- Proprioception: the ability to imagine where your body is in space without looking at it.
- Eyesight: the ability to find "true north" and/or where the horizon is.
- Vestibular sense: the ability to sense movement, and know where your head and body are in space. When the vestibular system is not working it's the classic inner ear problem: Meniere's disease, dizziness, vertigo.
Wednesday, December 23, 2020
Sunday, December 13, 2020
This image looks like right side of Michelle's brain is gone. But this this image is taken in radiological convention. What is radiological convention? Imagine you've entered a patient's room. You are at the foot of the bed looking at them. That's radiological convention: As if you're standing at the foot of their bed.
Tuesday, November 10, 2020
Friday, October 30, 2020
Let me come straight to the point: There are three ways to drive changes in your brain to help you move better. All three effect very similar parts of the brain. And here is something that warms my lazy heart: Two of them you don't have to move a muscle!
The image above is from researchers Robert M Hardwick, Svenja Caspers, Simon B Eickhoff, and Stephan P Swinnen. (Reference)
What moves your body? It always starts with the brain!
We all know that muscles move us. But the brain moves muscles. This idea is lost on a lot of clinicians in rehab. They'll talk about muscle strength, range of motion, quality of movement, etc. etc. etc., but not talk about the brain. Why don't they talk about it? They can't see it. They can't measure it. And really, they can't help it.
How do you get the brain to change to move better?
There's a bunch of ways to get the brain to rewire for better movement.
1: Move. This is called repetitive practice. "We are we repeatedly do. Excellence, then, is not an act but a habit.” (Will Durant, paraphrasing Aristotle). The more you do a movement repetitively, the more the part of the brain that controls that movement is activated.* Note: No one else can do if for you, it has to be you doing the work. Musicians know it, athletes know it, dancers know it, martial artists know it, and now you know! More info here.
2: Imagine a movement. This is called mental imagery, or mental practice. If you imagine doing a movement the way you did it prior to your brain injury, the part of the brain that controls that movement is activated.* More info here.
3: Watch someone else do the movement. This is called action observation. If you watch someone do a movement, the part of the brain that you use to do that movement is activated.* Find instructions here.
About this image:
Tuesday, September 29, 2020
I'm reading the book tPA for Stroke: The Story of a Controversial Drug* about the clot busting drug that's used in "block" (ischemic) strokes. It was published in 2011.
The book tells the long, winding, political, and controversial path tissue plasminogen activator (tPA) took to get to market, and then be—somewhat at least—accepted as a treatment for ischemic (block) strokes. Is TPA still controversial? For some reason, yes.
Interesting Facts About TPA
•A study by the American Heart Association looked at data from 300,000+ ischemic stroke patients, TPA was administered to 3.3% of patients.
⇒2.2% of patients at regular hospitals got tPA
⇒6.7% at hospitals with PrimaryStroke Center Certification.
⇒Survivors are three times more likely to get tPA if at a certified stroke center.
•In 2019 the journal Stroke did a review of malpractice suits relating to treatment of stroke in hospitals
⇒Almost 30% of the cases were failure to treat with tPA.
⇒The average payout for pre-trail settlements was $1.8m. The average payout for court verdicts was almost $10m.
•A 2020 article in the Journal of the American Academy of Neurology found “Overall, about one-quarter of eligible patients with AIS (‘block stroke’) presenting within 2 hours of stroke onset failed to receive tPA treatment.”
⇒The article points out that women and minorities are undertreated with tPA because of course they are.
•Speaking of women: Another 2020 article in the Journal of the American Academy of Neurology found…
⇒Compared to men, women were 30% less likely get tPA.
⇒Sidenote: Women are also less likely to receive aggressive treatment when it comes to heart attack.
•Weird Science: tPA is never safe for hemorrhagic strokes. Except sometimes.
⇒There are multiple studies (1, 2, 3) showing that tPA can be used to increase longevity, decrease incrainial pressure (pressure on the brain inside the skull), and reduce injury to neurons from hydrocephaly (brain swelling). Note: t-PA in "bleed" stroke shows efficacy in ongoing clinical trials, not yet in clinical practice. The data we're waiting on is from the CLEAR III trial.
•Can tPA be given for a second stroke? Yes! About 25% of survivors will have a second stroke. So its important to know two things:
⇒You should know the FAST test. Better yet, know A better version of the test.
