Friday, August 22, 2014

Dangerous Phrases

In the Seinfeld episode "The Kiss Hello" George Costanza describes his physical therapist as “… so mentally gifted that we mustn't disturb the delicate genius.” This could describe many of us involved in neurorehabilitation. We assume that we’re making the treatment choices for stroke swurvivors because we have a lot of experience. A lot of experience is a good thing, right?

Not necessarily.

“It works in my patients”

Neurorehabilitation research is now in a “golden age” with an exponential rise in diagnostics. This allows researches to test new treatments ever more accurately. We can now see, with functional magnetic resonance imaging (fMRI), the work of the brain as it attempts to control movement. Triangulate changes in fMRI with computer-driven kinematic data capture, movement outcome measures and algorithmic data analysis and a three dimensional view of patient progress become startlingly clear. But like the proverbial tree falling in a forest, are therapists listening? 

“It works in my patients” represents observation as justification of treatment. Researchers call observations “anecdotal data.” Anecdotal data does not carry enough scientific weight to justify therapeutic interventions as best practice. Researchers do not consider observations robust enough to be published in journal articles, and journal articles provide the foundation for evidenced-based practice.

Example: I know a PT who perseverates that he has “fifteen years of neurological experience.” I recently asked him what therapeutic interventions he used for reduction of spasticity. He listed 5 or 6 treatments that “…reduce spasticity in my patients.” His answer was remarkable for two reasons. First, few of the interventions were effective, using peer-reviewed literature as metric. Second, he was not trained in measurement of spasticity, so even if something did work there’d be no way to measure success, or report that success in his notes.

“I’ve seen research that said…“ 

It is rare to find a therapist who reads rehabilitation research. Therapists often rely on textbooks and lectures from school, research filtered through magazines or seminars. There is nothing inherently wrong with these sources of information, but the process does promote a scatter-shot perception of available therapies and can lead to a patchwork of treatment strategies, which may or may not be considered “best practice.”

College and university professors often tend to teach what they know and they know what they were taught and what they've used clinically. This provides an echo chamber in which present teachings are based on old, often refuted, research. Proof of this is available through a quick Internet perusal of course descriptions and syllabi for PT/A and OT/A programs. The most didactic and clinical neurorehabilitative teachings on the secondary education level involve treatment techniques that are 50 years old and that remain largely unproven. Textbooks cannot possibly keep pace with the enormous amount of research that unfolds, daily. Our best hope remains the development of the doctor of physical therapy (DPT). DPT’s tend have an inherent appreciation for peer review research and, just as important, they have the skills to access that research. For their part, practicing therapists and assistants hold some responsibility to pull the best that rehabilitation research has into their practice. Entropy often exists because therapists are more comfortable with the known that is ineffective than something new and effective, but that has to be learned.

Example: I finished a talk on neuroplastcicty in stroke and a PT came up to me and said, “That stuff on neuroplasticity was really interesting. The only problem is that if the stroke survivor has loss of sensation and proprioception then there’s no way to get them to move in any sort of functional way.”

I was glad for the question because it was something I’d done quite a bit of research on. I discussed with the therapist how a critical mass of studies has shown that relatively normal and functional movement can be relearned without sensation and proprioception. The therapist was correctly referencing research but was referencing research that was over 60 years old and had been successfully and completely refuted in a large amount of animal and human studies. Therapists often know research. But now more than ever research has become such a fast moving beast that, don’t blink, what was “true” may no longer be.

“I use a mix of therapies”

Many therapists are successful, and many renowned, for a particular therapy mix. And it may be true that their mix that they’ve developed provides superior outcomes. But there are two inherent problems with using therapies not subjected to standardized testing:

1.    There is no way to know if the therapy actually works. Anecdotally (see “it works in my patients,” above) it may work but since there has been no clinical research there is no way to establish efficacy.

2.    Since a “mix” of therapies is inherently complicated to define in terms of dosage and individualized treatments for individual patients, actual definitions of the therapy are difficult to pin down and subsequently impossible to duplicate and test.

