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How new tech and an old concept are shaping stroke care

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Not so long ago, stroke patients were told by doctors that their brains wouldn’t recover. Now, it’s a very different picture, says Niamh Kennedy, lecturer in psychology at Ulster University.

“Now we know this isn’t true, and that the brain is constantly changing,” she says.

Kennedy’s research focuses on neuroplasticity, which is the concept that the brain can rewire itself. This has gone from an abstract concept to there being an explosion of research, she says.

“Neuroplasticity was first talked about over 100 years ago, but it wasn’t until the last 20 years that researchers have begun thinking about how to utilise this extraordinary phenomenon.”

Neuroplasticity is all about connections. Neurons are connected to each other by synapses, and a good connection between them allows pathways to form that can affect a person’s movement, speech, memory and learning, Kennedy says.

The amount of neurotrophins, proteins that induce the survival, development and function of neurons, spike after a stroke, sending a cascading chemical reaction in the brain that promotes reorganisation, Kennedy says. In other words, the brain becomes primed for recovery.

“We know from animal research that, in an ideal world, when someone has had a stroke and has stabilised, we’d be boot-camping these people, we’d be sending them for rehab 9-5 for 12 weeks,” she says.

“Now, after you have a brain injury, we know that the brain is trying to do what it can for itself. Neuroplasticity starts to peak after a brain injury, which means in the first few days and weeks after a stroke is the optimum time to use increased levels of neuroplasticity to start rehab and start recovery.

“Only 20 years ago, when someone had a stroke they were seen as being sick, and basically went to bed for three weeks until they were better, then doctors started to think about whether to give the patient rehab.”

The brain starts by absorbing as much of the swelling and blood as it can after an injury, then starts the process of releases more neurotransmitters and neurotrophins to begin to reorganise.

“They say that the formation of new synapses increases up to eight times its usual rate after a stroke, flooding the brain with mechanisms and chemical messengers that help the brain be as efficient as possible,” Kennedy says.

We all depend on neuroplasticity in our daily lives to learn new things, but it’s particularly important after a brain injury or stroke. For decades, rehab has been using interventions that centre around neuroplasticity to reorganise the brain after damage and help patients regain functions they lost.

Kennedy uses non-invasive brain Transcranial Magnetic Stimulation (TMS), a very weak magnet that can be placed on a person’s head to measure the amount of neuroplasticity by looking at changes and activity in the brain.

This, she says, allows researchers to look at the living brain in more detail. Using TMS, Kennedy can look at a patient’s cortical activity, send it off to a physiotherapist and measure it again to see how the brain changes as the patient recovers function.

It’s arguably much less restrictive than MRIs, which are expensive and not routinely available, Kennedy says. Although TMS is specialist equipment, one costs around £10,000 to £15,000, compared to one or two million pounds for an MRI.

TMS can also be done in conjunction with other standard clinical measures, such as walking speed. It is also used in treatment for patients with depression who aren’t responsive to drugs.

Kennedy is working on research looking at patients’ arm function after a stroke, measuring neuroplasticity before and after physiotherapy to see brain changes and cortical pathway changes because of the intervention.

This will help researchers to see more holistically how someone recovers from a stroke, instead of just relying on behavioural measures, such as completing tasks, she says, where progress can sometimes come down to using other muscles to compensate.

Non-invasive brain stimulation is mainly a research tool, but it has the potential to be incorporated more widely into stroke units, Kennedy says, to investigate patients’ brain connectivity and plasticity or potentially predict recovery following a stroke.

“For people with the worst outcomes, however, you might invest money differently. Instead of putting them through SAS-style physiotherapy to get them walking if it’s unlikely they’ll walk again, let’s concentrate on making sure their mobility skills, such as the use of their arms, is prioritised,” Kennedy says.

However, she warns, there is potential for misuse.

“You don’t want something that determines a patient isn’t worth doing rehab on. The severity of someone’s stroke is still the best predictor.”

