Podcasts about practical neurology

  Episode: 140 Taking Charge After Stroke: Self-Determination and Recovery with Vivian Fu   In this episode you will discover: ● The Conversation Is the Intervention — A structured, facilitated conversation that centers a person's identity, hopes, and vision for their best day produces measurable improvements in quality of life and independence a year after stroke. Connection isn't soft — it's evidence-based. ● Reframe the Expert in the Room — Take Charge asks clinicians to resist offering advice, validation, or direction — and to trust that the person with stroke already holds the wisdom they need. The hardest part of the facilitator role is staying out of the way. ● Self-Determination Is Not a Luxury — When people with stroke are supported to set their own direction, outcomes improve, costs decrease, and the effects last for years. Building systems that protect that autonomy isn't idealistic — it's what the data demands.   Welcome to the Aphasia Access Aphasia Conversations Podcast. I'm Katie Strong from Central Michigan University and a member of the Aphasia Access Podcast Working Group, a community dedicated to supporting better aphasia care.   Today I'm speaking with Dr. Vivian Fu, a stroke neurologist living and working in Kelowna, British Columbia, the unceded territories of the Syilx / Okanagan people. Vivian trained in Aotearoa New Zealand, where she completed her PhD running the Taking Charge After Stroke trial. Take Charge showed that people with stroke who were supported to follow their own self-determination had much better quality of life and independence a year after their stroke. The second Take Charge RCT showed that two sessions about six weeks apart produce better outcomes than one session. Vivian strives to embed the Take Charge philosophy in her daily practice, and is focused on improving access to high quality stroke care for rural, regional, and underrepresented populations.   I have been looking forward to this conversation. What drew me to Take Charge was how it reframes the question entirely — from what does the clinician do for this person to what does this person want for their own life. That shift is deceptively simple, and as you'll hear, the evidence behind it is anything but.   Let's get into it.   Katie Strong:  Welcome, Vivian. Vivian Fu: Thank you so much for having me, Katie. I'd like to start off with my Pepeha. This is an introduction in Te Reo Māori, which is the indigenous language of the people of Aotearoa New Zealand, and I'll just translate each line. Nō Hong Kong ōku tīpuna. My ancestors come from Hong Kong. I tipu ake au ki Aotearoa. I grew up in Aotearoa, New Zealand. E noho ana au ki Ki-Low-Na. I live in Kelowna, British Columbia. Ko tēnei taku mihi ki ngā tāngata whenua o te rohe nei. I like to pay my deepest respects to the first peoples of this land. I live on the unceded territories of the Syilx and Okanagan peoples. Ko tēnei taku mihi ki ngā maunga, ki ngā awa, ki ngā roto, ki ngā Papatuānuku, o te rohe nei. I'd like to pay my deepest respects to the mountains, rivers, and the lakes, and to Mother Earth. All these important landmarks that have been here for millennia. Nō reira, tēna koutou, tēna koutou, tēna koutou katoa. Therefore, hello, hello, hello, Ko Vivian Fu tōku ingoa. Lovely to be here. Katie Strong:  Well, I'm so glad you're here. And I wanted to start off today asking about the Take Charge program that you've been working with, and talk to me about how that began. What was the origin of that? Vivian Fu:  Sure, so really this work began in probably the late 90s early 2000s when clinicians in Aotearoa New Zealand realized that there were different outcomes for people who were Māori compared with non-Māori, and I guess an important point to illustrate is that in Aotearoa society we view things in a very bicultural lens, and by that I mean Tangata Whenua, who are the people of the land, so indigenous people of the Māori and Tangata Tiriti, so everyone else are people of the treaty. It doesn't really matter where you come from, but you are a person of the treaty if you live in Aotearoa, and so it's a bicultural lens, and so we always look at things in that way, and that's how our kind of entire society is grounded upon that. And so when we look at health outcomes, what we could see back then, and unfortunately what we, in a way, still see now is that Māori were experiencing a stroke at about 20 years younger than non-Māori, and they were more likely to die from their stroke, and also more likely to be severely disabled. And so there was a difference in life expectancy, a difference in overall rehabilitation access, difference in overall outcomes, and so it started off with Professor Matire Harwood's work. She is Tangata Whenua, and in her PhD, she was looking at why there were these differences in outcomes and wanting to address them. And so that started off with the Māori and Pacific Stroke Study, which was essentially conducted in just Māori and Pacific people in Aotearoa, New Zealand, out of many different centers around the country. It was a four arm study.. It was a randomized control trial, and it looked at a conversation, which was labeled as the "Take Charge" session, but it was, it was really a connection and a conversation versus a professionally made DVD from the New Zealand Stroke Foundation about people's experiences and stories after stroke. And then the fourth arm of the trial was getting both of those interventions, and there was a control group. So there were three active groups in one control group. And what the researchers basically found was that anybody who had received this session of discussion and connection did much better a year after stroke in terms of quality of life, independence, and caregiver strain. And so that was the first sort of indication that there was something in that conversation that was really important. Unfortunately, it didn't really take off in terms of being able to be implemented, and so then Dr. Harry McNaughton, who was Dr. Harwood's supervisor wrote multiple grants and tried to get this session into much more of a bigger trial with some some type of implementation, and that's where I came along and we essentially did two things. We operationalized the intervention into something that had a bit of a framework, so with a bit of a booklet and a bit of a structure to follow. Really looking into what was it about that conversation that was so powerful and made such a difference to people, and tried to put those things into practice. Then, secondly, to conduct a second trial in New Zealand out of seven centers for people with stroke who were non-Māori and non-Pacific, because the struggle that we came across was that it was only shown to be effective in a small group of people, but not in everybody, and so we had to do things backwards. And so that was really where it all began, from these principles of self-determination, so Tino Rangatiratanga, which is a really important principle in Te Ao Māori, and in the world of Māori, but also knowing that Māori and a lot of indigenous peoples, we think of health as this concept called Te Whare Tapa Whā, for example, which is the house with four walls. So a person is never just their body and their physical health, there are other walls that keep the house upright. So mental health, spiritual health, and family health, whānau is so important, and feeling as though you have strong foundations in where you belong is also really important. So it's that really holistic look at health of an individual and how we can address all of those things in an intervention is really where it all came from. Katie Strong:  Thank you for sharing. I appreciate the backstory, and also just the idea of what you're thinking about from a holistic health standpoint. I know our listeners are probably curious, some of them might not have heard about Take Charge before, so this is the first time of them hearing about this, and so I was hoping, Vivian, you could give us an overview of what the intervention is, and then maybe walk us through what a session actually looks like in practice. Vivian Fu: Yeah, absolutely. So I'll talk you through the session in the way that it was done in the larger Take Charge trial. So this was done in 400 non-Māori, non-Pacific people with stroke, and our trial there had three arms. So there was a control group, there was a group that received just one session, and then there was a group that received two sessions six weeks apart roughly. The sessions were provided by a trained facilitator, and they were timed roughly somewhere between three to 18 weeks after stroke. So quite a large window, really, depending on when the person with stroke was ready to receive it. So the short version of what it looks like is it's based off the booklet and it's done face to face. It's a conversation and the facilitator is trained at the beginning to really try and establish a relationship…to build a relationship. There's a concept in Te Ao Māori called Whakawhanaungatanga, which is really sort of seeking another person's identity, recognizing who they are as a person, and trying to build connections. And so I guess in English, we think of that as building rapport, building trust. And so it in our trial was done face to face. We have also looked at ways of doing this via telehealth as well, which is, you can imagine, is a little bit different. But that step is really important, and we knew that it was important also in the initial Māori and Pacific trial, because the facilitators who were trained were actually ethnicity matched. So that's something where I think it came quite naturally in that trial, but in the second trial we really wanted to ensure that a relationship was built, and then there are three pages, initial pages in the booklet that look at different things. So the first page is looking at how the person has been affected by the stroke, and then asking them to think about actually who they really are as a person. It's a very simple concept, and a very sort of simple question, but for many people that's the first time they've really been asked that and have had to think about that. So anything that comes to mind that they can relate to, you know, who they are. An individual, and what it is that they love, so for example, for me, I would say, "I'm a mum, and I'm, I'm a stroke neurologist, I am a painter, I'm a poet, I'm someone who loves going for walks in hikes," and, you know, so those kinds of things, and it, and it kind of really builds on on that person's identity and who they are in the world. And so that's that sort of page one. It's really about establishing identity and sense of self. And then the second page is talking then about my hopes and fears. And that might be a tricky one, really, for a lot of people to start talking about and thinking about. They may not want to express that, they may not have been asked that. Sometimes it brings out a lot of emotion, and that's why that initial beginning part of establishing trust and in a kind of a psychological safety space is really important. And then the third page is imagining or envisioning what my best day looks like. And you can be as wild and fantastical about that as you like. When we train our facilitators, we asked them to do these exercises as well themselves, so they can get a really good sense of what that's like, and I had a lovely training session with community health workers from Tanaha First Nation in Cranbrook, BC, and one of one of the attendees in the group said she'd love to have breakfast with a Sasquatch, and so that was absolutely, you know, it was so culturally relevant, so important. Katie Strong:  That makes my Pacific Northwest roots just smile there! Vivian Fu: Exactly! Just so unique to that individual and to where they are in the world. And it's not something you can, you can pluck out of a textbook or pluck out of anything, right. It's where they are. I love that activity. It's quite magical what comes out. And then after those three pages are done, then there are some pages that are specifically related to goal setting, which may or may not be relevant to the person in front of you, things like a physical page, emotional, social, financial, health management type pages. And that really is a way to think about or encourage the person to think about, or we know what are the things that do matter to you, and and what are the things you would like to achieve in the long run, and what are some ways you might be able to break that down into achievable steps that you would personally want to do. But the session in practice can look like anything out of that. It can look from a person at session one being completely clammed up about not wanting to dig deep or not not being ready to engage in that. Or just kind of being, you know, keeping it all to themselves, and thinking about it, and ruminating about it, and then session two, looking very different after they've had that six weeks to think about it themselves. It can look like blank pages, or it could look like a person coming up with all sorts of brilliant ideas. Hopefully, you know, we always encourage if they can write the person with stroke as the one who is writing in the notebook. They keep it. They stick it on their fridge. They do whatever they like with it. They write in it in their own time, but it's completely fine to have blank pages. It's completely fine to have nothing come out of that conversation, nothing verbal, but it's just a space to an invitation to dig deep, and if there's something to say to feel heard. And I guess there was another question. I think that's quite important with regards to what the facilitator is doing, what are they not doing, and the facilitator is trained specifically to listen and ask questions and reflect the ideas that are being expressed by the person with stroke, but what they're not doing is they're not offering any advice or suggestions or pathways forward or how abouts or what abouts. They are not, and this is probably the hardest part. They're not passing any judgment, and that includes good judgment. So, by saying something like, "oh, that sounds like a really good idea", which seems like a really normal response from most people, it kind of implies that there are other ideas that are less good. Or the person with stroke might feel as though they are needing to have that kind of external validation, that external approval, and, and what we don't want is to for them to feel like they're doing this or saying this or thinking these things for the facilitator. We want them to think about it for themselves. And so all we encourage people to respond, is "oh, so you'd like to ride your bike, that's really interesting. How, how do you think you'll, you'll go about doing that?" You know, it's, it's much more neutral, but reflective way of speaking and listening, I guess. Katie Strong:  I am curious, how long is the training, or you know, what kinds of.. what we didn't talk about this, but I know people are going to want to know. So, what does it take to be trained? Vivian Fu: This is quite funny. This is a thing that sort of been on my mind ever since we've started implementation around the world, and I have this ultimate goal of operate like actually making the training have some type of qualification and fidelity, and some structure. There is structure, but it's essentially myself or Harry doing a Zoom with people, and it takes maybe say four hours. But ideally, what we'd love to do is to have sort of recorded videos, and then we'd have live sessions, and then we'd have assessments, and then you get a certificate at the end. I have neither the budget or the… Katie Strong: There's always the next step, for sure. Vivian Fu: I'd love to be for people to be able to say, "Oh, I'm Take Charge trained" and for them to be able to like "Look, I've got this qualification, I'm Take Charge trained, I know how to do this," and especially for if we were thinking about doing it in more clinical trial settings, I think that's really important, but also, you know, for people, you know, to have on their CV, if they're moving between jobs and things, I think it's so useful. But yeah, basically people get in touch with myself or Harry and say, "Hi, we'd like to be trained, can you fit us in?" And we just do it for free. Katie Strong:  Lovely, I love it. And the other question I had as you were talking was how long is a typical session or or is there is there length? Vivian Fu: So in the trial what our facilitators did was they because it was face to face and they had to drive between people's houses, they booked in the session, usually at 10:30 in the morning, and then another session, I think, if I remember correctly, either maybe it was 1:30 in the afternoon. And so you can probably surmise that for people with stroke, usually the 10:30 slot is the most popular. And you know, some people would would prefer to wake up earlier and be ready earlier, so they might ask for something like 9 o'clock and then they might usually go for about an hour and a half to two hours if it's a good going session, and they're really digging deep, and there's a lot to say. And often you know that first half an hour is, "Here's a cup of tea and a biscuit. Let's get to know each other. Tell me all about what happened with your stroke." That kind of stuff, so that listening and connecting stuff actually takes takes a while to establish, and I think people just allowed for that time. Then they'd do a second session in the afternoon again. There are lots of things, you know, cognitive problems, fatigue is a big one. So, if people felt like they couldn't keep going, the facilitator would say , "That's totally fine, we'll book in for, you know, do the rest of this another time, is that okay?" It was fine to really just, you can truncate it and break it up as much as the person really wants. Katie Strong:  Thank you. I appreciate the extra information. You had a recent publication in 2025 with some colleagues that looked at this work from a qualitative lens.  You came up with some themes about doing things my way, coming to my own wisdom, and they're just so deeply related to identity, and what struck me was the contrast participants drew between Take Charge care and standard care, where they described being put in a box receiving scripted advice that had really nothing to do with who they were as a person. And when someone gets to tell the story of who they are to a genuinely good listener, something shifts. I was just curious, if you could think about what you think is happening there, or what you found in your study. Vivian Fu: Well, I think for the most part, as a, you know, as a clinician, if we think about from the moment the person has a stroke, they disempowered from that very moment.  