Monday, December 24, 2012

Flexible and measurable DIY plan

Everyone needs a plan. At work we have schedules and care plans and goals. During our education we have schedules and syllabi and tests. Athletes, with the aid of coaches, have a plan for every practice, and benchmarks are built into every practice.

Most stroke survivors don't have a plan. Sure, therapists set a plan with goals during therapy. But once discharged, survivors tend to drift, hoping not to lose what has been recovered.  Instead, the most recovery is achieved when the focus is on further gains.

Upon discharge from traditional therapy, survivors enter a new chapter in recovery. Their recovery plan is essential in optimizing their recovery. This is true for the short-term, and for the rest of their lives. 

There are three aspects to every successful recovery plan.
Measurable benchmarks. Gains made during the chronic period after stroke are hard to see because they tend to be modest. Specific goals should be stated and strived for. If the patient says, "I will walk 500 yards by September," then a 500-yard route should be mapped out. The total goal should be chunked in a way that the survivor sees incremental gains toward the entire goal (i.e., 50, then 100, then 200 yards and so on).  

Focus on what YOU can do. For recovery to continue beyond the traditional therapy period, the survivor has to drive his own therapy. This dovetails well with the concept that for the brain to rewire, neuroplastcially, the patient has to drive his own nervous system. The recovery plan should emphasize self-reliance. Not only should survivors be able to do most of the therapy themselves, but they should also understand how to progress their efforts. 

Make the plan flexible. Stroke recovery research is galloping along. What comes of this research? New treatment options. All these new treatments dictates that the survivor be flexible enough to incorporate new ideas into their plan. But there's something else that requires flexibility: the survivor changes. One thing that every researcher agrees about: Intensity rules. So if the survivor chnages and intesity rules, the foucs must change while the level of intesity increases.

Otherwise you're just spinning your wheels.

Wednesday, December 19, 2012

Sen. Mark Kirk has skin in the game. Twice.

Below is a video of Sen. Mark Kirk. He had a stroke back in January. He appears to have left hemiparesis, and some dysarthria. He seems like a really hard worker who deserves to get every bit of recovery he can. He's a great inspiration. But.... He has this line at the very end of the video: 

"I can't wait to go back to work to vote to spend less..."

He is a fan of the way health care is being run now. And I guess he should be. It seems as if no expense was spared in his case. He probably has money, and that doesn't hurt. But much of it was paid for by his congressional healthcare plan. And here's some funny... 

Full article here.

Wednesday, December 12, 2012

You are an athlete.

[Addendum from a comment left by the author of the blog, "Thankful for everyday!" Here's the comment:
"When I first started having symptoms (not realizing I had a bleeding tumor) I thought I could "exercise away" all the bad only made me worse. I was sure I would feel better after pushing myself, WRONG."

RIGHT! In both human and animal models, too much exercise too soon can make things worse! You should not put "the pedal to the metal" until the sub-acute phase. Its a long story, and a bit more nuanced (and detailed in the 2nd ed. of Stronger). Wait for the MD and therapists to say "Go!" After day 14 just about everyone is ready for intensity. But for some survivors it may be significantly earlier. And you don't want to wait too long, because then learned non-use sets in.]

There are two kinds of survivors who recover from stroke faster than others: Athletes and musicians. (Anyone who has been a high level athlete, dancer, musician, etc.)

And while the manifestation of individual strokes would make my hypothesis near impossible to test, there are three reasons to believe that it may be true. 

Reason one: There may very well be hypertrophy of the motor portions of the brain in both athletes and musicians. We know that massed practice will reconfigure the brain, with new neurons recruited and new pathways developed. And which populations are, by definition, involved massed practice? Athletes and musicians. 

Reason two: As anyone who is either an athlete or a musician knows, both these populations know how to train. And I don't mean just, "Yeah, I did my therapy today" kind of training. I mean the "I dream about therapy, wake up and plan my day around therapy and dedicate most of my time to therapy" kind of training. 

Reason three: Athletes and musicians are often extremely motivated to get back to their instrument or their sport.

Both athletes and musicians understand all the factors that are important to stroke rehab. They know how to practice with vigor and focus. They know the commitment of time and resources that such practice involves. And they know that if their practice routine changes, they will get different results. 

Successful survivors are true athletes. Their "level of competition" is somewhat limited, to be sure. But, on the other hand, they have the most devoted fans in sport: Their loved ones. And their families and friends have every reason, both altruistic and self-serving, to coach, cajole, encourage, support and embolden their athlete towards success.

Thursday, December 6, 2012

Fish oil may help recovery.

Note: With regard to any supplementation -- Ask your doctor first. Ask your doctor first. Ask your doctor first. Thank you.

Fish oil may help many aspects of recovery from stroke. In my book (now in the second edition, available for pre-order, just sayin') I put it this way:

 Fish oil may help stroke survivors in two ways:
1. DHA and EPA may help to reduce swelling in the brain after stroke.
2. Fish oil helps overall function of the nervous system and is considered “neuroprotective” (a substance that protects the nervous system).

