Q and A.

My focus on stroke recovery has been near myopic for the last decade. I do professional talks and seminars, write general and coauthor journal articles about the subject. And there is also this blog. As you can imagine, all this writing attracts questions. I get questions from stroke survivors, caregivers and therapists. Many of the questions are heartbreaking but all of them are thought provoking. And I put a lot of effort into the answers.

Here are some examples...

The following question was from a 70-year-old M.D.

Q: I read with interest your wonderful work about spasticity and stroke. I suffered a stroke with left hemiplegia and spasticity about two years ago. I can walk slowly with a crane but I’m not very stable. Most annoying, however, is the spasticity in my elbow, wrist and fingers which is constantly flexed. The flexion increases during walking. I have weak dorsiflexion and severe plantarflexion of the big toe causing a shuffling gait. I am two years post; do you think there can be any improvement in gait and spasticity?

A: Thank you for the kind words about my work. Spasticity can only be reduced by reestablishing cortical control over the spastic muscles. Cortical control is reestablished through repetitive movement of the limbs. So, as much as you can move the arm, the better. Also, be careful not to let contracture set in. Because the joints of the arm are postured in the same place for a long periods of time (because of the spasticity) the cortical representation of those joints shrinks. Meanwhile, the soft tissue can also shrink. If enough soft tissue shrinkage has taken place this contracture can mean that no further gains can be made without surgery. So have an occupational or physical therapist develop a good and safe stretching program. Follow the program daily.

Also, consider electrical stimulation (ES). ES will move the joint through its range of motion--giving a good stretch. ES will also activate weak muscles, and ES has been shown to drive neuroplastic changes in the brain. Usually, once trained, you can do this at home, without a therapist. Generally the muscles that get ES are the weaker of the muscle groups (i.e. the finger/wrist extensors on the back of the arm.)

From a wife whose husband is ~ 1 year post stroke.

Q: I am always encouraging and try to be positive all the time; I ALWAYS say "WHEN you recover," never "IF you recover." Lately I wonder if I am just fooling him and me. EVERYTHING I read lately says global aphasia and apraxia have a very poor prognosis. Your book and your blog are very encouraging, but they do not address these issues very much.

A: Yes. You're right. And it is a major deficit in my book and in the generalized discussion about stroke recovery. "How do I know when I'm there?" How do we know when recovery has ended? I would start by making the argument that it's never ending. Because even if there is no further gains in terms of movement and communication, survivors still have to work hard just to tread water against the general decline of aging.

As you well know, your husband has had brain injury. I hate saying this because it seems like a cliché and a cop-out, but you have a new normal. And he has a new normal. Having said that, I wouldn't give up. I would keep going as much as you both can tolerate, but with plenty of vacations (from the struggle) and rest. You may find yourself settling into some sort of "maintenance program" as a hedge against natural effects of aging. But don't be afraid to pepper the maintenance program with new stuff as it comes into view.

And the truth be told, full recovery, as defined as fully the way the stroke survivor was prior to the stroke, almost never happens.

The following question was from a PT

Q: I just read your article “Using Gait Speed as a Marker for Progress” (advance for PT and rehab medicine, March 8, 2010). I was wondering if it is still a valid test if assistive devices are used. Thanks for sharing the information!

A: My understanding is that the validity is only without an assistive device. Look at it this way; let’s say somebody walks a given speed without an assistive device, and then walks faster with an assistive device. If you accept that gait speed is an overall health indicator, then the assistive device would somehow make them healthier. Probably not a valid assumption. Having said that, there may be some importance to increased gait velocity even with an assistive device. In other words, although a bit of an empirical leap, if, over time somebody is walking faster with a cane, that would be seen as a good thing. In clinical research the question of testing gait speed with or without the assistive device (or orthotic for that matter) always comes up. Generally, gait speed without any orthotic or assistive device as more indicative of a true baseline.

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Game Yourself Bright

Over the years I've had a lot of questions about recovery of cognitive function. And it's difficult question because it's not my area. Or is it?

My Dad. Super smart.
(I was adopted.)

The word cognitive is quite broad. According to our smart uncle Wikipedia the word cognitive refers to the brain's ability to do any of the following:

Memory, association, concept formation, language, attention, perception, action, problem solving and mental imagery.

Whether you're learning how to move better or learning mathematics or French or whatever, the processes are similar. Both involve physical change within the brain. Both happen in the 1 to 3 mm cortex of the brain, and both involve repetitive challenging practice. There is no separation between "cognitive" and "motor learning." 