Something happens where they just aren't themselves, and they are brought into a merge. A bunch of things happen to them that they can't really even speak up about. You know, they're popped in a scanner. They might get thrombolised, you know, all these things are happening. And the person doesn't really know what's going on. There are a lot of important qualitative studies that have been done, looking at that element of feeling disempowered, and what somebody in New Zealand study described as feeling gut-wrenchingly emotional. You know, experiences that that aren't heard and aren't ever expressed to to anyone in the healthcare side and aren't dealt with, and so, if you think about that, just that trauma of having a stroke and then going through all of that stuff, and you know, ending up in a bed somewhere on a ward with strangers on the other side of a curtain, and it's really pretty traumatic. And so I think what was powerful with Take Charge was it's an it's an opportunity for someone to finally tell their story and feel heard and for all that stuff to just come out. And a lot of the time you know people might say, "Oh, well, you could talk to your family, you can talk to your kids, or, you know, whatever. Once you get home" but actually, a lot of people don't feel like talking to those who are closest to them about how much it affected them, and there is still an element of stigma. There's still an element of, "Oh, you know, you look great physically, you to someone we know having had a big health scare, and then kind of coming back into that. But there's there's a real dissonance between what is going on inside a person and and how other people are reacting to them coming back into "normal spaces". And so I think the ability to tell your story from the very get go. You know, all of the messiness of it. All the things that went wrong, and then to have somebody listen to that really gives meaning to it and makes it real, but it also helps that person really reestablish their sense of power to regain some power from that that they had lost. And there's a lot of power in story, and I think the kind of, you know, lovely thing about it is that sort of all indigenous cultures sort of be like, you know, First Nations, Māori, Gaelic, a lot of cultures really put a lot of value in the power of storytelling. And that is how historically things were really passed down, and so I think it's through that ability to be able to feel heard and to tell your story that then the person who is speaking can actually hear themselves say things out loud for the first time. And then understand the power and the value and the worth in their words and their experience, and that is that process of coming to my own wisdom, is "Oh, actually, you know, I do know about my body. I am, I am the expert, not these people in their white coats, or you know, with their expertise, I am the expert. I know what I need. I can plan my rehabilitation. I can go back to the things that I want to do, and this is how I'm going to do it." And it's that, that kind of reestablishment of confidence and strength and hope that is so powerful. I think. Katie Strong: I agree. I agree, Vivian. As you know, our listeners are primarily speech language pathologists working with people with aphasia. We also have people with aphasia that are listening, and researchers as well. But you know, the capacity for language being disrupted by aphasia. I was just curious, with Take Charge, as you've studied it, is you know, really a talking therapy with writing, and, and those sorts of things, and so I was just curious, you know, what would it take to extend this kind of intervention to people with aphasia, and what principles would you want to most preserve in the adaptation. Vivian Fu: Yeah, thank you. That's such an important question. We certainly, in the Take Charge trial, included people with aphasia in the trial, and the way that we sort of just included them was if they could understand or the consent form and could mark an "x" on the form, we'd be happy to to have them included, and so we had people with mild to moderate and moderate to severe aphasia in the trial. And we hadn't made any specific changes or tweaks to the intervention, the facilitator just did what they could with what we had. But I think what has come out of reviews of the implementation of Take Charge now in New Zealand is that it is really important for us to look at how we can adapt the intervention for people with aphasia. I think for the facilitators in the trial, what they did was they allowed a lot more time, so the usual two and a half hours became three and a half hours, and that was fine if the person could continue. But also I think from the report we need to look at alternative ways of how we can complete some of these activities, whether it's providing images where people can point, whether it's a lot more inclusion of their family, their whānau important people to them who can help with, you know, subtle guidance, and, and, and having sort of lived with the person now, can read their non-verbal expressions a lot better than a stranger, a facilitator can and can help with the guidance of participating. And really, while Take Charge has been translated, I think, now into seven or eight different languages, we really need to adapt Take Charge to other communication needs and other languages, but what I.. so my role.. sorry, I didn't.. I'd actually say this, but my role in the in the large trial was as the blinded outcomes assessor, so I went around at one year after stroke. I traveled around to the 400 or so different other people, participants' homes around the country, and I sat in their living rooms, and I listened to their stories again. And then I did all of their outcome instruments and got all of their outcomes done, but I did not know which group they were allocated to. And then I locked all the data, and then I'd say, "Hey, so which group did you get Take Charge or not?" And it was really, it was good. I think out of the 400 there were only two people who, when I turned up, actually had the booklet on the table, and so you know, I just ignored it, and then, but yeah, it was, it was really good in terms of sort of blinding and masking, and then sort of having a guess as I was going through and checking where things were at. It was such a privilege for me to, as a stroke doctor, I think you know people don't usually get to do this as a physician, but to, to meet so many different people with so many different stories, and a number of people who still had moderate to severe aphasia, and and were telling me about the impacts of that on their life. But we were still able to communicate a year after stroke, and so I think it is so important that we don't exclude people with cognitive and communication difficulties. We have to adapt the things that we have to make it work for them. What I'd love is to be able to have some kind of focus group with people with aphasia, and, and show them Take Charge, and realize, oh, what can we do? How would this work better for you? Katie Strong:  I love that, and well. Well, and we haven't talked about the materials yet, but I do have to say they're so accessible, or they're very accessible from a visual standpoint as well. Vivian Fu: Thank you. Yes, we are actually modifying them and making the font bigger and having better graphics. We started off with stick figures that Harry drew, and then I think we're actually making them a lot nicer in terms of the graphics, but what we do have at the moment is actually available online for free, and you can just download them as a package. It's if you Google it, it's the Medical Research Institute of New Zealand, or www.mrinz.ac.nz  and then under programs, and we spell that as p r o g r a m m e s, and then under programs slash forward slash stroke, I think is where it lives, and at the bottom of the page you should be able to download, a training package and the booklet itself. Katie Strong: Yes, lovely, and we'll have the links on our show notes as well, so you can check those out, listeners, if you're interested. So, thank you. You have two randomized controlled trials that you've talked a little bit about, and a cost effectiveness analysis and qualitative work, all pointing in the same direction that the cost data suggests that Take Charge actually might save money, and that is remarkable, and lots of evidence showing that, but still, it's a challenge in implementing into standard practice, and I was curious if you could talk with us about what you think stands between what the evidence shows and what actually gets implemented. Vivian Fu: Sure, gosh, I love this question. It's it applies for so many interventions, I think, specifically for Take Charge, it's a number of things. So definitely the stuff that affects other interventions being implemented, but for Take Charge itself, it started off with a huge amount of disbelief bias, so people, you know, even after I presented the main results of the second trial at the European Stroke Conference in gosh, when was that? 2019 pre-COVID in Milan. So this is a huge international stroke conference, and this was a plenary session. People stood up and took photos of the results and went, you know, there was this collective gasp throughout the audience of 6000 odd people, but there's just this disbelief that something as simple as a conversation can make a difference to people's objective quality quantitative outcomes, like the, you know, Bartel or the FIM, what they, you know, what their physical outcomes are like at a year. And what their quality of life is like. I think for people who are stroke researchers, a lot of the focus is on that initial 24 to 48 hours after stroke. And you know, that that's kind of where that's kind of where all the funding goes, isn't it? So it's the pre-hospital stuff, and then the interventional things you can stick catheters into and thrombolysis, and you know that's, and that's all great. You know, I, as a stroke physician, I love that part of stroke as well, but to think that you could possibly do something at three to 18 weeks after stroke that could change a person's outcome by a year, and actually we've got a long-term follow-up study now that says that those those same magnitude of changes are still present at five years between the groups is, you know, kind of gobsmacking. And people just go, surely you've fudged this, or surely this can't be true. And so there's this huge disbelief bias that stopped us from being able to publish initially, and it was only after I presented the results in Milan that that we got accepted into a journal. And we'd been trying for about a year beforehand, and, and so there's, there's that disbelief. But also in the way that it has to be provided, you know, it's probably considered quite labor intensive. You know, one on one home visits, and that's why people of other researchers who do believe in Take Charge are now looking at providing take charge in different ways. Like I did a telehealth trial in Canada, in southern Alberta, when I was there as a fellow in Calgary, and there's potential other work that's being. Done in Australia with Take Charge, looking at providing it by computer avatars, by even maybe even AI, and maybe in a larger sort of telehealth format. And so you know other ways of doing it, but I think ultimately it's kind of cultural inertia, because you know, "We've never done this, this is not part of who we are. Why would we need to start something new?" There's probably kind of an established way of thinking about clinician and, and patient, rather than person with stroke, in still in how we practice, and this idea that the therapist and doctor are experts. And so I think it really challenges that dogma and challenges clinician's role, and therefore there's a resistance to accept that this is something that is useful and helpful, and actually doesn't, you know, you don't need to take it personally. You're still doing great work. Take Charge is just a tool that helps supplement everything else that's going on, and so there's a lack of time, and I think we also get quite, as practicing clinicians, we get quite tunnel visioned into this, you know, hamster wheel of go to work, treat all these people, go home. We just keep doing it. Hoping that things will get better for them, but, you know, we, it's only when we start looking at alternative interventions and alternative things that work and start trialing them and being open to that, that I think things will really start to change. We've certainly had interest from random little parts around the world. I think it's been translated into Latvian. I've got people from Sweden who are interested. A little hospital in Germany, and then parts of it's been trialed in pilot studies in the UK. And Harry and I last year trained a whole bunch of occupational therapists in Hong Kong, so you know it is, it is kind of picking up, slowly but surely. Katie Strong: Well to me, you know, most stroke survivors, or people with stroke, as you're referring to them, have chronic challenges, and so all of the early intervention, while important, doesn't necessarily help somebody navigate that longer term change. And so I love that this is just such an empowering way of putting that power back into the person's life, which it seems like it is showing up n in the results that you're sharing. Vivian Fu: Oh, absolutely. I mean, if we think about it, if we just think about thrombectomy and thrombolysis, somewhere between five to 15% of all people with stroke are eligible, and then receive the treatment. That leaves what?, 85 to 95% of people who don't get to receive that. And even after they receive the treatment, there are consequences of stroke that are beyond the physical that don't you know don't have any other thing to address them apart from our routine care, so I completely agree with you. Katie Strong: Well, thinking about what clinicians might be able to do tomorrow or you know, in the near future, for our speech-language pathologists or other practitioners who are listening today and are feeling the pull of this work, and you know, really encouraged by it, but are you know working in an embedded productivity driven impairment focused system, what's one thing that they could do differently in the very next clinical encounter that they have? Vivian Fu:  We have a paper, I think it's written. Oh gosh, where did it.. where did it get published? I think it was published in Practical Neurology. It's titled something, something intrinsic motivation. I should know better. Katie Strong: I'm going find out, and I don't think I read that one, so I'm gonna find it, and I'll put the link in the show notes for everybody. Vivian Fu: Sorry,Harry about the promo, but yeah, I'll send it to you, but essentially it's written to give some guidance on how you can embed Take Charge into your daily clinical practice. And it's written for neurologists, but honestly it applies to everybody.  One of the key things is when you have that next encounter, obviously you know therapists do this a lot better than doctors do, but they ask a lot about, you know, what's outside of the person's life and what's important to them, but maybe move away just, you know, from the very practical questions like "How many steps do you have going in and out of your house?, and How do you hang up your washing?", or whatever, but it's, you know, really much less functional, but more, "Who are you? Tell me a bit more about yourself. What do you love doing? What gets you out of bed?" You know, if I might, the one that I like to use a lot on my ward rounds is, "If you weren't in this hospital bed right now, where would you rather be? What would you rather be doing?", and I do that on my rounds, and it's incredible, because you know, I'll hear all sorts of things, "I'll, you know, be on my boat fishing out on the lake", or I think this lady was like 84 or something. "I'll be with my girlfriends, we'll be having coffee at Tim Hortons", you know, and it's just, I don't know, it's something so unique to that person that I could never, you know, they're in their hospital pajamas with a whole bunch of stuff stuck to them, and I can't envisage them doing that, and yet I'm like, I want you to imagine yourself there. Where would you rather be? Okay, so everybody, that's our goal. It's not to get her home or to get her walking again. Our goal is to get her back in Tim Hortons with her eight friends, having coffee, like that is what this person loves to do. And I think that you know that inquiry, that it shows you care, it shows you see them as an individual, and I think it completely shifts your rehab focus, and then you can ask more questions about that, and they, you know, then you have this whole conversation about about what their life is like. And I think that part of being seen, even if it's only within 60 seconds, makes such a difference to that person. So that's one thing. The second thing I'd be, you know, doing is I'm trying to involve family as much as possible, as much as the person wants, and basically, just seeing them as an individual makes a huge difference already to the way you practice, that would be what I'd focus on. Katie Strong: Agreed, agreed. Well, Vivian, is there something you wish people asked you about this work that they rarely do, something about Take Charge or stroke recovery more broadly that you think the field hasn't quite caught up to yet. Vivian Fu:  Oh gosh, this is a tricky one. I think one thing we ought to recognize is that everybody is doing the best that they can with what they have. And you know, we're not as clinicians on the ground on the front line, we're not involved with funding decisions, and what projects get funded and which ones don't. And there will be the ambitious amongst your listeners, who I really hope will be like, "Oh my gosh, I can apply for this little grant, and I'm going to pilot this, and I think we should give this a go with our people." and I think that is absolutely a great idea to have. And, and I would, myself and Harry will do everything that we possibly can to help support such projects from where we are. I think the important thing to think about is that every little bit that you do makes a difference, and to not feel as though, because you know your funding runs out, or you don't get it, or the world is such a bleak place that you know it's not worth continuing to try. Because people with stroke who see you do this work, they will be grateful for it. And also the patient partners I've met that I've spoken with, and all of the people whom I've interviewed with the qualitative work, they're also happy to be part of something like this. And so even if it's a pilot project. Even if it's, you know, something that may not last, you'd be so surprised at how much momentum you can build with a movement of people who see the value in this and then take it further and further, And that's what I've been really impressed by, and kind of stunned by in all these different locations around the world who have contacted me. I've just been like, "Wow, can't believe [this]." There's this wonderful group in Hunter Medical Research Institute down in Australia, who basically took Take Charge back to their own unique Aboriginal community, the Gamilaroi peoples of that particular area of Australia. They have, like Canada and like the States, they have 1000s of tribes and lots of different groups that all speak completely different languages, but they took it to their local group, and they broke down, take charge into little bits, and then rebuilt it into an intervention that just works for them, and it's called "Yarning Up after Stroke", because what they do is they have a yarn. They yarn, and that's the way they tell their stories. It's yarning, and so you know, I just think it's incredible. Like, they got funding for it, they did it, and now it's an ongoing project that just keeps on in the community being provided to their people, and it's fantastic. So, I think it'll evolve. I love to see how it evolves, and I certainly don't think of, you know, this isn't the kind of intervention that we go around patenting and making a ton of money out of. It's the kind of intervention that everybody makes their own, and hopefully with a lot of input by people with stroke, Katie Strong: I love it. Thank you. Thank you so much for being our guest today, and sharing about Take Charge, and your generosity in sharing about the intervention, and if people are interested in reaching out to contact you, so thank you so much, Vivian. Vivian Fu:  Thank you so much for having me. I hope I haven't spoken too long. Katie Strong: Oh no, it's perfect. Vivian Fu: I'm always happy to be contacted, and yeah, very happy to support anyone who'd like to explore this further. Katie Strong: Thanks so much. On behalf of Aphasia Access, thank you for listening. For references and resources mentioned in today's show, please see our show notes, available on our website at www.aphasiaaccess.org. There you can also become a member of our organization, browse our growing library of materials, and find out about the Aphasia Access Academy. If you have an idea for a future podcast episode, email us at info@aphasiaaccess.org. For Aphasia Access Conversations, here at Central Michigan University in the Strong Story Lab, I'm Katie Strong. Dr. Fu's Email  dr.vivianfu@gmail.com  Resources and Readings Fu, V. (2019). Taking Charge After Stroke: A novel, community-based intervention to improve the lives of people with stroke. https://www.semanticscholar.org/paper/Taking-Charge-After-Stroke:-A-novel,-intervention-Fu/3bc1dbb271f425c72e146510088856e3aad8683e  Fu, V., Fernando, K. M., Bright, F., Riley, J., McPherson, K., & McNaughton, H. (2025). Coming to my own wisdom: A qualitative study exploring the role of the Take Charge intervention in stroke recovery. Clinical Rehabilitation, 39(3), 377–387. https://doi.org/10.1177/02692155241310770 Fu, V., Weatherall, M., McPherson, K., Taylor, W., McRae, A., Thomson, T., Gommans, J., Green, G., Harwood, M., Ranta, A., Hanger, C., Riley, J., & McNaughton, H. (2020). Taking Charge after stroke: A randomized controlled trial of a person-centered, self-directed rehabilitation intervention. International Journal of Stroke, 15(9), 954–964. https://doi.org/10.1177/1747493020915144 Fu, V., Thompson, S., Kayes, N., & Bright, F. (2025). Supporting long-term meaningful outcomes in stroke rehabilitation. Current Neurology and Neuroscience Reports, 25, 17. https://doi.org/10.1007/s11910-025-01403-z Harwood, M., Weatherall, M., Talemaitoga, A., Barber, P. A., Gommans, J., Taylor, W., McPherson, K., & McNaughton, H. (2011). Taking charge after stroke: Promoting self-directed rehabilitation to improve quality of life - a randomized controlled trial. Clinical Rehabilitation, 26(6), 493-501. https://doi.org/10.1177/0269215511426017  Te Ao, B., Harwood, M., Fu, V., Weatherall, M., McPherson, K., Taylor, W. J., McRae, A., Thomson, T., Gommans, J., Green, G., Ranta, A., Hanger, C., Riley, J., & McNaughton, H. (2022). Economic analysis of the 'Take Charge' intervention for people following stroke: Results from a randomised trial. Clinical Rehabilitation, 36(2), 240–250. https://doi.org/10.1177/02692155211040727 McNaughton, H., & Fu, V. (2023). Intrinsic motivation. Practical Neurology, 23(6), 489-492.  https://pn.bmj.com/content/23/6/489  McNaughton, H., Gommans, J., McPherson, K., Harwood, M., & Fu, V. (2023). A cohesive, person-centric evidence-based model for successful rehabilitation after stroke and other disabling conditions. Clinical Rehabilitation, 37(7), 975-985. https://doi.org/10.1177/02692155221145433   Medical Research Institute of New Zealand. (n.d.). Take Charge rehabilitation resources. https://www.mrinz.ac.nz/take-charge-rehabilitation-resources World Stroke Organization. (n.d.). Taking Charge after stroke: A person-centred approach to life after stroke [Webinar]. https://www.world-stroke.org/what-we-do/education-and-research/education/webinars/taking-charge-after-stroke-a-person-centred-approach-to-life-after-stroke  

