Hemorrhagic (bleed) Stroke, Simplified (but its still complicated)

Hemorrhagic stroke: 

Bleed in the brain or brainstem. 

These two are the two types of hemorrhagic (bleed) stroke: 

1. Intracerebral hemorrhage: In the "meat" of the brain (cerebrum).

2. Subarachnoid hemorrhage: Between the brain and the meninges (meninges, the layers of "brain wrap" and surround the entire brain). 

Approximately 25% of patients with subarachnoid hemorrhage die within 24 hours, with or without medical attention. 

• Other disorders that involve bleeding inside the skull include epidural hematomas and subdural hematomas, which are usually caused by a head injury. These disorders cause symptoms that sometimes resemble those of a stroke.

Credit: Wikimedia Commons

Vocal Music Listening Helps Recover Language

Everyone knows that listening to music is good for your brain, staves off dementia and Alzheimer's, and may be beneficial for gait, the timing of upper extremity function, communication outcomes, and quality of life after stroke. 

myc.com

And it may help people with aphasia recover language. But the same question always comes up: What kind of music is the best?

 

Kinda a cool study from the great country of Finland may have answered that that question (for survivors with aphasia, at least).

They had three groups:

1. Listened to music with a singer singing lyrics 

2. instrumental music (with no sung lyrics) 

3. narrated audiobooks.

 

The  winner? “Vocal music”—music that included sung lyrics.

But there was another thing they did: They interviewed the participants to find out their favorite music.

So...

1. Listen to music to help language recovery

2. Choose music that has sung lyrics

3. Choose music you love

Dosage:

    ✔️ 1 hour a day

    ✔️ 2 months

    ✔️ Keep a diary to make sure you stick to it

STROKE DEPICTED IN A CARTOON!

This is a re-post of an earlier blog entry. Still pertinent!

Have a look at this cartoon. In poor taste, yes. But it manages to raise awareness and it does it in a way that is comically accurate. 

Here is your quiz: Watch the vid and then do this: Just below the cartoon, highlight the invisible text by left clicking and dragging to the bottom of the post. Therein lies my observation of what the cartoon gets right. If you'd like me to add anything I've missed, put it in the comments or email me.

Highlight text below↓↓↓↓↓↓↓↓↓↓↓↓↓
1. Drop foot 
2. Inability to clear ground during swing phase of gait 
3. Flaccid left upper 
4. Lack of sensation left upper 
5. Caregiver concern regarding driving 
6. Difficulty with spacial issues while driving 
7. Left hemiparesis, no aphasia! 

In the comments section Jim Sparks points to a part in the episode where a treatment that is not proven to work, works!

A Show For Survivors

Hi Survivors (and caregivers, clinicians and clinical students:)!

An OT friend and I recently launched a "radio show" (the kids call it a podcast:). 

Its all about stroke/brain injury recovery.

Below are link to some episodes you may find helpful...

• Stop Falling!
• Mirror Therapy
  
• Learned Non-use
• What  Does  Work I
• What  Does  Work II
• What Doesn't Work I
• What Doesn't Work II
• Sensation Recovery
• Measuring Recovery
• Neuroplastic Beats Spastic
• How Repetition Rules Recovery
• Subluxation and Shoulder Pain
• Constraint Induced Therapy: Part I
• Constraint Induced Therapy: Part II
• Bilateral Training for the Arm, and Leg
• Super Survivor Kathy Spencer On Successful Recovery

The Feel of Recovery

Below is an article I wrote in a PT trade magazine years ago. 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.

Rehab clinicians have seen it all... from the proprioceptive deficits of the apraxic survivor, to the hyper-sensitivity of survivors with shoulder/hand syndrome (RSD), stroke deals an unpredictable hand of sensory dysfunction to many survivors. Approximately 60% of stroke survivors have some sort of sensation loss. Of all the squealae after stroke, loss of sensation is the most perplexing for researchers. Most research focuses on the effect of interventions on recovery of movement and function.  There are reasons that research focuses on movement and not on sensation.

For instance, movement is considered more important. In some ways it is. Edward Taub, the developer of constraint induced therapy (CIT), proved that primates could move limbs they couldn’t feel before he was out of graduate school in the 1960’s. So if movement can be relearned without sensation, there is less focus on that that relearning. Also, any gains in recovery of movement are easily seen, and we focus on what we can see. Sensation is much more difficult to measure. But any therapist worth their salt knows that sensation impacts on movement. Movement is the Ying to movement’s Yang; neither does well in isolation.

