Pete On a Podcast

I was interviewed on the Strokecast podcast by Super Survivor Bill Monroe. 

We talked about stroke recovery while touching on everything from Malcolm Gladwell, to the power of revenge.

Get better movement without moving a muscle

Let me come straight to the point: There  are three ways to drive changes in your brain to help you move better. All three effect very similar parts of the brain. And here is something that warms my lazy heart: Two of them you don't have to move a muscle!

The image above is from researchers Robert M Hardwick, Svenja Caspers, Simon B Eickhoff, and Stephan P Swinnen. (Reference)

What moves your body? It always starts with the brain!

We all know that muscles move us. But the brain moves muscles. This  idea is lost on a lot of clinicians in rehab. They'll talk about muscle strength, range of motion, quality of movement, etc. etc. etc., but not talk about the brain. Why don't they talk about it? They can't see it. They can't measure it. And really, they can't help it. 

How do you get the brain to change to move better?

There's a bunch of ways to get the brain to rewire for better movement. 

1: Move. This is called repetitive practice. "We are we repeatedly do. Excellence, then, is not an act but a habit.” (Will Durant, paraphrasing Aristotle). The more you do a movement repetitively, the more the part of the brain that controls that movement is activated.* Note: No one else can do if for you, it has to be you doing the work. Musicians know it, athletes know it, dancers know it, martial artists know it, and now you know! More info here. 

2: Imagine a movement. This is called mental imagery, or mental practice. If you imagine doing a movement the way you did it prior to your brain injury, the part of the brain that controls that movement is activated.* More info here. 

3: Watch someone else do the movement. This is called action observation. If you watch someone do a movement, the part of the brain that you use to do that movement is activated.* Find instructions here. 

About this image:

This three-pane image above shows the parts of the brain activated during movement, action observation, and mental practice. 

There are differences. For instance, in action observation the part of the brain that is used for vision is activated because the observer is seeing someone else do the movement. But overall, there is a lot of overlay between the three activities!

*Using all three of these techniques will activate movement centers in the brain. If they are activated enough, that part of the brain gets bigger. How much is enough? I'll argue at least 1200 repetitions in a single-joint movement. All three also add more blood vessels, and more connections in the brain. 

tPA: 𝙎𝙩𝙞𝙡𝙡 Not Used Enough

I'm reading the book tPA for Stroke: The Story of a Controversial Drug* about the clot busting drug that's used in "block" (ischemic) strokes. It was published in 2011. Is TPA still controversial? For some reason, yes.

Interesting facts about TPA

•A study by the American Heart Association looked at data from 300,000+ ischemic stroke patients, TPA was administered to 3.3% of patients. 

⇒2.2% of patients at regular hospitals got tPA

⇒6.7% at hospitals with Primary Stroke Center Certification. 

⇒Survivors are three times more likely to get tPA if at a certified stroke center.

·     •In 2019 the journal Stroke did a review of malpractice suits relating to treatment of stroke in hospitals

⇒Almost 30% of the cases were failure to treat with tPA.

⇒The average payout for pre-trail settlements was $1.8m. The average payout for court verdicts was almost $10m.

·      •A 2020 article in the Journal of the American Academy of Neurology found “Overall, about one-quarter of eligible patients with AIS (‘block stroke’) presenting within 2 hours of stroke onset failed to receive tPA treatment.”

⇒The article points out that women and minorities are undertreated with tPA because of course they are.

·   •Speaking of women: Another 2020 article in the Journal of the American Academy of Neurology found…

⇒Compared to men, women were 30% less likely get tPA.

⇒Sidenote: Women are also less likely to receive aggressive treatment when it comes to heart attack. (link)

·     •Weird Science: tPA is never safe for hemorrhagic strokes. Except sometimes.

           ⇒There are multiple studies (1, 2, 3) showing that tPA can be used to increase longevity, decrease incrainial pressure (pressure on the brain inside the skull), and reduce injury to neurons from hydrocephaly (brain swelling). Note: t-PA in "bleed" stroke shows efficacy in ongoing clinical trials, not yet in clinical practice. The data we're waiting on is from the CLEAR III trial. 

