Saturday, November 30, 2013

Cerebellar stroke

Somebody gave my book a crappy review because there's nothing specifically about  cerebellar strokes. But there is. A stroke can happen in the cerebrum, cerebellum, or brain stem. I don't have anything specifically about the cerebrum strokes or brain stem strokes or cerebellar strokes. I just have stuff about stroke. 

Is there something inherently different about cerebellar stroke vis-a-vie strokes in the cerebrum or brain stem? No. What about a stroke that hits the posterolateral thalamus? Maybe the folks who have had a stroke that hit the posterolateral thalamus (or was exclusive to white matter or only hit the pituitary gland, or any of the other dozens of structures in the brain) should get their own chapters or books.  Actually, I'd love to see that happen. In the mean time, my book is a review of the neuroplastic process that encompasses all of those. Recovery from all of them fall under the same neuroplastic model of stroke recovery.

I don't like the template for recovery being contingent on where the stroke is. Again and again I stress that the view that the brain is NOT cordoned off into specific compartments that necessarily control specific functions. This notion, that the brain is sectioned off into independent exclusive sections is called the "mechanistic view of the brain". In fact, in my book there is a whole section (NEUROPLASTICITY AND HOW SCIENCE GOT IT WRONG) about this (brain=machine) mistaken perspective. 

Is there something inherently different about cerebellar stroke? No. 

What does the cerebellum do?

Cerebellum is Latin for "little brain." It sits at the bottom and back of the brain (3D animation here). The cerebellum is involved in providing precision and coordination movement. The cerebellum is said to "calibrate" movement. It doesn't initiate movement, it just makes movement smooth and coordinated. People who have had a cerebellar stroke often have an uncoordinated tremor. For example, if they were to reach out and try to touch target in front of them, and then their nose they would have difficulty targeting towards both. As the person got closer to the target end to their nose tremor in the targeting finger would increase. This phenomenon, called ataxia, is very similar to a phenomenon known as intention tremor. Find a possible neuroplastic option for the treatment of intention tremor here.

Notes about the cerebellum and cerebellar stroke.
  • Compared to the rest of the brain, damage to the cerebellum is a little "backwards." In most strokes, if the stroke affects the right side of the brain, the left side of the body is weak or paralyzed, and vice versa. With the cerebellum is the stroke is on the right side, the right side of the body is affected.
  • Cerebellar strokes are unusual. About 2% of all strokes are cerebellar.
  • It would be well and good to assume that the cerebellum is only involved in coordinating movement. However, like much of the brain, the cerebellum is poorly understood. It is now believed to have at least some role in higher level thinking as well as emotions
  • (Find an interesting piece on a cerebellar stroke survivor here.)
How do I rehab after cerebellar stroke?

It turns out that the same rules of plasticity available to the rest of the  brain are available to the cerebellum as well. Here's my suggestion: Forget about where the stroke was. Instead, focus your efforts on sequalae.

Sunday, November 10, 2013

The Vanillaization of Your Recovery

I'm not a big fan of WebMD. I'm not even sure why people read it. I guess if you just "Google it" -- whatever "it" is, WebMD is one of the first things to show up. But imagine if you had to rely on this site for serious information about anything medical? It seems that everything I read on it is a sort of a whitewashed, dated, vanilla attempt.
For example: I read an article on WebMD recently entitled, "Stroke Recovery and Arm Rehab: Important Questions." Poststroke arm rehab is one of my areas of interest, so I at least wanted to see what it said. Here's what the article says: Nothing about: arm rehab. Which you think it would've said something about arm rehab. Because it's in the title.

What I found instead was a bunch of, you guessed it, whitewashed, dated vanilla. The article is in a question and answer format. Below, I paraphrase them, and then add my

1. What caused my stroke?
What WebMD says, paraphrased: Types of stroke, relative incidence, etc.

What I say: This is the same information that can be found everywhere on the web. By the time most stroke survivors leave the hospital they are going to know most of this stuff.

2. Am I at risk for a second stroke?
What WebMD says, paraphrased: Yes, you are, talk to your doctor.
What I say: Yawn

3. What is the stroke recovery process?
What WebMD says, paraphrased: Your rehab program will be tailored to you. You'll do "assisted exercises" in the hospital. Then you may go to a rehab hospital, and then home. Rehabilitation takes place for 3-6 months. But "patients" can continue to make gains after this if you "... practice the skills (you) learned in rehabilitation."

What I say: "Assisted exercises" is meaningless. In the hospital survivors will generally be called upon to do whatever it is that they can do, assisted or otherwise. The article does say that you "may go to an inpatient rehab facility" but it does not add "if you are lucky." It also says that you'll go home. Nursing homes are full of people that didn't make it that far. 

