Wednesday, December 16, 2009

Pusher Syndrome

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...

Tuesday, November 10, 2009

2 welcome mentions...

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!


Friday, October 30, 2009

A Rare non-stroke recovery entry: Hand washing

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!

Thursday, October 8, 2009

Stroke Recovery and Rehabilitation: A Head Game.

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.


Wednesday, September 9, 2009

Rewiring Around Dysphasia

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.

Tuesday, September 1, 2009


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.

Wednesday, August 26, 2009

See me Heal me Touch me Feel me

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.

Tuesday, August 11, 2009

The National Stroke Association endorses Stronger After Stroke

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.

Monday, July 27, 2009

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

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.

Thursday, July 9, 2009

An appreciated review

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. 

Tuesday, June 30, 2009

Neuroplastification RAWK

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.

                    Click on image for video.

Tuesday, June 2, 2009

Better late than never yay!

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!


Wednesday, May 20, 2009

Hard Work = Recovery.

The shift in rehabilitation has been 180° in about 15 years. Prior to the prospective payment system (~1998), therapists were able 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.


Friday, May 15, 2009

So My Scurrying May Help Mankind

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.


Sunday, May 3, 2009

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

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.

Tuesday, April 28, 2009

"Functional" ≠ Stroke Recovery

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? 

Thursday, April 23, 2009

Puts Things In Perspective, Don't It?

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

Click here to see what she does with half a brain.: 

Wednesday, April 22, 2009

Stroke Recovery. Wired.

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.


Monday, April 20, 2009

Jim Thorpe. The World's Smartest Man?

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.

Friday, April 17, 2009

The Forgotten Leg

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.

Saturday, April 11, 2009

Two Great Tastes

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!

Sunday, March 29, 2009

Another Coward With A Gun

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.

Sunday, March 15, 2009



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, to 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 really?)


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.


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.


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.


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.

Wednesday, March 11, 2009

Radio Interview

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...


Sunday, March 8, 2009

Stroke Struck. Rock Roll.

"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."

Wednesday, March 4, 2009

I'm jus' sayin'

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.

Tuesday, February 24, 2009

Little = Lots

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.

Friday, February 20, 2009

The body after stroke. Working in mysterious ways.

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.

Thursday, February 12, 2009

How stroke survivors can be so wrong it hurts them.

“A pessimist is one who makes difficulties of his opportunities and an optimist is one who makes opportunities of his difficulties.”

~Harry Truman

In my job I do a lot of outcome measures (tests) of stroke survivors . I test the movement of arms and I test legs and I test spasticity and I test reflexes and on and on. I almost always end up having the same conversation with stroke survivors.

  • Survivor: “I can’t move my arm. It’s paralyzed" While they this they usually bring their arm across the chest.
  • Me: “You’re moving it right now” 
  • Survivor: “I guess, but its useless”
  • Me: "Can you move your hand?" “NO, not at all." (I ask these questions to get a ballpark of where they are in their recovery. These are just preliminary questions before I launch into the full battery of tests--which can take hours.)
And on the conversation goes...
  • Me: I’ve learned not to trust stroke survivors on the "Can you move your hand" one.
  • Stroke survivor: "Even Dr. – (A prominent local doctor) said I can’t move my hand! "
  • Me: "What do doctors know?" (I JOKE.) I take their hand and open it. They usually have some spasticity but I'm usually able to open it pretty fully.
  • Me: Squeeze my hand.

Their fingers came into a fist.

I’ll tell you why they think they have no movement; therapists and doctors tell stroke survivors they no FUNCTIONAL movement. Unfortunately what they hear is that they have no movement that would do any good, so they didn’t bother using the movement
they have.

This leads to further loss of cortical (brain) representation of the muscles involved. Active movement is lost and, probably, passively will eventually be lost. On the other hand, if therapists had left
stroke survivor with the following, they would have been a lot better off:

“You have great movement. You are lucky because many survivors are flaccid. They are so weak that the muscles that hold the shoulder in place can’t even do that... so they have a permanently dislocated shoulder. So you are in good shape—something is going on and when something is going on you can build on that. But from here on out, you have a responsibility to the bad-side arm, hand and leg. If you are willing to work very hard you can get more movement out of the arm and leg. The more you use whatever movement you have, the more movement you will gain. You’ll gain muscle. You’ll force more of your brain to control that side and you will get more movement. This will require a lot of work including many repetitions on 'the edge of your ability'--where movement is the hardest. But you will make gains."

So you can continue to believe that you can’t do anything with the arm and this will happen: The amount of brain dedicated to that arm will be lost. The muscle thickness in that arm will be lost. The muscle strength will be lost. The muscle length and the PROM will be lost. Eventually the limb will be turned into an “appendix limb” with no use other than aesthetics. “I might as well cut off this arm. It just gets in the way.”

