Sunday, December 25, 2011

Stroke and Hyperbaric Oxygen Therapy

Hyperbaric oxygen therapy (HBOT) is something that's often touted to help stroke recovery. HBOT involves the breathing of pure oxygen while in a sealed chamber. The oxygen is  pressurized at 1-1/2 to 3 times normal atmospheric pressure.

HBOT is used medically for the effective treatment of
  • decompression sickness (commonly known as "the bends")
  • severe carbon monoxide poisoning
  • certain kinds of wounds, injuries, and skin infections
  • certain infections

Does it work in stroke? Bottom line: There is insufficient evidence to recommend its use. And it does come with risks.

It may work but the ducks get in the way...

The story of HBOT for brain injury including stroke is full of clinicians, characters and quacks. One of them is William Hammesfahr, a neurologist. You might recognize the name; in the famous Terri Schiavo case Hammesfah disagreed with almost every other MD, saying that Schiavo could recover from what had been described as a "irreversible persistent vegetative state." Hammesfahr claimed that he could "cure" Schiavo to "the point of being able to communicate." Hammesfahr suggested HBOT should be part of Schiavo's treatment.

The board of medicine in Florida in 2003 accused Hammesfahr of "...performing medical treatment below the standard of care, engaging in false advertising concerning his treatment of strokes, and exploiting a patient for financial gain."

Hammesfahr also claimed to be "nominated for a Nobel Prize."  Someone had recommended him for the prize, but that someone wasn't qualified to nominate for the prize. "Qualified Nominators" are a very small and select group of previous laureates and academicians primarily from Denmark, Finland, Iceland, and Norway.

Otherwise, I could nominate you, you could nominate me, and we could both claim to be Nobel Laureate nominees

The legacy of weirdness continues when it comes to hyperbaric treatment...

The mantle for HBOT seems to have been passed from Hammesfahr to the Neubauer hyperbaric neurologic center.  (It is worthwhile looking at all the credentials. The photos are interesting as well...

addendum 11.3.13, all links on that page now lead to a page that says "You have tried to access a link that does not have a page associated with it.". A great take on the clinic can be found here.  (Apparently, the director of the clinic holds no malpractice insurance. "Why?," you might ask. Read on!)

Still, it's not a question of personalities; the question is, does it work?

It may. Definitely more research needs to be done. It seems to work acutely in animal studies. In rats studies it seems as if there's a better survival rate as well as better outcomes if done within the first few days after stroke. This makes sense.  The brain is, during the first few days after stroke, trying to recover. Being hyper infused with oxygen may be a good thing.

And therein lies the rub. If you have a stroke survivor in the  HBOT sealed chamber during the first few days after stroke and there is an emergency you can't get to them. If you try to pull them out of the chamber immediately they get "the bends" described by Wikipedia thusly...

"Decompression sickness (DCS; also known as divers' disease, the bends or caisson disease) describes a condition arising from dissolved gases coming out of solution into bubbles inside the body on depressurization."

And bad things have been known to happen in the HBOT chambers. In at least some studies there is an increase in seizures. There've also been explosions and fires (remember this is compressed pure oxygen; highly flammable.) Here  is a case where a victim died, and another victim was critically injured in the HBOT chamber. The accident happened at the Neubauer Hyperbaric neurologic Center. 

Here is what I've gotten from my research into HBOT:
  • A variety of reviews have concluded that was insufficient evidence to prove the effectiveness or ineffectiveness
  • A 2005 systematic review of the evidence for HBOT in the treatment of stroke showed no benefit to the treatment
  • A review of 12 randomized studies using HBOT with multiple sclerosis suggested that there is no clinically significant benefit from the administration of HBOT.

Bottom line: HBOT may work during the acute phase after stroke. However, a lot more research needs to be done and the safety issues need to be addressed before it can be recommended.


Saturday, December 24, 2011

Stroke Recovery, Stroke Rehabilitation: A Message to Therapists

There you sit, face to face with a stroke survivor. Only a few days ago he was a vibrant, energetic community member... employee... family member and now is sitting in front of you…. aphasic… hemiparetic …scared. The family sits anxiously behind him. They’re eager to get their loved one back and now they look to you. “When?” they ask. “How?” they inquire. And make no mistake, no matter who has talked to them before and no matter how blunt other health professionals have been, they hold hope for full recovery. Between their expectations and their slowly materializing nightmares, you are the last line of defense.

This is not a good time to ask, “Are my skills up to this?”

What if you simply want to do what is the best neurological therapy available? What if you want to treat based on the best available scientific evidence. What if you don't want to be influenced by the wide variety of competing schools of neurorehabilitation, each with their own books and seminars and cult of personality leaders? 

Want to scrape all the BS away? Go here: meta-analysis.