TMS is currently being trialled in some university hospitals in Australia and New Zealand, Kennedy says, to see if it can be used after a stroke to predict recovery, as TMS can show if the pathways between the brain and muscles are intact. Where they are, this could indicate a better recovery than if someone is given brain stimulation and their muscles don’t respond.

“This is important because stroke survivors are now in hospital for a lot less time, so there’s no time to try something and it not work well for a patient. Any additional information you can get to try and personalise someone’s rehab is seen as really positive,” Kennedy says.

Like all new technologies, TMS will take time, she says. Once it’s been trialled, it might be incorporated into clinical practice via university hospitals, and then physios may start using it more often.

It’s key that neuroplasticity is at the centre of stroke rehab, Kennedy argues, because the brain needs a lot of repetition to strengthen its pathways.

“That’s why rehab is such hard work. Our brains are sponges, we need to keep repeating things to get them into our heads.”

“You also need an enriched, stimulating environment with social interaction, of which there isn’t much in hospital. I worry about how, with Covid-19, people are having fewer visitors and less interaction, and their brains aren’t getting as much stimulation or interest,” Kennedy says.

Kennedy is also concerned that the Covid-19 pandemic will slow recovery as diagnoses as delayed.

“There’s evidence coming out that fewer people turned up at A&E with suspected strokes during lockdown, even though we know the rate is reasonably stable.

“This means people won’t have begun treatment or rehab and recovery promptly, therefore there’s a missed opportunity to stop the stroke becoming so bad, a missed opportunity for the golden time. The sooner we can start therapies and treatment, often the better.”

Kennedy says it’s an exciting time to be in stroke research, and a promising time for stroke survivors.

“Stroke research, although it’s always crying out for more rehab, is also trying to improve efficiency of rehab and interventions. I’m interested in how, the more we understand how the brain works and how it changes after brain damage, for example after a stroke, it allows us to have a better understanding of how it fixes itself and how we can promote that, and see how interventions can improve recovery as much as possible.

“It’s exciting, all the different things we’re beginning to learn about the brain and how some of this research is being translated into clinical practice with new technologies, from brain stimulation to virtual reality.

“There’s a slow path to adoption in the UK system, however, especially as the NHS needs loads of evidence.”

And, Kennedy adds, there’s much more research to be done.

“Researchers feel that brain stimulation is a promising technique, but people seem to respond differently to it. We need to understand why this is, then apply it in the best way for stroke survivors.”

Neuroplasticity isn’t a panacea, Kennedy concedes, but emerging technology that allows the patient to use it to their full advantage is very promising.

“If neuroplasticity was perfect, everyone would make a full recovery from a stroke. It gives stroke survivors a bit of hope that they can salvage things back.”

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Neurokinex unveils winning Christmas card design

Eight-year-old Jasper’s creation will be this year’s festive fundraiser for the specialist neurophysio

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Over the past four years, the team at Neurokinex and some of its young clients at Neurokinex Kids have taken part in a fun and festive Christmas card charity design competition.

All the children’s designs are put forward to a public vote with the winner’s design then made up into a Christmas card that is sold to help raise awareness and vital funds for the charity. 

This year’s winning design

This year’s winning Neurokinex Kids Christmas card was designed by Jasper, eight, who also drew the winning design of the very first Neurokinex Christmas Card in 2018 when he was just four years old.

Jasper was the first paediatric client to attend Neurokinex aged just two in March 2016. Born fit and well, he contracted Hand, Foot & Mouth disease at a children’s party. A rare complication resulted in an enlarged heart and Jasper was admitted to hospital and put on life support. However, when the doctors brought him round, Jasper couldn’t move his legs: a blood clot had damaged his lower spinal cord and he was paralysed from the waist down.

After Jasper was discharged from Stoke Mandeville spinal care hospital in March 2016, his mum Kate started to look for specialist rehabilitation to give Jasper his best chance of recovery. She was initially recommended to visit the NeuroRecovery Network facility in Louisville and the family flew to the US in May 2015. At that time, the ground-breaking work being done in Louisville was only available at a select few NRN affiliated sites in America.

