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Time is Brain! Can VR Help Stroke Survivors? Return to Work after Stroke?

Hot off the press: News and fascinating studies on stroke from Medscape.

Mobile stroke units are helping save lives. (360 degree image.) Ambulances outfitted with a CT scanner, radiologic technician and a stroke fellowship trained nurse practitioner or physician in addition to the EMT (emergency medial technician) driver and paramedic, relay the images in real time to a radiologist or neouroimaging neurologist. The images are evaluated for bleeding or no, yes or no to tPA by a stroke team member, and tPA can begin immediately. (tPA = tissue plasminogen activator, a protein given intravenously to dissolve clots in ischemic stroke.) Patients treated with tPA or who require thrombectomy (clot removal) are then directly admitted to stroke teams at a stroke center most appropriate for the level of care needed (comprehensive stroke center vs primary stroke center), bypassing the Emergency Room. As a result, the median time from arrival on the scent to administration of tPA in the field is 13 minutes! (Contrast this with the time windows in the final study below.)

Virtual reality helps post stroke therapy for arm motor function recovery!! Pitted one on one against physical therapy, VR matched the results in effectiveness. This is exciting, as virtual reality is more portable and may ultimately be less expensive than a hands on physical therapist. One huge step in reducing barriers to out patient rehab.

Another study of return to work after stroke found that 34% of the patients who were working at the time of their stroke were re-employed at three months; however at one year, this decreased to 27%, at 5 years 25% and at 10 years, 10% . (No doubt in part, age related.) Patients who returned to work within the initial year were more likely to still be employed 10 years later, than those who returned later.

Interestingly, study showed those who return to work after stroke have higher rates of anxiety and depression at both one and five years. Why? The authors postulate “lack of coping or adaption, social factors or workplace factors such as the work climate…. fatigue, cognition, and personal factors.”

In my case, workplace factors loomed large. Though I returned to work at 1 year, thankfully I did not suffer depression. I did have performance anxiety, which I coped with by being more deliberate and triple checking my work. Banging on all cylinders, aware of my diminished processing speed and working even when it left no energy for my family was hard enough. But the work climate was definitely hostile; being considered a “drag on productivity” tipped the scales, and I left work.

A study looking at return to work after stroke found “post-stroke depression predicted not returning to work almost to the same extent as physical disability.”

In that study “non-manual labor patients were less likely to return to work." The authors suggest, “More people in manual labor might have been physically able to go back to work, whereas people in office jobs may have been limited because of deficits in cognition”. However another speculated it may be more a matter of means. "In my experience, the white collar workers have the financial means to retire after they've had a stroke." Another suggested “the biggest predictor of return to work is your age.” The small numbers who return to work may be since the majority of stroke survivors (especially ischemic) “are close to the retirement age already.”

From the 2018 European Stroke Conference:

A paper on Transient Ischemia Attack, TIA, minor or mini stroke, or symptoms of stroke that disappear rapidly on their own was presented at thee 2018 European Stroke Conference

Analysis of the TIA registry found patients who have experienced a TIA or minor stroke still have a rising risk for recurrent stroke out to 5 years after the initial event, not the 1 year previously established.

“These patients were well treated in terms of guideline-recommended secondary prevention but still their risk of having a stroke in the next few years is unacceptably high." Trials are underway to assess new approaches to lower the risk.

A cautionary word on TIA. That the symptoms disappear rapidly does not mean everything is ok. TIA NEEDS emergency treatment, and should not be ignored. “TIA or “mini stroke” is an warning of an impending stroke!!

A stroke is often referred to by doctors as a cerebrovascular accident, but a stroke is rarely an “accident.” The underlying conditions of a stroke are usually present for years before a stroke occurs, although the symptoms of a stroke may occur suddenly." (This from the conclusion of the article that described the new tongue deviation sign for stroke.)

Only by taking action after a TIA can you prevent a stroke or reduce its severity. And multiple TIA's can lead to vascular dementia.

And lastly, this:

Looking at quality indicators of ischemic stroke care, “"There were no quality measures that favored females.”

“Door-to-needle time less than 60 minutes, arrival at a stroke unit before 4 hours, and use of thrombectomy (blood clot removal) were among quality measures that men were more likely to experience than women in a study of more than 83,000 hospital admissions for acute stroke. Men were also more likely to receive a swallow screen within 4 hours, physiotherapy assessment within 72 hours, and early supported discharge compared with women in the study.” (Those mobile units might help level the playing field!)

And there you have it.

We have a lot of work to do, with access to care, treatment, rehab and decreasing the treatment discrepancies. Teams all around the world are tackling these issues.

But armed with this knowledge, you can fight for your self and your loved ones until the systems improve.

Ok, that’s all the medical updates for now. Next week, back to the personal.

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