The Stroke Recovery Blog

Meaningful: Driving Stroke Recovery

2012-02-18T19:38:00.000-08:00

When practicing to relearn movement effort should be task-specific. That is, tasks or component parts of a task should be practiced. Choose tasks that are very meaningful. The more meaningful the task, the more motivation available. The more motivated, the more effort will be brought to bear. The more effort exerted, the more neuroplastic (brain rewiring) change will be driven.

What motivates you? Fear? Friends not dropping by because you can't play cards anymore? Clients not trusting you because you've had a stroke? Recovery is not supposed to be comfortable. A dash of desperation is necessary.

Stretching After Stroke

2012-02-11T08:07:00.000-08:00

Address soft tissue shortening.

Until soft tissue shortening is addressed (i.e. muscle tightness), the chronic (post 3 month) survivor has no chance of functional recovery. You can do a ton of hard work but if the muscle length is not there, that's as far as you'll go. It's that simple. This is particularly true of the tendency toward the shortening of soft tissue in the elbow, wrist, finger flexors in the arm and hand. In the leg and foot the main concern is the calf muscle. This muscle often shortens because the calf often has spasticity. Spasticity keeps the foot pointed down in that position, if held long enough will shorten the muscle.

There is a tendency for patients with chronic stroke to limit their stretching of at-risk joints to a few times a day. I would suggest that, given no pathological or orthopedic reasons not to, stretching should be done often. (Always: check with you friendly neighborhood PT or OT!)

Any therapist who works with any patient population with spasticity should know the implications of Botox and intrathecal baclofen, the range of oral medications as well as splinting. The anti-spasticity qualities of these medications are beyond the scope of this article, but they are important in the treatment of spasticity. And therapists are often the clinicians who can redirect patients back to physiatrists and neurologists. These docs then can suggest appropriate meds.

Upon discharge, therapists should "read the riot act" to stroke survivors. Therapists should inform them of the dangers of soft tissue shortening, including decreased function, less chance for future rehabilitation, pain and contracture.

(Note: There is considerable debate about the effectiveness of stretching out spastic muscles. This debate is not among clinicians as much as waged within the world of rehabilitation research. However, even though the scientists are not yet fully convinced, there's reasons to stretch outside of retention of tissue length. For example, the number one cause of poststroke shoulder pain is not subluxation (shoulder separation due to weakness of the shoulder muscles). The number one causes adhesions that build up in the capsule the shoulder. What keeps these adhesions at bay? Stretching. Or at least "ranging". "Ranging" is a term that therapists use to mean not necessary to be stretching, but taking the joint through its full range of motion. Ranging is done passively, as his stretching. That is, stroke survivors limb is moved through its available painless range of motion, but some outside force does it. It might be clinician, a caregiver, or the survivor themselves ranging the joint.)

~

Stroke Recovery: One Myth, Two MDs

2012-02-02T10:36:00.000-08:00

Assume no plateau.

Time and time again, the idea of a plateau in post-stroke recovery has been refuted, both in research and anecdotally. It is the responsibility of the therapist to let the patient know that the culmination of therapy this is not the beginning of the end, but the end of the beginning. The patient's rehabilitative efforts after discharge can be confusing, frustrating and not always entirely fruitful. But motivated patients can make gains if they are willing to try new ideas, adapt and research new techniques.

Know the role of the physiatrist and neurologist.

I've asked physiatrists how often they suggest that their patients should schedule an appointment with them, once they've been discharged from therapies. Their answers tend to be all over the place. "If there is a change in function," or "If the patient is having an issue with meds," or "Once a year." But when a typical patient with stroke, who is perhaps five years post-stroke, is asked, "Who is your physiatrist?" the usual answer is, "I don't have any problems with my feet."

The fact is that patients with stroke often lose touch with their physiatrists because many don't see the need for a doctor who directed their acute rehabilitation. They know they've "plateaued"—so why would they need the "stroke doctor" (as physiatrists and neurologists are often called)? But there are good reasons to reintroduce yourself to your physiatrist. Only physiatrists and neurologists are trained to measure nuanced change, know about the latest applicable medications, and understand the true breadth of rehabilitative care as it relates to patients with stroke.

Stroke Survivors Are...

2012-01-28T18:31:00.000-08:00

Athletes___

There are two populations of patients who usually recover from stroke faster than others (or, at least, have a great advantage): Athletes (incl. dance, yoga, martial arts, etc.) and musicians.

There are three reasons for this...

Reason one: There may very well be hypertrophy of the motor portions of the brain in both athletes and musicians. We know that massed practice will reconfigure the brain, with new neurons recruited and new pathways developed. And which populations are, by definition, involved in massed practice? Athletes and musicians.

Reason two: As anyone who is either an athlete or a musician knows, both these populations know how to train. And I don't mean just, "Yeah, I did my therapy today" kind of training. I mean the "I dream about therapy, wake up and plan my day around therapy and dedicate most of my time to therapy," kind of training.

Reason three: Athletes and musicians are often extremely motivated to get back to their instrument or their sport.

Both athletes and musicians understand all the factors that are important to stroke rehab. They know how to practice with vigor and focus. They know the commitment of time and resources that such practice involves. And they know that if their practice routine changes, they will get different results.

Stroke survivors are true athletes. Lower level athletes playing a higher stakes game. But on the other hand, they have the most devoted fans in sport: Their loved ones. And their families and friends have every reason, both altruistic and self-serving, to coach, cajole, encourage, support and embolden their athlete toward success.

Repetitive Recovery and Rehabilitation

2012-01-18T18:58:00.000-08:00

Modern clinical rehab research has confirmed what many rehabilitation clinicians have assumed to be true: Post-stroke motor recovery requires repetitive practice (RP). Many clinicians use RP as a tool to restore movement. But as is true with many core concepts in stroke recovery is also true with regard to RP. Namely, what rehab research reveals and what rehab clinicians use are two very different things. Bottom line: The fly in the ointment is the amount. Clinicians in rehab don't encourage enough repetitions.

The absolute minimum number of repetitions needed to drive cortical changes (brain rewiring) for a single joint movement is approximately 2,000. If it's a multiplanar, multi-joint movement, the numbers are in the tens of thousands if not hundreds of thousands of repetitions. Researchers in neuroscience talk about more than that; often the number of repetitions needed for quality movement is in the millions.

How many repetitions do clinicians in rehabilitation typically ask stroke survivors to perform per session? Studies in which clinicians are observed as they work with stroke survivors show that patients typically attempt approximately 50 repetitions in the average therapy session. A stroke survivor would need 40 sessions to get enough RP for a single joint.

I strongly advocate offloading much of the work to the person who owns the nervous system in question-the survivor. That is, to get enough RP to provide robust enough brain rewiring to promote quality movement, much of the work must be done when the survivor is not with the clinician. And this is a problem because many clinicians believe that if stroke survivors are encouraged to move without proper guidance, they'll use the stereotypical patterns available (called synergistic movement). If used enough, so the thinking goes, these movement patterns will be ingrained and the "incorrect" movement will never be unlearned. This perspective, reduced, sounds weird: "The more you move, the worse you'll get." It sounds weird because it erodes a foundational belief of the therapies: Exercise helps the brain and body heal.

It is true that repetitive practice of wrong movement will lead to more wrong movement. In athletes the idea of "bad practice leads to bad performance" is well known. This is why athletes strive to practice with perfect form. Stroke survivors are no different. Unless there is a precise evaluation of movement deficits, there's no way to tell what should be practiced. When it comes to movement, quality matters. And quality matters for many reasons, because bad movement:

• Takes more energy than good movement;

• Takes more time than good movement;

• Can lead to injuries;

• Can lead to a lack of enjoyment of a wide range of activities;

• Looks bad, which has social implications.

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 post-stroke 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 whether movement is increasing or decreasing in quality. Finally, we use technologies like functional magnetic resonance imaging and transcranial magnetic stimulation to determine whether the part of the brain dedicated to movement is expanding.

But what of my earlier suggestion of offloading much of the work onto the survivor? Because it takes so many repetitions to drive robust change, they are to do much of the work. So stroke survivors must evaluate their own movement. And once they evaluate the movement, they must adjust according to the evaluation. 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, it is 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 and where you are now, and can suggest what to work on next.

It comes down to a lot of the right kind of practice. As Vince Lombardi put it, "Practice does not make perfect. Only perfect practice makes perfect."

A great sentiment but...

2012-01-16T08:21:00.000-08:00

The question becomes, what to do next? An important question every time you ask it. Even if mistakes are made, even if the wrong choice is made, keep making decisions. Even if you are not absolutely OBSESSIONAL about recovery, forever dedicate a part of yourself to the question...

What to do next?

Whatever the answer, make it outside the comfort zone.* Or, to put it another way:

"Intensity of practice after stroke: More is better."

*While remaining safe.

Stroke and Hyperbaric Oxygen Therapy

2011-12-25T19:39:00.000-08:00

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...). 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.

~~

Stroke Recovery, Stroke Rehabilitation: A Message to Therapists

2011-12-24T08:49:00.000-08:00

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.

The Tao Stroke Recovery

2011-12-17T22:47:00.000-08:00

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

What Task-Specific Stroke Recovery Really Does

2011-12-03T07:58:00.000-08:00

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.

Do it yourself!

2011-11-22T21:36:00.000-08:00

I don't care how great a therapist is, if they see a patient a half hour 3 times a week, they're not going to elicit robust enough neuroplastic change to provide better and lasting movement. That's what all the research says. Survivors (families, pipe up!) should demand the “home exercise program” (HEP) during the first week of therapy. Why? Because they will get much greater gains if they work 4 hours every day than if they work a half hour 3 times a week, or 2 hours a day, 5 days a week or whatever. Too often the HEP reflects nothing more than a watered-down version of the very exercises that precipitated the plateau.

HEP does not stand for "hand 'em photocopies". A HEP should start from day one. And the “H” part of should be defined as wherever the survivor is staying; skilled nursing, the hospital, wherever, they should be given tons of homework and survivors should be encouraged, threatened, cajoled, coached and convinced to follow through on the home work. And families should be involved in this effort as much as possible.

A private affair

2011-11-21T21:18:00.000-08:00

What if recovery were a competition? What if some one measured your level of recovery at 2 days, 2 months and 2 years. Would the % that you got better, from baseline to the zenith of recovery beat others?

Is making it a competition a bad thing? There are classic stories, one of which is in Norman Doidge's "The brain that changes itself" of stroke survivors competing against each other within the context of constraint induced therapy.

During most of stroke recovery victory is a private affair.
You are the only one who will know if you prevail. You are competing against yourself and for yourself.

Safe, functional, g'bye!

2011-11-03T21:47:00.000-07:00

Some clinicians think that neuroplasticity means little in the every day life of someone who suffers from brain damage. These neuroplastic naysayers believe that change in the brain is not worth a hill of beans if there’s no “functional change”. I rather disagree. I think that “function” is a manifestation of what insurance companies think will get patients out the door as quickly and inexpensively as possible. Consider ambulation. Insurers believe that someone walking, no matter how ugly the gait, no matter the orthopedic risk, no matter the bracing or assistive device, is better than not walking.

So what happens? Therapists slap on AFO’s and call it toast. Everybody’s happy, right? The only problem is that a more natural, neuroplastic recovery of dorsiflexion is now made impossible by a rigid orthosis that disallows the very movement that stroke survivors are trying to recover! Penny wise but pound foolish, insurance companies impede the very process of recovery. Neuroplastic change is the only true substrate of recovery from brain damage. Everything else from bracing to stretching are local Band-Aids ameliorating symptom rather than cause.

Barking up the right tree.

2011-11-01T07:44:00.000-07:00

Here's a made up story: I dropped my computer down the stairs the other day. Thankfully, it still turned on. But then the computer screen wouldn’t work! I shook the screen. I turned it on and off. I pushed all the buttons. All the screen said was NO INPUT SIGNAL. What should I do? Well anybody who's ever owned a computer knows that it has nothing to do with screen and has everything to do with the computer.

Stroke is an injury to the brain. Peripheral nerves and muscles (unless and until atrophy and/or muscle shortening sets in) are working just fine.

But when it comes to stroke recovery "we" (including clinitians and survivors) focus on the affected parts of the body. We put an orthotic on it, stretch it, splint it, move it, measure it, worry about it...

We focus on the symptoms rather than the cause. We focus on the screen rather than the computer. We focus on the limb rather than the brain.

Symptoms, computer screens and limbs are easy. We can see them, touch them, and measure them.

But let's be clear. The basic paradigm shift presented by research is that it's not about the limb…it's about the brain.

Good thing the brain responds to simple rules. What are those rules? Let me answer that question with questions. Take something that you learned in your life... anything. How did you learn it? Did you offload the process of learning to someone else? Was that learning easy? Did you wait for someone else to test you, or did you test yourself?

Will decides movement. Movement rewires brain. Brain controls limbs.
~

The largest study ever done on stroke rehabilitation...

2011-10-07T07:12:00.000-07:00

The portion of the NIH that deals with stroke is called the NINDS (National Institute of Neurological Disorders and Stroke). Out of all of the neurological disorders Stroke gets its own letter. Why? Because it's the leading cause of long term disability.

The largest study this country (USA) has ever done on stroke rehabilitation was funded by the NINDS. It was called the LEAPS trial (The Locomotor Experience Applied Post-Stroke). The LEAPS trial tested "Body-Weight–Supported Treadmill Rehabilitation after Stroke" I'll call it "body weight supported treadmill training" or simply, BWSTT. This is a treatment where the stroke survivor walks on a treadmill while having a portion of their body weight supported by a harness.

The results of the LEAPS trial was published in the New England Journal of Medicine (abstract here), which makes little sense to me. You can hardly get therapists to read their own national association's journal (APTA, AOTA, etc.), let alone a medical journal.

I recently interviewed one of the principal investigators on the Leaps trial; Katherine Sullivan. You can read the entire interview here.

The trial had mixed results. The first thing that caught my eye was the number of "serious adverse events" in the people that got the BWSTT, compared to the control group (The control group got regular physical therapy).

