Sunday, December 3, 2017

How much does it cost to have a stroke?

The cost of having a stroke is variable. For instance, in the United States, stroke can easily bankrupt you-- or not, depending on your insurance, your wealth, and the combination of both. In Europe it is much less of a burden. Or, lets say, the burden is more shared. But it does not matter where you are, almost always there are extra expenses along with less income.

But the data is scarce. You'd think the amount having a stroke might cost someone would be well studied. It is not. At least not lately (most studies were done in the 90s). There is a lot of research on the macro issue; how much of a burden it is on a country or a national health care system. But not much on the individual's burden. The best estimate is this: 

The long-term costs of stroke The lifetime cost of a first stroke occurring in 1990 (not including lost wages) was estimated to be $228,030 ($462,126 today, adjusted for inflation) for an ischemic (block) stroke. There is one more recent study that suggests the amount is $140,048 ($283,821.68 today). In Germany the cost estimate is 43,129 EUR.

But both of these estimates seem low. 

Finally, there is no way to estimate the cost. How do you estimate what might have been?

If you are struggling with the issue of expenses after stroke-- at least here in the US, there is a resource that may help.

Thursday, November 23, 2017

Motor Relearning After Stroke: Hardwiring Recovery

Motor learning is what everyone does to learn any new movement. Motor relearning is what stroke survivors do to recover any lost movement. In some ways learning movement and relearning movement after stroke are the same; they both rely on the neurons in the brain to control movement. In some ways learning and relearning a movement are inherently different because a new and different part of the brain is used to control the movement. And there is a more obvious and less science-heavy difference: Learning a movement is fun. Relearning a movement is fraught with frustration.

Motor Learning And Motor Relearning: The Differences.

For stroke survivors, the part of the brain that was used their entire lives to control particular movements is dead. The dead portion of the brain becomes a fluid-filled cavity (called an infarct). Some of the neurons used in the pre-stroke movement may be reengaged. But those neurons will have to create novel relationships with other neurons to recover the pre-stroke movement. There is no potential to relearn a movement in the same way it was originally learned.
Motor relearning after stroke has another distinction from motor learning. Most motor learning that we do is derived from play. The joy of learning a new skill propels us the development of that skill. Consider skiing. You start out and you fall (and fall and fall) and you get very wet and very cold. And then you do something right and that feeling of making the turn and carving the snow becomes the carrot at the end of the motor learning stick. But stroke survivors are not learning new skills; they’re simply relearning movements that they used to do perfectly well as they attempt to cajole new neurons to do old tricks. Where’s the fun in that?
The fact that motor relearning is not necessarily fun provides a supreme challenge to the coaching abilities and motivational skills of therapists as they shepherd stroke survivors, not towards the joy of playful motor learning, but towards the monumental task of motor relearning.

Motor Learning And Motor Relearning: The similarities.

In some ways relearning to move after stroke and “regular” motor learning are similar. Both require neuroplastic rewiring of the motor and sensory portions of the brain. Both types of learning require the learner to do the hard work (or play) of learning. No therapist, no matter how talented, can learn it for them. This is where the coaching skills of clinicians are tested. Motor relearning only happens if the stroke survivor remains motivated to move. And stroke survivors will only remain motivated if they know why they're doing what they're doing. The neuroscience is clear: only through the volitional movement of the stroke survivor does neuroplastic brain rewiring take place. Providing stroke survivors with a nervous system “user’s manual” complete with “instructions” and even “troubleshooting tips” is vital to the process of recovery. And just like any good manual, the simpler the better.

Motor learning simplified

Therapists usually think about the nervous system in terms of upper motor neuron vs. lower motor neuron, brain vs. spinal cord or central nervous system vs. peripheral nervous system. There is another way to view the part of the nervous system that impacts motor learning: front vs. back.
Consider the following thought experiment. You decide you will scratch your head, but you don’t want to mess up your hair, so you need a single nail to fall on the exact epicenter of itchiness. You begin by estimating where your arm and hand is in space (proprioception). Messages from the muscle spindles, Golgi tendon organs and other proprioceptors provide the feeling of the position of the hand and arm. That feeling becomes a sensory impulse that enters the back (dorsal root) of the spinal cord. The impulse travels up the spinal cord and ends up in the back of the brain, in the sensory portion of the cortex, just behind the central sulcus, a large fissure that separates the front of the brain from the back. The impulse, with “fine-tuning” by other parts of the brain, jumps to the anterior portion of brain and provides a movement strategy. These instructions descend the spinal cord and exit the front of the spinal cord. The impulse then goes into peripheral nerves which terminate at the target muscles that power the movement. To review:

The impulse goes from the proprioceptors in the limb 
toàthe back of the spinal cord 
toà the back of the brain 
toà the front of the brain 
andà out the front of the spinal cord.