Fish oil helps promote the neuroplastic process and appears to help the brain recover after stroke. Fish oil helps restore a neurotransmitter after traumatic brain injury. It may do the same after stroke.

Fish oil "treatment is able to facilitate functional recovery after (stroke)." It probably also reduces mortality after stroke.

Great general discussion of fish oil here. It turns out that cheap fish oil is just as good as the expensive stuff.

Remember, always ask your doctor first!

Tuesday, November 20, 2012

Saebo in the news...

I'm a fan of one of this blog's advertisers, Saebo. The two guys who started the company are brothers, both occupational therapists. (Find another set of brothers that are both occupational therapists and I'll send you a free copy of my book.) I like the culture that Saebo brings to stroke recovery. Everything they make has a commonsensical perspective engineered in. 

Saebo makes the SaeboStretch. Unlike static splints which hold the hand in a static position, the SaeboStretch allows the fingers to flex when they need to (often to protect the joints of the fingers). The 'Stretch then slowly pushes the fingers back to the desired position. 
Link here.

And, as it turns out, Gabrielle Giffords sports one!

Monday, November 19, 2012

Stinking after droke

As stated before, I'm not a big fan of drinking after stroke. I found some interesting statements here about the issue:

The effects of alcohol may put you at further risk after a stroke, and you will need to review your drinking and consider cutting down, especially if you were a heavy drinker beforehand.There are a number of factors you need to consider – talk to your GP for more advice: 
  • Following a stroke you may be more vulnerable to alcohol and its negative effects such as sleep disturbance, poor balance and impaired speech. 
  • Alcohol may worsen mood swings and depression, which are common after a stroke. It may affect your memory and thinking, making you forgetful and less able to make sound judgements. 
  • If you are out after dark, you should remember that alcohol can reduce night vision by 25 per cent and slow down reaction times by 10-30 per cent. 
  • Alcohol acts on the kidneys, creating excessive amounts of urine, which may make you dehydrated. If you are suffering from headaches, the dehydrating effect of alcohol is likely to make them worse. 
  • Alcoholic drinks are high in calories that have no nutritional value. If you are less active than before your stroke, you will need to reduce your calorie intake (especially these ‘empty’ calories) to avoid becoming overweight. Alcohol may make it harder for your body to absorb essential nutrients such as vitamin B1 and calcium. If you are less active and not absorbing calcium properly, your bones may become weakened. 
  • Drinking alcohol may be harmful when taking medicines that are sometimes needed after a stroke. Ask your GP or pharmacist about whether you may drink at all and if so, what the sensible limits are for you. You may be advised to stop drinking for the first month or two after starting a new medicine so that your body can get used to its effects. 
  • If you are taking blood-thinning medications such as warfarin, it may be important to establish a routine of what you eat and drink. If you do drink you should ask at your anticoagulant clinic about your alcohol intake and how much you can safely drink on a regular basis.
 By: "stroke recovery blog" "stroke blog"

Friday, November 16, 2012

Gotcha. Can't win, don't try.

Bill a stroke survivor has trouble putting on headphones. 

He is able to get the headphones on using just his "good" side. Here's how he does it: First an earpiece on the "good" side and then use the same hand to move the other over to his "bad" side ear. 

Now let's say instead of using only the "good side" he uses both sides. His "good side" hand picks up the headphones, and then his "bad side" hand grasps the other side of the headphones and he puts them on. But in order to get the "bad side" involved he has to do a bunch of weird movements. He hikes up his shoulder, pulls his arm away from his body, and uses an awkward grasp to put the headphone on his ear.

Which do you think would be better? Which would be better in the short run? Which would be better in the long run?

In the short run it may be better to do it with just the "good" arm. It might be quicker, and take less effort. 

But in the long run what would be the effect? First of all he'll never learn how to use both arms for that skill. Also, since he's only using the "good" side for that movement, all the other tasks that use similar movements would not be practiced. And a lot of things use that same movement (Brushing teeth and hair, shaving, feeding, etc.) So he'd have less practice specific to putting on headphones, and then less carryover of that task to other tasks.

But here's the funny part: There are a lot of therapists who believe that he should do it one-handed. The thinking is this: The movement needed to complete the task of both arms is "bad" movement. 

And, so the thinking goes, the more "bad" movement that you use, the more that "bad" movement will be "ingrained". Like a bad habit.

This idea, that "bad" movement should not be encouraged always struck me strange on the face of it. This is the thinking: "The more you move the worse you'll get." 

But everything we know about the brain suggests exactly the opposite. The more you practice something the better you get.

There is a weird assumption that is made: You will never try to move better, you will only use the "bad" movement forevermore. The idea is, survivors don't know what good movement is. Because survivors don't know what good movement is, you need a therapist there to correct you. Which... I don't know about you... sounds like it'll cost you a lot of money.

