Tuesday, September 12, 2017

Movement is good full stop.

When I worked at the Kessler Institute in NJ, there was an idea for a study that bounced around for a few weeks. The study would involve answering this question: 

What would be the effect of a swift kick in the butt on stroke recovery? 

I'm pretty sure that study would never pass the ethics board. But(t) it is a joke that got to a fundamental truth: Clinicians make the process of recovery too complicated.

There is this notion among many clinicians that there should be a constant striving towards "function." That is, that the survivor should work towards some particular goal (i.e.: walking, dressing, eating, toileting, etc.)

I disagree. Movement, irrespective of function, is important. Here's an example…

Constraint induced therapy (CIT) for the upper extremity (arm and hand) involves working the arm and hand – a lot.

At the end of CIT, the survivor may, or may not be any more "functional." But maybe the wrong things are tested. If you're working with the upper extremity, then you'll test the upper extremity. But here's a weird side effect of CIT: better walking. Why? Because arm swing is made better. We may not think about the arms with regard to walking, but they are important in balance and timing.

And other things that are often not measured very often get better. Things like a reduction spasticity, less shoulder pain, more active range of motion. Movement, irrespective of function, is good.

Sunday, September 3, 2017

What are your chances of having a stroke? Where do you live?

 
Your chance of having a stroke may be influenced by where you live. Click on the map or the list and it will take you to the full interactive site.
Keep in mind: ~1 in 3 survivors will have a second stroke. If this map also reflects subsequent strokes, you may be able to modify whatever behaviors inherent in your geography.

Monday, July 31, 2017

Better movement through beer.

cutris.blogspot.com
When you build a house you want to build a strong foundation. When it's a tree grows, it doesn't grow from the leaves inward, it grows from the seed outward. For every process of growth, there is a beginning, a foundation, a germinal point.

What is the foundation for movement after stroke? If you ask most therapists they will say it is trunk (torso) control. 
Trunk Control

Focus on trunk control is the analog to building a good foundation for a house. Trunk control, so the thinking goes, will provide a good foundation for the arms and legs to do their thing. 

Therapists will often continually talk about the trunk as being the most important foundational part of the movement. The way it is taught in therapy school is "proximal stability for distal mobility". And this idea-- to work from "the inside out" is not wrong per se. It's just not particularly right.

Some therapists obsess about the trunk. But what if we flipped it? What if the driver foundation of learning movement is the hand? Or the feet? But I actually don't think it is those, either.

The foundation of movement is the will of the mover.  
  • Mind: Expressed as intention (I want to do something)
  • Brain: Starts the movement (Expressed as an electrochemical command) 
  • Muscles: Move the limb (muscle contraction)
  • Hand: Expresses the original intention (grab a beer)
So the driver here is beer. Or sex. Or chocolate. The driver of motor (movement) control is the will of the person. The trunk will follow what the will decides.

Imagine an infant. They reach because they want something. There is no one there to hold them and they may be a little unsteady, but their intention to reach makes their balance better. 

The “will” of the hand drives the changes needed in the trunk. The trunk will learn, in a natural way, to get the hand where it needs to be. 

Thursday, June 1, 2017

Make the Home Exercise Program AWESOME!!

Years after stroke survivors have been discharged from therapy, recovery can continue.

Of course, the speed of recovery diminishes over time. There is no time that is quite as fertile as the period of natural recovery in the first few months after stroke. 

But recovery can continue. Stroke survivors should be encouraged to see discharge from therapy not as the beginning of the end, but as the end of the beginning. The baton of the conductor of the grand symphony of recovery is passed from therapists to survivor. 

Most of the time therapists will leave stroke survivors with little guidance for further recovery. Some therapists think “HEP” stands for “Hand ‘em photocopies.” Too often the HEP reflects nothing more than a watered down version of the exercises that were done in the clinic. 

Irony: The survivor is left with the same exercises that caused the very plateau that caused the discharge! 
A good home exercise program will help the survivor to continue making progress if it is started the day the therapist meets the survivor. Therapy itself can be part of the HEP. If the survivor and caregivers can see what goes into the basic concepts that therapists use all the time, they will be able to direct their own recovery long after they’ve forgotten your name. 

The HEP should explain:
--progression of exercise, 
--measuring and documenting progress, 
--tips on equipment needed for a home gym. 

Therapists: Your job is done. You would have liked more time with them, but this is all manged care has allowed. At least, you’ve helped them to be functional, safe and return home. 

Survivors: Your job has just doubled. Not only do survivors have to continue the quest towards recovery through their own efforts, but they have to do it without therapist's guidance. Leaving stroke survivors with the tools they need to continue the quest is critical helping them to be in the best position to reach the highest level of potential recovery.

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