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Newer Treatments in Stroke Rehabilitation through Occupational Therapy[edit]

Since Occupational Therapy is a field that is ever evolving and treatments are unique to each individual it should be noted that new techniques and forms of treatment are constantly being introduced and tested. One of these is electrographic biofeedback or EMG. In this treatment electrodes are placed over the muscle group of the affected area, the patient is then told to relax and contract the muscle. They are then shown visual and or auditory feedback (OT: Evidence Based Interventions for Stroke pg 146). This can even be in the form of a game. It is a form of operant conditioning and has proved positive results.

There have also been some studies done on the use of robotics to aide in the rehabilitation of the post-stroke treatment. This allows therapists to focus very clearly on one particular muscle group while adjusting the intensity quite accurately to the patient. However robotics can be quite expensive and not every facility will have the means to provide a service like this.

Lastly one of the newer trends is the use of virtual reality. This is somewhat similar to EMG where it provides a visual stimulus for the patient. This stimulus can be anything from watching the actual movement of a wrist or the swinging of a golf club or baseball bat. Of course this depends on the level of impairment and where they are in their recovery.

Gillen, G., & Burkhardt, A. (2004). Stroke rehabilitation: A function-based approach. St. Louis MO: Mosby. A functional guide to the rehabilitation of patients who have suffered cerebrovascular accidents (stroke).

Krug, Giulianne, MA OTR/L, and Guy McCommack, PhD, OTR/L. Occupational Therapy: Evidence Based Interventions for Stroke. 2009. MS. University of Missouri, Mar. 2009. Web. 3 Apr. 2014. A reference to current treatments in Occupational Therapy for stroke. Intended for practicing physicians and health care providers.

Teasell, Robert W., MD, and Lalit Kalra, MD. "What's New in Stroke Rehabilitation." What's New in Stroke Rehabilitation. N.p., 3 Dec. 2003. Web. 03 Apr. 2014.Somewhat outdated but trends in rehabilitation of stroke. — Preceding unsigned comment added by Cmpowers23 (talkcontribs) 19:35, 6 April 2014 (UTC)

Are you proposing to add this to the article? JFW | T@lk 21:23, 7 April 2014 (UTC)

Circulatory Shock vs Hypoperfusion[edit]

Jfdwolff - This is an interesting point and I am not sure that the two are equal. There are cases reported of watershed infarcts in patients with chronic heart failure who take too much antihypertensive medication. Would this be considered circulatory shock? Or is it rather the dysfunction of cerebral autoregulation coupled with hypotension. Perhaps the wording should be changed from "systemic hypoperfusion" to "cerebral hypoperfusion"? I do not feel strongly on this one way or another but I think it is worth mulling over. See "Mechanisms" in this article for more: "Elisa Cuadrado-Godia, Angel Ois, Jaume Roquer. Heart Failure in Acute Ischemic Stroke. Curr Cardiol Rev. 2010 August; 6(3): 202–213. PMCID: PMC2994112" Acallen88 (talk) 16:13, 9 April 2014 (UTC)

I agree cerebral hypoperfusion is better as systemic hypoperfusion may not always be present. Doc James (talk · contribs · email) (if I write on your page reply on mine) 22:19, 7 May 2014 (UTC)

Semi-protected edit request on 8 October 2014[edit]

The section entitled "thrombolysis" requires editing because it fails to adequately address the fact that this treatment option is controversial. I propose replacing this section with the following:

Thrombolysis Thrombolysis with recombinant tissue plasminogen activator (rtPA) is a controversial treatment for acute ischemic stroke. A randomised controlled trial (RCT) in 1995 reported that patients treated within three hours of the onset of symptoms were 12% more likely to be in the “alive and independent” group three months after treatment1. A second study in 2008 reported that patients treated between three and 4.5 hours were 7% more likely to be alive and independent2. Treatment does not improve survival. A 2012 systematic review calculated that treatment produces an extra 2.5% risk of death in the short term and an overall 6% increased risk of deterioration due to intracranial haemorrhage (bleeding in the brain)3. Treatment is endorsed by the American Heart Association (AHA), the European Stroke Organisation, and the Australian Stroke Foundation.

Critics of this therapy argue that in contrast to the two positive studies above, nine large RCT showed no benefit to stroke patients4-12, including four that were stopped early due to excess harm7-10. The two positive studies have also been criticised as having major design flaws, especially that the placebo groups of both studies included people with more severe strokes, making the outcome of those in the treated groups look better by comparison13, 14. Published systematic reviews vary in terms of which RCT they include or exclude from their analysis, which has a major impact on the calculated outcomes3, 15, and concern has been expressed about experts having declared financial ties to the manufacturer, including the AHA panel, and authors of the systematic reviews and published statistical analyses16. Treatment is not endorsed as “standard of care” by the American Academy of Emergency Medicine, the Canadian Association of Emergency Physicians, or the Australasian College for Emergency Medicine17-19.

1. Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. New England Journal of Medicine. 1995;333(24):1581-7. 2. Hacke W, Kaste M, Bluhmki E, Brozman M, Davalos A, Guidetti D, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. New England Journal of Medicine. 2008;359(13):1317-29. 3. Wardlaw JM, Murray V, Berge E, del Zoppo G, Sandercock P, Lindley RL, et al. Recombinant tissue plasminogen activator for acute ischaemic stroke: an updated systematic review and meta-analysis. Lancet. 2012;379(9834):2364-72. 4. Randomised controlled trial of streptokinase, aspirin, and combination of both in treatment of acute ischaemic stroke. Multicentre Acute Stroke Trial--Italy (MAST-I) Group. Lancet. 1995;346(8989):1509-14. 5. Hacke W, Kaste M, Fieschi C, Toni D, Lesaffre E, von Kummer R, et al. Intravenous thrombolysis with recombinant tissue plasminogen activator for acute hemispheric stroke. The European Cooperative Acute Stroke Study (ECASS). JAMA. 1995;274(13):1017-25. 6. Hacke W, Kaste M, Fieschi C, von Kummer R, Davalos A, Meier D, et al. Randomised double-blind placebo-controlled trial of thrombolytic therapy with intravenous alteplase in acute ischaemic stroke (ECASS II). Second European-Australasian Acute Stroke Study Investigators. Lancet. 1998;352(9136):1245-51. 7. Thrombolytic therapy with streptokinase in acute ischemic stroke. The Multicenter Acute Stroke Trial--Europe Study Group. New England Journal of Medicine. 1996;335(3):145-50. 8. Donnan GA, Davis SM, Chambers BR, Gates PC, Hankey GJ, McNeil JJ, et al. Streptokinase for acute ischemic stroke with relationship to time of administration: Australian Streptokinase (ASK) Trial Study Group. JAMA. 1996;276(12):961-6. 9. Clark WM, Wissman S, Albers GW, Jhamandas JH, Madden KP, Hamilton S. Recombinant tissue-type plasminogen activator (Alteplase) for ischemic stroke 3 to 5 hours after symptom onset. The ATLANTIS Study: a randomized controlled trial. Alteplase Thrombolysis for Acute Noninterventional Therapy in Ischemic Stroke. JAMA. 1999;282(21):2019-26. 10. Clark WM, Albers GW, Madden KP, Hamilton S. The rtPA (alteplase) 0- to 6-hour acute stroke trial, part A (A0276g) : results of a double-blind, placebo-controlled, multicenter study. Thromblytic therapy in acute ischemic stroke study investigators. Stroke. 2000;31(4):811-6. 11. Hacke W, Furlan AJ, Al-Rawi Y, Davalos A, Fiebach JB, Gruber F, et al. Intravenous desmoteplase in patients with acute ischaemic stroke selected by MRI perfusion-diffusion weighted imaging or perfusion CT (DIAS-2): a prospective, randomised, double-blind, placebo-controlled study. Lancet Neurology. 2009;8(2):141-50. 12. group ISTc, Sandercock P, Wardlaw JM, Lindley RI, Dennis M, Cohen G, et al. The benefits and harms of intravenous thrombolysis with recombinant tissue plasminogen activator within 6 h of acute ischaemic stroke (the third international stroke trial [IST-3]): a randomised controlled trial. Lancet. 2012;379(9834):2352-63. 13. Fatovich DM. Believing is seeing: Stroke thrombolysis remains unproven after the third international stroke trial (IST-3). Emergency Medicine Australasia. 2012;24(5):477-9. 14. Hoffman JR, Schriger DL. A Graphic Reanalysis of the NINDS Trial. Annals of Emergency Medicine. 2009;54(3):329-36.e35. 15. Wardlaw JM, Murray V, Berge E, Del Zoppo GJ. Thrombolysis for acute ischaemic stroke. Cochrane Database of Systematic Reviews. 2009(4):CD000213. 16. Lenzer J. Why we can't trust clinical guidelines. British Medical Journal. 2013;346(f3830). 17. Position statement on intravenous thrombolysis for ischaemic stroke. 2012; Available from: 18. AAEM. Position Statement on the Use of Intravenous Thrombolytic Therapy in the Treatment of Stroke. American Academy of Emergency Medicine; 2002 [07 May 2014]; Available from: 19. CAEP. Position statement: Thrombolytic Therapy For Acute Ischemic Stroke. [cited 2014 10 October]; Available from: (talk) 06:36, 10 October 2014 (UTC)

For starters we typically only use secondary sources from the last 5 years. These include recent meta analysis. There is this 2014 Cochrane review and this 2014 Lancet review
It is not controversial before 3 hours and after 4.5 hours. The controversy is between these two times and we say "Between three and four and a half hours the effects are less clear." already Doc James (talk · contribs · email) (if I write on your page reply on mine) 20:42, 10 October 2014 (UTC)

Be VERY careful between ischemic and hemorraghic stroke[edit]

Not that any Pt's themselves would try to use anticoagulants etc themselves... but it is KEY to differentiate between ISCHEMIC and HEMORRAGHIC stroke. I am aware the intro does this, however, surgery fails to CLEARLY outline that aspirin, anticoagulants, and carotid endarterectomy is for ischemic stroke ONLY, and is actually CONTRAindicated in hemorraghic stroke, and brain MRI is usually done to rule OUT hemorraghic type if suspected!! VERY important from medical standpoint just to let you know! (talk) 10:22, 14 October 2014 (UTC)

CT is usually done to r/o bleeds. Will look at the surgery section. Doc James (talk · contribs · email) (if I write on your page reply on mine) 11:17, 14 October 2014 (UTC)