Luckily for Jasper, the NRN had just named the Neurokinex rehabilitation centre in Crawley as its first and only affiliate outside of the US, bringing this amazing treatment much closer to home. Kate flew the family home and Jasper started at Neurokinex. Two years later, in March 2018, Neurokinex opened Neurokinex Kids, a purpose-built activity gym upstairs at the main Neurokinex rehab centre to fully cater for their younger clients. 

Not just for fun, but providing therapy too 

Whilst designing the Christmas card is great festive fun for the kids, it’s also another opportunity to provide important therapy. 

Neurokinex Kids delivers ground-breaking work and defies diagnoses, focusing above and below the child’s point of injury in a bid to stimulate sensation and rehabilitation. It looks more like a play centre than a therapy suite with its bright and cheerful set-up. Here, children aged six months to 12 years engage in specialist rehab therapy through play, largely unaware how hard they are working because they’re having so much fun.

Designing the Christmas cards works many different muscle groups for the children as part of their vital therapy and gives the opportunity to focus on something different. It builds engagement, strengthens their relationship with their trainers and helps their families ‘give back’ to Neurokinex Kids. 

Last year, Ryan, eight, wowed everyone by using only his mouth and a paintbrush to create his design of a snowman. He did this at Neurokinex Kids as part of his ongoing therapy and was placed into a standing position to paint it, which made keeping his head in control even more challenging. 

In 2019, aged just two, Ralph’s design of snowmen using his footprints was chosen as the winning picture. A charming card, it was poignant because when Ralph first arrived at Neurokinex his hips were out of alignment and his feet were twisted backwards – meaning his ‘side by side’ snowmen wouldn’t have been possible. This was because when Ralph was just two weeks old he suffered a spinal stroke which had caused damage to his spinal cord and left him paralysed from the waist down. 

Raising vital funds 

Each year the Neurokinex Christmas card raises awareness and vital funds for the charity. A pack of 10 cards costs £6.50 and you can buy them here https://neurokinex.org/christmas-cards/

 

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Brain injury

Saliva test to diagnose concussion set to trial in football

Through a new joint action plan on brain health, education and research are identified as being at the heart of understanding concussion

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A breakthrough saliva test to diagnose concussion is set to be trialled in the Premier League, with a series of research projects also given backing, as efforts to protect players from the impact of head injury are stepped up within English football. 

In a new joint action plan on brain health, the need for research, education, awareness and support for players has been recognised, with a series of steps identified to better manage head injuries and to further understand the links between football and neurodegenerative disease.

The plan – from The FA, Premier League, EFL and PFA – includes a raft of measures, including the funding of an academic study to validate a diagnostic tool that uses salivary biomarkers, with reports that a trial could begin in the sport later this season.

It follows the publication of the SCRUM study findings in March, which showed a saliva biomarker tool was able to accurately detect concussion in elite male rugby players.

SCRUM, led by academics at the University of Birmingham, successfully predicted the outcome of head injury assessments in 94 per cent of cases during testing in the 2018-19 Premiership and Championship season. 

Furthermore, The FA is supporting the new BrainHOPE study, part of the wider Prevent Dementia study, which starts in 2022 at Glasgow University. 

The study will give an analysis of deterioration of cognitive function in the mid-life of ex-professional footballers to understand potential early interventions which could help reduce risk or speed of developing dementia. Its £1.2m investment will run until the 2024/25 season.

It is also partnering with the RFU and Premiership Rugby to expand the Advanced BRAIN Health Clinic, a new specialist clinical service and associated research programme for retired elite rugby players. The expansion to retired football players is due to start operating in 2022.

Trials of a new revolutionary mouthguard which includes a sensor that can relay real-time information to the sidelines – launched with players from Liverpool and Manchester City last season – is being expanded to include additional teams across the Premier League, EFL and The Barclays FA Women’s Super League (WSL).

Education is also highlighted as being of significant importance, and an expert working group formed by the Premier League is devising neck strengthening guidance. This will provide clubs with an introductory programme which is recommended to be implemented by strength and conditioning coaches.

