Is walking right after stroke good?

I've been involved in stroke recovery research for a long time. And I do a lot of seminars on stroke recovery. A lot of clinicians that come to the seminars take this posture: Just tell me what the treatment options are and how to do them. This demand assumes that there are a lot of treatment options. It also assumes that those treatment options are "proven." And it assumes that things can be made simple and immediately clinically applicable.

Overall the posture suggests Dunning Kruger effect. The Dunning Kruger effect is simple and measurable:

1. The less you know about a subject, the more you estimate you know.
2. The more you know about a subject, the less you estimate you know.

The Dunning Kruger effect in action: You ask two people about galaxies; one is an astrophysicist, the other is a six-year-old. The astrophysicist says, "There so much more that we need to discover. We're not even sure how many there are." You ask a six-year-old and he says, "I know all about galaxies. There is a moon, and he goes up and down, and it squiggles, and then there's the Earth's
and the sun goes around and around and you can take a spaceship to it."

The Dunning Kruger effect in post stroke rehabilitation
 
We don't know much about what helps stroke survivors recover. There. I said it. That there is a lot of confusion about what helps stroke survivors recover does not sit well with rehabilitation clinicians. And one of the reasons it does not sit well is that there are a lot of folks that try to sell treatment options that are "proven." This mucks up the waters. Let's say you're rehab clinicians looking for answers. Are you going to listen to the person who says "Well, we really don't know, we're not really sure, none of this is proven, but this is what we think..." or are you going to listen to the person who says, "I have this great thing that works and it's super fantastic and it works all the time." The folks who are real sure that their treatment option is the bees knees of stroke rehab are often out to sell something. Like a machine, or a "pay us to learn" technique. But those of us in the research game are more equivocal.

In other words, the thing that research does, which is discover things layer by layer in a slow plodding scientific process, is not very satisfying.

Let me give you an example. I got an e-mail recently from a therapist who had been to the seminar. This therapist asked a very specific question: "Is very early mobilization after stroke good or not?"

Mobilization means "Getting them up and walking." "Very early" is a designation that means within the first 24 hours of the first symptoms of stroke. Simple question, right? The answer should either be yes. Or it could be no.

Except it's neither. It's "We don't know." In the few studies that have been done on this subject (there are ongoing studies which might provide more clarity) the conclusion is, we don't know. On one hand, it is commonly believed that many problems early after stroke are caused by immobilization. Things like infections (especially in the lungs) and blood clots breaking off and causing all kinds of vascular problems. Further, getting somebody up and walking after stroke, especially in animal experiments, seems to help promote brain plasticity.

The problem is that the brain is very vulnerable after stroke. And one of the things it's vulnerable to is decreased blood flow. And when somebody is in an upright position is decreased blood flow to the brain. 

A quick review of lit...

• The Cochrane review: At present there is insufficient evidence to support or refute the effects of routine very early mobilisation after stroke.
• An article looking at quality of life: Conclusions. Very early mobilization may help improve long-term quality of life after stroke, particularly in relation to functional independence, but this requires further examination.
• An article where they interviewed therapists, docs and nurses: Conclusion: Our study shows that most clinicians had concerns in relation to early mobilisation of stroke patients and more clinicians had concerns for haemorrhagic than for ischaemic stroke.
• An article looking at very early mobilization and depression: Conclusion: Very early mobilization may reduce depressive symptoms in stroke patients at 7 days post-stroke.
• Early mobilization out of bed after stroke may be all good: Conclusion: It seems to reduce severe complications but not cerebral blood flow:
• Early mobilization out of bed after stroke, maybe: Conclusions: Insufficient data are available to prove the beneficial effects of early mobilisation after stroke.

There. Does that clear things up?

Exercise helps recovery because it strengthens what?

Interesting video, below, by one of my favorite neuroscientists, Dale Corbett.  For the record: There is no one I know up doing a better job of translating what neuroscientists have to offer to stroke recovery. Have a watch. The insights really start at 1:40 in. I'll post my critique below the video.  

The overall message is important. Exercise is essential. It is unfortunate that the message is sort of convoluted in this video. They're talking first about TIA, and how if you have a TIA you should use exercise as a way to lessen the chance of a full-blown stroke. Then the discussion takes an obtuse tangent into how exercise is important to recovery, and then with no real explanation doubles back to talking about TIA again. Still, while maybe the messages should have been separated, both are important. 

1:50 Another person, besides Corbett, whose interviewed in this video is William Mcillroy, who like Corbett is a PhD. I quibble a bit with Mcillroy's statement that exercise can be started "...as short as two weeks after stroke." Charitably, this is highly debatable. Once a patient is medically stable, intensity should be increased to tolerance. There is no one-size-fits-all timeline for every survivor that is rigid enough to predict that someone can start exercise "as short as two weeks after stroke." In fact, it could be much shorter. For instance, in a survivor who is medically stable day 4, waiting another 10 days to start a progressively rigorous exercise program would allow learned nonuse to take hold. 

