Rockin' Recovery

I'm here in Finland, above the Arctic Circle, the home country of my wife, Aila. We're visiting for 3 weeks.

This is a great country for clearing one's head. The things that matter to "us" seem to trouble them less. Their perspective has changed my perspective!

There is a particular study the Fins have done on stroke recovery that has caught my eye several times over the past few years. Part of it is that any study that says "stroke" and "Finland" will get my attention. Part of it is that music is so personally important. The following quote comes from this article.

"A daily dose of one’s favorite pop melodies, classical music or jazz can speed recovery from debilitating strokes, according to a study published recently. When stroke patients in Finland listened to music for a couple of hours each day, verbal memory and attention span improved significantly compared to patients who received no musical stimulation, or who listened only to stories read out loud, the study reports.

Those exposed to music also experienced less depression than the other two control groups.

Three months after a stroke, verbal memory was boosted by 60 percent in music listeners, by 18 percent in audio book listeners, and by 29 percent in non-listeners, according to the lead author Teppo Sarkamo, PhD, a neuroscientist at Helsinki University in Finland.

The differences held true after six months as well, says the study, which is published in a recent issue of the journal, Brain. Sarkamo’s findings bolster a growing body of research pointing to the benefits of music and music therapy for conditions including autism, schizophrenia, and dementia. But this is the first time music alone has been shown to have a positive effect on victims of brain injury, such as stroke, he says.

“Everyday music listening during early stroke recovery offers a valuable addition to the patients’ care, especially if other active forms of rehabilitation are not yet feasible,” Sarkamo says."

Also, this systematic review seems to further indicate music can help in a number of ways.

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It's the whole enchilada.

Stroke. The leading cause of long-term disability. It's not the leading cause of short-term disability. That's probably headache or back pain. And it's not, like, the fifth leading cause of long-term disability. It is the LEADING cause of LONG TERM disability. It's the big kahuna. It's the whole enchilada.
 

Figure stroke recovery out and it will inform you about everything that the brain does. Insights into cortical plasticity? Done. Recovering after dramatic brain injury. Done. Learning? Done.

Here's some irony:

There is only one treatment option for recovery from stroke that has the same level of testing as any drug on the shelf of a drugstore. One. Constraint induced therapy (CIT).

So you would think that every rehab hospital would do CIT. But, not so much.

Part of the problem is the foggy perception that many clinicians have about what CIT is. Read this article, and then have your therapist read it.

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It's okay. I speak aphasic.

You're the first responder to a serious car accident. You try to talk to one of the two people in the car - the only one that's conscious. But everything that she desperately tries to tell you seems to trip on her tongue. Is she in shock?

A house is burning down and you are a firefighter. You need to make quick decisions about whether to send your crew inside the burning house. A woman outside the house is desperately trying to tell you something. But... can't... quite...

The Drake Center in Cincinnati Ohio is having a training session for first responders on how to communicate with folks with expressive aphasia. Please click on the flyer, below.

Note that the address of the Drake center is:

151 W. Galbraith Rd.

Cincinnati, OH 45215

Please e-mail me if you have any questions...

2 great videos by Canadian neuroscientist Dale Corbett

The emerging translation of this stuff to clinical practice will be interesting.

Here's another lecture he did. The first half an hour is about his work using hypothermia as a way of treating acute stroke. Right around 29:27 is when he starts talking about rehab.

Pizza And Therapy: So Much In Common

Some stroke survivors end up frustrated when therapies end. Generally stroke survivors want more therapy. And there's a reason for this.

Let me explain it this way: I have a friend, a food scientist. His job is to make food so desirable, so delicious and so irresistible that you never want to stop buying it. He was a very funny guy, my friend. So please don't misunderstand; this was a joke. One day he said, "I've been thinking about developing a food, maybe pizza, and having in the sauce, pot. Then when people finish eating the pizza they'd get the munchies and buy more pizza."

Therapy is very pot-like. At the point at which stroke survivors "plateau" therapies have to end. So the stroke survivor attempts to scratch and claw their way back into therapy.