But let's say they're right. Let's say that if you do the task with both arms you would never do it "correctly." Now you have a decision to make. Do you do it "incorrectly" for the rest of your life, or do you not try to use the "bad" arm?

It was me, I would make the decision to use the "bad" arm. Why? Well first of all I stand a much better chance of learning to move the "bad" side better if I use it in every day tasks... every day. Second, movements from one task can feed forward to other tasks that used similar movements. So I might retrain not just for one task, but for a whole bunch of tasks. Third, I don't let the whole portion of my brain "lie fallow" and not do anything. The brain hates not doing anything. The brain goes through what's called "a pruning of the dendritic arbor." It's a fancy way of saying "use it or lose it." If a portion of the brain is not used, the neurons in that part of the brain start to shrink -- or "prune."

But there's another important reason to use any movement you have. Maybe, at the "end of the day" the task remains awkward and uncoordinated. So what? How many people play golf, enjoy it, but don't play perfectly (all of us)? How many people ski, and enjoy it, and don't have perfect form? What about music, or painting, or writing...

Bart: You make me sick, Homer. You're the one that told me I could do anything if I just put my mind to it.
Homer: Well now that you're a little bit older I can tell you that's a crock. No matter how good you are at something, there's always about a million people better than you.
Bart: Gotcha. Can't win, don't try.

 This is my suggestion: Continue trying to do everything. And every time you do it try to make it a little bit better.  

Everybody wants to be an expert before they start. But to become an expert involves a lot of hard work. May as well begin now...

 By: "stroke recovery blog" "stroke blog"

Tuesday, November 13, 2012

Function: You get what you want but not what you need.

Function. Function. Function. Function.
That's all you ever hear. "We're trying to get the patient functional." 
Why? 2 reasons: 

1. You want survivors to be functional. You want them to be able do every day, real-world tasks. When therapy ends, the therapist wants the patient to be able to do as much for themselves as they possibly can. Function is a good thing, no doubt. 

2. Generally, function is paid for. Lets say the goal is walking. If the patient is not walking, at some point, you have to end therapy. And with the ending of therapy comes the ending of payment.

But there's a problem with this "focus on function." I can be functional and walking, but require a cane an orthotic on my ankle. The cane is used to overcome the weakness of the affected leg. The orthotic on the ankle is used to overcome the inability to lift the foot. Focusing on function means overcoming a deficit. Sounds good, right? But if you are using a cane an orthotic have you really overcome the deficit? Maybe we shouldn't chew. We can put everything in a blender.

I've long been an advocate of a focus on recovery, not function. Think of recovery as a game of soccer. Function is a score of 1 to 0. You win. But there are two ways to win. One way to win is to pick up the ball with your hands and throw it in the goal. The other is training hard, practicing with your team, getting in good shape, practicing skills, getting in the game, and putting all the practice into, well, practice. Using the "good" extremity to accomplish goals (known as compensatory movement), orthotics, assist devices, etc. etc. does not lead to recovery. 

Very often function flies in the face of recovery area. For instance, a person may very well have some dorsiflexion (the ability to lift the foot at the ankle). But the movement is often weak and incomplete. Therefore it is "nonfunctional." And so it is ignored. And if a movement is ignored the portion of the brain representing that movement will get smaller. 

And so the ability to lift the foot will decrease. And so the movement is ignored even more. And so there is less brain involved, and so on and so on and so on. This process is known as learned nonuse.
 By: "stroke recovery blog" "stroke blog"

Thursday, November 8, 2012

Therapy is upside down.

When a survivor first has their stroke the brain is very vulnerable. And because it's vulnerable the survivor shouldn't do very much. The first few days after stroke is a time to convalesce. There is a time to add intensity to the recovery effort. But during the first few days, generally referred to as the acute phase, is not when intensity should be attempted. There are more important things to do. Like saving as much brain is possible (the domain of medical doctors).
So what do therapists do during acute phase? Most therapists involved in acute care will tell you the same thing: "We do whatever they can." That is, whatever the patient is physically able to do is encouraged. But there is often not very much the stroke survivor can do. Yet therapy immediately after stroke is generous. There is often hours per day slated for acute care therapy. But that's not when hours are needed. Hours are needed during the subacute phase.

The subacute phase is usually defined as "seven days to three months." But this is actually a misrepresentation. The fact is, like anything with stroke, it's different for every survivor. Each phase, in fact, happens in a different time for each individual survivor. In any case, it's the subacute phase when intensive efforts towards recovery should begin. Yet for many stroke survivors there's actually a reduction in the number of hours of therapy during the subacute phase as compared to the acute phase. In this way, therapy for stroke survivors is upside down.