2:20 Both PhD's talk about how exercise is good for the brain. Corbett talks about how exercise helps cognition, and points out exercise also helps sensory motor recovery. I would remind anyone who is willing to listen: sensation and motor behavior are cognitive. We learn sensation and movement the same way we learn French, or trumpet, or algebra. That is, changes in motor and sensory behavior happen involve the same brain processes as any other kind of learning.

2:50 I'm not sure that there should be such an unequivocal endorsement of balance retraining using biofeedback. Certainly the research is not there yet. 

Having said all that, I think this is a really great video with some really essential points. Interviews can be misrepresented because the person being interviewed is not doing the editing. The points these guys were making may have been a ton more cogent in the original interviews. 

The best line is by Dr. Corbett: 

 "It's still early days and you know we're nowhere near to the level that I think we can get to. And if we can understand what the mechanisms are then we might be able to optimally better design exercise programs to improve stroke recovery." 

"Until then, anyone trying to sell you certainty is after your wallet," he didn't add.

Try: to attempt to do or accomplish

Here is clarification of a paragraph in the previous post:

Of course, there's a fine line between the exercise and movement needed to relearn movement. But the emphasis on trying to build muscle is as mistaken as changing the oil in a car with no gas: Its a good thing, but hardly the main issue.

This difference between exercise and repetitive practice (movement needed to relearn movement) may seem like a distinction without a difference. In fact, both build muscle and both drive plastic changes in the brain. The distinction is in the focus. Repetitive practice paradigms focus on driving changes in the motor and sensory cortices of the brain, not specifically in changes in muscle strength. Sure, muscles will build. But focusing on strengthening is like climbing a ladder to the top only to find the ladder is leaning against the wrong building. Stroke is brain damage. And, unlike most other forms of acquired brain injury, stroke involves just one part of the brain. So if a survivor is, say, 2 years post-stroke and they can’t open their hand and then, later they can, that is not a reflection of muscular strength. It is a clear indication of a change in the brain. The muscles have been there all along. Muscle strengthening is the easy part. 

Clinicians often sweat the fact that survivors have limited energy for therapy. But does it need to be very strenuous to be beneficial? No! The ability to open the hand (or lift the foot or straighten the elbow or move the mouth) can be done while sitting in a comfy chair. Each attempt should be focused and deliberate. The very ends of the movement should be the point of focus. Each attest is measured as a success if it is just beyond the previous attempt.

Details are the devil

Because it involves the brain, stroke recovery is complicated. The brain is complicated, so anything that involves the brain is complicated as well.

Except that's not true. And it's more than not true. Complexity, when it comes to stroke recovery, is evil. 

Of course, complexity is out there if you want it. There are "treatment options" that force therapists to spend thousands of dollars and weeks of their life getting trained in the devil in the details. Some of these treatment options have been around for 40 years, but new ones are invented every year. Do these therapies work? They generally fall into two categories; 1. Been around forever, the data doesn't look good. 2. They're completely untested.

Anyhoo... with regard to stroke, complexity is evil. Complexity separates the survivor from recovery. Why? It turns out that no matter what any clinician is telling you, only you can make you better. Remember the old-fashioned way of saying "teach me?" It was "learn me." Learn me to do math. No one can you learn you stuff. You have to learn it. That seems rational to just about everyone when it comes to learning that involves the brain; things like learning math and chemistry and French. But for some reasons when we talking about movement, its not considered learning. But it is.

• Learning math involves changes in the structure and function of neurons in the brain. So does learning how to move.
• Learning math involves neurons in the cortex (the outer shell of the brain). So does learning how to move.
• Learning math involves repeated attempts towards the correct outcome. So does learning how to move.
• Learning math increasing complexity. So does learning how to move.

How complexity kills recovery.

• If instructions from a clinician are complicated ("Move your arm up but keep you shoulder down now turn your hand blah blah blah") movement performance gets worse.
• If the pieces that go into recovery are complicated the survivor will not be able to drive their nervous system towards recovery. Complexity make it impossible for survivors to work towards recovery on their own.
• Learning complicated treatment options ties up clinician's scarce education resources (time and money).

In every sense of the word, regaining the ability to move after stroke is learning. People, especially clinicians, want to talk about muscle weakness. "These exercise will help you move better." No they won't. What helps you relearn how to move after stroke is moving, not exercise. Of course, there's a fine line between the exercise and movement needed to relearn movement. But the emphasis on trying to build muscle is as mistaken as changing the oil in a car with no gas: Its a good thing, but hardly the main issue.