The calculus made by stroke survivors is simple:

therapist = recovery.

Understand, therapist have to discharge patients after the first plateau. This is the rule. It is a rule concocted by insurance companies and the Prospective Payment System, part of the balanced budget act. "Balanced budget act." How quaint!

The rule says, paraphrased, "As soon as a stroke survivor plateaus they must be discharged." The thinking is "Why is this person still in therapy if they're making little if any progress?" But recovery is really about multiple plateaus, that happen for many years to come.

The first plateau is formed by two forces. One force is the fact that therapists have a limited set of tools, and they're under pressure to get people safe, able to live their lives, and out the door. The other force is neurological. The neurons that were "stunned" after the stroke have all come back online. This usually happens during subacute -->phase – the first 3 to 6 months after stroke. As these neurons come back online recovery is relatively "easy".

The end of the "easy" part hearkens the "chronic" era of post-stroke life. At this point the stroke survivor is essentially on their own. During this period you can still make progress, and much of that progress has to be made without a therapist. The stroke survivor should have a good strong plan when they are discharged from therapies. Once that plan has run its course and a second plateau kicks in, the stroke survivor should go back to therapist looking for the next plan, to take them to the next plateau.

Recovery is a series of plateaus. And every once in a while you need someone to throw you a rope.

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Q&A

I get so many questions about stroke recovery from survivors and caregivers and therapists. Many of the questions are sad. Survivors and their loved-ones often contact me when they don't have any resources providing direction towards further recovery.

I could probably write a book of questions and answers I get.

Instead, I wrote an article.



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Need an Aggressive Physiatrist and/or Neurologist?

If you're looking for aggressive teammates in your quest towards recovery, there are ways of finding them.

If you are looking for an aggressive neurologists and physiatrists click here. At the top right of the page enter your ZIP code.

Doctors that administer Botox for spasticity reduction tend to be of the aggressive variety.

If you are looking for a physiatrist in your area click here for a searchable database (based on zip code) of PM&R (physical medicine and rehab.) Physicians.

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BOTOX PARTY?

After years of trying Allergan has FDA approval for Botox for spasticity for the upper extremity. However, this does not mean Botox will be any less expensive, at least in the short term.

Would Botox be helpful to you? A neurologist or physiatrist would help you make that decision. Occupational and physical therapists can help you make the decision as well. But understand, Botox is just a Band-Aid, and a temporary Band-Aid at that. You can get injected, and have relief for a few months. That's great, but will not help you resolve the issues that created spasticity in the first place.

Sometimes, if you're super lucky, Botox allows heretofore hidden extension to emerge. For example Botoxing the finger flexors may allow the finger extensors to extend the fingers a little bit.

If you and your doctor decide on Botox, make sure a script is written for therapy. Have the therapist work specifically on recovery options that will help you take advantage of the opportunity that Botox provides.

Imagine if your hand is locked pretty tightly into a fist. The Botox may provide just a little bit of movement into extension. This will provide you an opportunity to use repetitive practice to reestablish cortical (brain) control over the extensors.

Botox is expensive but they do provide help in some cases. Click on either picture to find out more.


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The Ultimate Crystal Ball?

It turns out the the speed you walk (gait speed) is predictive of so many things that folks are now calling it "The Sixth Vital Sign." But here's some funny: everybody is calling everything the sixth vital sign including:

• Urinary continence
• End-tidal CO2
• Emotional distress
• Spirometry
• Glucose
• Functional Status
• Intracranial pressure
• Shortness of breath
• Molecular Genetics, in Oncology

Who will become the sixth, who knows? Some of these require a test in which the tester needs to be trained. Others are self-reported and we lie. But gait speed requires a stopwatch and 2 meters of hallway. Then just read the gait speed tea leaves! 
Here's a full explanation I wrote recently!
Here's another version!

Exercise. Because.

I was interviewed for this article on the Cleveland Clinic website. What I like most about it is that it also mentions one of my neuroscience heroes John Ratey. The fact that I'm mentioned before him- and more often- is just plain wrong.

