RATS!

Its all about the hand.
For anyone interested in evidence-based stroke recovery treatment options, the lower extremity offers a much smaller palette than the upper extremity. Simply, there are a lot less evidence-based treatment options for the lower extremity.

One of the reasons this is true is because the ankle foot orthosis is an effective way of providing compensation for the deficits in gait after stroke. Another reason is that canes and walkers are also extraordinarily effective at compensating for gait deviations and deficits poststroke.

There are other reasons. For instance, there is the general consensus among therapists that what comes back first is the leg, and later on the arm and hand. This is a classic gotcha question for therapists teaching students. "What comes back first the upper or lower extremity?" The wise student will say the politically correct answer; the lower extremity. But this is not necessarily true. We tend to focus very much on hand and all its intricate movements, especially finger extension. But in the lower extremity we don't typically look at the analog of finger extension: toe extension. Why does nobody care about toe extension? Simple: The toes are hidden by the shoes. Also, toe extension is not essential to a functional gait. Toe extension which helps raise the ankle is compensated for by the ankle foot orthosis.

Another reason for the near myopic focus on the upper extremity is that it's more interesting. The shoulder has more range of motion in more planes and pivots than it's analog the hip. But but more movement in the shoulder is small potatoes.

The main reason for the focus on the upper extremity is the hand. Even before brain imaging the hand fascinated researchers. This delicate instrument at the distal end of the limb drives clinical rehabilitation research related to stroke. There is a common belief that if you can get the hand "back in the game" and somehow get the hand to grasp release every other aspect of the upper extremity will come back naturally. This is because the entire upper extremity is there at the behest of the hand. You could further argue, although a bit of a stretch, that the reason we walk is to get the hand where it needs to go so that the hand can do what it needs to do.

But there's another huge reason. The brain. The swath of real estate that hand takes up on the brain is huge. The point to point representation of the brain is called the homunculus. The hand takes up almost as much room as the entire face! The face! Where our mouth is! Where our eyes are! Where are ears are! Our identity! When it comes to the brain the hand is, quite literally, huge.

Enter neuroscience, almost all of whom focus on the brain. Neuroscientists are fascinated with the hand for a few reasons. First of all, because of its delicacy, if you figure out the hand the rest of the body is easy. If you are interested in motor learning there's no better laboratory than the hand.

But there may be another reason that neuroscientists are fascinated with the hand. Imagine if you doing clinical research on stroke survivors. They all are different ages, have had their stroke in different parts of their brain, they're all in different physical shape, they all have different diets, they all have different sequelae, etc. etc.

Now imagine you're doing research and you can have as many study participants as you want and they all have a stroke in exactly the same spot, be the same age, eat the same diet, wake up at the same time in the morning, always show up on time and that you can easily blind (not let them know which group there in) and are genetically related!

Where can you find such study participants? Rats! (And mice) But why rats and mice? Why are rats and mice so important to the equation of figuring out the science of motor learning in the hand? Here's why...

Freaky, huh?

"Best New Medical Weblog"!

I am very happy to report that one of my favorite websites ever Medgadget has nominated the Stroke Recovery Blog as a "Best New Medical Weblog"!

Also, this is the perfect time to tell you about Medgadget. It really is a cool site. It is a one-stop portal to emergent technology in medicine. For stroke survivors it is a good place to go every once in a while. There is a drop-down menu on the right side of the website which has an entry for "rehab".

Alternatively, you can put something like "stroke rehabilitation" into the search box. If you do that one such entry involves our team at the Drake Center rehabilitation hospital here in Cincinnati.

Tools, Techniques and Technology

I do a lot of seminars on driving cortical neuroplastic change, one of the unequivocal bedrocks of recovery, in stroke survivors. I've done talks in some of the best rehab hospitals in this country. I've also done talks in rural areas where the nearest rehab hospital is hundreds of miles away. Some of the attendees have access to a smorgasbord of leading-edge technologies. Some home care therapists have access to very little technology. And whatever technology they do have has to fit in the car. Some have immediate access to neurologists and physiatrists. Other's laugh when I say "Kick it upstairs to physiatry." "We rarely see any doctors,” they say. Rehab settings run the gamut; feast or famine or somewhere in between.