For instance the BWSTT group had more recurrent strokes, more fractures and more hospitalizations than the "regular therapy" group. The BWSTT group also had more falls.

The other thing that immediately pops out is the conclusion that the authors come to:

BWSTT "...was not shown to be superior to progressive exercise at home managed by a physical therapist."

I actually think that BWSTT works well for some stroke survivors. This is one trial, and although it's a well-run trial, maybe there were some problems with the way it was set up. Pure conjecture on my part, but the amount of time that they had people on the treadmill seems excessive. They were on the treadmill for up to 30 minutes, followed by 15 minutes of overground walking.

The amount of time spent doing an intervention is called "dosage". And just like any drug, if you get the dosage wrong it can do more harm than good. I suspect that BWSTT at a lower dosage, along with leg strengthening, and cardiovascular strengthening would be more beneficial. Of course, for some stroke survivors, especially younger ones, the dosage could be increased.

And that's really one of the points that Dr. Sullivan makes in the interview. The way a randomized controlled trial (like the LEAPS trial) is run, is nothing like the way that therapists typically do therapy. Therapists are more sensitive to the needs of the patient. But once patients -- called "participants" in research studies -- into a scientific protocol, it's one-size-fits-all. But one size does not fit all. Why? Because every stroke is different.

It's a cliché because it's true.

Stronger After Stroke: ............................................... The lost chapter

2011-09-03T06:49:00.000-07:00

I'm not sure what it is about the Canadians, but they do great work regarding stroke. There's only about 50,000 strokes per year in Canada (in the US there's about 850,000). But the Canadians put a ton of resources behind it. Plus they have a great back story. Donald Hebb, Wilder Penfield, David Sackett, Dale Corbett, Bob Teasell-- not all of them involved in stroke rehabilitation per se, but all of them have had a huge impact on the discussion.

I did talk up in Canada, last December, in Alberta. Nice little town called Lethbridge.

Before you do a talk you have to send your PowerPoint slides to the people sponsoring the talk. And you have to do this pretty early because they need time to make sure that it all prints well, etc. etc. I sent my slides up to this very nice physiotherapist/neuroscience PhD candidate coordinating the talk. She emailed me a few days later... The slides look great, but you have this whole section on this thing... "reimbursement"? Nobody's going to understand what you're talking about.

Grrr. Canada.

It turns out their big problem, in Alberta at least, is difficulty discharging stroke survivors.

Therapist: "Well Mr. Smith, it's time for you to be discharged, you've plateaued."

Mr. Smith: "I'm not going anywhere, eh?"

It's a good problem to have.

In any case, the point of this blog entry is not to celebrate Canada and its great work for stroke, but to talk about a couple of different Canadian online resources for stroke survivors.

Apparently, I had a chapter in Stronger After Stroke that was deleted by the publisher. All this info ended up in the book, but not as detailed as you will read it, below.

So here it is, the lost Stronger After Stroke chapter!

========================================

Stroke Recovery Research Made Quick And Easy

What is it?

When you had your stroke, you landed a new job: Recovery researcher. Your recovery depends on knowing what the latest and greatest stroke recovery research has to offer. It would be nice if you could lean on clinicians to satisfy your need to know. No such luck. Most doctors and therapists treat many diseases and cannot be expected to be familiar with all the latest techniques, modalities, and technology.

The good news is that hundreds of millions of dollars of funding is being spent on stroke recovery research, around the country and around the world. Some of the best minds in science are coordinating multi-site trials, cutting edge technology and armies of researchers to find better ways for you to recover after stroke. You should benefit from all this expensive creativity and hard work! But in order to benefit from all this research you need to know what it says. The suggestions in this section will allow you to quickly and easily access the latest and greatest stroke recovery research.

How is it done?

Once you’ve had a stroke, you need information. You need it because your recovery is directly related to how well you implement what science develops. But there can be problems getting this information in a form you can use. For instance:

Where do you find the time and the know-how to find accurate and up to date information about the most effective stroke recovery options?
How do you sort through the hundreds of articles that are coming out every month on stroke and stroke recovery?
Even if you can find this information, how will you understand what the researchers are saying?
Is there one simple and easily read resource that tells you what the latest and greatest stroke recovery research says?

Yes, there is!

Dr. Robert Teasell and colleagues at the University of Western Ontario have written a complete and straightforward resource that allows you to get all the up to date information you need quickly and easily. This resource is called The Evidence-Based Review of Stroke Rehabilitation (EBRSR) and can be found on the web at: www.ebrsr.com. The EBRSR is a study of all the peer reviewed articles available worldwide. “Peer reviewed” articles are journal articles that are scrutinized by a group of scientists that work in the field of stroke rehabilitation research. These “peers” review the articles to ensure its scientific integrity before they are published. Dr. Teasell’s resource provides a reliable and concise review of all the peer reviewed articles on the subject of stroke recovery.

Robert Teasell

The EBRSR has 21 “modules” that cover every area of stroke rehabilitation. Here is a partial list.

The arm and hand
The leg and foot and walking
Speech
Outpatient stroke rehabilitation
Community reintegration
Painful “bad side” shoulder

The great thing about this information is that each module opens with an easily readable list that explains which therapies work, which does not work and which are promising but still unproven. Not only that, but it is updated every 6 months, and it’s free! If you want more than just the “bottom line” these modules have several layers of information including full references to the research articles that are reviewed. The EBRSR is an easy way of accessing the latest and greatest that stroke rehab research has to offer. The EBRSR makes your research as simple or as detailed as you require. If you are willing to spend about 10 minuets every six months you will know more about what the research says about stroke recovery than most clinicians! A lot of healthcare workers don’t know about this resource so the information may be new to them. Remember, clinicians usually treat many problems, not just stroke. They cannot be complete experts because they have limited time to absorb an ever expanding amount of research in all the areas they treat. Knowing what the research says will help you guide doctors, therapists, nurses and other healthcare workers as you work to recover.

There is another fantastic resource for determining what does, and what does not work in the fight for recovery from stroke. It is called StrokEngine. It is produced by McGill University in Canada and includes the work of some of the biggest names in stroke research, including the previously mentioned Dr. Teasell. This resource is updated continually and allows you to explore recovery, therapy by therapy. For instance, let’s say you’ve heard that “therapy X” works helps folks recover. The StrokEngine allows you to look up just that therapy and see if it holds promise. Once you’ve chosen a therapy you can go to a section called “Patient / Family Info”. Once there you can go to a section called “Does it Work for Stroke?” which gets to the bottom line about that therapy. Just like the EBRSR, this resource allows you to look at each item as simply and quickly as you want, but the details are there if you wish. StrokEngine can be found at: http://strokengine.ca/.

What precautions should be taken?
Make sure that your doctor reviews whatever treatment options you are implementing into your training program. When considering a treatment option make sure it is shown to be effective in peer reviewed literature.

~

Motor deficits beware: Wolf on the hunt.

2011-07-31T05:57:00.000-07:00

Okay, I'm a "stroke recovery nerd". But this is cool... so Stephen Wolf, the PT PhD that ran the big constraint induced trial back in 2005 has a really cool trial going on...

Of course, there's the whole repetitive task specific thing -- just like constraint induced. But what I really like about this is the focus on the survivor figuring out what the next step in motor learning is. That is, the survivor is the most important part in the process of recovery. And to his credit this is something Wolf has been promoting for a really long time. Even constraint induced, really, is all about the survivor driving their own nervous system towards recovery.

A couple of funny things about this video; the fact that he did it not in some sort of sterile looking environment but in an area that's typical of an OT workspace. Tons of stuff, vaguely categorized, piled on top of each other. A thing of beauty if you appreciate it. The other thing that pops is the level of movement he's suggesting. Have you tried to take the cap off of meds lately? I'm not hemiparetic but I struggle a lot with those safety bottles. And then he suggests that the stroke survivor would use a very delicate "three jaw chuck" grasp to pick up pills... that's just about the highest level of motor recovery that you could pretty much possibly have. "Enough finite movement" indeed!

Of course, they would probably tell me that they are making sure that tasks are within the ability of even their lowest level participants.

~

Huge in Malaysia

2011-07-06T21:02:00.000-07:00

Big news: Stronger After Stroke has been translated into Malay, the language of Malaysia and Indonesia. It costs Harga: Rp 53.000,- but its worth it, because, as it says on the front cover, "Untuk para pasien stroke, terapis serta orang-orang terkasih mereka, Stronger After Stroke menyajikan filosofi perawatan yang baru, lebih efektif, dan sangat sederhana."

And that's gotta be worth something.

The arm bone's connected to the...mouth?

2011-06-09T08:47:00.000-07:00

If you train better arm movement, you get better speech. It might have to do with the fact that the hand and mouth control centers on the brain sit next to each other. It might also have to do with the fact that humans probably used hand gestures before we used speech so the two are probably linked in very basic ways.

Click here for a synopsis of this phenomenon from our lab.

In France we're all aphasic

2011-06-01T20:04:00.000-07:00

A friend of mine just got back from France.

He carried this...

Which means this...

Neuroscience: "Are you listening?"

2011-05-10T08:28:00.000-07:00

Most therapists suspect there is a pretty wide disconnect between what research reveals works to aid in stroke recovery and the treatment options that therapists typically do. One of the reasons for this disconnect is the “meet ‘em, greet ‘em, treat ‘em and street ‘em” perspective hoisted on therapists by managed care. Therapists are sensitive to Rule # 1: Get them safe, functional and out the door. If the best therapeutic option means slowing down the process, it will not see the light of day.

But there is another big reason research fails to resonate with therapists. Much of the “bench side to bedside” rift exists because the two groups (researchers and clinicians) simply don't talk. Mostly, PTs talk to PTs and OTs talk to OTs and if we're feeling really radical we go to a talk or read a paper by an SLP. And if we're feeling truly outlandish we'll go to a talk or read a paper by a neurologist or physiatrist. But is physiatry and neurology where the action is? Neurologists have a vital part to play in stroke recovery, but their input is typically limited to the saving as many neurons as possible hyperacutely (the first few hours post stroke). Physiatrists have the responsibility of dealing with co morbidities and sequelae as well as coordinating recovery efforts through the subacute phase. Generally, physiatry is not involved in the process of driving the massive cortical rewiring needed to aid in motor recovery.

That task is left to stroke survivors, guided by therapists.

We could look to psychology and psychiatry. They do know about the brain. And they have a massive advantage when it comes to knowing how to rewire the brain: they've been working on systems to change the brain since Freud. Edward Taub, the developer of constraint induced therapy, a treatment option that has shown promise in many large clinical trials, is a psychologist. So both psychiatry and psychology are disciplines worth listening to.

Clinical researchers from many disciplines are vigorously trying to solve the conundrum that is stroke recovery. This forces therapists into uncomfortable territory; those who wish to remain evidence-based end up having to listen to researchers outside of PT and OT. And these researchers often speak a different language, write in different journals, work with different treatment techniques, and use different outcome measures. And, as you’ll see, they often work with a different sort of “patient”.

Physical and occupational therapy, physiatry, neurology, psychology and psychiatry. Regarding the question of what systems are best suited to rewire the brain for recovery after stroke, all these disciplines have something to add to the discussion. But, more and more with the passage of time, they will pale in comparison to another branch of science: neuroscience.

Most neuroscientists have a near myopic focus on "unpacking" the 100 billion neurons and quadrillion synapses in the brain. Neuroscientists are involved in the development of a full spectrum of systems to drive massive brain rewiring. And systems to drive brain plasticity post-stroke are no exception.

One of the reasons that neuroscience is such a great source of information has to do with the difference in the actual study participants. Let's say you are a researcher and want to do a double-blind placebo-controlled study. You give a little blue pill to participate A, and a little blue pill to participant B. One is the "real" pill and the other is a placebo. You don't know which pill they got, and they don't know which pill they got. The study is double blinded. There is a study coordinator in the back room who knows who got what pill, but both you and the participants are blinded. How do you do that in stroke-specific rehabilitation research? Participants sign informed consent—this is federal law when it comes to using human subjects in research. The informed consent document may say something like "You will either get a treadmill or you won't get a treadmill for training." In that situation you can single-blind; you can blind the person that's doing the testing. But you can't blind the participant. They know whether or not they got a treadmill. There are other problems with human participants as well. Stroke survivors have strokes in different parts of their brain, they have different comorbidities and sequelae, they are of different ages and have different motivation levels—to name just a few confounds.

Neuroscientists typically use animal models. Animals are easy to blind; they don't know a treadmill from a glass of milk. And animals can all be given their stroke in exactly the same spot.

In any case, PT and OT are tasked with taking what all these branches of science have revealed, making sense of them and making them available for stroke survivors. As insurmountable as that task seems the payoff is a much richer and robust palette of treatment options.

After stroke, spasticity is a bad thing—but things could be worse.

2011-05-07T21:04:00.000-07:00

Flaccidity is an example of a point in the poststroke arc of recovery with consequences as bad, or worse, than spasticity. Spasticity carries with it the potential for contracture, pressure sores, pain, joint instability and deformities. Flaccidity, too, carries obvious physical risks (i.e., subluxation, muscle atrophy, etc.). But flaccidity also provides an ominous window onto the prognosis of the limb. Flaccidity says 2 things: “Recovery will have to wait” and/or “Recovery may have ended”.

There are two kinds of paralysis; flaccid paralysis and spastic paralysis. Most of the patients therapists see fall into neither category. Part of the reason that therapists typically don't see truly paralyzed patients is because, traditionally at least, little can be done to help. With the advent and broadening use of intrathecal baclofen, injectable neurolytics and the dorsal root rhizotomy, etc., the potential for treatment has broadened. Still, most of the people that are candidates for treatments that aim to improve limb movement are not going to be hemiplegic (paralyzed) -- they'll be hemiparetic (weak). The question becomes, is there more potential and somebody who has near flaccid or spastic?

