Sunday, December 25, 2011

Stroke and Hyperbaric Oxygen Therapy

Hyperbaric oxygen therapy (HBOT) is something that's often touted to help stroke recovery. HBOT involves the breathing of pure oxygen while in a sealed chamber. The oxygen is  pressurized at 1-1/2 to 3 times normal atmospheric pressure.

HBOT is used medically for the effective treatment of
  • decompression sickness (commonly known as "the bends")
  • severe carbon monoxide poisoning
  • certain kinds of wounds, injuries, and skin infections
  • certain infections

Does it work in stroke? Bottom line: There is insufficient evidence to recommend its use. And it does come with risks.

It may work but the ducks get in the way...

The story of HBOT for brain injury including stroke is full of clinicians, characters and quacks. One of them is William Hammesfahr, a neurologist. You might recognize the name; in the famous Terri Schiavo case Hammesfah disagreed with almost every other MD, saying that Schiavo could recover from what had been described as a "irreversible persistent vegetative state." Hammesfahr claimed that he could "cure" Schiavo to "the point of being able to communicate." Hammesfahr suggested HBOT should be part of Schiavo's treatment.

The board of medicine in Florida in 2003 accused Hammesfahr of "...performing medical treatment below the standard of care, engaging in false advertising concerning his treatment of strokes, and exploiting a patient for financial gain."

Hammesfahr also claimed to be "nominated for a Nobel Prize."  Someone had recommended him for the prize, but that someone wasn't qualified to nominate for the prize. "Qualified Nominators" are a very small and select group of previous laureates and academicians primarily from Denmark, Finland, Iceland and Norway.

Otherwise, I could nominate you, you could nominate me, and all would be peachy.

The legacy of weirdness continues when it comes to hyperbaric treatment...

The mantle for HBOT seems to have been passed from Hammesfahr to the Neubauer hyperbaric neurologic center.  (It is worthwhile looking at all the credentials. The photos are interesting as well...addendum 11.3.13, all links on that page now lead to a page that says " You have tried to access a link that does not have a page associated with it."). A great take on the clinic can be found here.  (Apparently, the director of the clinic holds no malpractice insurance. "Why?," you might ask. Read on!)

Still, it's not a question of personalities; the question is, does it work?

It may. Definitely more research needs to be done. It seems to work acutely in animal studies. In rats studies it seems as if there's a better survival rate as well as better outcomes if done within the first few days after stroke. This makes sense.  The brain is, during the first few days after stroke, trying to recover. Being hyper infused with oxygen is probably is a good thing.

And therein lies the rub. If you have a stroke survivor in the  HBOT sealed chamber during the first few days after stroke and there is an emergency you can't get to them. If you try to pull them out of the chamber immediately they get "the bends" described by Wikipedia thusly...

"Decompression sickness (DCS; also known as divers' disease, the bends or caisson disease) describes a condition arising from dissolved gases coming out of solution into bubbles inside the body on depressurization."

And bad things have been known to happen in the HBOT chambers. In at least some studies there is an increase in seizures. There've also been explosions and fires (remember this is compressed pure oxygen; highly flammable.) Here  is a case where a victim died, and another victim was critically injured in the HBOT chamber. The accident happened at the Neubauer Hyperbaric neurologic Center. 

Here is what I've gotten from my research into HBOT:
  • A variety of reviews have concluded that was insufficient evidence to prove the effectiveness or ineffectiveness
  • A 2005 systematic review of the evidence for HBOT in the treatment of stroke showed no benefit to the treatment
  • A review of 12 randomized studies using HBOT with multiple sclerosis suggested that there is no clinically significant benefit from the administration of HBOT.

Bottom line: HBOT may work during the acute phase after stroke. However, a lot more research needs to be done and the safety issues need to be addressed before it can be recommended.


Saturday, December 24, 2011

Stroke Recovery, Stroke Rehabilitation: A Message to Therapists

There you sit, face to face with a stroke survivor. Only a few days ago he was a vibrant, energetic community member... employee... family member and now is sitting in front of you…. aphasic… hemiparetic …scared. The family sits anxiously behind him. They’re eager to get their loved one back and now they look to you. “When?” they ask. “How?” they inquire. And make no mistake, no matter who has talked to them before and no matter how blunt other health professionals have been, they hold hope for full recovery. Between their expectations and their slowly materializing nightmares, you are the last line of defense.

