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Stroke Smart Magazine

November/December 2008

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2008 The Year in review
Research and News that will Change the Face of Stroke

By Stephen J. Page, Ph.D., Christy Bailey, Jane Staller, Colette LaFosse, MSG, Chris MacDonell

Every year, exciting new discoveries are made about how brain function can be recovered and neural pathways rewired after a stroke. Scientists now know that people can continue to benefit from new therapies, even years after their strokes. Some research leads to new treatments. Other research doesn’t pan out. And year after year, people just like you use their voices to help stroke survivors receive the care that they need.

StrokeSmart™ asked a panel of experts to identify the top advancements in the stroke arena for 2008. These developments may change the way stroke is viewed, prevented, treated, covered by insurance, and more.


Aggressive Diabetes Treatment Does Not Reduce Stroke Risk

Background: Standard treatment of diabetes, which includes reducing blood sugar levels, has been shown to lower stroke and heart attack risk. Following the “more is better” logic, researchers wondered if a more intensive treatment of blood sugar could even further reduce stroke and heart attack risk. Scientists compared two strategies for reducing blood sugar levels: an aggressive reduction of blood sugar levels to a near normal-level, similar to that of people who do not have diabetes, versus a standard reduction of blood sugar levels.

The Results: The more aggressive treatment did not decrease risk for stroke or heart attack and actually increased the risk of death.

Why This Matters: Having diabetes increases stroke risk. But standard treatment turns out to be safer and is just as effective as intensive treatment for lowering that risk.


Home-Based Motor Imagery Improves Walking

Background: Making improvements in walking abilities after a stroke requires a lot of practice. But for many patients, walking practice at home is not safe. Machines for walking can help, but are often expensive and require special training or help from others. In looking for a safer rehabilitation technique, scientists wondered if motor imagery, sometimes called mental practice, could help. Research has shown that, when people mentally rehearse a particular movement, they activate the same muscles and the same parts of the brain that are stimulated when they physically perform the movement. The technique has been used successfully by elite athletes for years. In addition, mentally rehearsing certain arm movements had increased the effectiveness of arm therapy after stroke in a recent study. The question remained: Could the technique be used to improve walking? Researchers studied home-based mental rehearsal of various aspects of walking over a six-week period on 17 stroke survivors.

The Results: Walking improved when motor imagery was used. Study results, published in 2008, showed that walking speed, cadence, length of stride when walking, and several other areas increased.

Why This Matters: Motor imagery is a safe, noninvasive, inexpensive rehabilitation strategy that requires no equipment and minimal set-up. And it works.

Modified Constraint Induced Therapy Increases Arm use and Function

Background: In recent years, constraint-induced movement therapy (CIT) has been shown to increase the use and function of the affected, weaker arm, even years after stroke. CIT involves the forced use of the weak arm by restricting a patient’s stronger arm. The downside of CIT has always been the time commitment: most patients receive six hours per day of therapy, five times a week, for two weeks. Because of this intensive practice schedule, CIT participation has been shown to cause fatigue, frustration, and noncompliance in many patients. In addition, CIT is expensive and not reimbursed by many insurance companies. Modified constraint-induced therapy (mCIT), which requires half an hour per day of clinical contact time, three days per week for 10 weeks, plus home practice, has provided comparable results in studies. But how would these short periods of weak arm use compare to other therapies? Scientists compared mCIT to conventional affected arm therapy or no therapy in people more than a year after stroke.

The Results: People who received mCIT showed much larger improvements in affected arm use and function than those who received conventional therapy or no therapy at all. People who received mCIT were able to write, strike computer keys, and perform other activities that they had not performed in years.\

Why This Matters: Modified constraint-induced movement therapy sessions with a therapist can improve the use of the affected arm and often are covered by health insurance.

Get the Same Arm Improvement With or Without Cortical Stimulation

Background: Once scientists identified that new neural pathways could be formed in the brain after stroke, they began to look for ways to jumpstart the process. One idea was to electrically stimulate the outermost layer of the brain. Called cortical stimulation, the technique involves the placement of a small electrode on the part of the brain that controls the affected area. Over six to eight weeks, the patient’s brain is stimulated while he or she is given arm therapy. Scientists believed that activating the parts of the brain that control hand and arm movement during therapy would help the brain initiate and perform hand and arm exercises during therapy. In small studies, the addition of cortical stimulation to traditional arm therapy improved arm movement more than therapy alone. But could the same results be replicated in a larger study?

The Results: No difference. In a national study of more than 200 stroke survivors, people who received cortical stimulation plus therapy showed the same arm movement increases as those who received therapy only. Both showed improvements in their ability to move their arms and in the speed with which they performed various activities.

Why This Matters: Task specific, repetitive affected arm therapy, even when administered years after stroke, can still be of some benefit to stroke survivors.

The Effects of Robotic Arm Training and Traditional Arm Therapy Are Comparable

Background: Some studies have reported benefits associated with using robotics as part of stroke movement retraining. But robots are expensive and not widely available. So, is it worth the trouble and expense? Scientists examined whether stroke survivors using robotics would show increased arm movement compared with those receiving the same amount of therapy manually from a therapist.