We can look to pioneering physical therapist Signe Brunnström for insight. Brunnström’s six stages (Thanks “Pink House On The Corner” blog!) of recovery provide the ultimate template for recovery from stroke. Stage I is flaccid (although reflexes are available), stage II is harkened by the emergence of spasticity and synergies, and in stage III synergies and spasticity are at their zenith. So the progression is clear; flaccidity to spasticity. And as with much of Brunnström’s work there is an underlying wisdom; spasticity, as disdained and dangerous as it is, is preferable to flaccidity. This is especially true early after stroke. A patient with emergent spasticity can work in a repetitive and demanding fashion very early in the arc of recovery. And when it comes to stroke recovery, early is better. This is as true in rat models as it is in clinical trials involving human participants. But if somebody's flaccid, how you begin rehab? Although most patients do not remain flaccid, the delay that flaccidity creates provides a much more shallow recovery trajectory.

Spasticity may have another advantage over flaccidity with regard to issues outside of the progression towards recovery. Often the flaccid limb, whose dearth of sensation usually parallels its dearth of movement, is at risk of injury. Bluntly, the world can be a dangerous place to a flaccid limb. Like a weakling in a neighborhood of bullies, the flaccid limb is surrounded by walls, corners, countertops and other unforgiving surfaces. In the lower extremity is usually less of an issue because the flaccid limb can be controlled within the confines of a wheelchair. In the upper extremity the limb is often put in a trough and/or sling to protect the limb. These forms of stabilizing the upper extremity protect the limb in two ways; keeping the arm from flailing with the potential for injury; protecting the shoulder from subluxation.

Spasticity manages to protect the limb from these “bullies.” In the upper extremity the spastic posture brings the arm across the body, internally rotated and flexed at the elbow wrist and fingers. This posture is dictated by the overwhelming strength of the flexors and internal rotators. For an unprotected arm spasticity can be seen as a good thing, simply because it keeps the limb out of trouble.

Beyond providing an immature protection mechanism, spasticity may do other beneficial things as well. Spasticity may induce Wolf’s law, which states that bone will remodel through osteoblastic activity dependent on the loads it’s placed under. That is, the pull of muscle on bone is what keeps bones from becoming osteoporotic. This is particularly important issue because stroke survivors tend to fall towards the affected side. Because there is less bone strength on that side there is a higher chance of fracture. Spasticity may also improve circulation because of the activity in the triceps surae (gastroc, soleus). The primary way blood is delivered from the extremities back to the heart and lungs is the muscle contraction. With regard to the circulatory system spasticity is preferential to flaccidity, because the blood gets shunted towards the heart and lungs. Spasticity also maintains muscle bulk because, as pathologic as it is, at least the muscle is contracting.

Most importantly, spasticity provides a crude template for future recovery. But despite its advantage over flaccidity, all is not rosy with regard to spasticity. As the first line of defense, therapists are tasked with interrupting the march towards contracture. Tools in neurology and physiatry are helping with that task. Serial casting and a dedicated stretching program are also essential tools. The bottom line is, as much as spasticity is a welcome visitor it is best when it is exactly the: a visitor. Spasticity allows for at least the chance of its visit being shortened by allowing for movement in some planes and pivots. Take what spasticity give as you usher it out the door.

Formisano R, Pantano P, Buzzi MG, Vinicola V, Penta F, Barbanti P, Lenzi GL. Late motor recovery is influenced by muscle tone changes after stroke. Arch Phys Med Rehabil. 2005 Feb;86(2):308-11. PubMed PMID: 15706559.

Neuroaid::::::::::::::::::::::::::::::Partial Truth and Petty Theft

2011-04-16T16:30:00.000-07:00

Neuroaid is a drug that is made from traditional Chinese herbs that purports to improve recovery after stroke. It has long been an easy joke among neurologists, psychiatrists and researchers. Here is an actual email:

Colleagues:

It looks like millions of lives will be restored. How absent minded of me to tell patients that there is no “magic bullet” for all of these years…and shame on you therapists and physicians for not giving the below to your patients. Thank goodness for Neuroaid.

I really had no opinion about it because on the face the claims seemed dubious so I never took the time to unpack the research.

But that all changed when neuroaid decided to call their blog "The Stroke Recovery Blog." And the way they did it was insidious and devious. The actual blog is not called TSRB, but Google finds it as such.

It is true: you cannot copyright a blog name, especially not one with a generic name like TSRB. But they picked this name for a reason: Y'all have made this the most widely read stroke recovery blog on the internets. Back in the 80's hipsters used to call it "Jumping someone else's train." The Cure even wrote a song about it: You cop someone else's idea, and claim its your own.

In any case, their choosing to steal this blog's name made me realize that the company that makes neuroaid may not be completely truthful.

So I did a bit of investigation....

There are several problems with their research.

There is an obvious conflict of interest with regard to many of the folks involved in the research. That is, the people who are doing the research work for the company. This is bad, and it happens all the time. The profit motive may (or may not) sway the researchers to "massage the data" so that the data suggests that the product is AWESOME!!!
Consider Marie Germaine Bousser of neuroaid's scientific advisory board. She is also one of the researchers of the product. The same is true with others on neuoraid's scientific advisory board. Here's my question...how do they get away with that? The lab I work in does trials of products all the time but we have to sign conflict of interest forms that clearly separate us from the product tested. A lab can get itself in trouble (and often through sheer osmosis, other labs at the same and related universities) when you get paid for your "research". (If you want a nerdy take on this issue, click here.)
Neuroaid is made with at least 5 ingredients that are probably available in any Chinese drug store in any major American or European city. You can also buy them online. Here's one on Amazon. (Have a look at Mike's take on this in the comments section link at the bottom of this post for more info on obtaining the drug in alternative ways. Thanks Mike!) According to their site "...the price for NeuroAiD .... One month of treatment is US $488, including shipping fees. The standard 3-month treatment costs US$1,346 including shipping fees."
The main way of measuring the drug in their biggest clinical trail was something called the "Comprehensive Function Score component of the Diagnostic Therapeutic Effects of Apoplexy." Stroke specific outcome measures is my area. Since the late 90s I've done all kinds of tests of recovery from stroke. I've never heard of the the test they use. And there is no way to research it. Medline has no mention of it. Google only produces results that reference guess who?
Neuroaid claims it increases BDNF, an important substrate of recovery after stroke. As with many of their claims, there is a grain of truth here. They did find an increase of BDNF in one French study of rodents.
"Alternative medicine that works is called medicine." I think my colleague's email, in blue above, suggests the primary problem. If neuroaid had reached the level of evidence that neuroaid claims then why would MDs not suggest it's use? Because MDs don't want people to recover because....uh...
NOTE: I don't know this drug does not work. But by any stretch, the evidence is thin.

Bottom line:

Employees of a company make dubious claims about their own product.
Company's PR firm decides to hijack "hits" from an informational blog to their profitable website disguised as a blog.
Reference articles

Gabrielle Giffords: An Unpredictable Prognosis

2011-03-03T18:05:00.000-08:00

I find it interesting the way the media has reflected the rehabilitation of congresswoman Gabrielle Giffords. "She is talking," they say. "And walking." "And responding to commands” “And moving both arms” An article in the British paper The Independent puts the hyper optimism this way…

In the weeks since, doctors have been impressed by her recovery, which has been described variously in press reports as "miraculous", "astonishing" and "confounding all expectations". On Sunday the Observer carried a piece headlined "Triumph of the human spirit heals the wounds of Arizona tragedy".

But what's the truth about her prognosis for recovery? I wish her best, of course. But I'm skeptical that the hype is an accurate representation of the recovery. Anyone declaring this anything but a work in progress is whistling a bit of Dixie.

A good article about the anatomy (literally) of the injury is available in Scientific American.

The article points out that there are 2 things affected by a bullet to the brain. First, the obvious death of the neurons that lies in the path of the bullet. Second, neurons outside of the direct path are damaged by waves of pressure that follows the bullet.

The bullet went in the front of her head and exited the back, we think. It may have taken the opposite trajectory, experts disagree. Her eye socket was affected. She had surgery to repair the socket 2 weeks or so ago, but more surgery is needed.

A nurse that works with the Congresswoman touches her head where the wound is on Gifford's forehead.

Here are some reasons to be skeptical that the media representation is an accurate representation.

1. Her injury will allow for relatively rapid recovery early (now) whereas recovery will be much more difficult as time goes on. There are 2 reasons for this:

The swelling in her brain is receding and all the chemicals which rushed to the site (cytokines, enzymes, etc.) begin to dissipate allowing the brain to work better.
Through a process known as "cortical shock," neurons "lie low" immediately after injury but rapidly come back on line early in recovery (now). The recovery that come early is relatively rapid. And, compared to later, recovery is relatively "easy". Once all the surviving neurons are back on line, recovery takes a ton of work.

2. There are 2 levels of recovery; one is to get back to be able to take care of herself. The second is to get to the level where she can continue to work as a congresswoman. Number one is doable. Number two...?

3. The bullet entered the left side of the front of her head and traveled through her brain, exiting through the left side of the back of the head. It did not cross into the right side of her brain. Language is typically on the left side of the brain. She's been responding to commands so she's not receptively aphasic. Although it is still to be determined the complexity of information she can process, regarding basic commands, she can understand what’s being said to her. But the speech...that’s a whole other thing. She’s been involved with Melodic Intonation Therapy (MIT) which uses the right (uninjured) part of the brain and she’s been singing the lyrics from songs. But she’s doing this because her speech may be very limited. Conjecture on my part; but if she had volitional speech they’d be focusing on that.

4. People make the mistake of thinking that a brain injury is simply the brain minus the dead tissue. But, because of a process known as diaschisis, other areas of the brain are affected. It is not the brain minus the hole in the brain. It is the brain, minus the hole, plus the effect on all the other parts of the brain that that hole used to communicate with. The brain is very “use it or loose it.” So when a portion of the brain dies, neurons that used to communicate with that area essentially shrink in a process known as “dedritic pruning.” And there are other issues as well, most of which people who would read this blog would know. Brain injury affects

personality
impulse control
sense of humor (I've even seen cases where the sense of humor has increased)
attention span
visual processing
flexibility and problem solving ability
...and the list goes on and on.

A more three-dimensional perspective will be available in about a year. But the process of recovery may extend throughout her life.

I wish the congresswoman the best.

Reporter has TIA on air.

2011-02-15T10:03:00.000-08:00

Stroke can rear its ugly self in so many ways. Aphasia is one way. Many thought this was an example...

Multisource political news, world news, and entertainment news analysis by Newsy.com

Further info from the Associated Press

"LOS ANGELES -- The CBS-TV station in Los Angeles says a reporter who spoke incoherently during a segment on the Grammy Awards is feeling fine.

Serene Branson was checked by paramedics immediately after her Grammys report Sunday from outside the downtown Los Angeles arena where the awards where held, according to the station's website.

The young woman's vital signs were normal and she wasn't hospitalized, CBS said. A colleague took her home as a precaution and she said she was "feeling fine" Monday, according to the channel. "

She told her local CBS station last week, "My head was definitely pounding and I was very uncomfortable and I knew something wasn't right. I was terrified and confused. Confused. What had just happened? At that point they sat me down, then my right cheek went numb. My right hand went numb and I lost some sensation in my arm."

Can't talk? Right side numb with no sensation? Its a "complex migraine"? Really? Really?

This lady went through the same thing...

Diet Stroke?

2011-02-11T06:16:00.000-08:00

My friend Todd hipped me to this... Do diet sodas cause vascular disease and stroke?

The popular media has decided this study was "dubious" because corporate sponsors told them so.

And "Diet Stroke?" is the perfect headline, right? But no other headlines picked "Diet Stroke"...?

Hmmm... wonder why.

26 months

2011-02-04T08:23:00.000-08:00

In my book I talk about "super survivors" defined as a survivor who is “…so unwilling to let go of their career, their independence, or a personal passion that they are compelled to recover. They intertwine recovery with what they love to do.”

When somebody can use their life's passion to drive recovery everything is made easier.

It's easier for the therapist because they don't have to work so hard to motivate.
It's easier for the stroke survivor because they have a cherished task on which to focus.
It's easier for the survivor’s brain because when it comes to driving plastic changes "the power is in the focus.” And we tend to focus on what we care about.

There are other things that motivate survivors towards recovery. Things like career (and by extension money), fear (i.e. falling), friendship (many survivors talk about friends who have "ditched" them after their stroke), the need for independence etc. etc. All of these can be extraordinarily important, although I would suggest that they may be somewhat less important than the goals of the "super survivor" focused on a cherished task.

But if the scale goes from "I need to get better because of friends, money, fear etc." to “I need to get better in order to get back to guitar playing (a cherished task)" there is actually one step further.

That step is called Kathy.

Kathy Spencer is the only survivor I know who has reached a “nirvana of recovery”.

People who get really good at stuff are not necessarily completely focused on outcomes. Most folks who become expert at something are focused on process. The goal in great musicians and athletes and students etc. is to learn. To learn is to forcibly rewire the brain. Relearning of movement after stroke is learning, called motor learning. I’ve discussed this before; learning new movements and learning French, piano, math or anything else is the same. They all happen through rewiring existing neurons in the cortex of the brain.

Learning ain’t easy. It necessarily takes work. But let me ask you this…Which student is going to get a better grade…

Jack: “I’m studying because I want a good grade.”

Jill: “I’m studying because this stuff is really cool.”

Outcome focused Vs. process focused.

Obviously the lines can get blurred because as more ability you have the more that can be done to achieve the outcome. But survivors spend much of their time in a no-mans land where they are working, but are not yet able to use their limbs functionally. And this is where the plot is often lost. If your only interest is the outcome you’ll probably say “the outcome is so far away and I may not get there.” If your interest is process the question is, “What can I do to get just a little bit more?

It seems to me like Kathy Spencer fell in love with the process. And it's tough to fall in love with the process that, unlike practicing soccer and guitar, had no guarantee for success, and where you’re not learning anything new, really. With Kathy it seems to be a leap of faith, although as you'll see faith may have had a bit to do with it.

In the video below Kathy explains a little bit about the process she went through to recover. What is interesting to me is, not so much the particular exercises she did (these will be different for every survivor) but the perspective she takes. 26 months of hard work during which there was no guarantee.

