Organization of stroke care in Japan

Takafumi Kubota^1,2, Arsalan Anwar^3, and Sidra Saleem³

1.     Department of Neurology, Teine Keijinkai Hospital, Sapporo, Japan
2.     Department of Neurology, University Hospitals of Cleveland Medical Center/Case Western Reserve University, OH, U.S.A.
3.     Department of Internal Medicine, Dr. Ruth Pfau Hospital, Karachi, Pakistan.

Abstract

In Japan, stroke is one of the major health problems. In particular, stroke has become a major factor in disability-adjusted life-years as the population ages, and is a significant burden on medical expenses. Therefore, Japan makes many efforts to lower age-adjusted mortality from stroke and extend a healthy life expectancy.

Stroke is the second most common cause of mortality and disability-adjusted life-years (DALYs), worldwide [1]. In Japan, the mortality rate of stroke has declined from 180 per 10000 in 1970 to 87 per 10000 in 2018, however, it still remains the fourth most common cause of death after cancer, cardiovascular disease, and senility [2]. The DALYs impact produced by this disease is 30% of the Japanese population. Therefore, the economic health care burden produced by stroke is 1.56 trillion dollars in health costs and 1.74 trillion dollars in nursing care costs [3]. The subtypes of ischemic stroke have also been changing. In the last four decades, as a result of changes in the salty traditional diet to the western fatty diet as well as the prevention of hypertension, the incidence of lacunar infarction in ischemic stroke steadily declined by 59% for men and by 28% for women [4]. On the other hand, the percentage of cardio-embolic and atherothrombotic stroke in ischemic stroke increased from 44.9% in 1984-1998 to 60.7% in 1998-2000 [5]. 

  The decline in stroke incidence is due to the contribution of Japan Stroke Society (JSS), which was established in 1975. It has provided a wide range of initiatives such as acute care, prevention, education, and rehabilitation. Currently, the JSS works with the Japanese Circulation Society (JCS) on two main goals to improve individual lives and reduce the economic burden. The first goal is to lower age-adjusted mortality from stroke and cardiovascular disease by 5% in 5 years and by 10% in 10 years.  The second goal is extending a healthy life expectancy. To achieve these two goals, the JSS has five strategies as follows; (1) Human resource development, (2) Enhancement of the medical system, (3) Promotion of registration business, (4) Prevention, and (5) Strengthening of clinical and basic research [6].   

  In Japan, there are 1,369 certified training institutions of the Japan Neurosurgical Society, the Japanese Society of Neurology, and/or the JSS. The institutions are divided into two types of the center. First, the primary stroke center (PSS) can perform standard evaluations such as MRI or CT and treatment including recombinant tissue plasminogen activator (rtPA) at any time in twenty-hour seven.  The necessary requirements for PSS were published in 2017, and the application of the primary stroke center was started in July 2019. Second, the comprehensive stroke center (CSC) is capable of advanced neurosurgery, endovascular surgery, stroke care unit and/or intensive care unit in addition to PSS requirements. The distribution, number, and mutual relationship of each other will be organized within a few years [3,7-9].

  For functional recovery after acute stroke care, rehabilitation medicine for stroke in Japan has improved since the beginning of the convalescent rehabilitation ward in 2000.  The patients can be hospitalized for rehabilitation up to 180 days with national health insurance, 3 hours per day including weekends of rehabilitation.  The convalescent rehabilitation hospitals have increased up to 1,348 hospitals and 76,631 beds (60 beds per 100,000) in 2015 which can cover the demand of 25 beds per 100,000 [10].  After being discharged from the convalescent rehabilitation hospitals, the patients are treated by the regional comprehensive care system such as outpatient clinics, visiting nursing stations, and home rehabilitation [7].

  The JSS also actively works to prevent stroke through lifestyle modifications and educating people about prevention. The prevention is primarily divided into four stages based on the severity as follows; (1) Improvement of lifestyle through public education, (2) Intervention for lifestyle-related diseases through primary care, (3) Early detection and intervention of stroke, and (4) Decrease in the mortality associated with stroke.  The JSS sets each goal in four stages and monitors the results [7].

