Monday, April 7, 2014

Falls. Bad.


Here is your challenge: 

In the comments section, write everything that this survivor could do better in order to get up the stairs more safely. 

We all know that falls are bad. 

Falls can kill you. For survivors, falls are especially bad. Stroke affects balance, coordination, strength, and any number of other things that can lead to an increased risk of falls. On top of that, survivors tend to fall towards their affected side. In the affected side tends to be more osteoporotic. So have at it. This is good place to start as anywhere. What is this gentleman doing wrong? How do you do differently? What can you suggest?

Thursday, March 20, 2014

The neuroplastic model of hypersensativity reduction after stroke for fun!!

Hypersensativity after stroke can come in two basic flavors:

1. A touch (or some other stimulus that normally does not hurt) hurts. A lot. This is called allodynia.

2. Something that usually does hurt hurts a lot more that it should. In other words, it hurts a lot more than it might on the unaffetced side. This is called hyperalgesia.

So how might you treat this. Lets go to the never-ending neuoplastic well, shall we? We know that stroke damages the brain which may cause the altering and amplifiying of sensation. So what if we used the same process to reverse it? These are hypothetical (although some have been tested) so keep that in mind. So what are the neuroplastic model to treat? Possibilities include...

1. TENS (mild electrical stimulation). Dosage here.
2. A placebo. An example would be suggesting a manual therapy (like message or manipulation of the extremity) will help reduce it. Discussion here.
3. Comparison. Put the gel on the unaffected side and say, "See, its just a bit cold. We'll take exactly the same gel (it can even be done at the same time)and put it on the 'bad' side and they'll-hopefully-feel the same.
4. Mirror therapy. Set it up like this: Have him look only at the unaffected side as either the survivor or someone else gives the "good" limb the stimulus which is painful to the "bad" limb. It will look like its getting put on the affected side, but with no pain.

Further reading here.  Duscussion of the difference between hyperalgesia and allodynia here.

Wednesday, March 19, 2014

Friday, March 7, 2014

Why Dynasplint is half dead (and all dead for survivors)

Do you have muscles tightened by spasticity? 

Sarcomeres are the small units in muscle that contract when your muscles contract. (Great image here. Look at the bottom right corner.)  Sarcomeres will increase in numbers when muscle is put through a prolonged stretch. Increasing sarcomeres is how muscles are lengthened. Lengthening of muscle and increasing sarcomeres increases flexibility. Which is a good thing because we can talk about neuroplasticity until the cows come home but if your arm (or whatever) "won't go that way," all bets are off.
OK. So how might you increase the number of sarcomeres? One way that many clinicians think works is called "dynamic splinting." The idea is that you'd wear something that would hold you in a position that would stretch you. If you could wear it at that posture for 2-3 hours, the clinician would "dial in" a more "aggressive" range of motion. Over time you'd gain sarcomeres which would allow you to have more range of motion. 

Sounds groovy, right?

It works for, say, marital artists who want flexibility so they can KICK ASS.

Stretching ROCKS! Sometimes!
You stretch, you get a longer muscle, everybody's happy!

But yeah. That whole science thing gets in the way. Don't you just hate science?

It turns out that the way to elongate (add sarcomeres)  "normal" muscle is nothing like the way you'd do it in spastic muscle. To stretch spastic muscles so they gain length, the stretch must be held at least 48 hours. And dynamic splints are not kept on for anywhere near that long; a few hours, max. 

And here's another little interesting tidbit. The 600 pound gorilla of dynamic splints is a company call DynaSplint (get it?) and they've had a little bit of trouble lately. The kind of trouble where they may have defrauded the Federal Govmint. And they laid off 500 workers in one day. Which makes sense since it was a DynaSplint salesperson that was the whistle-blower that brought the whole company down. Which then triggered their bank to stop their operating budget.

