Session Chairs: Julie Bernhardt, Australia and Christina Jern, Switzerland

Report by Prof. Dr. Zdravka Poljaković, Croatia

This session was chaired by professor Julie Bernhard from Australia and professor Christina Jern from Sweden and introduced by prof Bernhardt. There were five lectures on the program, covering some new insights in the field of recovery and rehabilitation. The session had various topics, which opened some new doors and inspired the audience to join this developing field.

The New International Stroke Recovery and Rehabilitation Alliance: Goals And 5-Year Plan to Advance Recovery Science

First lecture by prof Bernhard explained to the audience The New International Stroke Recovery and Rehabilitation Alliance (ISRRA) and its goals. The main aim of this Alliance is to support and encourage high-quality clinical trials in biology of recovery, to encourage structured process of care (rehabilitation), shift it more to the acute phase of stroke as well as to take care about cost benefit of rehabilitation and recovery processes. One of the goals would also be to organize centers of Clinical Excellences in order to provide higher level of structured rehabilitation.

In the next lecture, Anna-Sophia Wahl a Branco Weiss Fellow (ETH Zurich) and Junior Group Leader at the Brain Research Institute, presented her point of view considering targets for next clinical trials. In her talk she concentrated on several points for clinical trials: intrinsic repair, plasticity and behavioral modifications. Of special interest in the on-going trials is the investigation of the possibilities of enhancing spontaneous recovery with a specific therapy (forming of meaningful spreading) as well as to study the connection between the hind and fore  limb (which might share the same neuronal network).

Recovery Clinical Trials at A Crossroads: Rethinking Trial Designs

Kate Hayward from Melbourne presented some pitfalls in the clinical trial designs, as well as some typical mistakes which can mislead the outcomes of the trial. She presented also some usual models of clinical trials with its possible advantages and disadvantages especially talking about rehabilitation trials.

Cognition: Recovery Epochs, Therapeutic Windows, Biomarkers and Candidate Therapies

Especially interesting topic was covered in the next lecture from dr Clarkson  a behavioural neuropharmacologist and lecturer of neuroanatomy from New Zealand, whose main interest are cognition and cognitive impairment. In his comprehensive overview of anatomy and physiology of cognition, as well as cognitive impairment after stroke he showed also results of recent investigations considering the importance of white matter lesions and reactive astrogliosis in cognitive impairment, importance of prefrontal cortex stroke in delayed onset stroke dementia and small vessel disease and silent strokes in impairments of some special functions, like odor preference.

The Promise of Recovery Genetics: Hope Or Hype

The session ended with a highly „up to date“ topic, namely recovery genetics, a lecture given by professor Jern from Sweden. In this new field in stroke, a lot of research has been done in the past 20 years. Therefore, in 2007., the International Stroke Genetics Consortium (ISGC) was formed, in order to conduct and encourage clinical studies for genetic in stroke. One of the largest studies, MEGASTROKE, brought news to this field by discovering 35 novel loci associated with stroke alone, and some even associated with specific types of stroke. However, „recovery genes“ are still to be discovered. As stroke outcome vary widely, which can not be explained by known factors, the question about existance of genes which might influence the outcome remains open. Several studies showed conflicting results although at least one showed that some alleles were associated with worse stroke outcome. Furthermore, as injury and recovery operate in different time windows and through different pathways, it is highly possible that different gene variants may be at play at different time points. This hot topic so remains open, which is one of the most important reason why the Global Alliance for ISGC is formed in order to facilitate data sharing and collaboration of international groups and researchers dealing with stroke genetics.

In conclusion to this session – in the stroke world, recovery is the primary goal. However, as even advanced methods of acute therapy are not always sufficient to achieve good results advancing the science of recovery and rehabilitations remains crucial for a large percent of the stroke patients.

Session Chairs: Julie Bernhardt, Australia and Friedhelm Hummel, Switzerland

Report by Prof. Dr. Zdravka Poljaković, Croatia

Maybe the best way to describe this session in few words would be: challenging topic itself, with excellent presentation of controverse opinions decorated with highly interesting discussion, lot of questions and respectable number of listeners (more than 500).

Brain Repair Is the Right Target to Improve Outcome or Brain Repair Does Not Work, Reorganisation Is Key?

The session started with the lecture of professor Krakauer from The Johns Hopkins University who presented his view of recovery model, based on training-induced recovery without reorganization of cortex. According to this opinion, recovery of function is a result of  recovery of preexisting cortico-subcortical connections. The CON part was presented by  dr Ballester, a post-doctoral researcher from IBEC, Spain, with the main message: „early behaviour training drives the recovery“, explaining also the importance of critical time-window for rehabilitation (which is much more than preassumed 6 months, probably even much more than 1 year).

The More the Better – More Therapy Can Improve Recovery or It’s Just Spontaneous Recovery – Therapy Only Drives Behavioral Compensation?

Further PRO and CON part of the session continued with the lecture of prof Ward from UCL Queen Square, whose  respectable work in the field of brain recovery and rehabilitation is widely recognized for long time. Prof Ward spoke about the importance of precise evaluation of duration of the specific therapy and measurement of recovery. In his lecture he managed to convince the audience that more therapy improves recovery, but only if we really understand the words „more“, the complexity of specific „therapies“ as well as the meaning of „recovery“ considering possibility of participation in certain activities and behavioral repairment (especially if we believe that behavioral repair requires neural repairment). Professor Kwakkel, from Amsterdam University Medical Center, presented on the other hand his opinion about recovery potentials, which is based on the model of spontaneous recovery potentials during time. Using the well known „Time is brain“ model, he explained the importance of time impact in the process of recovery and clinical improvement after stroke in acute, subacute and chronic phase. According to his work, significant changes (improvement) occur in the first weeks after stroke (up to ten weeks), meaning that spontaneous recovery is the clue, and that time changes explain up to 90% of variations in the outcome. Therapy is than not so much interaction and neural repairment but learning of new ways of coping, it is actually a way of compensation of the lost abilities.

Non-Invasive Brain Stimulation Is Getting Close to Clinical Application for Stroke or Non-Invasive Brain Stimulation for Stroke Recovery Has Failed?

Finally, the last two speakers talked about non-invasive brain stimulation in stroke, showing the possibilities of this  therapy, as well as limitations. The first talk from prof Thiel from McGill University in Montreal, a stroke neurologist, concentrated mainly on repetitive transcranial magnetic stimulation (rTMS) and influence of this method to recovery of motor functions and speech disturbances in subacute and chronic phase after stroke. In his talk he presented good results of the method, still with the conclusion that further studies are necessary to prove those results, as well as define the exact time of starting and ending this sort of rehabilitation. The last speaker, dr Branscheit from University Hospital Zurich, presented a critical review of the most important studies in the field of non-invasive brain stimulation in stroke, whose main concerns are apparently small samples, „one-size fits all“ approach and short time of follow-up. In her conclusion slide she emphasized that the rational of the studies should be stated very clearly, that also technical facts must be systematically assessed and that trials must be designed to fit one or two features (and not more) as well as be long-lasting.

After the lectures, the session chairs opened the Q&A session and discussion. As already said, it was a lot to ask, and a lot to discuss. The whole session lasted nearly two hours. And there was more left to say…