Friday, January 15, 2010

Stroke Recovery: Easy Concepts and Hard Work

Let’s face it. There is a lot of bad information about stroke recovery. And the cheaper it is to publish information (I’m talking to you Internet) the lower the quality becomes.
Much of the info on stroke recovery is either stale or unreliable. Most of it falls into 2 categories:
  1. Filtered through the medical model. This info tends to be stereotypic, redundant, risk free and out of date.
  2. Unsubstantiated or weakly substantiated. This info is usually written by caregivers or stroke survivors themselves.
Don’t get me wrong; both the medical model and survivors and caregivers provide valuable information. I have long believed that the secret of recovery is locked within stroke survivors who have gone the furthest on the road to recovery. The problem is that, as much as it’s a cliché, every stroke is different. There are tons of variables, including:
  1. Sequelae (health problem related to the stroke)
  2. Comorbidities (health problems unrelated to the stroke)
  3. Motivation of the stroke survivor (The more motivated, the more recovery)
  4. Recourses (time, energy, helping hands, money, etc.)
  5. Age (generally, the younger, the better the outcomes)
And there are a hundred other variables that can affect recovery. One of the most important is the location of the area killed by the stroke. A pea sized stroke in one area leaves the survivor unable to talk. In another area the survivor walks great, but can’t use their arm. In yet another area, a pea-sized dead zone allows for a relatively easy and full recovery. So when a stroke survivor writes a book about recovery, they are really writing about their recovery. And because of the variables mentioned, each journey through recovery, and each recovery endpoint, is unique.
I wrote a book about stroke recovery. I wrote it because I have been involved in stroke recovery research for a decade and I have learned a thing or two. Writing a book was easy because there is plenty to report on. Researchers from around the globe are adding their voice to an ever expanding ball of knowledge. And that ball, like much of science, is not perfect. It is misshapen and complicated and hard to visualize all at once. Part of this is because there are many different sciences involved. Input from neuroscience, physiatry, biomedical engineering, physical and occupational therapy and others makes the whole ball hard to conceptualize. But what is emerging from all these complexities are remarkably simple concepts.
I have come to a few basic conclusions about stroke recovery. Here is a list of core principals that can be used by any stroke survivor to promote recovery.
-Recovery is hard work. If it’s easy, you’re doing it wrong.
-The absolute foundation of recovery from stroke is neuroplastic rewiring of the brain.
-What drives recovery are relatively simple concepts that have been used by athletes (and other hyper-skill learners), since the beginning of time.
-Recovery is best served by
    1. Repetitive practice of movements…
    2. …that are related to a task or tasks…
    3. …that is/are important to the stroke survivor and that are practiced…
    4. …many hours a day…
    5. …and are made more challenging as skill is acquired.

Electrical stimulation can be used to help stroke survivors recover in many ways including:

  1. Keeping soft tissue (including muscle, blood vessels and nerves) elongated
  2. Jump starting movement in survivors who have little or no movement
  3. Reestablishing sensation in survivors who have sensation loss
  4. building strength in muscles that are not quite ready to move on their own
  5. Stroke survivors should stretch more than they do.
  6. Stroke survivors should “bank” (develop a reserve of) cardiovascular (heart/lung) and muscular strength.
  7. Measuring recovery from stroke is essential to recovery from stroke. During different periods of recovery can accelerate, slow and stall. During the slow and stall periods—periods when most survivors give up—measuring small improvements is necessary. A bunch of small improvements = large improvement.
  8. You have to do it yourself (DIY). This DIY concept is essential in 2 ways:
  • Only you can rewire your brain.
  • If you have to rely on therapists and other clinicians to reach you highest level of potential recovery, you’ll run out of time and money before you’re done.
Focus on 2 things;
    1. Making sure that you are not allowing soft tissue to shorten. If it shortens permanently, it doesn’t matter how much “recovery” you get, the joint will not be able to move.
    2. Driving brain rewiring change towards recovery. How do you know if your brain is changing? A “Yes” to the following questions will help determine if you are rewiring your brain:
    • Are your limbs moving better?
    • Can you feel your limbs more?
    • Is your balance getting better?
    • Is your hand able to grasp wider objects?
    • Are you walking faster?
    • …and much more will tell you if you are rewiring your brain. Remember, the foundation of relearning movement is changes in the brain, not in the limbs. Although the limbs get credit, it’s the brain moving those limbs. The limbs tell us what is going on in the brain.
The basics of recovery from stroke are simple. The work required is difficult. Recovery from stroke, even years after the event, is available to any stroke survivor. The key is to bring your focus and power to your own quest for recovery.


Dean said...

Peter, I agree with all of your comments, but I think the first item to be done is to get a specific diagnosis of what parts of the brain were damaged. That way survivors will be able to compare strokes to each other and actual therapies. I absolutely do not believe the comment, all stroke recoveries are different, that is just laziness on the part of the medical field. In my case I was never told that half of my motor cortex was dead and all of my pre-motor cortex was dead. All I was told was that I had an ischemic stroke. Keep up the good work.

Peter G Levine said...

Dean, always good to hear from you. Here's my take... all strokes are different. A millimeter difference in 2 identical brains can make huge difference in how the stroke manifests and potential outcome. I do agree with you that scans will be used to plan recovery strategies. we're just not there yet. Best, -pete

Larry said...

I am so impressed with your writing. I just bought your book! One thing that called out to me was your emphatic statement that the absolute foundation of recovery from stroke is neuroplastic rewiring of the brain. Years ago, I learned some techniques originally developed to help dyslexic children improve movement and their ability to learn. I tried them with some stroke patients and it instantaneously rewired stumbling movements into much more graceful movement. A person limited to walking a couple of blocks could walk two miles with just 6 treatments. As a Massage Therapist, I have much more to learn about stroke and I appreciate your knowledge. I look forward to reading your book!

Peter said...


If you wouldn't mind, could you please e-mail me at

Your reference to dyslexia is interesting. Some of the best research on neuroplastic change is done by Michael Merzenich. He has a treatment for dyslexia that relies on sounds. He says that dyslexia is a sound processing problem. And people who don't hear sounds, also have trouble reading them. So, yeah, a direct connection.

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