Tuesday, October 29, 2013

Therapists are not like oncologists.

Therapists are not like oncologists.

Imagine an oncologist who has no idea what the latest treatment is. Imagine now that they are trying to cover their butts. "You have cancer, but I have something that works in my patients." "Something that works in your patients?" Even in your distress something seems odd about that statement. "Does it work in all patients or just in yours?" Its one of those questions you think twice about asking an MD because it smacks of sarcasm and hints a possible incompetence. But it is exactly the most rational question.

Of course, of an oncologist you'd not have to ask this question because oncologists are required by law to use the most effective treatment. If they do not do the latest and greatest they can get sued. Into oblivion.

People die of cancer. People generally don't die of bad therapy.

Now imagine your therapists says this... "You've had a stroke but I have something that works in my patients." "Does it work in all patients or just in yours?" There are 2 possible answers:

1. I have a lot of clinical experience, and in my experience it works.
2. Actually, its not ME saying it works in MY patients, but the research says it works in patients with your sequalae (symptoms).

I feel safer with #2.

#1 could have an unspoken "...but I've never really collected data or analyzed data or compared it to a control group or blinded myself during your measurement, or done anything else that science does to make sure that my data is "clean"."

"Does it work in all patients or just in yours?" is really the question, "Is there research that says it works?"

Encourage therapists to have a look at their diploma. It'll say, clear as day "Associate's of applied SCIENCE," "Bachelors of SCIENCE," "Masters of SCIENCE," and so on. The the notion that they base treatment solely on clinical experience is dangerous. One of the biggest determinants of recovery is the therapist sitting in front of you. Do yourself a favor, and do them a favor: Call them on the evidence.

Saturday, October 19, 2013

Building the Recovery Wall

Scott Gallagher posted a comment to a previous blog post. I'll paste that comment at the bottom.

What caught my eye in his comment is the conflict between repetition and quality. The conflict goes like this: If you do a ton of repetitions you may not concentrate on quality. If you concentrate on quality you may not hit enough repetitions.

I do a lot of talks about stroke recovery to clinicians. There is a small but vocal group of therapists who believe that if you don't focus on quality you may as well not practice. "Perfect practice means perfect recovery." I completely disagree. What if the survivor doesn't move perfectly? The answer by these clinicians is "I use hand over hand techniques to make sure that they do." Basically, they move the stroke survivor in the proper arc of movement. (BTW: the original quote was, "Practice does not make perfect. Only perfect practice makes perfect." - Vince Lombardi. Vince Lombardi was dealing with professional athletes. If he was coaching peewee football his quote would've been "We're not asking for perfection, we're asking you practice.")

There's several problems with stroke recovery put to this "If its not perfect, don't bother" philosophy. First of all, who's to say what "good" movement is after stroke? If somebody's trying to learn golf and they suck, nobody stands behind them and says, "You're doing it wrong." The more you practice golf, the better you'll get. Should you practice proper technique? Yes. But stroke survivors know proper technique. They've been doing these movements for all the years prior to their stroke. And even if they forgot they can model with the unaffected side.
Second, this philosophy suggests a therapist. "Don't move unless I'm there to help you move." Alternatively this can be expressed as, "The more you move the worse you'll get." But therapists can't be with the survivor all the time, and the survivor doesn't have enough money in their pocket to pay for endless therapy. There is some good news... "The more you move the worse you'll get." Hogwash. Moving a lot on your own leads to better movement as long as you make the movements challenging (always reaching beyond you present ability).

Third, when's the last time you saw a coach with their hands all over a player? When's the last time you saw a music teacher with their hands overlapping the hands of the trumpet player? Learning movement involves mistakes corrected.

Scott Gallagher puts it this way "...any time I tried to insert control or effectiveness into my program, whether it would be with walking or with the hand, it would drive the repetition numbers down and my recovery would stall." And I know that is taken out of context, but as it stands as a quote I agree with it.

Scott Gallagher: If complete recovery is the goal, one problem might be in the sheer numbers involved. I have no reason to think that my stroke was anything but whatever might be considered a normal stroke, but currently in measured distance I'm at 5,112 walking miles. I'm so close to recovered, I'd say 5,000 miles is what it took for me to fully walk normally again. I tried speed walking, but the problem I was having was that any time I tried to insert control or effectiveness into my program, whether it would be with walking or with the hand, it would drive the repetition numbers down and my recovery would stall. My strategy, then, became one of brute force: keep it simple and push those repetition numbers up. But even if I had effectively used speed walking, how effective could it be? Even if it took 3,000 miles off my total distance, that would still leave 2,000 miles left to cover. I only made it through by switching from an exercise-based program to a mind and motivation-strengthening program. For all but a very, very few the repetitions required for full stroke recovery may make it, although possible, simply unfeasible. Come to think of it, though, your post may have been intended for a less hardened recovery program. Thanks.