But Wikipedia has it wrong, or rather, incomplete. Movement and cognition are inexorably linked. There is a term for it: Motor cognition. People say, that's impossible. Movement is what dumb jocks do. But, again, motor learning is learning, and motor cognition is cognitive. Ironically, Wikipedia has a page on motor cognition.

I have another entry where I argue that great athletes have great minds. It involves the great Jim Thorpe, so you know its good.

I think what most people are talking about when they talk about cognitive function is the ability to think clearly. What is it that they say about intelligence? It's is the ability to keep two thoughts in your head at the same time-- something like that. I think a lot of stroke survivors lament the loss of part of their ability to think. Unfortunately, many people assume that stroke survivors necessarily have lost mental capacity. But, of course, many have not. I can't tell you how many people I know that have had a stroke and they're still smarter than me. "Unfair!" I might yelp if I was petty, which I'm not. (Unfair!)

So what can one do to develop an increase in, let's call it, "intellectual capacity"? It may very well be video gaming. There are many in physical rehabilitation who love the idea of using the Wii for physical rehab. They call it Wiihabilitation, because, cute. There's actually some serious questions about whether these games actually help physical recovery. But can gaming help you remember where you put your keys? Can it help you "keep two thoughts in your head at the same time"? It turns out it can.In fact, there's a game that aims to do exactly that. It's call the N-Back. Find the actual game here. 

NOTE: Some games don't work at all. Find my take on Lumosity here. Gaming may not be the best way to boost cognition.

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Speed is Good.

The ability to get from one place to another is essential to every animal. The speed at which travel takes place is an essential to determining the success or failure of everything from food acquisition to escaping danger. Gait requires input from the brain, spinal cord, peripheral nerves, muscular power, and joint and cardiovascular health.

Because of all these systems are required to coordinate gait, gait speed is an indicator of the health of many physiological systems. In all animals, gait speed decreases with age. In humans, the speed of our mobility is predictive of so much more than if we will eat, or are eaten.

What is remarkable about testing gait speed is how much it reveals about people. Here is a laundry list.

• A decline in gait speed predicts a decline in attention
• An increase in gait speed predicts a substantial decline in mortality while a decrease in gait speed predicts an increase chance of mortality
• Gait speed correlates well with functional ability, future health status and the patient’s confidence in their balance
• Gait speed predicts where discharge will take place (home, SNF, etc.), the chance of hospitalization, an increase in medical costs, disability and mortality
• Gait speed predicts the need for rehabilitation
• Gait speed can be used to determine the effectiveness of a particular rehabilitation treatment option.
• Gait speed can be used as a surrogate for quality of gait; the faster the walking, generally speaking, the higher the quality of gait.

And much more!

Note: Walking speed is not only predictive of decline, it can also predict improvement. The faster the better.

My fav "recognize stroke symptoms" videos!

My fav is this  one from Penny Marshall (and other famous folks)...

More...

Make them walk funny and look lousy in shorts forever!

Warning: ENDING THE USE OF AN AFO CAN LEAD TO FALLS AND INJURIES.

Never discontinue the use of an orthotic without first consulting the appropriate health care provider. Then call your doctor. Then have your doc talk to any other providers as needed. Then discuss it some more. Thank you.

It seems like a no-brainer. “Ted”, has hemiparesis and the classic signs of drop foot: Emerging spasticity in the super-strong muscles that push the foot down at the ankle. He also has a weakness of the muscles that lift the foot. On top of that, he has balance problems and weakness the muscles that stabilize the ankle. The safety imperative is intense. Everybody hates falls.

AFOs solve all of these problems and allow for an almost immediate functional gait. This allows stroke survivors to get on their feet, out the door and on with their life. AFOs work really well. They do the job. They allow survivors to be functional.

But “functional” sometimes collides with “recovery”.

What would recovery be in Ted’s case? Let’s define “recovery” as “progress towards being the same as prior to the stroke.” Will the AFO help or hurt recovery?

Consider what is happening in Ted’s brain. The area of stroke is infracted. This area is now devoid of living neurons and will soon be completely filled with cerebral spinal fluid. There is an area surrounding the infarct called the penumbra. This area is kept alive through anastomosis. Like cars going around a traffic jam by taking the back roads, blood cells are delivered through smaller, secondary vessels. This allows the neurons in the penumbra to stay alive--barely. 
But neurons in the penumbra have problems besides just a reduction in blood flow. The intense biological processes initiated by the stroke soaks the penumbric neurons in a metabolic soup. This further “stuns” the neurons.

That’s what’s happening in Ted’s brain. But what is happening in Ted’s life?

