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Stroke

Walking at faster speed ‘can improve stroke survivors’ dual-task capability’

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Training stroke survivors to walk at a faster speed during recovery can help improve the brain function that enables people to walk and perform another task simultaneously, known as dual-task walking.

One common effect of stroke is that survivors often struggle to walk and do tasks that involve thinking at the same time, such as walking and holding a conversation, or planning what to do next. 

To be able to effectively walk in the community, cognitive effort is needed to navigate safely and deal with distractions, and many people fail to regain this ability after a stroke.

However, through new research led by by academics at Oxford Brookes University and funded by the Stroke Association, the impact of faster walking during recovery has been discovered. 

The new research analysed data from a previously-run trial to compare how people who walked slowly and people who walked at faster speeds responded to dual-task training.

“When we compared slower walkers and people who walked at a faster pace – still slower, but closer to walking speeds we expect to see in people who have not had a stroke – both increased their walking speeds after the training,” said Dr Johnny Collett, senior clinical research Fellow in the Centre for Movement, Occupational and Rehabilitation Sciences at Oxford Brookes University.

“However, those who could walk faster at the beginning of the training also improved their ability to walk and think at the same time.”

Researchers believed that a reason why people struggle with dual-task walking after a stroke may be linked to their walking automaticity. This pattern is linked to the cyclic pattern of walking whereby one step ‘signals’ the next step to follow. If someone walks very slowly this pattern could be disrupted so that walking becomes more like independent steps, rather than a cycle.

As part of the new research, scientists at the University of Oxford used advanced imaging to track how people’s brains responded to the training. 

Changes found in the brain supported the findings that people with stroke who walked slower, had a less automatic control of  walking. Those who walked at a faster pace had changes in the brain consistent with adaptations that may be necessary for controlling gait in more complex environments.

“These findings show that, for those who walk slowly, initially focusing on improving walking speed may increase their capacity to improve dual-task walking,” adds Dr Collett. 

“Greater consideration of walking automaticity may help to better tailor intervention and direct a staged approach of increasing complexity to make people better able to walk in the community.”

Dr Rubina Ahmed, director for research and policy at the Stroke Association, says: “Stroke strikes every five minutes and has devastating physical and mental impacts. Whilst four out of five stroke survivors recover the ability to walk, most find it hard outside of hospital which has a big impact on their well-being and independence. 

“By funding this research our charity has helped to highlight that training focused on walking speeds could be an important part of rehabilitation for some stroke survivors’ recoveries. 

“Research like this is key to finding new treatments and improving stroke care, so that stroke survivors can regain the mobility and independence they need to rebuild their lives.”

Stroke

‘Screen for loneliness in stroke survivors’

Calls come after a first-of-its-kind study reveals at least one in three people are living with clinical levels of loneliness post-stroke

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At least one in three stroke survivors are living with clinical levels of loneliness, a new study has found, prompting calls for clinicians to routinely screen for such a situation and devise a bespoke solution for each patient. 

The research, the first large-scale study of its kind, revealed that stroke survivors are at least 70 per cent more likely than the general population to experience loneliness. 

Prevalence rates of loneliness among survivors ranged from 30 to 44 per cent, with levels of anxiety and depression – both of which are recognised as psychological consequences of stroke and are routinely screened for in clinical assessment – at 25 per cent and 30 per cent respectively. 

The study, from the University of Bangor, revealed that many who are not objectively socially isolated may  experience high levels of loneliness. This suggests that it’s the individual’s subjective experience of their social situation that is important, rather than the quantity of social contact.

Calls have now been made for greater recognition of loneliness as a consequence of stroke, and for action to be taken to give appropriate support to each person affected. 

“Clinicians need to start thinking about the whole profile of the person cognitively, taking into account their pre-stroke personality and who they are, rather than ‘one size fits all’ approach of peer support or social groups, which is unlikely to always be the answer,” says Dr Christopher Byrne, who led the study and whose work received the 2021 British Neuropsychological Society Humphreys & Riddoch Prize. 

“The findings suggest that one in three people who come into the clinical room are suffering from loneliness and that’s really quite heartbreaking. We need to screen for loneliness and think about how to make interventions on an individual basis.”

The research team, including Dr Richard Ramsey from Macquarie University, Sydney, Australia, analysed ONS data from 21,874 people in Wales between 2016 and 2018, of whom 244 had a history of stroke – a percentage broadly replicated among the wider UK population. 

The findings that up to 44 per cent of those with a history of stroke reporting they are lonely marks a three-fold increase on studies looking at loneliness among the general population, and double the level seen in general primary care outpatients. 

The fact loneliness exceeded instances of depression and anxiety is a significant finding, says Dr Byrne, who also works in the North Wales Brain Injury Service. 

“I started to recognise that loneliness was a very common problem for people with ABI. While clinicians routinely assess for anxiety and depression, no-one asks whether someone is feeling lonely,” he says.  

“This was a common occurrence in the clinical room, but the support just isn’t there. This is why I wanted to do this research. In the NHS, we get people along to social groups and peer support, but I think the research helps to show the need for more tailored intervention.  

“The fact that we found people can be lonely even in an environment with a lot of social contact, which is very different to social isolation, and presents the challenge of how can we help in these situations? 

“This helps to show that interventions should target greater quality rather than quantity, and they need to be determined individually taking into account the holistic picture of the patient.”

Dr Rudi Coetzer, clinical director at The Disabilities Trust and honorary professor at Bangor University, supervised Dr Byrne’s research. 

