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.

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