By: "stroke recovery blog" "stroke blog"

Saturday, October 20, 2012

Here Come the Vendors

I do a lot of talks about stroke recovery. About 80 per year. I learn so much from the therapists I talk to. Many of them are committed, caring, bright and motivated. I like the fact that I'm doing my talk to good people.

But there is one segment of therapists that can be tough to love. 

Attending my seminars have been lots people from a variety of companies. These companies usually represent products. Sometimes they represent services, clinical trials, organizations, etc. But usually it’s products. And for me, these people can be very dangerous. They either want to know what I'm saying about their product or want me to promote their product. Those who want to know what I'm saying about their product never voluntarily tell me where they work. Those that want to promote their product are just the opposite. At some point in the seminar they'll approach me and talk up their product. And it's always uncomfortable. 

Many of the products have little or no scientific evidence behind them. Doing the research to provide evidence for a product is expensive and laborious. It's quicker, cheaper and less fraught with risk to just put your product to market, and promote it. And I become a part of their promotion. So when I'm approached, it usually feels like hucksterism. It feels like I'm being sold on a product so that my seminar might become a platform for promotion.

People will hand me their card, and talk about the product. That card will become a reminder to look at product up. So how do I look it up? I try to strip away the product name in order to get to the core of the product, and then research that core. For example, let's say somebody is selling Stroke-A-Way. If I look up Stroke-A-Way all I'll find is what Stroke-A-Way wants me to find. So instead, I look up the "active ingredient" (concept, or exercise, or whatever). I try to see if the active ingredient is scientifically based.

But what if it doesn't work? A lot of times I can go straight to clinical research sites during the seminar and look the "active ingredient" up. I can also send out a quick e-mail to experts in the field (I've been in research for a long time; lots of contacts) and ask their opinion.

So: What if the product sucks?

If the product has no evidence, I don't advocate it. And if you're a vendor, and I say your product
has no evidence, you'll be pissed. But you shouldn't be. You're at the course, you read the course description, and you know I'm in research. So... I'm going to do the research.

I wish these folks would read their diploma. On there- someplace- is the word "science." It'll be an Associate of Science, a Bachelor of Science, a Masters of Science, or Doctorate of Science. When you got your license you dedicated yourself to providing treatment options based in... science.

So bringing it up in the seminar is not just dangerous for me, it's dangerous for the vendor. What if, because the vendor made me aware of the product, I research the product. And what if I find no evidence it works? The next time somebody asks me about the product I'll say there's no evidence behind it. I have to. It's my job. It probably would have been better had they not talked to me about it at all.

You know what the most widely read entry in this entire blog is? The entry on neuroaid. I only became aware of the product because they copped the name of this blog; The Stroke Recovery Blog. The theft got my attention, and made me do the research to find out that it...
  • had a very low level of evidence behind it
  • was available in a less expensive form
  • used researchers who had a clear conflict of interest to promote it.
So if you get my attention, be prepared for the inevitable question: Is it evidence-based? This is my job. And I talked to  a lot of stroke survivors who want it to be the job of every clinician. Figure out what works, and then do it. And the stuff the doesn't work. Don't do it.

BTW: Frankly, I don't necessarily advocate the products advertised on this blog. However, I will not accept advertisement for products A)
that clearly don't work or B) competing products exists which better provide the "active ingredient."
By: "stroke recovery blog" "stroke blog"

Wednesday, October 10, 2012

Sex After Stroke

A recent article showed that sex was at least "least somewhat important" in approximately half of men 75 years and older. Odds were reduced in interest and participation in sexual activity the higher the age, if the partner had physical limitations and the use of antidepressants and beta blockers.

So what is the effect of stroke on sexual activity? 
Almost 75% of strokes occur in folks over 65. Added to the advanced age of most stroke survivors there is also usually add increase in medications as a result of a stroke. There are also the mental and physical impacts of stroke that take a toll on sexuality. Included reasons are to believe that the stroke may affect the relationship, financial issues and low self-esteem.

Stroke is not usually cause sexual dysfunction. 
But there are a variety of us psychological issues that do impact sex after stroke. The new challenges that stroke survivors and caregivers have to go through when they get home block out everything else. Scheduling health care workers, dealing with managed care and paperwork, as well challenges of getting to and from all the appointments are just some of the problems that get in the way of other, more fun, things. There is a period after stroke in which sex usually doesn't take place. But this little is usually temporary. For instance, 80% of men with erectile dysfunction after stroke regained the ability to have sex a few months later. And that change was spontaneous.

There is a general belief that after stroke sex can cause another stroke. This hardly ever happens (although it may be true in people with parallel heart disease -- consult your physician). Despite the fact that sex is safe after stroke as many as half of all survivors fear that sex may cause harm. Many partners of survivors also have fear that sex will cause another stroke in their partner.

