Pusher syndrome. Some stroke survivors have their sense of balance knocked out of whack by the stroke. Their sense of what upright (true vertical) is off by about 20°. And guess which way they think true vertical is? Bonus-towards the affected side! And guess which way they will usually fall (if they do but they shouldn't because falls can...whats the word...kill. Yeah. As in death.)? Towards the affected side-double bonus! And if they fall towards the affected side that's bad because guess which side usually has thinner and more brittle bones? Bingo!
And here's the "funny" part: Therapists may be causing pusher syndrome.
On the left: The American Stroke Association's magazine, Stroke Connection. On the right: George Mason University's magazine, Mason Spirit. I'm an alum. You can also click here to find a quick blurb about the book on the GMU magazine website.
I'm a big fan of hand washing. Eliminating bacteria and viruses from hands makes sense. It doubly makes sense because my home is often infested with a problem of a much bigger size: Children. My kids, their friends. Their friends friends friends friends. I am the steely-eyed Great Wall of China of bacterial and viral stoppage! Mean! Wash your hands I say. Most kids go in to the bathroom. My kids could go anywhere in the house to clean their hands.
We generally use iso-propanol rubbing alcohol to clean our hands. There are mist spray bottles in the bathrooms, kitchen and on desks. The rule is, if the dirt is visible, wash your hands. No visible dirt? Use the alcohol. I implemented this house rule a couple of years ago. I based it on the fact that children will not follow the "sing your ABCs" length of washing rule. They get in, sorta wash, and then sorta dry. I had read an article--which I am having trouble re-locating-- which said that using alcohol killed more germs than hand washing.
Then a few weeks ago, this from Kathleen Sebelius (nÊe Gilligan-- She'll will be working closely with the Professor and MaryAnn.") "Lil' Buddy Gilligan taught us all how to sneeze. After she teaches the proper sneeze she endorses a brand-name gel hand sanitizer. She is an expert on all things medical because, hey, former governor of Kansas--hello! And then c'mon-- she names the brand? Why? I'm sure she was just trying to ride a moment of cuteness. Or maybe she owns stock? As Glen Beck would say, "I'm jus' saying..."
What is best for washing hands? Well, it would be nice if there was one answer. But there are several. It's science. If you want definitive answers, try religion.
Part of the problem is that most research focuses on hand-washing Vs. alcohol gels. But there are many other options. So who should we really trust? Dentists! They've been grappling with this issue since the 80's. And what conclusion have the come to? Its neither hand-washing or gel. In fact, hand washing and alcohol gel do worse than everything else tested in dentistry.
For the rest of us non-dentists it is a given; Hand washing is effective. But in some tests, the gel hand sanitizers do better. However, there are many chemicals in the gel, including the gel itself, that make me wary.
Mental practice. Athletes do it, musicians do it, anyone who does highly skilled movement benefits from it. It's inexpensive, takes little to no equipment and little energy, and it's well researched.
Mental practice ties into my entire philosophy of stroke recovery: If it works in athletes, then it works in stroke survivors.
Here's an article about our team that outlines a new study that were doing. We've done many mental practice studies before.
I wrote this article for a trade magazine for speech therapists (ADVANCE for Speech-Language Pathologists and Audiologists).
The article's bottom line is that the same sort of neuroplastic rewiring needed to, say, open and close the hand, is also needed to help with swallowing.
Def: The rewiring of the brains of entire populations caused by a novel technology, event or change in circumstance.
Example: TV has led to a metaneuroplastification of the American people in many ways. This includes the rewiring of cortical regions that effects behaviors from eating habits to shortened attention spans.
There, I've coined it. If you use it you owe me a nickle.
An interesting study here. Bottom line: Some stroke survivors can feel when they touch the affected side, but cannot feel it when someone else touches them. This experiment basically shows that, in fact, they do feel better when they do it themselves.
Implications: reestablishing sensation may involve repeatedly touching of the affected side by the unaffected side. Maybe. Still, the question of how to neuroplastcially rewire sensation is interesting because sensation and movement are essential to each other.