The idea that you will continue to make progress if you practice the skills that you learned in rehabilitation is nonsense. The reason that people plateau is because they continue to practice the same thing in the same way.

4. How long will my recovery from stroke take?
What WebMD says, paraphrased: Recovery is different for everyone, but for most it's a lifelong process.

What I say: If it's a lifelong process you're doing it wrong. Recovery ends at the point in which you have recovered enough to spend too much time living to spend more time recovering. Maybe they mean that exercise should continue through the end of life.

5. Am I at risk for depression after a stroke?
What WebMD says, paraphrased: Becoming depressed after stroke is common because of the changes in the brain and because of the lamenting of losses caused by the stroke. Depression can be treated with medication and/or counseling.

What I say: You know what else is a great treatment for mild to moderate depression? Exercise. I would think that's pretty germane to this article. Just sayin'.

6. What medications will I be taking and do they have any side effects?
What WebMD says, paraphrased: You'll probably be put on a blood thinner. Talk to your doctor.

What I say: Hopefully you are not reading an article to find out about post stroke medications.

7. When should I call my doctor?

What WebMD says, paraphrased: If you have symptoms of a stroke. They then list the symptoms.

What I say: No quarrel with this one.

So there it is. Now you know how to use your arm again. Off you go!

Saturday, November 9, 2013

Acute stroke care, environmental complexity, and the damned cell phone

In a recent seminar I was talking about how, in a general sense, the more complex the environment after stroke, the better. The idea is that "environmental complexity" leads to further recovery.

Hospitals are the real problem. In the hospital survivors are not much engaged after their stroke. Compared to prior to their stroke survivors have less conversations, less time to play, learn and socialize. And the brain hates this comparative social isolation. The brain hates it so much that the brain ends up learning movement less than if the survivor was engaged. Bottom line, have the survivor involved in conversations (as best they can) play with objects (tinker), play games, etc.

But. There may be a limit.

I was talking to a therapist at one of my seminars and she was saying that she agreed that increasing environmental complexity was a good thing. But, she said, often caregiver descend on the survivors room but are so engaged with their cells and iPads that the survivor gets a lot of cacophony and little engagement. Folks visit but they don't necessarily help.

Just sayin'.

Friday, November 1, 2013

Perfect not.

Should practice of movement after stroke concentrate on perfection. I guess. But what stroke survivor is going to be perfect? This was addressed in an earlier entry. To quote that entry: "There is a small but vocal group of therapists who believe that if you don't focus on quality you may as well not practice."

Why should the practice be perfect when the next step should be better. If you look way up to perfect there's too much room to say "Forget it. Too hard." And you have every excuse to forget it because it will be too hard.

Focus on the small goals ahead of you, not perfection. 

There is a great blog called Seth's Blog. He has an entry that might be helpful. In it he says,

"Growth is messy and dangerous. Life is messy and dangerous. When we insist on a guarantee, an ever-increasing standard in everything we measure and a Hollywood ending, we get none of those."

 In another entry he quotes someone as saying, "I find myself getting uninterested/unmotivated on projects that I start. The emotion of deciding to start has faded and the results are slow to keep me motivated." He answers this plateau by saying, "The real work comes after the novelty wears off." Like me, Seth is not a big fan of perfection mostly because it gets in the way of forward movement. Here are some more Seth quotes about perfection and perfect:

  • Perfection is overrated, particularly if it keeps you from trying things that are interesting.
  • Perfect doesn't mean flawless. Perfect means it does exactly what I need it to do.
  • The object isn’t to be perfect. The goal isn’t to hold back until you’ve created something beyond reproach. I believe the opposite is true. Our birthright is to fail and to fail often, but to fail in search of something bigger than we can imagine. To do anything else is to waste it all.
  • Perfect is the enemy of good. [Voltaire] No doubt about it.
And on and on... Still some readers of this blog have chimed in and what they say has value (as pulled from the comments section)...

Blogger Linda said... ...if not precision perhaps focus seems like a good idea to me. 

Pete: Agree! Head towards challenging, not perfection.

Scott Gallagher said... If I'm ever going to get someone to do what it might take, I'm going to have to convince them that “thousands of miles” and “millions of repetitions” is unremarkable enough (and it is) for them to go ahead and spend a few short years to knock 'em out.

Pete: Is there anything to be said for that "few years" beyond "I practiced." Was it interesting in any way? Was there a spiritual element? Did it test you in new ways that helped you grow or know yourself (or others) better?

Barb Polan said...Give me reps over quality anytime. remember: some stroke survivors can't do ANYTHING. the expectation of high quality is absurd. And damaging.

Pete: Forgive therapists; they've not had a stroke. The expectation of high quality is absurd, for most survivors. And for survivors who are nudging up against high quality movements, then great! But most survivors will not hedge high quality but the rules remain the same: Get better.

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