Example: I spoke to an OTA program recently and showed some data that a particular therapy technique was not effective in chronic stroke survivors. While I was speaking I noticed that a few of the students were hiding their faces. “What?” I asked. They whispered, “Our program director loves that therapy, she’s certified in it and says it’s the best.” After I finished speaking the program director came to the podium and I said, “I’m sorry. I didn't mean to insult—.“ She cut me off. “It’s OK, I use a mix of therapies,” she said.

I didn't have ANY data on her mix.

Sunday, August 17, 2014

A blog entry about football-induced brain injury.

There is a problem when it comes to the issue of football and brain injury....

Friday, July 25, 2014

Flaccid or spastic; what strategy works best?

Here's a recently email question I got....

Hi there,

I recently read your article about spasticity located here

The article seems to focus on therapies and treatments for patients who still have some motor control over muscles -- i.e. the brain is still in the loop.  Would the same treatments apply to a patient with little or no muscle control over muscles. i.e. muscles remain mostly flaccid post stroke.  Or is there little in the way of physical therapy that can be applied in this situation?

Specific patient is currently being treated with ativan and tizanidine, with the resulting effect that their ability to remain active is significantly deteriorated due to drowsiness.

(Name withheld)

Muscles hate to be overstretched, so if the brain is not online (as is often true after stroke) the muscles rely on the spinal cord to take over the job of protecting the muscles from being overstretched. But the spinal cord is a dumb brain. It can only tell muscles to tighten. The bottom line is: once the spinal cord takes over you end up with tight spastic muscles.

There is emerging research that suggests that if you can reestablish brain control over spastic muscles, the spinal cord will get it out of the way, and spasticity will decline.

So, as you can see the question, above, is a bit confusing because the writer asks, "Will the same treatments apply… in muscles that remained mostly flaccid post stroke?"

When the muscle is flaccid, there is no brain control over the muscle. If that's the case early in recovery (the first few weeks) you may find that the survivor becomes spastic or regains voluntary movement through the arc of recovery. But if the survivor is flaccid for more than a few weeks, the only thing that may have potential is electrical stimulation.  

(Note: because tizanidine -trade name Zanaflex- in particular is used specifically for spasticity, the person you are talking about is spastic. In that case they would have voluntary control into flexion - i.e. if you passively stretch the fingers to "open" the hand, they can squeeze your hand. If this is true, then I'd follow this strategy. It is a common misconception that everyone who is spastic has no control over their muscles. If they can squeeze, have them squeeze over and over and over and over... Tough to do when "their ability to remain active is significantly deteriorated due to drowsiness.")

If you want to see all this blog's entries on spasticity click here.

Friday, July 11, 2014

Pot Decreases Spasticity.

If you want to reduce spastcicity, move to Colorado. Pot (or the active ingredients in pot) can potentially reduce spasticity. This includes every pathology in which spasticity is a sequelae, like...

  • stroke
  • multiple sclerosis
  • spinal cord injury 
  • dystonia (see reference section)

  • But wait there's more! It turns out that pot make have a beneifit for much of what ails survivors from arterial disease to seizures (10% of survivors experience a seizures). So why has your MD not talked to you about Mary Jane as a possible treatment for, well, anything? Simple. It is  the burning weed with its roots in hell duh!

    And its dangerous. Very Very Dangerous.

    Monday, June 30, 2014

    Vision Problems After Stroke

    Two great resources if you have vision problems caused by stroke. 

    Both of these are presented by the University College London. Both are free!

    The first one is for a disorder called Hemianopic Alexia (HA). 

    HA is difficulty tracking along a line of text to find the next word in a sentence. If you have this problem, click on the image, below.

    The same organization has options for hemianopia (loss of vision to one side) and spatial neglect (loss of attention to items on one side).  You can find training for those here.

    Sunday, June 22, 2014

    You Done Yet?

