Dammit Jim I'm a Doctor

Four or five years ago I created a PowerPoint slide for a series of talks that my colleague and noted stroke recovery researcher Stephen J. Page do. It was sort of a joke slide; above is a copy of it. The idea was that at some point in the distant future Dr. "Bones" McCoy would have a machine that you simply point at a stroke survivors brain that makes the boo boo go bye-bye. Of course it was a joke ha ha.

A few months ago we got a transcranial magnetic stimulation (TMS) machine that has a special aiming feature on it. You play it like a video game. First MRI data is fed into the TMS machine. This allows for whoever is doing the treatment to see the person's brain as they "zap" it with electromagnetism. The treatments are being done by a couple of our lab's physical therapists. When the stroke survivors brain is "zapped" the the muscle that corresponds to that part of the brain, the part of the brain they are targeting, twitches.

The B1XGX: Stroke Eliminator. Not such a joke anymore.

The Secret to Recovery. Period.

I think I've found the answer to recovery from stroke. Honestly. Call the Nobel committee. The answer may be in the first Q&A in an article I wrote with the help of John Farrell of Saebo. And realize, you don't need any equipment to do this, Saebo or otherwise. If you have any questions, email me 'cause it gets a bit complicated. Intuitive, but complicated.

Survivor Must Haves

There are two publications, both free, that provide information that may be essential to recovery. If you are really on the ball regarding emerging recovery technologies, then these may be a bit low-level. But even if you do a good job of figuring out what's new in the stroke recovery game, these two magazines will still be helpful.

Stroke Smart and Stroke Connection. Great articles (usually of the feel-good variety), research updates (in easily read format) and advertisements. And its the ads that I read it for because some of the technologies that our lab tests, as well as others form smaller manufacturers are in these mags. Basically, SS and SC are quick and easy ways to keep on top of whats goin' down. Order them on line or call them.

Stroke Smart 800-787-6537
Stroke Connection 1-888-478-7653

Wine and Movement.

Motor. Motor. Motor. That's all you ever hear about when it comes to stroke recovery. In rehabilitation research we tend to obsess over movement. Movement quality, movement speed, and how movement effects function. Of course movement is only half the equation. The other half is the feeling of movement. Now-- I know, you're thinking, "Oooh, he's going to get all squishy with the feelings..." Nope. The feeling of a movement is an essential to learning how to move. If you cannot feel the movement, every time you do the movement, it's like the first time. Lack of feeling the eliminates an essential part of the motor learning feedback loop. I did a talk recently to therapists and between spiels a therapist came up and told me that, like me, she thought that the feeling of movement (called proprioception) could be re-taught after stroke. And she put it in a very interesting way. She said it's like learning to appreciate fine wine; at first you can't tell table wine from a 1939 Château-whatever. But over time, as your palate develops, you learn to taste subtle differences. Bottom line: proprioception can be re-taught.

Chicks dig smart...

I am currently reading the Cambridge handbook of expertise and expert performance. I do this all the time; I buy really fat books (this one has almost 900 pages) mostly to impress my wife. Then I find myself drawn into them bit by bit. It turns out that this book has quite a bit of information that relates to stroke recovery.

I do a lot of seminars talking to therapists about stroke recovery. I generally push neuroplasticity (“brain rewiring”) as the foundation for all recovery from stroke. And the easiest way to rewire the brain is to do repetition of whatever movement the stroke survivor is trying to recover. The therapists, curious lot that they are, always ask, “How many repetitions of the movement have to happen before the brain rewires?” The problem is that this question cannot be answered with a-one-number-fits-all answer. The number of repetitions needed depends on how much movement there is to begin with, how focused the stroke survivor is in the practice, how complicated the movement is, etc. etc. The very fat book I'm reading says that there is general agreement that to become an expert in anything takes 10 years. We also know that to become a very high-level athlete, musician, or acquire a skill like carpet weaving takes more than 1 million repetitions of the movement(s).

So the question I have is, when does recovery end? After 1 million repetitions? After 10 years? If either of these is in the right ballpark, another question follows, “Why are stroke survivors discharged from therapies within a year or so of their stroke?”

Yay!

Stronger After Stroke is one of the highest ranking books on stroke rehabilitation or stroke recovery. Luminaries such as Janet Carr (who I have a post about, further down) and Joel Stein, MD (a well known stroke recovery expert/physiatrist) have books out that are ranked a bit lower than Stronger. Jill Bolt-Taylor (A Stroke of Insight) is going to be on Oprah today. My book shows up on the same page as hers on web sites, so I fully expect to be able to buy a boat before the day is through.

Check out the screenshot for rankings.


And here's a photo of my new boat...