  In conclusion, Japan is aware of the impact of stroke on individual life and economic burden. In the last 40 years, Japan makes many efforts to lower age-adjusted mortality from stroke and improve the outcomes.

Reference

[1]  Johnson CO, Nguyen M, Roth GA, Nichols E, Alam T, Abate D, Abd-Allah F, Abdelalim A, Abraha HN, Abu-Rmeileh NM, Adebayo OM. Global, regional, and national burden of stroke, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. The Lancet Neurology. 2019 May 1;18(5):439-58.

[2]  Statistics and Information Department, Ministry of Health, Labor and Welfare (MHLW), Japan. Overview of Demographic Statistics Monthly Report  2018. https://www.mhlw.go.jp/toukei/saikin/hw/jinkou/geppo/nengai18/dl/gaikyou30.pdf.  (accessed Dec 23, 2019).

[3]      Toyoda K, Sonoda K, Sato S, Yoshimura Sl. The Japan Stroke Databank Current stroke care in Japan and ideal stroke registries. Shinkeichiryo 2018;35(3)192. https://www.jstage.jst.go.jp/article/jsnt/35/3/35_188/_pdf/-char/ja. (accessed Dec 23, 2019).

[4]     Kubo M, Kiyohara Y, Ninomiya T, Tanizaki Y, Yonemoto K, Doi Y, Hata J, Oishi Y, Shikata K, Iida M. Decreasing incidence of lacunar vs other types of cerebral infarction in a Japanese population. Neurology 2006;66:1539–1544

[5]      Yukito Shinohara. Regional Differences in Incidence and Management of Stroke – Is There Any Difference between Western and Japanese Guidelines on Antiplatelet Therapy?. Crebrovasc Dis 2006;21(suppl 1):17–24 DOI: 10.1159/000090358

[6]      Kokubo K.  Changes in stroke Japan and other countries.  Japanese Journal of Cardiovascular Disease Prevention 2017; 52(3) 223-232.  http://www.jacd.info/library/jjcdp/review/52-3_01_%20kokubo.pdf. (accessed Dec 23, 2019).

[7]      The Japan Stroke Society.  5-year plan to overcome stroke and cardiovascular diseases. http://www.jsts.gr.jp/img/five_year_plan.pdf.  (accessed Nov 23 2019).

[8] Iihara K, Nishimura K, Kada A, Nakagawara J, Ogasawara K, Ono J, Shiokawa Y, Aruga T, Miyachi S, Nagata I, Toyoda K. Effects of comprehensive stroke care capabilities on in-hospital mortality of patients with ischemic and hemorrhagic stroke: J-ASPECT study. PloS one. 2014 May 14;9(5):e96819.

[9] Toyoda K, Inoue M, Koga M. Small but steady steps in stroke medicine in Japan. Journal of the American Heart Association. 2019 Aug 20;8(16):e013306.

[10]      Miyai I.  Update on stroke rehabilitation.  Shinkeichiryo 2016;33(3)389-393. https://www.jstage.jst.go.jp/article/jsnt/33/3/33_389/_pdf. (accessed Dec 23, 2019).

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Seven minutes in stroke - Dr A Antonio Arauz

Dr A Antonio Aruz

Stroke Clinic

Instituto Nacional de Neurologia y Neurocirugía Manuel Velasco Suárez

Mexico City

1. What inspired you towards neuroscience?

Honestly, my first option was cardiology, but I was accepted into a great Mexican Neuroscience Institution (Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez) and there I began to deepen in Neurosciences. It has been a great adventure. The challenge of neurological diagnosis, the exact location of brain lesions, based on clinical findings. The breakthrough in diagnostic and treatment methods are fascinating. 

2. Why stroke?

Stroke is one of the leading causes of death in Mexico, but mainly it is the leading cause of disability. In the 80s the study of patients with stroke was completely different, but it was a major clinical diagnostic challenge. That’s why I decided cerebrovascular field.  I’am lucky to have witnessed the great changes in the diagnosis and treatment of stroke. At the beginning (20 years ago) that I began the study of cerebral vascular diseases, there was little that could be done in the acute treatment of ischemic stroke. Things are now, totally different. 