Back to front. You scratch your head. But let’s say you miss your target and your nails land in the wrong place. You use this feedback to self-correct and you again send an impulse from the back to the front of your nervous system. Your nails target the exact point of itchiness. The adjustment that you’ve made is the essence of motor learning. In this thought experiment each attempt was felt and each feeling was used to mitigate the next attempt.
          Now let's continue the thought experiment with a more complicated movement. Consider typing. Typing involves precise and delicate movements of the fingers. Learning how to type involves feeling the position of the fingers (proprioceptive input) followed by repeated attempts to hit the correct keys on the keyboard (motor output). Each time the pinky finger makes a foray towards the “enter” key the feeling of a correct attempt is processed by the brain. If enough repeated attempts are successful, the movement is learned. If the learned movement is done over weeks or months or years, it is seared as a neuronal pathway into the brain. This is why we never forget how to ride a bike or swim even if we haven't done either in years. The motor strategies are “hardwired”. Hardwiring useful patterns of movement in stroke survivors is motor relearning.

Saturday, November 4, 2017

Shocking Subluxation

Electrical stimulation for subluxation. There's a lot of info out there, and its confusing. That's where I come in!

Here ya go...

There has been some debate about where electrodes should be placed for NMES and subluxation. Traditionally, the placement has been the deltoid and supraspinatus. However, it has been pointed out that the placement over the supraspinatus is problematic because the supraspinatus is covered by the upper trapezius. It is thus unlikely that the supraspinatus can be activated by surface stimulation. A better choice is the deltoid and the infraspinatus and teres minor.


Tuesday, October 31, 2017

Lower Extremity Recovery After Stroke: Nothing New Under The Sun

Research into post-stroke rehabilitation has tipped some sacred cows. Traditional neurofacilitation techniques have generally wilted under the intense glare of clinical research. 1 Partial weight supported walking had mixed results in the LEAPS trial. Robotic devices seem to provide no benefit beyond that of conventional therapy. But all this bad news is actually good news for a number of reasons.
First, we need to know what doesn't work and what is equivocal. Clinical research is not about coddling the status quo, it's about getting us closer to the truth. And in this regard it is brutal. Once a particular treatment option is tested the researchers are left with the basic question: what does the data say? At that point the data becomes impersonal. It says what it says. The data may tear a hole right through a cherished intervention. But this is a good thing. We need to know what does not work. But there is nuance as well... we may find out that something isn’t AS effective as we thought it was. Or we may find out its effective, but not as effective as other things. Or we may find out that we don't know its level of efficacy. That’s a core irony of research: sometimes research reveals that we just don’t know. I think this is what often makes clinicians in rehab distrustful of research. What research reveals is often muddled, difficult to interpret and delineates few definitive positions. But that's what science does. Physicists argue about the origin of the universe, anthropologists argue about the origin of species, geologists disagree about where the oil is etc. etc. But in healthcare there seems to be this perspective that you're not allowed to be indecisive. You're the clinician; you have to know the answers because the patient is right there in front of you and needs treatment. But maybe it's not indecisiveness. Maybe its thoughtfulness.
Research takes time and it is often difficult to interpret, true. But it also provides the best general guidelines for clinical practice. And it’s not all “bad” news; research does give us clues as to what does work. And what research is revealing about what works for the lower extremity after stroke, well… let’s just say there's not very much new under the sun. What got me thinking about the power of the basics of rehab was a simple statement in a recent systematic review. This was the statement...