The latest highlights from the journal will deliver confidence when managing complex everyday presentations. In this podcast for the August 2026 issue of Practical Neurology, co-editors Phil Smith and Geraint Fuller present the key highlights from a cracking 100-page edition spanning the full spectrum of neurological care. They examine how to accurately diagnose papilloedema and distinguish swollen optic discs from pseudo-swelling or other mimics. Next, they discuss a comprehensive guide to the Parkinson's disease follow-up consultation, focusing on non-motor symptoms, lifestyle advice, and long-term management. The editors also explore a structured approach to assessing neurogenic bladder, bowel, and sexual dysfunction, before covering the key clinical clues and investigations for evaluating pulsatile tinnitus. They also review the intricate link between chronic kidney disease and cognitive impairment, and finish with a critical look at the practical uses and limitations of subhairline EEG monitoring in neurocritical care. Read the issue: https://pn.bmj.com/content/26/4 Please subscribe to the Practical Neurology podcast on your favourite platform to get the latest podcast every month. If you enjoy our podcast, you can leave us a review or a comment on Apple Podcasts (https://apple.co/3vVPClm) or Spotify (https://spoti.fi/4baxjsQ). We'd love to hear your feedback on social media - @PracticalNeurol. Production and editing by Brian O'Toole, Nick Currey and Letícia Amorim. Thank you for listening. 

In this special episode coming live from the Association of British Neurologists (ABN) annual meeting in Birmingham, Practical Neurology co-editors Phil Smith and Geraint Fuller join hosts Ruth Wood and Babak Soleimani to discuss the perennial clinical and educational value of case reports in which, in a rare event, the patients are actually referred to directly by their first names. The team discusses two compelling, patient-centered narratives. They look at a complex case of refractory focal epilepsy from 2024 where the patient actively partnered in the high-stakes decision to balance seizure freedom against a predicted post-surgical motor deficit.  A review of a poignant "Me and My Neurological Illness" piece written in 2016 by a prominent epileptologist is a reflection on his subtle subacute presentation of autoimmune encephalitis,  how a doctor's baseline cognitive reserve can mask complex focal seizures, and the unique clinical and personal challenges faced when dealing with medical colleagues who lack diagnostic insight into their own condition. Archive papers discussed in this episode: Case Report 1: Complicated epilepsy surgery: importance of balancing benefit and deficit. https://pn.bmj.com/content/24/5/393 Case Report 2: Me and my neurological illness. Autoimmune limbic encephalitis due to VGKC-Ab. Thanks for the memory. Leo Robin (Title of song, 1937).  https://pn.bmj.com/content/16/2/162   Read the full papers on Practical Neurology.   Please subscribe to the Practical Neurology podcast on your favourite platform to get the latest episodes. If you enjoy our podcast, you can leave us a review or a comment on Apple Podcasts (https://apple.co/3vVPClm) or Spotify (https://spoti.fi/4baxjsQ). We'd love to hear your feedback on social media - @PracticalNeurol. Production and editing by Brian O'Toole, Letícia Amorim and Pritesh Kapadia. Thank you for listening.

What's the real difference between a night owl and a morning lark? The Editors' Choice paper for the June 2026 issue of Practical Neurology is a review of all the ways sleep intersects with neurological practice. Last author Prof. Guy Leschziner¹ joins PN podcast editor Dr. Amy Ross Russell to the wide variety of sleep-related disorders: insomnia, hypersomnolence, and sleep-related movement disorders. Each category contains pitfalls to be avoided when treating, like overlooking critical signs or reaching for drugs too eagerly. You'll also learn about "sleep reactivity", teenage sleep patterns in the animal kingdom, and diagnostic insight that can be gained from partners. Sleep neurology: pearls and pitfalls 1. Sleep Disorders Centre, Guy's and St Thomas' Hospitals NHS Trust, London, England, UK Please subscribe to the Practical Neurology podcast on your favourite platform to get the latest episodes. If you enjoy our podcast, you can leave us a review or a comment on Apple Podcasts (https://apple.co/3vVPClm) or Spotify (https://spoti.fi/4baxjsQ). We'd love to hear your feedback on social media - @PracticalNeurol. This episode was hosted by PN's podcast editor Dr. Amy Ross Russell. Production by Amy Ross Russell and Brian O'Toole. Editing by Brian O'Toole. Thank you for listening.

The latest highlights from the journal are set to give confidence when trying something new. In this podcast for the June 2026 issue of Practical Neurology, co-editors Phil Smith and Geraint Fuller bring a distillation of the wisdom found in the journal's pages. They explain the crucial role of a Zeitgeber for healthy sleep cycles, question the involvement of drugs like SSRIs in seizures, and share a transatlantic follow-up to the ABN myasthenia gravis guidelines which provides an approach to optimising over all patient well-being.  There's also a guide to recent treatment of Parkinson's using foslevodopa-foscarbidopa infusion, also known as Produodopa. Then the editors explore the structure of the retina while touching on optic neuritis, and finish with limb-shaking transient ischaemic attacks, an early warning signal for stroke. Listen to the very end for some editorial insight into practical uses for the podcast itself! Read the issue: https://pn.bmj.com/content/26/3/205 Please subscribe to the Practical Neurology podcast on your favourite platform to get the latest podcast every month. If you enjoy our podcast, you can leave us a review or a comment on Apple Podcasts (https://apple.co/3vVPClm) or Spotify (https://spoti.fi/4baxjsQ). We'd love to hear your feedback on social media - @PracticalNeurol. Production and editing by Brian O'Toole. Thank you for listening. 

