Friday, June 19, 2020

SPACE TO RECOVER—THE HOME GYM

(Note: Having a place to work out at home is essential when COVID-19 makes it hard to attend therapy. Here is a free chapter from my book Stronger After Stroke that offers suggestion for a at-home stroke recovery gym.)

Clearly, it’s easier to study at the library, do paperwork at your desk, and cook in the kitchen. Every stroke survivor also needs a space within his or her home dedicated to recovery. It should be a space where you can focus on recovering from your stroke. Like a library, it should only have the distractions you want; like a desk, it should be organized; like a kitchen, it should have all the recovery tools you need. Some stroke survivors prefer to pursue at least some of their recovery effort in a community gym. Even if one joins a community gym (see the section Space to Focus—The Community Gym, later in this chapter), there are great reasons for having a home gym as well. 

How Is It Done? 
Your home gym can be a basement, an extra bedroom, or a corner of a room. It does not have to be big and does not have to have any more equipment than you need.

It should have what is necessary to facilitate recovery. This may include exercise equipment, a TV, VCR, DVD player, a stereo, and inspirational art. Build your gym as a place of sanctuary and a place of work. Ideas for equipment include: 

• A treadmill 
• A recumbent cycle 
• An upper body ergometer (hand cycle) 
• An exercise mat 
• Parallel bars or other equipment used to maintain balance 
• Weights 
• Resistance bands 
• Electrical stimulation devices 
• Balls, decks of cards, or other “toys” 
• A mirror


This list can be as long or as short as it needs to be. A small amount of simple equipment that is well thought out and well used is better than a lot of expensive equipment left in a corner. Doctors and therapists can help compile a list of needed equipment. 

What Precautions Should Be Taken? 
Be prudent when assembling the gym and think safety first. Any exercise or therapy equipment has inherent dangers. For instance, a treadmill provides a moving surface that may be inappropriate for some stroke survivors. Even something as simple as a ball can facilitate a loss of balance that can cause a fall. Consider installing grab-bars for any balance exercises you do. Make sure the floor is nonslip given the footwear you expect to use. Doctors will tell you if an exercise or therapy is safe, and therapists will explain how to do the exercise or therapy in the most effective way possible.

Saturday, May 9, 2020

Stroke evaluations drop by nearly 40% during COVID-19 pandemic


The New England journal of medicine published an article on May 8th that said the number of people being evaluated in hospitals for stroke has dropped by 40% during the pandemic.

What Covid really looks like
Here is the study's visual description of that drop.
Click to make larger

Not only are they not being tested, stroke survivors don't even come into the hospital, or wait too long to see treatment. And in a situation where time is brain, that is not good.

You can find a layman's perspective of this study here.

Saturday, February 15, 2020

Spasticity: Can ANYTHING be done?

What reduces spasticity? 
Does anything eliminate spasticity?  

Below is an outline of various spasticity-reduction treatments.

Treatments that will permanently reduce or eliminate spasticity.

The neuroplastic model of spasticity reduction. I developed this one years ago. You can find an outline of it from my book here. It is the only non-surgical, permanent option on this list. Here is the emerging evidence for the "neuroplastic model of spasticity reduction."
Note: there is a lot of other clinical evidence that this model works, but it is typically wrapped up in research of other therapies that use a lot of repetitions.  Here are some of them:

Dorsal root rhizotomy (or selective dorsal rhizotomy). The one "medical" thing that does reduce spasticity in a long-term way is the one that nobody ever talks about. It's neurosurgery— this is in children, but they do it in adults as well. For the right person, its perfect and permanent.   

Treatments that will temporarily reduce or eliminate spasticity.

Ice. If you ice the spastic muscle for about 20 to 30 minutes you'll get about 20 minutes to a half an hour of a reduction in spasticity.  

Heat. Don't do it. It exacerbates spasticity.  

Weight-bearing. This is one that a lot of therapists love. Whether you're standing on the leg that's spastic, or putting weight through the upper extremity that spastic, there is a reduction in spasticity. That reduction will last until the next big volitional movement and then the survivor will be right back to where they started.  

Stretch. Always the first line of defense. There's a lot of good reasons to stretch, but it does absolutely nothing in the long-term. This was established by not one but two Cochrane reviews. It didn't even reduce contracture formation.  

Botox (and other neurolytics). Back in the day there were a couple of formulations of Botox. Eventually you would become immune to one so they'd use the other one. You'd  become immune to that, and that was the last time it would be effective. Now they have so many formulations that you can be on Botox for the rest of your life. It's a Band-Aid. When it wears off, it's done. It's also an expensive, and often painful Band-Aid. Oh, and it gets in the way of my neuroplastic model.