This is not a good time to ask, “Are my skills up to this?”

What if you simply want to do what is the best neurological therapy available? What if you want to treat based on the best available scientific evidence. What if you don't want to be influenced by the wide variety of competing schools of neurorehabilitation, each with their own books and seminars and cult of personality leaders? 

Want to scrape all the BS away? Go here: meta-analysis.

A meta-analysis is simply a study of studies. Researchers take all the available pertinent studies and then determine which studies are worthy of inclusion based on a variety of criterion. Then, of the studies that make the cut, each is given a certain weight depending on the number of participants (more is generally better), if they are blinded, the quality of outcome measures, and so on. All the available data is run through an algorithm and voila! Meta-analyses provide a “box score”. Simplified, it will look like this:

Therapy “XYZ” = -8.5
Therapy “123” = 9.3
Therapy “EFG” = 7.2
Therapy “ABC” = 27.6

Therapy “ABC” looks best, doesn’t it? Are you using “ABC”?

But trust in meta-analyses assumes trust in the scientific method. Phrases like evidence based and best practice are contingent on an inherent belief in the scientific method as related to rehabilitation research. 

(There is actually a remarkable amount of resistance to the scientific method, not just in rehabilitation but everywhere... deniers of global warming, human existence in the current form for the last quarter million years, evolution, a man on the moon, etc. etc. I was find it interesting that folks that are willing to deny science embrace it wholeheartedly if they are diagnosed with cancer. Oncology; based in science.)

Rehabilitation clinicians, in all their forms, graduate from colleges and colleges within universities that are usually called something like "College of allied health science." 

With regard to rehabilitation research for stroke, what exactly is involved in the scientific method? How do medical and research doctors come to conclusions about what does and does not work?

As with many things medical, it started with Hippocrates. Hippocrates was the first to describe stroke, transient ischemic attacks and aphasia. Hippocrates, however, provided no clues on how to rehab stroke survivors and for more than 2400 years little was written and we know of few interventions used to facilitate recovery from stroke.

Fast-forward to the period from the early 1950’s until the early 1980’s. Individual therapists armed with “keen observational skills”, pencil, paper and a goniometer published their observations and claimed it an effective therapeutic intervention. During this period, therapists could reasonably say, “I know it works because I’ve seen it work in my patients.” or “There are no better alternatives”. Now, anyone armed with the power of meta-analysis can refute these claims with a simple statement.

“Prove it.”

In many ways clinical rehabilitation research can trace it’s genesis to widespread hospital usage of functional magnetic resonance imaging (fMRI) in the 1980’s. Suddenly researchers were able to see the fruit of their therapy by simply examining before/after images of brains of study participants. Why is this so important? Because if fMRI shows activity during purposeful movement and that activity did not exist prior to the intervention, then there is reasonable proof of neuroplasticity. And neuroplasticity is the foundation of all lasting change in the ability to move.

Research and medical doctors have used cutting edge diagnostics including kinematics, electromyography, brain imaging, and the most reliable and valid outcome measures to completely reshape the world of stroke rehabilitation. In fact, it’s not a world at all. It’s an expanding universe.

And why is stroke rehabilitation it expanding so rapidly? A basic understanding of the sheer enormity of dollars provides some insight.
  • $52 billion is spent on stroke care each year. 
  • The projected costs for stroke for the next 45 years: $2 Trillion.
  • There are 50 million stroke survivors worldwide. (In a global  economy.)
Enter entrepreneurs. Entrepreneurs have completely changed the way stroke rehabilitation is conceptualized, researched, and administered. Medical device companies, business minded bioengineers, electrical engineers, biological and clinical neuroscientists, doctors and therapists are aggressively seeking a piece of the burgeoning multi-trillion dollar stroke rehabilitation pie. This explosive increase in the number of gizmos and treatment techniques has created a total mutation of the paradigm for rehabilitation for stroke. The resultant technological tsunami will force an unprecedented marriage between patient and technology while forging a massive adaptation by universities that train therapists, and facilities that want to continue treating stroke survivors.

And make no mistake; entrepreneurs are marketing directly to stroke survivors. If you want insight into this process have a look at the advertisements in the two major free magazines for stroke survivors; the magazine of the National Stroke Association Stroke Smart and Stroke Connection magazine, published by the American Stroke Association.

