieve this goal.

    Understanding the neuronal mechanisms underlying language recovery by studying treatment-induced changes

    Measuring neuronal correlates of good (or poor) language recovery could help to identify patients who might benefit (or not) from a specific therapeutic method and can contribute to the development of effective neuroscience-based neurorehabilitation techniques. The study of therapy-induced neuroplasticity in PSA offers the possibility to systematically control for potentially confounding variables while at the same time measuring behavioural and neuronal changes following speech and language therapy (SLT) within a reasonable time frame. Previous findings do not allow to determine whether any behavioural or neurophysiological changes were caused by a specific therapeutic technique or by other factors. This differentiation is only possible by randomized controlled trials (RCTs) with chronic patients (> 1 year post stroke), for whom spontaneous remission effects can be excluded. Only RCTs with at least two active treatment groups and a no-treatment waiting-list group will ultimately allow to determine the specificity and amount of therapy-induced changes. Additionally, multiple pre-, and post-therapy scanning sessions will help to control for repeated scanning effects (Fridriksson et al., 2006). Although none of the clinical RCTs conducted in chronic aphasia comprised measurement of brain correlates before and after therapy, a promising heuristic is provided by efficient intensive interventions in chronic PSA patients. In fact, some intensive interventions have proved to lead to significant and consistent improvements of language performance (Brady et al., 2016; Breitenstein et al., 2017) and may therefore be good candidates to study neuroplasticity.

    Neuroplasticity after intensive aphasia treatment methods

    Within a short period of time (for example < 4 weeks), spontaneous, non-therapy-related neuronal changes are highly unlikely in chronic patients, therefore, one can interpret any changes in behaviour and brain activity across short-term intervals as treatment-induced. While intensive training can lead to such changes already within days or weeks (see Berthier & Pulvermüller, 2011), these effects are unlikely for non-intensive methods. In fact, several RCTs demonstrated higher efficacy of intensive SLT compared to non-intensive treatment (Brady et al., 2016). Although it is not entirely clear yet, which treatment intensity and duration is required to induce optimal recovery, meta-analyses suggest a minimum of 1-2 hours a day over a period of 2-4 weeks (Bhogal et al., 2003). This therapy frequency might be regarded as intensive treatment.
    The efficacy of intensive therapies can be explained by neuroscientific principles of learning and memory: high intensity and massed practice facilitates and enhances learning and cortical plasticity by correlated neuronal activity and by strengthening of synaptic contacts between neurons (Berthier and Pulvermüller, 2011). From this perspective, any intensive cognitive-behavioural intervention can maximize the effects of training-induced brain plasticity, which is ultimately a consequence of effective learning. Similarly, multiple repetitions of stimuli or tasks applied during language training, as well as the imitation of language skills modelled by language therapists will enhance learning and re-structuring of residual language networks. However, it should be noted that intensity, repetition, or inter-individual patient characteristics are not the only factors impacting on learning and language recovery. For example, a recent cross-over RCT demonstrated a significant influence of the therapy method used: Communicative-pragmatic and behaviourally relevant language training in social interactions resulted in significantly better recovery than equally intensive conventional exercises such as naming and describing pictures (Stahl et al., 2016). The importance of behavioural relevance and effective neurorehabilitation techniques for functional outcome has also been suggested in the context of motor deficits caused by stroke (e.g. Taub et al., 2002). Behaviourally relevant therapeutic methods delivered at high intensity could provide an avenue towards effective treatment in chronic PSA and may help to increase motivation, engagement and compliance of patients.

    Neuroplastic changes in the left and right hemisphere following intensive short-term aphasia therapy

