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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.

Losing weight is really easy–just look at all those authors who’ve gone broke writing  diet books.  Wait a minute; I got that twisted around.  Losing weight is tough and quite a few folks have become celebrities through their diet books.  This time of the year is no joke for those of us inclined to gain weight, so no more vain attempts at humor.  The pharmaceutical industry gave the magic diet pill a whirl, but Redux and Fen-phen imploded with reports of serious cardiovascular problems and had to be withdrawn from the market in 1997.  Then along came Meridia to fill the void.

We treat a lot of patients with stroke at Atlanta Hyperbaric, but we are the first to admit that hyperbaric oxygen therapy for stroke is a little bit like closing the barn door after the horse runs away.  It is always better to prevent strokes than treat strokes and obesity is an undisputed risk factor for stroke.  It would be great if a  diet pill with minimal risk really did exist.

Meridia is about the only drug left on the market for treatment of obesity, so it was a little disheartening to read that the drug may be associated with a small, but increased risk of cardiovascular complications, including stroke. The FDA reported the findings last month but has not ordered any labeling changes.  The results are considered preliminary.   The agency said that although its analysis of the data is ongoing, the findings “highlight the importance of avoiding the use of sibutramine [Meridia] in patients with a history of coronary artery disease (heart disease), congestive heart failure (CHF), arrhythmias, or stroke, as recommended in the current sibutramine labeling.”

Sorry to throw cold water on the holiday cheer.  It looks like its back to the jiu jitsu academy after New Years.

Atlanta Hyperbaric sits right in the middle of the stroke belt.  I’ve mentioned before that stroke is the third

The Stroke Belt

leading cause of death in the United States.  About half a million people have strokes every year and about 150,000 die from stroke.  Stroke is more common in men and in African Americans.  The best known risk factors for stroke are high blood pressure, cigarette smoking and obesity.

Its been known since the 1950’s that we in the Deep South have a higher than average rate of strokes and death from strokes. A recent study found that if you were born in and continued to live in Alabama, Arkansas, Georgia, Mississippi, North Carolina, South Carolina or Tennessee as an adult, you have about a third greater chance of having a stroke than the rest of the country.

Exactly why we are at such a high risk for stroke remains a mystery, but we do know a few things.  At least the rates of stroke seem to be declining a bit.  In 1980, African Americans born and living in the stroke belt had a 55% higher incidence of stroke, but by 2000, the incidence had dropped to 34%.  The corresponding numbers for whites were 45% in 1980 and 34% in 2000.  Even being born outside and living here as an adult carries a higher risk, but the highest risk is lifelong residence.  As far as anyone knows, the increase risk of stroke in the stroke belt has nothing to do with social resources, access to medical care, race, sex or age.  Whatever causes the increase risk, however, apparently affects us at a very young age and the longer we live here, the worse risk we have.  Risk be damned, I like it here. The South’s motto: American by birth, Southern by the grace of God.

At least we have a few things we can do to treat strokes.  If the stroke victim can get to the hospital quickly, he can get the clot busting drug, TPA.  The venerable drug minocycline shows great promise for stroke treatment even as long as 24 hours after the stroke.

Of course, hyperbaric oxygen is the most underutilized of stroke treatments.  Hyperbaric oxygen therapy helps to restore the blood supply to the stroke penumbra. Importantly, the new blood supply to the stroke penumbra is permanent and the recovered brain tissue can learn to take on the function of the adjacent damaged brain  by a phenomenon known as brain plasticity. And, although we believe that the earlier that hyperbaric oxygen therapy is started after the stroke the better, good results can still be seen years later.

All I can hope for is that over time, more and more people will learn of the utility of hyperbaric oxygen for treating stroke

I’ve been treating stroke, cerebral palsy and  other patients with neurological problems at Atlanta Hyperbaric & Wound Care Clinic, LLC since the mid-1990’s.  I’ve seen so many good results with hyperbaric oxygen treatment of neurologic injury patients it always anguishes me that so few who would benefit ever get treated.  Of course, as I’ve discussed before, science has little to do with the under-utilization of hyperbaric oxygen for neurologic injury or any other indication, for that matter.