   •Can tPA be given for a second stroke? Yes! About 25% of survivors will have a second stroke. So its important to know two things: 

⇒You should know the FAST test. Better yet, know my better version of the test.

⇒tPA is safe and just as effective for a second stroke. Or, if you want it more science-y: "Repeated use of IV-tPA was not associated with an increased risk of intracerebral hemorrhage or death in patients with recurrent acute ischemic stroke."

*The author, Justin Allen Zivin, MD, Ph.D., passed away in 2018 at age 71. He dedicated his career to identifying treatments for stroke, specifically the use of tissue plasminogen activator, or tPA... He encouraged the National Institute of Neurological Disorders and Stroke to change the paradigm for clinical stroke research, organizing a study that required a complete rethinking of how stroke care is managed.

F$#^R& The Plateau!

Three quick suggestions to continue breaking though plateaus: 

Change things up. Do not fall into what athletes call habituation; doing the same thing and expecting better movement. Work (within sane limits of safety) beyond your ability. In other words, the same old will get you more of the same old movement. New, done correctly, will get you new movement.

Let an athletic trainer help you be a better athlete. Explore the option of working with an athletic trainer (AT). (Note: In the USA an AT is a Masters degree. They understand what a stroke is, and safety concerns). The AT may help unleash your inner athlete. Therapists sometimes focus on reducing deficits. They have to: They're trying to get you safe, "functional," and back home. ATs tend to focus on better movement, and will look at survivors the way they look at any athlete. To them, you'll just be another athlete. A "low level athlete playing a higher stakes game."

If you don't work out, plan on weakness. Never underestimate the value of the hard work you are doing in the gym (home gym, place where you exercise/ meditate/ stretch, etc.). Survivors take twice as much energy as aged-matched couch potatoes to do every movement (i.e. dressing, walking bathing). So survivors need “banked” energy to live their life. On top of that, survivors need even more energy to do the hard work of recovery. 

SPACE TO RECOVER—THE HOME GYM

(Note: Having a place to work out at home is essential when COVID-19 makes it hard to attend therapy. Here is a free chapter from my book Stronger After Stroke that offers suggestion for an at-home stroke recovery gym.)

My kids in our home gym

Clearly, it’s easier to study at the library, do paperwork at your desk, and cook in the kitchen. Every stroke survivor also needs a space within his or her home dedicated to recovery. It should be a space where you can focus on recovering from your stroke. Like a library, it should only have the distractions you want; like a desk, it should be organized; like a kitchen, it should have all the recovery tools you need. Some stroke survivors prefer to pursue at least some of their recovery effort in a community gym. Even if one joins a community gym (see the section Space to Focus—The Community Gym, later in this chapter), there are great reasons for having a home gym as well. 

How Is It Done? 

Your home gym can be a basement, an extra bedroom, or a corner of a room. It does not have to be big and does not have to have any more equipment than you need.

It should have what is necessary to facilitate recovery. This may include exercise equipment, a TV, VCR, DVD player, a stereo, and inspirational art. Build your gym as a place of sanctuary and a place of work. Ideas for equipment include: 

Seven buck at Goodwill!

A treadmill 

A recumbent cycle 

An upper body ergometer (hand cycle) 

An exercise mat 

something used to maintain balance (sturdy chair, etc.) 

Weights 

Resistance bands 

Electrical stimulation devices 

Balls, decks of cards, or other “toys” 

A mirror

This list can be as long or as short as it needs to be. A small amount of simple equipment that is well thought out and well used is better than a lot of expensive equipment left in a corner. Doctors and therapists can help compile a list of needed equipment. 

What Precautions Should Be Taken? 

Be prudent when assembling the gym and think safety first. Any exercise or therapy equipment has inherent dangers. For instance, a treadmill provides a moving surface that may be inappropriate for some stroke survivors. Even something as simple as a ball can facilitate a loss of balance that can cause a fall. Consider installing grab-bars for any balance exercises you do. Make sure the floor is nonslip given the footwear you expect to use. Doctors will tell you if an exercise or therapy is safe, and therapists will explain how to do the exercise or therapy in the most effective way possible.