Monday, January 6, 2020

Sorry not Sorry: Stroke Recovery is NOT Proximal to Distal.

There's an old saying among clinicians: Recovery from stroke is proximal to distal. That is, there is a predictable pattern of recovery: proximal (closer to the body) to distal (further from the body). 

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.…
But proximal to distal is not accurate any more than assuming that the sun circles the earth because it always rises in the east and sets in the west. Both are based on observation, but neither is based on what is actually happens. 

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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