A meta-analysis is simply a study of studies. Researchers take all the available pertinent studies and then determine which studies are worthy of inclusion based on a variety of criterion. Then, of the studies that make the cut, each is given a certain weight depending on the number of participants (more is generally better), if they are blinded, the quality of outcome measures, and so on. All the available data is run through an algorithm and voila! Meta-analyses provide a “box score”. Simplified, it will look like this:

Therapy “XYZ” = -8.5
Therapy “123” = 9.3
Therapy “EFG” = 7.2
Therapy “ABC” = 27.6

Therapy “ABC” looks best, doesn’t it? Are you using “ABC”?

But trust in meta-analyses assumes trust in the scientific method. Phrases like evidence based and best practice are contingent on an inherent belief in the scientific method as related to rehabilitation research. 

(There is actually a remarkable amount of resistance to the scientific method, not just in rehabilitation but everywhere... deniers of global warming, human existence in the current form for the last quarter million years, evolution, a man on the moon, etc. etc. I find it interesting that folks that are willing to deny science embrace it wholeheartedly if they are diagnosed with cancer. Oncology; based in science.)

Rehabilitation clinicians, in all their forms, graduate from colleges and colleges within universities that are usually called something like "College of allied health science." 

With regard to rehabilitation research for stroke, what exactly is involved in the scientific method? How do medical and research doctors come to conclusions about what does and does not work?

As with many things medical, it started with Hippocrates. Hippocrates was the first to describe stroke, transient ischemic attacks and aphasia. Hippocrates, however, provided no clues on how to rehab stroke survivors and for more than 2400 years little was written and we know of few interventions used to facilitate recovery from stroke.

Fast-forward to the period from the early 1950’s until the early 1980’s. Individual therapists armed with “keen observational skills”, pencil, paper and a goniometer published their observations and claimed it an effective therapeutic intervention. During this period, therapists could reasonably say, “I know it works because I’ve seen it work in my patients.” or “There are no better alternatives”. Now, anyone armed with the power of meta-analysis can refute these claims with a simple statement.

“Prove it.”

In many ways clinical rehabilitation research can trace it’s genesis to widespread hospital usage of functional magnetic resonance imaging (fMRI) in the 1980’s. Suddenly researchers were able to see the fruit of their therapy by simply examining before/after images of brains of study participants. Why is this so important? Because if fMRI shows activity during purposeful movement and that activity did not exist prior to the intervention, then there is reasonable proof of neuroplasticity. And neuroplasticity is the foundation of all lasting change in the ability to move.

Research and medical doctors have used cutting edge diagnostics including kinematics, electromyography, brain imaging, and the most reliable and valid outcome measures to completely reshape the world of stroke rehabilitation. In fact, it’s not a world at all. It’s an expanding universe.

And why is stroke rehabilitation it expanding so rapidly? A basic understanding of the sheer enormity of dollars provides some insight.
  • $52 billion is spent on stroke care each year. 
  • The projected costs for stroke for the next 45 years: $2 Trillion.
  • There are 50 million stroke survivors worldwide. (In a global  economy.)
Enter entrepreneurs. Entrepreneurs have completely changed the way stroke rehabilitation is conceptualized, researched, and administered. Medical device companies, business minded bioengineers, electrical engineers, biological and clinical neuroscientists, doctors and therapists are aggressively seeking a piece of the burgeoning multi-trillion dollar stroke rehabilitation pie. This explosive increase in the number of gizmos and treatment techniques has created a total mutation of the paradigm for rehabilitation for stroke. The resultant technological tsunami will force an unprecedented marriage between patient and technology while forging a massive adaptation by universities that train therapists, and facilities that want to continue treating stroke survivors.

And make no mistake; entrepreneurs are marketing directly to stroke survivors. If you want insight into this process have a look at the advertisements in the two major free magazines for stroke survivors; the magazine of the National Stroke Association Stroke Smart and Stroke Connection magazine, published by the American Stroke Association.

And what of stroke survivors? Have they not always strived towards full recovery? Unfortunately, the history of stroke survivors is story of warehousing and lowered expectations. But don’t blink: things are changing fast. Baby boomer’s increased economic clout and heightened expectations intersecting with the mushrooming middle class in less developed countries has and will continue to create a new breed of stroke survivor who will want, need and expect more recovery.

And all this leads to more high quality stroke rehabilitation research.

Rapid technological change has led to ever more accurate determination of an intervention’s effectiveness and if effective, how effective.  The force of a flood of dollars, both public and private, has changed the way stroke rehabilitation research is realized. Modern research often involves hundreds of specifically randomized participants and involves medical personnel (often including therapists) with degrees specific to their responsibilities within the study. Further, there are institutional review boards to guarantee ethical standards within the research trails, federal (FDA) oversight, and precise handling of collected data. Private, for profit companies, with and without the aid of public funding (NIH, NINDS, public and private universities) are spending hundreds of millions of dollars, on a variety of modalities and therapeutic interventions designed to ameliorate the residual aspects of stroke.

