Saturday, May 14, 2016

Extry! Extry! I was kinda wrong!

Passive stretching has been used by therapists on survivors forever. Does stretching do anything to help recovery? So far as we know- no.

But there are therapists who don't want to hear this. I do a ton o' talks on stroke recovery and if you tell some therapists that stretching does not help survivors, therapists can get feisty. "If that doesn't work what am I supposed to do - they're tight and can't move."

Typically I tell them that they're probably not doing harm but they're not helping much either.

The thing is, I'm always reading research to update the message. I found an article that says that if a survivor is stretched, it may help. There are a couple of flys in the ointment, however... In this case, a therapist did not stretch them. Here's what they did:
  • What moved the survivors: Subjects wore an actuated glove orthosis that cyclically moved their fingers and thumb
  • How the survivors were moved: From a relaxed/flexed posture into neutral extension 
  • How long were they moved: 30 minutes on 3 consecutive days
  • What they gained: Improvement was observed immediately after the stretching (this is to be expected- stretching does have a short term effect, although any long-term effect is questionable). Here's the potential new news: largely maintained up to 1 hour poststretching, with significant carryover for the 3 days for some outcomes. That was true for what they called "subacute" survivors (defined as "2 to 6 months"- which is a misrepresentation of "subacute" after stroke) but not true (it did not work as well) in "chronic" survivors.
So, what have we learned? Stretching a survivor passively with a computer-driven actuated glove orthosis-- if they are 2-6 months after the stroke-- provides some short term benefits.

And they wonder why everyone outside of research hates research...

Monday, May 2, 2016

Electrical Stimulation after Stroke MADE EASY

Lets say you wanted to do electrical stimulation (eStim) to help your recovery. But....

There are 2 things stopping you:

1. You don't know what to do
2. eStim is really expensive

Let me help you with that... 

eStim is easy and cheap.

First the EZ part: How do you do it.

There are 3 parts to any eStim setup:

1. Machine

2. Lead wires

3. Electrodes

Put 2 electrodes (they're usually sticky) over the muscle you want to work. Typically, after stroke there are two sets of muscles that everyone focuses on:

1. The wrist and finger extensors. These will pull the wrist up and open the fingers.

2. The muscles that lift the foot to (hopefully) end drop-foot.

So, where do the electrodes go again?

Wrist/ fingers:

The muscles that lift the foot:

As EZ as ABC!A. Attach the lead wires from the machine to the electrodes.B. Stick the electrodes on according to the images, above. Optimal placement will vary from person to person because everyone's anatomy is different. And, after stroke, every survivor's deficit will require slight changes in electrode placement-- according to their needs.C. Turn up the eStim. If you are getting the movement you want, take a photo of the electrode placement, or put a pen mark on you skin, so you can remember where then "perfect" electrode spot is.How long should I do it for?I've been involved in a lot of what is called "dosing" clinical trials for eStim (here are a few). Figuring dosing for eStim is just what like figuring dosing for a drug: How much should I take? Is it different for every survivor? Yes. Does it depend on how much brain damage there was? Yes. Does it depend on other things as well? Yes.  Let me give you the EZ bottom line here...The only way you'll learn how much eStim you need and learn how to use the machine... is to use the machine. Manuals and rules are nice, but practice is better. Put the electrodes on and turn up the estim slowly. Once you get the movement you want, note the amount of eStim you used (measured in milliamps or mA).Two important notes (this gets a bit technical, but you can handle it!)1. Make sure you gradate up the eStim. Basically, its the same as any exercise program: Start slowly, and work up to more over time. Why gradate up? When eStim is used and there is muscle contraction, that muscle is being worked. It is firing, and just like with any muscle work you can end up sore (or worse) if you do too much too soon. So gradate up something like this:Day 1: 2 minutes. 
Day 2: 4 minutes.
Day 3: 6 minutes.
Day 4: 10 minutes.
Day 5: 5 minutes twice a day.
Day 6: 8 minutes twice a day.
Day 7: 10 minutes twice a day. 
And so on... until you hit the optimal dose and then stay there. This will give your muscles time to build gradually. If you get sore- reduce the dose.

2. Make sure you ramp up up the eStim. (A little more technical, sorry!). When eStim makes your muscle fire it does not just effect that muscle. It also effects that muscle's antagonist (the muscle that moves in the opposite direction). Example: Elbow flexors (benders) and extensors (straighteners). If you eStim the muscles that straighten the elbow, the muscles that bend the elbow will be forced to relax. And I think you'd agree, in most survivors where the elbow is always bent, it would be good (great!) to relax the muscles that bend the elbow. (Note: this phenomenonwhen one muscle the contractsits opposing muscle relaxes was discovered by one of my neuroscience heroes: Sir. Charles Sherrington.)

So that's good: You use eStim to contract one muscle and relax the opposite muscle. But there is one problem...
If the eStim is put on so that the highest amount of eStim that is set happens all at once, a paradoxical thing happens. The muscle that should relax (the opposite or antagonist muscle) actually fires. So now both muscles are firing and essentially fighting each other. 
So make sure the "ramp up time" is at least 2 seconds. The machine will let you control the amount of ramp up time. Make it 2-5 seconds. This extra time will give the antagonist muscle time to not feel threatened and relax. 
So it will look something like this:

1. First, get an appropriate healthcare worker involved. An OT or PT will work. Have them read this blog entry and help you set it up- first time at least.

2. There are a bunch of precautions for eStim. You can find them here... but they can be misinterpreted so always: get an appropriate healthcare worker involved.Price: Cheap!eStim is cheap. Below are some examples. You're looking for NMES (where the muscle actually fires) not TENS (where you can feel it but the muscle does not fire).HEREHERE and HERE

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