Saturday, May 14, 2016

Extry! Extry! I was kinda wrong!

Passive stretching has been used by therapists on survivors forever. Does stretching do anything to help recovery? So far as we know- no.

But there are therapists who don't want to hear this. I do a ton o' talks on stroke recovery and if you tell some therapists that stretching does not help survivors, therapists can get feisty. "If that doesn't work what am I supposed to do - they're tight and can't move."

Typically I tell them that they're probably not doing harm but they're not helping much either.

The thing is, I'm always reading research to update the message. I found an article that says that if a survivor is stretched, it may help. There are a couple of flys in the ointment, however... In this case, a therapist did not stretch them. Here's what they did:
  • What moved the survivors: Subjects wore an actuated glove orthosis that cyclically moved their fingers and thumb
  • How the survivors were moved: From a relaxed/flexed posture into neutral extension 
  • How long were they moved: 30 minutes on 3 consecutive days
  • What they gained: Improvement was observed immediately after the stretching (this is to be expected- stretching does have a short term effect, although any long-term effect is questionable). Here's the potential new news: largely maintained up to 1 hour poststretching, with significant carryover for the 3 days for some outcomes. That was true for what they called "subacute" survivors (defined as "2 to 6 months"- which is a misrepresentation of "subacute" after stroke) but not true (it did not work as well) in "chronic" survivors.
So, what have we learned? Stretching a survivor passively with a computer-driven actuated glove orthosis-- if they are 2-6 months after the stroke-- provides some short term benefits.

And they wonder why everyone outside of research hates research...

Monday, May 2, 2016

Electrical Stimulation after Stroke MADE EASY

Lets say you wanted to do electrical stimulation (eStim) to help your recovery. But....

There are 2 things stopping you:

1. You don't know what to do
2. eStim is really expensive

Let me help you with that... 

eStim is easy and cheap.

First the EZ part: How do you do it.

There are 3 parts to any eStim setup:

1. Machine

2. Lead wires

3. Electrodes

Put 2 electrodes (they're usually sticky) over the muscle you want to work. Typically, after stroke there are two sets of muscles that everyone focus on:

1. The finger and wrist extensors. These will pull the wrist up and open the fingers.

2. The muscles that lift the foot and end drop-foot.

So, where do the electrodes go again?

1. Wrist/ fingers:


2. The muscles that lift the foot:

1. Attach the lead wires from the machine to the sticky electrodes.2. Stick the electrodes on according to the images, above. Optimal placement will vary from person to person because everyone's anatomy is different. And, after stroke, every survivor's deficit will require slight changes in electrode placement- according to their needs.3. Turn up the eStim. If you are getting the movement you want, take a photo of the electrode placement, or put a pen mark on you skin.
How long should I do it for?I've been involved in a lot of what is called "dosing" clinical trials for eStim (here are a few). Figuring dosing for eStim is just what like figuring dosing for a drug: How much should I take? Is it different for every survivor? Yes. Does it depend on how much brain damage there was? Yes. Does it depend on other things as well? Yes.  Let me give you the EZ bottom line here...The only way you'll learn how much eStim you need and learn how to use the machine... is to use the machine. Manuals and rules are nice, but practice is better. Put the electrodes on and turn up the estim slowly. Once you get the movement you want, note the amount of eStim you used (measured in milliamps or mA).Two important notes (this gets a bit technical, but you can handle it!)1. Make sure you gradate up the eStim. Basically, its the same as any exercise program: Start slowly, and work up to more over time. Why gradate up? When eStim is used and there is muscle contraction, that muscle is being worked. It is firing. just like with any muscle work, you can end up sore and worse if you do too much too soon. So gradate up something like this:Day 1: 2 minutes. Day 2: 4 minutes. Day 3: 6 minutes. Day 4: 10 minutes. Day 5: 5 minutes twice a day. Day 6: 8 minutes twice a day. Day 7: 10 minutes twice a day. And so on... until you hit the optimal does and then stay there. This will give your muscles time to build gradually. If you get sore- reduce the dose.

1. Make sure you ramp up up the eStim. (A little more technical, sorry!). When eStim makes your muscle fire it does not just effect that muscle. It also effects that muscle's antagonist (the muscle that moves in the opposite direction). Example: Elbow flexors (benders) and extensors (straighteners). If you eStim the muscles that straighten the elbow, if do properly, the muscles that bend the elbow will be forced to relax. And I think you'd agree, in most survivors where the elbow is always bent, it would be good (great!) to relax the muscles that bend the elbow. (Note: this phenomenon-- when one muscle the contracts, its opposing muscle relaxes) was discovered by one of my neuroscience heroes: Sir. Charles Sherrington. Lookin' good Papa! 
So that's good: You use eStim to contract one muscle and relax the opposite muscle. But there is one problem...
If the eStim is put on so that the highest amount of eStim that is set happens all at once, a paradoxical thing happens. The muscle that should relax (the opposite or antagonist muscle) actually fires. So now both muscles are firing and essentially fighting each other. 
So make sure the "ramp up time" is at least 2 seconds. The machine will let you control the amount of ramp up time. Make it 2-5 seconds. This extra time will give the antagonist muscle time to not feel threatened and relax. 
So it will look something like this:

1. First, get an appropriate healthcare worker involved. An OT or PT will work. Have them read this blog entry and help you set it up- first time at least.
2. There are a bunch of precautions for eStim. You can find them here... but they can be misinterpreted so always: get an appropriate healthcare worker involved.