And all of that is only half the battle. In order for studies to be distributed in a manner that is respected by the medical community at large, it has to be published in peer-reviewed journals. Even once the study is done there is an expectation that the same or similar studies will follow that speak directly to reliability (the ability for an intervention to have the same or very similar results over and over.) Once a critical mass of research is done on a therapeutic intervention meta-analysis is done to, essentially, provide a numerical “score” that pits therapy against therapy and declares a winner.

 “I will continue with diligence to keep abreast of advances in medicine.” So says the Hippocratic Oath. Medical doctors have endeared themselves to the public for centuries, millennia really, by accepting a direct influence of science on their professional practice. Therapists and assistants should do the same.

This is not a good moment to ask,  “Are my skills up to this?”

Unless they are.

Saturday, December 17, 2011

The Tao Stroke Recovery

I would like to respond to Dean, someone who has supported my book from the very beginning, and has supported this blog. It's impossible to even calculate how much Dean has help me get my message out. 

He has even come to one of my talks!

Dean posted a comment which you can find here.

In his comment he disagreed with the premise of a blog entry I wrote. I basically said that stroke survivors should focus on specific tasks while they're trying to recover. It's called "task specific training". It's benefit has to do with motivation; the more important the task is to the survivor, the more motivation available to the survivor on their quest towards recovery. The tediousness of working towards recovery is mitigated by the survivor's inherent interest in the task that they're trying to accomplish.

And Dean brought up an excellent point. It's the same point that is often made by clinicians when the issue of task specific training comes up. As Dean put it "Task-specific training is just taking the easy way out because if you can't walk properly you're not going to get better by practicing bad walking." Dean goes on to point out that unless there is a precise evaluation of movement deficits, there's no way to tell what should be practiced.

And I totally agree. While I'm a big proponent of focusing on a valued task to provide motivation, bad practice leads to bad movement. When it comes to movement, quality matters. And quality matters for many reasons.
  • bad movement takes more energy than good movement
  • bad movement takes more time than good movement
  • bad movement can lead to injuries
  • bad movement can lead to a lack of enjoyment of a wide range of activities
  • bad movement looks bad which has social implications
  • etc., etc.

So how does a stroke survivor reverse "bad practice leads to that movement"? That is, how do you do "good practice that leads to good movement"? 

My lab work has focused on stroke specific outcome measures testing poststroke movement. I used a laundry list of these outcome measures. They are often complicated and require special equipment. We also use movement analysis laboratories that collect thousands of bits of data to determine if movement is increasing or decreasing in quality. Finally, we use technologies like functional magnetic resonance imaging and transcranial magnetic stimulation to determine if the part of the brain dedicated to movement is expanding.

But for the stroke survivor trying to improve quality of movement, some of the simplest "data collection" works quite well. 
  • Using mirrors to provide real-time feedback can be helpful. 
  • Using a mirror at the end of a treadmill can provide insight into the quality of gait.  
  • In the upper extremity is often helpful to use the "good" side to remind yourself what "normal" looks like.  
  • Videotaping specific movements throughout the arc of recovery can be helpful as well. Video provides a chronological log of where you were, where you are, and can be suggestive of what to work on next.

"Practice does not make perfect. Only perfect practice makes perfect."
Vince Lombardi

Saturday, December 3, 2011

What Task-Specific Stroke Recovery Really Does

Find out what they want. 

"Task specificity" and "task-specific training" are buzzwords in stroke-specific neurorehabilitation research. The foundation of recovery from stroke is rewiring of the cortex "around" the area of infarct. And the best way for anyone to rewire their brain is to focus. 

As completely as possible, the focus should be on a specific task. Most therapists will tell you that they do task-specific training.

PTs and OTs have every right to claim that what they work on is task-specific. ADLs ("activities of daily living"; the focus of much of OT) transfers, walking, etc. are inherently task-specific. But working on recovery using the "task-specific" approach can be magnified if you focus on tasks that are vital to the survivor.

You might ask, "What is more vital than ADLs, standing, walking and transferring?"

The answer is, "Ask the survivor."

The more focus, the more rewiring. Let's consider someone who has not had a stroke: Jim. Let's say Jim decides to take French because he is required to take a foreign language for school. Now consider Tina. She is an American who grew up in Texas but is now living in France.

Which of the two will get the most robust brain rewiring dedicated to learning French? Tina, quite a bit; Jim, not so much. Tina will naturally bring quite a bit more focus to the task. So there will be quite a bit more rewiring.

Now let's consider relearning walking after stroke. Walking means much more than simply getting from place to place. The ability to walk can impact the ability to be independent, the ability to earn a living, friendships, self-esteem and much more.

Walking, especially in a clinical setting, may or may not be tied to what really matters to the stroke survivor. I worked with one stroke survivor who told me, "I can't continue to walk funny. It's bad for business."

He was a surveyor. When he went on construction sites the other workers didn't believe he could do the job. And they believed this because, although his speech and cognition were perfect, his movements were typically hemiparetic. In this case, the motivation is not walking, it's really the ability to make a living.

