Monday, July 4, 2016

Early intensive exercise after stroke IS NOT GOOD.

Intensive rehab after stroke. It's not a good idea, but most clinicians think it is. That's what happens when researchers, who don't know how to keep it clear and simple are interviewed by journalists who know nothing about stroke.     By the time the journalist publishes the research is completely misunderstood.

Here's an example...

What a load of crap.  

The real problem? Well meaning therapists take this nonsense to heart and think more intensity of exercise during the acute phase (broadly, the first 7 days) is better.
C'mon everybody!
Let's go to the gym!!
Intensive rehab right after stroke... (all links)
What the heck does "early" mean?
The problem here is poor communication. The truth is, If too much intensity is introduced too soon (again, broadly, during the first 7 days) the brain damage from the stroke can be made worse. Most survivors will tell you that the first few days after stroke they were barely conscious.

What the heck does "intense" mean?
This article suggests that early "intensive" rehab helps. Here's an experiment: Sit back and imagine what "intense rehab" is. Got an image in your head? OK. Now compare that image with what they did in this research. 

In this study "intensive therapy" involved a "skilled prehension task." A grasping task! Oh, yeah, and it was with mice! With a planned, controlled stroke (like yours probably wasn't) and they were trained on the task right up to the day of the stroke, and then continued training after the stroke. AND... They used mice that were "70 to 120 days old." Guess how long mice live? The type of mice they used in this experiment live (conservatively) 365 days! These were young mice with no other illnesses. Which is pretty much nothing like the highly heterogeneous pathology of stroke. Did they have any mice that were the equivalent of 85 years old, that were on dialysis, recovering from a hip replacement and had a history of falls? No. How, based on this research, does the researcher (who is an MD) conclude that rehab should be 'early' and 'intense'? I'm all for learning from animal research for the good of survivors but let's be careful not to get the cart too far ahead of the horse.

In fact, had the researcher and the reporter knew how and what to communicate, it woulda sounded like this... "In studies of young healthy mice that we give a stroke to, repetitive grasping tasks help mice recover the ability to grasp."

Most therapists know this notion that, in the first few days after the stroke "more is always better" is stupid. And its not just stupid because the science says its stupid (which it does). Its stupid because most stroke survivors can't tolerate multiple hours of intensive therapy after their stroke. And therapists often resent MDs who suggest therapists should force the issue. I've heard of massive clinical dust-ups about what should be a simple question with a simple answer: Should a survivor walk in the first 24 hours after stroke? If someone thinks they know the answer to this one, they're lying.

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?

Wednesday, June 22, 2016

So first of all, just look at this picture.

Use what you love to recover. Recover to do what you love.

Second, drop what you’re doing and join Facebook's Young Stroke Survivors group. 

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.

And, 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...

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