Friday, January 24, 2014

Since when is “productive” fun?


When it comes to stroke recovery, no clinician, no matter how skilled, can "do it for them." Recovery from stroke is dependent on repetitive and demanding practice by the owner of the damaged nervous system—the survivor. If done correctly repetitive and demanding practice drives cortical plasticity ("brain rewiring") robustly enough to be evident in increased quality of movement. 
But this sort of repetitive practice is boring! Repetitive practice does not necessarily involve functional activity. For example, a clinician, seeing a deficit in the last 15 or 20° of dorsiflexion, may have the patient repetitively practice dorsiflexion, irrespective of ambulation. At least in that example the end goal, whether it's stated or not, is obvious; walking. In the upper extremity repetitive practice of single joint movements may or may not relate to any particular everyday activity. Instead repetitive practice may be used just to increase active range of motion in those joints. Because it does not involve anything functional, repetitive practice can be inherently boring.  And what makes it even more boring is that stroke survivors aren't even working on anything novel; there relearning movement that they used to do perfectly well. So where's the motivation? 
The motivation ends up being a conjuring. Some of this motivation may come from the minds of clinicians. OTs, PTs and speech therapists should try to make repetitive practice as interesting as possible. But some of this motivation comes from the survivor. The survivor needs the imagination enough to understand how this hard and boring work will help realize potential.

Sunday, January 19, 2014

The STROKE-O-MATIC 76

When it comes to selling stroke-recovery machines to therapists, the phrase "another tool in the toolbox" is all the rage. Vendors (sellers) use the toolbox idea to soft-peddle to therapists. Here's how the pitch goes...

"We have this great new machine. It works great. Now, I'm not saying to pitch what you use. I'm just saying that this machine of mine is...another tool in the toolbox." But therapy time is very (very), very limited. So, Ms. Therapist, if you use their machine, there'll be no time for what you have been using. And the vendor knows this. 

But the vendor is scared to say their version of the truth which is, "My machine works better than what you have been using" because that suggests the therapist has been providing something less than the best. (And you don't insult the client, right?) But that's exactly what they are saying. My machine works better than what you usually use... Instead, the vender, fearing being considered condescending treats the clinician like a child and says, "You're doing just fine. This is just another tool for your toolbox." Its like telling a child, "I love Joey, your (stinking, puked-on) Teddy bear  too. But lets just get another Teddy. You can keep Joey too (in the garbage!) but we'll buy you this new one."


I find this even more condescending to therapists than giving it to them straight. Vendors, if you think your thingy works better, say so. Not to is spineless because you've not stepped up for the people who need you. No, not therapists (your bank account or your boss). You've not stepped up for survivors. If your thing works, get behind it. And if you are truly behind it, soft-peddling just makes you someone who'd rather make the sale than do the right thing.

Of course, if you want $ over integrity, you'll get neither.

Sunday, January 12, 2014

Don't forget the Yang

If movement is the yin, sensation is the yang. Try to zip up your zipper with gloves on. Its hard to even find the zipper! Part of the finding and the zipping is being able to feel. The feeling of the zipper tells you where the zipper is, how much force it will need to be pulled up, the angle of pull that is the most efficient, etc., etc.
For many survivors, its more than just losing the feeling of the zipper between their fingertips, its also the feeling of the entire arm and hand that may either be diminished or lost. If you think its hard to pull up a zipper because you can't feel the zipper, imagine how hard it is to pull up a zipper if you can't tell where your hand is! This ability to feel where the extremity is in space (without looking at it) is called proprioception. Proprioception, when intact, is a constant feedback loop. 

Little organs in your muscles, tendons and joints tell your brain where your limbs are without you looking at them. You adjust your movement according to this information. As you adjust your position, your muscles continue to tell you where you are! 

All this information runs through your nerves (from muscles to brain and back) at about 300 feet per second. But it may all "fall on deaf ears." If the portion of the brain that "listens" to proprioception is killed by the stroke, none of that information will get through.

Is proprioception retrainable?
Anyone who reads this blog, or my book, or practically any article I've written knows that I think the whole darned system is retrainable. The research is somewhat unclear because its hard to measure proprioception. You can measure movement, but how do you measure feeling? But. There is a lot of research that says, basically, the more you move, the better your movement becomes. And, there is a general belief that better movement requires two things:
  1. Better control over muscles
  2. Better proprioception
So, if you are moving better, we can assume that you are probably feeling the movement better.

And "use it or lose it" is in play. We know that if a survivor moves less, the area in the brain that controls that movement shrinks. But the areas in the brain involved in proprioception also shrink. 

So move! A lot! Its a twofer! If you move you regain control over movement and the feeling of movement! That then gives you a wider palette of movement! And, if you work really hard (and are lucky) your movement will be integrated into your everyday! And that's the holy grail of stroke recovery!

More tips to recover proprioception here.

Thursday, January 9, 2014

What if you made it harder?

There are a lot of things out there that can help make the life of the survivor easier. Assistive devices that can aid in everything from walking to eating, for instance. There are apps to help aphasic folks communicate. There are even books that give you "Tips for Making Life Easier.

There are really really good reasons to have these "helpers." One of those reasons is safety. Take AFOs, for example. I've been an advocate of attempting to "walk out of" the AFO. AFOs help folks who can't lift their foot, walk. And if its a safety issue then, by all means, keep it!! But if a set of muscles is not used it will atrophy. In the case of the AFO, the orthotic eliminates the need to use the dorsi flexors which lift the foot. But that muscles will atrophy is only half the problem.

The other thing that atrophies is the portion of the brain that controls that movement.  In short order (weeks) the number of connections between neurons in the brain rapidly decreases. Is that what we want? Generally, no (but for safety, yes, maybe.)

So all this time is spent on making life easier but making life harder is the place to be.  Find suggestions here and here and here.

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