26 months.

And yes, she mentions my book but I pinky swear, I was going to blog on this within the first 20 seconds of watching this great vid.

VOTE!

2011-02-03T10:38:00.000-08:00

I'm a fan of Dean's Stroke Musings. There is a bunch of information for folks interested in the nexus of stroke recovery and neuroplasticity. He writes from a hardened position of someone who has been there and back looking for some legitimate change among the wooden nickles.

Please feel free to vote for his blog in the catigory of Best Medical Weblog in the patient category in the 2010 Medical Weblog Awards, hosted by Medgadget.

Vote Here!

RATS!

2011-01-31T19:09:00.000-08:00

Its all about the hand.
For anyone interested in evidence-based stroke recovery treatment options, the lower extremity offers a much smaller palette than the upper extremity. Simply, there are a lot less evidence-based treatment options for the lower extremity.

One of the reasons this is true is because the ankle foot orthosis is an effective way of providing compensation for the deficits in gait after stroke. Another reason is that canes and walkers are also extraordinarily effective at compensating for gait deviations and deficits poststroke.

There are other reasons. For instance, there is the general consensus among therapists that what comes back first is the leg, and later on the arm and hand. This is a classic gotcha question for therapists teaching students. "What comes back first the upper or lower extremity?" The wise student will say the politically correct answer; the lower extremity. But this is not necessarily true. We tend to focus very much on hand and all its intricate movements, especially finger extension. But in the lower extremity we don't typically look at the analog of finger extension: toe extension. Why does nobody care about toe extension? Simple: The toes are hidden by the shoes. Also, toe extension is not essential to a functional gait. Toe extension which helps raise the ankle is compensated for by the ankle foot orthosis.

Another reason for the near myopic focus on the upper extremity is that it's more interesting. The shoulder has more range of motion in more planes and pivots than it's analog the hip. But but more movement in the shoulder is small potatoes.

The main reason for the focus on the upper extremity is the hand. Even before brain imaging the hand fascinated researchers. This delicate instrument at the distal end of the limb drives clinical rehabilitation research related to stroke. There is a common belief that if you can get the hand "back in the game" and somehow get the hand to grasp release every other aspect of the upper extremity will come back naturally. This is because the entire upper extremity is there at the behest of the hand. You could further argue, although a bit of a stretch, that the reason we walk is to get the hand where it needs to go so that the hand can do what it needs to do.

But there's another huge reason. The brain. The swath of real estate that hand takes up on the brain is huge. The point to point representation of the brain is called the homunculus. The hand takes up almost as much room as the entire face! The face! Where our mouth is! Where our eyes are! Where are ears are! Our identity! When it comes to the brain the hand is, quite literally, huge.

Enter neuroscience, almost all of whom focus on the brain. Neuroscientists are fascinated with the hand for a few reasons. First of all, because of its delicacy, if you figure out the hand the rest of the body is easy. If you are interested in motor learning there's no better laboratory than the hand.

But there may be another reason that neuroscientists are fascinated with the hand. Imagine if you doing clinical research on stroke survivors. They all are different ages, have had their stroke in different parts of their brain, they're all in different physical shape, they all have different diets, they all have different sequelae, etc. etc.

Now imagine you're doing research and you can have as many study participants as you want and they all have a stroke in exactly the same spot, be the same age, eat the same diet, wake up at the same time in the morning, always show up on time and that you can easily blind (not let them know which group there in) and are genetically related!

Where can you find such study participants? Rats! (And mice) But why rats and mice? Why are rats and mice so important to the equation of figuring out the science of motor learning in the hand? Here's why...

Freaky, huh?

"Best New Medical Weblog"!

2011-01-28T12:02:00.000-08:00

I am very happy to report that one of my favorite websites ever Medgadget has nominated the Stroke Recovery Blog as a "Best New Medical Weblog"!

Also, this is the perfect time to tell you about Medgadget. It really is a cool site. It is a one-stop portal to emergent technology in medicine. For stroke survivors it is a good place to go every once in a while. There is a drop-down menu on the right side of the website which has an entry for "rehab".

Alternatively, you can put something like "stroke rehabilitation" into the search box. If you do that one such entry involves our team at the Drake Center rehabilitation hospital here in Cincinnati.

Tools, Techniques and Technology

2011-01-15T16:47:00.000-08:00

I do a lot of seminars on driving cortical neuroplastic change, the unequivocal bedrock of recovery, in stroke survivors. I've done talks in some of the best rehab hospitals in this country. I've also done talks in rural areas where the nearest rehab hospital is hundreds of miles away. Some of the attendees have access to a smorgasbord of leading-edge technologies. Some home care therapists have access to very little technology. And whatever technology they do have has to fit in the car. Some have immediate access to neurologists and physiatrists. Other's laugh when I say "Kick it upstairs to physiatry." "We rarely see any doctors,” they say. Rehab settings run the gamut; feast or famine or somewhere in between.

When I do talks I always remind myself of a particular touchstone that reminds me of why I, again and again, get up in front of therapists in the first place. It goes something like this: "If I was a stroke survivor knowing what I know about stroke recovery, what would I want therapist to know?" This question has served me well. I challenge clinicians as an informed advocate.

There are people, facilities and technologies that are essential to achieving the highest level of recovery. It is unfortunate that many facilities and therapists don’t have accesses to these tools. Stroke is the leading cause of long term disability. Recovery deserves the best tools. The clinical expertise is there. Clinicians spend a tremendous amount of time, energy and money being trained to be the best they can be. But just like every other profession from astronaut to auto mechanic, the right tools and access to the right people are essential.

During seminars I’ll ask, who has access to XYZ technology? Who has the availability of a physiatrist? Who has access to somebody who can do serial casting? Who has access to e-stim orthotics, or a particular splint or a partial weight supported trainer, etc.? Usually the same one or two or three people raise their hands. If the talk is in a hospital setting where all the clinicians are from that hospital they may all raise their hands. If it's a rural area where many are involved in skilled nursing or home health care, very few raise their hands.

Having access to and an understanding of a handful of technologies is essential to standard of care for stroke survivors. Also essential is access to clinicians with the right skill set. So what and who is essential? If I were to start "Pete's Center for Stroke Recovery" I would have access to the following before the doors ever opened.

Treadmills. Treadmills are never ending parallel bars. They expand the size of the gym with a very small footprint. Put a mirror in front of them and they become instantaneous feedback machines. They also provide an essential bit of quantifiable data: speed of gait.

Recumbent, 4-limb bilateral trainer. Recumbent trainers do not have to break the bank. Inexpensive ones can be found for $2500 or so. These are essential not only as a pre-ambulation device, but also because they develop cardiovascular and muscular strength; "banking" both are essential to doing the hard work of recovery.

Some sort of harnessing system for gait training. Stroke recovery works best with over-challenge. Challenge drives neuroplasticity and neuroplasticity drives recovery. It's impossible to over challenge with standard gait training (a gait belt and guarding). The fear of falling on the part of the survivor and the therapist runs headlong into the challenge that needs to be realized. If the survivor is harnessed, falls are impossible and challenge flourishes. Partial weight sported walking is but one option that requires harnessing. Speed intensive treadmill training (also known as speed dependant treadmill training) has shown stellar efficacy in increasing speed of gait (please see my previous article in Advance entitled "Using Gait Speed as a Marker for Progress" for description of the importance of gait speed in recovery, and as an outcome measure). The usual suspect in this category is the LiteGait. But that's not the only option. Google "parachute harness" and you'll find a ton of inexpensive options. Of course you need something to hang the harness from, but this could be more of an issue of your facility's maintenance department, and less an issue of buying an expensive piece of equipment. Over ground systems may be a better option for some gyms. NeuroGym, Biodex and other companies make over ground systems that provide an inexpensive harnessing option.

Cyclic electrical stimulation. The problem with e-stim generally is that the machines tend to intimidate most clinicians. But there are so many good things that e-stim dies that it is no longer optional. From reestablishing sensation to keeping soft tissue shortening at bay, e-stim is essential a certain points in the arc of recovery.

EMG based electrical stimulation (EMG-e-stim). This “next generation” of e-stim is important once a minute amount of movement is possible. It is believed that EMG-e-stim drives cortical changes which leads to small increases in movement. And small increases in movement are important in the early stages of repetitive practice paradigms.

Access to serial casting. Essential to fighting the good fight against soft tissue shortening. There are no splints that have shown clinical efficacy in increasing soft tissue length. Serial casting is the only nonsurgical treatment option to increase PROM of joints that have established contracture.

Access to neurologists, and especially physiatrists. Without them it's very difficult to deal with issues that range from spasticity to pain.

A constraint induced therapy (CIT) program. Although usually only benefiting higher-level stroke survivors, CIT is essential to the stroke recovery endgame.

Q and A.

2010-12-28T22:20:00.000-08:00

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.

~

Game Yourself Bright

2010-12-21T05:19:00.000-08:00

Over the years I've had a lot of questions about recovery of cognitive function. And it's difficult question because it's not my area. Or is it?

My Dad. Super smart.
(I was adopted.)

The word cognitive is quite broad. According to our smart uncle Wikipedia the word cognitive refers to the brain's ability to do any of the following:

Memory, association, concept formation, language, attention, perception, action, problem solving and mental imagery.

As you can see, many of those terms can relate to movement. In fact, motor learning (the learning of new physical movement, or relearning in the case of stroke survivors) is like any other cognitive function. Whether you're learning how to move better or learning mathematics or French or whatever, the processes are similar. Both involve physical change within the brain. Both happen in the 1 to 3 mm cortex of the brain, and both involve repetitive challenging practice. There is no separation between "cognitive" and "motor learning."

I think what most people are talking about when they talk about cognitive function is the ability to think clearly. What is it that they say about intelligence? It's is the ability to keep two thoughts in your head at the same time- something like that. I think a lot of stroke survivors lament the loss of part of their ability to think. Unfortunately, many people assume that stroke survivors necessarily have lost mental capacity. But, of course, many have not. I can't tell you how many people I know that have had a stroke and they're still smarter than me. "Unfair!" I might yelp if I was petty, which I'm not. (Unfair!)

So what can one do to develop an increase in, let's call it, "intellectual capacity"? It may very well be video gaming. There are many in physical rehabilitation who love the idea of using the Wii for physical rehab. They call it Wiihabilitation, because, cute. There's actually some serious questions about whether these games actually help physical recovery. But can gaming help you remember where you put your keys? Can it help you "keep two thoughts in your head at the same time"? It turns out it can. This has implications for parents worldwide (whew!). It has indications for stroke survivors as well.

~

Speed is Good.

2010-12-13T14:18:00.000-08:00

The ability to get from one place to another is essential to every animal. The speed at which travel takes place is an essential to determining the success or failure of everything from food acquisition to escaping danger. Gait requires input from the brain, spinal cord, peripheral nerves, muscular power, and joint and cardiovascular health.

Because of all these systems are required to coordinate gait, gait speed is an indicator of the health of many physiological systems. In all animals, gait speed decreases with age. In humans, the speed of our mobility is predictive of so much more than if we will eat, or are eaten.

What is remarkable about testing gait speed is how much it reveals about people. Here is a laundry list.

A decline in gait speed predicts a decline in attention
An increase in gait speed predicts a substantial decline in mortality while a decrease in gait speed predicts an increase chance of mortality
Gait speed correlates well with functional ability, future health status and the patient’s confidence in their balance
Gait speed predicts where discharge will take place (home, SNF, etc.), the chance of hospitalization, an increase in medical costs, disability and mortality
Gait speed predicts the need for rehabilitation
Gait speed can be used to determine the effectiveness of a particular rehabilitation treatment option.
Gait speed can be used as a surrogate for quality of gait; the faster the walking, generally speaking, the higher the quality of gait.

And much more!

Also, gait speed is modifiable. Walking speed is not only predictive of decline, it can also predict improvement.

FAST made funny.

2010-11-27T18:41:00.000-08:00

I was watching some TV show and this great "know the symptoms of stroke" PSA came on. But I've been unable to find a link to the video. (No! Problem solved, Thanks Linda!) It manages to make the point and make it funny. And funny always works.

Here are some other clever ones. My fav is this first one from Penny Marshall.

Another good one can be found here.

~

Make them walk funny and look lousy in shorts forever!

2010-11-19T14:26:00.000-08:00

(Warning: ENDING THE USE OF AN AFO CAN LEAD TO FALLS AND INJURIES.

Never discontinue the use of an orthotic without first consulting the appropriate health care provider. Then call your doctor. Then have your doc talk to any other providers as needed. Then discuss it some more. Thank you.)

It seems like a no-brainer. “Ted”, has hemiparesis and the classic signs of drop foot: Emerging spasticity in the super-strong muscles that push the foot down at the ankle. He also has a weakness of the muscles that lift the foot. On top of that, he has balance problems and weakness the muscles that stabilize the ankle. The safety imperative is intense. Everybody hates falls.

AFOs solve all of these problems and allow for an almost immediate functional gait. This allows stroke survivors to get on their feet, out the door and on with their life. AFOs work really well. They do the job. They allow clients to be functional.

But “functional” sometimes collides with “recovery”.

What would recovery be in Ted’s case? Let’s define “recovery” as “progress towards being the same as prior to the stroke.” Will the AFO help or hurt recovery?

Consider what is happening in Ted’s brain. The area of stroke is infracted. This area is now devoid of living neurons and will soon be completely filled with cerebral spinal fluid. There is an area surrounding the infarct called the penumbra. This area is kept alive through anastamosis. Like cars going around a traffic jam by taking the back roads, blood cells are delivered through smaller, secondary vessels. This allows the neurons in the penumbra to stay alive--barely. But neurons in the penumbra have another problem as well. The intense biological processes initiated by the stroke soaks the penumbric neurons in a metabolic soup. This further “stuns” the neurons.

That’s what’s happening in Ted’s brain. But what is happening in Ted’s life?

