Monday, April 29, 2013

Details are the devil

Because it involves the brain, stroke recovery is complicated. The brain is complicated, so anything that involves the brain is complicated as well.

Except that's not true. And it's more than not true. Complexity, when it comes to stroke recovery, is evil. 

Of course, complexity is out there if you want it. There are "treatment options" that force therapists to spend thousands of dollars and weeks of their life getting trained in the devil in the details. Some of these treatment options have been around for 40 years, but new ones are invented every year. Do these therapies work? They generally fall into two categories; 1. Been around forever, the data doesn't look good. 2. They're completely untested.

Anyhoo... with regard to stroke, complexity is evil. Complexity separates the survivor from recovery. Why? It turns out that no matter what any clinician is telling you, only you can make you better. Remember the old-fashioned way of saying "teach me?" It was "learn me." Learn me to do math. No one can you learn you stuff. You have to learn it. That seems rational to just about everyone when it comes to learning that involves the brain; things like learning math and chemistry and French. But for some reasons when we talking about movement, its not considered learning. But it is.
  • Learning math involves changes in the structure and function of neurons in the brain. So does learning how to move.
  • Learning math involves neurons in the cortex (the outer shell of the brain). So does learning how to move.
  • Learning math involves repeated attempts towards the correct outcome. So does learning how to move.
  • Learning math increasing complexity. So does learning how to move.

How complexity kills recovery.
  • If instructions from a clinician are complicated ("Move your arm up but keep you shoulder down now turn your hand blah blah blah") movement performance gets worse.
  • If the pieces that go into recovery are complicated the survivor will not be able to drive their nervous system towards recovery. Complexity make it impossible for survivors to work towards recovery on their own.
  • Learning complicated treatment options ties up clinician's scarce education resources (time and money).
In every sense of the word, regaining the ability to move after stroke is learning. People, especially clinicians, want to talk about muscle weakness. "These exercise will help you move better." No they won't. What helps you relearn how to move after stroke is moving, not exercise. Of course, there's a fine line between the exercise and movement needed to relearn movement. But the emphasis on trying to build muscle is as mistaken as changing the oil in a car with no gas: Its a good thing, but hardly the main issue.

Monday, April 15, 2013

Recovery with a Beat

With the lower extremity "function" is inherently bilateral. That is, because the primary function of the lower extremities is ambulation, bilaterality is inherent. 

(By "advantage" I do not suggest that I buy into the concept that the lower extremities come back before the upper extremities post-stroke. This is common wisdom in rehab, but it may be incorrect. The only way to prove the lower extremity comes back before the upper extremity would be to measure the most distal element of both: the fingers and toes. Measuring toe extension in comparison to finger extension has, to my knowledge, never been done.)

Beyond bilaterality, ambulation is also inherently rhythmic. The rhythm after stroke is disrupted and made unequal. And rhythm is what bilateral leg training with rhythmic auditory cueing attempts to re-establish in the lower extremity.

That is, if you re-establish the rhythm of gait, you will go a long way to re-establish symmetry of both step length and step timing.

There are commercial systems that use a heel switch so that the moment of heel strike is radio-delivered to headphones. The patient hears their own heel strike through the headphones, as well as a beat that they have to match with each heel strike.

But as is true with many technologies purported to help stroke survivors relearn movement, no special system is really needed to bring the idea of rhythmicity into gait.

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. 

Wednesday, April 3, 2013

Intention tremor, and a possible neuroplastic treatment

In stroke intention tremor is caused by damage to the cerebellum. 

The cerebellum is important in fine coordination. If the stroke damages the cerebellum fine motor coordination suffers. 

(Note: Intention tremor is different from essential tremor, often found in Parkinson's) 

It is called intention tremor because the tremor happens when somebody moves intentionally. So let's say the intended movement is touching the nose with a fingertip. With intention tremor, the trajectory toward the nose is good until the finger gets close to the nose (closer to the intended target) and the tremor begins. As the New York Times put it:

Intention (or kinetic) tremors: These tremors occur at the end of a purposeful (intended) movement, such as writing, pressing a button, or reaching for an object. The tremor will often disappear while the affected body part is at rest.

Outside of stroke it is often seen in long-term alcoholics. So here's my first suggestion: If you have intention tremors, don't drink. Other drugs can cause tremors as well. So, the "Brown Bag Medication Review" may help in reducing tremors.

How has intention tremor typically been treated? 

Intention tremor is notoriously difficult to treat. There are several drugs that are used for treatment, but they all work for some of the people some of the time. (Here's an example of an herbal "remedy.")

Other things that had been tried:

Physical therapy: In some people it works great to temporarily reduce tremors. It's not cure.
Meditation, yoga, deep breathing exercises, biofeedback have all been used with varying levels of success.

The neuroplastic model
So what is the neuroplastic model for overcoming intention tremor? I guess the first question is: Is there a neuroplastic model? Is there anything that can be done to rewire the brain "around" this movement disorder?

We will wait for neuroscience to catch up to that question. It could take decades, it could take centuries. On the other hand, somebody could come up with a really good way of applying the brain's inherent plasticity tomorrow. So you never know.

Having said all that, I still have some suggestions that may very well rewire the brain to help overcome this issue. Here are my suggestions:

Mirror therapy. This is the way that mirror therapy would be applied:

Just like in mirror therapy for movement recovery, you look only at the "good" side. That is, you only see the flawless movement of the unaffected side.

Bimanual training. This option involves having the "good" train the "bad." It's a simple enough concept; whatever the good hand does, the bad hand attempts to copy.

Monday, April 1, 2013

Your meds are probably wrong. And its probably gonna hurt.

The statistics about medications and falls are pretty clear. The more medications, the more chance of falls. This is as true in stroke survivors as anybody else. 

But stroke survivors automatically have two additional things going against them:
1. They are usually on more medications
2. They are more likely to fall in the first place

But there are other reasons to reconsider medications. In 2008 almost 2,000,000 people became ill or injured because of the use of prescription drugs. These are from "medication errors." 

So how do you go about reconsidering medications? The "Brown Bag Medication Review." And you should do it. (My favorite line: “Out of 10-15 brown bag reviews, only 2 were accurate.”) About 50% of the time the meds will, in some way, be wrong.
The idea is you throw all your medications in a brown paper bag.
In the bag should be... 
  • All prescription medicines (including pills and creams).
  • All over-the-counter medicine they take regularly.
  • All vitamins and supplements.
  • All herbal medicines.
All medications are placed on the counter in the exam room. The physician or pharmacist, with your help, decides which meds to keep, which to pitch and which dosages to tweak. Also decided...

• Tips for safe and effective medication use
• Answers to your questions about medications 

Once the whole thing is  figured out you are given a card that has all the information on it. This information would be available for you to review, and for you to hand to doctors, dentists, etc. who may need to know your medications at a glance.

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