Thursday, March 20, 2014

The neuroplastic model of hypersensativity reduction after stroke for fun!!

Hypersensativity after stroke can come in two basic flavors:

1. A touch (or some other stimulus that normally does not hurt) hurts. A lot. This is called allodynia.

2. Something that usually does hurt hurts a lot more that it should. In other words, it hurts a lot more than it might on the unaffetced side. This is called hyperalgesia.

So how might you treat this. Lets go to the never-ending neuoplastic well, shall we? We know that stroke damages the brain which may cause the altering and amplifiying of sensation. So what if we used the same process to reverse it? These are hypothetical (although some have been tested) so keep that in mind. So what are the neuroplastic model to treat? Possibilities include...

1. TENS (mild electrical stimulation). Dosage here.
2. A placebo. An example would be suggesting a manual therapy (like message or manipulation of the extremity) will help reduce it. Discussion here.
3. Comparison. Put the gel on the unaffected side and say, "See, its just a bit cold. We'll take exactly the same gel (it can even be done at the same time)and put it on the 'bad' side and they'll-hopefully-feel the same.
4. Mirror therapy. Set it up like this: Have him look only at the unaffected side as either the survivor or someone else gives the "good" limb the stimulus which is painful to the "bad" limb. It will look like its getting put on the affected side, but with no pain.

Further reading here.  Duscussion of the difference between hyperalgesia and allodynia here.

Friday, March 7, 2014

Why Dynasplint is half dead (and all dead for survivors)

Do you have muscles tightened by spasticity? 

Sarcomeres are the small units in muscle that contract when your muscles contract. (Great image here. Look at the bottom right corner.)  Sarcomeres will increase in numbers when muscle is put through a prolonged stretch. Increasing sarcomeres is how muscles are lengthened. Lengthening of muscle and increasing sarcomeres increases flexibility. Which is a good thing because we can talk about neuroplasticity until the cows come home but if your arm (or whatever) "won't go that way," all bets are off.
OK. So how might you increase the number of sarcomeres? One way that many clinicians think works is called "dynamic splinting." The idea is that you'd wear something that would hold you in a position that would stretch you. If you could wear it at that posture for 2-3 hours, the clinician would "dial in" a more "aggressive" range of motion. Over time you'd gain sarcomeres which would allow you to have more range of motion. 

Sounds groovy, right?

It works for, say, marital artists who want flexibility so they can KICK ASS.

Stretching ROCKS! Sometimes!
You stretch, you get a longer muscle, everybody's happy!

But yeah. That whole science thing gets in the way. Don't you just hate science?

It turns out that the way to elongate (add sarcomeres)  "normal" muscle is nothing like the way you'd do it in spastic muscle. To stretch spastic muscles so they gain length, the stretch must be held at least 48 hours. And dynamic splints are not kept on for anywhere near that long; a few hours, max. 

And here's another little interesting tidbit. The 600 pound gorilla of dynamic splints is a company call DynaSplint (get it?) and they've had a little bit of trouble lately. The kind of trouble where they may have defrauded the Federal Govmint. And they laid off 500 workers in one day. Which makes sense since it was a DynaSplint salesperson that was the whistle-blower that brought the whole company down. Which then triggered their bank to stop their operating budget.

And while I have no idea of any of those problems are warranted, one thing I do know is that they are fraudulent in another way. Again and again they claim that their splinting systems help folks with spasticity. They also claim they increase muscle length. Don't buy it!

Wednesday, March 5, 2014


Electrical Stimulation (E-Stim)
Rhythmic Bilateral ARM Training 
Rhythmic Bilateral LEG Training 
    Mirror Therapy
    Increasing walking speed 
    Constraint Induced Therapy (CIT)
      CIT early after stroke may not be a good idea
        Amazing CIT dissertation by STACY L. FRITZ that includes:
        Sensation Recovery
        Why task specific practice important in neurorehab
        Electrical Stimulation (E-Stim)

        Spasticity and sleep

        Mirror therapy reduces spasticity

        Stretch (any form, duration, or arc of time) does not decrease Spasticity
        Selective dorsal rhizotomy (SDR) success in adults
        Botox strength increased, and uptake time decreased with EStim
        Researching Stroke Recovery
          Clinical Guidelines from around the World
          Information About Other Forms of Brain Injury
          Find Stroke-Recovery Research in Your Area
          Two Free Stroke-Specific Magazines
          Measuring Recovery
          Cognitive (mental) Tests
          Posterior Pusher Syndrome (or) posterior pelvic tilting
          Walking within within 24 hours after stroke: help or hurt?
          ·  An article where they interviewed therapists, docs and nurses: Conclusion: Our study shows that most clinicians had concerns in relation to early mobilization of stroke patients and more clinicians had concerns for hemorrhagic than for ischemic stroke.
          · An article looking at very early mobilization and depression: Conclusion: Very early mobilization may reduce depressive symptoms in stroke patients at 7 days post-stroke.
          · Early mobilization out of bed after stroke may be all good: Conclusion: It seems to reduce severe complications but not cerebral blood flow:
          · Early mobilization out of bed after stroke, maybeConclusions: Insufficient data are available to prove the beneficial effects of early mobilization after stroke.
          · A Very Early Rehabilitation Trial for Stroke (AVERT): Conclusions: Fewer patients in the very early mobilisation group had a favourable outcome than those in the usual care group. 
          · The LEAPS trial (the largest study ever done on post-stroke rehab): "patients who received early locomotor training experienced more multiple falls."

          The curious case of NDT.

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