The PT's initial assessment of Ted’s gait is that there is a clear need for an AFO. Once the order is written, the AFO will take 2-3 weeks to fabricate. In the meantime therapists have begun gait training using an ace bandage tied to his lower leg. This forces the foot up and stabilizes the ankle. Ted is given a cane. Ted does well with this system and is able to walk 20 yards. He still fatigues easily, so a recumbent stepper is used to build cardiovascular strength.

Okay, now back to Ted’s brain. The neurons stunned by the stroke are starting to come back “on line”. The blockage has cleared in the primary artery. The metabolic soup that provided such a harsh environment for the neurons has dissipated. The neurons are ready to go back and do what they’ve always done; help Ted walk. But these neurons are never called upon.

They never will be.

Once the AFO arrives, Ted takes to it well. The gait training and cardio work he's done pays off. The AFO works so much better than the ace bandage that Ted immediately walks longer than he ever has. Ted is functional.

Meanwhile, the area of the cortex jam-packed full of neurons that control the ankle is shrinking. Rapidly. In a process known as learned nonuse the area will shrink to half its size in just a few weeks. Languishing for long enough will force the remaining neurons to migrate to some other task. Other neurons will go through "synaptic pruning" and they'll communicate less and less with the neurons around them. The muscles of that push the foot down may atrophy and will certainly shorten. The muscles that pull the foot up at the ankle are not called upon. The AFO does that work. The muscles that pull the foot up are small to begin with (relative to the muscles that push the foot down). And they begin to atrophy. Ted will have the AFO as a lifelong companion. The orthotic will substantially change his style of walking and may have future orthopedic implications.

What's the alternative? Managed care leaves few options and little time. Stroke survivors want to go home and their caregivers want them home. This is why AFOs seem like a blessing. 

      But a new perspective is emerging. There are researchers that advocate early electrical stimulation (e-stim) as a possible hedge against learned nonuse. E-stim has the potential to jump start movement, promote muscle building, calm spasticity and may even have an impact cortically. Repetitive practice with and without the help of robotics, gaming applications and task specific training may begin to bring the stunned cells of the penumbra back on line. A menagerie of emerging treatment options from mirror therapy to bilateral training to lower extremity constraint induced therapy also seem to have potential. But there are more flies in the ointment than ointment at this point. Research is far from definitive answers. One thing we do know is that the brain is a market economy. The “goods” (neurons) go to the “customers” (whatever movement is asked for). If nothing is asked of them neurons will find something else to do. As recovery is unmasked after stroke, every effort should be made to guide neurons “back home”. This will require more time to allow the arc of natural recovery to emerge. It will also require more focus on what is not easily seen: neuroplastic change in the brain. “Seeing” neuroplastic change requires sensitive, stroke-specific outcome measures.

    In other words, this shift in treatment philosophy, from “focus on functional” to “realizing recovery” is as much a work in progress for therapists as it is researchers.

What we do...

Here's a spankin' new flier from our lab. It gives a good overview of what we do.

Click on the images and then click again to make them larger!

Seeing Stroke

Traditionally, the numbers for stroke have been written like this: "In the United States, 750,000 strokes per year. 500,000 new strokes, and the remaining 250,000 recurrent strokes." But by 2015 the estimate is well over 1 million per year. And here's where the stats get grim.

The "well over 1 million per year" bumps the number of recurrent strokes to over 300,000. For the five years after a stroke the chances of having another stroke are somewhere between 25 and 40%. So here's the question: do you know the symptoms of stroke? If you're stroke survivor, of course you do. Or do you? You might very well be an expert in the symptoms of stroke you HAD. But what if you have another one? Would you know the symptoms? So what are the symptoms that you're supposed to know? I work for the University of Cincinnati. They suggest the

FAST test. But its a mnemonic and here's some funny: I get confused about it even though I talk about it, a lot. I think, OK, FAST. What does the F stand for? Why Fast, of course, but yeah, not so much.

So what are the symptoms that stroke survivors should know? One way is to use the FAST test. FAST is based on the Cincinnati Prehospital Stroke Scale and National Institutes of Health Stroke Scale. FAST was developed by Rosie Miller, RN, a nurse who worked with The Greater Cincinnati / Northern Kentucky Stroke Team for 15+ years.

FAST stands for:

· FACE: Ask the person to smile. Do both sides of the mouth, elevate equally?

· ARMS: Ask the person to raise both arms. Do both arms lift equally?

· SPEECH: Ask the person to repeat a sentence. Are they able to repeat a sentence? Are the words slurred?

· TIME: If the person shows any of these symptoms of, call 911 or get to the hospital FAST.

