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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San Antonio hosted the American Stroke Association’s International Stroke Conference this week. I didn’t attend but my colleagues at Medpagetoday came through again, with extensive coverage, including video.

The conference reported hundreds of studies on stroke, but not one involved hyperbaric oxygen. Although academics are quick to demand more studies to prove the utility of hyperbaric oxygen for any role in the treatment of stroke, either acutely or for rehabilitation, no one is willing to fund the research. Main stream opinion about hyperbaric oxygen involves circular reasoning: hyperbaric oxygen for stroke treatment, though promising, is unproven, therefore, more research is needed before using it for stroke therapy. But, no funds are available for research because hyperbaric oxygen is unproven. As I’ve discussed previously, the decision to treat a patient should be based on a cost-benefit analysis of the available information and not on an arbitrary standard of proof. After all, there can never be enough data.

Although the favorite topic of Atlanta Hyperbaric never came up at the ASA meeting, researchers reported many important findings. Most of the studies would probably only interest professionals, but a few had more general appeal:

Anything more refreshing than a cup of coffee in the morning? If so, perhaps you should reconsider.

Maybe coffee helps prevent strokes: Based on a 12-year study of 9,978 men and 12,254 women from the U.K., the overall risk of stroke was 30% less in those who drank at least one cup of coffee a day. Making statistical adjustments for other stroke risk factors did not change the overall results.

Surgery versus stenting: The first report from the CREST study, which was a multi-center trial of carotid endarterectomy compared to angioplasty and stenting, came out about even for the two procedures. Much more analysis of the data will be forthcoming, but it looks like angioplasty with stenting is about as safe and effective as the older, better studied endarterectomy.

Stroke patients may be getting younger: In the greater Cincinnati area during 2005, the average age of patients presenting with a first stroke was 68.4, which had dropped from 71.3 in 1993 and the percentage of patients with stroke younger than 45 increased from 4.5% to 7.3%. The speculation may be that incidence of stroke risk factors such as diabetes, hypertension, and obesity is increasing among younger people.

Get married: In a 34-year follow up study of about 10,000 men, an Israeli researcher reported that single men had a 64% increased risk of stroke. But, men who reported unsuccessful marriages had strokes at just as high a rate as single men. Speculation ranged from the benefits of having someone remind you to take medicines or avoiding unhealthy food to having someone get you to the hospital in the event of symptoms.

Atlanta Hyperbaric treats stroke patients and we always look carefully at new stroke research for ways to help our patients.  From time to time reports come out that raise important practical questions and today I want to discuss two of them.

The strain of caring for a disabled spouse appears to increase the risk of stroke.  Psychosocial stress is a widely studied risk factor in stroke and coronary artery disease.  Researchers in Tampa took a look at data from the REGARDS (REasons for Geographic and Racial Differences in Stroke) study, a continuing epidemiological assessment of stroke and coronary heart disease incidence and mortality in a large national sample of adults over age 45. The researchers reported about 12% of Americans older than 45  have “family caregiving responsibilities.”

Of the more than 30,000 participants in the study, the researchers found 767 who lived with and cared for a disabled spouse and had no history of stroke or coronary heart disease. Based on interviews and home visits, the researchers divided the participants into those reporting high, some, or no strain associated with caregiving.  The researchers reported high care-giving strain associated with a 13.62% 10-year risk of stroke, which was 23% higher than the estimated stroke risk of 11.06% for caregivers reporting no strain. African-American men with high care-giving stress had an estimated 10-year stroke risk of 26.95%,  white men had a 10-year risk of about 15% and white and African-American women had risks between 10% and 12%.

The authors discuss with candor some of the limitations of their study, but the general conclusion-someone who found great strain in caring for a disabled spouse had an increased stroke risk-seems valid enough.  The association, in my view, should be pointed out to patients’ families so that they can find ways to help relieve the strain, if possible.

The second study comes out of Sweden and looks at stroke-patient compliance with their medications to prevent future strokes. To avoid errors in self-reporting, these researchers linked data from the national stroke registry with that of the national prescribed-drug registry. The analysis involved 21,077 stroke survivors, whose clinical records were compared with prescription data from July 1, 2005 to Oct. 31, 2008.  About 50% of stroke survivors stopped taking stroke-preventing meds within two years of hospital discharge.  A fourth of patients had stopped blood-pressure meds at two years, and almost half had discontinued their statins, e.g. Lipitor, Crestor etc.  More than half had quit prescribed anticoagulants, e.g.,Coumadin, and more than a third had stopped taking antiplatelet medication, e.g., aspirin, Plavix.

Physicians grapple with medication adherence all the time.  Compliance with hyperbaric oxygen therapy here at Atlanta Hyperbaric was a difficult problem during 2009, with almost every single patient who dropped out stating that he was missing too much work and feared losing his job in this recession-wracked economy.  In fact, Atlanta Hyperbaric is going to start offering expanded hours for our patients to do our share to help out.  The best thing we as physicians can do about medication compliance, in my opinion, is to take the time to explain to patients how important the medications are to their well being.  It seems simple enough, but I believe most physicians are unable or unwilling to spend this extra time.