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.