Initiating treatment as soon as possible is vital because time saved is neurons saved. Every minute 2 million neurons and 14 billion synapses die.

It should be pointed out that there's some controversy about the FAST test. The FAST test is great because it is simple. And simple is good. If it's not simple people will forget what the letters stand for. But any test of signs and symptoms of an emerging stroke should be comprehensive enough to capture as many strokes in as possible. Which signs and symptoms to include is hotly debated. Even in the English-speaking world (US, UK, Canada, Australia and New Zealand) there is discrepancy over which and how many and which to include. Further, the wordings used in the various lists are inconsistent. Although there is little research to compare other ways of informing the public, the FAST test has been put to the test. Kleindorfer et al did a study in which they determined that the FAST test missed only about 8% of ischemic strokes but up to 30% of hemorrhagic strokes.

What else is typically included in tests other than the FAST test? Other tests include numbness, intense headache, vision issues, balance problems, loss of coordination, dizziness, difficulty swallowing, and confusion. Also included in some of the tests are the words "even if temporary" after the signs and symptoms. This is an attempt to capture transient attacks which often act as precursor warning signs of a full on stroke.

Consistency is essential to the success of communicating the symptoms and urgency of stroke to the general public. A single unified message increases the number of times it would be experienced by the general public. This would allow for more repetitive memorization of that consistent message. Again, however, there has been insufficient research to indicate which of the mnemonic devices is the most effective at capturing the most strokes.

But there may be a bigger question than what specific signs and symptoms to add. The question is: how do we best learn? Quick, answer this question: You see somebody that looks panicked and is holding their hand to their throat. What pathology does this represent? Here's another one: You see somebody clutching their chest. What is the pathology? While hardly comprehensive, the visual impact of these two examples is universally understood. The question is not what mnemonic is the best, but whether mnemonics are the best way. In my book, "Stronger After Stroke" (Demos 2008) I mention the Cincinnati Prehospital Stroke Scale. But I also suggest another way of memorizing the signs and symptoms of stroke: visualizing. Here's what I suggest:

The easiest way (to memorize the symptoms of stroke) is to start at the top of the head and move downward.

• Skull: Sudden, severe headache and/or dizziness with no known cause.

• Eyes: Sudden trouble seeing in one or both eyes.

• Face: Facial weakness.

• Ears: Sudden trouble understanding.

• Mouth: Sudden trouble speaking.

• Body: Sudden numbness, weakness or paralysis on one side of the body.

Stroke survivors have a much higher chance of having a second stroke than the general population has of having a first stroke. No matter what system you use, educate stroke survivors of the risk of recurrent stroke. And make sure they know as many signs and symptoms as possible.

Isn't there a machine for that?

I was over at dean's stroke musings a cool stroke recovery blog. He had a link to a study that showed that there were some changes in the brain when limbs are moved passively. Lets say you can't flex or extend your wrist. Will passively moving the wrist make it better? That is, if you move the "bad" wrist with your "good" hand, or have someone else move your wrist-- will that help the wrist move by itself? Will it change the part of the brain that controls the "bad" wrist? According to the study, there were brain changes. But. They didn't measure movement changes. Their bottom line: "These findings provide a potential neural substrate to account for alterations in motor and sensory function in stroke patients in response to long-term passive movement interventions." Which is a good point. Let's say you have a machine (which this study did) that moves the wrist back and forth, a half-hour per day. Would that help? Certainly those who make robotics like the Myomo (Val from our lab!) or the REO would have us believe that there are both brain changes and movement changes. There are many therapists who rely on hands-on techniques in which they "facilitate" movement by handling patients. The efficacy of those therapies remains questionable. But it may be a matter of dosage. If the machine can do it for a half hour (or 5 hours) at one joint, consistently, that's a little different than having a therapist do it for a 20 minutes at many joints. Also, robots (like the Myomo and REO) are very sensitive (using EMG or computers) to when the survivor needs help and when they don't. So that may make a big difference as well. Where does this leave the question "Does passive help?" So far as I can tell: moving the limb passively won't hurt and may help. Doing it with robotics seems to provide enough duration and specificity to provide measurable changes in movement. But the bottom line remains the same: Doing any movement yourself is always better than having someone else do it. So these options are for folks who have trouble moving the joint at all. Once you can move it with no help, it should be "all you." --

The upward spiral of recovery (II)

What tools are needed to allow for stroke survivors to drive their own recovery once they are discharged from therapy? It all starts with the home exercise program (HEP). Building the HEP should be initiated in the acute setting and continue to develop through subacute treatment. If the stroke survivor is unable to attend to an explanation of the arc of recovery and how the HEP fits into it, caregivers and family members may be educated instead. Once the stroke survivor is able to absorb the information, they would be the focus of education about the HEP. The amount of time recovering under the guidance of therapists is usually measured in months. The amount of time in which the patients is guiding their recovery is measured in decades. So the HEP becomes a flexible document.