3. What have been the highs so far?

To be able to work in a multidisciplinary team, including neurosurgeons, interventionists and rehabilitation specialists, and with colleagues from other countries, in multinational groups, but mainly participate in the training of medical doctors, neurologists, and stroke neurologists.

I still feel excited that our manuscripts are accepted and see them published. And of course, seeing the recovery of a patient after stroke is always a great achievement. 

4. What have been the lows?

It has always been frustrating to have nothing to offer to our patients and this is frequent in many cases. Although there are great advances in acute ischemic stroke, there is little we can do in intracerebral hemorrhages, in some vascular malformations, etc. 

Driving change in the national/local stroke care system it is often frustrating. The public policies in my country are almost impossible to modify and try to have an acute stroke treatment system, is still a pending issue in Mexico. 

5. How do you balance work life with the needs of home life?

It is always a challenge. In my case, it has been changing over time, with the different stages of growth of my sons. However, family is always the priority. Thankfully my wife Alma, and my son’s Eduardo and Fernando have been very supportive.

6. Who are your most important mentors and how did you find them?

I am very grateful to Fernando Barinagarrementeria for introducing me to the field of vascular Neurology. Over the time Fernando has been not only an academic mentor. He has been a friend and I have had the privilege of sharing with him many projects, meetings, trips, as well as discussions about stroke, politics and life itself.

During my time as a Neurology resident, in addition to Fernando, there were some other professors who undoubtedly influenced my training. 

7. What are your most important collaborations and how have you built them?

I am also fortunate to have been able to have very important collaborations. For example with Peter Sandercook and the IST3 group, or in the SPS3 project with Oscar Benavente and Bob Hart. 

Other important collaborations have arisen from my interest in arterial dissections and cerebral venous thrombosis in our population, which has allowed us to participate in collaborative work groups. 

More recently in the ESUS working group and NAVIGATE ESUS trial. Although this was a negative trial, it has generated many manuscripts published in high impact journals. A good example is the sub-analysis of the regional, sex and age differences in Diagnostic testing published in International Journal of Stroke. 

These collaborations have been built by the publication on specific topics, by reference of other colleagues or by previous collaborations. 

Dr George Ntaois on 'Oral anticoagulation versus antiplatelet/placebo for stroke prevention in patients with heart failure and sinus rhythm'

PODCAST release: Dr George Ntaois on 'Oral anticoagulation versus antiplatelet/placebo for stroke prevention in patients with heart failure and sinus rhythm'

Link to article here

Seven minutes in stroke - Dr Xia Wang

Dr Xia Wang in collaboration with Dr Tom Moullaali and Professor Rustam Salman at the University of Edinburgh submitted the article 

‘Who will benefit more from low - dose alteplase in acute ischaemic stroke?’ to the International Journal of Stroke. Dr Wang answered our Seven minutes in stroke giving us a little insight into where our stroke researchers and clinicians began their relationship with stroke.

1. What inspired you towards neuroscience?

Neuroscience is pretty cool! It is one of the last great frontiers of knowledge spanning from molecules, through cells and pathways, all the way up to complex human behaviour. Clever neuroscience tricks have been applied to all the aspects of our lives. For example, Instagram used it in the logo design to appeal to human being’s subconscious minds. The thick white line of the camera on the logo against the rich colourful background creates high levels of eye-catching visual saliency. Designs that are visually salient get looked at earlier, more often, and for longer.

2. Why stroke?

Stroke is the leading cause of death in China, with the country accounting for roughly one third of worldwide stroke mortality. Stroke burden is much higher in northern rural area where I am from. Compared with other parts of China, the prevalence of major risk factors for stroke remains high; the salt intake is much higher; tobacco use is highly prevalent; the awareness rate, treatment rate, and control rate of hypertension and diabetes are low. After stroke, stroke care quality and secondary prevention are all in a very low quality therefore the recurrent stroke rate is higher. Stroke research could help me to understand this area more and helpful to tackle the great challenge in my hometown.