It's the return of Merlin. Not the birdsong identification app this time, but the Rolls-Royce Merlin - engine of the historic Supermarine Spitfire warplane. The Case Reports trio are faced with another set of patient puzzles to work through in this latest episode. In the first case (1:25), a 68-yo man, retired from farming, presents with a 6-year history of behavioural changes. Most notably, he had developed a sense of great pleasure in listening to engine sounds, like those of the historic aircraft flying over his house. He had become increasingly emotionally detached and ritualistic, and gained a sweet tooth. MR scans of the brain revealed an uncommon syndrome. https://pn.bmj.com/content/26/2/169 The second case (21:15) relates to a 47-yo woman who developed abnormal movements in all of her limbs. She had undergone a complex cardiac surgery 12 years before, and another prolonged cardiac surgery within recent weeks. The case discusses the longterm follow-up of her treatment for these involuntary movements. https://pn.bmj.com/content/26/2/157    The case reports discussion is hosted by Prof. Martin Turner¹, who is joined by Dr. Ruth Wood² and Dr. Babak Soleimani³ for a group examination of the features of each presentation, followed by a step-by-step walkthrough of how the diagnosis was made. These case reports and many others can be found in the October 2025 issue of the journal. (1) Professor of Clinical Neurology and Neuroscience at the Nuffield Department of Clinical Neurosciences, University of Oxford, and Consultant Neurologist at John Radcliffe Hospital. (2) Clinical Lecturer in Neurology at the Institute of Cognitive Neuroscience, University College London, and an Honorary Neurology SpR at the National Hospital for Neurology and Neurosurgery. (3) Clinical Research Fellow, Oxford Laboratory for Neuroimmunology and Immunopsychiatry, Nuffield Department of Medicine, University of Oxford Please subscribe to the Practical Neurology podcast on your favourite platform to get the latest podcast every month. If you enjoy our podcast, you can leave us a review or a comment on Apple Podcasts (https://apple.co/3vVPClm) or Spotify (https://bit.ly/4aXF46i). We'd love to hear your feedback on social media - @PracticalNeurol. Production and editing by Brian O'Toole. Thank you for listening.

What should a neurologist do when a routine MRI for migraine reveals incidental white matter lesions that look remarkably like Multiple Sclerosis (MS), despite the patient having no neurological symptoms? The Editors' Choice paper for the April 2026 issue of Practical Neurology is a practical guide to the clinical diagnosis and management of radiologically isolated syndrome (RIS). Author Dr. Audrey Reynolds¹ joins PN podcast editor Dr. Amy Ross Russell to discuss her work on how updated diagnostic criteria and advanced imaging markers now enable a more proactive, biological approach to the disease. Their discussion highlights the importance of risk stratification - using tools like CSF analysis and spinal imaging - to identify those most likely to benefit from early intervention with disease-modifying therapies. They also examine the delicate balance between preventing future disability and avoiding misdiagnosis in this rapidly evolving area of neurology. Read the paper: Radiologically isolated syndrome: a practical guide. (1) St Vincent's University Hospital, Dublin; University College Dublin, Ireland Please subscribe to the Practical Neurology podcast on your favourite platform to get the latest episodes. If you enjoy our podcast, you can leave us a review or a comment on Apple Podcasts (https://apple.co/3vVPClm) or Spotify (https://spoti.fi/4baxjsQ). We'd love to hear your feedback on social media - @PracticalNeurol. This episode was hosted by PN's podcast editor Dr. Amy Ross Russell. Production by Amy Ross Russell and  Brian O'Toole. Editing by Brian O'Toole. Thank you for listening.

In this Practical Neurology bonus international podcast linked to the February issue, host Alasdair Coles (Cambridge, UK) is joined by movement disorder specialist Dr. Ashley Paul (Johns Hopkins, US) and epilepsy expert Dr. Lata Vadlamudi (Brisbane, Australia) to discuss the integration of bone health into neurology clinics. They discuss the identification of osteoporosis in patients on steroids or anti-seizure medications and evaluate the use of FRAX assessment tools for neurological populations. They also address the implementation of screening protocols and checklists to prevent fragility fractures. Read the related paper: Osteoporosis and fracture risk: a practical guide for neurologists Participants: Professor Alasdair Coles is Head of Department for Clinical Neuroscience and also Co-Director of the Cambridge Centre for Myelin Repair, UK. Associate Professor Lata Vadlamudi, Senior Staff Specialist in Neurology at the Royal Brisbane and Women's Hospital, Australia. Dr. Ashley Paul, Assistant Professor of Neurology in the Division of Movement Disorders at Johns Hopkins University, USA. Please subscribe to the Practical Neurology podcast on your favourite platform to get the latest podcast every month. If you enjoy our podcast, you can leave us a review or a comment on Apple Podcasts (https://apple.co/3vVPClm) or Spotify (https://spoti.fi/4baxjsQ). We'd love to hear your feedback on social media - @PracticalNeurol. Production and editing by Letícia Amorim. Thank you for listening. 

As with any Darwinian subject, neurology is under constant evolution. This podcast for the April 2026 issue of Practical Neurology has co-editors Phil Smith and Geraint Fuller taking a look at some intriguing specimens from the neurological field. Populating the menagerie for this episode are the "reversed clock phenomenon", a new study on brain problems in retired sportspersons, a practice guide for biosimilar drugs, and a look at GLP-1 drugs. Also found inside are the "nocebo effect", radiologically isolated syndrome for multiple sclerosis identification, and a weighing up of stenting vs shunting. Read the issue: https://pn.bmj.com/content/26/2/103   Please subscribe to the Practical Neurology podcast on your favourite platform to get the latest podcast every month. If you enjoy our podcast, you can leave us a review or a comment on Apple Podcasts (https://apple.co/3vVPClm) or Spotify (https://spoti.fi/4baxjsQ). We'd love to hear your feedback on social media - @PracticalNeurol. Production and editing by Brian O'Toole. Thank you for listening. 

What unsuspecting dangers lie within a garden compost bin? The Case Reports team are back to uncover a new pair of neurological mysteries. The first case this episode (1:24) comes from Edinburgh, centred on an 88-yo woman who presents with headache and eye-pain on her right side. She receives an early diagnosis of migraine, but returns a few weeks later with intermittent vomiting and subsequent progressive visual loss. https://pn.bmj.com/content/26/1/83  The second case (19:51) from Wessex features a common presentation of tingling feet, with a 62-yo man who develops gait instability. More curious are a significant drop in his weight, as well as a scaly patch on his chest. https://pn.bmj.com/content/26/1/63   The case reports discussion is hosted by Prof. Martin Turner¹, who is joined by Dr. Ruth Wood² and Dr. Babak Soleimani³ for a group examination of the features of each presentation, followed by a step-by-step walkthrough of how the diagnosis was made. These case reports and many others can be found in the October 2025 issue of the journal. (1) Professor of Clinical Neurology and Neuroscience at the Nuffield Department of Clinical Neurosciences, University of Oxford, and Consultant Neurologist at John Radcliffe Hospital. (2) Clinical Lecturer in Neurology at the Institute of Cognitive Neuroscience, University College London, and an Honorary Neurology SpR at the National Hospital for Neurology and Neurosurgery. (3) Clinical Research Fellow, Oxford Laboratory for Neuroimmunology and Immunopsychiatry, Nuffield Department of Medicine, University of Oxford Please subscribe to the Practical Neurology podcast on your favourite platform to get the latest podcast every month. If you enjoy our podcast, you can leave us a review or a comment on Apple Podcasts (https://apple.co/3vVPClm) or Spotify (https://bit.ly/4aXF46i). We'd love to hear your feedback on social media - @PracticalNeurol. Production and editing by Brian O'Toole. Thank you for listening.

Many patients will affirm seeing clouds shaped like animals or other similar phenomena, which is why confirming pareidolia (seeing meaningful images in meaningless visual stimuli) is such a tricky symptom in dementia with Lewy bodies (DLB). While it may not be exclusive to DLB, placing such symptoms in the context of "the company it keeps" is a key method to narrowing down the diagnosis. The Editors' Choice paper for the February 2026 issue of Practical Neurology is a practical guide to the clinical diagnosis and management of DLB. Authors Dr. Sarah Fullam¹ ² and Dr. Seán O'Dowd¹ ³ join PN podcast editor Dr. Amy Ross Russell to discuss their work. They describe the importance of the initial examination, from the patient's gait to difficulties in word retrieval. They also touch on challenges in the use of biomarkers, which drugs may be helpful, and how to advise patients and their carers. Read the paper: Dementia with Lewy bodies: a practical guide to clinical diagnosis and management Special thanks to The Podcast Studios Dublin for their assistance with the recording of this episode. (1) Tallaght Institute of Memory and Cognition, Tallaght University Hospital, Dublin, Ireland (2) Trinity College Dublin School of Medicine, Dublin, Ireland (3) Trinity College Dublin Academic Unit of Neurology, Dublin, Ireland Please subscribe to the Practical Neurology podcast on your favourite platform to get the latest episodes. If you enjoy our podcast, you can leave us a review or a comment on Apple Podcasts (https://apple.co/3vVPClm) or Spotify (https://spoti.fi/4baxjsQ). We'd love to hear your feedback on social media - @PracticalNeurol. This episode was hosted by PN's podcast editor Dr. Amy Ross Russell. Production by Amy Ross Russell and  Brian O'Toole. Editing by Brian O'Toole. Thank you for listening.

When a patient says, "I biffed the car," how should that be translated? Puzzles like this represent the gap between description and diagnosis, and are a critical part of neurological practice. In this podcast for the February 2026 issue of Practical Neurology, editors Phil Smith and Geraint Fuller take turns decoding some of the mysteries of everyday neurology. They cover dementia with Lewy bodies, osteoporosis and fracture risk, and anxiety and depression in epilepsy patients, as a sample of some of the published work in the latest journal. There's also a guide to the latest stroke rehabilitation guidelines, freezing of gait, and a farewell to a 'nom de plume'. Read the issue: https://pn.bmj.com/content/26/1/1   Please subscribe to the Practical Neurology podcast on your favourite platform to get the latest podcast every month. If you enjoy our podcast, you can leave us a review or a comment on Apple Podcasts (https://apple.co/3vVPClm) or Spotify (https://spoti.fi/4baxjsQ). We'd love to hear your feedback on social media - @PracticalNeurol. Production and editing by Brian O'Toole. Thank you for listening. 

Eye pain can be a source of serious concern for patients, bringing worries about their eyesight. While uveitis is far from the only source of ocular pain, in many presentations of the condition it is a feature. In this Editors' Choice podcast, ophthalmic surgeon Mr. Harry Petrushkin¹ ² and neurologist Dr. Ruth Dubson³ join forces to explain a comprehensive approach to uveitis treatment. Host Dr. Amy Ross Russell leads the way through a refresher on eye anatomy and the spectrum of uveitis patients neurologists are likely to encounter. These are often the more serious of patients, requiring good working relationships across disciplines. They also speak of the overlap with neuroinflammatory presentations, and the eye manifestations seen in conditions like multiple sclerosis and sarcoidosis. Read the paper: Uveitis for Neurologists (1) Uveitis and Scleritis Service, Moorfields Eye Hospital NHS Foundation Trust, London, UK (2) Rheumatology Service, Great Ormond Street Hospital NHS Trust, London, UK (3) Blizard Institute, Queen Mary University London, London, UK Please subscribe to the Practical Neurology podcast on your favourite platform to get the latest podcast every month. If you enjoy our podcast, you can leave us a review or a comment on Apple Podcasts (https://apple.co/3vVPClm) or Spotify (https://spoti.fi/4baxjsQ). We'd love to hear your feedback on social media - @PracticalNeurol. Production by Amy Ross Russell and Brian O'Toole. Editing by Brian O'Toole. Thank you for listening. 