I came across an interesting article this week that firms up the long-suspected association between migraine headache and stroke.  Both disorders are common, so researchers must employ strong statistical methods to be certain that any association isn’t just chance coincidence of two common things.  Harvard researchers did a meta-analysis of nine separate statistical studies that looked at the association of stroke with migraine. The overall result was that migraine about doubles the risk of stroke.  At particular risk for stroke were patients who had aura with migraine.  In other words, the 15% or so who have a distinct warning that the migraine headache was about to start were at the highest risk for stroke.   Others with migraine who had increased risk of stroke were women, those under age 45, smokers, and women on oral contraceptives. An accompanying editorialist concluded that women with aura and migraine should give great thought before using oral contraceptives. Of course, anyone with migraines has to be scrupulous about treating cardiovascular risk factors, such as smoking.

A hyperbaric oxygen treatment can break a migraine attack and give a sufferer great relief.   Of course, hyperbaric oxygen treatment of migraines is usually not practical because of availability problems.  But, I once had a nurse working for me who sometimes had to slip into one of our chambers to get relief-it would break her attack and keep her in the clinic, instead of going home and letting the headache get the best of her.

Hyperbaric oxygen should be used far more often in stroke survivors than it is. Hyperbaric oxygen is safe-the patient is only exposed to oxygen for crying out loud!  Hyperbaric oxygen therapy for stroke may not reach the level of proof of efficacy to satisfy government bureaucrats or academic know-it-alls, but these two groups are rarely motivated by logic.  The threshold for treating strokes with hyperbaric oxygen should be low, because the risks are low and the potential benefits are high.  A real problem, however, is that in the earliest stage of a stroke, hyperbaric oxygen is not practical because it is not generally available.  Good ways to reduce stroke damage in the earliest stage would be welcome.  TPA is the only drug we have at the moment.

An interesting study came out recently showing that minocycline is very promising for early intervention in ischemic stroke.   Minocycline is highly neuroprotective in animal models and there is even some preliminary evidence in stroke patients.  Patients were responsive to low doses of minocycline up to 24 hours after the onset of stroke, providing a much longer treatment-opportunity window than TPA.

Because minocycline has been around for so many years and is so cheap, don’t expect the pharmaceutical industry to pay for the extraordinarily costly research that the government would demand before granting an indication for treatment of stroke.  And, of course, don’t expect your typical academic neurologist to treat stroke patients with minocycline-unless they happen to be involved in minocycline research.  No, the typical academic will tut-tut about the data and intone that a large, double-blind prospective study must be done first.

I hope I don’t have a stroke any time soon, but if I do, I will make sure I’m given IV minocycline.

Courtesy Centers for Disease Control and Prevention

Atlanta Hyperbaric treats stroke patients regularly.  So, when I come across interesting new information about strokes, I’ll pass it along.

Herpes zoster, or shingles, is a familiar disease that mostly occurs in the elderly, but not always.  In fact, I’ve deliberately shown a picture of a child with herpes zoster, just to illustrate that people of all ages get the disease. Zoster is caused by the same virus that causes chickenpox.  The typical elderly patient who gets zoster had an attack of chickenpox as a child, the virus stayed dormant for years and then returned as an attack of zoster decades later.  Patients with diseases of immunodeficiency get zoster at high rates.  Zoster is usually quite painful and I have often been struck by complaints of severe allodynia, or pain from light touch, such as slight rubbing by a garment.  The illustration shows a typical dermatomal distribution, i.e., along the path of a nerve root from the spine.

A medical group at Taipei Medical University in Taiwan recently reported that patients who had shingles were 31% more likely to suffer a stroke in the next year than a random control group.  Further analysis of the data showed that the zoster patients differed from the controls with a higher incidence of hypertension,  diabetes, coronary heart disease, renal disease, heart failure, and carotid/peripheral vascular disease. The researchers gave several possible explanations for their findings including the possibility that  the higher frequency of cardiovascular risk factors among the patients with zoster, suggested that the presence of the herpes virus might accelerate atherosclerosis development.