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Arm squeezing with blood pressure cuffs may improve stroke recovery

Reuters Health - 08/10/2020 - Patients given the clot-busting drug tPA after a stroke may have improved recovery with the addition of repeated remote ischemic postconditioning, a new study suggests.

The therapy involves using blood pressure cuffs to repeatedly cut off blood flow, then restore it, over approximately 40 minutes, according to the report published in Neurology.

"Repeated remote ischemic postconditioning (RIPC) combined with clot-busting drugs, namely as IV tPA in this study, can significantly facilitate recovery of nerve function and improve clinical prognosis of patients with stroke," said Dr. Guoliang Li, an associate professor in cardiology at the Atrial Fibrillation Centre at the First Affiliated Hospital of Xi'an Jiatong University in China.

"The combined therapy of RIPC and IV tPA has a lot of advantages, such as being noninvasive, easy-to-use, cost effective, safe and feasible," Dr. Li said in an email. "However, more studies are needed to confirm that the combined therapy is safe and effective before this experimental combined therapy can be performed at home."

Previous research had suggested that RIPC might activate some of the body's natural defenses and protect against tissue damage that can follow a stroke.

To test the effects of RIPC, Dr. Li and his colleagues recruited 68 patients, average age 65, who were hospitalized after having an ischemic stroke. All the patients were treated with tPA within four-and-a-half hours of the stroke. Half the patients were then randomly chosen to also receive daily RIPC.

During RPIC, participants wore blood pressure cuffs on both arms for 40 minutes, with alternating cycles of five minutes of inflation and three minutes of deflation. The patients received RPIC twice a day during an average hospital stay of 11.2 days.

Stroke recovery was measured on a scale of 0 to 5, in which a score of 0 represents no symptoms, 1 represents no significant disability despite some symptoms, and 2 represents slight disability leading to a patient being unable to participate in all their previous activities. Scores of 3 to 5 represent moderate to severe disability. Patients scoring 0-1 after three months are considered to have had a favorable recovery.

Three months after their strokes, 71.9% of the patients who received RPIC (23 out of 32) had scores representing a favorable recovery as compared to 50% (17 out of 34) of those who did not get therapy. After adjusting for age, stroke severity, and other factors that might affect recovery, the researchers found that patients who received RPIC were more likely to have a favorable recovery (adjusted risk ratio, 9.85) than those who did not.

The two patients who dropped out of the RIPC group because they could not tolerate the treatment -one due to skin redness and the other who was uncomfortable with the cuff pressure - were excluded from the analysis.

The researchers also found significantly lower S100 plasma levels and higher vascular endothelial growth factor levels in the RIPC group than in the controls.

It's not known exactly how RIPC might help, but Dr. Li has some ideas.

"The molecular mechanism of RIPC remains elusive and may be multifactorial," he said. "Previous work showed that RIPC plays an important part in the regulation of the inflammatory response, oxidative stress, vasodilatation, and apoptosis by releasing or inhibiting inflammatory cytokines, antioxidant proteins, vasodilators, and other neuroprotective substances from both the local position and brain. In addition, RIPC can improve the prognosis of stroke by promoting the collateral circulation in brain."

The new study is "very interesting," said Dr. Fan Z. Caprio, medical director of the stroke program at Northwestern Memorial Hospital in Chicago.

"It's a very novel approach," said Dr. Fan. "I would be interested to see if the results could be replicated in a larger study. I'd like to see a study that was really inclusive in order to generalize the findings to our stroke population."

Until then, Dr. Fan doesn't think anyone should be trying this therapy on their patients outside of a clinical trial. "This is still in the experimental phase," she said. "They showed it was relatively safe in that only two dropped out because of mild side effects, but again, this is a small cohort of patients."

By Linda Carroll

SOURCE: https://bit.ly/2Gu993m Neurology, online October 7, 2020.

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