If a therapist wanted help a client relearn sensation, how would they go about it? First, understand that sensation would, in fact, be relearned--in much the same way that movement is relearned. The same rules apply. We know that repetitive practice reestablishes movement. Although much more research needs to be done, repetitive feeling seems to help reestablish sensation. Also, movement itself seems to drive increases in sensation. The more the survivor moves, the more the sensation of movement becomes ingrained into the neurons of the brain and the more the brain “listens” to the feeling of the movement. The more the brain listens, the more neuroplastic rewiring occurs to make the brain more perceptive to the sensation.

There are two veins of inquiry that researchers are following that promote repetitive feeling; passive and active training.

Passive Training of Sensation (PTS)

PTS usually involves surface electrical stimulation. This would be delivered in much the same way transcutaneous electrical nerve stimulation (TENS) is. That is, there is no muscular contraction. The hypothesis is that continuous signals sent from the peripheral to central nervous system reallocate neurons to feeling the limbs. Stimulation sessions ranged from one session for one day to one session per day for several weeks. Other PTS paradigms have used pneumatic compression, thermal stimulation and vibration to a portion of the body.

Active Training of Sensation (ATS)

The research in this area has used a variety of training techniques. ATS involves having the stroke survivor actively involved in training. Included has been practice determining where limbs are in space with eyes closed (for proprioception) and practice with localizing sensation (“Where do you feel this?”). Also used is repeated challenge to stereognosis (the ability to perceive the form of an object held in the hand).

Ultimately, the best paradigms for reestablishing sensation involve the blending of ATS and PTS. Since the more movement that is done the better the brain becomes at listening, anything that compels the survivor to move will tend to drive sensory recovery. Repetitive practice paradigms, including CIT may be helpful in the recovery of movement and the sensation of movement.

Much more research is needed in this important area. Every study and systematic review of sensation after stroke agrees: The testing and treatment of post-stroke sensation deficit lags well behind the testing and treatment of movement.

Serrada I, et al. Does Sensory Retraining Improve Sensation and Sensorimotor Function Following Stroke: A Systematic Review and Meta-Analysis. Front Neurosci. 2019 Apr 30; PMID: 31114472

Rehabilitation of Somatic Sensation and Related Deficit of Motor Control in Patients With Pure Sensory Stroke

NOTTINGHAM SENSORY ASSESSMENT

The perfect stroke survivor.

The perfect stroke survivor would be male. Outcomes are better for males. Depression hits men less after stroke, and they tend to be both younger and in better shape prior to the stroke.

The perfect stroke survivor would be well educated. Folks who are well-educated get more recovery than the less educated.

The perfect stroke survivor would have significant economic resources. The well-off recover more than then moderate or low income folks.

The perfect stroke survivor would be African-American. African-Americans recover more than Caucasians and/or Puerto Ricans.

So, Who would be the perfect person to have a stroke?

Click here to find out!

◉◉◉◉◉Where do I start?◉◉◉◉◉ Lemme give you a hand with that.

I've done a ton of talks to rehab clinicians. Sometimes I get a simple but perplexing question... I have a stroke survivor on my caseload. Where do I start?

When I meet a survivor, the first thing I check out is the hemi-side hand. The hand tells you a ton: 

• Is spasticity an issue? If it is, spasticity will show up in spades in the hand. All those little joints, and those little muscles pulling those little appendages. And the massive strength difference between the muscles that close the hand against the muscles that open the hand. Let's put it this way, you can hang from one hand. Your entire body weight through those little appendages. The muscles that open the hand have the strength to do one thing: open the hand. There is a huge difference in strength between the two groups of muscle groups. So if the question is, Is spasticity a problem  the hand will usually be the first to reveal it.
• Is the survivor paying attention to that hand? Many survivors will play with the affected hand constantly grabbing it and opening it. This is a good sign; unilateral neglect is probs not an issue.
• Are they able to squeeze the hand shut from and opened position? A lot of people, even clinicians, think opening is a good thing, but closing is a bad thing. I think closing is a good thing and opening is even a better thing! You need both. It kind of like the joke: "How you feeling?" "I'm alive!" "Well that beats the alternative!" (OK, its a dad joke. But I'm a dad—so its OK!) So, being able to close the hand beats the alternative. The alternative is nothing. The dreaded flaccidity.
• Are they able to open the hand? Can they "relax-open" the hand. That is, can the survivor relax the flexors so much that, while there is not contraction of the muscles that open the hand, there is at least a relaxation of the muscles that close the hand. That relaxation is important. The first thing needed to open the hand is the ability to shut of the muscles that close the hand.
• How does the hand look? Is it swollen? Is it the same color as the unaffected side? Does it have the same
  
  amount of hair. Is it painful. All those can tell you something (esp. in someone who has a post-stroke shoulder dislocation).
• What's going on globally? The hand takes up huge swaths of the brain. In some ways the most visible reflection of the brain is the hand, so the hand gives you global perspective on the brain.