The PT's initial assessment of Ted’s gait is that there is a clear need for an AFO. Once the order is written, the AFO will take 2-3 weeks to fabricate. In the meantime therapists have begun gait training using an ace bandage tied to his lower leg. This forces the foot up and stabilizes the ankle. Ted is given a cane. Ted does well with this system and is able to walk 20 yards. He still fatigues easily, so a recumbent stepper is used to build cardiovascular strength.

Okay, now back to Ted’s brain. The neurons stunned by the stroke are starting to come back “on line”. The blockage has cleared in the primary artery. The metabolic soup that provided such a harsh environment for the neurons has dissipated. The neurons are ready to go back and do what they’ve always done; help Ted walk. But these neurons are never called upon.

They never will be.

Once the AFO arrives, Ted takes to it well. The gait training and cardio work he's done pays off. The AFO works so much better than the ace bandage that Ted immediately walks longer than he ever has. Ted is functional.

Meanwhile, the area of the cortex jam-packed full of neurons that control the ankle is shrinking. Rapidly. In a process known as learned nonuse the area will shrink to half its size in just a few weeks. Languishing for long enough will force the remaining neurons to migrate to some other task. Other neurons will go through "synaptic pruning" and they'll communicate less and less with the neurons around them. The muscles of that push the foot down may atrophy and will certainly shorten. The muscles that pull the foot up at the ankle are not called upon. The AFO does that work. The muscles that pull the foot up are small to begin with (relative to the muscles that push the foot down). And they begin to atrophy. Ted will have the AFO as a lifelong companion. The orthotic will substantially change his style of walking and may have future orthopedic implications.

But what’s the alternative? Managed care leaves few options and little time. Stroke survivors want to go home and their caregivers want them home. This is why AFOs seem like a blessing.

But a new perspective is emerging. There are researchers that advocate early electrical stimulation (e-stim) as a possible hedge against learned nonuse. E-stim has the potential to jump start movement, promote muscle building, calm spasticity and may even have an impact cortically. Repetitive practice with and without the help of robotics, gaming applications and task specific training may begin to bring the stunned cells of the penumbra back on line. A menagerie of emerging treatment options from mirror therapy to bilateral training to lower extremity constraint induced therapy also seem to have potential. But there are more flies in the ointment than ointment at this point. Research is far from definitive answers. One thing we do know is that the brain is a market economy. The “goods” (neurons) go to the “customers” (whatever movement is asked for). If nothing is asked of them neurons will find something else to do. As recovery is unmasked after stroke, every effort should be made to guide neurons “back home”. This will require more time to allow the arc of natural recovery to emerge. It will also require more focus on what is not easily seen: neuroplastic change in the brain. “Seeing” neuroplastic change requires sensitive, stroke-specific outcome measures.

In other words, this shift in treatment philosophy, from “focus on functional” to “realizing recovery” is as much a work in progress for therapists as it is researchers.

What we do...

2010-11-10T08:10:00.000-08:00

Here's a spankin' new flier from our lab. It gives a good overview of what we do.

Click on the images and then click again to make them larger!

Seeing Stroke

2010-11-06T13:36:00.000-07:00

Traditionally, the numbers for stroke have been written like this: "In the United States, 750,000 strokes per year. 500,000 new strokes, and the remaining 250,000 recurrent strokes." But by 2015 the estimate is well over 1 million per year. And here's where the stats get grim.

The "well over 1 million per year" bumps the number of recurrent strokes to over 300,000. For the five years after a stroke the is an chances of having another stroke are somewhere between 25 and 40%. So here's the question: do you know the symptoms of stroke? If you're stroke survivor, of course you do. Or do you? You might very well be an expert in the symptoms of stroke you HAD. But what if you have another one? Would you know the symptoms? So what are the symptoms that you're supposed to know? I work for the University of Cincinnati. They suggest the FAST test. But its a mnemonic and here's some funny: I get confused about it even though I talk about it, a lot. I think, OK, FAST. What does the F stand for? Why Fast, of course, but yeah, not so much.

So what are the symptoms that stroke survivors should know? One way is to use the FAST test. FAST is based on the Cincinnati Prehospital Stroke Scale and National Institutes of Health Stroke Scale. FAST was developed by Rosie Miller, RN, a nurse who worked with The Greater Cincinnati / Northern Kentucky Stroke Team for 15+ years.

FAST stands for:

· FACE: Ask the person to smile. Do both sides of the mouth, elevate equally?

· ARMS: Ask the person to raise both arms. Do both arms lift equally?

· SPEECH: Ask the person to repeat a sentence. Are they able to repeat a sentence? Are the words slurred?

· TIME: If the person shows any of these symptoms of, call 911 or get to the hospital FAST.

Initiating treatment as soon as possible is vital because time saved is neurons saved. Every minute 2 million neurons and 14 billion synapses die.

It should be pointed out that there's some controversy about the FAST test. The FAST test is great because it is simple. And simple is good. If it's not simple people will forget what the letters stand for. But any test of signs and symptoms of an emerging stroke should be comprehensive enough to capture as many strokes in as possible. Which signs and symptoms to include is hotly debated. Even in the English-speaking world (US, UK, Canada, Australia and New Zealand) there is discrepancy over which and how many and which to include. Further, the wordings used in the various lists are inconsistent. Although there is little research to compare other ways of informing the public, the FAST test has been put to the test. Kleindorfer et al did a study in which they determined that the FAST test missed only about 8% of ischemic strokes but up to 30% of hemorrhagic strokes.

What else is typically included in tests other than the FAST test? Other tests include numbness, intense headache, vision issues, balance problems, loss of coordination, dizziness, difficulty swallowing, and confusion. Also included in some of the tests are the words "even if temporary" after the signs and symptoms. This is an attempt to capture transient attacks which often act as precursor warning signs of a full on stroke.

Consistency is essential to the success of communicating the symptoms and urgency of stroke to the general public. A single unified message increases the number of times it would be experienced by the general public. This would allow for more repetitive memorization of that consistent message. Again, however, there has been insufficient research to indicate which of the mnemonic devices is the most effective at capturing the most strokes.

But there may be a bigger question than what specific signs and symptoms to add. The question is: how do we best learn? Quick, answer this question: You see somebody that looks panicked and is holding their hand to their throat. What pathology does this represent? Here's another one: You see somebody clutching their chest. What is the pathology? While hardly comprehensive, the visual impact of these two examples is universally understood. The question is not what mnemonic is the best, but whether mnemonics are the best way. In my book, "Stronger After Stroke" (Demos 2008) I mention the Cincinnati Prehospital Stroke Scale. But I also suggest another way of memorizing the signs and symptoms of stroke: visualizing. Here's what I suggest:

The easiest way (to memorize the symptoms of stroke) is to start at the top of the head and move downward.

• Skull: Sudden, severe headache and/or dizziness with no known cause.

• Eyes: Sudden trouble seeing in one or both eyes.

• Face: Facial weakness.

• Ears: Sudden trouble understanding.

• Mouth: Sudden trouble speaking.

• Body: Sudden numbness, weakness or paralysis on one side of the body.

Stroke survivors have a much higher chance of having a second stroke than the general population has of having a first stroke. No matter what system you use, educate stroke survivors of the risk of recurrent stroke. And make sure they know as many signs and symptoms as possible.

Isn't there a machine for that?

2010-10-02T11:09:00.000-07:00

I was over at dean's stroke musings a cool stroke recovery blog. He had a link to a study that showed that there were some changes in the brain when limbs are moved passively.

Lets say you can't flex or extend your wrist. Will passively moving the wrist make it better? That is, if you move the "bad" wrist with your "good" hand, or have someone else move your wrist-- will that help the wrist move by itself? Will it change the part of the brain that controls the "bad" wrist? According to the study, there were brain changes. But. They didn't measure movement changes.

Their bottom line: "These findings provide a potential neural substrate to account for alterations in motor and sensory function in stroke patients in response to long-term passive movement interventions."

Which is a good point. Let's say you have a machine (which this study did) that moves the wrist back and forth, a half-hour per day. Would that help? Certainly those who make robotics like the Myomo (Val from our lab!) or the REO would have us believe that there are both brain changes and movement changes. There are many therapists who rely on hands-on techniques in which they "facilitate" movement by handling patients. The efficacy of those therapies remains questionable. But it may be a matter of dosage. If the machine can do it for a half hour (or 5 hours) at one joint, consistently, that's a little different than having a therapist do it for a 20 minutes at many joints. Also, robots (like the Myomo and REO) are very sensitive (using EMG or computers) to when the survivor needs help and when they don't. So that may make a big difference as well.

Where does this leave the question "Does passive help?" So far as I can tell: moving the limb passively won't hurt and may help. Doing it with robotics seems to provide enough duration and specificity to provide measurable changes in movement.

But the bottom line remains the same: Doing any movement yourself is always better than having someone else do it. So these options are for folks who have trouble moving the joint at all.

Once you can move it with no help, it should be "all you."

--

The upward spiral of recovery (II)

2010-09-20T18:00:00.000-07:00

What tools are needed to allow for stroke survivors to drive their own recovery once they are discharged from therapy? It all starts with the home exercise program (HEP). Building the HEP should be initiated in the acute setting and continue to develop through subacute treatment. If the stroke survivor is unable to attend to an explanation of the arc of recovery and how the HEP fits into it, caregivers and family members may be educated instead. Once the stroke survivor is able to absorb the information, they would be the focus of education about the HEP. The amount of time recovering under the guidance of therapists is usually measured in months. The amount of time in which the patients is guiding their recovery is measured in decades. So the HEP becomes a flexible document.

The HEP should…

· Have the flexibility of progressing as the patient progresses

· Educate the patient on measuring progress

· Provide achievable milestones

· Provide benchmarks upon which the patient is directed back to therapy.

Upon discharge the HEP becomes an extension of the therapists’ and patients’ hard work. It's like teaching a kid to ride a bicycle. You hold them up, you run alongside, you guide them, and then you let go. We also tell our kids to keep pedaling because without the forward momentum, they fall. The HEP is the set of rules that will allow folks with brain injury continue their forward momentum. The hard work that patients have done with therapists is the first step on this upward spiral of recovery. But the HEP is the extension of that upward spiral. Finally, the patient fuse the HEP with their own plan of recovery that incorporates their own life. The life they lead drives recovery.

Therapists have to discharge patients once the patient has “plateaued.” However, research from many disciplines has refuted the concept of the definitive plateau. Any therapist worth their salt knows that recovery can continue, sometime spontaneously, well beyond the point of discharge. Unfortunately, the calculus made by many brain injured folks is simple: therapist=recovery. So part of the job of the therapist is to explain that recovery from brain injury is not just the plateau that precipitated discharge from subacute therapies. In fact, recovery becomes a lifelong series of plateaus.

Therapists are paid to be optimists. They know that focusing on disability is less effective than focusing on potential. Medical doctors have to low-ball any prognosis. Doctors feel uncomfortable setting expectations too high. An optimistic prognosis not realized goes against the medical ethics dictum; “first, do no harm.” If doctors set expectations too high, patient frustration (along with some pointed feedback) will be close behind. Therapists, on the other hand, have the responsibility of making clear the potential level of recovery. While doctors low-ball, therapists imagine. The act of transferring that imagination from therapist to patient is the proverbial "Apple a day."

Because everyone likes a cartoon!

2010-09-10T13:05:00.000-07:00

The Upward Spiral of Recovery

2010-09-03T09:39:00.000-07:00

There is a common suggestion among many in the "alternative medicine" industry expressed in the question: "If it means less business, why would your doctor want you to be healthy?” A strict emphasis on healthy lifestyle including diet and exercise would be like the proverbial "Apple a day" – keeping the doctor away. Doctors who do this – who keep themselves away as much as they can – are the best doctors. And therapists who "keep themselves away" are the best therapists.

Many pathologies allow for a definitive discharge point. The patient who has had a knee replacement gets therapy, and then goes home to live the rest of his life. But neurological disorders are different. Many, from Parkinson's to multiple sclerosis, are progressive. But what of non-progressive neurological disorders like stroke and traumatic brain injury? Does this "Apple a day" philosophy work? Is there a point at which these populations no longer need therapists?

Many patients with acquired brain injury believe that they will always need therapists. Most see therapists as essential to the recovery process, no matter how long (months, years, decades) it takes for them to achieve their highest level of potential recovery. But this view is incorrect.

There is a point at which therapists are no longer the fulcrum for recovery. Nor should they be for reasons that range from financial to practical. At discharge stroke survivors are, and should be, in complete control of their own recovery. During the chronic phase of recovery from stroke, the speed of recovery slows. In the chronic stage the physiological action of recovery is based on a lot of self-directed hard work.

Much of what is required is relatively simple, and revolves around the broad concept of repetitive practice. In order to take charge, stroke survivors need the tools to initiate and follow an "upward spiral of recovery.” This term is used to describe the path to the highest level of potential recovery. They "upward spiral of recovery" is driven by real-life demands for everything from coordination to cardiovascular strength.

brainu

2010-08-12T11:28:00.000-07:00

Exercise, does it help after stroke? Of course it does, but the word exercise is so broad it's darned near meaningless.

One of the things that's confusing is the way that clinicians have historically used the word exercise. They have almost always meant "doing a movement against resistance." The focus is generally on muscle building. But, although they're weakened, the muscles of stroke survivors are usually strong enough to do whatever. And the peripheral neurology is still intact. All the nerves outside of the brain injury are doing just fine. So the question becomes, why all the emphasis on muscle building?

The muscles are working. What's not working is the brain. Can exercise be directed at the brain? Yup. But the emphasis should come off of muscle strengthening and onto repetitive practice. Part of the confusion is that both kind of exercises (muscle building and repetitive practice) crossover. For instance, just working on muscle building will also drive some changes in the brain. Conversely, repetitive practice of movement will build muscle. Another thing that adds confusion is that fatigue is such a huge issue among stroke survivors. So exercise for the sake of building muscle (as well as cardiovascular exercise) is important. Still, the emphasis should be on the brain. I suppose you could simplify it as that old athletic training saying: "Less weight, more reps." Sort of. For more clarity please see this article.

Rockin' Recovery

2010-07-27T18:11:00.002-07:00

I'm here in Finland, above the Arctic Circle, the home of my wife, Aila. We're visiting for 3 weeks.