3. What have been the highs so far?

I have produced 20 publications in the last 2 years including in lead international journals – NEJM, Lancet, Lancet Neurology, and JAMA Neurology.  The new knowledge I produced has been recognised by 39 countries across 5 continents of Asia, Europe, North America, South America, and Australia.  It has been adopted by 160 academic institutes/industries and influenced beyond medicine area in other 12 area including Engineering, Agricultural and Biological Sciences, and Computer Science.

The paper I co-authored – from the ENhanced Control of Hypertension And Thrombolysis strokE stuDy (ENCHANTED) – has been cited by multiple clinical practice guidelines including the American Heart Association (AHA)/American Stroke Association (ASA). Australian Commission on Safety and Quality in Health Care found a profound reduction of healthcare cost of ADU $50 million per year through improvements in patient outcomes by applying ENCHANTED findings in Australia (http://apo.org.au/node/100526). I presented a subgroup analysis in the plenary session in European Stroke Conference in Milan in May.

4. What have been the lows?

Pressure from multiple applications including grants and fellowship to do every year, hard feelings from rejections and insecurity of funding.

5. How do you balance work life with the needs of home life?

I like cooking and swimming in my spare time, really look forward to hanging out with friends on the weekend.

6. Who are your most important mentors and how did you find them?

Professor Craig Anderson.

An email attached my resume with emphasis on excellent statistical skills reached Professor Craig Anderson in 2012. Then he decided to offer me an opportunity to be the statistician for INTERACT2, moved me from HIV research to stroke.

7. What are your most important collaborations and how have you built them?

Collaboration with Dr Tom Moullaali and Professor Rustam Salman at the University of Edinburgh

I co-supervised Dr Tom Moullaali while he was undertaking the visiting scholar at the George Institute Australia in 2016 and 2018. We worked on individual patient data (IPD) meta analysis on blood pressure (BP) lowering treatment for acute intracerebral haemorrhage and the paper has been accepted by Lancet Neurology. Prof Rustam Salman, the supervisor of Dr Tom Moullaali, worked closely with me during his sabbatical leave at the George Institute Australia in 2014. We have co-authored some papers. I have applied an exchange award from the National Heart Foundation, if successful, it would be a great opportunity to visit them and immerse myself in a different research institute environment.

Seven minutes in stroke - Dr Li Xiaofeng

In the coming weeks we will online publish the article Granulocyte Colony-Stimulating Factor and Stromal Cell-Derived Factor-1 Combination Therapy: A More Effective Treatment for Cerebral Ischemic Stroke the subitting author Dr Li Xiaofeng has answered our Seven Minutes in Stroke. 

1. What inspired you towards neuroscience? 

Neuroscience is the final frontier of the human body, and many mysteries remain to be revealed. Most importantly, there are many intractable neurological diseases, such as AD, PD and stroke, that still need to be further investigated to elucidate the mechanims and develop new therapeutic strategies. 

2. Why stroke? Among those intractable neurological diseases, stroke is currently the first cause of death in Chinese residents. Currently, one person has a new stroke every 12 seconds, and one person dies of a stroke every 21 seconds. My grandfather died of ICH, so I chose neurology as my profession after graduating from college, and I hope I can devote myself  and make my contributions in stroke research and clinical treatment.

3. What have been the highs so far? Our research team will be very excited when our animal experiments have made significant progress. The conclusion of our study are useful for guiding clinicians in clinical practice. Although the results cannot be used directly in the clinic, the can allow clinicians to keep thinking and be prudent in their treatment, which is a good thing for patients.

4. What have been the lows? The data obtained from our current study in animas cannot be immediately applied in clinical practice. The safety and side effects of drug combinations in our study are unknown, and further preclinical studies and clinical trials are needed for translation.