Electrical stimulation (E-Stim)Typically this involves reciprocal inhibition of the spastic flexors. Put simply: You E-Stim the muscles opposite the powerful felor muscles that cause the problem. Example: E-Stim the elbow extensors (triceps) to relax the elbow flexors (biceps, etc.). various doses will provide a temporary reduction is spastcicity.

Monday, January 6, 2020

Sorry not Sorry: Stroke Recovery is NOT Proximal to Distal.


There's an old saying among clinicians: Recovery from stroke is proximal to distal. That is, there is a predictable pattern of recovery: proximal (closer to the body) to distal (further from the body). 

Assuming this may hurt recovery.




The 'proximal to distal' crowd would say recovery in the arm/hand would be in this order:

first to come back are the muscles in the shoulder and shoulder blades, 
then progress to the elbow, 
then to the forearm, 
then to the wrist, 
then the hand, 
then the finger joints close to the hand, 
then the finger joints furthest from the hand.…
But proximal to distal is not accurate any more than assuming that the sun circles the earth because it always rises in the east and sets in the west. Both are based on observation, but neither is based on what is actually happens. 

Here's what actually happens:

1.   You have a stroke; one side of your body is affected
2. The proximal muscles (i.e. shoulder) have bilateral innervation; both sides of your brain control the proximal muscles.
3.  Your shoulder comes back first not because of the "proximal to distal rule" but because your brain never ceded control over the shoulder muscles.
4.  The clinician sees the shoulder coming back before everything else and figures, "That's the proximal to distal rule!"

You might argue, "If the shoulder comes back first, then maybe the reason is wrong, but its a distinction without a difference. Survivors will still see proximal to distal return."

But what if the fingers are coming back first? Clinicians may not think to test the hand because the shoulder is not back. Or they may focus on shoulder control even though the hand can drive shoulder control if hand movement is recognized and encouraged.

In the lower extremity, the problem can be even worse. Proximal muscles would move the hip, and those are what are focused on. Meanwhile, an AFO (ankle brace) is routinely put on the survivor even though the ankle (a distal moment) may be coming back on its own.

And AFOs are easy to walk into, but hard to get rid of.

Sunday, November 17, 2019

Clinicians: When it comes to stroke recovery: KISS





When it comes to stroke recovery, clinicians would do well to keep it simple.

There's two important reasons...

One. The coolest new stroke recovery stuff comes from neuroscience. And the neuroscience perspective makes things really simple. 

People hear the word neuroscience and they assume everything's going to get really complicated really fast. And while there is nuance in the brain that wins people Nobel Prizes, the global perspective neuroscience provides simplifies recovery. There is good news for people like me who spend a lot of time trying to explain stroke recovery: Some of the greatest neuroscientists in the world are really good at making the brain simple.

In other words, just as you don't need to know where the carburetor is— or even what a carburetor does— you can still drive a car. We don't need to memorize Brodmann areas, or the role of the substantia nigra, or the details of fMRI to understand how the brain works. What's much more pertinent, and much more interesting, are the global perspectives neuroscience provides. That is, if you use neuroscience not to answer "what is a carburetor", but instead to answer "where does the key go?" Where's the knob for the lights? Where's the turn signal? When it comes to the global perspective, neuroscience begins to answer simple but vital questions. Like:  

What does the brain pay attention to? What forces the brain to learn? What kinds of things can fool the brain into learning? What kinds of things—what kinds of simple things—can be used to challenge the brain in a way that's productive for relearning movement after stroke?

Two. The other reason it's simple is purely technical. Only the owner of the brain can drive changes in their brain. Because learning, including what's called motor learning after stroke, requires that the survivor understands the process, on some level at least, it has to be simple. 

Nobody likes complexity. But complexity can be even more vexing to somebody who has suffered a brain injury. Don't get me wrong, I've met plenty of survivors that are smarter than I am after their stroke. But most people have had a stroke are focused on recovery and keeping their life somewhat on track than complicated recovery options.

To review... 
It has to be simple because it is simple, and because stroke survivors generally don't do complicated.

Here's the good news: the stuff that works the best is really simple. It relies on core concepts like bilateral training, introducing rhythmicity, forcing use, repetitive practice, etc

I do a lot of talks to clinicians. And it's amazing how many people will trust a complex treatment that they really don't understand over a simple treatment that they would have understood the moment they learned how to walk. What I would counsel therapists is this: If it's too complicated for you to get it from a simple explanation, you should probably save your money and save your patient's time, because that complicated stuff usually doesn't work.

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