Task-specific gait training improves gait post-stroke.
Wow. That's not very research-y. It pretty much says that walking helps retrain walking. Clinicians in rehabilitation have been doing gait training since before Mary McMillan. Then again, nothing should be assumed. I've seen clinical research that questions many of the foundational assumptions from both PT and OT.
So gait training works. That's good to know. What else works to rehabilitate the lower extremities after stroke? Balance training seems to work, although some techniques work better than others. For instance repetitive sit to stand protocols, tai chi, and cycling training seem to work, whereas body vibration, biofeedback in standing practice don't.
Strength training helps lower extremity function. Some clinicians in rehab are concerned that strength training will exacerbate spasticity. Intuitively that makes sense; if you increase the strength of muscles used during walking you will also increase the strength of some overwhelmingly strong spastic muscles, thereby increasing spasticity. But as counterintuitive as it may seem, increasing muscular strength does not increase spasticity. In fact, muscles that are spastic are actually weaker than their counterpart of the contralateral side. Bottom line: muscle strengthening does not decrease motor control and, in some patients at least, increases distance walked and gait speed.
Cardiovascular training seems to be helpful in improving gait post-stroke. In some studies cardio training has been observed to decrease need for assistance during ambulation, and increase walking speed and distance.Strength training and cardio training, cornerstones of rehabilitation since its inception may simply work because movement after a stroke is so fatiguing. In fact, fatigue is the leading complaint among stroke survivors. When age matched against folks who don’t exercise but are otherwise healthy, stroke survivors have half as much cardio strength and half as much affected-side strength. And you can add to that the fact that everything a survivor does (usually measured against walking) takes twice as much energy. And energy is essential to implementing most leading edge concepts in lower extremity stroke rehabilitation. For instance, we know that intensity works rehabilitate the lower extremity after stroke. Robust repetitive practice protocols rewire the brain after stroke to provide for better motor outcomes. But patients may not be able to benefit from these protocols because they are simply too pooped to practice. “Banking” energy, through strengthening of the cardiovascular and muscular systems can give survivors a fighting chance on their road to recovery.
So, there it is. What we always thought worked, works.

  1. Kollen BJ, Lennon S, Lyons B, et al. The effectiveness of the Bobath concept in stroke rehabilitation: what is the evidence? Stroke 2009;40:e89-e97.
  2. Saunders DH, Greig CA, Mead GE, Young A. Physical fitness training for stroke patients. Cochrane Database Syst Rev 2009.

Saturday, October 14, 2017

SAS blog: In the Top Ten stroke blogs online

The Stronger After Stroke blog was named one of the top ten stroke blogs online by Medical News Today (MNT).

Up against The National Stroke Association, The American Stroke Association and The World Stroke Association. 


Tuesday, September 12, 2017

Movement is good full stop.

When I worked at the Kessler Institute in NJ, there was an idea for a study that bounced around for a few weeks. The study would involve answering this question: 

What would be the effect of a swift kick in the butt on stroke recovery? 

I'm pretty sure that study would never pass the ethics board. But(t) it is a joke that got to a fundamental truth: Clinicians make the process of recovery too complicated.

There is this notion among many clinicians that there should be a constant striving towards "function." That is, that the survivor should work towards some particular goal (i.e.: walking, dressing, eating, toileting, etc.)

I disagree. Movement, irrespective of function, is important. Here's an example…

Constraint induced therapy (CIT) for the upper extremity (arm and hand) involves working the arm and hand – a lot.

At the end of CIT, the survivor may, or may not be any more "functional." But maybe the wrong things are tested. If you're working with the upper extremity, then you'll test the upper extremity. But here's a weird side effect of CIT: better walking. Why? Because arm swing is made better. We may not think about the arms with regard to walking, but they are important in balance and timing.

And other things that are often not measured very often get better. Things like a reduction spasticity, less shoulder pain, more active range of motion. Movement, irrespective of function, is good.

Sunday, September 3, 2017

What are your chances of having a stroke? Where do you live?

Your chance of having a stroke may be influenced by where you live. Click on the map or the list and it will take you to the full interactive site.
Keep in mind: ~1 in 3 survivors will have a second stroke. If this map also reflects subsequent strokes, you may be able to modify whatever behaviors inherent in your geography.

Monday, July 31, 2017

Better movement through beer.
When you build a house you want to build a strong foundation. When a tree grows, it doesn't grow from the leaves inward, it grows from the seed outward. For every process of growth, there is a beginning, a foundation, a germinal point.

What is the foundation for movement after stroke? If you ask most therapists they will say it is trunk (torso) control. 
Trunk Control

Focus on trunk control is the analog to building a good foundation for a house. Trunk control, so the thinking goes, will provide a good foundation for the arms and legs to do their thing. 

Therapists will often continually talk about the trunk as being the most important foundational part of the movement. The way it is taught in therapy school is "proximal stability for distal mobility". And this idea-- to work from "the inside out" is not wrong per se. It's just not particularly right.

Some therapists obsess about the trunk. But what if we flipped it? What if the driver foundation of learning movement is the hand? Or the feet? But I actually don't think it is those, either.

The foundation of movement is the will of the mover.  
  • Mind: Expressed as intention (I want to do something)
  • Brain: Starts the movement (Expressed as an electrochemical command) 
  • Muscles: Move the limb (muscle contraction)
  • Hand: Expresses the original intention (grab a beer)
So the driver here is beer. Or sex. Or chocolate. The driver of motor (movement) control is the will of the person. The trunk will follow what the will decides.

Imagine an infant. They reach because they want something. There is no one there to hold them and they may be a little unsteady, but their intention to reach makes their balance better. 