So as a clinician—or survivor, or caregiver—the first thing to ask is, how is the hand doing?

Audio: Stop Falling!

 https://nogginsandneurons.podbean.com/e/stop-falling/

✨Find the website with all the episodes here.

Find all episodes on your fav podcast provider: 

✨Google Podcasts     

✨iTunes    

✨Spotify

10 things that work against survivors.

1. Fault: survivors, caregivers. Most stroke survivors don't get to the hospital nearly soon enough. A lot of stroke survivors, as they are having the stroke, feel overwhelmed with  fatigue-- so they go to sleep. And this delays getting to the hospital. Many other symptoms of stroke are either ignored, or passed off as completely separate issues.

2. Fault: MDs. Once in the hospital stroke is often misdiagnosed. For instance: I cannot tell you how many young survivors have told me that-- once they got to the hospital-- all anyone asked them about was their drug use. Over and over again. Sometime that's germane; you want to know about potential meds interactions and/or if a drug may have caused the stroke. But often MDs will see the young survivor and jump to the conclusion that the symptoms are caused by illegal drugs. This can delay treatment, or reduce the change of getting a particular treatment.

3. Fault: managed care. Survivors are often rushed from the hospital without the clinicians involved being able to take the time to figure out what the next best step is. How rushed? After stroke it is not uncommon for the survivor to be discharged from the hospital within a few days (2-3)! The mean length of hospital stay for stroke survivors in the US? 5.2 days. In the Netherlands its 25 days!  

4. Fault: managed care, clinicians. Survivors are often sent from hospital to sub optimal situations. And where survivors are sent next will impact not only recovery, but also is predictive of how much longer they'll live. Ref1 ... Ref2

5. Fault: managed care, clinician. Too much therapy too soon within rehabilitation hospitals can be dangerous to the recovering brain. Survivors are often discharged from hospitals to rehab hospitals. Rehab hospitals require a minimum of 3 hours a day of rehab. Because survivors are discharged soon after their stroke (see #4., above) they are forced to do "too much, too soon" and this can hurt the recovering brain.

6. Fault: managed care, clinicians. Survivors, especially within the first week of their stroke, are often not given enough opportunity and tools to get decent sleep. Decent sleep is absolutely necessary to post stroke recovery. Noisy environments, sleep interrupted by clinical visits, visiting family.. many things work against the survivor getting the ZZZs necessary to recovery to the fullest potential.

7. Fault: clinicians. Rehabilitation clinicians are sometimes very well trained in the best treatment for stroke recovery. But they are often not trained nearly enough. Clinicians treat many pathologies – and stroke is only one of them. Survivors would be best served by being sent to facilities designed and trained to be the best for stroke.

8. Fault: managed care, clinicians. Stroke survivors are often discharged from therapy once there is a perceived "plateau". But this plateau is often more an artifact of poor outcome measures than actual potential for progress.

9. Fault: clinicians. What survivors will do "with the rest of their life" after they are discharged from therapy is often left to happenstance. Clinicians would serve survivors well by working with the survivor immediately "from the first session" as to what the plan should be once their discharge.

10. Fault: stroke survivors. Survivors often do not work particularly hard after therapy ends. This is usually because the survivor doesn't believe that they can get any better. They don't believe that they can get any better for two reasons: a. Because they've "plateaued" the survivor does not believe they can get any better b. Clinicians often lead the survivor to believe that once they are discharged from therapy – partly because they plateaued and partly because they're no longer under the care of the therapist –  they won't get any better. How to combat that here.

Audio: Super Survivor Kathy Spencer On Successful Recovery

 

Kathy Spencer is a survivor who had a stroke. 

Then she kicked its ass.

✨Find the website with all the episodes here.

Find all episodes on your fav podcast provider: 

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✨iTunes    

✨Spotify

Audio: The Best Ways To Measure Recovery

Here is a short discussion on how to measure small (but important!) changes towards recovery.

✨Find the website with all the episodes here.

Find all episodes on your fav podcast provider: 

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✨iTunes    

✨Spotify

A short discussion about stroke recovery with Ron Clark from Chat and Spin Radio.