Another stroke survivor told me, "I can't cope with this constant fear of falling." The motivation here is not walking, but fear. I know stroke survivors who have lost friendships because of their stroke. "As soon as I had my stroke, the boys stopped coming around."

Another survivor told me, "The fact that I've lost the use of my hand keeps me from doing things with my friends." The motivation here is friendship. Other stroke survivors hate being dependent on their families.

Fear, friendship, career, independence. All of these are powerful motivators.
In some ways it's easier for occupational therapists. They ask, "What is it that you have to do? What is it that you love to do?"

The answers will be as varied as stroke survivors. One might say painting is the most important thing. Another might say golf. Another might say child care.

For OTs, "task specificity" can be just about anything. An OT can work on hand grasp/release. Putting grasp/release within the context of a highly valued task is relatively easy. And putting it within the context of a valued task will drive more cortical plasticity (thus more recovery) much more than stacking cones or playing with a pegboard.

Support Motivation
So how can PTs and PTAs promote the same sort of focus to walking as an OT promotes in a vital task done with the upper extremities? The first thing to do is to listen. "Patient education" time can be used as "therapist education" time. What did the stroke survivor do before his stroke? What did he do for a living? Did he ever play any sports or instruments? What were his hobbies?

Revealing the activities that patients most want to recover reveals what drives them. And what drives them drives their nervous system toward recovery.

But there is a gorilla in the room. What if their motivator is beyond their present capacity? Walking a golf course may be the ambition. But even nine holes of a par 3 is a couple of miles. So what is the first step in recovering enough robust walking to take the survivor miles?

First, the ambition must be revealed. Once walking a golf course is established as the goal, the goal is always kept in mind. An essential aspect of task-specific training is keeping the task in sight.

For instance, even if the painter can't yet paint, a paint brush and paints are kept as reminders of the task to be accomplished. But how do you keep a golf course in line of sight?

Keeping the task front and center is a matter of allowing the vista of a golf course to form within the walls of a therapy gym. The survivor may never make it to the golf course but the love of the game will have him walking further than he might have.

Research has revealed better tools than ever to help survivors along their journey. From partial weight-supported intensive treadmill training, tools to recover walking after stroke increase in numbers and in their evidence. But don't let survivors forget what most motivates them. The most powerful tools live inside the survivor.

Tuesday, November 22, 2011

Do it yourself!

I don't care how great a therapist is, if they see a patient a half hour 3 times a week, they're not going to elicit robust enough neuroplastic change to provide better and lasting movement. That's what all the research says. Survivors (families, pipe up!) should demand the “home exercise program” (HEP) during the first week of therapy. Why? Because they will get much greater gains if they work 4 hours every day than if they work a half hour 3 times a week, or 2 hours a day, 5 days a week or whatever. Too often the HEP reflects nothing more than a watered-down version of the very exercises that precipitated the plateau. 

HEP does not stand for "hand 'em photocopies". A HEP should start from day one. And the “H” part of should be defined as wherever the survivor is staying; skilled nursing, the hospital, wherever, they should be given tons of homework and survivors should be encouraged, threatened, cajoled, coached and convinced to follow through on the home work. And families should be involved in this effort as much as possible.

Monday, November 21, 2011

A private affair

What if recovery were a competition? What if someone measured your level of recovery at 2 days, 2 months and 2 years. Would the % that you got better, from baseline to the zenith of recovery beat others? 

Is making it a competition a bad thing? There are classic stories, one of which is in Norman Doidge's "The brain that changes itself" of stroke survivors competing against each other within the context of constraint induced therapy.

During most of stroke recovery,
victory is a private affair. 
You are the only one who will know if you prevail. You are competing against yourself and for yourself.

Thursday, November 3, 2011

Safe, functional, g'bye!

Some clinicians think that neuroplasticity means little in the every day life of someone who suffers from brain damage. These neuroplastic naysayers believe that change in the brain is not worth a hill of beans if there’s no “functional change”. I rather disagree. I think that “function” is a manifestation of what insurance companies think will get patients out the door as quickly and inexpensively as possible. Consider ambulation. Insurers believe that someone walking, no matter how ugly the gait, no matter the orthopedic risk, no matter the bracing or assistive device, is better than not walking. 

So what happens? Therapists slap on AFO’s and call it toast. Everybody’s happy, right? The only problem is that a more natural, recovery of dorsiflexion is now made impossible by a rigid orthosis that disallows the very movement that stroke survivors are trying to recover! Penny wise and pound foolish, insurance companies impede the very process of recovery. And that's prior to the plateau, as the brain is coming back online. Once the survivor is chronic, there is no further gain at the ankle, despite potential neuroplastic change that may be available during the chronic phase. change is the only true substrate of recovery from brain damage. Everything else from bracing to stretching are local Band-Aids ameliorating symptom rather than cause.

Tuesday, November 1, 2011

Barking up the right tree.