The HEP should…

· Have the flexibility of progressing as the patient progresses

· Educate the patient on measuring progress

· Provide achievable milestones

· Provide benchmarks upon which the patient is directed back to therapy.

Upon discharge the HEP becomes an extension of the therapists’ and patients’ hard work. It's like teaching a kid to ride a bicycle. You hold them up, you run alongside, you guide them, and then you let go. We also tell our kids to keep pedaling because without the forward momentum, they fall. The HEP is the set of rules that will allow folks with brain injury continue their forward momentum. The hard work that patients have done with therapists is the first step on this upward spiral of recovery. But the HEP is the extension of that upward spiral. Finally, the patient fuse the HEP with their own plan of recovery that incorporates their own life. The life they lead drives recovery.

Therapists have to discharge patients once the patient has “plateaued.” However, research from many disciplines has refuted the concept of the definitive plateau. Any therapist worth their salt knows that recovery can continue, sometime spontaneously, well beyond the point of discharge. Unfortunately, the calculus made by many brain injured folks is simple: therapist=recovery. So part of the job of the therapist is to explain that recovery from brain injury is not just the plateau that precipitated discharge from subacute therapies. In fact, recovery becomes a lifelong series of plateaus.

Therapists are paid to be optimists. They know that focusing on disability is less effective than focusing on potential. Medical doctors have to low-ball any prognosis. Doctors feel uncomfortable setting expectations too high. An optimistic prognosis not realized goes against the medical ethics dictum; “first, do no harm.” If doctors set expectations too high, patient frustration (along with some pointed feedback) will be close behind. Therapists, on the other hand, have the responsibility of making clear the potential level of recovery. While doctors low-ball, therapists imagine. The act of transferring that imagination from therapist to patient is the proverbial "Apple a day."

Because everyone likes a cartoon!

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The Upward Spiral of Recovery

There is a common suggestion among many in the "alternative medicine" industry expressed in the question: "If it means less business, why would your doctor want you to be healthy?” A strict emphasis on healthy lifestyle including diet and exercise would be like the proverbial "Apple a day" – keeping the doctor away. Doctors who do this – who keep themselves away as much as they can – are the best doctors. And therapists who "keep themselves away" are the best therapists.

Many pathologies allow for a definitive discharge point. The patient who has had a knee replacement gets therapy, and then goes home to live the rest of his life. But neurological disorders are different. Many, from Parkinson's to multiple sclerosis, are progressive. But what of non-progressive neurological disorders like stroke and traumatic brain injury? Does this "Apple a day" philosophy work? Is there a point at which these populations no longer need therapists?

Many patients with acquired brain injury believe that they will always need therapists. Most see therapists as essential to the recovery process, no matter how long (months, years, decades) it takes for them to achieve their highest level of potential recovery. But this view is incorrect.

There is a point at which therapists are no longer the fulcrum for recovery. Nor should they be for reasons that range from financial to practical. At discharge stroke survivors are, and should be, in complete control of their own recovery. During the chronic phase of recovery from stroke, the speed of recovery slows. In the chronic stage the physiological action of recovery is based on a lot of self-directed hard work.

Much of what is required is relatively simple, and revolves around the broad concept of repetitive practice. In order to take charge, stroke survivors need the tools to initiate and follow an "upward spiral of recovery.” This term is used to describe the path to the highest level of potential recovery. The "upward spiral of recovery" is driven by real-life demands for everything from coordination to cardiovascular strength.

brainu

Exercise, does it help after stroke? Of course it does, but the word exercise is so broad it's darned near meaningless.

One of the things that's confusing is the way that clinicians have historically used the word exercise. They have almost always meant "doing a movement against resistance." The focus is generally on muscle building. But, although they're weakened, the muscles of stroke survivors are usually strong enough to do whatever. And the peripheral neurology is still intact. All the nerves outside of the brain injury are doing just fine. So the question becomes, why all the emphasis on muscle building?

The muscles are working. What's not working is the brain. Can exercise be directed at the brain? Yup. But the emphasis should come off of muscle strengthening and onto repetitive practice. Part of the confusion is that both kind of exercises (muscle building and repetitive practice) crossover. For instance, just working on muscle building will also drive some changes in the brain. Conversely, repetitive practice of movement will build muscle. Another thing that adds confusion is that fatigue is such a huge issue among stroke survivors. So exercise for the sake of building muscle (as well as cardiovascular exercise) is important. Still, the emphasis should be on the brain. I suppose you could simplify it as that old athletic training saying: "Less weight, more reps." Sort of. For more clarity please see this article.