 

What Works (and what does not): Movement, Spasticity, Contracture

Here is a great article on what works—and what doesn't—for movement, spasticity, and contracture. It's in CP, and tracks well with similar reviews in stroke recovery for all ages. 

Its a systematic review. Here's the good news: This'll be as simple as possible and no simpler. There is a great "State of the Evidence Traffic Lights" chart that makes the whole thing simple. At the very bottom is the full chart. Also note: What this review says does not work.

What works: Movement

 Click any image to make it larger.

What works: 

Spasticity

What works: 

Contracture

Novak I, Morgan C, Fahey M, et al. State of the Evidence Traffic Lights 2019: Systematic Review of Interventions for Preventing and Treating Children with Cerebral Palsy. Curr Neurol Neurosci Rep. 2020;20(2):3. Published 2020 Feb 21. doi:10.1007/s11910-020-1022-z

Connie Smiley, Super Survivor

Connie Smiley, one of my favorite people and a survivor who was a friend to our lab for years, passed August 6, 2019; I just found out.  

Connie was zero-nonsense and smart, and exemplified what a super survivor is. 

From an earlier post:

A super survivor  is “…someone 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 motivate.
• It's easier for the stroke survivor because they have a cherished task which drives recovery.
• 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.

Rewiring the brain in a way that is robust enough to reestablish control over wayward muscles takes a concentrated focus on the affected-side of the body. The focus needs to be near total. This level of focus is only accessible to stroke survivors who have a passion or avocation that drives them to the highest possible level of recovery. Connie Smiley was a survivor who used her avocation to drive her nervous systems towards recovery far beyond any expectations.

Smiley had her stroke "The day before Easter," as she remembers it, 1991. The stroke was on the right side of her brain, affecting her left, non-dominant side. Prior to her stroke, Smiley was fully aware of the absolutely devastating impact stroke. “My husband lived for almost 6 years in a nursing home following his stroke. The damage was too severe to recover—even though he tried. One of the things that motivated me was seeing the restrictive life he led. I realized that the same could be true for me, but I decided that, if there was anything I could do towards recovery, I would do it.” 

It is not unusual for stroke survivors to use the fear of a “restrictive life” as a powerful motivator. Fear of isolation, fear of falling, fear of dependence–all can motivate. And motivation is vital to overcoming one of the hardest parts of recovery from stroke: there is often little interest in relearning how to move. There is none of the inherent joy of learning as the stroke survivor relearns movement that they used to do perfectly well. But fear of a “restrictive life” was not Smiley's only motivator. It was not even her primary motivator.

Smiley has a master’s degree in education and has been a teacher of one sort or another, since. For more than 30 years she taught primary school. While she was teaching school she began volunteering at the Cincinnati Zoo, eventually landing a paid full-time position managing the Zoo’s community outreach program. Her job involved bringing small animals local schools and introducing the kids to the animals.  She has the war wounds to prove it! Smiley has been bit by every type of mammal she has handled. She sports scars from snakes, alligators, bearded dragons and was once taloned by a hawk. Although she was forced into retirement by her stroke she almost immediately went back to work at the zoo.

As Smiley got back to work, a remarkable neuroplastic metamorphosis took place. In order for Smiley to be able to handle the animals she was forced to use the limited dexterity in her affected left hand. Because she was powerfully motivated by her avocation, the amount of neuroplastic rewiring was remarkable. But what was more remarkable was where the rewiring took place. Smiley enrolled in a series of clinical trials at our lab; at the time at University of Cincinnati. All of the clinical trials involved brain scans; functional magnetic resonance imaging (fMRI) of Smiley's brain. Traditional MRI provides a static picture of the brain. Functional MRI involves doing something, in Connie's case a finger tapping task, in the MRI machine. The fMRI machine measures change in blood flow in the brain as the task is being done.

Usually, the fingers of the left hand are controlled by the motor cortex that is on the right side of the brain. But Smiley had rewired her own brain in a rather curious way. When her fMRI was analyzed it was found that she was controlling her left hand, not with the right side of the brain, but with the left side. What made it even more curious was that the scan showed that the left hand had essentially "borrowed" neuronal firepower from the area of the brain usually controls the right-hand.

Neuroplasticity happens. The brain decides where it happens. Connie showed us that the brain can do the right thing in the "wrong" part of the brain. That's what super survivors do.

Thank you Connie!!

My interview on the ReneMarie Stroke Of Luck TV Show.

My interviews starts at about five minutes in...