Price: Cheap!

eStim is cheap. Below are some examples. You're looking for NMES (where the muscle actually fires) not TENS (where you can feel it but the muscle does not fire).


Thursday, April 14, 2016

Get an MRI of your brain. Keep a copy.

One thing I recommend to every survivor: Get an MRI of your brain and keep a copy.


First of all, an MRI can tell you a lot about what parts of your brain were damaged. Knowing where the damage was can give you insight into potential recovery. 

And an MRI (probably) comes with good news: You probs didn't suffer from as much brain damage as you thought you did. In fact, the average stroke (stress average) kills about 2% of the brain. And the brain is a highly resilient and transitory environment. It is very plastic. So that's good news, not much damage in an environment that can make up for its own weaknesses. 

What is a massive stroke?

MDs often describe a stroke as massive. The problem is, there is no definition for that word when it comes to stroke.

What a free book? Here's you quiz...
Here I will offer a challenge. (If I lose, I will recant and send you a free sighed copy of my book (yay!?). When a stroke is defined as massive, how much of the brain has to die to be considered massive? I'll take a % or a # of neurons, or any other quantifiable definition

Here's what I suspect: The word massive has never been defined at all for stroke. MDs use the word like they use many words: to define what they can't define. Massive tells you nothing, as does hemiparesis, cognition, unilateral neglect, etc., etc. These are terms that are used a lot but provide no quantitative measurement. Take hemiparesis. This term runs the span from someone who can barely lift their shoulder to someone who you'd not recognize as having a stroke at all.
And poorly defined terms like massive end up providing a self-fulfilled prophecy. "I had a massive stroke." It sounds bad and it may be bad. But because its not well defined, it may not be bad. It may be pretty small. How small? Get you an MRI of your brain, or if you had one (you probably did) get a copy. And embrace it. Frame it and put it on your wall. It might be the most inspiring piece of art you have.

Thursday, March 10, 2016

Is it too late for you to get better - no.

Let's say you're a chronic stroke survivor. You know "chronic" – it's the time after your plateau. Typically the chronic phase goes from 3 months to the end of the stroke survivors life. Do you still have a chance to get better during the chronic phase? 


There's actually good scientific reason to believe that you can get better after the plateau – once you are chronic.

And here it is…

Typically survivors are forced through rehab as soon as possible. Facilities are expensive and home is cheap, so off you go! The problem is that to get the survivor out the door, compensatory strategies are implemented. Things like AFOs and using the good arm to get everything done. It makes sense, these things do get people out of the system. The problem is those same strategies also hurt the survivors brain.

In fact, if compensation is taught during the first 10 days after stroke it hurts future function of the "bad" side.

OK, but how does this all help the chronic survivor? It sounds like it would hurt recovery.

Here's why: Since the survivor is encouraged to use the "good" side, the "bad" side of the brain sits fallow- doing nothing. The upshot is that many survivors have a huge portion of the brain, usually adjacent to the area damaged by the stroke, that is on vacation. You've heard of 'use it or lose it'? Well, they've lost it. BUT, it can be regained. How?
Here & here & here & here are some ideas.

Friday, February 12, 2016

Enriched Environments help recovery after stroke

Remember: SHE
Social interaction

What is an enriched environment (EE)?

An EE is something that forces you to learn. Forced to learn. You have to be forced to learn. Learning can be forced by everything from curiosity to circumstance. 

In fact, the brain will not learn (change) unless its forced. Why would your brain change if it is comfortable? What if the brain changes while you're comfortable? It may change to the point where you are no longer comfortable. 

And a lack of comfort is icky.

Travel is an EE because it forces you to learn. When you are somewhere other than home you don't know whats around the next corner. You are challenged into something new and different. You are forced by your new (enriched) environment to learn. 
But how can stroke survivors use EE to recover?

Travel is not the only form of EE. Lets take a big driver of EE in humans: Social interaction. Sure, it easier to ignore everyone and hope no one talks to you. Especially after stroke when, according to the research, you're about a million times more likely to "socially isolated." In the long run it may be a heck of a lot more comfortable not to engage whats-his-name (what the heck is his name??) than to engage in conversation. But if you do engage in conversation your brain is in for a hell of a ride

Here is a list of what we think social interaction does for the brain after stroke:

  • Reduces death rate
  • Increases total recovery of functional skills
  • Increases speed of recovery of functional skills
  • Redice risk of risk of developing depression 
  • Increases post-stroke quality of life
  • Increases speed of recovery of walking
  • (link)
But social interaction is not the only (fun!) way to use EE to recover. Here are some other ways:
  • Do something with your hands. The hands are very important to the brain. The hands take up huge swaths of the brain because the hands have so much responsibility. My suggestion? Do something with your hands that you enjoy, even if you have to do it with your "good" side.
  • Exercise is considered an enrichment of environment.

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