Thank you Scott! 
                                                                                            ©Stronger After Stroke Blog

Wednesday, October 16, 2013

Walking Faster Means Walking Better

      When it comes to walking most folks (survivors and therapists) focus on one thing: Distance walked. The distance you can walk is important. For instance you might need enough stamina to be able to get out of the car walk 50 yards to the supermarket, walk another couple hundred yards through the supermarket, and walk back another 50 yards to your car. That's 300 yards of walking. So its important to be able to nail the distance that you can walk.

But there is another element of walking that's at least as equally important as distance walked: The speed of walking.

Measuring distance walked is easy enough. You can measure out a certain distance across the floor. If you can walk further you can base distance on the number of times you can go around a track (in United States its usually 400 yards). Further than that and you can measure the distance walked using Google maps.

The standardized way of measuring the speed of walking is very simple. All you need is 20 meters in a straight line, and a stopwatch.

Perpendicular to the 10 meter line you mark off four lines: The starting line, 5 meters in, 15 meters in, and at the end of the 20 meters. (See diagram below)

There is a chair at the beginning and at the end of the 20 meters. The survivor gets out of their chair and walks the first 5 meters. The person who is timing (it can easily be the stroke survivor themselves) clicks the stopwatch when they get to the 5 meter line. The survivor then walks the intermediate 10 meters, and the stopwatch is clicked again at the end of that 10 meters. The survivor then decelerates during the last five meters.

There are a few other rules...
1. The survivor usually does two passes, and the two times are averaged.
2. The survivor is asked to walk at a "comfortable speed," not, for instance, as fast as they can. Just a safe and comfortable speed. This is called "self-selected speed."
3. The 10 meter walk test is done over an arc of time to see if speeds increase over that arc. For this reason it is important to make all the tests apples to apples. The survivor should be timed at the same time of day, wearing the same clothes, wearing the same shoes and AFO, same cane, across the same floor, etc. etc.

So what does your hard work tell you? A ton. For instance, walking speed can be used to determine the effectiveness of a particular rehabilitation treatment option. That is, walking speed can be used as a surrogate for quality of gait; the faster the walking, generally speaking, the higher the quality of gait. Higher walking speed is generally associated with less falls, and less fear of falling.

I've written a more detailed description of the 10-meter walk test here.

                                                  ©Stronger After Stroke Blog

Wednesday, October 2, 2013

Stretching reduces spasticity. Yeah, no.

OK class, here's your quiz:

1. Stretching decreases spasticity T/F
2. Stretching increases the length of spastic muscles T/F
3. Stretching reduces the chance of contracture (muscle stuck at a shortened length) T/F
4. Stretch helps make joints more mobile T/F

First of all, why stretching is good: 

Stretch is good for joints. Every time we move, joints are "lubricated." That is, joints require movement in order for the fluid in the joint (synovial fluid) to be properly distributed. Stroke survivors, because they are typically weak on one side, don't get the joints on the "bad" side to move enough. How much is enough? Look at it this way, on the "good" side your joints, all of them, will be moved through their entire arc of movement (called range of motion) dozens if not hundreds of times per day. How many times are your "bad" side joints moved? Because they have trouble moving, it is wise to move them either with the "good" side doing the work, or a caregiver doing the work. This is called passive ranging.

But while stretching may be good for joints, the affect of stretch on muscles and other soft tissue (ligaments, blood vessels, fat, etc.) is, so far as the science says, negligible. So the answer to your quiz is F, F, F, and F.

I know this is hard to believe. And it is counter to what some therapists think. But it is confusing. There is an immediate effect of stretch on spasticity, everyone knows that. But this is one of the many reasons stroke is so devious; what is true now may not be true 5 minutes from now.

This is a frustration for many clinicians. You observe something is true (i.e. spasticity wanes with stretch) only to find that with the next big movement by the survivor, spasticity comes right back.

Further reading from this blog on spasticity here and here
                                                     ©Stronger After Stroke Blog

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