The Results: No difference. People who received the robotic therapy showed the same arm movement increases as people who received therapy from a therapist. Both showed improvements in their ability to move their arms, equal reductions in spasticity, and equal changes in range of motion. Even changes in pain, depression, and joint stability were equal between the two groups.

Why This Matters: If the use of robotic therapy is not covered by your insurance or available in your area, treatment with a therapist will provide the same results.

Stroke Treatment

Window Opened Wider for tPA use

Background: In 1996, t-PA was approved by the U.S. Food and Drug Administration (FDA) to treat acute ischemic stroke in the first three hours after the start of symptoms. Since then, stroke patients have been given a three-hour window to get to the hospital fast or they wouldn’t be candidates for the clot-buster drug. But could the life-saving, damage-reversing drug be used after three hours? The European Cooperative Acute Stroke Study (ECASS 3) tested the safety and effectiveness of t-PA when given between three and four-and-a-half hours after the start of symptoms.

Results: The study results, published in the September 25, 2008, issue of the New England Journal of Medicine, showed that the use of t-PA was beneficial even when given more than three hours after the onset of symptoms. On the down side, the use of t-PA in this timeframe was linked to bleeding in the brain in some patients. However, the rate was no higher than reported previously in patients treated within three hours and was not associated with higher death rates.

Why This Matters: Once the a wider window is approved by the FDA, doctors may be able to successfully use the clot-buster t-PA on more acute ischemic stroke patients. That said, having more time does not mean that you should take more time.

Penumbra System: A New Tool to Remove Clots in Stroke Patients

Background: On January 7, Penumbra Inc. announced that it had received FDA clearance to start marketing its Penumbra System to remove clots that cause some acute ischemic strokes. The system, which helps restore brain blood flow by clearing blocked vessels, can be used up to eight hours after the start of stroke symptoms. With the help of x-ray technology to see inside the body, the system involves a small tube being moved through blood vessels from the groin to the clot in the brain. The system dislodges the clot and a suction device grabs and removes it. By year’s end, company representatives predict that the Penumbra system will be used to treat stroke patients in about 200 medical centers in the United States

Why This Matters: In the past, ischemic stroke patients who arrived at the hospital beyond the three hour window required for the clot-buster drug t-PA had limited treatment options. With an eight-hour window, the Penumbra System allows more stroke patients to be treated and more brain cells to be saved.

Concentric Medical Adds Another Clot Removal Product to the Stroke Toolkit

Background: On July 28, Concentric Medical, Inc. announced the U.S. launch of the V series of its Merci Retriever® device. Much like a corkscrew grabbing a cork, the Merci Retriever® grabs a blood clot in the brain and removes it. The V series retrievers are designed to be even more efficient than the original version, with one end more tightly coiled and one end more loosely coiled, and availability of different shapes and sizes. Like the Penumbra system, the Merci Retriever® can be used to remove clots in stroke patients up to eight hours after symptom onset. The Merci Retriever® was the first device to be cleared by the FDA to remove clots in ischemic stroke patients. To date, Concentric estimates that more than 9,000 patients have been treated with its devices.

Why This Matters: Again, with more options available to treat stroke patients, more brain cells and more lives can be saved.

TIA Starts to Get the Attention it Deserves

Background: Doctors and patients are starting to take transient ischemic attacks (TIAs), or mini-strokes, more seriously. Studies show that many people who have a TIA go on to have a more serious stroke within days. And yet, historically there has been little emphasis on urgent care until now. This year, medical professionals around the country were introduced to a new tool, called the ABCD2 score, to help identify TIA patients at high risk for a more serious stroke. The ABCD2 score was identified as one of the most important health developments of the year in Emergency Physicians Monthly, a publication for emergency doctors.

Why This Matters: The ABCD2 tool helps doctors begin appropriate treatment quickly to prevent a more serious stroke in high risk patients.

Legislative issues

Safety of Seniors Act Signed into Law

Background: On April 23, 2008, President George W. Bush signed the Safety of Seniors Act into law (Public Law 110-202). The Safety of Seniors Act, also known as the Keeping Seniors Safe from Falls Act, marks a significant legislative victory. The new law allows the secretary of Health and Human Services to conduct research and evaluate programs that would reduce the incidence and public health burden of falls. Of particular interest to the therapy professions are training opportunities for practitioners to teach other health care professionals about fall prevention strategies and to raise awareness about falls, which kill more than 16,000 Americans a year and result in $19.2 billion dollars in health care costs.

Why This Matters: About 40 percent of stroke survivors suffer a major fall in the first year after stroke. With more medical professionals focused on fall prevention, fewer people will suffer falls.

HR 6331 Provides Medicare Improvements

Background: Under current Medicare rules, limits or “caps” are placed on the amount paid out for outpatient rehabilitation services for an individual in a calendar year. The 2008 limit is $1,810 for physical and speech therapy, with an additional $1,810 for occupational therapy. On July 15, 2008, the United States House of Representatives and Senate voted to override a Presidential veto of HR 6331, which allows additional coverage beyond the current limits. HR 6331 helps approximately 4.4 million Medicare beneficiaries who have suffered a stroke receive additional coverage for physical, occupational, and speech-language therapies.

Why This Matters: With expanded limits, stroke survivors can receive more of the therapy they desperately need.


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