And what of stroke survivors? Have they not always strived towards full recovery? Unfortunately, the history of stroke survivors is story of warehousing and lowered expectations. But don’t blink: things are changing fast. Baby boomer’s increased economic clout and heightened expectations intersecting with the mushrooming middle class in less developed countries has and will continue to create a new breed of stroke survivor who will want, need and expect more recovery.

And all this leads to more high quality stroke rehabilitation research.

Rapid technological change has led to ever more accurate determination of an intervention’s effectiveness and if effective, how effective.  The force of a flood of dollars, both public and private, has changed the way stroke rehabilitation research is realized. Modern research often involves hundreds of specifically randomized participants and involves medical personnel (often including therapists) with degrees specific to their responsibilities within the study. Further, there are institutional review boards to guarantee ethical standards within the research trails, federal (FDA) oversight, and precise handling of collected data. Private, for profit companies, with and without the aid of public funding (NIH, NINDS, public and private universities) are spending hundreds of millions of dollars, on a variety of modalities and therapeutic interventions designed to ameliorate the residual aspects of stroke.

And all of that is only half the battle. In order for studies to be distributed in a manner that is respected by the medical community at large, it has to be published in peer-reviewed journals. Even once the study is done there is an expectation that the same or similar studies will follow that speak directly to reliability (the ability for an intervention to have the same or very similar results over and over.) Once a critical mass of research is done on a therapeutic intervention meta-analysis is done to, essentially, provide a numerical “score” that pits therapy against therapy and declares a winner.

 “I will continue with diligence to keep abreast of advances in medicine.” So says the Hippocratic Oath. Medical doctors have endeared themselves to the public for centuries, millennia really, by accepting a direct influence of science on their professional practice. Therapists and assistants should do the same.

This is not a good moment to ask,  “Are my skills up to this?”

Unless they are.

Saturday, December 17, 2011

The Tao Stroke Recovery

I would like to respond to Dean, someone who has supported my book from the very beginning, and has supported this blog. It's impossible to even calculate how much Dean has help me get my message out. 

He has even come to one of my talks!

Dean posted a comment which you can find here.

In his comment he disagreed with the premise of a blog entry I wrote. I basically said that stroke survivors should focus on specific tasks while they're trying to recover. It's called "task specific training". It's benefit has to do with motivation; the more important the task is to the survivor, the more motivation available to the survivor on their quest towards recovery. The tediousness of working towards recovery is mitigated by the survivor's inherent interest in the task that they're trying to accomplish.

And Dean brought up an excellent point. It's the same point that is often made by clinicians when the issue of task specific training comes up. As Dean put it "Task-specific training is just taking the easy way out because if you can't walk properly you're not going to get better by practicing bad walking." Dean goes on to point out that unless there is a precise evaluation of movement deficits, there's no way to tell what should be practiced.

And I totally agree. While I'm a big proponent of focusing on a valued task to provide motivation, bad practice leads to bad movement. When it comes to movement, quality matters. And quality matters for many reasons.
  • bad movement takes more energy than good movement
  • bad movement takes more time than good movement
  • bad movement can lead to injuries
  • bad movement can lead to a lack of enjoyment of a wide range of activities
  • bad movement looks bad which has social implications
  • etc., etc.

So how does a stroke survivor reverse "bad practice leads to that movement"? That is, how do you do "good practice that leads to good movement"? 

My lab work has focused on stroke specific outcome measures testing poststroke movement. I used a laundry list of these outcome measures. They are often complicated and require special equipment. We also use movement analysis laboratories that collect thousands of bits of data to determine if movement is increasing or decreasing in quality. Finally, we use technologies like functional magnetic resonance imaging and transcranial magnetic stimulation to determine if the part of the brain dedicated to movement is expanding.

But for the stroke survivor trying to improve quality of movement, some of the simplest "data collection" works quite well. 
  • Using mirrors to provide real-time feedback can be helpful. 
  • Using a mirror at the end of a treadmill can provide insight into the quality of gait.  
  • In the upper extremity is often helpful to use the "good" side to remind yourself what "normal" looks like.  
  • Videotaping specific movements throughout the arc of recovery can be helpful as well. Video provides a chronological log of where you were, where you are, and can be suggestive of what to work on next.