Here's a made up story: I dropped my computer down the stairs the other day. Thankfully, it still turned on. But then the computer screen wouldn’t work! I shook the screen. I turned it on and off. I pushed all the buttons. All the screen said was NO INPUT SIGNAL. What should I do? Well anybody who's ever owned a computer knows that it has nothing to do with screen and has everything to do with the computer.

Stroke is an injury to the brain. Peripheral nerves and muscles (unless and until atrophy and/or muscle shortening sets in) are working just fine.   

But when it comes to stroke recovery "we" (including clinitians and survivors) focus on the affected parts of the body. We put an orthotic on it, stretch it, splint it, move it, measure it, worry about it...

We focus on the symptoms rather than the cause. We focus on the screen rather than the computer. We focus on the limb rather than the brain.

Symptoms, computer screens and limbs are easy. We can see them, touch them, and measure them.

But let's be clear. The basic paradigm shift presented by research is that it's not about the limb…it's about the brain. 

Good thing the brain responds to simple rules. What are those rules? Let me answer that question with questions. Take something that you learned in your life... anything. How did you learn it?  Did you offload the process of learning to someone else? Was that learning easy?  Did you wait for someone else to test you, or did you test yourself?

Will decides movement. Movement rewires brain. Brain controls limbs.

Friday, October 7, 2011

The largest study ever done on stroke rehabilitation...

The portion of the NIH that deals with stroke is called the NINDS (National Institute of Neurological Disorders and Stroke). Out of all of the neurological disorders Stroke gets its own letter. Why? Because it's the leading cause of long term disability.

The largest study this country (USA) has ever done on stroke rehabilitation was funded by the NINDS. It was called the  LEAPS trial (The Locomotor Experience Applied Post-Stroke). The LEAPS trial tested "Body-Weight–Supported Treadmill Rehabilitation after Stroke" I'll call it "body weight supported treadmill training" or simply, BWSTT. This is a treatment where the stroke survivor walks on a treadmill while having a portion of their body weight supported by a harness. 

The results of the LEAPS trial was published in the New England Journal of Medicine (abstract here), which makes little sense to me. You can hardly get therapists to read their own national association's journal (APTA, AOTA, etc.),  let alone a medical journal.

I recently interviewed one of the principal investigators on the Leaps trial; Katherine Sullivan. You can read the entire interview here.

The trial had mixed results. The first thing that caught my eye was the number of "serious adverse events" in the people that got the BWSTT, compared to the control group (The control group got regular physical therapy).

For instance the BWSTT group had more recurrent strokes, more fractures and more hospitalizations than the "regular therapy" group. The BWSTT group also had more falls.

The other thing that immediately pops out is the conclusion that the authors come to:

BWSTT "...was not shown to be superior to progressive exercise at home managed by a physical therapist."

I actually think that BWSTT works well for some stroke survivors. This is one trial, and although it's a well-run trial, maybe there were some problems with the way it was set up. Pure conjecture on my part, but the amount of time that they had people on the treadmill seems excessive. They were on the treadmill for up to 30 minutes, followed by 15 minutes of overground walking.

The amount of time spent doing an intervention is called "dosage". And just like any drug, if you get the dosage wrong it can do more harm than good. I suspect that BWSTT at a lower dosage, along with leg strengthening, and cardiovascular strengthening would be more beneficial. Of course, for some stroke survivors, especially younger ones, the dosage could be increased.

And that's really one of the points that Dr. Sullivan makes in the interview. The way a randomized controlled trial (like the LEAPS trial) is run, is nothing like the way that therapists typically do therapy. Therapists are more sensitive to the needs of the patient. But once patients -- called "participants" in research studies -- into a scientific protocol, it's one-size-fits-all. But one size does not fit all. Why? Because every stroke is different. 

It's a clichΓ© because it's true. 


Saturday, September 3, 2011

Stronger After Stroke: ............................................... The lost chapter

I'm not sure what it is about the Canadians, but they do great work regarding stroke. There's only about 50,000 strokes per year in Canada (in the US there's about 850,000). But the Canadians put a ton of resources behind it. Plus they have a great back story. Donald Hebb, Wilder Penfield, David Sackett, Dale Corbett, Bob Teasell--  not all of them involved in stroke rehabilitation per se, but all of them have had a huge impact on the discussion.

I did talk up in Canada, last December, in Alberta. Nice little town called Lethbridge. 

Kmsiever at en.wikipedia
 Before you do a talk you have to send your PowerPoint slides to the people sponsoring the talk. And you have to do this pretty early because they need time to make sure that it all prints well, etc. etc. I sent my slides up to this very nice physiotherapist/neuroscience PhD candidate coordinating the talk. She emailed me a few days later... The slides look great, but you have this whole section on this thing... "reimbursement"? Nobody's going to understand what you're talking about.

Grrr. Canada.

It turns out their big problem, in Alberta at least, is difficulty discharging stroke survivors.

Therapist: "Well Mr. Smith, it's time for you to be discharged, you've plateaued." 
Mr. Smith: "I'm not going anywhere, eh?"

