Thursday, June 23, 2016

Stroke rehab: Where do I start?

I do a ton of talks to OTs and PTs (mostly-- some other clinicians mixed in there from time to time). Sometimes I get a specific question. Its a simple question, but perplexing.

"When treating a stroke survivor where do I start? What should I look for first?"

Here's the way I answer this question...

When I meet a survivor, the first thing I check out is the hemi-side hand. The hand tells you a ton:
  • Is spasticity an issue? If it is it will show up in spades in the hand. All those little joints, and those little muscles pulling those little appendages. And the massive strength
    difference between the muscles that close the hand against the muscles that open the hand. Let's put it this way, you can hang from one hand. Your entire body weight through those little appendages. The muscles that open the hand have the strength to do one thing: open the hand. There is a huge difference in strength between the two groups of muscle groups. So if the question is, Is spasticity a problem  the hand will usually be the first to reveal it.
  • Is the survivor paying attention to that hand? Many survivors will play with the affected hand constantly grabbing it and opening it. This is a good sign; unilateral neglect is probs not an issue.
  • Are they able to squeeze the hand shut from and opened position? A lot of people, even clinicians, think that closing the hand is a bad thing. Opening is a good thing, but closing is a bad thing. I think closing is a good thing and opening is even a better thing! You need both. It kind of like the joke: "How you feeling?" "I'm alive!" "Well that beats the alternative!" (OK, its a dad joke. But I'm a dad- so its OK!) So, being able to close the hand beats the alternative. The alternative is nothing. The dreaded flaccidity.
  • Are they able to open the hand? Can they "relax-open" the hand. That is, can the survivor relax the flexors so much that, while there is not activation of the muscles that open the hand, there is at least a deactivation of the muscles that close the hand. That deactivation is important. Why? Because of the point made above- those muscles are incredibly strong vs the opposing muscles. So the first thing needed to open the hand is the ability to shut of the muscles that close the hand.
  • How does the hand look? Is it swollen? Is it the same color as the unaffected side? Does it have the same
    amount of hair. Is it painful. All those can tell you something (esp. in someone who has a post-stroke shoulder dislocation).
  • What's going on globally? The hand takes up huge swaths of the brain. In some ways the most visible reflection of the brain is the hand, so the hand gives you global perspective on the brain.
So as a clinical or survivor or caregiver, the first thing to ask is, how is the hand doing?

Tuesday, June 14, 2016

This is a post about nothing. Well- really its about one thing.

So first of all, just look at this picture.
Use what you love to recover. Recover to do what you love.

Second, drop what your doing and join Facebook's Young Stroke Survivors group. 

(Here's the link but you have to login first).

Just do it. The end.

Friday, June 3, 2016

You've been Botoxed!! (now what?)

(Disclaimer: I've been involved in clinical trials funded by the company Allergan. Allegan makes Botox.)

In the early 2000's our lab worked with the company that makes Botox (Allergan) to update their message. Up until that point their message was pretty clear: You have spasticity, and Botox temporarily reduces it- the end.

But it is a Band-Aid. It wears off in 2-3 months. Not only does it wear off but some people- after a few injections- become immune to it. Once the immunity builds up it no longer works.

But, again, it's a Band-Aid. 

Most survivors who have spasticity want more than a Band-Aid. They want a true reduction – a reduction not controlled by any medication.

So we worked hard with Allergan to have them change and focus their message. And, to their credit, since then in all their literature and all their communications, they have added to their message.

The old message
Take Botox, it will reduce your spasticity.

The new message
Once you are "under the influence" take that "vacation from spasticity" and use it as an opportunity to move towards recovery.

You've been Botoxed!! (now what?)

Once Botoxed make sure to follow up physical or occupational therapy. Have therapists work on the following:

1. Botox and repetitive practice.
Sometimes, you get lucky and the Botox "unmasks" some movement that before the Botox was not available. Let's say your hand is constantly fisted. 

The doc Botoxes the muscles that close the hand. Botox usually takes 7-10 days to start to work. In this case, once it does work the muscles that open the hand are free from the overwhelming strength that causes the fisting. A bit of active finger extension (opening the hand) becomes available. From that point therapy should focus on as much repetitive practice of finger extension (hand opening) as possible.

2.  Botox and electrical stimulation (EStim).
As before, imagine your finger flexors are spastic. They hold your hand in a tight fist constantly. The doctor Botoxes your finger flexors, and those flexors release – allowing the hand open. The problem is the finger extensors (the muscles that open the hand) are weak because they haven't been used. EStim does two things – it activates and strengthens the muscles that open hand, while relaxing the muscles that close to hand. This is why EStim is helpful your irrespective of Botox: EStim activates the opening of the hand while relaxing the muscles that close to hand. But when EStim is done with Botox, it magnifies both.

3. Botox and Mirror therapy 
Another thing we can be tried is mirror therapy. You can find a review of mirror therapy here.

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).


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