I was interviewed a while ago and peppered with questions from one of the great interviewers of all time: Mark McEwen. 

ReneMarie's show is great to check out. She has a ton of great content geared towards stroke survivors and recovery.

These guys let me go on and on about a bunch o' stuff including how much its costs to have a stroke, using mental practice as a recovery tool, why empathy is an occupational hazard for therapists, how the medical system in the USA hurts stroke survivors, why athletes and musicians may recover more than most people, why gains are easier early in recovery, and more!

A couple of days after this show, Mark called me and told me amazing stories about interviewing presidents and other famous people, his career, and his recovery. He said that when his sons (twins, Miles and Griffin) were young he'd talk to them about his career and they would be like, "Old dude reliving the boring old days." But then they came into his office one day and realized the photographs were of Jordon, and Ali, and a whole bunch of other famous athletes and musicians.

"That was a good day."

"𝗜 𝗳𝗮𝗹𝗹 𝗼𝗳𝘁𝗲𝗻. 𝗪𝗵𝗮𝘁 𝗱𝗼 𝗜 𝗱𝗼?"

Bottom line: You can make your balance better, and have less falls (and have less fear of falling). But it takes a lot of work, because of course it does. And, don't work on the wrong thing. OK, New Bottom Line: It's hard work, and a fundamental mistake (BOOMER JOKE ALERT) may trip you up. 

Is it a balance problem?

The outside world sees the cause for unsteady walking as a balance problem. If somebody falls they go to therapy for balance training, because they lost their balance. 

But, you may say, I don't have bad balance. I know what upright is, but my muscles won't fire when I tell them to, so I fall! It's a muscle problem, not a balance problem. If that's the way you look at it, you're not wrong.

I'm going to say something pretty radical here, so make sure you check with the appropriate healthcare worker before buying into this... 

You may not have a balance problem. 

Balance problems come form a loss or deficit of one or more of the following:

1. Proprioception: the ability to imagine where your body is in space without looking at it. 
2. Eyesight: the ability to find "true north" and/or where the horizon is.
3. Vestibular sense:  the ability to sense movement, and know where your head and body are in space. When the vestibular system is not working it's the classic inner ear problem:  Meniere's disease, dizziness, vertigo.

Proprioception, Eyesight, Vestibular sense. Let's just call them: PEV

It's only a balance problem if you have a problem with one or more of PEV.

And a lot of survivors have problems with PEV, no doubt. But lets say you're a survivor that does not have these problems, why do clinicians and everybody else say you have balance problems? Because: From the outside it looks like you have poor balance. And you do lose your balance. So how is that not balance problem? In any case, you might say: Who cares what the cause is? Even if there's another cause, its a distinction without a difference. I'm still a fall risk.

It's important to know what is causing the "balance problems" because you don't want to bark up the wrong tree. And, it is true, there may be multiple trees. What's another tree? Muscles.

You may have fine PEV (unless you drink a lot, it which case you need another kind of rehab:) So its something else: Muscles. Maybe you know damned well where you are and what you need to do to retain your balance. But the stroke stops you from moving your muscles correctly to "catch" yourself. 

But again, so what? Well, here's the thing. PEV stuff has a "neoplastic model"—a way of changing the brain to lesson or fix the problem. And if you have problems with them, then focus on PEV.

But if you don't have balance problems related to PEV, but have muscles that won't cooperate, then the best recovery option is repetitive practice. 

I've been in stroke-specific research for a long time. And one of my fav quotes in clinical research is also one of the most obvious and most hilarious: Task-specific gait training improves gait post-stroke. (EBRSR)

Walking makes walking better. Hmmmm. Whoda thunk?

But what if you can't practice walking because you're afraid you'll fall? Here's some ideas (ASK A QUALIFIED HEALTHCARE WORKER ABOUT THESE SUGGESTIONS!)

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 $350 or so. These are essential not only as a pre-ambulation device, but also because they develop cardiovascular and muscular strength. The thing is, fatigue leads to falls. And if your walking has been compromised by stroke, walking takes twice as much muscular and cardio strength as it takes someone who walks "normally."  "banking" both muscle and cardio strength 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 dependent treadmill training) has shown stellar efficacy in increasing speed of gait. And speed is good. The usual suspect in this category is the LiteGait. 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.

One last important note:

Falls very often happen in four situations:

• Starting walking

• Stopping walking

• Turning

• Uneven surfaces

So if you find yourself in one of those four situations (and it may happen hundreds of times a day) stop, consider, and then go.