Tuesday, April 28, 2009

"Functional" ≠ Stroke Recovery

The focus, nay obsession, clinicians have with "function" has the potential to hinder recovery. Basically the word function and the word recovery are used interchangeably. But they mean different things.

"Function" is a buzzword that makes everybody in rehab feel good. But it has its downside. Focusing on function gets in the way of the neuroplastic rewiring necessary for the fullest recovery endpoint. How can this be? Let me ask this rhetorical...

Does using a boat make you a better swimmer?

For a fuller and less haiku-y explanation... click here.

Thursday, April 23, 2009

Puts Things In Perspective, Don't It?

Who is the person who has had the most neuroplastic change in their brain? Michael Jordan? Eddie Van Halen? Yo-Yo Ma? Einstein?

I've always claimed that it is Michelle Mack

Click here to see what she does with half a brain.: 

Wednesday, April 22, 2009

Stroke Recovery. Wired.

File this under "I couldn't have said it better myself...waitaminute...I did!" I sent an email recently to Ben Philipson, the developer of one of the three EMG-based electrical stimulation machines. These machines are an important part of stroke recovery and rehabilitation.

Since I can't say it any better (again) I leave with this link to his blog.


Monday, April 20, 2009

Jim Thorpe. The World's Smartest Man?

I never understood the argument that athletes get paid too much. A kid grows up, shows up at practice, usually for multiple sports in the rain and snow and heat. Sweats, works, develops skills. And then at the end of 15-20 years or so of hard work it pays off with a 10,000 to one shot and a pro contract. I always imagine the people who complain the most are people who’ve never worked really hard for anything in their life.

"I worked really hard. I just chose to develop my brain,” they would counter. But they'd be comparatively lazy. They only developed their brain. Athletes develop their brains too, but the development is done through structured and dedicated bodily movement. It is a different part of the brain, but it is still the cortex. It's still neurons and synapses blending and communicating. It's still neuroplasticity.

Research into stroke recovery has revealed a simple truth: If someone was an athlete, at any point in their life (not necessarily right before their stroke), they have a better chance of a more full recovery. Why might former athletes do better? Is it because the movement portion of the brain, the part that is typically injured after stroke, is bigger in athletes? Or is it because athletes are used to training insanely hard for results?

I asked this of a neurologist and neurosurgeon, Prithika Chariwhen when we met at a shared talk in Munich 3 years ago. Her answer was simple (considering she was a brain surgeon); “Probably both."

Stroke survivors need to be athletes. By extension stroke survivors also need to be dancers and yogis and musicians. Work as hard as athletes.

And for all those nincompoops who think using your motor cortex is just plain dumb, click on this.

Friday, April 17, 2009

The Forgotten Leg

Constraint induced therapy (CIT) and modified constraint induced therapy (mCIT). We know them and we love them. These recovery options are richly researched and intuitive. I mean really, how much thought does it take? "If I tie up my 'good’ arm, and work really hard with my 'bad' arm and hand it will move better.” Duh, hello.

The concept of CIT has been extrapolated to everything. For instance there is CIAT (constraint induced aphasia therapy). CIAT is based on the same old idea: If the stroke survivor forces themselves to talk a lot, talking gets better. In many ways a constraint induced therapy is the trunk from which all the theoretical branches spring. And that trunk is as solid as it can be. "Practice makes perfect.” “We are what we repeatedly do.” “Use it or lose it.” Cliché, cliché, cliché but true, true, true.

All good news to be sure. But one bit of the body that has been left to drag behind: The leg. How would you do the CIT for the lower extremity (LECIT)? You could tie up your good leg, but falls, decubitus ulcers, hospitalization, throwing a clot, having another stroke, so let's say… no.

But still the idea is compelling enough for researchers and device makers across the rehabilitation spectrum to want to claim LECIT as their own. I wrote an article about the competing perspectives.

The bottom line is that to adhere to the spirit of constraint induced therapy, you have to overstress the affected leg. And this requires caution. And a therapist. And a lot of work.

Saturday, April 11, 2009

Two Great Tastes

Figuring out what helps a stroke survivor recovery may involve finding that one magic bullet. But it probably won't. It will probably be a few magic bullets, a smattering of magic hand grenades and a ton of magic TNT. Enough of this explosive rhetoric!

The point is, recovery requires multiple recovery strategies. As time goes on, the combination of strategies will change.

There is a tendency among many researchers to focus on their little piece of the pie. They'll pioneer treatment "X". They'll develop treatment "X". They'll advocate "X" and they'll cling to "X" forevermore.

Our lab takes a bit of a different tact. If different things work for different survivors at different times you damn sure better have a feel for the whole ball o' wax.

Here is a recent study our team did fusing "Two great tastes that taste great together".

Bon appetit!