When I do talks I always remind myself of a particular touchstone that reminds me of why I, again and again, get up in front of therapists in the first place. It goes something like this: "If I was a stroke survivor knowing what I know about stroke recovery, what would I want therapist to know?" This question has served me well. I challenge clinicians as an informed advocate.

There are people, facilities and technologies that are essential to achieving the highest level of recovery. It is unfortunate that many facilities and therapists don’t have accesses to these tools. Stroke is the leading cause of long term disability. Recovery deserves the best tools. The clinical expertise is there. Clinicians spend a tremendous amount of time, energy and money being trained to be the best they can be. But just like every other profession from astronaut to auto mechanic, the right tools and access to the right people are essential.

During seminars I’ll ask, who has access to XYZ technology? Who has the availability of a physiatrist? Who has access to somebody who can do serial casting? Who has access to e-stim orthotics, or a particular splint or a partial weight supported trainer, etc.? Usually the same one or two or three people raise their hands. If the talk is in a hospital setting where all the clinicians are from that hospital they may all raise their hands. If it's a rural area where many are involved in skilled nursing or home health care, very few raise their hands.

Having access to and an understanding of a handful of technologies is essential to standard of care for stroke survivors. Also essential is access to clinicians with the right skill set. So what and who is essential? If I were to start "Pete's Center for Stroke Recovery" I would have access to the following before the doors ever opened.

Treadmills. Treadmills are never ending parallel bars. They expand the size of the gym with a very small footprint. Put a mirror in front of them and they become instantaneous feedback machines. They also provide an essential bit of quantifiable data: speed of gait.

Recumbent, 4-limb bilateral trainer. Recumbent trainers do not have to break the bank. Inexpensive ones can be found for $350 or so. These are essential not only as a pre-ambulation device, but also because they develop cardiovascular and muscular strength; "banking" both are essential to doing the hard work of recovery.

Some sort of harnessing system for gait training. Stroke recovery works best with over-challenge. Challenge drives neuroplasticity and neuroplasticity drives recovery. It's impossible to over challenge with standard gait training (a gait belt and guarding). The fear of falling on the part of the survivor and the therapist runs headlong into the challenge that needs to be realized. If the survivor is harnessed, falls are impossible and challenge flourishes. Partial weight sported walking is but one option that requires harnessing. Speed intensive treadmill training (also known as speed dependent treadmill training) has shown stellar efficacy in increasing speed of gait. The usual suspect in this category is the LiteGait. Over ground systems may be a better option for some gyms. NeuroGym, Biodex and other companies make over ground systems that provide an inexpensive harnessing option.

Cyclic electrical stimulation. The problem with e-stim generally is that the machines tend to intimidate most clinicians. But there are so many good things that e-stim dies that it is no longer optional. From reestablishing sensation to keeping soft tissue shortening at bay, e-stim is essential a certain points in the arc of recovery.

EMG based electrical stimulation (EMG-e-stim). This “next generation” of e-stim is important once a minute amount of movement is possible. It is believed that EMG-e-stim drives cortical changes which leads to small increases in movement. And small increases in movement are important in the early stages of repetitive practice paradigms.

Access to serial casting. Essential to fighting the good fight against soft tissue shortening. There are no splints that have shown clinical efficacy in increasing soft tissue length. Serial casting is the only nonsurgical treatment option to increase PROM of joints that have established contracture.

Access to neurologists, and especially physiatrists. Without them it's very difficult to deal with issues that range from spasticity to pain.

A constraint induced therapy (CIT) program. Although usually only benefiting higher-level stroke survivors, CIT is essential to the stroke recovery endgame.