Tuesday, March 6, 2018

Stroke is a hellish cat...

Stroke is a hellish cat gnawing its way through different disparate parts of the brain. Let's see how!!

The average stroke kills less than 3% of the total number of neurons in the brain. And that is way worse than it sounds. That small area of infarct insidiously exports itself to all reaches of the brain.

The first part of this process happens when the area surrounding the dead area (the penumbra) is "dragged into" the damaged part of the brain. And this surrounding area is not usually re-incorporated into the brains function. Through a process known as "learned nonuse," a healthcare system hell-bent (a lot of hell in this post sorry) – not on recovery – but rather on getting survivors to no longer be a burden on the healthcare system. And the word "burden" is euphemistic – it means cash.

Because the focus is on getting rid of the patient, and not recovery, the area surrounding the stroke is not used. And it is usually not used for the rest of the person's life. But the insidious nature is of stroke is not yet fully realized.

Many different areas of the brain outside of the dead zone, and the penumbra, are dragged into the mayhem. A process known as diaschisis takes over, and exports the damage to outpost throughout the brain. Why does this happen? Because the entire brain is interconnected, when one system goes down (The part of the brain killed by the stroke) and all the other areas connected to that dead zone also become either less functional or non-functional. Look at it this way: the classic neuroscience way of putting the way the brain operates is this: "neurons that fire together wired together." That means one part of the brain, if it communicates with a completely different part of the brain, we'll both benefit. If one of those area dies (as in stroke) the undamaged other area will also become less functional. But diaschisis is not the end of the story. The insidious nature the rambling and insidious nature of stroke marches on…

The next issue has to do with the strokes affect on the survivors life. After their stroke, survivors will typically become less socially engaged, less employable, less mobile, etc. The bad news is that the brain is designed to be socially engaged, engaged in productive activity, and to explore new things. The upshot of a less engaged brain is this: the entire brain goes through a literal "pruning". In fact, neuroscientists call this process a "pruning of the dendritic arbor." Throughout the brain neurons no longer use for the daily skills they once were, disengage from each other. In a sort of bad neuroplasticity, the brain becomes less capable. But, you guessed it, we're not done yet…

The final, and one of the worst and most insidious effects of the stroke is this: through a series of direct communication and chemical reactions, the "reptilian brain" is dragged into the evil march of stroke. Areas like the hippocampus and limbic system – areas that are responsible for emotions, and mood regulation, are also wracked by the stroke.

It is heartening, and it certainly is a point of view that I have promoted over the years, that the average stroke is really small. And the stroke sits in a highly redundant, and highly changeable (plastic) environment. All of that seems like good news. You have a small area of death, surrounded by a large family of neurons willing to take over for those that are killed by the stroke.

But the more I learn about stroke the more I understand that the stroke is not just the stroke. Echos of that small area reverberate. The ripple effect of that small area wraps its tentacles around-- and through-- the entire brain. 

Thursday, February 1, 2018

DIY Mirror Therapy Box

Final mirror box
Mirror therapy is great. Even if the survivor cannot move the "bad-side" limb at all, using a mirror will fool the brain into thinking the "bad" limb into think it is moving. And because the brain is fooled, the brain changes.

How do you do mirror therapy? Click here to find out!

How do you make a mirror box cheaply and easily? Here are instructions...

What you need to buy
(click here)

What you need to make
(click here)

Tuesday, January 9, 2018

Heaven on Wheels...

Tissue Plasminogen Activator (tPA) is a clot-busting drug. It can radically reduce the physical problems after stroke. tPA has been used for years, but not enough. There are 2 things that get in the way of tPA being used more:

1.There is reluctance among some MDs to administer it; they think they may get sued for causing a worse stroke (remember: tPA is only for "block" ischemic stroke, but would make a "bleed" hemorrhagic stroke worse).

2. Survivors often miss the "window" of time tPA is thought to be effective (~3-4 hours). Only about one third of all survivors call 911 after their stroke. That is, very few survivors access emergency care that would be required to administer tPA.

The first issue, above, is discussed here. Irony: MDs are more likely to get sued if they don't administer tPA!

The second issue, this may change. There is new technology and it’s on wheels! Have a look at this vid.

More videos here.

Sunday, December 3, 2017

How much does it cost to have a stroke?

The cost of having a stroke is variable. For instance, in the United States, stroke can easily bankrupt you-- or not, depending on your insurance, your wealth, and the combination of both. In other countries in Europe it is much less of a burden. Or, lets say, the burden is more shared. But it does not matter where you are, almost always there are extra expenses along with less income.

But the data is scarce. You'd think the amount having a stroke might cost someone would be well studied. It is not. At least not lately (most studies were done in the 90s). There is a lot of research on the macro issue; how much of a burden it is on a country or a national health care system. But not much on the individual's burden. The best estimate is this: 

The long-term costs of stroke (not including lost wages is $163,432.37  for an ischemic stroke.  There is one more recent study that suggests the amount is $140,048.