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The Splint That Bounces Back

The wrists and hands of stroke survivors are always a challenge. In human beings the powerful muscles that close the hand and bend the fingers are essential for everything from climbing to carrying to to pulling.But after stroke, just like many of the muscles on the affected side, these large wrist and finger bending muscles get spastic. And when they do they overpower the much smaller muscles that extend the wrist and fingers.

    After stroke the fingers and wrist are flexed almost all the time and these muscles shorten and the wrist and fingers become even harder to straighten.
   The way occupational therapy has traditionally dealt with this problem is to splint the wrist and fingers. Occupational therapists (OT's) use a material called thermoplastic which is shaped into what is considered a good position for the wrist and fingers.

   But there's a problem with these splints. First of all, the splint is only as good as the OT's skill. Second these are static/rigid splints; that is, if the fingers get more flexible these rigid splints don't take advantage of these gains. Conversely if range of motion is lost and the fingers get tighter the splint does not reflect that change either. This can be damaging to the tissue around the fingers and wrist as the hand is forced into a rigid splint that's too "small".

   You could hire an OT every few months to fabricate a new splint, but that gets costly. I'm actually a big fan of a product called the SaeboStretch. This split is not static. It moves as your hand moves. If you want to bend your fingers, you can. This splint is made out of material that is flexible but elastic. That is, it can be bent but it always wants to return to its original position. This provides low-load pressure into the proper position. In this way this splint takes advantage of any increased elasticity in muscles and other soft tissue. I've had experts on splinting tell me point-blank that this is the only off-the-shelf splint that they'll recommend.

You can find information on the splint here.

A Good Excuse to Watch Football

When I worked at the Kessler Institute, a big rehab hospital in New Jersey, I worked with exercise physiologist Quin Bond. He changed my perspective about stroke recovery. The way athletic trainers and exercise physiologists look at stroke recovery is different from the way therapists typically view it. Therapists generally view recovery from stroke as a finite proposition. There is a beginning and an end. Most of scientific medicine views stroke recovery the same: finite. Exercise physiologists tend to see stroke recovery is infinite. Athletic trainers, the same. If you're used to working with athletes you're used to people who see progress is infinite. Athletes are always trying to make themselves better at their sport, stronger and faster. There is no difference between athletes and stroke survivors. Stroke survivor simply lower-level athletes playing higher stakes game. There's very little that works with athletes that doesn't work with stroke survivors. Every fundamental concept in athletic training can be superimposed on stroke recovery. Again, lower-level, but the same basic concepts hold true. Training concepts that athletes use can be used to recover from stroke. Basic concepts such as multiple hours (massed) practice, weight training, cardiovascular training, pushing the limits of ability and cross training, etc. all work superimposed on stroke recovery. The bottom line is that stroke survivors should see athletes as inspirational figures.

The photo is of Steve Prefontaine who exemplified the pursuit of the infinite.

Stroke recovery: A Leap Of Faith

I wrote this article recently. I describe Stroke recovery as a leap of faith, not unlike other leaps of faith we constantly take. Here are some highlights...

• I talked to a stroke group the other day. They were about 30 strong, and they were feisty. I do talks all over the country on the state of stroke recovery research. I have spoken to audiences that have included therapists, doctors and researchers. But nothing is quite like staring down the barrel of a group of stroke survivors. They've lived through stroke and have, to whatever degree, experienced the loss of control that defines brain damage. Each person who survives stroke is dealt a unique "hand of loss" causing the dispossession of everything from language to limbs, from emotions to personal independence. Stroke survivors have literally been there and back. They can be a bit prickly when someone suggests that they need to work harder. And that's just what I was suggesting.
• Much of what I believe helps a stroke survivor recover involves a leap of faith. I believe that massed practice works. Massed practice involves literally massing hours of practice together. I believe repetitive practice works. Repetitive practice involves doing the same movement, repeatedly, until long after sanity screams to stop.
• I believe that there is no way to recover unless the stroke survivor stays aware of new developments for stroke recovery as they emerge. I think stroke survivors need to have a strong cardiovascular and muscular foundation in order to have the energy to do all the other things necessary to recover to the highest level of potential. In short, I believe that stroke recovery is best served if efforts toward recovery are treated like a full-time job