We've gathered the NaPS lab to answer all your fascinating questions on all things sleep! A perfect bitesize episode to get stuck into the marvellous world of sleep. 1. How does sleep deprivation affect mental health? - Answered by Martha WawrzutaBunney, B. G. , Bunney, W. E. (2013). Mechanisms of Rapid Antidepressant Effects of Sleep Deprivation Therapy: Clock Genes and Circadian Rhythms. Biological PsychiatryFang, H., Tu, S., Sheng, J., Shao, A. (2018). Depression in sleep disturbance: A review on a bidirectional relationship, mechanisms and treatment. Journal of Cellular and Molecular Medicine2. What is narcolepsy? - Answered by Kyrillos MeshrekyLeschziner G., Narcolepsy: a clinical review, Practical Neurology 2014;14:323-3313. Does the full moon affect sleep? - Answered by Al Saqib MajumderCasiraghi, L. et al. (2021). Moonstruck sleep: Synchronization of human sleep with the moon cycle under field conditions. Chaput, J. P. et al. (2016). Are Children Like Werewolves? Full Moon and Its Association with Sleep and Activity Behaviors in an International Sample of Children. Sleep Medicine4. How does a smart watch track sleep? - Answered by Yan Wang5. What is orthosomnia? - Answered by Sophie Smith Baron, K.G., et al. (2017) Orthosomnia: Are some patients taking the quantified self too far? J Clin Sleep Med6. What is sleep regression and how long does it last? - Answered by Mo AbdellahiWeinraub, M. et al. (2012). Patterns of developmental change in infants' nighttime sleep awakenings from 6 through 36 months of age. Developmental PsychologyBruni O. et al. (2014) Longitudinal study of sleep behavior in normal infants during the first year of life. J Clin Sleep Med7. Does Magnesium Citrate help you sleep? - Answered by Dulni PeramunugamageMagnesium for sleep, Sleep Foundation, 20258. Does dark chocolate help you sleep? - Answered by Martha Nguyen Abdoli, E. et al. (2024). A clinical trial of the effects of cocoa rich chocolate on depression and sleep quality in menopausal women. Scientific reports,Garbarino, S., Garbarino, E., & Lanteri, P. (2022). Circadian Rhythm, Mood, and Temporal Patterns of Eating Chocolate: A Scoping Review of Physiology, Findings, and Future Directions. NutrientsMusic by Sergio Prosvirini from PixabayCheck out our NaPS website to find out more about the podcast, our research and events. This recording is the property of the Sleep Science Podcast and not for resale.

Another set of intriguing cases from the latest issue of the journal, pored over by the Case Reports team.  In the first case, a 24-yo man presents acutely with reduced consciousness, following 3 days of right-sided headache. His mother reports sudden behavioural changes with jerky movements and enlarged pupils. He is agitated, not obeying commands and not moving his left-side limbs. He had a history of autism and vascular Ehlers-Danlos syndrome and was on medication for stroke prevention. An MRI scan led to a differential diagnosis of Posterior Reversible Encephalopathy Syndrome (PRES), but the final conclusion came post-discharge after a further review of his scans.  https://pn.bmj.com/content/25/6/549 The second report (19:37) describes two curious instances of functional neurological disorder (FND), both of which improved after the patients were in comatose states. The first patient is a 59-yo man who had developed muscle weakness shortly after at car crash at age 49, and had subsequently been reliant on a wheelchair for more than 8 years. Recently the patient had been infected simultaneously with severe cases of flu and COVID-19, during which he had been sedated and placed in an induced coma for several weeks. Awakening from the coma, the patient showed surprising signs of new mobility. In the second patient, a 40-yo woman presented with flaccid paralysis of her left arm, with loss of sensation up to the shoulder. She had a history of bipolar disorder and agoraphobia. She was diagnosed with FND and participated in physiotherapy and hypnotherapy with no improvement. Thirteen months later she was readmitted following an overdose on a mix of analgesics and sedatives, and was ventilated in the ITU for several hours. Upon waking the patient noticed that her previously paralyzed arm had completely recovered. https://pn.bmj.com/content/25/6/562  Further reading: Advances in functional Neurological disorder (BMJ Neurology Open)   The case reports discussion is hosted by Prof. Martin Turner¹, who is joined by Dr. Ruth Wood² and Dr. Babak Soleimani³ for a group examination of the features of each presentation, followed by a step-by-step walkthrough of how the diagnosis was made. These case reports and many others can be found in the October 2025 issue of the journal. (1) Professor of Clinical Neurology and Neuroscience at the Nuffield Department of Clinical Neurosciences, University of Oxford, and Consultant Neurologist at John Radcliffe Hospital. (2) Neurology Registrar, University Hospitals Sussex. (3) Clinical Research Fellow, Oxford Laboratory for Neuroimmunology and Immunopsychiatry, Nuffield Department of Medicine, University of Oxford Please subscribe to the Practical Neurology podcast on your favourite platform to get the latest podcast every month. If you enjoy our podcast, you can leave us a review or a comment on Apple Podcasts (https://apple.co/3vVPClm) or Spotify (https://spoti.fi/4baxjsQ). We'd love to hear your feedback on social media - @PracticalNeurol. Production and editing by Brian O'Toole. Thank you for listening.

Neurology requires some detective work at times, and identifying the patterns of symptoms associated with drug misuse can be a tricky mystery indeed. For this episode, we're receiving a masterclass from Dr. Robin Howard¹ on the wide variety of drugs that bring patients into hospital, as well as the mechanisms they act on. His paper "Neurological aspects of drug misuse" is the Editors' Choice for the October 2025 issue, and he joins PN podcast editor Dr. Amy Ross Russell in the studio. From the new dangers of synthetic psychoactives to the profound consequences of chronic use, the discussion unveils critical clinical presentations every neurologist should recognize. We delve into fascinating phenomena including "punding," compulsive repetitive behaviors seen with stimulant abuse, and the rare but striking CHANTER syndrome, with its signs of disturbed consciousness and extensive cerebellar involvement. Hear too about the distinctive spongiform leukoencephalopathy associated with "chasing the dragon," a dangerous method of heroin inhalation, but which can also be caused by cocaine usage.   Read the paper: https://pn.bmj.com/content/25/5/411   (1) Guy's and St. Thomas' NHS Foundation Trust, London, UK   Please subscribe to the Practical Neurology podcast on your favourite platform to get the latest podcast every month. If you enjoy our podcast, you can leave us a review or a comment on Apple Podcasts (https://apple.co/3vVPClm) or Spotify (https://spoti.fi/4baxjsQ). We'd love to hear your feedback on social media - @PracticalNeurol. Production by Amy Ross Russell and Brian O'Toole and editing by Brian O'Toole. Thank you for listening. 

Who do we need to scan? Behind the constant considerations of irradiation risk and resource usage, there is nuance to be found. Parkinson's disease - being a clinical diagnosis - doesn't suggest a need for imaging, yet one case in this issue argues that should not be an absolute rule. Another paper brings in the context of a specific patient: does one man really need 50 CT scans in his life? There's also an unboxing of uveitis, diagnosis of Alexander disease in adults, and an exploration of connections between the microbiome and neurology. This being the fifth(!) Christmas podcast for editors Phil Smith and Geraint Fuller, they finish with the annual crossword and book club update, featuring hot cross buns and hummingbirds. Read the issue: https://pn.bmj.com/content/25/6/501   Please subscribe to the Practical Neurology podcast on your favourite platform to get the latest podcast every month. If you enjoy our podcast, you can leave us a review or a comment on Apple Podcasts (https://apple.co/3vVPClm) or Spotify (https://spoti.fi/4baxjsQ). We'd love to hear your feedback on social media - @PracticalNeurol. Production and editing by Brian O'Toole. Thank you for listening. 

Two new cases from the latest issue of the journal present the podcast team with some rare explanations, and a chance to test yourself on food trivia.   In the first case (1:18), from Malaysia, a 49-yo left-handed woman develops 10 days of recurrent left-sided focal facial seizures. These seizures progressed to epilepsia partialis continua, which is controlled with some difficulty by employing a broad range of six different anti-seizure medications. Further symptoms arose during monitoring, including emotional lability as well as dystonia, left arm dysfunction, dysphasia and dysarthria. EEG imaging showed focal slowing in the right hemisphere. https://pn.bmj.com/content/25/5/475 The second case (22:20) features a Northamptonshire chef in her 60s, who presents to the emergency department with a week-long history of nausea, vomiting, and abdominal pain. This progressed to dysphagia and dypsnoea, as well as a downshift in the pitch of her voice. Her conditioned worsened, with respiratory arrest requiring CPR to re-establish circulation. Neurological examination was initially done while sedated, showed fixed and dilated pupils.  https://pn.bmj.com/content/25/5/493 Overloaded with Greek terms today? Here are some definitions from BMJ Best Practice and NHS UK: Dystonia is a movement disorder characterised by sustained involuntary muscle contractions and abnormal postures of the trunk, neck, face, or extremities. Dysphasia, also known as aphasia, is an acquired impairment of language that affects comprehension and production of words, sentences, and/or discourse. Dysarthria is difficulty with speaking, caused by damage or weakness of the muscles needed for speech. Dysphagia is difficulty with the act of swallowing solids or liquids. Dyspnoea, also known as shortness of breath or breathlessness, is a subjective sensation of breathing discomfort. The case reports discussion is hosted by Prof. Martin Turner¹, who is joined by Dr. Ruth Wood² and Dr. Babak Soleimani³ for a group examination of the features of each presentation, followed by a step-by-step walkthrough of how the diagnosis was made. These case reports and many others can be found in the October 2025 issue of the journal. (1) Professor of Clinical Neurology and Neuroscience at the Nuffield Department of Clinical Neurosciences, University of Oxford, and Consultant Neurologist at John Radcliffe Hospital. (2) Neurology Registrar, University Hospitals Sussex. (3) Clinical Research Fellow, Oxford Laboratory for Neuroimmunology and Immunopsychiatry, Nuffield Department of Medicine, University of Oxford Please subscribe to the Practical Neurology podcast on your favourite platform to get the latest podcast every month. If you enjoy our podcast, you can leave us a review or a comment on Apple Podcasts (https://apple.co/3vVPClm) or Spotify (https://spoti.fi/4baxjsQ). We'd love to hear your feedback on social media - @PracticalNeurol. Production and editing by Brian O'Toole. Thank you for listening.

In this special international episode, we explore the 2025 update of the Association of British Neurologists' guidelines on managing autoimmune myasthenia gravis. Ten years after the previous recommendations, significant changes have been introduced. We emphasise the importance of daily steroids, early thymectomy, rituximab, and emerging targeted therapies transforming patient care. We also examine how these updates influence frontline care in the UK, Australia, and the USA, and why a multidisciplinary approach remains vital in the management of MG.   Participants: Professor Alasdair Coles is Head of Department for Clinical Neuroscience and also Co-Director of the Cambridge Centre for Myelin Repair, UK. Associate Professor Katherine Buzzard, Clinical Lead, Eastern Health Multiple Sclerosis and Neuroimmunology Service, Melbourne, Australia. Dr. Christopher Doughty, MD is a board-certified neurologist, and affiliated with Brigham and Women's Hospital, in Boston, Massachusetts, USA. Read the paper (https://pn.bmj.com/content/25/5/422), which is part of the October issue of the Practical Neurology journal.   Please subscribe to the Practical Neurology podcast on your favourite platform to get the latest podcast every month. If you enjoy our podcast, you can leave us a review or a comment on Apple Podcasts (https://apple.co/3vVPClm) or Spotify (https://spoti.fi/4baxjsQ). We'd love to hear your feedback on social media - @PracticalNeurol. Production and editing by Letícia Amorim. Thank you for listening. 

Another packed episode for this month's issue of the journal. There's a special emphasis on case reports this time, showing their value as a way to understand the rarely encountered. For the more common conditions there are guidelines, and the editors give you an introduction to the new ABN guidelines on myasthenia gravis, as a preview to an upcoming full episode on the topic. There's a birder's take on the use of EEG for status epilepticus, a review of the benefits and challenges for digital health records, and some deliberation on ophthalmological pronunciation. Plus, an opportunity to test your knowledge on illicit drug slang: do you know your "jeff" from your "khat"? Read the highlights: https://pn.bmj.com/content/25/5/391   Please subscribe to the Practical Neurology podcast on your favourite platform to get the latest podcast every month. If you enjoy our podcast, you can leave us a review or a comment on Apple Podcasts (https://apple.co/3vVPClm) or Spotify (https://spoti.fi/4baxjsQ). We'd love to hear your feedback on social media - @PracticalNeurol. Production by Brian Kennedy, Letícia Amorim. Editing by Brian O'Toole. Thank you for listening.