But both of these estimates seem low. I have heard survivors say that their stroke has cost has cost more than a quarter of a million dollars. 

Finally, there is no way to estimate the cost. How do you estimate what might have been?

If you are struggling with the issue of expenses after stroke-- at least here in the US, there is a resource that may help.

Thursday, November 23, 2017

Motor Relearning After Stroke: Hardwiring Recovery

Motor learning is what everyone does to learn any new movement. Motor relearning is what stroke survivors do to recover any lost movement. In some ways learning movement and relearning movement after stroke are the same; they both rely on the neurons in the brain to control movement. In some ways learning and relearning a movement are inherently different because a new and different part of the brain is used to control the movement. And there is a more obvious and less science-heavy difference: Learning a movement is fun. Relearning a movement is fraught with frustration.

Motor Learning And Motor Relearning: The Differences.

For stroke survivors, the part of the brain that was used their entire lives to control particular movements is dead. The dead portion of the brain becomes a fluid-filled cavity (called an infarct). Some of the neurons used in the pre-stroke movement may be reengaged. But those neurons will have to create novel relationships with other neurons to recover the pre-stroke movement. There is no potential to relearn a movement in the same way it was originally learned.
Motor relearning after stroke has another distinction from motor learning. Most motor learning that we do is derived from play. The joy of learning a new skill propels us the development of that skill. Consider skiing. You start out and you fall (and fall and fall) and you get very wet and very cold. And then you do something right and that feeling of making the turn and carving the snow becomes the carrot at the end of the motor learning stick. But stroke survivors are not learning new skills; they’re simply relearning movements that they used to do perfectly well as they attempt to cajole new neurons to do old tricks. Where’s the fun in that?
The fact that motor relearning is not necessarily fun provides a supreme challenge to the coaching abilities and motivational skills of therapists as they shepherd stroke survivors, not towards the joy of playful motor learning, but towards the monumental task of motor relearning.

Motor Learning And Motor Relearning: The similarities.

In some ways relearning to move after stroke and “regular” motor learning are similar. Both require neuroplastic rewiring of the motor and sensory portions of the brain. Both types of learning require the learner to do the hard work (or play) of learning. No therapist, no matter how talented, can learn it for them. This is where the coaching skills of clinicians are tested. Motor relearning only happens if the stroke survivor remains motivated to move. And stroke survivors will only remain motivated if they know why they're doing what they're doing. The neuroscience is clear: only through the volitional movement of the stroke survivor does neuroplastic brain rewiring take place. Providing stroke survivors with a nervous system “user’s manual” complete with “instructions” and even “troubleshooting tips” is vital to the process of recovery. And just like any good manual, the simpler the better.

Motor learning simplified

Therapists usually think about the nervous system in terms of upper motor neuron vs. lower motor neuron, brain vs. spinal cord or central nervous system vs. peripheral nervous system. There is another way to view the part of the nervous system that impacts motor learning: front vs. back.
Consider the following thought experiment. You decide you will scratch your head, but you don’t want to mess up your hair, so you need a single nail to fall on the exact epicenter of itchiness. You begin by estimating where your arm and hand is in space (proprioception). Messages from the muscle spindles, Golgi tendon organs and other proprioceptors provide the feeling of the position of the hand and arm. That feeling becomes a sensory impulse that enters the back (dorsal root) of the spinal cord. The impulse travels up the spinal cord and ends up in the back of the brain, in the sensory portion of the cortex, just behind the central sulcus, a large fissure that separates the front of the brain from the back. The impulse, with “fine-tuning” by other parts of the brain, jumps to the anterior portion of brain and provides a movement strategy. These instructions descend the spinal cord and exit the front of the spinal cord. The impulse then goes into peripheral nerves which terminate at the target muscles that power the movement. To review:

·       The impulse goes from the proprioceptors in the limb toàthe back of the spinal cord toà the back of the brain toà the front of the brain andà out the front of the spinal cord.

Back to front. You scratch your head. But let’s say you miss your target and your nails land in the wrong place. You use this feedback to self-correct and you again send an impulse from the back to the front of your nervous system. Your nails target the exact point of itchiness. The adjustment that you’ve made is the essence of motor learning. In this thought experiment each attempt was felt and each feeling was used to mitigate the next attempt.
          Now let's continue the thought experiment with a more complicated movement. Consider typing. Typing involves precise and delicate movements of the fingers. Learning how to type involves feeling the position of the fingers (proprioceptive input) followed by repeated attempts to hit the correct keys on the keyboard (motor output). Each time the pinky finger makes a foray towards the “enter” key the feeling of a correct attempt is processed by the brain. If enough repeated attempts are successful, the movement is learned. If the learned movement is done over weeks or months or years, it is seared as a neuronal pathway into the brain. This is why we never forget how to ride a bike or swim even if we haven't done either in years. The motor strategies are “hardwired”. Hardwiring useful patterns of movement in stroke survivors is motor relearning.

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