”This novel research utilising big data helps to make more visible the profound loneliness many persons with stroke experience and reminds us of the importance of considering in greater depth the emotional lives of those we care for after brain injury,” he said. 

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Stroke

Anger and upset ‘can trigger stroke’

Physical exertion can also be significant in the immediate run-up to a stroke, the INTERSTROKE study has found

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Anger, upset and physical exertion can all be factors in triggering stroke, a global study has found. 

The INTERSTROKE research, which looks into causes of stroke, revealed one in 11 survivors had experienced a period of anger or upset in the hour leading up to it. 

Furthermore, one in 20 patients had engaged in heavy physical exertion.

INTERSTROKE, the largest research project of its kind, analysed 13,462 cases of acute stroke, involving patients with a range of ethnic backgrounds in 32 countries around the world.

“Our research found that anger or emotional upset was linked to an approximately 30 per cent increase in risk of stroke during one hour after an episode – with a greater increase if the patient did not have a history of depression,” said Professor Andrew Smyth, professor of clinical epidemiology at NUI Galway – which co-led the study – director of the HRB-Clinical Research Facility Galway and a consultant nephrologist at Galway University Hospitals.

“The odds were also greater for those with a lower level of education.

“We also found that heavy physical exertion was linked to an approximately 60 per cent increase in risk is of intracerebral haemorrhage during the one hour after the episode of heavy exertion. 

“There was a greater increase for women and less risk for those with a normal BMI.

“The study also concluded that there was no increase with exposure to both triggers of anger and heavy physical exertion.”

Dr Michelle Canavan, consultant stroke physician at Galway University Hospitals and Professor Andrew Smyth, professor of clinical epidemiology at NUI Galway

The research analysed patterns in patients who suffered ischemic stroke – the most common type of stroke, which occurs when a blood clot blocks or narrows an artery leading to the brain – and also intracerebral haemorrhage,  which is less common and involves bleeding within the brain tissue itself.

Co-author of the paper, Dr Michelle Canavan, consultant stroke physician at Galway University Hospitals, said: “Our message is for people to practice mental and physical wellness at all ages. 

“But it is also important for some people to avoid heavy physical exertion, particularly if they are high-risk of cardiovascular, while also adopting a healthy lifestyle of regular exercise.”

The global INTERSTROKE study was co-led by Professor Martin O’Donnell, professor of neurovascular medicine at NUI Galway, and consultant stroke physician at Galway University Hospitals, in collaboration with Prof Salim Yusuf of the Population Health Research Institute of McMaster University and Hamilton Health Sciences, Canada.

“Some of the best ways to prevent stroke are to maintain a healthy lifestyle, treat high blood pressure and not to smoke, but our research also shows other events such as an episode of anger or upset or a period of heavy physical exertion independently increase the short-term risk,” Prof O’Donnell said.

“We would emphasise that a brief episode of heavy physical exertion is different to getting regular physical activity, which reduces the long-term risk of stroke.”

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Research

1 in 100 COVID patients develop brain conditions

A new study reveals the risk of stroke, haemorrhage or encephalitis as a result of the virus

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Around one in 100 patients hospitalised with COVID-19 will develop brain conditions including stroke and haemorrhage as a result of the virus, the largest multi-site study to date has found. 

The multi-institutional research investigated brain complications of COVID and found that complications of the central nervous system can occur in one in 100 people. 

“Much has been written about the overall pulmonary problems related to COVID-19, but we do not often talk about the other organs that can be affected,” said study lead author Dr Scott H. Faro, professor of radiology and neurology and director of the division of neuroradiology/head and neck imaging at Thomas Jefferson University in Philadelphia. 

“Our study shows that central nervous system complications represent a significant cause of morbidity and mortality in this devastating pandemic.”

The most common complication was ischemic stroke, with an incidence of 6.2 per cent, followed by intracranial haemorrhage (3.72 per cent) and encephalitis (0.47 per cent), an inflammation of the brain.

Dr Faro initiated the study after discovering that existing literature on central nervous system complications in hospitalised COVID-19 infected patients was based on a relatively small number of cases.

To derive a more complete picture, he and his colleagues analysed nearly 40,000 cases of hospitalised COVID-19 positive patients from seven US and four western European university hospitals. 

The patients had been admitted between September 2019 and June 2020. Their average age was 66 years old, and there were twice as many men as women.

The most common cause of admission was confusion and altered mental status, followed by fever. Many of the patients had co-morbidities like hypertension, cardiac disease and diabetes.

There were 442 acute neuroimaging findings that were most likely associated with the viral infection. The overall incidence of central nervous system complications in this large patient group was 1.2 per cent.

“Of all the inpatients who had imaging such as MRI or a CT scan of brain, the exam was positive approximately ten per cent of the time,” Dr Faro said. 

“The incidence of 1.2 per cent means that a little more than one in 100 patients admitted to the hospital with COVID-19 are going to have a brain problem of some sort.”

The researchers also discovered a small percentage of unusual findings, such as acute disseminating encephalomyelitis, an inflammation of the brain and spinal cord, and posterior reversible encephalopathy syndrome, a syndrome that mimics many of the symptoms of a stroke.

“It is important to know an accurate incidence of all the major central nervous system complications,” Dr Faro said. 

“There should probably be a low threshold to order brain imaging for patients with COVID-19.”

The study is being presented at the annual meeting of the Radiological Society of North America (RSNA).

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