By: "stroke recovery blog" "stroke blog"

Wednesday, October 3, 2012

Walking in Rhythm

During stroke recovery "the good trains the bad." This is known as "bilateral training." In anyone, stroke or not, it is true "the good trains the bad." Here's an example: I'm a drummer. I'm right-hand dominant. If I try to tap my left hand as fast as I can it is not as fast as if I tap it alternately with the right dominant hand. Research has found that my left hand will not only be quicker, but it will be more accurate when I do the movement with my right hand. So I will be both faster and hit the drum where it should be hit.

In stroke survivors bilateral training can be used to begin the recovery process. And it can be used to help stroke survivors with very little movement. Survivors with very little movement are sometimes called "lower-level." (This designation says nothing about the ability to think, only the ability to move.) The reason bilateral training works for lower-level stroke survivors is because the way bilateral training may work. And I say may, because nobody's really sure. Bilateral training may work because the two limbs communicate with each other even when that communication does not go through the brain. It's the reason infants step even before they can walk.
Click here: See a baby walk before it can walk

It's why, in animal experiments, you can sever the spinal cord but the back legs will automatically go into walking pattern when they're put on a treadmill. It has to do with neural networks that are in the spinal cord. These networks are collectively called the central pattern generator (CPG). The CPG allows for limbs to communicate from the fingertips of one hand to the fingertips of the opposite hand (or "toe to toe"), right through the spinal cord.

In the arms and legs, bilateral training is relatively straightforward. In the arms you would have each arm trying to hit a target. You could have both hands attempting to alternate to hit a target. You could also have it set up so the "good "hand has to hit a target that much further away than the "bad" hand. You can also do this with a rhythm. The idea would be to use a metronome (click, click, click, rhythmically) or music where the drumbeat would dictate when each hand would have to meet the target.

In the lower extremity it similar: there is a rhythmic component. You would try to take exactly the same step length with the "good" and "bad" legs. A rhythmic component is added the same way as the arms: music, or a metronome is used to establish be in each footfall happens on each beat. It is thought that reestablishing the rhythmicity of gait will help reestablish the symmetry of gait.

As I said in a PT trade mag...

"A simple metronome either heard through headphones or carried by the therapist next to the stroke survivor can be used to promote the re-establishment of rhythmicity of gait. Plugging the ears using standard noise-reducing plugs can boost the volume of footfall to make that obvious to the survivor. The trick is then to match the footfall to the beat."

By: "stroke recovery blog" "stroke blog"

Friday, September 21, 2012

Stroke = Dog Tired

As many as 70% of stroke survivors complain about fatigue. Many stroke survivors think that fatigue is the worst thing caused by their stroke. 

Stroke survivors should be four times as tired as everyone else, and I can prove it. Research shows that, when you compare survivors to age-matched “couch potatoes," the stroke survivors are in half as good cardiovascular health. Research also shows that most everything (i.e. walking, dressing, bathing etc.) takes twice as much energy after a stroke. Mathematically… 

(Twice as much energy needed) 

x (half as much energy available) 
= (I need a nap)

The best thing you can do is stay in good cardiovascular and muscular shape. This means resistance training and cardio work. It may be counter-intuitive, but exercise increases energy. Other things that will help increase energy levels include 

• Eating well 
• drinking plenty of water 
• sleeping well

"stroke recovery blog"  "stroke blog"  "stronger after stroke blog"

Tuesday, September 18, 2012

What do doctors know?

Show me a neurologist or physiatrist who does not know that recovery can continue after a year and I'll show you someone who should lose their license.

In some ways doctors are forced by the Hippocratic Oath to lowball any estimate of recovery. If a doctor says you won't recover, and then you do, they can say “Great!” If a doctor says, "You can expect a great recovery” and you don't, they have done you harm.

In terms of having a doctor understand rehabilitation per se, it's probably not going to happen. The responsibility for rehabilitation is offloaded to therapists. The one exception to this may be physiatrists. However, although they may be very aware of various recovery options, they are not trained in rehabilitation techniques.

Of course, MDs can be a driving force towards recovery. Each clinician (MD, therapist) has a unique role to play. Some MDs are not very well versed in all things recovery. If you want to find aggressive MDs and therapists, click this link >>> 

By: "stroke recovery blog"  "stroke blog"  "stronger after stroke blog"

Thursday, September 13, 2012

Reading to Recover

Ever want trip up a therapist? Ask this question: What's the latest stroke recovery research say? The answers will be, politely, inconsistent. Some therapists actually know a lot. Others haven't read their professional journals, ever. Look for facilities and therapists that are "evidence-based" (basing treatment on the best available scientific evidence). Being evidence-based is sort of like having a GPS.

Imagine you have two people; one person has an absolutely stellar sense of direction. They never seem to get lost. The other person has no sense direction at all. They get lost in their own neighborhood. Let's say the “neighborhood looser” buys a GPS. Now who has a better sense of direction?