5. How do you balance work life with the needs of home life? I have always regarded the work of neurology as an interest rather than just a career, doing a good job at work time, taking care of my family during the rest time, and taking neuroscience research as an interest if there is extra rest time.

6. Who are your most important mentors and how did you find them?

Professor Mei YuanWu, Department of Neurology, Union Hospital of Huazhong University of Science and Technology, was my doctoral tutor. As of this year, Professor Mei has been working in neurology for 50 years. I met him at a domestic stroke meeting. I studied at Union Hospital for three years.

7. What are your most important collaborations and how have you built them? In 2005, our neurology department established a cooperative relationship with the Department of Neurology of Tiantan Hospital. Professor Wang Yongjun of Tiantan Hospital has been a visiting professor of our hospital. I met Professor Wang in 2002 and studied in Tiantan Hospital for half a year. Professor Wang is the first scholar to promote the Stroke Unit in China. I respect Professor Wang and his achievements in the field of stroke prevention in China.

Li Xiaofeng

Chief physician

Department of Neurology,The People's Hospital of Guangxi Zhuang Autonomous Region,  China.        

                 

Seven Minutes in Stroke - Benjamn T. King

Dr Benjamin King from  the Department of Neurology, Dell Medical School and the University of Texas submitting author of the manuscript 'Optimal Delay Time to Initiate Anticoagulation after Ischemic Stroke in Atrial Fibrillation (START): methodology of a pragmatic, response-adaptive, prospective randomized clinical trial.' published in the International Journal of Stroke. 

1.      What inspired you towards neuroscience?

Unsurprisingly, I came to the field of neuro-epidemiology in a roundabout way, but the neurosciences were always a focus. My undergraduate program at Bard College provided the opportunity to partner with a team building a zebrafish neuroscience lab from the ground up. I was thrilled by my time studying the mechanism of addiction in this model, but I was also determined to move on to human subjects research. From there I went to work at inpatient psychiatric care facilities for a while, but never left the mind/brain question behind.

2. Why stroke?
As we all know, stroke results in a massive amount of disability and death. Public health training recognizes the benefits of addressing the largest drivers of disease burden such as this. Moving the needle even slightly in the prevention, care, or recovery from stroke can lead to inflated population health benefits. I was developing and managing research in emergency medicine when our first acute ischemic stroke trial came along.  It didn’t take long before that became our focus.

I'm lucky to really love the work I do

3.      What have been the highs so far?

I’m lucky to really love the work I do. There is something special that happens when a completely new research question gets introduced – usually when one of my clinician partners kicks down my door out of the blue – and we get to start solving a design question from scratch. There is also a great feeling when you get to see the work you do as an epidemiologist lead to changes in service delivery.  Add to that any and every time I get to take a crack at a clean dataset …and there are too many highs to count.

4. What have been the lows?
Peer-reviewed rejections of grant proposals never seem to get easier.  I’m proud of our wins, but I’m still learning to shake off the losses.

5. How do you balance work life with the needs of home life?
My wife and I both work long hours. She has a background in social work, from before her law career, and does a good job of reminding both of us about the importance of self-care. Setting aside time for ourselves is key. It requires hard work at both ends of the spectrum.

6. Who are your most important mentors and how did you find them?
Dr. Truman Milling hired me to build the Emergency Medicine research program in Austin and we have been working and writing together ever since. It is a truly rare thing to find a clinician with his gift for writing and the technical aspects of research design. When Dr. Steven Warach relocated to Austin from his position as the head of intramural research at NINDS our team leapt at the chance to manage his research program. I have been benefiting from his leadership ever since.  His perspective and insights have literally helped to shape the modern era of vascular neurology practice.

Finally, my epidemiologic training was mentored by some of the greatest methodologists in both epidemiology and biostatistics. My doctoral advisor, Dr. Steven Kelder, has shown me over and over that the field of epidemiology can be used to enact real, systemic changes by studying and testing solutions to complex problems. I first met Dr. Kelder during the master’s program, when I walked into his office unannounced and asked for a job… over a decade before asking him to be my advisor.