Tuesday, April 7, 2009

The Feel of Recovery

Below is an article I wrote in a PT trade magazine years ago. It describes, theoretically at least, how to get sensation back after stroke. Turns out, nothing new under the sun. Getting back sensation is the same as getting back movement. Repeated attempts at feeling drives the brain to be better at feeling. 

There are 2 ways of retraining feeling: active and passive. Passive seems to be more for tactile stuff, active is more for proprioception (the feel of movement).

But movement and sensation double back on each other. Movement affects sensation because if you can't move the brain stops listening for movement. And if you can't feel, your movement goes haywire.

The Feel Of Recovery
My first job in research was at the exemplary Kessler Institute in New Jersey. My second day on the job I was told to read a series of papers on stroke-specific outcome measures—physical tests—that I was going to be doing. I read furiously for 2 hours or so but realized that I wasn’t going to be able to finish reading the articles that day, let alone assimilate all the information therein. My boss, a PT, PhD said something I’ll never forget. “Take as long as you need.” No time limit within reason. I could spend days reading, highlighting, absorbing and cogitating and triangulating with other research and get paid to do it.
Ever since then, in every research capacity I’ve worked I’ve taken time to read interesting peer-reviewed articles. I realize most therapists don’t have the time to do this. Most of the folks who tout being evidenced-based know clinicians only have an hour or so per week to spare for reading within their area of interest. Is it a coincidence that an hour per week is about the time folks spend in their morning constitutional? Maybe we should publish our studies on toilet paper! Of course, there's only one problem with that plan ….wait for it…you can only read it once!
I thought it might be of some benefit to condense something I’ve been reading about lately: Recovery of sensation post-stroke. We’ve all seen it, from the procreative deficits of the apraxic survivor to the hyper-sensitivity of survivors with shoulder/hand syndrome (RSD), stroke deals an unpredictable hand of sensory dysfunction to many survivors. Approximately 60% of stroke survivors have some sort of sensation loss. Of all the squealae after stroke, loss of sensation is the most perplexing for researchers. Most research focuses on the effect of interventions on recovery of movement and function.  There are reasons that research focuses on movement and not on sensation.
For instance, movement is considered more important. In some ways it is. Edward Taub, the developer of constraint induced therapy (CIT), proved that primates could move limbs they couldn’t feel before he was out of graduate school in the 1960’s. So if movement can be relearned without sensation, there is every reason to promote that relearning. Also, any gains in recovery of movement are easily seen, and we focus on what we can see. Sensation is much more difficult to measure. But any therapist worth their salt knows that sensation impacts on movement. Movement is the Ying to movement’s Yang; neither does well in isolation.
If a therapist wanted help a client relearn sensation, how would they go about it? First, understand that sensation would, in fact, be relearned--in much the same way that movement is relearned. The same rules apply. We know that repetitive practice reestablishes movement. Although much more research needs to be done, repetitive feeling seems to help reestablish sensation. Also, movement itself seems to drive increases in sensation. The more the survivor moves, the more the sensation of movement becomes ingrained into the neurons of the brain and the more the brain “listens” to the feeling of the movement. The more the brain listens, the more neuroplastic rewiring occurs to make the brain more perceptive to the sensation.
There are two veins of inquiry that researchers are following that promote repetitive feeling; passive and active training.

Passive Training of Sensation (PTS)
PTS usually involves surface electrical stimulation. This would be delivered in much the same way transcutaneous electrical nerve stimulation (TENS) is. That is, there is no muscular contraction. The hypothesis is that continuous signals sent from the peripheral to central nervous system reallocate neurons to feeling the limbs. Stimulation sessions ranged from one session for one day to one session per day for several weeks. Other PTS paradigms have used pneumatic compression, thermal stimulation and vibration to a portion of the body.

Active Training of Sensation (ATS)
The research in this area has used a variety of training techniques. ATS involves having the stroke survivor actively involved in training. Included has been practice determining where limbs are in space with eyes closed (for proprioception) and practice with localizing sensation (“Where do you feel this?”). Also used is repeated challenge to stereognosis (the ability to perceive the form of an object held in the hand).
Ultimately, the best paradigms for reestablishing sensation involve the blending of ATS and PTS. Since the more movement that is done the better the brain becomes at listening, anything that compels the survivor to move will tend to drive sensory recovery. Repetitive practice paradigms, including CIT may be helpful in the recovery of movement and the sensation of movement.
Much more research is needed in this important area. Every study and systematic review of sensation after stroke agrees: The testing and treatment of post-stroke sensation deficit lags well behind the testing and treatment of movement.

Schabrun SM, Hillier S. Evidence for the retraining of sensation after stroke: a systematic review. Clin Rehabil. 2009 Jan;23(1):27-39.

Sullivan JE, Hedman LD. Sensory dysfunction following stroke: incidence, significance, examination, and intervention.Top Stroke Rehabil. 2008 May-Jun;15(3):200-17. Review.

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