And while I have no idea of any of those problems are warranted, one thing I do know is that they are fraudulent in another way. Again and again they claim that their splinting systems help folks with spasticity. They also claim they increase muscle length. Don't buy it!

Monday, February 24, 2014

the most important gizmo for recovery is you

I do stroke recovery talks to PTs and OTs (and a mix of other clinicians, survivors and caregivers) all over the US. Today I'm in Cheyenne, WY. 
Between Casper and Cheyenne
I've had many conversations with therapists over the years. One of the things that's remarkable is how little consistency  there is in the tools therapists have. Some therapists have every gizmo known to man, others have little other than their creativity and a few standard tools. Imagine the difference between working in a leading-edge rehab hospital vs. an on-the-road home care therapist.
That's me. The king of PowerPoint.

Do "stroke recovery machines" make a difference? Within reason, no. There are a few tools that may be essential. For instance, electrical stimulation, parallel bars and a mirror may be essential at some points in some survivor's recovery. Really, much more important is the training of the therapist. This is not just true in stroke rehab but in many areas of medicine; outcomes are directly tied to the training of the clinician. For most survivors, the knowledge of the therapist is the most important gizmo. 

But remember, they'll "discharge" you at some point and then the most important gizmo for recovery is you (and caregivers!).

Tuesday, February 11, 2014

Don't stop. Don't stagnate. Don't let a lull convince you recovery has ended.

What about "Long-Term Rehab Management of Stroke"? What do we know about stroke recovery as we get into months and years and decades? 
What does this post have
to do with this girl?

The first thing we know is that its nonsense to believe that recovery has some sort of expiration date. I like the idea of someone coasting for a month or longer and then recommitting themselves to recovery. Its never too late.
What does tend to happen is "adaptation." The word refers to the notion that if you do the same techniques you get the same results. Survivors and therapists can both cause adaptation. Therapists can get used to what they use and go automatic and unimaginative with treatments. Survivors can get lazy and not push against their present abilities. 

Bottom line: There is good  evidence in the research that so-called "chronic" survivors can continue to make progress.

Don't stop. Don't stagnate. Don't let a lull convince you recovery has ended.

Thursday, February 6, 2014

Wanna write a book?

From the publisher of my book...You can email her directly (contact info, below) if you're interested. Best, -pete

"I’ve been thinking about two possible new books on stroke for our list and I wondered if you might know of anyone who might be interested in writing them:
A Caregiver’s Guide to Stroke: a handbook to help the caregiver, addressing all of the issues and best practices they should know about: creating and managing a health care team, dealing with the various physical, emotional and cognitive issues, etc. The right author would most likely be a social worker, therapist, or professional caregiver.
Myths vs. Facts on stroke: a book aimed at dispelling the myths/misinformation about the causes, treatment, physical and cognitive impact of stroke." 

Julia Pastore
Executive Editor, Demos Health Publishing

Tuesday, February 4, 2014

Yes! Stretch!

The small units that make up muscles are called sarcomeres.
Help! Stretch me!
Sarcomeres shorten when we contract our muscles. When we stretch for a long time, there is an increase in the number of sarcomeres. Literally, muscles get longer.

For example, increased flexibility is directly related to an increased number of sarcomeres. One of the ways that the number of sarcomeres can increase happens to all of us: Growth from birth to out 21st year. Growth in the length of bones during childhood provides a prolonged stretch of muscles. As muscles are stretched to their physiological limit they react by developing an increase number of sarcomeres. Stretch has to be of sufficient duration for this remodeling of muscle to occur.

The opposite is true as well. When muscles are left in shortened position, the number of sarcomeres decreases. Nothing provides a prolonged shortening of muscles like spasticity after stroke and brain injury.

So all the rules of stretching are thrown out the window when the muscle is spastic.

How is spastic muscle different than normal muscle? Let me count the ways...

Spastic muscles... 
have lost some (if not all) communication with the brain.
are often kept in a shortened position on the "bad" side for long periods of time.
are not subject to the same rules of stretch. (That rule: The more you stretch the longer the muscle will become.)