The “will” of the hand drives the changes needed in the trunk. The trunk will learn, in a natural way, to get the hand where it needs to be. 

Thursday, June 1, 2017

Make the Home Exercise Program AWESOME!!

Years after stroke survivors have been discharged from therapy, recovery can continue.

Of course, the speed of recovery diminishes over time. There is no time that is quite as fertile as the period of natural recovery in the first few months after stroke. 

But recovery can continue. Stroke survivors should be encouraged to see discharge from therapy as not the beginning of the end, but as the end of the beginning. The baton of the conductor of the grand symphony of recovery is passed from therapists to survivor. 

Most of the time therapists will leave stroke survivors with little guidance for further recovery. Some therapists think “HEP” stands for “Hand ‘em photocopies.” Too often the HEP reflects nothing more than a watered down version of the exercises that were done in the clinic. 

Irony: The survivor is left with the same exercises that caused the very plateau that caused the discharge! 

Therapists have a very good reason for prescribing the same exercises as were done in the clinic: They don't want you to go home, do an exercise that you don't fully know how to do, and get hurt.
A good home exercise program will help the survivor to continue making progress once they are home. The HEP can and should be started the day the therapist meets the survivor. Therapy itself can be part of the HEP. If the survivor and caregivers can see what goes into the basic concepts that therapists use all the time, they will be able to direct their own recovery long after they’ve forgotten your name. 

The HEP should explain:
àprogression of exercise, 
àmeasuring and documenting progress, 
àtips on equipment needed for a home gym. 

Therapists: Your job is done. You would have liked more time with them, but this is all manged care has allowed. At least, you’ve helped them to be functional, safe and return home. 

Survivors: Your job has just doubled. Not only do survivors have to continue the quest towards recovery through their own efforts, but they have to do it without therapist's guidance. Leaving stroke survivors with the tools they need to continue the quest is critical helping them to be in the best position to reach the highest level of potential recovery.

Tuesday, May 2, 2017

Facebook Recovery

If you want great ideas for recovery, where do you find them? One of the best resources— I turn to it all the time for ideas— is the Young Stroke Survivors Global Network. Its a Facebook page chockablock full of suggestions, discussions, videos, links...

And lets face it... a lot of stuff on the web is either complicated or dubious:

Complicated: clinical research
Dubious: websites that exist to sell you something

Young survivors (young= willing and able to hyper-focus on recovery) come up with the best ideas. They're often educated and ambitious and willing to try to "push the issue." 

Wednesday, April 19, 2017

“Pusher” Syndrome-- the neuroplastic model of recovery

Pusher syndrome (PS) is an altered sense of reality. 

Survivors with PS (sometimes known as "pushers") believe that they are sitting or standing “upright” when they are tilted approximately 18° towards the "bad” side. 

Therapists may be exacerbating pusher syndrome. When survivors with PS are forced to a “upright” they feel like they're leaning too far towards the "bad" side. “Pushers” react to this feeling by leaning towards the affected side. They see any attempt to get them truly straight as a serious threat that inspires fear. 

Another term for pusher syndrome is listing phenomenon. This may be a more accurate term because "pushers" only become "pushers" when they are pushed. Anyone who was shoved 18° out of balance would push back! There are other terms that have been used for PS including:
·       ipsilateral pushing
·       contraversive pushing
·       pusher behavior.

PS affects approximately 5% (although some estimates are as high as 50%) of all stroke survivors.

Survivors with PS have had damage to portion of the brain that controls the feeling of upright body posture. The area damaged is called the posterolateral thalamus. Loss of this area causes PS.

Balance is determined by 3 systems: vision, vestibular (inner ear) and proprioception. Patients with PS typically only have damage to one of the 3 systems: proprioception. Clinicians can help by directing patient focus to the balance systems that are still intact. Therapists can help pushers by helping them to attend to vertical visual cues. One technique involves having the therapist sit in front of the seated patient. Then use any visual cues available in the room, or the therapist’s own body (i.e. the forearm held vertically) to have the patient reorient themselves to true vertical. Carr and Shepard (reference below) suggest having the patient purposely, and within a safety-controlled environment, repeatedly reach for an object towards the hemiparetic side. The patient is then instructed to bring themselves back to visually confirmed true vertical. This simple technique hits on two basic concepts of the neuroplastic model; task specificity (reaching for an object creating a challenge to balance) and repetitive practice. The repetitive practice in this case is repeatedly reorienting to true vertical. Therapists can help pushers by teaching the necessary movements needed to realign to vertical. As is true with many of the recovery options that drive neuroplastic change, it is repeated self-correction that rewires the brain.