Recovery with a Beat

With the lower extremity "function" is inherently bilateral. That is, because the primary function of the lower extremities is ambulation, bilaterality is inherent. 

(By "advantage" I do not suggest that I buy into the concept that the lower extremities come back before the upper extremities post-stroke. This is common wisdom in rehab, but it may be incorrect. The only way to prove the lower extremity comes back before the upper extremity would be to measure the most distal element of both: the fingers and toes. Measuring toe extension in comparison to finger extension has, to my knowledge, never been done.)

Beyond bilaterality, ambulation is also inherently rhythmic. The rhythm after stroke is disrupted and made unequal. And rhythm is what bilateral leg training with rhythmic auditory cueing attempts to re-establish in the lower extremity.

That is, if you re-establish the rhythm of gait, you will go a long way to re-establish symmetry of both step length and step timing.

There are commercial systems that use a heel switch so that the moment of heel strike is radio-delivered to headphones. The patient hears their own heel strike through the headphones, as well as a beat that they have to match with each heel strike.

But as is true with many technologies purported to help stroke survivors relearn movement, no special system is really needed to bring the idea of rhythmicity into gait.

A simple metronome either heard through headphones or carried by the therapist next to the stroke survivor can be used to promote the re-establishment of rhythmicity of gait. Plugging the ears using standard noise-reducing plugs can boost the volume of footfall to make that obvious to the survivor. The trick is then to match the footfall to the beat. 

Intention tremor, and a possible neuroplastic treatment

In stroke intention tremor is caused by damage to the cerebellum. 

The cerebellum is important in fine coordination. If the stroke damages the cerebellum fine motor coordination suffers. 

(Note: Intention tremor is different from essential tremor, often found in Parkinson's) 

It is called intention tremor because the tremor happens when somebody moves intentionally. So let's say the intended movement is touching your nose with a fingertip. If someone has intention tremor the trajectory toward the nose is good but when they get close to the nose (closer to the intended target) the tremor begins. As the New York Times put it:

Intention (or kinetic) tremors: These tremors occur at the end of a purposeful (intended) movement, such as writing, pressing a button, or reaching for an object. The tremor will often disappear while the affected body part is at rest.

Outside of stroke it is often seen long-term alcoholics. So here's my first suggestion: If you have intention tremors, don't drink. Other drugs can cause tremors as well. So, the "Brown Bag Medication Review" may help in reducing tremors.

How has intention tremor typically been treated? 

Intention tremor is notoriously difficult to treat. There are several drugs that are used for treatment, but they all work for some of the people some of the time. (Here's an example of an herbal "remedy.")

Other things that had been tried:

Physical therapy: In some people it works great to temporarily reduce tremors. It's not cure.
 

Meditation, yoga, deep breathing exercises, biofeedback have all been used with varying levels of success.

The neuroplastic model
So what is the neuroplastic model for overcoming intention tremor? I guess the first question is: Is there a neuroplastic model? Is there anything that can be done to rewire the brain "around" this movement disorder?

We will wait for neuroscience to catch up to that question. It could take decades, it could take centuries. On the other hand, somebody could come up with a really good way of applying the brain's inherent plasticity tomorrow. So you never know.

Having said all that, I still have some suggestions that may very well rewire the brain to help overcome this issue. Here are my suggestions:

Mirror therapy. This is the way that mirror therapy would be applied:

Just like in mirror therapy for movement recovery, you look only at the "good" side. That is, you only see the flawless movement of the unaffected side.

Bimanual training. This option involves having the "good" train the "bad." It's a simple enough concept; whatever the good hand does, the bad hand attempts to copy.

Your meds are probably wrong. And its probably gonna hurt.

The statistics about medications and falls are pretty clear. The more medications, the more chance of falls. This is as true in stroke survivors as anybody else. 

But stroke survivors automatically have two additional things going against them:
1. They are usually on more medications
2. They are more likely to fall in the first place

But there are other reasons to reconsider medications. In 2008 almost 2,000,000 people became ill or injured because of the use of prescription drugs. These are from "medication errors." 

Here is a video that outlines the problem and possible solution.

So how do you go about reconsidering medications? The "Brown Bag Medication Review." And you should do it. (My favorite line: “Out of 10-15 brown bag reviews, only 2 were accurate.”) About 50% of the time the meds will, in some way, be wrong.

The idea is you throw all your medications in a brown paper bag.
 

In the bag should be... 

• All prescription medicines (including pills and creams).
• All over-the-counter medicine they take regularly.
• All vitamins and supplements.
• All herbal medicines.