"Practice does not make perfect. Only perfect practice makes perfect."
Vince Lombardi

Saturday, December 3, 2011

What Task-Specific Stroke Recovery Really Does

Find out what they want. 

"Task specificity" and "task-specific training" are buzzwords in stroke-specific neurorehabilitation research. The foundation of recovery from stroke is rewiring of the cortex "around" the area of infarct. And the best way for anyone to rewire their brain is to focus. 

As completely as possible, the focus should be on a specific task. Most therapists will tell you that they do task-specific training.

PTs and OTs have every right to claim that what they work on is task-specific. ADLs ("activities of daily living"; the focus of much of OT) transfers, walking, etc. are inherently task-specific. But working on recovery using the "task-specific" approach can be magnified if you focus on tasks that are vital to the survivor.

You might ask, "What is more vital than ADLs, standing, walking and transferring?"

The answer is, "Ask the survivor."

The more focus, the more rewiring. Let's consider someone who has not had a stroke: Jim. Let's say Jim decides to take French because he is required to take a foreign language for school. Now consider Tina. She is an American who grew up in Texas but is now living in France.

Which of the two will get the most robust brain rewiring dedicated to learning French? Tina, quite a bit; Jim, not so much. Tina will naturally bring quite a bit more focus to the task. So there will be quite a bit more rewiring.

Now let's consider relearning walking after stroke. Walking means much more than simply getting from place to place. The ability to walk can impact the ability to be independent, the ability to earn a living, friendships, self-esteem and much more.

Walking, especially in a clinical setting, may or may not be tied to what really matters to the stroke survivor. I worked with one stroke survivor who told me, "I can't continue to walk funny. It's bad for business."

He was a surveyor. When he went on construction sites the other workers didn't believe he could do the job. And they believed this because, although his speech and cognition were perfect, his movements were typically hemiparetic. In this case, the motivation is not walking, it's really the ability to make a living.

Another stroke survivor told me, "I can't cope with this constant fear of falling." The motivation here is not walking, but fear. I know stroke survivors who have lost friendships because of their stroke. "As soon as I had my stroke, the boys stopped coming around."

Another survivor told me, "The fact that I've lost the use of my hand keeps me from doing things with my friends." The motivation here is friendship. Other stroke survivors hate being dependent on their families.

Fear, friendship, career, independence. All of these are powerful motivators.
In some ways it's easier for occupational therapists. They ask, "What is it that you have to do? What is it that you love to do?"

The answers will be as varied as stroke survivors. One might say painting is the most important thing. Another might say golf. Another might say child care.

For OTs, "task specificity" can be just about anything. An OT can work on hand grasp/release. Putting grasp/release within the context of a highly valued task is relatively easy. And putting it within the context of a valued task will drive more cortical plasticity (thus more recovery) much more than stacking cones or playing with a pegboard.

Support Motivation
So how can PTs and PTAs promote the same sort of focus to walking as an OT promotes in a vital task done with the upper extremities? The first thing to do is to listen. "Patient education" time can be used as "therapist education" time. What did the stroke survivor do before his stroke? What did he do for a living? Did he ever play any sports or instruments? What were his hobbies?

Revealing the activities that patients most want to recover reveals what drives them. And what drives them drives their nervous system toward recovery.

But there is a gorilla in the room. What if their motivator is beyond their present capacity? Walking a golf course may be the ambition. But even nine holes of a par 3 is a couple of miles. So what is the first step in recovering enough robust walking to take the survivor miles?

First, the ambition must be revealed. Once walking a golf course is established as the goal, the goal is always kept in mind. An essential aspect of task-specific training is keeping the task in sight.

For instance, even if the painter can't yet paint, a paint brush and paints are kept as reminders of the task to be accomplished. But how do you keep a golf course in line of sight?

Keeping the task front and center is a matter of allowing the vista of a golf course to form within the walls of a therapy gym. The survivor may never make it to the golf course but the love of the game will have him walking further than he might have.

Research has revealed better tools than ever to help survivors along their journey. From partial weight-supported intensive treadmill training, tools to recover walking after stroke increase in numbers and in their evidence. But don't let survivors forget what most motivates them. The most powerful tools live inside the survivor.

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