In the grassroots game, authorities are working with brain injury charity Headway on a campaign – set to launch later this season – that will seek to improve awareness of concussion and ensure existing guidance is understood and accepted as standard practice. Referees will also be given greater support in dealing with concussion. 

“Understanding the risk factors of neurodegenerative disease in football is an incredibly complex area of medical science which requires exploration of many different lines of research,” said FA chief executive Mark Bullingham. 

“Football is working together to try to build a more complete picture by supporting a variety of projects.  Until we have a greater level of understanding, we are also reducing the potential risk factors. 

“This new joint action plan will further help to build our understanding across English football of this complex area.”

Richard Masters, Premier League chief executive, said: “It is important that football has come together to work collaboratively on this issue. With the help of experts, and alongside other sports with similar challenges, we want to ensure we have the right approach in place to protect the welfare of players.”

Trevor Birch, CEO of the EFL, said: “English football has a collective responsibility to understand and act upon the risk factors of neurodegenerative disease and therefore the EFL is pleased to support the game’s new joint action plan on brain health. 

“By working together in this collaborative approach, we will acquire the information to be better equipped to improve safeguarding measures for those who play football at all levels of competition.”

Maheta Molango, PFA Chief Executive – who has pledged to donate his brain to research to increase understanding of neurodegenerative illness – added: “A joined-up approach is essential to improve the health and safety of our current and future members. 

“A co-ordinated response is also required to provide comprehensive and dedicated support to our former players, and their families, currently living with dementia and other neurodegenerative diseases.

“This is a vital and complex area. It has to be the top priority for all involved in football.”

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Non-invasive technique ‘could replace need for brain surgery’

The new PING approach could help treat some of the most challenging and complex neurological diseases

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A new non-invasive technique has been developed to remove faulty brain circuits that could allow medics to treat debilitating neurological diseases without the need for conventional brain surgery.

If successfully translated into operating theatres, the breakthrough has been hailed as potentially revolutionary in the treatment of some of the most challenging and complex neurological diseases, including epilepsy, movement disorders and others. 

The PING approach, developed by the University of Virginia and Stanford University, uses low intensity focused ultrasound waves combined with micro-bubbles to briefly penetrate the brain’s natural defences and allow the targeted delivery of a neurotoxin. 

This neurotoxin kills the culprit brain cells while sparing other healthy cells and preserving the surrounding brain architecture.

“This novel surgical strategy has the potential to supplant existing neurosurgical procedures used for the treatment of neurological disorders that don’t respond to medication,” said researcher Dr Kevin S. Lee, of UVA’s departments of neuroscience and neurosurgery and the Center for Brain Immunology and Glia (BIG). 

“This unique approach eliminates the diseased brain cells, spares adjacent healthy cells and achieves these outcomes without even having to cut into the scalp.”

PING has already demonstrated exciting potential in laboratory studies. For instance, one of the promising applications for PING could be for the surgical treatment of epilepsies that do not respond to medication. 

Around a third of patients with epilepsy do not respond to anti-seizure drugs, and surgery can reduce or eliminate seizures for some of them. 

Dr Lee and his team, along with their collaborators at Stanford, have shown that PING can reduce or eliminate seizures in two research models of epilepsy. 

Dr Kevin S. Lee

The findings raise the possibility of treating epilepsy in a carefully-targeted and non-invasive manner without the need for traditional brain surgery.

Another important potential advantage of PING is that it could encourage the surgical treatment of appropriate patients with epilepsy who are reluctant to undergo conventional invasive or ablative surgery.

A key advantage of the approach is its incredible precision. PING harnesses the power of magnetic-resonance imaging (MRI) to let scientists peer inside the skull so that they can precisely guide sound waves to open the body’s natural blood-brain barrier exactly where needed. 

“If this strategy translates to the clinic,” the researchers write in their new paper, “the noninvasive nature and specificity of the procedure could positively influence both physician referrals for and patient confidence in surgery for medically intractable neurological disorders.”

“Our hope is that the PING strategy will become a key element in the next generation of very precise, noninvasive, neurosurgical approaches to treat major neurological disorders,” said Dr Lee, who is part of the UVA Brain Institute.

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