Pushers should be encouraged to hold a vertical position no matter what everyday task they’re doing. This incorporates another core concept in the neuroplastic model: massed practice. Therapists who encourage constant realignment to true vertical—in and out of the therapy gym—help the survivor mass their attempts at righting and equilibrium reactions.

Although certainly not proven, I would bet that the rewiring necessary to correct PS does not happen in the thalamic region—the region damaged in stroke survivors with PS. Using repetitive, task specific massed practice may instead force an enlargement and/or strengthening of the cortical representation of the intact vestibular and visual systems. 

Therapists can help PS patients by providing shepherding guidance on this necessary neuroplastic journey.

1. Karnath HO, Broetz D. Understanding and treating "pusher syndrome". Phys Ther.2003 Dec;83(12):1119-25. 
2. Shepherd RB, Carr JA. Response to Discussion Paper: New aspects for the physiotherapy of pushing behaviour, D. Broetz and H.-O. Karnath, Neurorehabilitation 20 (2005), 133-138. NeuroRehabilitation. 2005;20(4):343-5.  

Tuesday, April 18, 2017

Work the good side and the bad side gets...better?

I do a lot of talks. Tons of them. Constantly. To therapists. And I say to them usually early in the day, "Look, I'm staring down the barrel of hundreds of years (sometimes more than a thousand) years of clinical expertise. One of my goals today is to have you share your best ideas. That way, tomorrow, when I do another talk, I can present your idea, claim its my own, and give you no credit." They laugh. Its funny because its true. And they do give me their ideas and I do steal them and then present them in my book, articles, talks, or this lovely blog. 

And here's a stroke-recovery strategy I got the other day form the fine therapists at BONE Physical therapy and Rehabilitation (they appear not to have a website, but that link will at least get you a phone number.) They're in Columbus, GA.

Training the "good" side

In folks who have not had a stroke, we've known this for decades: If you strengthen only one side (say, your left side) the other side strengthens too.

It's true in survivors as well: If you strengthen (so says some preliminary research) the unaffected side, the effected side gets stronger. A researcher at the University of Victoria, Canada, Katie Dragert, appear to be the scientists who have explored this issue the most.

Here's an example: If you do resistance training for the dorsiflexion on the "good" side...
... the "bad side" gets stronger.

How did they do it? 
•Stroke survivors did performed 6 weeks of maximal dorsiflexion. 
•What did they gain on the "good side"?
~34% strength increase on the "good side."
•What did they gain on the "bad side"? 
~31% strength increase on the "bad side." 

We also know that bilateral training -- when you use both sides together, the "good" side helps the "bad" side become more coordinated. your challenge is to find a way to put these two concepts...
1. strengthen the good to strengthen the bad
2. use the good to train the bad
into recovery.

Thursday, April 6, 2017

"My dream for the future is to help as many people as I can possibly help"

I get a chance to communicate to a lot of survivors. I've treated them clinically and in experimental research protocols. I've also been in contact with a lot of survivors during my talks. And then of course, social media and email. 

Survivors, to varying degrees, are usually pretty good at explaining with appropriate passion what its like to have, survive and thrive after stroke.

One of best I've found so far has been Bill Torres. Find his story here. (Bring tissues.)

Tuesday, February 28, 2017

Drink Up!

I got an interesting question from a therapist at a recent stroke talk: "What is the effect of dehydration on stroke recovery?"

I said what I often say when interesting questions come up that I don't have an answer for: "Email me that question… We'll look at it together"

It turns out the dehydration is thought to be a cause of stroke.

Further, if a stroke survivor is dehydrated when they're admitted to hospital, worse recovery can be predicted. And dehydration when admitted is predictor of discharge to long-term care (read: nursing home).

So, drink up! because, more than one third of all survivors will have another stroke.

Saturday, January 14, 2017

Can Stress Cause a Stroke? You bet!

If you've had a stroke you have ~35% chance of another stroke. Finally proof: Stress can cause a stroke. 
(Stress= ↑ Blood Clotting = Stroke)
Debbie Reynolds died recently just one day after her daughter, Carrie Fisher died. The press says she died of a "broken heart." And that is probably true. There is now science that shows that stress can cause stroke and other cardio vascular diseases. 
(The Lancet abstract to this research here. Non-nerd take here.)

But the connection between stroke and stress is indirect. Here's the story:

The amygdalae (plural; there are 2 of them. Singular: amygdala) are small marble sized structures responsible for emotions.

In folks who have cardiovascular disease (like stroke) there is more activity in the amygdala.

This increased activity causes more C-reactive protein in the blood. C-reactive protein you guessed it— clots blood

Blood clot in the brain = stroke.

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