All medications are placed on the counter in the exam room. The physician or pharmacist, with your help, decides which meds to keep, which to pitch and which dosgages to tweak. Also decided...

• Tips for safe and effective medication use
• Answers to your questions about medications 

Once the whole thing is  figured out you are given a card that has all the information on it. This information would be available for you to review, and for you to hand to doctors, dentists, etc. who may need to know your medications at a glance.

More info here.

Hell Yes.

Can someone get better after they "plateaued?" Hell yes.

What is the plateau? 

It's the point at which all of the neurons that were "stunned" by the stroke have come back online. Why were the neurons stunned in the first  place? The stunning of neurons is known as "cortical shock." Neurons, right after the stroke, are fighting a battle to survive. And while they're fighting this battle, they don't work. These neurons eventually come back online. They usually come back online between one week and three or four months after the stroke. This is known as the subacute phase. (Note: there is no "one size fits all" timeline for these events. Two stroke survivors can have radically different timelines.)

In any case, at some point these neurons come back online. Recovery is sometimes very rapid and relatively "easy" during this phase. This kind of recovery, stunned neurons coming back online, is known as natural recovery, or spontaneous recovery. In other words, "Not a lot of work, but a lot of recovery."
 

Eventually, all of the neurons that were stunned are back online. The survivor "plateaus" and the chronic phase of stroke begins. Once this happens there is a discernible reduction in the rate of recovery. The reduction is because there's no neurons to come back online and help the process along. But recovery can still happen.

It's just that recovery takes a different form. Now neurons from around the brain have to be recruited in order to make up for the neurons killed by the stroke. This makes recovery a much different (and effortful) process during the chronic phase, than during subacute phase.

But... you hear this all the time. I even hear this from therapists. They'll say something like, "We ended therapy with this guy, 14 months later he walks through the door and he can do stuff that he couldn't do when he was discharged!" This sort of recovery can then trigger more rehab. Remember, rehab ends when the person plateaus. (Its a managed care thing.) So if there are changes in the ability to move, therapy can be justified. So you could go through the cycle where you work your butt off to get a little bit better, which then triggers more therapy. 

It's a beautiful cycle, and it can continue for decades.

~

Exercise. Energy. Recovery.

There are good reasons for muscle strengthening after stroke, of course. But therapists know these reasons well. For instance, the muscles on the affected side, even the ones that are the most spastic and seem overwhelmingly strong, are usually no more than half as strong as the unaffected side. Because spasticity is such an issue after stroke, some clinicians believe that strengthening "tight" spastic muscles will exacerbate spasticity. Research has shown that this is untrue; exercising muscles does not increase spasticity. It is important to focus on the muscles that are the weakest, of course. For instance, most stroke survivors have no problem at all bending their elbow, but extending their elbow is often very difficult, especially at the end of the range of motion. In this case it would be wise to work the triceps because it is the weaker of the two muscle groups. 

The other form of exercise that therapists focus on is cardiovascular. Unfortunately stroke survivors get a double whammy: They are in half as good cardiovascular shape as age-matched couch potatoes, but everything they do takes twice as much energy. A good example is walking. Before stroke, walking takes very little energy. Most of the energy is expended in small bursts of muscle power, perfectly timed to use momentum forces and gravitational pull. After stroke, gait loses its subtlety and coordination. The gait that is typically left in the wake of stroke uses twice as much energy as prior to the stroke.

So cardio and muscular strengthening are important, but viewed as more of a "pre-process" than the process itself. In fact, many of the leading-edge treatment options (i.e., repetitive practice, CIT, forced use) are considered "intensive." They require that the survivor "hits the ground running" and be able to withstand the rigors of the intensity right from the get-go. In this regard there is a necessity for the survivor to be in pretty good cardiovascular and muscular shape prior to the initiation of treatment. Once the survivor has the stamina, the focus comes off the body and shifts to the brain.

Why a little means a lot

10°. 

10° is all you need to qualify for constraint induced therapy. Just a tiny bit of movement. Just a little bit of movement in the fingers and a little bit of movement in the wrist. This would be movement that many clinicians would call "nonfunctional" movement. That is, many clinicians make the unfortunate mistake of thinking that a small amount of movement is not helpful. The thinking is, small amounts of movement won't help you live your life, so who cares?

But every bit of neuroscience is very clear about this: a little bit movement can lead to more movement through repetitive and demanding practice. Move as much as you can. It may be ugly, it may be "incorrect," it may be "nonfunctional," and it may be "useless." But this is probably more true: Small amounts of movement may turn into something beautiful, something correct, something functional, and something useful. If someone is telling you that your movement is unimportant, or harmful, or irrelevant, politely don't listen.

~