Wednesday, May 26, 2010

Pizza And Therapy: So Much In Common

Some stroke survivors end up frustrated when therapies end. Generally stroke survivors want more therapy. And there's a reason for this.

Let me explain it this way: I have a friend, a food scientist. His job is to make food so desirable, so delicious and so irresistible that you never want to stop buying it. He was a very funny guy, my friend. So please don't misunderstand; this was a joke. One day he said, "I've been thinking about developing a food, maybe pizza, and having in the sauce, pot. Then when people finish eating the pizza they'd get the munchies and buy more pizza."

Therapy is very pot-like. At the point at which stroke survivors "plateau" therapies have to end. So the stroke survivor attempts to scratch and claw their way back into therapy.
The calculus made by stroke survivors is simple:

therapist = recovery.

Understand, therapist have to discharge patients after the first plateau. This is the rule. It is a rule concocted by insurance companies and the Prospective Payment System, part of the balanced budget act. "Balanced budget act."
How quaint!

The rule says, paraphrased, "As soon as a stroke survivor plateaus they must be discharged." The thinking is "Why is this person still in therapy if they're making little if any progress?" But recovery is really about multiple plateaus, that happen for many years to come.

The first plateau is formed by two forces. One force is the fact that therapists have a limited set of tools, and they're under pressure to get people safe, able to live their lives, and out the door. The other force is neurological. The neurons that were "stunned" after the stroke have all come back online. This usually happens during subacute
-->phase – the first 3 to 6 months after stroke. As these neurons come back online recovery is relatively "easy".

The end of the "easy" part hearkens the "chronic" era of post-stroke life. At this point the stroke survivor is essentially on their own.
During this period you can still make progress, and much of that progress has to be made without a therapist. The stroke survivor should have a good strong plan when they are discharged from therapies. Once that plan has run its course and a second plateau kicks in, the stroke survivor should go back to therapist looking for the next plan, to take them to the next plateau.

Recovery is a series of plateaus. And every once in a while you need someone to throw you a rope.



Dean said...

Thanks Peter, finally I heard from a hard science guy the concept of stunned neurons coming back online in the relatively easy spontaneous recovery. Is it possible for any type of scan to be able to tell the size and location of that penumbra? With that knowledge I would think that therapists could tailor the therapies between the easy neuroplasicity and the hard neuroplasticity. And we stop with the blanket statement of 'Use it or lose it', since that would only apply to functions in the penumbra.

Kevin said...

Hi, I think that any therapy that can help a person is good and we should consider it as a option when we feel we have a problem. Some people don´t feel like going to a face to face session of psychology because they don´t feel comfortable or need another kind of help. Therefore, Online counseling might be an alternative for those who enjoy privacy and would like an effective method. I tried it and it worked extremely well for me. For those who need it, that is my advice.

Peter G Levine said...

Dean, thanks for the post. Spontaneous recovery: a great term. That's exactly what it is. Sometimes stuff comes back without the survivor even trying.

Great question about the penumbra. Yes, MRI can pick up an approximation of the penumbra. and another great point; therapists could use that information to help understand when to push the limb, and one to teach compensatory strategies.

Thanks again Dean!

Peter G Levine said...


Thanks for the comment.

I was talking about occupational, physical therapy, and speech therapy.

Dean said...

Peter, once again I am thinking too much about this stuff. I tried to bypass the plateau roadblock by just lying about my abilities. I said I wanted to work on getting on/off an escalator as a goal to get back to work. I already was able to do it. My goal of using my affected arm/hand to open the refrigerator door was never met, even now 4 years later I can't do it. Spasticity of the finger flexors is the first problem, then the biceps and the pecs.

Peter G Levine said...


Plateaus can be permanent, there's no doubt about that. The confluence of natural aging, limited available resources (of any form), and a reluctance for the stroke survivor to let the hard work of recovery interfere with their life essentially causes a plateau. No one can tell you one recovery ends but you. But please keep in mind -- even the best athletes have plateaus.

Consider the great Buddhist saying: Great faith. Great doubt. Great effort.

Thanks Dean.

Sharon said...

A good reference for recovery is Jill Boltons book "My Stroke Of Insight". She states that she needed to tell herself a thousand times a day that she needed to do the work. I printed that out and posted it so that when I start to get discouraged with how slow recovery goes I have a reminder that it is important not to give up. Then when I look back, I see that there has been more improvement.

Peter G Levine said...

Sharon, thanks for the comment.

Ms. Taylor's thesis falls apart on many levels. This is especially sad given the fact that her posture is as an expert.

Here is a good critical review:



Mike said...

DSince ny stroke is a bleed in the basal ganglia,I guess the concept of penumbra doesn't apply tome.Guess I've to rely on reorganization of the brain keep on moving the joints and massage the hand and fingers' I can continue with the CIMT-like activity I do.Kinda frustrating, but it's the only thing I can do for now to get my hand back.

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