Convincing the Experts

• When I speak to therapists about this emerging research-based paradigm shift, there is some push back. Therapists give me a sideways look and let me know that I'm whistling a bit of Dixie if I think that most stroke survivors are going to be willing to carry out a complicated and labor-intensive plan.
• Stroke survivors are more blunt. "Six hours a day of practice! I have better things to do, thanks!" They also ask questions that require absolute answers. "If I do put in the time and effort, what return can I expect?" they demand. "What about the repetitive practice? How many times do I have to repeat a movement before my brain rewires enough to do the movement right?"
• I've learned to be direct when answering. I tell them, "There are no guarantees. You could work very hard and get very little return. No one knows how many repetitions are needed. Some people think the magic number is 10,000. Others think it's closer to 150,000. Some researchers suggest a million or two. But even if we knew the 'optimal' number, the fact is that the number of repetitions needed is different for every survivor because of any number of variables." Well, to stroke survivors, this is the cherry on top of a mud pie, let me tell you. But I have an ace up my sleeve—and that ace is a mirror.
• I asked the members of the group what they did before their stroke. One gent had been a lawyer. Another was a farmer. And I have just spent three years writing a book. The three of us were a collective of experts in leaps of faith.
• I suggested to them that the monumental challenge of law school followed by the bar review then the bar exam (a three-day, six-hours-per-day exam) were several leaps of faith. Betting the farm on the mysterious and unpredictable miracle of life, year-in and year-out, through flood and draught, is the farmer's perpetual leap of faith. And what of the three years spent writing a book distilling the very message I was now telling them? This may have been the ultimate folly. I am guaranteed of selling only five copies—all of them to my mom."

Falls. Only funny in the movies.

There are few luminaries in the stroke recovery game that I really respect. Few bring anything new and most just add to an expanding din of quasi-misinformation. Two that I do respect are Carr and Shepard. These two Aussie therapists are vanguards of the paradigm shift that stroke recovery theory is now in. They have a book called Stroke Rehabilitation (go figure) that has some gems in it. One of those gems is about what causes falls after stroke. I hate falls. Heck, I’ve broken bones falling. For stroke survivors, falls can be the beginning of the end. There is a statistic that has always resonated with me: If someone is 65+ and they have a fall that lands them in hospital for at least one night they have a 50% chance of dying in the next year! And up to that 70 % of patients have a fall in the six months after their stroke.

So what do Carr and Shepard say about falling? Falls very often happen in four situations:

• Starting walking

• Stopping walking

• Turning

• Uneven surfaces

Posterior Pusher Syndrome (or) posterior pelvic tilting

Here are links to articles that provide ideas that may help with pelvic tilt problems.

Image is also clickable.

The core stabilization exercise consisted of three subparts, bed exercises, wedge exercises, and ball exercises using a Swiss ball. First, the bed exercises without devices consisted of bridge exercise, bridge exercise with legs crossed, bridge exercise with one leg, curl-ups with straight reaching, curl-ups with diagonal reaching, bird dog exercise, and side bridge exercise. Second, the wedge exercises consisted of curl-ups with straight reaching, curl-ups with diagonal reaching, and curl-ups with arms crossed. Finally, the ball exercises consisted of bridge exercise, bridge exercise to the side, bridge- ups, abdominal curl-ups, bird dog exercise, and push-ups.

Set up a consultation with Pete here

Reviews...

The consultation is personalized and organized. You'd probably get a lot of the material in Pete's book, but it's hard to read the whole book and know what's applicable to you. Pete takes the time to listen and find out what's important to you and tailors his consultation to you. Another thing I like about the consultation is that Pete is accessible afterwards. He always responded to my emails, and in a timely manner.

LQ, New Jersey

After my 28 year old son suffered an anoxic brain injury, we  had a very helpful consultation with Mr. Levine, which I highly recommend for personalized evaluation and treatment ideas.  It was done by video chat and he was incredibly thorough and offered many plans and suggestions. He is an amazing advocate and resource for those who have suffered a stroke, as well as their caregivers. Frankly, I think he is brilliant, a true healer combining science with compassion and encouragement. The consultation was an opportunity to get direct input tailored to my son’s situation. I especially appreciated the summary you sent afterwards.

RM, Connecticut

Our favorite aspect of the consultation was being able to benefit from Peter's rare combination of kindness and expertise while being miles away. Thanks to technology, it almost felt like we were physically in the same room with Peter. And it helped a lot that he kindly looked at material (emailed video) beforehand-- he was already knowledgeable to make the most of our consultation. Throughout our interactions, Peter was extremely amiable and willing to help. His empathetic approach was heartening for our survivor relative, and for everyone as a family. And his advice gave us hope that more can be done to take our patient to the best place she can go as her recovery progresses. Moreover, Peter's consultation report was thorough and full of actionable items---big and small---which we are enthusiastically implementing. Overall, Peter gave us the gift of his expertise, with patience, care, and kindness. We could not be more thankful.

JU, Mexico City

I felt it was so individualized to my Dad. I felt he really took the time to learn how my Dad was moving after his stroke.  I liked the convenience of Dad not having to leave his home for the consult.  I felt I was getting current expert research based advice.  I really appreciated that the consult was so thorough and with many helpful suggestions.  Also,  all my questions after the consult were responded to in a timely manner.  I felt Pete was really interested in how my Dad was recovering even though he never met him in person.  I really feel Pete is trying to improve the lives of stroke patients!