Imagine you have two therapists; one therapist is very smart, intuitive, conscientious, and caring. Everyone says they are a great therapist. The other therapist is sloppy, snotty and disorganized. Let's say snotty therapist reads a lot of stroke recovery research and implements what he reads. Now who is the better therapist?

By: "stroke recovery blog"  "stroke blog"  "stronger after stroke blog"

Thursday, September 6, 2012

Simple. Brain. Recovery. Game.

Stroke recovery involves neuroplasticity. You can slice it and you can dice it but the bottom line always comes back to stroke as brain injury -- and how to overcome it. If you can't get the brain to reorganize around the injury, recovery is toast.

• Spasticity: caused by brain damage.

• Inability to feel the movement: caused by brain damage.

• Unilateral neglect (decreased attention to the “bad” side): caused by brain damage.

• Lack of control over the affected arm and leg: caused by brain damage.

• Aphasia: caused by brain damage

• Vision problems: caused by brain damage

• And much more!: caused by brain damage

So the answer to the question “… how might movement problems be overcome?” is simple: Rewire your brain.

And it is good that it is simple because only the stroke survivor can do it. A therapist could have a double major physical and occupational therapist PhD from Harvard school of Super Duper Rehab summa cum laude with postdoctoral training as a Rhodes Scholar and they still can't do it for you. You know the old Smokey the Bear poster: "Only you can prevent forest fires"? For stroke survivors the poster should say: "Only you can drive neuroplastic change". Fortunately, the rules for rewiring your brain are very, very simple. Unfortunately, rewiring takes a tremendous amount of hard work.

And what does it take? Repetitive practice.
Repetitive practice is boring.
So try spicing up with a video game yay!

"stroke recovery blog" "stroke recovery blog" "stroke recovery blog" "stroke recovery blog" "stroke recovery blog" "stroke recovery blog" "stroke recovery blog"

Wednesday, August 15, 2012

When all you have is a hammer everything looks like a nail

I got an email from an author the other day. He’s written a book about stroke recovery. He said that he’d heard that I did “...not like presenting other peoples' work as helpful for stroke survivors." I explained to him my position this way:

I work in rehab research; have since the 90's. All of that research has been stroke-specific. One of the things I've learned is that clinicians had made the mistake over and over and over (for decades) of buying into completely ineffective treatment options. They did this for 2 reasons:

1. The treatment had/has a charismatic leader
2. Clinicians in rehab don't typically read research.

So even if large studies came out and say "Those things don't work" clinicians just kept/keep on doing (and promoting, and selling books about, and teaching) them. And then there are categories of "treatments" that have no research (standardized, controlled trials) at all supporting them. So in my talks (I do many) I start by saying "Most of what has been used for stroke recovery is ineffective or untested. Here's what we think we know…” And most clinitians get it. They're pros. They want better tools.

I actually promote (when appropriate) a bunch of people and ideas. But anything endorsed is evidenced based and what that means is very specific: Has the treatment option reached meta-analysis and did that meta-analysis show efficacy? If it has and it does I'm all in.

If not, I let people know.

What I find from survivors is that they want us to hash this stuff out. They want us to have these discussions and not just stick with the same old because it’s what we feel comfortable.

Tuesday, August 7, 2012

E-Stim. If dude can do it, so can you.

(EZ directions for doing electrical stimulation after stroke can be found here)

Electrical stimulation (e-stim) after stroke is the single most important modality there is for recovery. A modality is...application of something therapeutic like a hot pack or cold gel or...e-stim. Part of the reason e-stim is so important is that it does so many different things. 

Drunk smoking guys 

use e-stim for fun!

But here's some funny: Some OTs (occupational therapists) cannot do e-stim clinically. Why? It turns out that—in some States—OTs have to get a special post-secondary education certification to do it. Which was always weird to me. You know that ad where you can use the stim "ab-exerciser" that’s supposed to give you ripped abs while you lounge around because the e-stim builds muscle? And who’s ordering that? Some drunk guy at 2 in the morning. HE can do it, but OTs can't? 

E-stim does so much that its lack of use clinically for survivors has flummoxed me for years. The reasons given for not doing it clinically tend to be of the Its too complex to set up variety. 
Jesse says: 
E-stim is not just for 
drunk folks and kids!

Enter my 10 year old son, Jesse. I have a lot of e-stim machines stored in my basement. I've accumulated them over time in various ways. And boys will be boys, and boys (and their friends) will go into the basement and put electrodes all over themselves and turn up the stim and see what pops. And they figure the machine out. Because e-stim works like this: Put on the electrodes (they stick to your skin) and turn up the stim. And see what happens. And that’s it.

And yet many clinicians shy away from e-stim. They shy away from something that can do everything from help recovery of sensation, to stretching to building muscle to starting the neuroplastic process. So talk to 'em. And if they have any questions, tell 'em to email me.

Note: There are some serious contraindications to doing estim in some folks. i.e., they can mess up pacemakers and other electronic devices. So always ask your doc first!