The wonders of the animal kingdom make an absorbing reappearance this episode, so grab your scuba mask before listening - or your chef's hat. The first case this month is the kind that even an experienced neurologist would be nervous to encounter (1:35). A holidaymaker in his sixties presents to the emergency department with vomiting, dizziness, and an inability to walk, amongst several other symptoms. A suspicion of stroke was quickly replaced by a different hypothesis following discussions with the patient's family members. https://pn.bmj.com/content/25/4/377   The second case follows a presentation over the span of multiple decades (18:44). A woman first presents in her thirties with extreme lethargy and occasional migraines. She was diagnosed with panhypopituitarism and treated with steroid replacement. Following breast cancer in her late forties, treated by surgery and radiotherapy, the migraines worsened, prompting further investigation. https://pn.bmj.com/content/25/4/359   The case reports discussion is hosted by Prof. Martin Turner¹, who is joined by Dr. Ruth Wood² and Dr. Babak Soleimani³ for a group examination of the features of each presentation, followed by a step-by-step walkthrough of how the diagnosis was made. These case reports and many others can be found in the June 2025 issue of the journal. (1) Professor of Clinical Neurology and Neuroscience at the Nuffield Department of Clinical Neurosciences, University of Oxford, and Consultant Neurologist at John Radcliffe Hospital. (2) Neurology Registrar, University Hospitals Sussex. (3) Clinical Research Fellow, Oxford Laboratory for Neuroimmunology and Immunopsychiatry, Nuffield Department of Medicine, University of Oxford Please subscribe to the Practical Neurology podcast on your favourite platform to get the latest podcast every month. If you enjoy our podcast, you can leave us a review or a comment on Apple Podcasts (https://apple.co/3vVPClm) or Spotify (https://spoti.fi/4baxjsQ). We'd love to hear your feedback on social media - @PracticalNeurol. Production by Brian Kennedy, Letícia Amorim. Editing by Brian O'Toole. Thank you for listening.

"This is a disorder that you don't want to miss", says Prof. Jon Stone¹, describing the condition at the heart of this episode, alongside co-author Dr. Huw Green². Their paper "Health anxiety in a neurological setting" is the subject of the Editors' Choice podcast for the August 2025 issue, hosted by Dr. Amy Ross Russell. They cover the assumptions to avoid, the problematic pattern of patient reassurance and return, effective treatment methods, and even touch on a light bit of existentialism. Read the paper: https://pn.bmj.com/content/25/4/330 See also: https://neurosymptoms.org/ (1) Neuropsychology, Addenbrooke's Hospital, Cambridge, UK (2) Department of Clinical Neurosciences, University of Edinburgh, Edinburgh, UK Please subscribe to the Practical Neurology podcast on your favourite platform to get the latest podcast every month. If you enjoy our podcast, you can leave us a review or a comment on Apple Podcasts (https://apple.co/3vVPClm) or Spotify (https://spoti.fi/4baxjsQ). We'd love to hear your feedback on social media - @PracticalNeurol. Production by Amy Ross Russell and Brian O'Toole, editing by Brian O'Toole. Thank you for listening. 

Simplification is everything - that's the message for the latest issue of the journal. Assisted by a cast of characters including Albert Einstein and deep sea sponges, your editors Phil Smith and Geraint Fuller take on topics from hyponatraemia to health anxiety. You'll also find bread and butter epileptology, somatosensory evoked potentials, creatine kinase, and a guide for exploring the hinterlands of essential tremor.   Read the issue: https://pn.bmj.com/content/25/4/297    Please subscribe to the Practical Neurology podcast on your favourite platform to get the latest podcast every month. If you enjoy our podcast, you can leave us a review or a comment on Apple Podcasts (https://apple.co/3vVPClm) or Spotify (https://spoti.fi/4baxjsQ). We'd love to hear your feedback on social media - @PracticalNeurol. Production and editing by Brian O'Toole. Thank you for listening. 

In the latest bonus podcast, the practical use of intravenous immunoglobulin is discussed with perspectives from three continents. Participants: Professor Alasdair Coles is Head of Department for Clinical Neuroscience and also Co-Director of the Cambridge Centre for Myelin Repair, UK. Dr. Lynette Kiers is a Clinical Associate Professor at The University of Melbourne, and Director of Clinical Neurophysiology at the Royal Melbourne Hospital, Australia. Dr. Christopher Hahn is an Associate Clinical Professor of Neurology at the University of Calgary's Cumming School of Medicine, and the Medical Director of the Calgary Electromyography Lab, Canada. Read the paper (https://pn.bmj.com/content/25/3/228) which is part of the June issue of the Practical Neurology journal.   Please subscribe to the Practical Neurology podcast on your favourite platform to get the latest podcast every month. If you enjoy our podcast, you can leave us a review or a comment on Apple Podcasts (https://apple.co/3vVPClm) or Spotify (https://spoti.fi/4baxjsQ). We'd love to hear your feedback on social media - @PracticalNeurol. Production and editing by Letícia Amorim. Thank you for listening. 

Gastric sleeve surgery is the key feature of a pair of recent cases from the journal, which start this episode (1:17). Both cases feature 25-yo women with presentations in common: paraesthesia and limb weakness, along with disordered eye movement. Their symptoms arose soon after the gastrectomy operation.  https://pn.bmj.com/content/25/3/268  The second report is a "true grey case" (22:14), with a myriad of presenting symptoms in a 27-yo man: fevers, weight loss, lethargy, light sensitivity, and skin plaques around the nose and mouth. Steroid treatment was started with a suspicion of a  connective tissue disease, but was halted when his condition soon worsened. Some feathered friends of the podcast shine a light on the diagnosis. https://pn.bmj.com/content/25/3/253  The case reports discussion is hosted by Prof. Martin Turner¹, who is joined by Dr. Ruth Wood² and Dr. Babak Soleimani³ for a group examination of the features of each presentation, followed by a step-by-step walkthrough of how the diagnosis was made. These case reports and many others can be found in the June 2025 issue of the journal. (1) Professor of Clinical Neurology and Neuroscience at the Nuffield Department of Clinical Neurosciences, University of Oxford, and Consultant Neurologist at John Radcliffe Hospital. (2) Neurology Registrar, University Hospitals Sussex. (3) Clinical Research Fellow, Oxford Laboratory for Neuroimmunology and Immunopsychiatry, Nuffield Department of Medicine, University of Oxford Please subscribe to the Practical Neurology podcast on your favourite platform to get the latest podcast every month. If you enjoy our podcast, you can leave us a review or a comment on Apple Podcasts (https://apple.co/3vVPClm) or Spotify (https://spoti.fi/4baxjsQ). We'd love to hear your feedback on social media - @PracticalNeurol. Production by Amy Ross Russell and Brian O'Toole, editing by Brian O'Toole. Thank you for listening.

A neuroinflammatory disorder with the potential to affect virtually any organ in the body, IgG4-related disease is a challenge on many fronts. The latest Editors' Choice paper in the June 2025 issue takes on this systemic disease, presenting a treatment algorithm for its management. This episode, PN's podcast editor Dr. Amy Ross Russell speaks with author Dr. Claire Rice. Hear an overview on the disease background, the signs in presentation, what to look for in the histology, and steroid treatment strategy.    Read the paper: IgG4-related disease in the nervous system    Please subscribe to the Practical Neurology podcast on your favourite platform to get the latest podcast every month. If you enjoy our podcast, you can leave us a review or a comment on Apple Podcasts (https://apple.co/3vVPClm) or Spotify (https://spoti.fi/4baxjsQ). We'd love to hear your feedback on social media - @PracticalNeurol. Production by Amy Ross Russell and Brian O'Toole. Editing by Brian O'Toole. Thank you for listening. 

This episode's theme is new diseases, whether they are newly described, or old diseases back in a new form. We start off with IgG4-related disease, a chronic multisystem disorder that is still being understood. Then there is a genetics paper on repeat expansion disorders, a group of conditions often thought as disparate but with quite a few commonalities. Next along is a fascinating case following gastric sleeve bariatric surgery, highlighting the dangers of travelling for unsupervised surgeries, and raising the question, “Are you getting enough soil in your diet?” There's also a discussion of what else Hoover's sign might represent, and the evolution of immunoglobulin use. Closing the episode is a paper offering a masterclass on the assessment of best interests in  prolonged disorder of consciousness.   Read the issue: https://pn.bmj.com/content/25/3/199   Please subscribe to the Practical Neurology podcast on your favourite platform to get the latest podcast every month. If you enjoy our podcast, you can leave us a review or a comment on Apple Podcasts (https://apple.co/3vVPClm) or Spotify (https://spoti.fi/4baxjsQ). We'd love to hear your feedback on social media - @PracticalNeurol. Production and editing by Brian O'Toole. Thank you for listening. 

Two wide open cases from the latest issue of the journal. Starting with a case from Italy (1:18), of a 63-yo man having a history of behavioural and cognitive problems since retiring. His many changes included low mood, significant weight loss, and problems with sleep and temperature regulation. He had a background of type 2 diabetes. Initial treatment was on a suspicion of Alzheimer's, but there was no clinical improvement. https://pn.bmj.com/content/25/2/159  A case from the United States is next (17:36), featuring a 66-yo lady experiencing 10 days of generalised weakness, with episodes of forgetfulness and a series of falls. She had previously been treated for left-sided ophthalmic herpes zoster. Neurological examination showed mild right arm and leg weakness. https://pn.bmj.com/content/25/2/164    The case reports discussion is hosted by Prof. Martin Turner¹, who is joined by Dr. Ruth Wood² and Dr. Babak Soleimani³ for a group examination of the features of each presentation, followed by a step-by-step walkthrough of how the diagnosis was made. These case reports and many others can be found in the February 2025 issue of the journal. (1) Professor of Clinical Neurology and Neuroscience at the Nuffield Department of Clinical Neurosciences, University of Oxford, and Consultant Neurologist at John Radcliffe Hospital. (2) Neurology Registrar, University Hospitals Sussex. (3) Clinical Research Fellow, Oxford Laboratory for Neuroimmunology and Immunopsychiatry, Nuffield Department of Medicine, University of Oxford Please subscribe to the Practical Neurology podcast on your favourite platform to get the latest podcast every month. If you enjoy our podcast, you can leave us a review or a comment on Apple Podcasts (https://apple.co/3vVPClm) or Spotify (https://spoti.fi/4baxjsQ). We'd love to hear your feedback on social media - @PracticalNeurol. Production and editing by Brian O'Toole. Thank you for listening. 

Immune checkpoint inhibitors can significantly improve cancer survival rates. But resulting immune-related toxicities are common, requiring multidisciplinary cooperation between oncology and neurology.  This episode, PN's podcast editor Dr. Amy Ross Russell speaks with a panel of experts on the balancing act required when treating cancer patients with these new drugs. Oncologist Dr. Heather Shaw is alongside neurologists Dr. Aisling Carr and Dr. Mark Willis, and they are amongst the authors of the editors' choice paper for the latest issue of Practical Neurology. Read the paper: Neurological complications of immune checkpoint inhibitors: a practical guide  Please subscribe to the Practical Neurology podcast on your favourite platform to get the latest podcast every month. If you enjoy our podcast, you can leave us a review or a comment on Apple Podcasts (https://apple.co/3vVPClm) or Spotify (https://spoti.fi/4baxjsQ). We'd love to hear your feedback on social media - @PracticalNeurol. Production by Letícia Amorim, Brian Kennedy, Amy Ross Russell and Brian O'Toole. Editing by Brian O'Toole. Thank you for listening. 

The latest guidelines on disease-modifying treatment in multiple sclerosis (MS) from the Association of British Neurologists is discussed in this intercontinental podcast with perspectives from the UK, the USA, and Australia.   Participants: Professor Alasdair Coles is Head of Department for Clinical Neuroscience and also Co-Director of the Cambridge Centre for Myelin Repair, UK. Dr. Tamara Kaplan is Assistant Professor of Neurology at Harvard Medical School, and is also affiliated with the Brigham and Women's Hospital, Boston, USA. Professor Michael Barnett is a consultant neurologist at Royal Prince Alfred Hospital Sydney, Central Clinical School, and Director of the RPAH MS Clinic and the MS Clinical Trials Unit at the Brain and Mind Centre, University of Sydney, Australia. Read the paper (https://pn.bmj.com/content/25/1/18) which is part of the February issue of the Practical Neurology journal.   Please subscribe to the Practical Neurology podcast on your favourite platform to get the latest podcast every month. If you enjoy our podcast, you can leave us a review or a comment on Apple Podcasts (https://apple.co/3vVPClm) or Spotify (https://spoti.fi/4baxjsQ). We'd love to hear your feedback on social media - @PracticalNeurol. Production and editing by Letícia Amorim. Thank you for listening.     

It's a podcast of pairs this time, for the latest issue of the journal. There's two hosts, two halves of the brain, two sides to a clinical debate, and two themes to the episode itself. Leading off is a discussion on peripheral neurology, taking a look at the editors' choice paper on immune checkpoint inhibitors. That's followed by a paper on  secondary hypertension, and another on small fibre neuropathies. The second half covers elements of cognitive neurology, including a topic with increasing awareness - that of brain fog. There's the dramatically named STOP-BANG questionnaire, a notable appearance from a monkey, and a reflection on modern practices for cognitive assessment. Read the issue: https://pn.bmj.com/content/25/2/101 Listen to Dr. Laura McWhirter on the JNNP podcast: Brain fog demystified Please subscribe to the Practical Neurology podcast on your favourite platform to get the latest podcast every month. If you enjoy our podcast, you can leave us a review or a comment on Apple Podcasts (https://apple.co/3vVPClm) or Spotify (https://spoti.fi/4baxjsQ). We'd love to hear your feedback on social media - @PracticalNeurol. Production by Letícia Amorim and Brian O'Toole. Editing by Brian O'Toole. Thank you for listening. 