This is a great country for clearing one's head. The things that matter to "us" seem to trouble them less. Their perspective has changed my perspective!

There is a particular study the Fins have done on stroke recovery that has caught my eye several times over the past few years. Part of it is that any study that says "stroke" and "Finland" will get my attention. Part of it is that music is so personally important. The following quote comes from this article Therapy Times

"A daily dose of one’s favorite pop melodies, classical music or jazz can speed recovery from debilitating strokes, according to a study published recently. When stroke patients in Finland listened to music for a couple of hours each day, verbal memory and attention span improved significantly compared to patients who received no musical stimulation, or who listened only to stories read out loud, the study reports.

Those exposed to music also experienced less depression than the other two control groups.

Three months after a stroke, verbal memory was boosted by 60 percent in music listeners, by 18 percent in audio book listeners, and by 29 percent in non-listeners, according to the lead author Teppo Sarkamo, PhD, a neuroscientist at Helsinki University in Finland.

The differences held true after six months as well, says the study, which is published in a recent issue of the journal, Brain. Sarkamo’s findings bolster a growing body of research pointing to the benefits of music and music therapy for conditions including autism, schizophrenia, and dementia. But this is the first time music alone has been shown to have a positive effect on victims of brain injury, such as stroke, he says.

“Everyday music listening during early stroke recovery offers a valuable addition to the patients’ care, especially if other active forms of rehabilitation are not yet feasible,” Sarkamo says."

Also, this systematic review seems to further indicate music can help in a number of ways.

`

Oh la-la! It's like a bad romance.

2010-07-15T09:42:00.000-07:00

Stroke. The leading cause of long-term disability. It's not the leading cause of short-term disability. That's probably headache or back pain. And it's not, like, the fifth leading cause of long-term disability. It is the LEADING cause of LONG TERM disability. It's the big kahuna. It's the whole enchilada. It's the Lady Gaga of things that require recovery. Like, for instance Lady Gaga. Who requires recovery. Heh. And my kids keep telling me I'm not funny. Pfft.

Figure stroke recovery out and it will inform you about everything that the brain does. Insights into cortical plasticity? Done. Recovering after dramatic brain injury. Done. Learning? Done.

Here's some irony:

There is only one treatment option for recovery from stroke that has the same level of testing as any drug on the shelf of a drugstore. One. Constraint induced therapy (CIT).

So you would think that every rehab hospital would do CIT. But, not so much.

Part of the problem is the foggy perception that many clinicians have about what CIT is. Read this article, and then have your therapist read it.

~

It's okay. I speak aphasic.

2010-06-24T07:18:00.000-07:00

You're the first responder to a serious car accident. You try to talk to one of the two people in the car - the only one that's conscious. But everything that she desperately tries to tell you seems to trip on her tongue. Is she in shock?

A house is burning down and you are a firefighter. You need to make quick decisions about whether to send your crew inside the burning house. A woman outside the house is desperately trying to tell you something. But... can't... quite...

The Drake Center in Cincinnati Ohio is having a training session for first responders on how to communicate with folks with expressive aphasia. Please click on the flyer, below.

Note that the address of the Drake center is:

151 W. Galbraith Rd.

Cincinnati, OH 45215

Please e-mail me if you have any questions...

2 great videos by Canadian neuroscientist Dale Corbett

2010-06-06T11:44:00.000-07:00

The emerging translation of this stuff to clinical practice will be interesting.

Here's another lecture he did. The first half an hour is about his work using hypothermia as a way of treating acute stroke. Right around 29:27 is when he starts talking about rehab.

Pizza And Therapy: So Much In Common

2010-05-26T07:59:00.000-07:00

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.

_

Q&A

2010-05-10T15:09:00.000-07:00

I get so many questions about stroke recovery from survivors and caregivers and therapists. Many of the questions are sad. Survivors and their loved-ones often contact me when they don't have any resources providing direction towards further recovery.

I could probably write a book of questions and answers I get.

Instead, I wrote an article.

___

BOTOX PARTY?

2010-03-19T12:37:00.000-07:00

After years of trying Allergan has FDA approval for Botox for spasticity for the upper extremity. However, this does not mean Botox will be any less expensive, at least in the short term.

Would Botox be helpful to you? A neurologist or physiatrist would help you make that decision. Occupational and physical therapists can help you make the decision as well. But understand, Botox is just a Band-Aid, and a temporary Band-Aid at that. You can get injected, and have relief for a few months. That's great, but will not help you resolve the issues that created spasticity in the first place.

Sometimes, if you're super lucky, Botox allows heretofore hidden extension to emerge. For example Botoxing the finger flexors may allow the finger extensors to extend the fingers a little bit.

If you and your doctor decide on Botox, make sure a script is written for therapy. Have the therapist work specifically on recovery options that will help you take advantage of the opportunity that Botox provides.

Imagine if your hand is locked pretty tightly into a fist. The Botox may provide just a little bit of movement into extension. This will provide you an opportunity to use repetitive practice to reestablish cortical (brain) control over the extensors.

Botox is expensive but they do provide help in some cases. Click on either picture to find out more.

***

The Ultimate Crystal Ball?

2010-03-14T06:36:00.000-07:00

It turns out the the speed you walk (gait speed) is predictive of so many things that folks are now calling it "The Sixth Vital Sign." But here's some funny: everybody is calling everything the sixth vital sign including:

Urinary continence

End-tidal CO2

Emotional distress

Spirometry

Glucose

Functional Status

Intracranial pressure

Shortness of breath

Molecular Genetics, in Oncology

Who will become the sixth, who knows? Some of these require a test in which the tester needs to be trained. Others are self-reported and we lie. But gait speed requires a stopwatch and 2 meters of hallway. Then just read the gait speed tea leaves!
Here's a full explanation I wrote recently!
Here's another version!

Exercise. Because.

2010-01-18T09:41:00.000-08:00

I was interviewed for this article on the Cleveland Clinic website. What I like most about it is that it also mentions one of my neuroscience heroes John Ratey. The fact that I'm mentioned before him- and more often- is just plain wrong.

The focus of this article is the impact of exercise on stroke recovery. But exercise per se does not necessarily drive the sort of cortical changes needed to recover. Of course, it is important to do both cardiovascular and strengthening exercises after stroke, if for no other reason than the fact that life poststroke takes so much energy for two reasons:

~Typically everything a stroke survivor does takes twice as much energy. A good example of this is walking. A stroke survivor takes an average of twice as much energy to walk as someone who has not had a stroke.
~Stroke survivors are in about half as good a shape as age matched couch potatoes.
~Although it hasn't been measured, neuroplasticity takes energy. We're not sure how much. But when you consider that the brain gets 20% of total body oxygen consumption, while it only represents 2% of total body weight, you can imagine how much energy it takes to drive neuroplastic change.

So the bottom line is that stroke recovery needs energy. And exercise is good for banking energy.

~

Stroke Recovery: Easy Concepts and Hard Work

2010-01-15T10:20:00.000-08:00

Let’s face it. There is a lot of bad information about stroke recovery. And the cheaper it is to publish information (I’m talking to you Internet) the lower the quality becomes.

Much of the info on stroke recovery is either stale or unreliable. Most of it falls into 2 categories:

Filtered through the medical model. This info tends to be stereotypic, redundant, risk free and out of date.
Unsubstantiated or weakly substantiated. This info is usually written by caregivers or stroke survivors themselves.

Don’t get me wrong; both the medical model and survivors and caregivers provide valuable information. I have long believed that the secret of recovery is locked within stroke survivors who have gone the furthest on the road to recovery. The problem is that, as much as it’s a cliché, every stroke is different. There are tons of variables, including:

Sequelae (health problem related to the stroke)
Comorbidities (health problems unrelated to the stroke)
Motivation of the stroke survivor (The more motivated, the more recovery)
Recourses (time, energy, helping hands, money, etc.)
Age (generally, the younger, the better the outcomes)

And there are a hundred other variables that can affect recovery. One of the most important is the location of the area killed by the stroke. A pea sized stroke in one area leaves the survivor unable to talk. In another area the survivor walks great, but can’t use their arm. In yet another area, a pea-sized dead zone allows for a relatively easy and full recovery. So when a stroke survivor writes a book about recovery, they are really writing about their recovery. And because of the variables mentioned, each journey through recovery, and each recovery endpoint, is unique.

I wrote a book about stroke recovery. I wrote it because I have been involved in stroke recovery research for a decade and I have learned a thing or two. Writing a book was easy because there is plenty to report on. Researchers from around the globe are adding their voice to an ever expanding ball of knowledge. And that ball, like much of science, is not perfect. It is misshapen and complicated and hard to visualize all at once. Part of this is because there are many different sciences involved. Input from neuroscience, physiatry, biomedical engineering, physical and occupational therapy and others makes the whole ball hard to conceptualize. But what is emerging from all these complexities are remarkably simple concepts.

I have come to a few basic conclusions about stroke recovery. Here is a list of core principals that can be used by any stroke survivor to promote recovery.

-Recovery is hard work. If it’s easy, you’re doing it wrong.
-The absolute foundation of recovery from stroke is neuroplastic rewiring of the brain.
-What drives recovery are relatively simple concepts that have been used by athletes (and other hyper-skill learners), since the beginning of time.
-Recovery is best served by

Repetitive practice of movements…
…that are related to a task or tasks…
…that is/are important to the stroke survivor and that are practiced…
…many hours a day…
…and are made more challenging as skill is acquired.

Electrical stimulation can be used to help stroke survivors recover in many ways including:

Keeping soft tissue (including muscle, blood vessels and nerves) elongated
Jump starting movement in survivors who have little or no movement
Reestablishing sensation in survivors who have sensation loss
building strength in muscles that are not quite ready to move on their own
Stroke survivors should stretch more than they do.
Stroke survivors should “bank” (develop a reserve of) cardiovascular (heart/lung) and muscular strength.
Measuring recovery from stroke is essential to recovery from stroke. During different periods of recovery can accelerate, slow and stall. During the slow and stall periods—periods when most survivors give up—measuring small improvements is necessary. A bunch of small improvements = large improvement.
You have to do it yourself (DIY). This DIY concept is essential in 2 ways:

Only you can rewire your brain.
If you have to rely on therapists and other clinicians to reach you highest level of potential recovery, you’ll run out of time and money before you’re done.

Focus on 2 things;

Making sure that you are not allowing soft tissue to shorten. If it shortens permanently, it doesn’t matter how much “recovery” you get, the joint will not be able to move.
Driving brain rewiring change towards recovery. How do you know if your brain is changing? A “Yes” to the following questions will help determine if you are rewiring your brain:

Are your limbs moving better?
Can you feel your limbs more?
Is your balance getting better?
Is your hand able to grasp wider objects?
Are you walking faster?
…and much more will tell you if you are rewiring your brain. Remember, the foundation of relearning movement is changes in the brain, not in the limbs. Although the limbs get credit, it’s the brain moving those limbs. The limbs tell us what is going on in the brain.

The basics of recovery from stroke are simple. The work required is difficult. Recovery from stroke, even years after the event, is available to any stroke survivor. The key is to bring your focus and power to your own quest for recovery.

Stroke Swag!

2009-12-31T12:27:00.000-08:00

Cafepress has some interesting stroke-related swag found here. My son, just looking over my shoulder, says the ones with swear words are "gross," so here's some clean ones...

On boxer shorts...

I like this one too...on a tee shirt...

~

Pusher Syndrome

2009-12-16T05:58:00.000-08:00

Pusher syndrome. Some stroke survivors have their sense of balance knocked out of whack by the stroke. Their sense of what upright (true vertical) is off by about 20°. And guess which way they think true vertical is? Bonus-towards the affected side! And guess which way they will usually fall (if they do but they shouldn't because falls can...whats the word...kill. Yeah. As in death.)? Towards the affected side-double bonus! And if they fall towards the affected side that's bad because guess which side usually has thinner and more brittle bones? Bingo!

And here's the "funny" part: Therapists may be causing pusher syndrome.

How? Read on.

~

2 welcome mentions...

2009-11-10T08:25:00.001-08:00

Click to make larger!

On the left: The American Stroke Association's magazine, Stroke Connection.
On the right: George Mason University's magazine, Mason Spirit. I'm an alum. You can also click here to find a quick blurb about the book on the GMU magazine website.

Go Pats!

-

A Rare non-stroke recovery entry: Hand washing

2009-10-30T02:57:00.000-07:00

I'm a big fan of hand washing. Eliminating bacteria and viruses from hands makes sense. It doubly makes sense because my home is often infested with a problem of a much bigger size: Children. My kids, their friends. Their friends friends friends friends. I am the steely-eyed Great Wall of China of bacterial and viral stoppage! Mean! Wash your hands I say. Most kids go in to the bathroom. My kids could go anywhere in the house to clean their hands.

We generally use iso-propanol rubbing alcohol to clean our hands. There are mist spray bottles in the bathrooms, kitchen and on desks. The rule is, if the dirt is visible, wash your hands. No visible dirt? Use the alcohol. I implemented this house rule a couple of years ago. I based it on the fact that children will not follow the "sing your ABCs" length of washing rule. They get in, sorta wash, and then sorta dry. I had read an article--which I am having trouble re-locating-- which said that using alcohol killed more germs than hand washing.

Then a few weeks ago, this from Kathleen Sebelius (née Gilligan-- She'll will be working closely with the Professor and MaryAnn.") "Lil' Buddy Gilligan taught us all how to sneeze. After she teaches the proper sneeze she endorses a brand-name gel hand sanitizer. She is an expert on all things medical because, hey, former governor of Kansas--hello! And then c'mon-- she names the brand? Why? I'm sure she was just trying to ride a moment of cuteness. Or maybe she owns stock? As Glen Beck would say, "I'm jus' saying..."

What is best for washing hands? Well, it would be nice if there was one answer. But there are several. It's science. If you want definitive answers, try religion.