It's a good problem to have.

In any case, the point of this blog entry is not to celebrate Canada and its great work for stroke, but to talk about a couple of different Canadian online resources for stroke survivors.

Apparently, I had a chapter in Stronger After Stroke that was deleted by the publisher. All this info ended up in the book, but not as detailed as you will read it, below.

So here it is, the lost Stronger After Stroke chapter!

Stroke Recovery Research Made Quick And Easy 

What is it?
When you had your stroke, you landed a new job: Recovery researcher. Your recovery depends on knowing what the latest and greatest stroke recovery research has to offer. It would be nice if you could lean on clinicians to satisfy your need to know. No such luck. Most doctors and therapists treat many diseases and cannot be expected to be familiar with all the latest techniques, modalities, and technology.

The good news is that hundreds of millions of dollars of funding is being spent on stroke recovery research, around the country and around the world. Some of the best minds in science are coordinating multi-site trials, cutting edge technology and armies of researchers to find better ways for you to recover after stroke. You should benefit from all this expensive creativity and hard work! But in order to benefit from all this research you need to know what it says. The suggestions in this section will allow you to quickly and easily access the latest and greatest stroke recovery research.

How is it done?
Once you’ve had a stroke, you need information. You need it because your recovery is directly related to how well you implement what science develops. But there can be problems getting this information in a form you can use. For instance: 
  • Where do you find the time and the know-how to find accurate and up to date information about the most effective stroke recovery options?
  •  How do you sort through the hundreds of articles that are coming out every month on stroke and stroke recovery?    
  • Even if you can find this information, how will you understand what the researchers are saying?     
  • Is there one simple and easily read resource that tells you what the latest and greatest stroke recovery research says?
Yes, there is!

Dr. Robert Teasell and colleagues at the University of Western Ontario have written a complete and straightforward resource that allows you to get all the up to date information you need quickly and easily. This resource is called The Evidence-Based Review of Stroke Rehabilitation (EBRSR) and can be found on the web at: The EBRSR is a study of all the peer reviewed articles available worldwide. “Peer reviewed” articles are journal articles that are scrutinized by a group of scientists that work in the field of stroke rehabilitation research. These “peers” review the articles to ensure its scientific integrity before they are published. Dr. Teasell’s resource provides a reliable and concise review of all the peer reviewed articles on the subject of stroke recovery. 
 Robert Teasell

The EBRSR has 21 “modules” that cover every area of stroke rehabilitation. Here is a partial list.
  • The arm and hand
  • The leg and foot and walking
  • Speech
  • Outpatient stroke rehabilitation
  • Community reintegration
  • Painful “bad side” shoulder
The great thing about this information is that each module opens with an easily readable list that explains which therapies work, which does not work and which are promising but still unproven. Not only that, but it is updated every 6 months, and it’s free! If you want more than just the “bottom line” these modules have several layers of information including full references to the research articles that are reviewed. The EBRSR is an easy way of accessing the latest and greatest that stroke rehab research has to offer. The EBRSR makes your research as simple or as detailed as you require. If you are willing to spend about 10 minuets every six months you will know more about what the research says about stroke recovery than most clinicians! A lot of healthcare workers don’t know about this resource so the information may be new to them. Remember, clinicians usually treat many problems, not just stroke. They cannot be complete experts because they have limited time to absorb an ever expanding amount of research in all the areas they treat. Knowing what the research says will help you guide doctors, therapists, nurses and other healthcare workers as you work to recover.

There is another fantastic resource for determining what does, and what does not work in the fight for recovery from stroke. It is called StrokEngine. It is produced by McGill University in Canada and includes the work of some of the biggest names in stroke research, including the previously mentioned Dr. Teasell. This resource is updated continually and allows you to explore recovery, therapy by therapy. For instance, let’s say you’ve heard that “therapy X” works helps folks recover. The StrokEngine allows you to look up just that therapy and see if it holds promise. Once you’ve chosen a therapy you can go to a section called “Patient / Family Info”. Once there you can go to a section called “Does it Work for Stroke?” which gets to the bottom line about that therapy. Just like the EBRSR, this resource allows you to look at each item as simply and quickly as you want, but the details are there if you wish. StrokEngine can be found at:

What precautions should be taken? 
Make sure that your doctor reviews whatever treatment options you are implementing into your training program. When considering a treatment option make sure it is shown to be effective in peer reviewed literature.  


Sunday, July 31, 2011

Motor deficits beware: Wolf on the hunt.

Okay, I'm a "stroke recovery nerd". But this is cool... so Stephen Wolf, the PT PhD that ran the big constraint induced trial back in 2005 has a really cool trial going on...

Of course, there's the whole repetitive task specific thing -- just like constraint induced. But what I really like about this is the focus on the survivor figuring out what the next step in motor learning is. That is, the survivor is the most important part in the process of recovery. And to his credit this is something Wolf has been promoting for a really long time. Even constraint induced, really, is all about the survivor driving their own nervous system towards recovery.