The National Stroke Association has chosen Stronger After Stroke as the first book ever mentioned in their first ever annual summer reading section! Click on the screen shot yay!
Let me tell you what the deal is here. This book ain't perfect. There is a lot I wish I had added. There are some aspects of it where I wish i had used other wording. There are parts I should have edited better.But this book continues to be the best selling book on stroke recovery and rehabilitation because it does something I'm very proud of: It has changed the discussion. Time and again I find folks "reverse engineering" stuff in the book and putting it in articles on the web and magazines. Thinly veiled plagiarism, yes, but this book is changing the discussion.Many stroke survivors confirm this.
I've been told a billion times (at least) that the book only confirms what they suspected all along; that they have control over their own recovery.
The problem with the whole "neuroplasticity is the bees knees" perspective on stroke recovery is that there is a feeling that bad practice will lead to bad movement. That bad movement, so the thinking goes, will lead to bad neuroplastic rewiring. But to pay a therapist to keep the survivor "moving correctly" is prohibitive. It takes too much therapist time, too much money and is unproven. Enter robotics.
The idea is to get a machine that makes the job easier and the treatment more effective. You still need a therapist there...for now. But the end game in most of these technologies is: "Go home with it, do a lot of hard work. Come back and I'll get all the credit."
Here is my colleague, Valerie Hill Hermann, demonstrating new robotic technology, the MYOMO, with a stroke survivor. Val has a new American Heart Association grant to study the device.
Most of my work in research has been on the arm and hand of stroke survivors. It is a joke among therapist; occupational therapist only deal with the upper extremity, and physical therapist only deal with the lower extremity. Of course this is a generalization that's not entirely accurate. Still, I have a special affinity for occupational therapists and their work.It was a pleasant surprise to have a review from ADVANCE for Occupational Therapy Practitioners do a review of Stronger After Stroke.
In this video two great neuoplasticians, Michael Merzenich and Alvaro Pascual-Leone, talk shop. Pascual-Leone is the guru of TMS, a way of stimulation the brain without surgery or pain.
The most important part for stroke survivors may be at about 6:25 of the video. Dr. Merzenich asks Dr. Pascual-Leone how TMS might be used with "intensive training" to get more recovery. Merzenich nails it with this question because he understands that "two great tastes can taste great together" (TMS with "intensive training".)
He also understands that the training has to be intensive, which is essential to any discussion of recovery from stroke and other forms of brain injury.
The shift in rehabilitation has been 180° in about 15 years. Prior to the prospective payment system (~1998), therapists were able to treat stroke survivors for as long as the therapist liked. There was some question about whether this therapist-dictated system was cost-effective. So it was scuttled.
Other countries have therapist treat stroke survivors for longer time periods. In many European countries these longer treatment times result in more recovery.
So if more treatment is better, but cost savings dictate shorter treatment periods, what's a stroke survivor to do?
One easy answer is to go home and work hard. This is where my book, and other books, can help. The idea is to do "massed practice". Many hours a day of practice.
Hard, sweaty, ugly practice.
If this sounds uninviting, it should. But in order to rewire the brain after stroke hard, sweaty, ugly work needs to be done. Remember Michael Jordan didn't start out as Michael Jordan. He started out as awkward kid who was a crappy basketball player.
I have worked with a lot of PhD's and MDs over my 10 years in stroke-specific rehabilitation research. One thing I'll say about these groups is that they are brighter than average bears. (Little-known fact: Many have ginormous heads, where the bone and skin barely covers their pulsing arteries.)
In labs like ours and in previous labs in which I've worked, spontaneous conversations break out. I usually sit there dumbfounded and overwhelmed. Then I scurry back to my office, do some research, and then try to figure out what was actually said.
Let me digress (a lot). I was adopted. All of the people that were in my family, my parents and sisters, were smarter than me. Hey, it's the luck of the draw. But because I was used to scurrying back to my bedroom to figure things out, it felt natural as I interacted with these ginormous brained scientists.The key is making complicated junk simple.