Or you can believe that your arm will get better and you’ll work with it. If you do this, the following will happen: The amount of brain dedicated to that arm will increase. Spasticity will decline. The muscle thickness in that arm will increase. The muscle strength will increase. The muscle length and the passive movement will increase. It will probably never get as good as it once was, but it will, to some degree, recover.

Tuesday, February 3, 2009

Splain' the Brain: 4 Brain Books That Rawk.

I've read a ton on the brain. I read articles and blogs and books. Some of what I've read are downright unreadable; either poorly written or so detailed, science-y and specific that there were no real practical applications. And that's what I'm looking for: practical applications. I either want the book to be a tool I can use to help stroke survivors, or a tool I can use for myself.

Hey, my brain can use some work as well...

There are four books I've read recently and while all of them have we redeeming qualities, I like some more than others.

The first book of my list is Jeffrey Schwartz's book
"The Mind and the Brain: Neuroplasticity and the Power of Mental Force".

The whole book is really good, but the part on stroke recovery is brilliant. This book provides the historical back story for stroke recovery. Every stroke survivor and clinician working with stroke survivors, should read these chapters. It makes you feel in your bones what recovery is made of.


The second book I like is called
Synaptic Self: How Our Brains Become Who We Are, by Joseph E. LeDoux. This book is a relatively easy read and helps one understand the importance-- not of neurons (nerve cells)-- but of the connections between neurons (synapses). It's a hopeful book because these connections have a vast potential for growth. Generally speaking the number of neurons will not grow, but the connections between neurons can. Developing new connections is the essence of stroke recovery, and learning. Brilliant.


The third book that's interesting is The Brain That Changes Itself: Stories of Personal Triumph from the Frontiers of Brain Science, by Norman Doidge. It's a fine book, but I find much of the historical perspective of stroke recovery the same as Jeffrey Schwartz's book, which was written three or four years earlier.


The book I'm reading right now is called The Body Has a Mind of Its Own: How Body Maps in Your Brain Help You Do (Almost) Everything Better by Sandra Blakeslee and Matthew Blakeslee. The jury is still out on this one. It has some interesting tidbits scattered throughout. Not much of it is specifically related to stroke recovery, but it does have interesting comments about mirror therapy and mental imagery in stroke recovery.

I'm a big fan of mirror therapy as a potential aid. There is a whole chapter on it in my book. In terms of mental practice or imagery, our lab has done ( and continues to do) many studies in this area. If you're interested in our work on mental practice as related to stroke recovery, here is an example.

Wednesday, January 28, 2009

Young Stroke Survivors: Unique Ambitions Drive recovery.

Young stroke survivors are interesting to those of us in stroke-specific rehabilitation research because there is so much raw material and raw potential. Many younger stroke survivors have the effects of the stroke as the only problem they have. They are often not on meds, they have tons of energy, and they are not willing to give up the balance of their life.

Here is the gist:
Stroke in adulthood: A normal architecture, altered. Imagine building a new house. You build a good foundation, a solid frame, a strong roof, etc. You put in the plumbing, electrical, and walls. Your new house is done. Then one day you have an accident! You back your car into the corner of the house. That part of the house needs to be fixed. The foundation is still there, the solid frame still exist in most of the house, the roof is still good; plumbing, wiring, everything is still good. You only need to fix that one room.
•    A stroke in adulthood affects a normally developed brain. The size and location of the stroke determines what skills are lost.
•    Stroke in childhood: An altered architecture. Now imagine you neighbor builds a house, but he’s not a very good builder. The foundation is uneven and the frame is crooked. Everything that is built around the foundation and frame is affected by the poor basic architecture of the building. To “fix” the house would require starting from scratch.
•    A stroke in childhood affects how the brain develops. The brain in childhood is a blank slate. Neurons (nerve cells in the brain) haven’t “decided what they want to be when they grow up,” and whatever is imprinted on that blank slate affects the way the brain develops. Children have an immense amount of brain plasticity available to them. After stroke, children often do amazing things, given the amount of brain injury they have. There are classic examples of children who have a complete hemisphere (half of their brain) destroyed by stroke. In an adult, such a stroke would institutionalize the person for the rest of his or her life, but some children survive and thrive with half a brain. They are able to learn to read, write, have a sense of humor, be productive, and enjoy life. So it is unfair to describe the brain after a childhood stroke as having “poor architecture.” In fact, it could be considered “excellent architecture” given the amount of brain damage they have.

The impact of stroke before the brain is fully developed is much different than the impact of stroke after the brain is fully developed. The process of recovery in the two is very different, as well. In fact, it is only in the adult brain that is truly “recovery.” In childhood stroke becomes a part of development.

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