Monday, January 18, 2010

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.


Friday, January 15, 2010

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This info tends to be stereotypic, redundant, risk free and out of date.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 clichΓ©, 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

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