Part of the problem is that most research focuses on hand-washing Vs. alcohol gels. But there are many other options. So who should we really trust? Dentists! They've been grappling with this issue since the 80's. And what conclusion have the come to? Its neither hand-washing or gel. In fact, hand washing and alcohol gel do worse than everything else tested in dentistry.

For the rest of us non-dentists it is a given; Hand washing is effective. But in some tests, the gel hand sanitizers do better. However, there are many chemicals in the gel, including the gel itself, that make me wary.

Propylene Glycol, Tocopheryl Acetate, Aminomethyl Propanol, Carbomer, Fragrance, Glycerin, Isopropyl Myristate, Propylene Glycol, Tocopheryl Acetate, Aminomethyl Propanol, Carbomer, Fragrance (Parfum), Blue 1 (CI 42090), Yellow 5 (CI 19140). (Thanks Sanjay!)

So I choose straight alcohol. But unlike the former governor of Kansas , I am not an expert in this field. So trust your doctor!

Stroke Recovery and Rehabilitation: A Head Game.

2009-10-08T12:02:00.000-07:00

Mental practice. Athletes do it, musicians do it, anyone who does highly skilled movement benefits from it. It's inexpensive, takes little to no equipment and little energy, and it's well researched.

Mental practice ties into my entire philosophy of stroke recovery: If it works in athletes, then it works in stroke survivors.

Here's an article about our team that outlines a new study that were doing. We've done many mental practice studies before.

But this is the big kahuna.

`

G'head. Click the article.

2009-09-15T17:04:00.000-07:00

Extry!

Extry!

Rewiring Around Dysphasia

2009-09-09T12:30:00.000-07:00

I wrote this article for a trade magazine for speech therapists (ADVANCE for Speech-Language Pathologists and Audiologists).

The article's bottom line is that the same sort of neuroplastic rewiring needed to, say, open and close the hand, is also needed to help with swallowing.

~

METANEUROPLASTIFICATION

2009-09-01T07:45:00.000-07:00

Def: The rewiring of the brains of entire populations caused by a novel technology, event or change in circumstance.

Example: TV has led to a metaneuroplastification of the American people in many ways. This includes the rewiring of cortical regions that effects behaviors from eating habits to shortened attention spans.

There, I've coined it. If you use it you owe me a nickle.

See me Heal me Touch me Feel me

2009-08-26T18:09:00.000-07:00

An interesting study here. Bottom line: Some stroke survivors can feel when they touch the affected side, but cannot feel it when someone else touches them. This experiment basically shows that, in fact, they do feel better when they do it themselves.

Implications: reestablishing sensation may involve repeatedly touching of the affected side by the unaffected side. Maybe. Still, the question of how to neuroplastcially rewire sensation is interesting because sensation and movement are essential to each other.

...

The National Stroke Association endorses Stronger After Stroke

2009-08-11T19:29:00.000-07:00

The National Stroke Association has chosen Stronger After Stroke as the first book ever mentioned in their first ever annual summer reading section! Click on the screen shot yay!

Let me tell you what the deal is here. This book ain't perfect. There is a lot I wish I had added. There are some aspects of it where I wish i had used other wording. There are parts I should have edited better. But this book continues to be the best selling book on stroke recovery and rehabilitation because it does something I'm very proud of: It has changed the discussion. Time and again I find folks "reverse engineering" stuff in the book and putting it in articles on the web and magazines. Thinly veiled plagiarism, yes, but this book is changing the discussion. Many stroke survivors confirm this.

I've been told a billion times (at least) that the book only confirms what they suspected all along; that they have control over their own recovery.

We can make him better. Stronger. And with increased elbow extension.

2009-07-27T15:18:00.000-07:00

The problem with the whole "neuroplasticity is the bees knees" perspective on stroke recovery is that there is a feeling that bad practice will lead to bad movement. That bad movement, so the thinking goes, will lead to bad neuroplastic rewiring. But to pay a therapist to keep the survivor "moving correctly" is prohibitive. It takes too much therapist time, too much money and is unproven. Enter robotics.

The idea is to get a machine that makes the job easier and the treatment more effective. You still need a therapist there...for now. But the end game in most of these technologies is: "Go home with it, do a lot of hard work. Come back and I'll get all the credit."

Here is my colleague, Valerie Hill Hermann, demonstrating new robotic technology, the MYOMO, with a stroke survivor. Val has a new American Heart Association grant to study the device.

An appreciated review

2009-07-09T06:48:00.000-07:00

Most of my work in research has been on the arm and hand of stroke survivors. It is a joke among therapist; occupational therapist only deal with the upper extremity, and physical therapist only deal with the lower extremity. Of course this is a generalization that's not entirely accurate. Still, I have a special affinity for occupational therapists and their work.

It was a pleasant surprise to have a review from ADVANCE for Occupational Therapy Practitioners do a review of Stronger After Stroke.

.

Neuroplastification RAWK

2009-06-30T10:24:00.000-07:00

In this video two great neuoplasticians, Michael Merzenich and Alvaro Pascual-Leone, talk shop. Pascual-Leone is the guru of TMS, a way of stimulation the brain without surgery or pain.

The most important part for stroke survivors may be at about 6:25 of the video. Dr. Merzenich asks Dr. Pascual-Leone how TMS might be used with "intensive training" to get more recovery. Merzenich nails it with this question because he understands that "two great tastes can taste great together" (TMS with "intensive training".)

He also understands that the training has to be intensive, which is essential to any discussion of recovery from stroke and other forms of brain injury.

.

Good press. Always nice.

2009-06-15T14:04:00.001-07:00

Click on any image to make ginormous.

Better late than never yay!

2009-06-02T18:09:00.000-07:00

Me and a bunch o' my fellow labrats homeslices are speaking at this shindig which I should have blogged before but didn't because insert excuse.

A cool concept: lets get all the stroke nerds together to talk about the impact of technology which will eventually turn us all into Sony robots.

If yer in to this whole technology thang, click here. DANGER DANGER DANGER: YOU WILL FOREVER GET LOST IN THIS SITE!

~

An Excellent Review (if I do say so myself)

2009-05-26T07:30:00.000-07:00

Here is a review of my book. Me likey!

~

Another Radio Interview

2009-05-21T18:58:00.000-07:00

I did interview today with "PT Talker". It's about driving plastic changes in the brain after stroke of course. So sit back, relax and...

~

Hard Work = Recovery.

2009-05-20T09:27:00.000-07:00

I wrote this article last year. It makes a decent point.

The shift in rehabilitation has been 360° in about 15 years. Prior to the prospective payment system (~1998), therapists were able to to treat stroke survivors for as long as the therapist liked. There was some question about whether this therapist-dictated system was cost-effective. So it was scuttled.

Other countries have therapist treat stroke survivors for longer time periods. In many European countries these longer treatment times result in more recovery.

So if more treatment is better, but cost savings dictate shorter treatment periods, what's a stroke survivor to do?

One easy answer is to go home and work hard. This is where my book, and other books, can help. The idea is to do "massed practice". Many hours a day of practice.

Hard, sweaty, ugly practice.

If this sounds uninviting, it should. But in order to rewire the brain after stroke hard, sweaty, ugly work needs to be done. Remember Michael Jordan didn't start out as Michael Jordan. He started out as awkward kid who was a crappy basketball player.

Be Like Mike.

Hard Work = Recovery.

~

So My Scurrying May Help Mankind

2009-05-15T10:21:00.000-07:00

I have worked with a lot of PhD's and MDs over my 10 years in stroke-specific rehabilitation research. One thing I'll say about these groups is that they are brighter than average bears. (Little-known fact: Many have ginormous heads, where the bone and skin barely covers their pulsing arteries.)

In labs like ours and in previous labs in which I've worked, spontaneous conversations break out. I usually sit there dumbfounded and overwhelmed. Then I scurry back to my office, do some research, and then try to figure out what was actually said.

Let me digress (a lot). I was adopted. All of the people that were in my family, my parents and sisters, were smarter than me. Hey, it's the luck of the draw. But because I was used to scurrying back to my bedroom to figure things out, it felt natural as I interacted with these ginormous brained scientists. The key is making complicated junk simple.

Here is an article I wrote describing how we learn to move. It does, I hope, satisfy the two most important aspects of explaining stuff about stroke recovery:

Scientifically accurate. Easy to understand.

~

Stroke Recovery: How to make sense of “it all”

2009-05-03T13:48:00.000-07:00

I did an interview with Tom Haynes of the mighty Stroke Central. You have to scroll past the Jill Bolt Taylor/My stroke of insight stuff.

Tom culled questions from his members. Interesting questions. Tough questions.

"Functional" ≠ Stroke Recovery

2009-04-28T08:50:00.000-07:00

The focus, nay obsession, clinicians have with "function" has the potential to hinder recovery. Basically the word function and the word recovery are used interchangeably. But they mean different things.

"Function" is a buzzword that makes everybody in rehab feel good. But it has its downside. Focusing on function gets in the way of the neuroplastic rewiring necessary for the fullest recovery endpoint. How can this be? Let me ask this rhetorical...

Does using a boat make you a better swimmer?

For a fuller and less haiku-y explanation... click here.

Puts Things In Perspective, Don't It?

2009-04-23T11:01:00.000-07:00

Who is the person who has had the most neuroplastic change in their brain? Michael Jordan? Eddie Van Halen? Yo-Yo Ma? Einstein?

I've always claimed that it is Michelle Mack. But it seems there are many of these miracles.

Stroke Recovery. Wired.

2009-04-22T16:30:00.000-07:00

File this under "I couldn't have said it better myself...waitaminute...I did!" I sent an email recently to Ben Philipson, the developer of one of the three EMG-based electrical stimulation machines. These machines are an important part of stroke recovery and rehabilitation.

Since I can't say it any better (again) I leave with this link to his blog.

.

Jim Thorpe. The World's Smartest Man?

2009-04-20T17:54:00.000-07:00

I never understood the argument that athletes get paid too much. A kid grows up, shows up at practice, usually for multiple sports in the rain and snow and heat. Sweats, works, develops skills. And then at the end of 15-20 years or so of hard work it pays off with a 10,000 to one shot and a pro contract. I always imagine the people who complain the most are people who’ve never worked really hard for anything in their life.

"I worked really hard. I just chose to develop my brain,” they would counter. But they'd be comparatively lazy. They only developed their brain. Athletes develop their brains too, but the development is done through structured and dedicated bodily movement. It is a different part of the brain, but it is still the cortex. It's still neurons and synapses blending and communicating. It's still neuroplasticity.

Research into stroke recovery has revealed a simple truth: If someone was an athlete, at any point in their life (not necessarily right before their stroke), they have a better chance of a more full recovery. Why might former athletes do better? Is it because the movement portion of the brain, the part that is typically injured after stroke, is bigger in athletes? Or is it because athletes are used to training insanely hard for results?

I asked this of a neurologist and neurosurgeon, Prithika Chariwhen when we met at a shared talk in Munich 3 years ago. Her answer was simple (considering she was a brain surgeon); “Probably both."

Stroke survivors need to be athletes. By extension stroke survivors also need to be dancers and yogis and musicians. Work as hard as athletes.

And for all those nincompoops who think using your motor cortex is just plain dumb, click on this.

-

The Forgotten Leg

2009-04-17T11:38:00.000-07:00

Constraint induced therapy (CIT) and modified constraint induced therapy (mCIT). We know them and we love them. These recovery options are richly researched and intuitive. I mean really, how much thought does it take? "If I tie up my 'good’ arm, and work really hard with my 'bad' arm and hand it will move better.” Duh, hello.

The concept of CIT has been extrapolated to everything. For instance there is CIAT (constraint induced aphasia therapy). CIAT is based on the same old idea: If the stroke survivor forces themselves to talk a lot, talking gets better. In many ways a constraint induced therapy is the trunk from which all the theoretical branches spring. And that trunk is as solid as it can be. "Practice makes perfect.” “We are what we repeatedly do.” “Use it or lose it.” Cliché, cliché, cliché but true, true, true.

All good news to be sure. But one bit of the body that has been left to drag behind: The leg. How would you do the CIT for the lower extremity (LECIT)? You could tie up your good leg, but falls, decubitus ulcers, hospitalization, throwing a clot, having another stroke, so let's say… no.

But still the idea is compelling enough for researchers and device makers across the rehabilitation spectrum to want to claim LECIT as their own. I wrote an article about the competing perspectives.

The bottom line is that to adhere to the spirit of constraint induced therapy, you have to overstress the affected leg. And this requires caution. And a therapist. And a lot of work.

Two Great Tastes

2009-04-11T19:00:00.000-07:00

Figuring out what helps a stroke survivor recovery may involve finding that one magic bullet. But it probably won't. It will probably be a few magic bullets, a smattering of magic hand grenades and a ton of magic TNT. Enough of this explosive rhetoric!

The point is, recovery requires multiple recovery strategies. As time goes on, the combination of strategies will change.

There is a tendency among many researchers to focus on their little piece of the pie. They'll pioneer treatment "X". They'll develop treatment "X". They'll advocate "X" and they'll cling to "X" forevermore.

Our lab takes a bit of a different tact. If different things work for different survivors at different times you damn sure better have a feel for the whole ball o' wax.

Here is a recent study our team did fusing "Two great tastes that taste great together".

Bon appetit!

The Feel of Recovery

2009-04-07T15:45:00.000-07:00

Here is an article I wrote last month. It describes, theoretically at least, how to get sensation back after stroke. Turns out, nothing new under the sun. Getting back sensation is the same as getting back movement. Repeated attempts at feeling drives the brain to be better at feeling.

There are 2 ways of retraining feeling: active and passive. Passive seems to be more for tactile stuff, active is more for proprioception (the feel of movement).

But movement and sensation double back on each other. Movement affects sensation because if you can't move the brain stops listening for movement. And if you can't feel, your movement goes haywire.

Another Coward With A Gun

2009-03-29T20:07:00.000-07:00

OK. So a gunman goes into a nursing home and kills 7 nursing home patients. What a coward. "The slain patients ranged in age from 78 to 98." Whats next? "I'm going to blow away people in hospice!"