Rockin' Recovery

I'm here in Finland, above the Arctic Circle, the home country of my wife, Aila. We're visiting for 3 weeks.

This is a great country for clearing one's head. The things that matter to "us" seem to trouble them less. Their perspective has changed my perspective!

There is a particular study the Fins have done on stroke recovery that has caught my eye several times over the past few years. Part of it is that any study that says "stroke" and "Finland" will get my attention. Part of it is that music is so personally important. The following quote comes from this article.

"A daily dose of one’s favorite pop melodies, classical music or jazz can speed recovery from debilitating strokes, according to a study published recently. When stroke patients in Finland listened to music for a couple of hours each day, verbal memory and attention span improved significantly compared to patients who received no musical stimulation, or who listened only to stories read out loud, the study reports.

Those exposed to music also experienced less depression than the other two control groups.

Three months after a stroke, verbal memory was boosted by 60 percent in music listeners, by 18 percent in audio book listeners, and by 29 percent in non-listeners, according to the lead author Teppo Sarkamo, PhD, a neuroscientist at Helsinki University in Finland.

The differences held true after six months as well, says the study, which is published in a recent issue of the journal, Brain. Sarkamo’s findings bolster a growing body of research pointing to the benefits of music and music therapy for conditions including autism, schizophrenia, and dementia. But this is the first time music alone has been shown to have a positive effect on victims of brain injury, such as stroke, he says.

“Everyday music listening during early stroke recovery offers a valuable addition to the patients’ care, especially if other active forms of rehabilitation are not yet feasible,” Sarkamo says."

Also, this systematic review seems to further indicate music can help in a number of ways.

`

It's the whole enchilada.

Stroke. The leading cause of long-term disability. It's not the leading cause of short-term disability. That's probably headache or back pain. And it's not, like, the fifth leading cause of long-term disability. It is the LEADING cause of LONG TERM disability. It's the big kahuna. It's the whole enchilada.
 

Figure stroke recovery out and it will inform you about everything that the brain does. Insights into cortical plasticity? Done. Recovering after dramatic brain injury. Done. Learning? Done.

Here's some irony:

There is only one treatment option for recovery from stroke that has the same level of testing as any drug on the shelf of a drugstore. One. Constraint induced therapy (CIT).

So you would think that every rehab hospital would do CIT. But, not so much.

Part of the problem is the foggy perception that many clinicians have about what CIT is. Read this article, and then have your therapist read it.

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It's okay. I speak aphasic.

You're the first responder to a serious car accident. You try to talk to one of the two people in the car - the only one that's conscious. But everything that she desperately tries to tell you seems to trip on her tongue. Is she in shock?

A house is burning down and you are a firefighter. You need to make quick decisions about whether to send your crew inside the burning house. A woman outside the house is desperately trying to tell you something. But... can't... quite...

The Drake Center in Cincinnati Ohio is having a training session for first responders on how to communicate with folks with expressive aphasia. Please click on the flyer, below.

Note that the address of the Drake center is:

151 W. Galbraith Rd.

Cincinnati, OH 45215

Please e-mail me if you have any questions...

2 great videos by Canadian neuroscientist Dale Corbett

The emerging translation of this stuff to clinical practice will be interesting.

Here's another lecture he did. The first half an hour is about his work using hypothermia as a way of treating acute stroke. Right around 29:27 is when he starts talking about rehab.

Pizza And Therapy: So Much In Common

Some stroke survivors end up frustrated when therapies end. Generally stroke survivors want more therapy. And there's a reason for this.

Let me explain it this way: I have a friend, a food scientist. His job is to make food so desirable, so delicious and so irresistible that you never want to stop buying it. He was a very funny guy, my friend. So please don't misunderstand; this was a joke. One day he said, "I've been thinking about developing a food, maybe pizza, and having in the sauce, pot. Then when people finish eating the pizza they'd get the munchies and buy more pizza."

Therapy is very pot-like. At the point at which stroke survivors "plateau" therapies have to end. So the stroke survivor attempts to scratch and claw their way back into therapy.

The calculus made by stroke survivors is simple:

therapist = recovery.

Understand, therapist have to discharge patients after the first plateau. This is the rule. It is a rule concocted by insurance companies and the Prospective Payment System, part of the balanced budget act. "Balanced budget act." How quaint!