A puzzling pair of Case Reports from the most recent issue of the journal. First up (1:35) is a man in his mid-fifties, presenting with lumbar spine fractures, which then developed into confusion, vomiting, and abdominal pain. An x-ray showed  dilated intestinal loops and his blood sodium levels were low. https://pn.bmj.com/content/25/1/87 The second case (23:06) involves a 21-yo woman, who presented  at 18 weeks pregnant with  multiple episodes of right upper limb tonic extension, and subsequently developed new-onset refractory status epilepticus (NORSE). https://pn.bmj.com/content/25/1/56    The case reports discussion is hosted by Prof. Martin Turner¹, who is joined by Dr. Ruth Wood² and Dr. Xin You Tai³ for a group examination of the features of each presentation, followed by a step-by-step walkthrough of how the diagnosis was made. These case reports and many others can be found in the February 2025 issue of the journal. (1) Professor of Clinical Neurology and Neuroscience at the Nuffield Department of Clinical Neurosciences, University of Oxford, and Consultant Neurologist at John Radcliffe Hospital. (2) Neurology Registrar, University Hospitals Sussex. (3) Clinical Academic Fellow, Nuffield Department of Clinical Neurosciences, Oxford University, and Neurology Specialty registrar, Oxford University Hospital.  Please subscribe to the Practical Neurology podcast on your favourite platform to get the latest podcast every month. If you enjoy our podcast, you can leave us a review or a comment on Apple Podcasts (https://apple.co/3vVPClm) or Spotify (https://spoti.fi/4baxjsQ). We'd love to hear your feedback on social media - @PracticalNeurol. Production and editing by Letícia Amorim and Brian O'Toole. Thank you for listening. 

Intermittent painful spasms, stiffness and rigidity of the proximal and truncal muscles are only a few symptoms of the relatively uncommon Stiff-person syndrome (SPS). In this podcast, we delve into the characteristics and diagnosis of this complex autoimmune condition. PN's podcast editor Dr. Amy Ross Russell interviews Professor Saiju Jacob (University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK). The paper is the Editor's Choice paper of the February issue of Practical Neurology. The episode is released to coincide with world Encephalitis day. For more information about World encephalitis day, or encephalitis international please follow this link: https://www.encephalitis.info/world-encephalitis-day/  Please subscribe to the Practical Neurology podcast on your favourite platform to get the latest podcast every month. If you enjoy our podcast, you can leave us a review or a comment on Apple Podcasts (https://apple.co/3vVPClm) or Spotify (https://spoti.fi/4baxjsQ). We'd love to hear your feedback on social media - @PracticalNeurol. Production by Letícia Amorim and Brian O'Toole. Editing by Brian O'Toole. Thank you for listening. 

The practice of neurology is constantly changing, and the papers in this issue exemplify that trend. On this episode, journal editors Dr. Geraint Fuller and Prof. Philip Smith discuss their highlights from the latest issue of Practical Neurology, for February 2025. They begin with the editors' choice paper on stiff person syndrome, then speak about new guidance from the ABN on disease-modifying treatments for MS. There's also life-improving interventions for posterior cortical atrophy, changing attitudes towards stroke as a career option for neurologists, and management techniques for cryptococcal meningitis - including a resourceful substitute for India ink.  Read the issue: https://pn.bmj.com/content/25/1/1  Please subscribe to the Practical Neurology podcast on your favourite platform to get the latest podcast every month. If you enjoy our podcast, you can leave us a review or a comment on Apple Podcasts (https://apple.co/3vVPClm) or Spotify (https://spoti.fi/4baxjsQ). We'd love to hear your feedback on social media - @PracticalNeurol. Production by Letícia Amorim and Brian O'Toole. Editing by Brian O'Toole. Thank you for listening. 

Two more fascinating Case Reports from the latest issue of the journal. The first case (1:15) is of a 57-yo woman, with an intermittent posterior headache, which had an associated bilateral pressure-like sensation. Her symptoms had begun on a recent trip to Sri Lanka. https://pn.bmj.com/content/24/6/526  Following on is the second case (22:18), which features a 54-yo man experiencing deterioration in his speech and mobility. He had a background of chronic HIV infection with ongoing treatment. https://pn.bmj.com/content/24/6/507   The case reports discussion is hosted by Prof. Martin Turner¹, who is joined by Dr. Ruth Wood² and Dr. Xin You Tai³ for a group examination of the features of each presentation, followed by a step-by-step walkthrough of how the diagnosis was made. These case reports and many others can be found in the June 2024 issue of the journal. (1) Professor of Clinical Neurology and Neuroscience at the Nuffield Department of Clinical Neurosciences, University of Oxford, and Consultant Neurologist at John Radcliffe Hospital. (2) Neurology Registrar, University Hospitals Sussex. (3) Clinical Academic Fellow, Nuffield Department of Clinical Neurosciences, Oxford University, and Neurology Specialty registrar, Oxford University Hospital.  Please subscribe to the Practical Neurology podcast on your favourite platform to get the latest podcast every month. If you enjoy our podcast, you can leave us a review or a comment on Apple Podcasts (https://apple.co/3vVPClm) or Spotify (https://spoti.fi/4baxjsQ). We'd love to hear your feedback on social media - @PracticalNeurol. Production and editing by Letícia Amorim and Brian O'Toole. Thank you for listening. 

It's the Christmas Special for 2024! Joining Amy in the studio is Dr. Steven Lewis. Steven is the current secretary general of the World Federation of Neurology, and is based in the United States, where he works as a general neurologist. Their conversation builds on a recent article by Dr. Bas Bloem, "Islands and bridges in healthcare: the importance of general neurology”. Listen in for insights on the differences in training and practice in the US and UK, the value of developing a network as a neurologist, and the enduring need for general neurology's broad diagnostic approach. Related links: "Welcome to the mainland: general neurology's role in rescue from the islands of subspecialisation", the editorial by Dr. Steven Lewis "In defence of general neurology", an editorial by Dr. Neil Anderson Please subscribe to the Practical Neurology podcast on your favourite platform to get the latest podcast every month. If you enjoy our podcast, you can leave us a review or a comment on Apple Podcasts (https://apple.co/3vVPClm) or Spotify (https://spoti.fi/4baxjsQ). We'd love to hear your feedback on social media - @PracticalNeurol. Production and editing by Letícia Amorim, Amy Ross Russell, and Brian O'Toole. Thank you for listening. 

The often challenging diagnosis of neuromuscular junction (NMJ) disorders can be explained by suspicious red flags for the key differential diagnoses (mimics) and atypical presentations (chameleons).  In the latest Editor's Choice paper podcast, PN's podcast editor Dr. Amy Ross Russell interviews Dr Stephen Reddel and Dr Shadi El-Wahsh, both from the Concord Hospital, New South Wales, Australia, and the authors of Neuromuscular junction disorders: mimics and chameleons. Please subscribe to the Practical Neurology podcast on your favourite platform to get the latest podcast every month. If you enjoy our podcast, you can leave us a review or a comment on Apple Podcasts (https://apple.co/3vVPClm) or Spotify (https://spoti.fi/4baxjsQ). We'd love to hear your feedback on social media - @PracticalNeurol. Production and editing by Letícia Amorim, Amy Ross Russell, and Brian O'Toole. Thank you for listening. 

Neuromuscular junction disorders can present in a variety of challenging ways, with the potential to mislead neurologists. Journal editors Prof. Philip Smith and Dr. Geraint Fuller begin with this subject as they talk through the latest issue Practical Neurology, for December 2024. The conversation moves to neck flexion and brain zaps, reflects on the undiminished importance of "general" neurology, and also touches on maternal epilepsy risks, frailty's impact on stroke patients, timely recognition of glaucoma, and sustainable practices for green physicians. To finish, there's the now-traditional recital of eponymous syndromes. Read the issue: https://pn.bmj.com/content/24/6  Please subscribe to the Practical Neurology podcast on your favourite platform to get the latest podcast every month. If you enjoy our podcast, you can leave us a review or a comment on Apple Podcasts (https://apple.co/3vVPClm) or Spotify (https://spoti.fi/4baxjsQ). We'd love to hear your feedback on social media - @PracticalNeurol. Production by Letícia Amorim and Brian O'Toole. Editing by Brian O'Toole. Thank you for listening. 

Vertigo explained, including a way to easily remember the causes of Vertigo, as well as the different symptoms associated and the HINTS exam. Also covers vertigo pathophysiology, as well as the different treatment options for vertigo.Consider subscribing on YouTube (if you found any of the info useful!): https://www.youtube.com/channel/UCRks8wB6vgz0E7buP0L_5RQ?sub_confirmation=1Patreon: https://www.patreon.com/rhesusmedicineBuy Us A Coffee!: https://www.buymeacoffee.com/rhesusmedicineTimestamps:0:00 What is Vertigo? 1:11 Benign Paroxysmal Positional Vertigo2:52 Vestibular Migraine3:52 Meniere's Disease5:15 Persistent Postural Perceptual Dizziness6:59 Vestibular Neuritis8:17 Posterior Circulation Stroke9:24 HINTS Examination Central vs Peripheral VertigoReferences:Kaylie D, M - MSD Manual Pro (2022) - “Dizziness and Vertigo”. Available at https://www.msdmanuals.com/professional/ear-nose-and-throat-disorders/approach-to-the-patient-with-ear-problems/dizziness-and-vertigoHamiter, M - MSD Manual Pro (2023) - “ Benign Paroxysmal Positional Vertigo”. Available at https://www.msdmanuals.com/professional/ear-nose-and-throat-disorders/inner-ear-disorders/benign-paroxysmal-positional-vertigoLilien, V - The British Medical Journal (2019) - “Vestibular migraine”. Available at https://www.bmj.com/content/366/bmj.l4213.fullMeniere's UK - “Migraine Associated Vertigo”. Available at https://www.menieres.org.uk/information-and-support/symptoms-and-conditions/migraine-associated-vertigoHohnen, H - Geeky Medics (2020) - “The Head Impulse, Nystagmus, Test of Skew (HINTS) Examination”. Available at https://geekymedics.com/the-head-impulse-nystagmus-test-of-skew-hints-examination/Practical Neurology (2016) - “Persistent postural-perceptual dizziness (PPPD): a common, characteristic and treatable cause of chronic dizziness”. Available at https://pn.bmj.com/content/18/1/5Clinical Knowledge Summaries (2023) - “Ménière's disease”. Available at https://cks.nice.org.uk/topics/menieres-disease/Clinical Knowledge Summaries (2023) - “Vestibular neuronitis”. Available at https://cks.nice.org.uk/topics/vestibular-neuronitis/Please remember this podcast and all content from Rhesus Medicine is meant for educational purposes only and should not be used as a guide to diagnose or to treat. Please consult a healthcare professional for medical advice. 

The immune system is a recurring feature in the cases discussed in this edition of the Case Reports podcast. The first paper details the cases of two young women, sisters, presenting with overlapping conditions but resulting in tragically different outcomes (1:16). Both were in their twenties, had given birth recently, and developed limb weakness along with several other neurological symptoms. https://pn.bmj.com/content/24/5/422 Our second case is a 72-yo woman with a range of symptoms including diplopia, ptosis, myalgia, and worsening shortness of breath (21:27). She had had surgical resection of a malignant melanoma, and was receiving immunotherapy treatment. Her presentation resembled myasthenia gravis, but initial treatment did not yield a response. https://pn.bmj.com/content/24/5/428  The case reports discussion is hosted by Prof. Martin Turner¹, who is joined by Dr. Ruth Wood² and Dr. Xin You Tai³ for a group examination of the features of each presentation, followed by a step-by-step walkthrough of how the diagnosis was made. These case reports and many others can be found in the June 2024 issue of the journal. (1) Professor of Clinical Neurology and Neuroscience at the Nuffield Department of Clinical Neurosciences, University of Oxford, and Consultant Neurologist at John Radcliffe Hospital. (2) Neurology Registrar, University Hospitals Sussex. (3) Clinical Academic Fellow, Nuffield Department of Clinical Neurosciences, Oxford University, and Neurology Specialty registrar, Oxford University Hospital.  Please subscribe to the Practical Neurology podcast on your favourite platform to get the latest podcast every month. If you enjoy our podcast, you can leave us a review or a comment on Apple Podcasts (https://apple.co/3vVPClm) or Spotify (https://spoti.fi/4baxjsQ). We'd love to hear your feedback on social media - @PracticalNeurol. This episode was produced and edited by Brian O'Toole. Thank you for listening. 