MF, New Jersey

How to set up a consultation	1. Email: StrongerAfterStroke@yahoo.com 2. Put Consultation in the subject line. 3. That's it. You'll be emailed back ASAP!
What happens and what you get	We have a video chat. Then I do the necessary research and make suggestions for recovery specific to your unique situation are made. A sort of "Your Recovery" document is emailed to you. It will have images, diagrams, and clickable links— all related to your recovery. Recovery suggestions will include recovery options that are “off the radar” to most clinicians.  Included will be suggestions about recovery of movement, but may also include suggestions for other post-stroke/ brain injury problems that we've discussed during our chat (i.e. visual problems, fatigue, cognition, etc.).  Recovery suggestions will be based on my clinical research, book, and talks.  Once the consultation is completed, follow-up questions are encouraged!
How the video observation is done	A 30 to 45 FaceTime, Zoom (preferred), Duo, or Skype video interview is done to discuss your progress so far, and your ambitions for the future.
What it costs	$250   Payment is made after the consultation is delivered.
What you should keep in mind	Suggestions are to be evaluated by the appropriate medical professional.

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Knowing all the symptoms of stroke, not just the symptoms you had, is essential for survivors and their caregivers. Why? I think this graphic says it all:

• Here's an amazing (and scary) statistic: In the five years after a stroke, women have a 1 in 4 and men almost a 1 in 2 chance of having another stroke. Know all the symptoms, not just the ones you know all too well.

Caveman Therapy

I’ve long believed that the amount of recovery after stroke is directly related to the amount of challenge. The more challenge, the more recovery. If you take yourself out of your “safety zone” that zone naturally expands. This happens no matter the endeavor. From stretching yourself as an artist or learning a new language, challenge = betterment (or at least the chance of betterment). Stroke survivors tend to decrease rather than increase the challenge. By using a growing number of assistive devices and energy saving strategies their safety zone contacts. I have this theory that when people had stroke in the distant past, they would actually recover more. This is from an Advance for PT/As article I wrote in 2006:

“It would be hard for our world to be a safer and easier place for survivors of stroke. And that just may be bad news. If a prehistoric tribe had decided to aid in the recovery of the stroke survivor, the "therapy" would have been ferocious by today's standards. The vise grip created between the survival of the tribe and the needs of the individual would have necessitated early rehabilitative intervention centering on mobility. For obvious reasons, the ability to walk in a hunter-gatherer tribe would have been of paramount significance to the individual and the tribe. Stroke survivors had to learn to feed themselves or starve, toilet or suffer bacterial disease, and ambulate or get left behind. Their "forced-use therapy," "gait training," and "ADL training," as well as the amount of energy they put into rehabilitation was dictated by one thing: survival." (Vol. 16 •Issue 9 • Page 35)

But I missed a key point: The flip-side of the equation is what the stroke survivor would say to the tribe. “Ugh-UG-Uh. Umph-duffKAAAAHH!”, which loosely translated means, “Get the hell out of my way because I know damned well what the stakes are!”

Relax and Recover?

This is a great study. It basically says that if a joint is moved passively (someone else moves it or you move it with your "good" hand) there will be neuroplastic (brain rewiring) change. This has big implications for folks who are low level and need to start moving. After there is enough brain rewiring, you may be able to rewire enough to begin moving the joint under its won power. This gives some credence to passive movement that therapists have been doing for decades, but has never been proven effective.

Hemi Man. One Bad Dude.

Here's an article I wrote recently for Advance for Directors in Rehabilitation. They added a really cool graphic. I call Him "Hemi Man".

I basically say that they way rehabilitation is delivered to stroke survivors is a problem before it even starts. It turns out that you need waaaay more practice to recover from stroke than payers are willing to bankroll and clinics are able to provide. Check it out.

Do We Really Use Only 10% Of Our Brains?

For decades "they" have been trying to sell us that we only use 10% of our brain. They were saying this before we could take pictures of the brain working, with MRI. So even if they were right we wouldn't know. Now we can see what parts of the brain are used. Turns out, "they" were wrong. We use 100%. This is important for stroke survivors because rewiring the brain after stroke asks more from your brain. And after stroke there is less brain to work with.

Here's a link to an article I wrote for StrokeSmart magazine about the 10% brain myth.

Ten rules for successful rehab for patients with stroke.

I wrote this in 2005 but it's still a good thumbnail sketch of how to get closer to the highest possible level of recovery. It's written for theapists, and so, written in 'therapist speak'.

Small Study. Small Recovery Gains. Big Message.

This is a small study that I was involved in. We used the NeuroMove to get stroke survivors who have no movement in the wrist, to have some wrist extension. This is really important because a little movement can be used to jumpstart much bigger movements. The important line is "However, both groups showed a 21 degree increase in active affected wrist extension after (NeuroMove) use."