    A recent review (Crinion & Leff, 2015) of neuroplastic changes following therapy in PSA patients, reported consistent treatment-related brain activation changes in LH perilesional fronto-temporal regions and/or in the inferior frontal gyrus in the RH. Unfortunately, due to the heterogeneity of patient and non-patient variables in these intervention studies, it is difficult to draw any concise conclusions about the neuronal mechanisms underlying language recovery. Several factors might explain this variability of previous findings and could be relevant for interpreting treatment-related data and for identifying predictors of recovery. These factors include the phase of PSA (see Saur et al., 2006), symptom severity (Lazar et al., 2010), or education and cognitive reserve (Hillis & Tippett, 2014). Also, the degree of premorbid functional lateralization of language could influence functional recovery (Knecht et al., 2002), as well the type of aphasia. Interestingly, language recovery does not seem to be driven by lesion size (Mattioli et al., 2014), but more likely by lesion location and load: For example, the structural integrity of subcortical white matter tracts (i.e. the arcuate fasciculus, Marchina et al., 2011) and specific left hemispheric cortical regions have been identified to influence recovery (Fridriksson, 2010; Bonilha et al., 2016). Moreover, non-patient related factors (e.g. therapy method, intensity, and language task used during neuroimaging) may strongly influence recovery. By focusing on intensive and effective interventions with chronic patients, the number of potential confounds of previous research might be diminished. To date, very few studies on neuroplastic changes following intensive, successful SLT have been published. These studies will be focused on now: Intensive aphasia therapy (a minimum of 1-2h/d, for at least two weeks, Bhogal et al., 2003) combined with functional or structural neuroimaging in chronic PSA patients has been reported for three different methods. The first method, Constraint-Induced Aphasia Therapy (CIAT, Pulvermüller et al., 2001), also called Intensive Language Action Therapy (ILAT, Difrancesco et al., 2012) is one of the most researched SLTs and its clinical effectiveness has been demonstrated in several RCTs (Pulvermüller et al., 2001; Meinzer et al., 2005; Berthier et al., 2009; Stahl et al., 2016). The other two intensive therapy regimes, anomia treatment (Bonilha et al., 2016) and melodic intonation therapy (MIT, Schlaug et al., 2009) have shown to be effective, as evidenced by group studies or case series.
    CIAT/ILAT-induced changes in brain activation following two weeks of intensive training (3h/d) were observed using various neuroimaging methods and language tasks. A significant body of data was obtained with EEG and MEG and language tasks applied comprised lexical decisions (Pulvermüller et al., 2005), passive reading of words (Barbancho et al., 2015) and an auditory passive listening mismatch negativity (MMN, Näätänen et al., 1997) design (Mohr et al., 2016; Lucchese et al., 2016). The source estimates performed on EEG lexical decision data suggested activation changes in right-frontal and left-temporoparietal areas correlating with clinical language improvements (Pulvermüller et al., 2005). In an fMRI study, pre-post-therapy changes in neurometabolic brain activation brought about by ILAT were reported in RH frontotemporal areas when patients were auditorily processing complex and semantically ambiguous sentences (Mohr et al., 2014). A previous fMRI study (Meinzer et al., 2008) found ILAT-induced metabolic changes in LH perilesional areas during an overt naming task. Similarly, in an MEG study, ILAT led to enhancement of LH perilesional neuromagnetic activity evoked by words presented in a passive auditory MMN paradigm and which correlated with clinical improvements (Mohr et al., 2016).
    Although these intensive short-term studies were not RCTs, the results of several of them can be interpreted, because significant correlations between clinical language improvement and brain activation changes were found. As this therapy method uses communicative-pragmatic language training, involvement of residual language regions and neuroplasticity in both hemispheres can be assumed. Still, the diversity of results across studies of ILAT shows that the language task and stimulus type might be important factors that could influence the topography of neuroplastic changes.
    While bi-hemispheric neural recruitment and improvements of naming had previously been reported in short-term, intensive anomia treatment for trained items only (Fridriksson et al., 2006), recent studies found improved naming, and thus generalization effects, also for untrained items (Fridriksson et al., 2012). However, as this treatment method specifically focuses on naming, changes in other language domains were not reported. Neuroplastic changes following anomia treatment showed an increase of brain activation during picture naming which was observed in fronto-temporal LH perilesional areas with fMRI (Fridriksson et al., 2012). These activity changes across the two weeks of intensive training (also 3h/d) correlated with improvements in naming performance, which were associated with intact functional connections between preserved cortical areas of the language network that were responsive to therapy (Bonhila et al, 2016). Anomia therapy involves training of overt naming of concrete objects depicted on cards by using either semantic or phonological cueing and thus, focuses on one specific aspect of aphasia, namely anomia and linguistic naming excercises, but does not emphasise behavioural relevance or communicative use of language. Consequently, training-induced neuroplasticity may specifically tap into left-hemispheric residual language networks associated with the abilitiy to name objects.
    Using structural DTI before and after intensive melodic intonation therapy (MIT), an increase in fibre density and volume of the arcuate fasciculus in the RH was reported (Schlaug et al., 2009). However, as no correlation was found between language improvement and structural brain changes after therapy, it is difficult to interpret these structural data. Interestingly, in another study by this group, improvements in speech production after MIT correlated with structural changes in right hemisphere inferior frontal gyrus in patients with Broca’s aphasia (Wan et al., 2014). Language improvement in spontaneous speech and re-structuring of the language system in the RH after MIT could be driven by aspects of this therapy method which possibly involve right-hemisphere dominant cognitive and motor functions such as melodic intonation, rhythm, and left hand tapping (Schlaug et al., 2009). It should be noted though, that while treatment intensity and duration in ILAT/CIAT and anomia treatment studies were completely identical (3 h/d for 2 weeks), MIT was applied less intensively (1.5 h/d), but with longer duration (~ 16 weeks), resulting in approximately three times higher amounts of overall treatment for MIT than for the other two therapies.
    Overall, evidence suggests that intensive aphasia treatment in chronic PSA leads to reorganisation of the functional and structural language network in both hemispheres. The involvement of each hemisphere in neuroplasticity is probably independent from the neuroimaging method used, but may be strongly influenced by the therapy method, its intensity, duration and the language materials and tasks.

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