Thursday, February 12, 2009

How stroke survivors can be so wrong it hurts them.

“A pessimist is one who makes difficulties of his opportunities and an optimist is one who makes opportunities of his difficulties.”

~Harry Truman

In my job I do a lot of outcome measures (tests) of stroke survivors . I test the movement of arms and I test legs and I test spasticity and I test reflexes and on and on. I almost always end up having the same conversation with stroke survivors.

  • Survivor: “I can’t move my arm. It’s paralyzed" While they this they usually bring their arm across the chest.
  • Me: “You’re moving it right now” 
  • Survivor: “I guess, but its useless”
  • Me: "Can you move your hand?" “NO, not at all." (I ask these questions to get a ballpark of where they are in their recovery. These are just preliminary questions before I launch into the full battery of tests--which can take hours.)
And on the conversation goes...
  • Me: I’ve learned not to trust stroke survivors on the "Can you move your hand" one.
  • Stroke survivor: "Even Dr. – (A prominent local doctor) said I can’t move my hand! "
  • Me: "What do doctors know?" (I JOKE.) I take their hand and open it. They usually have some spasticity but I'm usually able to open it pretty fully.
  • Me: Squeeze my hand.

Their fingers came into a fist.

I’ll tell you why they think they have no movement; therapists and doctors tell stroke survivors they no FUNCTIONAL movement. Unfortunately what they hear is that they have no movement that would do any good, so they didn’t bother using the movement
they have.

This leads to further loss of cortical (brain) representation of the muscles involved. Active movement is lost and, probably, passively will eventually be lost. On the other hand, if therapists had left
stroke survivor with the following, they would have been a lot better off:

“You have great movement. You are lucky because many survivors are flaccid. They are so weak that the muscles that hold the shoulder in place can’t even do that... so they have a permanently dislocated shoulder. So you are in good shape—something is going on and when something is going on you can build on that. But from here on out, you have a responsibility to the bad-side arm, hand and leg. If you are willing to work very hard you can get more movement out of the arm and leg. The more you use whatever movement you have, the more movement you will gain. You’ll gain muscle. You’ll force more of your brain to control that side and you will get more movement. This will require a lot of work including many repetitions on 'the edge of your ability'--where movement is the hardest. But you will make gains."

So you can continue to believe that you can’t do anything with the arm and this will happen: The amount of brain dedicated to that arm will be lost. The muscle thickness in that arm will be lost. The muscle strength will be lost. The muscle length and the PROM will be lost. Eventually the limb will be turned into an “appendix limb” with no use other than aesthetics. “I might as well cut off this arm. It just gets in the way.”

Or you can believe that your arm will get better and you’ll work with it. If you do this, the following will happen: The amount of brain dedicated to that arm will increase. Spasticity will decline. The muscle thickness in that arm will increase. The muscle strength will increase. The muscle length and the passive movement will increase. It will probably never get as good as it once was, but it will, to some degree, recover.

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