A couple of funny things about this video; the fact that he did it not in some sort of sterile looking environment but in an area that's typical of an OT workspace. Tons of stuff, vaguely categorized, piled on top of each other. A thing of beauty if you appreciate it. The other thing that pops is the level of movement he's suggesting. Have you tried to take the cap off of meds lately? I'm not hemiparetic but I struggle a lot with those safety bottles. And then he suggests that the stroke survivor would use a very delicate "three jaw chuck" grasp to pick up pills... that's just about the highest level of motor recovery that you could pretty much possibly have. "Enough finite movement" indeed!

Of course, they would probably tell me that they are making sure that tasks are within the ability of even their lowest level participants.


Wednesday, July 6, 2011

Huge in Malaysia

Big news: Stronger After Stroke has been translated into Malay, the language of Malaysia and Indonesia. It costs Harga: Rp 53.000,- but its worth it, because, as it says on the front cover, "Untuk para pasien stroke, terapis serta orang-orang terkasih mereka, Stronger After Stroke menyajikan filosofi perawatan yang baru, lebih efektif, dan sangat sederhana."

And that's gotta be worth something.

Thursday, June 9, 2011

The arm bone's connected to the...mouth?

If you train better arm movement, you get better speech. It might have to do with the fact that the hand and mouth control centers on the brain sit next to each other. It might also have to do with the fact that humans probably used hand gestures before we used speech so the two are probably linked in very basic ways.

Click here for a synopsis of this phenomenon from our lab.

Wednesday, June 1, 2011

In France we're all aphasic

A friend of mine just got back from France.

He carried this...

Which means this...

Tuesday, May 10, 2011

Neuroscience: "Are you listening?"

Most therapists suspect there is a pretty wide disconnect between what research reveals works to aid in stroke recovery and the treatment options that therapists typically do. One of the reasons for this disconnect is the “meet ‘em, greet ‘em, treat ‘em and street ‘em” perspective hoisted on therapists by managed care. Therapists are sensitive to Rule # 1: Get them safe, functional and out the door. If the best therapeutic option means slowing down the process, it will not see the light of day.
But there is another big reason research fails to resonate with therapists. Much of the “bench side to bedside” rift exists because the two groups (researchers and clinicians) simply don't talk. Mostly, PTs talk to PTs and OTs talk to OTs and if we're feeling really radical we go to a talk or read a paper by an SLP. And if we're feeling truly outlandish we'll go to a talk or read a paper by a neurologist or physiatrist. But is physiatry and neurology where the action is? Neurologists have a vital part to play in stroke recovery, but their input is typically limited to the saving as many neurons as possible hyperacutely (the first few hours post stroke). Physiatrists have the responsibility of dealing with co morbidities and sequelae as well as coordinating recovery efforts through the subacute phase. Generally, physiatry is not involved in the process of driving the massive cortical rewiring needed to aid in motor recovery.
That task is left to stroke survivors, guided by therapists.
We could look to psychology and psychiatry. They do know about the brain. And they have a massive advantage when it comes to knowing how to rewire the brain: they've been working on systems to change the brain since Freud. Edward Taub, the developer of constraint induced therapy, a treatment option that has shown promise in many large clinical trials, is a psychologist. So both psychiatry and psychology are disciplines worth listening to.
Clinical researchers from many disciplines are vigorously trying to solve the conundrum that is stroke recovery. This forces therapists into uncomfortable territory; those who wish to remain evidence-based end up having to listen to researchers outside of PT and OT. And these researchers often speak a different language, write in different journals, work with different treatment techniques, and use different outcome measures. And, as you’ll see, they often work with a different sort of “patient”.
Physical and occupational therapy, physiatry, neurology, psychology and psychiatry. Regarding the question of what systems are best suited to rewire the brain for recovery after stroke, all these disciplines have something to add to the discussion. But, more and more with the passage of time, they will pale in comparison to another branch of science: neuroscience.
Most neuroscientists have a near myopic focus on "unpacking" the 100 billion neurons and quadrillion synapses in the brain. Neuroscientists are involved in the development of a full spectrum of systems to drive massive brain rewiring. And systems to drive brain plasticity post-stroke are no exception.
One of the reasons that neuroscience is such a great source of information has to do with the difference in the actual study participants. Let's say you are a researcher and want to do a double-blind placebo-controlled study. You give a little blue pill to participate A, and a little blue pill to participant B. One is the "real" pill and the other is a placebo. You don't know which pill they got, and they don't know which pill they got. The study is double blinded. There is a study coordinator in the back room who knows who got what pill, but both you and the participants are blinded. How do you do that in stroke-specific rehabilitation research? Participants sign informed consent—this is federal law when it comes to using human subjects in research. The informed consent document may say something like "You will either get a treadmill or you won't get a treadmill for training." In that situation you can single-blind; you can blind the person that's doing the testing. But you can't blind the participant. They know whether or not they got a treadmill. There are other problems with human participants as well. Stroke survivors have strokes in different parts of their brain, they have different comorbidities and sequelae, they are of different ages and have different motivation levels—to name just a few confounds. 
Neuroscientists typically use animal models. Animals are easy to blind; they don't know a treadmill from a glass of milk. And animals can all be given their stroke in exactly the same spot.
In any case, PT and OT are tasked with taking what all these branches of science have revealed, making sense of them and making them available for stroke survivors. As insurmountable as that task seems the payoff is a much richer and robust palette of treatment options.

