Robots are transforming medicine.  You can find them now in the operating room, the cardiac cath lab and the radiation oncology department.  So, when I came across a robot study used for stroke rehabilitation from the recent American Stroke Association meeting, I was intrigued.  Stroke rehabilitation is, after all, what we do at Atlanta Hyperbaric.

The study patients consisted of 127 stroke survivors at the Veterans Hospital in Providence, Rhode Island who were about two years out from their strokes.  The study patients were divided into three groups: robot-assisted rehabilitation, human-assisted rehabilitation and a control group who received ordinary care but without rehabilitation.  Keep in mind, this study looked at patients who had their strokes a long time before, so rehabilitation is not normally given this late.  The treatment groups had three one-hour sessions with either a human or a robot weekly for 12 weeks.  At 36 weeks of follow up, the treatment groups had “fairly modest” but statistically significant improvement compared to the controls and no difference in results were seen between the robot-assisted and human-assisted groups.

The authors made a disappointing observation to explain their disappointing results: “there’s very little available for people with chronic stroke.”  I guess they never heard of hyperbaric oxygen.

Every patient at Atlanta Hyperbaric gets his blood pressure taken. Measuring a patient’s blood pressure has become a ritual part of the medical examination since the early twentieth century and it didn’t take long to discover an association between high blood pressure and cardiovascular disease. I find it remarkable that after a hundred years of study, researchers are still discovering fundamental truths about this simple and routine medical test.

English researchers just reported that visit-to-visit variability of a patient’s blood pressure over time may be a stronger risk factor for stroke than average blood pressure. The authors looked at blood pressure measurements from four separate studies of patients who had been carefully checked for many years following a stroke or TIA. Overall, more than 10,000 patients had been followed. The researchers found that a high average systolic pressure was a weaker predictor of subsequent stroke than a large variability in systolic pressure over repeated measurements. The risk of stroke of those with the most variable blood pressure compared to those with the least variable blood pressure ranged from 1.78 to 4.84 across the four study groups.

In a companion study, different classes of anti-hypertensive drugs had different abilities to smooth out this variability in blood pressure. The researchers reviewed hundreds of drug trials for treatment of hypertension and discovered that calcium channel antagonists reduced blood pressure variability but ACE inhibitors and Beta blockers actually increased variability. Perhaps even more importantly, it looked like patients treated with the calcium channel antagonists had fewer strokes.

The authors concluded that, “To prevent stroke most effectively, blood-pressure-lowering drugs should reduce [average] blood pressure without increasing variability; ideally they should reduce both.”

Do these studies mean that physicians should be changing the way they treat and monitor their patients with hypertension? At least physicians need to start looking at this issue. It may not be enough just to reduce average blood pressure anymore.

Recovery from stroke is a major effort of Atlanta Hyperbaric.  Hyperbaric oxygen resupplies blood flow to the stroke penumbra, which leads to direct recovery of functional brain tissue, among other things.  Rehabilitation from stroke generally depends upon brain plasticity, or the ability of the brain to remodel brain cell connections in order to compensate for tissue death.  This brain remodeling activity occurs  through repetitive experience.  Exploring video games as a way to engage a stroke patient in an entertaining but repetitive fashion seems like a potentially helpful approach.

Researchers at the University of Toronto presented a study last month at the ASA stroke conference of use of the Nintendo Wii for stroke rehabilitation.   Twenty-two patients with recent mild-to-moderate stroke enrolled in the study.  The age of the patients averaged 61. All had some weakness in at least one of their arms, but were able to touch their chin and knee.  After playing for two weeks, the participants were able to shave off time from certain daily activities compared to controls who did not play the Wii.

In addition to conventional rehabilitation, half performed recreational therapy — playing cards and Jenga — and half played two Wii games, tennis and Cooking Mama.  Cooking Mama uses movements that simulate cutting a potato, peeling an onion, slicing meat, and shredding cheese — for eight one-hour sessions over two weeks.  A similarly high number of patients in each group completed all eight sessions — 90% with Wii and 80% with recreational therapy.

Only the patients in the Wii group significantly improved their fine motor function, measured using the Wolf Motor Function Test, which times patients while they perform daily activities, like grabbing a can of soda or folding a towel.  After adjustment for age, baseline functional status, and stroke severity, participants in the Wii group did significantly better on the test than the controls by 7.4 seconds.  Improvements of 2 seconds are believed to be clinically relevant.
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