Here is an article I wrote describing how we learn to move. It does, I hope, satisfy the two most important aspects of explaining stuff about stroke recovery:
The focus, nay obsession, clinicians have with "function" has the potential to hinder recovery. Basically the word function and the word recovery are used interchangeably. But they mean different things."Function" is a buzzword that makes everybody in rehab feel good. But it has its downside. Focusing on function gets in the way of the neuroplastic rewiring necessary for the fullest recovery endpoint. How can this be? Let me ask this rhetorical...
Does using a boat make you a better swimmer?
File this under "I couldn't have said it better myself...waitaminute...I did!" I sent an email recently to Ben Philipson, the developer of one of the three EMG-based electrical stimulation machines. These machines are an important part of stroke recovery and rehabilitation.
Since I can't say it any better (again) I leave with this link to his blog.
I never understood the argument that athletes get paid too much. A kid grows up, shows up at practice, usually for multiple sports in the rain and snow and heat. Sweats, works, develops skills. And then at the end of 15-20 years or so of hard work it pays off with a 10,000 to one shot and a pro contract. I always imagine the people who complain the most are people who’ve never worked really hard for anything in their life.
"I worked really hard. I just chose to develop my brain,” they would counter. But they'd be comparatively lazy. They only developed their brain. Athletes develop their brains too, but the development is done through structured and dedicated bodily movement. It is a different part of the brain, but it is still the cortex. It's still neurons and synapses blending and communicating. It's still neuroplasticity.
Research into stroke recovery has revealed a simple truth: If someone was an athlete, at any point in their life (not necessarily right before their stroke), they have a better chance of a more full recovery. Why might former athletes do better? Is it because the movement portion of the brain, the part that is typically injured after stroke, is bigger in athletes? Or is it because athletes are used to training insanely hard for results?
I asked this of a neurologist and neurosurgeon, Prithika Chariwhen when we met at a shared talk in Munich 3 years ago. Her answer was simple (considering she was a brain surgeon); “Probably both."
Stroke survivors need to be athletes. By extension stroke survivors also need to be dancers and yogis and musicians. Work as hard as athletes.
And for all those nincompoops who think using your motor cortex is just plain dumb, click on this.
Constraint induced therapy (CIT) and modified constraint induced therapy (mCIT). We know them and we love them. These recovery options are richly researched and intuitive. I mean really, how much thought does it take? "If I tie up my 'good’ arm, and work really hard with my 'bad' arm and hand it will move better.” Duh, hello.
The concept of CIT has been extrapolated to everything. For instance there is CIAT (constraint induced aphasia therapy). CIAT is based on the same old idea: If the stroke survivor forces themselves to talk a lot, talking gets better. In many ways a constraint induced therapy is the trunk from which all the theoretical branches spring. And that trunk is as solid as it can be. "Practice makes perfect.” “We are what we repeatedly do.” “Use it or lose it.” ClichÊ, clichÊ,clichÊ but true, true, true.
All good news to be sure. But one bit of the body that has been left to drag behind: The leg. How would you do the CIT for the lower extremity (LECIT)? You could tie up your good leg, but falls, decubitus ulcers, hospitalization, throwing a clot, having another stroke, so let's say… no.
But still the idea is compelling enough for researchers and device makers across the rehabilitation spectrum to want to claim LECIT as their own. I wrote an article about the competing perspectives.
The bottom line is that to adhere to the spirit of constraint induced therapy, you have to overstress the affected leg. And this requires caution. And a therapist. And a lot of work.
Figuring out what helps a stroke survivor recovery may involve finding that one magic bullet. But it probably won't. It will probably be a few magic bullets, a smattering of magic hand grenades and a ton of magic TNT. Enough of this explosive rhetoric!
The point is, recovery requires multiple recovery strategies. As time goes on, the combination of strategies will change.
There is a tendency among many researchers to focus on their little piece of the pie. They'll pioneer treatment "X". They'll develop treatment "X". They'll advocate "X" and they'll cling to "X" forevermore.
Our lab takes a bit of a different tact. If different things work for different survivors at different times you damn sure better have a feel for the whole ball o' wax.