Tuesday, July 24, 2012

The perfect time to have a stroke?

I'd argue that the "best" age to have a stroke is 27. The entire brain is fully wired (the frontal lobe wires in the 26th year). You're young enough to undertake the rigors of recovery (recovery is statistically better the younger you are). But you're old enough to have your brain wired "normally" (recovery in children is often a mixed bag because the brain is not yet fully developed).

But what is the best day to have a stroke? Any day but the weekend. Turns out the having a stroke on the w/e means lower quality care than during the week. 

Saturday, July 21, 2012

Will and imagination

I do a ton of talks on stroke recovery. I come from the world of research. So my perspective is a bit different to the rehab clinicians I talk to. I do my best to ease them into the world of research. I explain where they can find leading edge stroke rehab info for themselves. I describe where we are in researching stroke recovery (not very far I’m afraid). I explain how the stuff from research can be used with their patients.

And there’s the rub. Therapists and other folks in rehab sometimes have a bit of difficulty imagining how to transfer the research to their practice.

"I'm in acute care (or skilled nursing, or an outpatient clinic, or in home care, or in long term care, etc.).  I can't implement this stuff. It takes too much time (or we don't have the equipment, or don't know how to bill for it, or nursing won't follow through, etc.). This stuff can't be used on my patients because they're not motivated enough (or have too many other medical problems, or are too "low level", or are too old, etc.)"

The core concepts of relearning how to move after stroke are simple. These concepts don’t have to be done clinically the way they’re done in research. In fact, they are often more effective in the clinic. They may be more effective because clinicians can change the treatment to fit individual survivors.  Research involves a one-size-fits-all implementation. Therapists can add and subtract, slow down and speed up, skip or add more treatments.  In research all those screw up consistency.

Some therapists have no problem with implementing this stuff. Some go well beyond what I suggest. For instance, they may dovetail suggested treatment options in a mix that is beyond anything researched. (Note to clinicians who do this: make sure you use valid and reliable outcome measures to prove to yourself that these things work.)

Whats the difference between those who can and those who can't?

Will and imagination.

Tuesday, July 3, 2012

A test that predicts when survivors may die

A test of mental ability after stroke can predict how long a survivor will live (Find the study here.)

Poor performance on these tests can predict mortality in stroke survivors, a full decade before death. Previous tests have shown a link between heart disease and dementia after stroke and mortality. This is the first to show small amounts of cognitive decline correlating to mortality.

Here are the tests that they used.
The longer it takes to do the tests the more "impaired psychomotor speed." Participants that were the slowest third of the group for both tests were more likely to die.

In this study, the mean result for TMT A was 47 seconds and for TMT B, 119 seconds.

Also a decline in mental function before a stroke can be an indicator of an impending stroke.

Good luck!

Saturday, June 30, 2012

What else can I do?

There is an inaccuracy in a recent Amazon review of Stronger After Stroke that I must correct... 

Here is part of the review:

"I have not read the book, but one of the reasons my father in law suffered a stroke was because he's blood pressure was too high due to alcohol consumption. In this book it says it's ok to have 4 oz of alcohol a day so my father in law has started drinking again. So I'm hoping I didn't start up the drinking with him by giving him this book."

Actually, there is no mention of alcohol at all, any place in the book. But the author of the review hadn't read the book, so how would they know?

Here's a part of the story that may be interesting only to me: I contacted Amazon, asking them to consider taking the review down. Amazon will only take down a review "If it in violation of one of Amazon's posted guidelines." One of posted guidelines is: "Customer reviews should be relevant to the product in question." The reviewer is clearly reviewing hearsay, not a book. In any case, I was amazed that Amazon has declined to take the review down. I'm a huge fan of Amazon! I'm disappointed.

I'm not an advocate of drinking after stroke.

Thank you.S

Saturday, June 23, 2012

Demanding Repetition

I do a lot of talks on stroke recovery. From Alaska to Florida, from New Hampshire to San Diego I'm all over the place all the time. I do these talks  for therapists; OT, PT, speech. Survivors and their caregivers show up as well. Also, medical device people, nurses, physiatrists, etc. So I get to talk to a lot of people about stroke. I always do the best I can to make things as simple as possible. Here is a really simple but profound way to look at stroke recovery...


That's it. Repetitive practice of the movement or sound or walking or skill or whatever. Of course repetitive practice has the habit of doing two things: 1) causing people to repeat things that they can do pretty well, over and over. 2) Plateau. People plateau (don't get any better) because they keep doing what they can do pretty well over and over.

That's where demanding comes in. Repeatedly practice the skill in a way that "nips at the edges" of your current ability.

Repetitive without demanding and progress will slow to a crawl.
Demanding without enough repetition will halt progress."the stroke blog" "The stroke recovery blog"

Sunday, June 10, 2012

Does "X" aid recovery after stroke?