Spasticity after brain injury keeps muscles (on the "bad" side) in a shortened position long enough to lose sarcomeres.

It comes as some surprise to most therapists, but there is very little scientific evidence that stretching muscle reduces spasticity. In the very short term there is a small reduction in spasticity. But spasticity is not reduced in any lasting way by stretching because spasticity is not caused by muscles. Spasticity is caused by brain injury. Brain injury causes the brain to cede muscular control to spinal reflexes. Increasing the number of sarcomeres will not reduce spasticity. If it did, every case of spasticity would be eliminated by a regimented stretching program. And wouldn't that be nice?

Soooooo... Should you not stretch? No! I mean yes! I'm confused! Yes, you should stretch!

Why should you stretch? Because even if stretch has no lasting effect on spastic muscle, there are several reasons to do it anyway. Stretch... 
feels good 
reduces spasticity for a sort amount of time 
is good for joints 
may be good for other tissue besides muscle (ligaments, veins/arteries, nerves, skin, etc.)

Friday, January 24, 2014

Since when is “productive” fun?

When it comes to stroke recovery, no clinician, no matter how skilled, can "do it for them." Recovery from stroke is dependent on repetitive and demanding practice by the owner of the damaged nervous system—the survivor. If done correctly repetitive and demanding practice drives cortical plasticity ("brain rewiring") robustly enough to be evident in increased quality of movement. 
But this sort of repetitive practice is boring! Repetitive practice does not necessarily involve functional activity. For example, a clinician, seeing a deficit in the last 15 or 20° of dorsiflexion, may have the patient repetitively practice dorsiflexion, irrespective of ambulation. At least in that example the end goal, whether it's stated or not, is obvious; walking. In the upper extremity repetitive practice of single joint movements may or may not relate to any particular everyday activity. Instead repetitive practice may be used just to increase active range of motion in those joints. Because it does not involve anything functional, repetitive practice can be inherently boring.  And what makes it even more boring is that stroke survivors aren't even working on anything novel; there relearning movement that they used to do perfectly well. So where's the motivation? 
The motivation ends up being a conjuring. Some of this motivation may come from the minds of clinicians. OTs, PTs and speech therapists should try to make repetitive practice as interesting as possible. But some of this motivation comes from the survivor. The survivor needs the imagination enough to understand how this hard and boring work will help realize potential.

Sunday, January 19, 2014


When it comes to selling stroke-recovery machines to therapists, the phrase "another tool in the toolbox" is all the rage. Vendors (sellers) use the toolbox idea to soft-peddle to therapists. Here's how the pitch goes...

"We have this great new machine. It works great. Now, I'm not saying to pitch what you use. I'm just saying that this machine of mine is...another tool in the toolbox." But therapy time is very (very), very limited. So, Ms. Therapist, if you use their machine, there'll be no time for what you have been using. And the vendor knows this. 

But the vendor is scared to say their version of the truth which is, "My machine works better than what you have been using" because that suggests the therapist has been providing something less than the best. (And you don't insult the client, right?) But that's exactly what they are saying. My machine works better than what you usually use... Instead, the vender, fearing being considered condescending treats the clinician like a child and says, "You're doing just fine. This is just another tool for your toolbox." Its like telling a child, "I love Joey, your (stinking, puked-on) Teddy bear  too. But lets just get another Teddy. You can keep Joey too (in the garbage!) but we'll buy you this new one."

I find this even more condescending to therapists than giving it to them straight. Vendors, if you think your thingy works better, say so. Not to is spineless because you've not stepped up for the people who need you. No, not therapists (your bank account or your boss). You've not stepped up for survivors. If your thing works, get behind it. And if you are truly behind it, soft-peddling just makes you someone who'd rather make the sale than do the right thing.

Of course, if you want $ over integrity, you'll get neither.