Dear Readers,

Welcome to NeuroAiD's April 2009 Newsletter. The idea of this monthly release is to share vital information for stroke patients and their families, and help them deal successfully with the common challenges life presents after a stroke.

This month, we would like to first of all deliver you an important message which is "No ibuprofen right after aspirin". You may be very familiar with both of the drugs but are you aware of their possible interaction? Further, we will highlight on hemiparesis rehabilitation. We will introduce you an interesting new concept of rehabilitation method which involves our imagination instead of repeat movements. At last, good news for those among you who have difficulties facing to a regular stroke rehab program, there's a new form of low tolerance long duration stroke rehab program initiated in Canada.

We want this to be more than a one-way communication, and would be most happy to hear back from you. What you have experienced and learned will be very valuable to others and we will make sure it reaches as many people in our community as possible. Do also let us know what topics you wish to read in future issues of your NeuroAiD's newsletter.

We would like to assist you in your return to daily life while recovering from stroke. As you are probably already aware, making the best use of time is of vital importance in your stroke recovery. Therefore, please allow us to call you at a number, day and time of your convenience, to hear your questions and explain our answers. If you agree, kindly email us the table below at info@neuroaid.com :

• Number :
• Date :
• Location / time zone :
• Person to ask for :

If you choose to contact us yourself instead, call us on our US toll free number: 1-800-882-4046 / +65-6478-9430 or email us at info@neuroaid.com

The NeuroAiD™ Team at Moleac

As a stroke survivor, you may be very familiar with aspirin. Many patients after an ischemic stroke are prescribed aspirin to.  Aspirin normally prevents the blocking of blood vessels. Aspirin shows a reduction of risk of recurrent strokes and transient ischemic attacks (TIAs) by 18%. Because of its established efficacy and low cost, aspirin is considered by many as first-line therapy in the majority of stroke patients.

Inevitably, you are at the same time more than familiar with ibuprofen (Non-steroidal anti-inflammatory drug – NSAID), a very common pain relief medicine. However, a group of researchers at the University of Buffalo in USA has shown that there’s a far less than ignorable interaction between the two drugs aspirin and ibuprofen. The study suggests that ibuprofen may block aspirin form its initial effect, and undermine its ability of prevention of a secondary stroke.

Conducted in 2008, this research has included a cohort of 28 patients in Dent Neurologic Institute were identified as taking both aspirin and ibuprofen daily and all were found to have no aspirin’s effect from their daily dosage. On the other hand, the effect is temporary because when afterwards, the researchers found in 18 of the 28 patients back for a second neurological visit after discontinuing NSAID, the sensitivity to aspirin is coming back. These patients also regained aspirin ability to prevent blocking blood vessels.

Though the study might be limited by its small size, the pharmacodynamics and clinical data are of a great importance. US FDA has released the warning saying “patients who use immediate-release aspirin (not enteric-coated) and take a single dose of ibuprofen, 400mg, should dose the ibuprofen at least 30 minutes or longer after aspirin ingestion, or more than 8 hours before aspirin ingestion to avoid attenuation of aspirin’s effect.”  In addition, the data from this trial suggest that even little as over-the-counter doses can all the same produce this pharmacodynamic interaction. Other medicine from the same category NSAID could also be risky while being taken with aspirin, like naproxen. Any doubt, please don’t hesitate to ask your physician.

It is the first one to demonstrate the clinical consequences of the aspirin-NSAID interaction in patients which delivered us an extremely important message: No Aspirin right after Ibuprofen.

This study also showed us that it is critical to notice unexpected interaction among drugs which are administrated in the same period of time. NeuroAid has been approved to be safe to stroke patients and lack of interaction with aspirin, this safety research of the therapy combining NeuroAid and aspirin has been published in Cerebral Vascular Diseases last May.

 

Sources:

Stroke (Journal)

Sciencedaily.com

As a consequence of a brain injury, the hemiparesis may occur and bring you spasticity, muscle weakness, and a persistent deficit in movement coordination. Such incoordination occurs at least in part because the brain part responsible for mediating an action intention and the part in charge of action execution are no longer intact.

Nearly 80% of people who have had a stroke have more or less trouble moving one side.  People with hemiparesis may have trouble moving their arms and legs, difficulty walking and may also experience a loss of balance. As a result, doing simple everyday activities could be difficult. Depending on the damaged area of the brain, the most common type is pure motor hemiparesis: Patients with pure motor hemiparesis have face, arm and leg weakness.

