Tuesday, December 28, 2010

Q and A.

My focus on stroke recovery has been near myopic for the last decade. I do professional talks and seminars, write general and coauthor journal articles about the subject. And there is also this blog. As you can imagine, all this writing attracts questions. I get questions from stroke survivors, caregivers and therapists. Many of the questions are heartbreaking but all of them are thought provoking. And I put a lot of effort into the answers.

Here are some examples...

The following question was from a 70-year-old M.D.

Q: I read with interest your wonderful work about spasticity and stroke. I suffered a stroke with left hemiplegia and spasticity about two years ago. I can walk slowly with a crane but I’m not very stable. Most annoying, however, is the spasticity in my elbow, wrist and fingers which is constantly flexed. The flexion increases during walking. I have weak dorsiflexion and severe plantarflexion of the big toe causing a shuffling gait. I am two years post; do you think there can be any improvement in gait and spasticity?

A: Thank you for the kind words about my work. Spasticity can only be reduced by reestablishing cortical control over the spastic muscles. Cortical control is reestablished through repetitive movement of the limbs. So, as much as you can move the arm, the better. Also, be careful not to let contracture set in. Because the joints of the arm are postured in the same place for a long periods of time (because of the spasticity) the cortical representation of those joints shrinks. Meanwhile, the soft tissue can also shrink. If enough soft tissue shrinkage has taken place this contracture can mean that no further gains can be made without surgery. So have an occupational or physical therapist develop a good and safe stretching program. Follow the program daily.

Also, consider electrical stimulation (ES). ES will move the joint through its range of motion--giving a good stretch. ES will also activate weak muscles, and ES has been shown to drive neuroplastic changes in the brain. Usually, once trained, you can do this at home, without a therapist. Generally the muscles that get ES are the weaker of the muscle groups (i.e. the finger/wrist extensors on the back of the arm.)

From a wife whose husband is ~ 1 year post stroke.

Q: I am always encouraging and try to be positive all the time; I ALWAYS say "WHEN you recover," never "IF you recover." Lately I wonder if I am just fooling him and me. EVERYTHING I read lately says global aphasia and apraxia have a very poor prognosis. Your book and your blog are very encouraging, but they do not address these issues very much.

A: Yes. You're right. And it is a major deficit in my book and in the generalized discussion about stroke recovery. "How do I know when I'm there?" How do we know when recovery has ended? I would start by making the argument that it's never ending. Because even if there is no further gains in terms of movement and communication, survivors still have to work hard just to tread water against the general decline of aging.

As you well know, your husband has had brain injury. I hate saying this because it seems like a cliché and a cop-out, but you have a new normal. And he has a new normal. Having said that, I wouldn't give up. I would keep going as much as you both can tolerate, but with plenty of vacations (from the struggle) and rest. You may find yourself settling into some sort of "maintenance program" as a hedge against natural effects of aging. But don't be afraid to pepper the maintenance program with new stuff as it comes into view.

And the truth be told, full recovery, as defined as fully the way the stroke survivor was prior to the stroke, almost never happens.

The following question was from a PT

Q: I just read your article “Using Gait Speed as a Marker for Progress” (advance for PT and rehab medicine, March 8, 2010). I was wondering if it is still a valid test if assistive devices are used. Thanks for sharing the information!

A: My understanding is that the validity is only without an assistive device. Look at it this way; let’s say somebody walks a given speed without an assistive device, and then walks faster with an assistive device. If you accept that gait speed is an overall health indicator, then the assistive device would somehow make them healthier. Probably not a valid assumption. Having said that, there may be some importance to increased gait velocity even with an assistive device. In other words, although a bit of an empirical leap, if, over time somebody is walking faster with a cane, that would be seen as a good thing. In clinical research the question of testing gait speed with or without the assistive device (or orthotic for that matter) always comes up. Generally, gait speed without any orthotic or assistive device as more indicative of a true baseline.


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