The rule says, paraphrased, "As soon as a stroke survivor plateaus they must be discharged." The thinking is "Why is this person still in therapy if they're making little if any progress?" But recovery is really about multiple plateaus, that happen for many years to come.

The first plateau is formed by two forces. One force is the fact that therapists have a limited set of tools, and they're under pressure to get people safe, able to live their lives, and out the door. The other force is neurological. The neurons that were "stunned" after the stroke have all come back online. This usually happens during subacute -->phase – the first 3 to 6 months after stroke. As these neurons come back online recovery is relatively "easy".

The end of the "easy" part hearkens the "chronic" era of post-stroke life. At this point the stroke survivor is essentially on their own. During this period you can still make progress, and much of that progress has to be made without a therapist. The stroke survivor should have a good strong plan when they are discharged from therapies. Once that plan has run its course and a second plateau kicks in, the stroke survivor should go back to therapist looking for the next plan, to take them to the next plateau.

Recovery is a series of plateaus. And every once in a while you need someone to throw you a rope.

_

Q&A

I get so many questions about stroke recovery from survivors and caregivers and therapists. Many of the questions are sad. Survivors and their loved-ones often contact me when they don't have any resources providing direction towards further recovery.

I could probably write a book of questions and answers I get.

Instead, I wrote an article.



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Need an Aggressive Physiatrist and/or Neurologist?

If you're looking for aggressive teammates in your quest towards recovery, there are ways of finding them.

If you are looking for an aggressive neurologists and physiatrists click here. At the top right of the page enter your ZIP code.

Doctors that administer Botox for spasticity reduction tend to be of the aggressive variety.

If you are looking for a physiatrist in your area click here for a searchable database (based on zip code) of PM&R (physical medicine and rehab.) Physicians.

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BOTOX PARTY?

After years of trying Allergan has FDA approval for Botox for spasticity for the upper extremity. However, this does not mean Botox will be any less expensive, at least in the short term.

Would Botox be helpful to you? A neurologist or physiatrist would help you make that decision. Occupational and physical therapists can help you make the decision as well. But understand, Botox is just a Band-Aid, and a temporary Band-Aid at that. You can get injected, and have relief for a few months. That's great, but will not help you resolve the issues that created spasticity in the first place.

Sometimes, if you're super lucky, Botox allows heretofore hidden extension to emerge. For example Botoxing the finger flexors may allow the finger extensors to extend the fingers a little bit.

If you and your doctor decide on Botox, make sure a script is written for therapy. Have the therapist work specifically on recovery options that will help you take advantage of the opportunity that Botox provides.

Imagine if your hand is locked pretty tightly into a fist. The Botox may provide just a little bit of movement into extension. This will provide you an opportunity to use repetitive practice to reestablish cortical (brain) control over the extensors.

Botox is expensive but they do provide help in some cases. Click on either picture to find out more.


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The Ultimate Crystal Ball?

It turns out the the speed you walk (gait speed) is predictive of so many things that folks are now calling it "The Sixth Vital Sign." But here's some funny: everybody is calling everything the sixth vital sign including:

• Urinary continence
• End-tidal CO2
• Emotional distress
• Spirometry
• Glucose
• Functional Status
• Intracranial pressure
• Shortness of breath
• Molecular Genetics, in Oncology

Who will become the sixth, who knows? Some of these require a test in which the tester needs to be trained. Others are self-reported and we lie. But gait speed requires a stopwatch and 2 meters of hallway. Then just read the gait speed tea leaves! 
Here's a full explanation I wrote recently!
Here's another version!

Exercise. Because.

I was interviewed for this article on the Cleveland Clinic website. What I like most about it is that it also mentions one of my neuroscience heroes John Ratey. The fact that I'm mentioned before him- and more often- is just plain wrong.

The focus of this article is the impact of exercise on stroke recovery. But exercise per se does not necessarily drive the sort of cortical changes needed to recover. Of course, it is important to do both cardiovascular and strengthening exercises after stroke, if for no other reason than the fact that life poststroke takes so much energy for two reasons:

• ~Typically everything a stroke survivor does takes twice as much energy. A good example of this is walking. A stroke survivor takes an average of twice as much energy to walk as someone who has not had a stroke.
• ~Stroke survivors are in about half as good a shape as age matched couch potatoes.
• ~Although it hasn't been measured, neuroplasticity takes energy. We're not sure how much. But when you consider that the brain gets 20% of total body oxygen consumption, while it only represents 2% of total body weight, you can imagine how much energy it takes to drive neuroplastic change.

So the bottom line is that stroke recovery needs energy. And exercise is good for banking energy.