    I'm always pretty confused about when recovery ends. I haven't had a stroke, so I only know what I've heard. For some people recovery ends when therapy ends. In fact it's pretty common that once therapy ends survivors actually decline to various degrees. But some people seem to trudge onward. I hear this a lot; "I've been at it for three years, and I'm still making progress. It's a long road – but it's worth it."

    Some survivors believe that recovery ends when they're able to do so much with their life that you're too busy living to continue working on recovery.

    But just like an athlete trying to get better, a little means a lot. This is the thing that clinicians often don't know. Clinicians think that the world is binary – that you're either functional or nonfunctional. That is you're either able to do the task (i.e. walking, dressing, etc.), or you're not. I've always thought it should be more nuanced than that; little bits of movement are important irrespective of the function. It probably comes from my involvement in research. In research you measure little bits of "better" movement.

    What good is "better" movement? What does it get you?
    Better movement means …

    less spasticity
    better blood flow (when muscles contract there is "venous return" of blood back towards the heart)
    better cardiovascular health (the more you move, the stronger your heart gets) 
    You get the idea. More movement generally means more health. And health is measurable. It's measurable in terms of... 
    •a reduced heart rate
    •less chance of falling
    •the ability to fight infection better etc. etc.
    So call it what you will. Recovery. 

    Sunday, June 15, 2014

    Recovery is done in three phases.

    Recovery from stroke is done in three phases.

    1. The acute phase (~day 1 to day 7 [note all time periods are highly variable]). This is usually done in the hospital. In terms of recovery your main responsibility is to keep yourself healthy. Therapists will typically focus on helping you do what you can do. This is a time for convalescence.
    2. The subacute phase (~day 7 to 3 months). This is usually done with some help from therapists. You will experience the most recovery during this phase. This is the time that rehabilitation should "put the pedal to the metal." This is where the hard work begins. During the subacute phase the brain is "primed" to recover. Make the most of this phase because it is a window of opportunity to reach the highest level of recovery.Squander it and squander the highest level of potential recovery.
    3. The chronic phase (~3 months to the end of life). Typically the survivor has very little contact with rehabilitation professionals during the chronic phase. This is the time to implement a "do-it-yourself" plan for recovery. Recovery comes at fits and starts and is much more difficult than during the subacute phase. Still, important gains can be made during this phase. Up to very recently it was thought that no recovery could be made during the chronic phase. We now know, however, because of the brain's amazing ability to rewire itself, essential progress can be made during the chronic phase.

    Sunday, June 8, 2014

    Gifts for Stroke Survivors: A list compiled with the help of the stellar Young Stroke Survivors Facebook group!

    The most important gift you can give a survivor is your time.  Often months and years later, the thing survivors remember
    most is the company they received. A phone call, a visit, a text.... seems so simple but not to the stroke survivor whose mobility is limited. Social interactions will also help the survivor recover.
    For survivors with children, organizing play dates for their kids can be a big help!

    Gift that survivors often cherish include

    • The gift of Food and Drink!
    • Chocolates or any other delicious food. However, be aware that stroke can often affect the ability to swallow so yummy food will be a tease!
    • Survivors often worry about their family eating well. Friends can organize and help by over dinner for my husband/ wife and kids every night.   
    • Clothes
      • New comfy pajamas
      • Comfortable snugly sweat pants (elastic waist!)
      • Shoelaces that you don't have to tie like the Yankz! Sure Lace System
      • Slippers
      • baseball cap to wear (to cover unwashed hair)
      • sweats with the person's favorite team logo
      • Comfy therapy clothes
      The gift of help
      Survivors will certainly appreciate the little services you can provide. These include...
      • A manicure/pedicure (A trip to the hair salon for a cut, color and pedi is often a favorite post-stroke gift. Survivors often feel so much better after a trip to the salon)
      • Massage of the affected with a hand/body cream
      • Hair styling
      • Clean clothes
       Useful gifts
      • A journal for all the millions of thoughts that buzz around the survivor's head... great stress management
      • Stuffed animals, especially ones that remind the survivor of their own pets
      • A "grabber" to pull tray over, pick up the phone, or pull the tv over. Survivors are sometime left alone for extended periods.
      • Video games
      • Dry shampoo and leave in conditioner
      • a new toothbrush
      • Electric shaver for face or legs. Survivors are often afraid to use a razor
      • Flowers
      • A fluffy comforter
      • Books and for survivors with trouble reading, books on tape. Or, read to the survivor!
      • Photos of loved ones. A photo album with lots of pictures, where they were taken etc. (Survivors often forgot a lot!) Positive sayings in there as well as written prayers and messages from other friends
      • An attractive medical ID bracelet that fits with the person's personality (jewelry-style, paracord, beaded, Velcro (like Road ID).
      Music gets its own category because music helps recovery, especially during the acute phase (~the first 7 days after stroke)