What works and what doesn't work to help recover after stroke? Research has revealed three broad categories:
1. It works
2. It doesn't work
3. We don't know yet

There is tons we don't know about stroke recovery. Stroke recovery is a million different puzzle pieces, with no picture on the front of the box to help out. But there are some resources to help answer some of the questions (at least)...

There is one website that answers, in layman's terms, what works and what doesn't work. Although the list is far from complete, it's a start. Thank you Canada!

stroke blog

stroke blogs

Monday, May 21, 2012

Stroke Recovery. Its About Time.

Stroke survivors are given such a short time to recover. For everyone "motor learning" takes repeated attempts in order to rewire the brain. How much more effort must motor learning take in folks who have billions of neurons killed by their stroke? The numbers get very large. I've heard "2000 for a single joint" and " 140,00" "and "10,000" and "Tens of thousands" and" millions." But guess what? Every stroke is different. So the numbers for you and how you are trying to move are different than her and what she is trying to move. I think I've come up with the perfect number for everyone. This is based on my dozens of peer-reviewed coauthored studies, and clinical research at both the Kessler Institute and the U of Cincinnati. But the number is algorithmic and gets very complicated. Ready? Here's the number...

"A lot."

It is commonly and scientifically accepted that that it takes at least 10 years to become an expert in any field. We ask stroke survivors to relearn difficult tasks such as walking within a few months to a few years of their stroke. And all this difficult motor learning is done against a backdrop in which portions of the brain that is usually used for walking is deceased. And then there's all the other variables like other health issues, depression, lack of energy, natural aging and on and on.

Anyone who has children and has gone through boxes and boxes of Band-Aids and knows that motor learning is a challenge. Skinned knees and elbows attest to this. It takes years for children to learn how to walk. How much time do we give stroke survivors whose primary neuronal circuitry for walking has been taken off-line —6 months? Stroke survivors are best served through a combination of personal empowerment and guidance from therapists. No matter how ugly, no matter how synergistic, no matter how submerged in spasticity, each volitional movement should be encouraged. People with acquired brain injury will only drive their own neuroplastic rewiring through repeated volitional attempts, that “nip at the edges” of their ability. Therapists have traditionally focused more on quality of movement and functional relevance than on a confluence of gained active range of motion. No matter how incremental, increased active range of motion in all pivots and planes provides a template for any and all future movements.

Friday, May 4, 2012

Video games+Tennis balls+ Anger=Recovery

A great article in the British newspaper The Telegraph. The article is by a stroke survivor who recovered well after an ischemic (block) stroke. He's hit on some very core ideas. Here are the most important points (comments in red are mine):
  • "...nobody in the hospital was going to tell me how to get better ..."
  • "I had to get out of hospital and cure myself."
  • "...found that major strides had been made in America in treating stroke victims." (USA! USA! USA!)
  • "Research there showed that damaged neural pathways could be re-routed" (Taub! Taub! Taub!)
  • "The key was speed. After three or four weeks, the brain seemed to start a permanent shut-down on these pathways." Not true. But the guy is a "High Master" which I think is a principal. He can be forgiven.
  • "I decided to bounce a tennis ball 2,000 times a day off the kitchen floor, missed catches not counting." Obsessive repetitive practice. I love it.
  • "The first day it took four hours to reach the target." Ambitious repetitive practice.
  • "...wrote out the alphabet, one line per letter, for two hours a day." Brilliant, I think the British say.
  • "I vowed to (type) 10 pages a day, typing out my corrections on my latest book with one finger. The first 10 pages took three days." I love this guy.
  • "I decided to recite the poems of Andrew Marvell for two hours a day..." Fighting aphasia by using something meaningful. This guy may have missed his calling: neuroscience.
  • "I marched up and down the stripes on the lawn for two hours a day." Very Monty Python.
  • To reestablish I coordination he used "a computer game flying a virtual F15 jet - or, in my case, crashing it thousands of times on the runway before finally landing it - after 40 hours' "flying" time." I think this is great. The idea of doing something fun to recover. When else in the middle of somebody's career are they allowed to play 40 hours of any game?
  • "I came close to giving up the grind of rehab. But by choosing tasks like writing the alphabet or counting how many times I could walk down the lawn without crossing a stripe, I could monitor my own progress." Okay, two things: close to giving up. But not giving up. And second: being able to "monitor progress" is essential to recovery because if you don't monitor things closely how do you know if you are getting any better?
  • "The difference between success and failure was...a deep anger that I was not offered more help to start with" You know, even Gandhi was not against anger. He just said you should use it wisely because it's very powerful. I'd say using anger to recover from stroke is using anger wisely. 
    •  Gandhi on Anger  "I have learned through bitter experience the one supreme lesson to conserve my anger, and as heat conserved is transmuted into energy, even so our anger controlled can be transmuted into a power which can move the world." 
Bravo High Master of stroke recovery!

Find the article here.

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