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.
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.