7. What are your most important collaborations and how have you built them?

As an epidemiologist I get to work in and around a lot of different specialties. One of my favorite endeavors is the collaboration built to connect our work in the tertiary care setting with housing and homelessness service agencies in our local community. In fact, my dissertation was a deep dive into the psychometric and validation testing of a popular vulnerability score measure used for housing resource prioritization. Honorable mentions go to our collaborators in the Lone Star Stroke Consortium, my partners in the Dell Medical School’s Department of Population Health and the Division of Psychology.

Seven Minutes in Stroke - Dr James Siegler

Dr James Siegler is the submitting author for the paper ‘CT perfusion in stroke mimics’ to the International Journal of Stroke which has been published online and allocated to the April edition of the journal for 2020. 

We asked Dr Siegler to tell us a little bit about himself in our Seven Minutes in Stroke professional series.

1. What inspired you towards neuroscience?

In high school, I was drawn to biology. At the time, my whole family began to seriously address the dementia symptoms of my great grandmother (who lived to be 106!), and I had wondered why this was. How could such a presumably healthy and active woman spend the remaining few years of her life in a memory fog? In college, my interest in neuroscience solidified as my questions were answered--and yet, even more questions emerged. So began my lifelong quest to understand the brain and the mind.

2. Why stroke?

In medical school, the most accomplished and supportive neurology mentor I could find was a stroke specialist. Dr. Sheryl Martin-Schild who was a recent addition to the Tulane faculty and soon after her appointment as the Stroke Director she led the team to swift approval as a Comprehensive Stroke Center. I initially found stroke interesting on a research level (only later came to enjoy it clinically). At the time, we were exploring the effects of combination antiplatelet therapy for secondary stroke prevention, extending the window for intravenous thrombolysis, and investigating unique tools for endovascular thrombectomy. It would be an understatement to say that stroke was witnessing a revolution in diagnosis and treatment.

3. What have been the highs so far?

Since my initial foray into stroke, as everyone knows, we are closing PFOs, expanding our knowledge of how to manage strokes due to unknown mechanisms, optimizing antiplatelet therapy for secondary stroke prevention, and we can now safely and effectively treat large vessel occlusions up to 24 hours after onset. With the exception of development of the head CT or the testing of alteplase, I can't think of any better "highs" in stroke research or clinical practice.

As far as my personal highs, I have been honored to participate in a number of these pivotal stroke trials (POINT, DEFUSE-3, NAVIGATE-ESUS, ARCADIA) and collaborate with some of these investigators in my own research. Learning from them has been instrumental to my career as a junior researcher.

4. What have been the lows?

Nothing out of the ordinary to say here; difficulties with a rigorous internship, challenges inherent to inflexible mentors. However, some of these are vital to our personal growth and they are informative of our roles as medical educators and leaders.

5. How do you balance work life with the needs of home life?

My wife and I have been fortunate enough to have recently given birth to our first daughter, Sofia, on June 29. My wife, Erika, has been BEYOND phenomenal in caring for our baby girl, and has always supported my academic interests. As a junior clinician, I can't say I've figured it out just yet. But from my early days as a Hopkins undergraduate, where I double majored in neuroscience and history of medicine, worked every semester in some sort of research lab, and still made time to find employment to pay for my room and board, I was forced into a life of efficiency and pragmatism. Taking these things with me through medical school and residency, and building on them, has helped me balance home life with work requirements and academic productivity.

‘If there is ever a choice to be made between life and work, 9 times out of 10 I will choose life.’

6. Who are your most important mentors and how did you find them?

Without a doubt the most instrumental mentor in my early career was Dr. Sheryl Martin-Schild. She took me on as a research assistant as a first-year medical student, where I worked with 3 other medical students developing a local stroke registry at Tulane University School of Medicine. Four years later, our team had grown to nearly 30 students and neurology residents, and we had published more than 20 original research papers. 