~

Stroke Recovery: Easy Concepts and Hard Work

Let’s face it. There is a lot of bad information about stroke recovery. And the cheaper it is to publish information (I’m talking to you Internet) the lower the quality becomes.

Much of the info on stroke recovery is either stale or unreliable. Most of it falls into 2 categories:

1. Filtered through the medical model. This info tends to be stereotypic, redundant, risk free and out of date.

2. Unsubstantiated or weakly substantiated. This info is usually written by caregivers or stroke survivors themselves.

Don’t get me wrong; both the medical model and survivors and caregivers provide valuable information. I have long believed that the secret of recovery is locked within stroke survivors who have gone the furthest on the road to recovery. The problem is that, as much as it’s a cliché, every stroke is different. There are tons of variables, including:

• Sequelae (health problem related to the stroke)
• Comorbidities (health problems unrelated to the stroke)
• Motivation of the stroke survivor (The more motivated, the more recovery)
• Resources (time, energy, helping hands, money, etc.)
• Age (generally, the younger, the better the outcomes)

And there are a hundred other variables that can affect recovery. One of the most important is the location of the area killed by the stroke. A pea sized stroke in one area leaves the survivor unable to talk. In another area the survivor walks great, but can’t use their arm. In yet another area, a pea-sized dead zone allows for a relatively easy and full recovery. So when a stroke survivor writes a book about recovery, they are really writing about their recovery. And because of the variables mentioned, each journey through recovery, and each recovery endpoint, is unique.

I wrote a book about stroke recovery. I wrote it because I have been involved in stroke recovery research for a decade and I have learned a thing or two. Writing a book was easy because there is plenty to report on. Researchers from around the globe are adding their voice to an ever expanding ball of knowledge. And that ball, like much of science, is not perfect. It is misshapen and complicated and hard to visualize all at once. Part of this is because there are many different sciences involved. Input from neuroscience, physiatry, biomedical engineering, physical and occupational therapy and others makes the whole ball hard to conceptualize. But what is emerging from all these complexities are remarkably simple concepts.

I have come to a few basic conclusions about stroke recovery. 

Core Concepts

-Recovery is hard work. If it’s easy, you’re doing it wrong.

-Once you've hit the first plateau, the foundation of recovery from stroke is neuroplastic rewiring of the brain. Prior to the first plateau the most important aspect of recovery is the healing of the brain (the resolution of the penumbra).

-What drives recovery are relatively simple concepts that have been used by athletes (and other hyper-skill learners), since the beginning of time.

-Recovery is best served by

Repetitive practice of movements…
…that are related to a task or tasks…
…that is/are important to the stroke survivor and that are practiced…
…many hours a day…
…and are made more challenging as skill is acquired.

Other core recovery suggestions

1. Stroke survivors should stretch more than they do.
2. Stroke survivors should “bank” (develop a reserve of) cardiovascular (heart/lung) and muscular strength.
3. Measuring recovery from stroke is essential to recovery from stroke. During different periods of recovery can accelerate, slow and stall. During the slow and stall periods—periods when most survivors give up—measuring small improvements is necessary. A bunch of small improvements = large improvement.
4. You have to do it yourself (DIY). This DIY concept is essential in 2 ways:
5. Only you can rewire your brain.
6. If you have to rely on therapists and other clinicians to reach you highest level of potential recovery, you’ll run out of time and money before you’re done.

Focus on 2 things;

1. Making sure that you are not allowing soft tissue to shorten. If it shortens permanently, it doesn’t matter how much “recovery” you get, the joint will not be able to move.
2. Driving brain rewiring change towards recovery. How do you know if your brain is changing? A “Yes” to the following questions will help determine if you are rewiring your brain:
• Are your limbs moving better?
• Can you feel your limbs more?
• Is your balance getting better?
• Is your hand able to grasp wider objects?
• Are you walking faster?
• …and much more will tell you if you are rewiring your brain. Remember, the foundation of relearning movement is changes in the brain, not in the limbs. Although the limbs get credit, it’s the brain moving those limbs. The limbs tell us what is going on in the brain.

The basics of recovery from stroke are simple. The work required is difficult. Recovery from stroke, even years after the event, is available to any stroke survivor. The key is to bring your focus and power to your own quest for recovery.

Electrical stimulation can be used to help stroke survivors recover in many ways including:

1. Keeping soft tissue (including muscle, blood vessels and nerves) elongated (see "Electrical stimulation (E-Stim)" bottom of the post HERE).
2. Jump starting movement in survivors who have little or no movement
3. Reestablishing sensation in survivors who have sensation loss
4. Building strength in muscles that are not quite ready to move on their own