"Could this presenting syndrome be caused by a neurotoxin?" Oftentimes neurologists will pass over toxins when diagnosing. Yet disease caused by neurotoxins is widespread, with many having quite typical syndromes.  In the studio to discuss this is the first author of the October 2024 Editors' Choice paper, Dr. Frederick Vonberg¹. He draws attention to some hobbies and occupations to watch out for, the global prevalence of lead poisoning, presentations of botulism, and the origin of the infamous Mad Hatter syndrome.  Read the paper: Neurotoxicology: a clinical systems-based review 1. National Hospital for Neurology and Neurosurgery, Queen Square, London, UK Please subscribe to the Practical Neurology podcast on your favourite platform to get the latest episodes. If you enjoy our podcast, you can leave us a review or a comment on Apple Podcasts (https://apple.co/3vVPClm) or Spotify (https://spoti.fi/4baxjsQ). We'd love to hear your feedback on social media - @PracticalNeurol. This episode was hosted by PN's podcast editor Dr. Amy Ross Russell. Production by Letícia Amorim, Brian O'Toole, and Amy Ross Russell. Editing by Brian O'Toole.

The surgical sieve and Occam's razor may sound like familiar diagnostic metaphors, but what about Crabtree's bludgeon? These are just a few of the tools touched on by journal editors editors Prof. Philip Smith and Dr. Geraint Fuller, as they discuss the October 2024 issue of Practical Neurology. They cover recent publications on oligoclonal bands, neurotoxicology, methotrexate, carotid artery disease, epilepsy surgery, and how unsolved cases remain part of the "art of neurology". To finish, there is a conversation on the topic of neurology podcasts themselves.  Read the issue: https://pn.bmj.com/content/24/5   Further reading: The BMJ - What Three Wise Men have to say about diagnosis JNNP - Neurotoxicology: what the neurologist needs to know   Please subscribe to the Practical Neurology podcast on your favourite platform to get the latest podcast every month. If you enjoy our podcast, you can leave us a review or a comment on Apple Podcasts (https://apple.co/3vVPClm) or Spotify (https://spoti.fi/4baxjsQ). We'd love to hear your feedback on social media - @PracticalNeurol. Production by Letícia Amorim and Brian O'Toole. Editing by Brian O'Toole. Thank you for listening. 

This month's cases both feature sudden onset neurological syndromes. The first case (1:23) is that of a 26-yo Brazilian man who awoke from sleep with weakness in all four limbs. The signs suggest a possibility of Guillain-Barré syndrome or polio. A normal cranial nerve examination follows, with no unusual findings - https://pn.bmj.com/content/24/4/342  A 69-yo woman is the subject of the second case (14:33), after she presents with sudden onset unsteadiness and slurred speech when getting out of bed. A stroke was initially examined for by CT head scan, proving unremarkable, but a subsequent MRI scan showed an intense midbrain lesion. The patient subsequently improved, but then returned three months later with occurrences of the same symptoms multiple times throughout the day - https://pn.bmj.com/content/24/4/310 The case reports discussion is hosted by Prof. Martin Turner (1), who is joined by Dr. Ruth Wood (2) and Dr. Xin You Tai (3) for a group examination of the features of each presentation, followed by a step-by-step walkthrough of how the diagnosis was made. These case reports and many others can be found in the August 2024 issue of the journal. (1) Professor of Clinical Neurology and Neuroscience at the Nuffield Department of Clinical Neurosciences, University of Oxford, and Consultant Neurologist at John Radcliffe Hospital. (2) Neurology Registrar, University Hospitals Sussex. (3) Clinical Academic Fellow, Nuffield Department of Clinical Neurosciences, Oxford University, and Neurology Specialty registrar, Oxford University Hospital.  Listen to the JNNP podcast, "Nutritional peripheral neuropathies, with Dr. Alexander Rossor" on Apple (https://apple.co/3WjTmrM), Spotify (https://spoti.fi/4bKOhNA), Web (https://bit.ly/4cYhx4m). Please subscribe to the Practical Neurology podcast on your favourite platform to get the latest podcast every month. If you enjoy our podcast, you can leave us a review or a comment on Apple Podcasts (https://apple.co/3vVPClm) or Spotify (https://spoti.fi/4baxjsQ). We'd love to hear your feedback on social media - @PracticalNeurol. This episode was produced and edited by Brian O'Toole. Thank you for listening. 

Genetic testing is a useful tool for any practising neurologist, but they must know how to interpret the results. This Editors' Choice podcast features two experts on the subject, Prof. Mary Reilly¹ and Dr. Christopher Record¹. They're in the studio to talk through their paper, covering the technology of genome sequencing itself, testing strategies, clinical use cases, and the constant changes in this developing field. Read the paper: Lessons and pitfalls of whole genome sequencing 1. Centre for Neuromuscular Diseases, Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK Please subscribe to the Practical Neurology podcast on your favourite platform to get the latest episodes. If you enjoy our podcast, you can leave us a review or a comment on Apple Podcasts (https://apple.co/3vVPClm) or Spotify (https://spoti.fi/4baxjsQ). We'd love to hear your feedback on social media - @PracticalNeurol. This episode was hosted by PN's podcast editor Dr. Amy Ross Russell. Production by Letícia Amorim, Brian O'Toole, and Amy Ross Russell. Editing by Brian O'Toole.

Journal editors Prof. Philip Smith and Dr. Geraint Fuller discuss the August 2024 issue of Practical Neurology, with room for mystery, history and practical advice. In particular, they cover topics like whole genome sequencing, foot surgery for Charcot-Marie-Tooth disease, safe prescribing in steroids, and fertility treatment for the epileptic. There are also good reasons for dusting off the old optokinetic nystagmus drum, and a touching story of neuro palliative care. Read the Highlights - https://pn.bmj.com/content/24/4/261 - and the full issue - https://pn.bmj.com/content/24/4. Please subscribe to the Practical Neurology podcast on your favourite platform to get the latest podcast every month. If you enjoy our podcast, you can leave us a review or a comment on Apple Podcasts (https://apple.co/3vVPClm) or Spotify (https://spoti.fi/4baxjsQ). We'd love to hear your feedback on social media - @PracticalNeurol. The PN podcast is produced by Letícia Amorim and edited by Brian O'Toole. Thank you for listening.

Two highly unusual cases in this edition of Case Reports. The first case describes a 64-yo woman presenting to the emergency department with a five day history of bizarre behaviours (1:45). A BBC radio show prompts her, out of character, to reflect aloud about her childhood, and she experiences recurrent periods of unresponsiveness followed by intense agitation. She was kept in hospital for scans and discharged after two weeks, but returned soon after with a similar presentation - (link) A lifetime bodybuilder is the patient in the second case (21:12), with a practice of anabolic steroid injection over several decades. He presents with a three year history of unsteadiness when walking and tingling in his feet, as well as reduced dexterity. His symptoms are found to be brought on by a toxicity from an unexpected source - (link) The case reports discussion is hosted by Prof. Martin Turner (1), who is joined by Dr. Ruth Wood (2) and Dr. Xin You Tai (3) for a group examination of the features of each presentation, followed by a step-by-step walkthrough of how the diagnosis was made. These case reports and many others can be found in the June 2024 issue of the journal. (1) Professor of Clinical Neurology and Neuroscience at the Nuffield Department of Clinical Neurosciences, University of Oxford, and Consultant Neurologist at John Radcliffe Hospital. (2) Neurology Registrar, University Hospitals Sussex. (3) Clinical Academic Fellow, Nuffield Department of Clinical Neurosciences, Oxford University, and Neurology Specialty registrar, Oxford University Hospital.  Listen to the JNNP podcast, "Nutritional peripheral neuropathies, with Dr. Alexander Rossor" on Apple (https://apple.co/3WjTmrM), Spotify (https://spoti.fi/4bKOhNA), Web (https://bit.ly/4cYhx4m). Please subscribe to the Practical Neurology podcast on your favourite platform to get the latest podcast every month. If you enjoy our podcast, you can leave us a review or a comment on Apple Podcasts (https://apple.co/3vVPClm) or Spotify (https://spoti.fi/4baxjsQ). We'd love to hear your feedback on social media - @PracticalNeurol. This episode was produced and edited by Brian O'Toole. Thank you for listening. 

Neurodegenerative disease is the subject of this month's Editors' Choice podcast, with Dr. Patrick Cullinane¹ and Dr. Zane Jaunmuktane.¹ They join the podcast for an overview of brain examination, explaining the process of protein misfolding, the spread of pathology through the brain, and what new discoveries can tell us about old diseases. Read the paper: Pathology of neurodegenerative disease for the general neurologist 1. Queen Square Brain Bank for Neurological Disorders, UCL Queen Square Institute of Neurology, London, UK Please subscribe to the Practical Neurology podcast on your favourite platform to get the latest episodes. If you enjoy our podcast, you can leave us a review or a comment on Apple Podcasts (https://apple.co/3vVPClm) or Spotify (https://spoti.fi/4baxjsQ). We'd love to hear your feedback on social media - @PracticalNeurol. This episode was hosted by PN's podcast editor Dr. Amy Ross Russell. Production by Letícia Amorim, Brian O'Toole, and Amy Ross Russell. Editing by Brian O'Toole. Special thanks to The Podcast Studios Dublin for their assistance with the recording of this episode, and thank you for listening.

Journal editors Prof. Philip Smith and Dr. Geraint Fuller discuss the June 2024 issue of Practical Neurology, covering some of the interesting articles published this month. A number of difficult challenges and tradeoffs are featured, relating to recent men-only guidance for sodium valproate use, folic acid dosing for women with epilepsy, post-mortem brain donation, and sexual dysfunction caused by neurological medication. There is also some insight into the treatment of hepatic encephalopathy and congenital myasthenia. Read the issue: https://pn.bmj.com/content/24/3 Further reading: Cancer Risk in Children of Mothers With Epilepsy and High-Dose Folic Acid Use During Pregnancy. Vegrim HM, Dreier JW, Alvestad S, et al. JAMA Neurol. 2022;79(11):1130–1138. Please subscribe to the Practical Neurology podcast on your favourite platform to get the latest podcast every month. If you enjoy our podcast, you can leave us a review or a comment on Apple Podcasts (https://apple.co/3vVPClm) or Spotify (https://spoti.fi/4baxjsQ). We'd love to hear your feedback on social media - @PracticalNeurol. The PN podcast is produced by Letícia Amorim and edited by Brian O'Toole. Thank you for listening.

The first of this episode's two case reports features a 62-yo man, referred from ophthalmology with a drooping eyelid, chronic coughing, and excess sweating in the face provoked by eating (1:21). An MR scan finds abnormal deposits in his brain - (link) The second report describes two patients (17:05), firstly a 70-yo man presenting with abnormal facial movements and weight loss, and secondly a 90-yo woman with abnormal movements of her right arm and leg. Routine blood tests at presentation for both patients were normal at presentation - (link) The case reports discussion is hosted by Prof. Martin Turner (1), who is joined by Dr. Ruth Wood (2) and Dr. Xin You Tai (3) for a group examination of the features of each presentation, followed by a step-by-step walkthrough of how the diagnosis was made. These case reports and many others can be found in the April 2024 issue of the journal. (1) Professor of Clinical Neurology and Neuroscience at the Nuffield Department of Clinical Neurosciences, University of Oxford, and Consultant Neurologist at John Radcliffe Hospital. (2) Neurology Registrar, University Hospitals Sussex. (3) Clinical Academic Fellow, Nuffield Department of Clinical Neurosciences, Oxford University, and Neurology Specialty registrar, Oxford University Hospital.  Please subscribe to the Practical Neurology podcast on your favourite platform to get the latest podcast every month. If you enjoy our podcast, you can leave us a review or a comment on Apple Podcasts (https://apple.co/3vVPClm) or Spotify (https://spoti.fi/4baxjsQ). We'd love to hear your feedback on social media - @PracticalNeurol. The PN podcast is produced by Letícia Amorim and edited by Brian O'Toole. Thank you for listening. 

Journal editors Prof. Philip Smith and Dr. Geraint Fuller discuss the April 2024 issue of Practical Neurology, covering some of the interesting articles published this month. Topics include inconsistencies observed in functional gait, the consequences of restrictive diets with reduced riboflavin, and a guideline to managing patients with spontaneous intracranial hypotension. In syndromic sightings there's a scattering of Ehlers-Danlos, Strachan and Alzheimer's to name but a few. Plus, some correspondence shedding light on the meaning behind an oversized comb - or was it an extreme brush? Read the issue: https://pn.bmj.com/content/24/2 Please subscribe to the Practical Neurology podcast on your favourite platform to get the latest podcast every month. If you enjoy our podcast, you can leave us a review or a comment on Apple Podcasts (https://apple.co/3vVPClm) or Spotify (https://spoti.fi/4baxjsQ). We'd love to hear your feedback on social media - @PracticalNeurol. The PN podcast is produced by Letícia Amorim and edited by Brian O'Toole. Thank you for listening.