Classic treatment consists of physical the occupational therapy as we mentioned several times in our previous editions. Electrical stimulation to the area of the brain as we presented recently also becomes an interesting treating approach. On the other hand, certain treatments can be helpful in relaxing the muscles in people who have spasticity referring to our last year June’s edition.

A quite common and systematic method is called Modified constraint-induced therapy (mCIT) and it has been presented in our last year January’s edition. It is a focused treatment to stroke patients with hemiparetic arms. Three times a week at their therapist for half an hour each time, patients are asked to practice focused exercises using their weak arm. This therapy could last for 10 weeks. Preliminary studies indicate that mCIT substantially improves affected upper limb use and function in stroke patients.

Certainly, repeated exercises could improve motor activity and allow for smooth controlled movement, as the brain will re-establish the neuronal circuit that mediates voluntary movement. However one disadvantage of this approach is that the recovery is dependent on performance of an impaired limb.

Is there any method independent of the behavioural output of a paretic limb? Yes. Today, we will introduce you another new therapy: Mental Practice, sometimes called Motor Imagery. This therapy is based on when people imagine themselves using a certain body part, areas of the brain and muscles can be activated as if the person is actually doing the activity.

Here is the small model to illustrate one way to do it.  The model demonstrates that mirror box for simulation of a left limb moving successfully. The right (unaffected) limb moves around in the “workspace”, giving a reflection of the left (paretic) limb moving successfully in space. You will be instructed to “imaging the reflected limb actually is your limb moving”.

Therefore, your observation of the reflected limb provided a direct perceptual cue of the paretic limb is completing a controlled movement. During the first weeks, you might just have to go through with very simple movements, later in subsequent weeks, you may be asked to do some simple object manipulation like holding a pen drawing some geometric shapes, all this while observing your paretic limb in the mirror.

Such experiment has already been carried early in 2003 in Rehabilitation Institute of Chicago. Patients showed significant increase ability and a decreased in time spent in practicing motor movement tasks. In 2007, a new study in USA which compared the effectiveness of a rehabilitation program with mental practice of specific arm movements to traditional rehabilitation has shown, that the patients receiving mental practice significant increases in daily arm function, which confirmed the previous conclusion.

There are no specific risks involved in participating in motor imagery and it is inexpensive. Motor imagery is actually quite easy to do at home, and many people find it a fun and relaxing way of having additional therapy. Ask your rehabilitation therapist to see if he/she can guide you as to

• how many times a week you should do motor imagery exercises,
• what specific activities and movements you should do,
• what activities you should not do,
• how long each motor imagery session should be,
• how to change activities as you improve.

Have a great imagination journey!

 

Sources:

American Stroke Association

Heart and Stroke Foundation of Canada

Archives of Physical Medicine and Rehabilitation

Reuters

Rehabilitation is a dynamic but also progressive process; it enables you with impairments to reach your optimal level, both mental and physical. It helps you to restore the maximal independence and to increase the quality of life.

It is important to have a high-personalized program. If after a stroke, you have complex medical conditions which prevent your participation in a regular stream rehabilitation program, a LTLD program may help you. What does LTLD stand for? The Low Tolerance, Long Duration (LTLD) Unit is a hospital-based program that provides multiple assessments of different disciplines and rehabilitation.

Usually, two types of stroke rehabilitation are usually practiced. It basically depends on the severity of stroke and your age. The disabilities and impairments are evaluated by several kinds of scores, from which doctors can judge the severity of the stroke and therefore put patients into 3 categories: mild, moderate and severe.

The regular stream stroke rehabilitation is geared towards patients with moderate strokes; and are generally 19-75 in age. Typically, they are able to tolerate a minimum of 60 minutes of therapy per session and their overall expected length of stay is approximately 30-60 days. However, stroke rehab patients who are older than 75 years of age may also be suitable for regular stream stroke rehab if they are able to meet these tolerance benchmarks. Regular stream stroke rehab is also able to accommodate stroke rehab patients with severe strokes if they are younger than 55 years of age, able to sit supported for more than 30 minutes at one time and can tolerate a minimum of 30 minutes of therapy per session.