    Wednesday, May 28, 2014

    An Open Letter to "Payers" Regarding Stroke recovery: You're Doing it Wrong

    Dear Insurance Providers, 

    I'm sure you want to help stroke survivors. A survivor that is home in the pursuit of happiness is healthier and cheaper. 

    But there's a problem... The systems that insurance companies and Medicare ("payers") have developed is a hodgepodge based on a patchwork of incorrect assumptions and old science.

    The following are some recommendations to better align insurance regulations with the aspirations of survivors.

    1. Make immediate screening for TPA mandatory, even in the most rural hospitals.

    2. Where a survivor goes for therapy matters. Unfortunately, the decision determining where the lion's share of recovery will take place is made within the first few days post-stroke way too soon. Given the emerging healing in the brain acutely there is simply no way for any clinician to predict where that survivor is going to be, functionally, in a week, let alone a month – or several months out. 

    There are some who believe that future movement can be predicted within the first week post stroke. However, those predictions are accurate only because they force a self-fulfilling prophecy. Based on the algorithmic prognosis, survivors are put in less than optimal rehabilitation settings. Thus, they do not reach the highest level of recovery  providing justification for the original in-hospital prediction.

    Instead of forcing therapists to make this decision in the first few days, wait until day 14. By then the resolution of the penumbra will have revealed true future potential-- at least in ischemic strokes. Hemorrhagic strokes take even longer to predict.

    3.  Clinicians are forced to discharge survivors once they have plateaued. However, given the massive potential brain plasticity, it is now known that plateau is a slowing, not an ending, of recovery. Given the potential for recovery into the chronic phase of stroke, complete disengagement from therapy is a mistake. I would strongly suggest maintenance visits with therapist, introduction to well-trained stroke specific exercises at local gyms and workout facilities, as well as distance (i.e. phone calls) with therapist.

    Peter G. Levine

    Saturday, May 17, 2014


    So here is a bit of good news: PT helps survivors recover. Which you woulda thought had already been proven, but here's some funny: Very little has been proven with rehab vis-à-vis stroke. And then there is the little problem of a pretty long tradition of clinicians in rehab deeply believing in therapies that, once examined in the light of well run research, looked very meh. And speaking of such...

    This article reviewing the effectiveness of PT on stroke recovery is a gem (and not just because it references more than 10 articles on which I'm a co-author!). It doesn't just comment broadly on PT post-stroke, it nuances it. Some things work, some things don't. Guess what goes in the "doesn't work bin?" Guess. Here's a hint, this blog has said this for a long time... Like here. And here. Thats right...


    As the authors put it:
    NDT has an unfavorable effect on length of stay, motor function (synergy), muscle strength of the arm, walking speed, spatiotemporal gait pattern functions like stride length, muscle tone, range of motion, balance, walking ability, arm-hand activities, and basic ADL. Insufficient evidence was found for NDT benefiting muscle strength of the leg, grip strength, muscle tone, brain activity, walking ability. 

    But. The overall message of this article bodes well for PT and for survivors. Namely: There is strong evidence for PT interventions... in all phases poststroke.

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