Saturday, May 7, 2011

After stroke, spasticity is a bad thing—but things could be worse.

Flaccidity is an example of a point in the poststroke arc of recovery with consequences as bad, or worse, than spasticity. Spasticity carries with it the potential for contracture, pressure sores, pain, joint problems and deformities. Flaccidity, too, carries obvious physical risks (i.e., subluxation, muscle atrophy, etc.). But flaccidity also provides an ominous window onto the prognosis of the limb. Flaccidity says 2 things: “Recovery will have to wait” and/or “Recovery may have ended”. 
There are two kinds of paralysis; flaccid paralysis and spastic paralysis. Most of the patients therapists see fall into neither category. Part of the reason that therapists typically don't see truly paralyzed patients is because, traditionally at least, little can be done to help. With the advent and broadening use of intrathecal baclofen, injectable neurolytics and the dorsal root rhizotomy, etc., the potential for treatment has broadened. Still, most of the people that are candidates for treatments that aim to improve limb movement are not going to be hemiplegic (paralyzed) -- they'll be hemiparetic (weak). The question becomes, is there more potential and somebody who has near flaccid or spastic?
We can look to pioneering physical therapist Signe BrunnstrΓΆm for insight. BrunnstrΓΆm’s six stages (Thanks “Pink House On The Corner” blog!) of recovery provide the ultimate template for recovery from stroke. Stage I is flaccid (although reflexes are available), stage II is harkened by the emergence of spasticity and synergies, and in stage III synergies and spasticity are at their zenith. So the progression is clear; flaccidity to spasticity. And as with much of BrunnstrΓΆm’s work there is an underlying wisdom; spasticity, as disdained and dangerous as it is, is preferable to flaccidity. This is especially true early after stroke. A patient with emergent spasticity can work in a repetitive and demanding fashion very early in the arc of recovery. And when it comes to stroke recovery, early is better. This is as true in rat models as it is in clinical trials involving human participants. But if somebody's flaccid, how you begin rehab? Although most patients do not remain flaccid, the delay that flaccidity creates provides a much more shallow recovery trajectory.
Spasticity may have another advantage over flaccidity with regard to issues outside of the progression towards recovery. Often the flaccid limb, whose dearth of sensation usually parallels its dearth of movement, is at risk of injury. Bluntly, the world can be a dangerous place to a flaccid limb. Like a weakling in a neighborhood of bullies, the flaccid limb is surrounded by walls, corners, countertops and other unforgiving surfaces. In the lower extremity is usually less of an issue because the flaccid limb can be controlled within the confines of a wheelchair. In the upper extremity the limb is often put in a trough and/or sling to protect the limb. These forms of stabilizing the upper extremity protect the limb in two ways; keeping the arm from flailing with the potential for injury; protecting the shoulder from subluxation.
Spasticity manages to protect the limb from these “bullies.” In the upper extremity the spastic posture brings the arm across the body, internally rotated and flexed at the elbow wrist and fingers. This posture is dictated by the overwhelming strength of the flexors and internal rotators. For an unprotected arm spasticity can be seen as a good thing, simply because it keeps the limb out of trouble.
Beyond providing an immature protection mechanism, spasticity may do other beneficial things as well. Spasticity may induce Wolf’s law, which states that bone will remodel through osteoblastic activity dependent on the loads it’s placed under. That is, the pull of muscle on bone is what keeps bones from becoming osteoporotic. This is particularly important issue because stroke survivors tend to fall towards the affected side. Because there is less bone strength on that side there is a higher chance of fracture. Spasticity may also improve circulation because of the activity in the triceps surae (gastroc, soleus). The primary way blood is delivered from the extremities back to the heart and lungs is the muscle contraction. With regard to the circulatory system spasticity is preferential to flaccidity, because the blood gets shunted towards the heart and lungs. Spasticity also maintains muscle bulk because, as pathologic as it is, at least the muscle is contracting.
Most importantly, spasticity provides a crude template for future recovery. But despite its advantage over flaccidity, all is not rosy with regard to spasticity. As the first line of defense, therapists are tasked with interrupting the march towards contracture. Tools in neurology and physiatry are helping with that task. Serial casting and a dedicated stretching program are also essential tools. The bottom line is, as much as spasticity is a welcome visitor it is best when it is exactly the: a visitor. Spasticity allows for at least the chance of its visit being shortened by allowing for movement in some planes and pivots. Take what spasticity give as you usher it out the door.

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