Read More

MR W.MERWE, (South Africa)
60 YEARS OLD

On 29th April 2008, my husband suffered from a major Ischemic Stroke and was totally paralyzed on his left side. His balance did not exist anymore, and he could not even sit. His swallow ability was affected and once he nearly died of it because of lack of knowledge.

He spent 34days in ICU where doctors fight for his life… After spending 7 weeks in hospital, we were called to a meeting where they told us that he would never be able to walk or use his left hand again and they could not tell us how long it will take to for him to start eating again. They also told us that due to his brain damage he is not able to read or write. They recommend that we put him in a rehabilitation facility 120km from home. I was devastated by this news. I had to make a decision and I decided to take him home and get help from a physiotherapist, an occupational therapist and a speech therapist.

I was so desperately eager to know more about stoke and its treatment that I started my search on the internet and found NeuroAid.  I sent them an e-mail to which they immediately contact me and I ordered a 3-month treatment. I received it within 5 days.

As my husband could not swallow, I opened the capsules and gave them to him through his feeding tube as indicated.

Within the next 10 days there was a major difference in his swallowing ability and his balance, and within a month the feeding tube was removed as he was able to eat again.  His leg is also starting moving! His long and short term memory is now perfect and he can even remember those tiny things that happen to him in hospital. His speech is also perfect and his facial expression has returned to normal. He is also able to take shower, shave and dress himself and is driving his car. As a keen gardener he is now even driving his frontend loader and does what he used to do.

His mobility in his left arm is also coming back and we believe within the next 3 months he will be able to use his left hand again.

He went to see the doctor who treated him in Pretoria, in December 2008, and was able to walk into his room.  The doctor was stunned and could not stop smiling. The doctor asked us to go to the rehab center and to show them this remarkable improvement, he also asked us to go to the wards and to show the patients that there is hope after a stroke.

We thank you NeuroAid and your team for the support during this difficult times and recommend NeuroAid to all stroke patients.

Is LTLD stroke rehabilitation right for you? LTLD stroke rehab is generally geared towards patients with severe strokes. This program is also appropriate for patients who may only have a moderate or mild stroke but are much older like more than 75 years of age. These patients often exhibit higher acuities, more complex care needs, higher resource needs, longer lengths of stay, and demonstrate slower gains in recovery. Depending on the age of the patients and severity of stroke, patients are able to tolerate between 20-30 minutes of therapy per session, and the average length of stay in LTLD stroke rehab generally ranges between 60-180 days.

Apart from the two factors like age and severity of stroke, if you have cognitive impairments and additional disorders or diseases that affect your ability to tolerate the intensity of a regular stroke rehab program, LTLD is a good alternative option. In summary, patients in need of LTLD stroke rehab may:

• Often have suffered from previous strokes
• Have multiple unfavourable disease conditions
• Lack relatively sufficient family support
• Have a sitting tolerance of not more than 5-10 minutes
• Present with aphasia
• Be disoriented with reduced judgment and insight
• Be incontinent

After all, you must be medically stable and demonstrate the potential to learn and improve function.

We are only aware of LTLD stroke therapy being available in Canada where it originated as of today. If you are available of other centres who practice LTLD, do let us know and we will make this information available to our newsletter subscribers.

Take the example of Toronto rehab center. LTLD rehab is provided by an inter professional team including physicians, nurses, physiotherapists, occupational therapists, speech language pathologists, pharmacists, an advanced practice clinician, service coordinator, social worker and other health professionals. 

Doctors in Toronto rehab insists on a very goal-oriented rehab program. When a patient arrives, the team works with them to establish some mutual goals and care givers track the success rate of these goals as one of the outcome measures. Patients will not see the drama of high-intensity rehab where significant changes occur in a shorter time. Progress is slow by nature of the type of patients.

It seems that the participants of this program appreciate this innovation. Sylvia, one of the patients under LTLD rehab program, said that LTLD rehab allowed her to regain her strength and confidence so she could once again live independently. “You need to accomplish things within your boundaries. That’s probably the most important thing to realize in this type of program—that people need to work at their own pace and participate as a member of the rehab team.”

Talk to your rehab experts f you are interested in the LTLD rehab program.

Sources:

Greater Toronto Area (GTA) Rehabilitation Network

Toronto Rehab magazine

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