I have to admit that none of my grades or test scores have ever attracted anyone's attention. I've always considered myself a hard worker, but somehow I could never get past some sort of ceiling created by multiple choice tests. Clinical research provided me with an opportunity to cultivate new skills, and I am so grateful for every mentor who has helped me along the way. No doubt because of our productivity at Tulane, I was able to match at the Hospital of the University of Pennsylvania and collaborate with internationally renown stroke researchers like Scott Kasner, Steve Messe, and Brett Cucchiara, as well as junior faculty Mike Mullen and Chris Favilla. Not to mention the unparalleled research support team of our stroke division!

7. What are your most important collaborations and how have you built them?

While I have been lucky to collaborate with many clinicians, scientists, statisticians, and other researchers, I believe my most important contribution to neurology and my most important collaborations have involved online medical education. As a senior neurology resident at the Hospital of the University of Pennsylvania, and an avid cyclist (spending hours and hours on my bike listening to a variety of music and podcasts) I thought it would be more useful to spend that time listening to clinical content. The state of podcasting in neurology back in 2015 was far less developed than podcasting in other medical disciplines (e.g., emergency medicine and internal medicine). I wanted to create something better.

So I recruited some amazing teachers and friends in neurology to help me produce my own neurology podcast, BrainWaves. Michael Rubenstein, Ali Hamedani, and my wife Erika Mejia, have all been HUGE collaborators and supporters in this regard. Without their help, we would not have been able to produce more than 170 episodes of this podcast with more than 300,000+ downloads. By the summer of 2019, we have collaborated with more than 70 unique clinicians and scientists across the US and internationally to generate this impressive body of work that targets trainees in neurology and medicine.

How have I built these collaborations? I ask nicely. :-) A carrot works better than a stick. It also helps to say "Your episode will be listened to by more than 2,000 people." For better or worse, I find this far more impactful than the majority of my research publications...

Cerebral microbleeds: beyond the microscope. Vincent Berezowski PODCAST

Cerebral microbleeds: beyond the microscope. Vincent Berezowski

Link to the article published in the International Journal of Stroke



Downloading podcasts from IJS HERE

Breaking Up Sitting Time after Stroke (BUST-Stroke)

Coralie English (@Coralie_English) 

Frequent, short bouts of exercises in standing can reduce your blood pressure after stroke

We have all heard the media stories about the dangers of sitting time ‘beware the chair’, ‘sitting is the new smoking’ and other such sensationalized headlines. Is there any truth to such statements and what, if anything, is the relevance to stroke recovery? Firstly, yes there is some truth to the headlines. 

While comparisons to the health risks of smoking are nonsensical, we do know that spending long periods of time sitting down each day is not good for you, particularly if you are also not getting enough exercise of the ‘huffing and puffing’ type. In fact, a large meta-analysis of data from over 1 million adults published in The Lancet in 2016 showed that amongst those people with the lowest levels of ‘huffing and puffing’ exercise, higher levels of sitting time were associated with a very large increase in the risk of cardiovascular disease. This is relevant for people with stroke for two reasons. 

• First, people with stroke are at particularly high risk for recurrent stroke and other cardiovascular diseases. 
• Second, we know that people with stroke fit this profile of very low levels of physical activity and high sitting time ((click here for link)). 

So, what can we do about it? 

Breaking up sitting time with frequent, short bouts of light intensity activity (e.g. exercises while standing or walking) may help. Studies in other population groups have found beneficial effects for this approach. 

My group has just completed the first ever study of this approach in people with stroke. We conducted a trial under tight experimental conditions and found that when stroke survivors stood up every 30 minutes and performed 3 minutes of light intensity exercises in standing (mini-squats, toe raises and marching on the spot), they had lower blood pressure over the day, compared to sitting continuously for 8 hours. Most importantly, this benefit occurred even in people who were taking blood pressure lowering medications. This is an important finding, because high blood pressure is the leading risk factor for stroke, and every small reduction in blood pressure reduces risk. Of course, doing standing exercises strictly for 3 minutes every half-hour each and every day is not feasible. Our group is now testing more practicable doses of exercises and their effects on blood pressure. In the meantime, ‘move more, sit less’ is a good mantra to live by for all of us!

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