⇒tPA is safe and just as effective for a second stroke. Or, if you want it more science-y: "Repeated use of IV-tPA was not associated with an increased risk of intracerebral hemorrhage or death in patients with recurrent acute ischemic stroke."
•Is tPA effective and safe if you're over 80? Yes!
*The author, Justin Allen Zivin, MD, Ph.D., passed away in 2018 at age 71. He dedicated his career to identifying treatments for stroke, specifically the use of tissue plasminogen activator, or tPA... He encouraged the National Institute of Neurological Disorders and Stroke to change the paradigm for clinical stroke research, organizing a study that required a complete rethinking of how stroke care is managed.
This book was co-authored by John Galbraith Simmons.
Thursday, August 27, 2020
Friday, June 19, 2020
|My kids in our home gym|
|Seven buck at Goodwill!|
A treadmillA recumbent cycleAn upper body ergometer (hand cycle)An exercise matsomething used to maintain balance (sturdy chair, etc.)WeightsResistance bandsElectrical stimulation devicesBalls, decks of cards, or other “toys”A mirror
Saturday, May 9, 2020
|What Covid really looks like|
|Click to make larger|
Saturday, February 15, 2020
Below is an outline of various spasticity-reduction treatments.
The neuroplastic model of spasticity reduction. I developed this one years ago. You can find an outline of it from my book here. It is the only non-surgical, permanent option on this list. Here is the emerging evidence for the "neuroplastic model of spasticity reduction."
- Motor learning therapy increased spastic muscle's contralesional cortical motor regions leading to decreased spasticity
- Intensive training in patients with increased muscle tone improves function without exacerbating spasticity
- CIT reduces spasticity 2017
- CIT reduces spasticity 2013
- CIT reduces spasticity and increases functional use
- CIT increases strength and decreases spasticity
Weight-bearing. This is one that a lot of therapists love. Whether you're standing on the leg that's spastic, or putting weight through the upper extremity that spastic, there is a reduction in spasticity. That reduction will last until the next big volitional movement and the spasticity comes back. But it is a great short-term strategy that helps set the survivor up for treatments that are more permanent.
Stretch. Always the first line of defense. There's a lot of good reasons to stretch, but it does absolutely nothing to reduce spasticity in the long-term. This was established by not one but two Cochrane reviews. It didn't even reduce contracture formation.
Botox (and other neurolytics). Back in the day there were a couple of formulations of Botox. Eventually you would become immune to one so they'd use the other one. You'd become immune to the second formulation, and that was the last time it would be effective. Now they have so many formulations that you can be on Botox for the rest of your life. It's a Band-Aid. When it wears off, it's done. It's also an expensive, and often painful Band-Aid. Oh, and it gets in the way of my neuroplastic model.
Electrical stimulation (E-Stim). Typically this involves reciprocal inhibition of the spastic flexors. Put simply: You E-Stim the muscles opposite the powerful flexor muscles that cause the problem. Example: E-Stim the elbow extensors (triceps) to relax the elbow flexors (biceps, etc.). Various doses will provide a temporary reduction is spasticity.
Monday, January 6, 2020
Assuming this may hurt recovery.
The 'proximal to distal' crowd would say recovery in the arm/hand would be in this order:
- first to come back are the muscles in the shoulder and shoulder blades,
- then progress to the elbow,
- then to the forearm,
- then to the wrist,
- then the hand,
- then the finger joints close to the hand,
- then the finger joints furthest from the hand.…
Here's what actually happens:
1. You have a stroke; one side of your body is affected
2. The proximal muscles (i.e. shoulder) have bilateral innervation; both sides of your brain control the proximal muscles.
3. Your shoulder comes back first not because of the "proximal to distal rule" but because your brain never ceded control over the shoulder muscles.
4. The clinician sees the shoulder coming back before everything else and figures, "That's the proximal to distal rule!"
You might argue, "If the shoulder comes back first, then maybe the reason is wrong, but its a distinction without a difference. Survivors will still see proximal to distal return."
But what if the fingers are coming back first? Clinicians may not think to test the hand because the shoulder is not back. Or they may focus on shoulder control even though the hand can drive shoulder control if hand movement is recognized and encouraged.
In the lower extremity, the problem can be even worse. Proximal muscles would move the hip, and those are what are focused on. Meanwhile, an AFO (ankle brace) is routinely put on the survivor even though the ankle (a distal moment) may be coming back on its own.
And AFOs are easy to walk into, but hard to get rid of.
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