The killer was 45. He was ..."armed with a rifle, a shotgun and other weapons." I mean, if you're in that much of a rage, wouldn't you look for some sort of challenge? What could the possible motivation be?

"My knee's been acting up. I need someone slower than me!"

I've worked in nursing homes. My wife is a PT in one that looks almost exactly like the one that was attacked. This one, in NC, was focused on folks with Alzheimer's. Cowardly, weird, sad, the end.

THE HISTORY OF STROKE RECOVERY

2009-03-15T09:42:00.000-07:00

INTRODUCTION

This is the history of stroke recovery. This is a perspective that is uniquely my own; a simplified version of a narrative built up in my head over the years. It will be in multiple parts. How many parts? Well, answering that question would involve fancy-underpancy planning, of which I have an aversion.

Histories are important because they tie people, which is what people like to think about (generally), to events. In this case “events” refers to the ambling from there to here; from not knowing what a stroke was to understanding quite a bit about not only stroke, but recovery, too. Like most of our collective story, it all starts with cavemen… I wrote an article about it. And there is a chapter in my book, about how cavemen might have handled stroke. (One editor suggested I change every “caveman” to “caveperson” which I didn’t do because, c'mon, really?)

PART I: STROKE RECOVERY, THE EARLY YEARS

Anyway…so it starts with our ancestors that lived in caves. More accurately, it wasn’t about where they lived, but how much they moved. They moved in hunter-gatherer tribes. These were small bands of individuals, begat (!) from our common Mom (or “CoMom”), Lucy. These folks walked and walked and walked, always on two legs. Two leg walking was good because allowed us to see more stuff (because we were taller), and use our hands to carry junk (because they weren’t doing anything else and we feared they’d dwindle into tiny T-Rex-style flippers with claws) and keep us cool in the Kalahari heat (because standing provides less surface area). As you can see, I’m no anthropomorficologist, but this is my story, so I’ll filter the facts the way I see fit thank you.

So we walked and roamed and found stuff and ate it. We were also really good at hunting because, although we're not the best sprinters, we were great at distances running and walking. So we would run after edible beasts at our own two-legged pace. Once we caught up to them, it was a 2 fer 1; They were too tired to run and/or fight, and they were so hot they were already half-cooked!

If an individual had a stroke, there would have been a general feeling that some sort of higher power was pissed. It was probably an omniscient female deity, because all of our deities were female back then. And no wonder. There is now a belief that our numbers shrunk to just a few thousand at one point, probably because of a severe drought. So anything that could give birth would be seen as (as Kung-Foo Panda would say) awesome and attractive. So once the ever-pregnant She-God decided you needed a smack-down, a smack-down smacked upon thee. And if She chose, she would give you a "smack upside the head", which is what cavefolk used to call a stroke. And as I mentioned in my article, there would have been a serious effort to get the stroke survivor on their feet and the “therapy” would have been focused and ferocious. And it would be directed not by a therapist, but by survival instinct. This instinct knows no rational bounds, and no stinkin’ stroke was going to stop us from surviving. The survival instinct is just not something we access much any more.

We’re now in the “fat and happy” part of evolution (anthropomorficologically speaking).

This is how I've put it earlier:

Early humans and hunter-gatherer tribes of today may have had one advantage over present-day humans: A capacity for hard work. These were rugged people who survived using extreme strength and physicality. They knew what hard physical work was and they knew no other lifestyle than that of survival.

Intensity and frequency of post-stroke rehabilitation is one of the hot topics among stroke researchers. Research has shown that patients spend as little as 13 percent of their day (8 a.m. to 5 p.m.) involved in rehabilitation efforts within the first 14 days after the stroke while spending 78 percent of their time in bed or sitting next to their bed. Might the ability of our evolutionary cousins to couple their huge capacity for physical work with the natural demands of life in a hunter-gatherer tribe have some lessons for today's stroke survivor?

Modern-day researchers believe there are lessons. This belief is reflected in so many of the newer recovery options that involve so many more hours of work. "Intensive therapy" and "over-challenge" is the way researchers put it. We’re trying to get stroke survivors, by hook or by trick, to access their inner survival instinct.

PART II: THE GREEKS ADD THEIR 2¢

And that’s the way it stood for 3 mill plus years. You’d get a stroke and you’d fight like hell to get back to where you once belonged.

Hippocrates showed up 2400 YEARS AGO and did something remarkable: he defined stroke. He wrote about stroke and aphasia and TIA’s (transient or “mini” strokes). He made up a word for it: Plesso. Which meant “Slapped upside the head by God.” 250 years later another Greek doc, Galen, said that he thought stroke was “thick and dense humors” built up in the ventricles of the brain. Which, you know, is a pretty good guess that sounds a bit like an ischemic (block) stroke. Galen was pretty interesting. He was the personal physician to Marcus Aurelius and Commodus, two of the characters in one of my fav flicks, Gladiator.

Then nada for a thousand years or so and then the Germans came up with the word “strAcian” whch loosely meant “bonked on the head with a kilo of Spätzle.” The derivative of this word is stroke. But Hippocrates’sess’s word, Plesso was the basis for the word apoplexy, which you still hear on old Andy Griffin episodes.

PART II: THE CLASS OF 1950

Working in the early 1900’s, Sir Charles Sherrington was a colossus of all things neurological. Sherrington was a Nobel winner (1932, functions of neurons). It is hard to explain how ginormous this guy was. His ideas on what drove human movement were law. One of his hypotheses was called reflexology. Reflexology basically said that all control over muscles came from the spinal cord, and was just a series of reflexes. The brain got involved, sure, but just a filter for the prime mover: reflexes.

“Sherringtonian reflexology” was adopted by many of the most influential physical therapists that ever lived. Sherrington had a great influence on PT and OT as it related to stroke. His influence was especially strong from the 1950's to the 1990's. From the '50s to the '70s was when physical and occupational therapy was just beginning to address stroke-specific therapies. The problem is they had inaccurate tests, so it was difficult to determine if what they were doing was actually working.

They had another problem, as well. Some therapists took Sherrington’s reflexology and smeared it on every aspect of stroke recovery like a kid with hot toast and runny peanut butter. For his part, Sherrington disavowed the idea that it was all about reflexes (and accepted that movement was controlled and learned in the brain) by the late '40s. Hey, he was a bright guy and a true scientist; if new evidence comes to light, you change. If you want definitive answers, look to religion.

The problem was that a few influential therapists, most forcefully Berta Bobath, never got the memo that it is in the brain, not the spinal cord, that control resides. In her book Adult Hemiplegia (1970), Bobath began writing about, teaching and generally espousing that it was all about reflexes—which come from the spinal cord. Bobath also believed the way survivors naturally move after stroke was so bad that therapists should not allow the movement to take place. The way that survivors move is called synergistic movement. It is still believed, by many therapists influenced by Bobath to be movement so evil that Bobath and her followers set about separating stroke survivors from the only movement they had! Fast forward to 2000 and the Bobath Center (sorry, Centre), the British seat of all things Bobath. They issued the following statement: “While certain activities are not encouraged in some cases, the idea of stopping a client from moving, especially if they are motivated to do so, cannot be supported on financial, moral or scientific grounds.” But it has been difficult to let go of a core concept that had been a cornerstone of the Bobath approach for decades. For example, in 2008 an article (p.133) defending the Bobath approach wrote, "Abnormal/atypical patterns of coordination need to be suppressed and unwanted movements controlled..." Under this premise, you'd need someone with you during the entire arc of recovery. Otherwise you might move wrong.

Stroke survivors need the ugly movement to get to good movement. Imagine yelling to a baby, “Look at you, you duck-footed fool! Bend your knees and stop falling!!” Imagine telling someone who is learning a language (or instrument, or anything), “Stop making mistakes!” Learning requires mistakes. Mistakes corrected are learning.

Bobath’s therapy, called neurodevelopmental technique (NDT) is still very popular, but it’s not very scientifically-based. (See Here. Here. Here. Here. And a great non-scientific discussion here). My suggestion is to avoid therapists who say I’m a “this-based therapist, or a that-based therapists.” Instead, look for therapists who say something along the lines of, “I’m an evidence-based therapist. I consider the best science and meld it with my clinical experience.”

Weirdly, a contemporary of Bobath, Signe Brunnström, who also published her best known work in 1970, was clear right out the box: Use any movement, synergistic or not. We now know we need to encourage “ugly” movement to rewire the brain neuroplastically. Not only that, but Brunnström suggested really forward thinking concepts that are accepted by stroke-recovery researchers all over the world. Among them were Brunnström’s “6 stages of recovery.” Despite the fact that Hippocrates had defined stroke 2400 years before, Brunnström was the first person to fully delineate the predictable steps towards recovery. It turns out that her stages of recovery are so accurate that they can be correlated with brain-scanning technology like MRI (see Here and here). Just like Einstein, Brunnström predicted stuff and then waited for the world to catch up. The bad news was that Bobath’s NDT was wildly more popular than Brunnström’s techniques. Why was Bobath more popular than Brunnström? It may have been a simple issue of duration of message. Brunnström was diagnosed with Alzheimers and began to live in a nursing home in 1976. Bobath died in 1991.

PART III: TAUB BUCKS THE POWERS THAT BE

Edward Taub represents the full-on separation from the “reflexes rule” argument. He showed, through animal testing that, even when you get rid of reflexes (with an operation that cuts nerves to the spinal cord) you can still learn new movement. Repetitive practice movement drives changes in the brain. Those changes lead to better movement. This ushered in constraint-induced therapy, and other ideas that were as simple as pie: repeat a movement and that movement will get better.

Just like the cavefolk did.

Well duh. And it only took us forever to figure out what we already knew.

My daughter wants to to play soccer now. The End.

Radio Interview

2009-03-11T19:04:00.000-07:00

I did a recent radio interview with Karla Calumet, a very nice professor and radio personality from Perry, Iowa. So get some tea, sit back, and...

Stroke Struck. Rock Roll.

2009-03-08T06:51:00.000-07:00

"I know a rock star. His name is Dave Grohl. He was the drummer in the band Nirvana and now heads the Foo Fighters.

I haven't talked to him since a thrilling evening in Atlanta backstage at a Nirvana concert in 1994. But I know how he got to be an amazing drummer. And it wasn't easy. First, let me tell you why his story has everything to do with (stroke recovery)."

I wrote this article last year. It's really about the power of very intense bursts of repetitive practice on learning (or relearning) movement.

Play me until you get blisters

I'm a drummer as well. Drumming is interesting because it hits (heh heh) on so many leading-edge topics in stroke recovery. One is cognitive. It turns out that there is a company that uses keeping a beat to drive better cognitive recovery. Drumming is also inherently bilateral (left, right); and bilateral training is a hot stroke-recovery idea. It may even help with the only long word I remember from school, dysdiadokinesia, an inability to do alternating (bilateral) movements after brain injury. Why did I remember it? Dude. I'm a drummer. And this brings up the next point: use what you love to drive recovery. The more intensely you love doing something the less it becomes therapy and the more it is just plain fun. Whats the old saying, "If you love your work, its not work."

I'm jus' sayin'

2009-03-04T19:30:00.001-08:00

Folks involved in rehabilitation research (like me!) have a lot to answer for. I read studies all the time. It’s almost impossible to figure out what the actual intervention (treatment) is. It's usually deep in the article as a couple of short sentences that tells you sort of what happened. If you read two or three articles about the same intervention you can piece them together, and get a feel for how to do the intervention. I work for a major university. I have access to all the articles I want. Even articles that are not on line because they are too old I have access to.

How is the typical therapist supposed to find the articles and have the time to sort the whole article out? I have no idea. And it sucks because it has consequences on the treatment of stroke survivors. I think that there should be a law that says that if you are doing any sort of research on human participants (subjects) that there should be a one-page explanation, in clear, simple and plain language that everyone can understand, what the intervention was, and what its clinical application is.

This photo is my son Jesse’s reaction when I told him about how researchers are trying to hoard all the thinkology.

Little = Lots

2009-02-24T17:22:00.000-08:00

I love this study. It was a small study that our lab did. Basically we used the NeuroMove and got people to move their wrists and fingers, just a little. The point is, if you can find the X factor that allows for just a little active (under your control) finger and wrist extension, then you can use other options to take you further. But the trick is getting the first few degrees of movement. And we did it. The end.

The body after stroke. Working in mysterious ways.

2009-02-20T07:00:00.000-08:00

Stroke is weird; unlike most neurological diseases, stroke is nonprogressive... A stroke survivor doesn't get more brain damage as time goes on. Unlike multiple sclerosis, Parkinson's, Lou Gehrig's disease, etc. stroke and other forms of brain injury do not get worse over time.

And through the process of neuroplastically rewiring the brain recovery happens. So there is an argument that can be made that says people can actually get "better" after stroke. This is going to sound twisted but... the stroke tells you what needs to be worked on. In other words, the very deficits that stroke presents are the exact things that need to be worked on to recover from stroke. It's hard to do, but stroke survivors should embrace those deficits as acceptable challenges.

There are other “deficits” after stroke that may also have a sort of internal logic. (Note: Deficits related to stroke--and other primary diseases are called sequelae).

Can sense be made of all the sequelae we fight so hard to get rid of after stroke? Is there a reason for them?

Movement close to the body (proximal, i.e. the hip and the shoulder) returns before movement that is far away from the body (distal, i.e. hand and foot). Why might this be? It may be because you can't do anything with the distal unless you can get the distal where it needs to be by using the proximal.

Spasticity is a reality for many stroke survivors. Spasticity may be considered internal protection mechanism, generated by muscles, to protect muscles.

Stroke survivors with one sided weakness can rarely move one joint without moving a whole bunch of other joints. This is called synergistic movement. In the hand and arm there are two such movements: the flexor synergy, which looks very much like a hand to mouth. There is also an extensor synergy. This movement looks very much like picking something up. If there are any movements that you don't want to lose they are feeding movements. These synergies look very much like feeding movements.

Heminopsia (a one sided visual deficit -- difficulty seeing towards the affected side) and unilateral neglect (ignoring the affected side) may provide a lack of focus on what does not work and focusing on what does work.