The focus of this article is the impact of exercise on stroke recovery. But exercise per se does not necessarily drive the sort of cortical changes needed to recover. Of course, it is important to do both cardiovascular and strengthening exercises after stroke, if for no other reason than the fact that life poststroke takes so much energy for two reasons:

• ~Typically everything a stroke survivor does takes twice as much energy. A good example of this is walking. A stroke survivor takes an average of twice as much energy to walk as someone who has not had a stroke.
• ~Stroke survivors are in about half as good a shape as age matched couch potatoes.
• ~Although it hasn't been measured, neuroplasticity takes energy. We're not sure how much. But when you consider that the brain gets 20% of total body oxygen consumption, while it only represents 2% of total body weight, you can imagine how much energy it takes to drive neuroplastic change.

So the bottom line is that stroke recovery needs energy. And exercise is good for banking energy.

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Stroke Recovery: Easy Concepts and Hard Work

Let’s face it. There is a lot of bad information about stroke recovery. And the cheaper it is to publish information (I’m talking to you Internet) the lower the quality becomes.

Much of the info on stroke recovery is either stale or unreliable. Most of it falls into 2 categories:

1. Filtered through the medical model. This info tends to be stereotypic, redundant, risk free and out of date.

2. Unsubstantiated or weakly substantiated. This info is usually written by caregivers or stroke survivors themselves.

Don’t get me wrong; both the medical model and survivors and caregivers provide valuable information. I have long believed that the secret of recovery is locked within stroke survivors who have gone the furthest on the road to recovery. The problem is that, as much as it’s a cliché, every stroke is different. There are tons of variables, including:

• Sequelae (health problem related to the stroke)
• Comorbidities (health problems unrelated to the stroke)
• Motivation of the stroke survivor (The more motivated, the more recovery)
• Resources (time, energy, helping hands, money, etc.)
• Age (generally, the younger, the better the outcomes)

And there are a hundred other variables that can affect recovery. One of the most important is the location of the area killed by the stroke. A pea sized stroke in one area leaves the survivor unable to talk. In another area the survivor walks great, but can’t use their arm. In yet another area, a pea-sized dead zone allows for a relatively easy and full recovery. So when a stroke survivor writes a book about recovery, they are really writing about their recovery. And because of the variables mentioned, each journey through recovery, and each recovery endpoint, is unique.

I wrote a book about stroke recovery. I wrote it because I have been involved in stroke recovery research for a decade and I have learned a thing or two. Writing a book was easy because there is plenty to report on. Researchers from around the globe are adding their voice to an ever expanding ball of knowledge. And that ball, like much of science, is not perfect. It is misshapen and complicated and hard to visualize all at once. Part of this is because there are many different sciences involved. Input from neuroscience, physiatry, biomedical engineering, physical and occupational therapy and others makes the whole ball hard to conceptualize. But what is emerging from all these complexities are remarkably simple concepts.

I have come to a few basic conclusions about stroke recovery. 

Core Concepts

-Recovery is hard work. If it’s easy, you’re doing it wrong.

-Once you've hit the first plateau, the foundation of recovery from stroke is neuroplastic rewiring of the brain. Prior to the first plateau the most important aspect of recovery is the healing of the brain (the resolution of the penumbra).

-What drives recovery are relatively simple concepts that have been used by athletes (and other hyper-skill learners), since the beginning of time.

-Recovery is best served by

Repetitive practice of movements…
…that are related to a task or tasks…
…that is/are important to the stroke survivor and that are practiced…
…many hours a day…
…and are made more challenging as skill is acquired.

Other core recovery suggestions

1. Stroke survivors should stretch more than they do.
2. Stroke survivors should “bank” (develop a reserve of) cardiovascular (heart/lung) and muscular strength.
3. Measuring recovery from stroke is essential to recovery from stroke. During different periods of recovery can accelerate, slow and stall. During the slow and stall periods—periods when most survivors give up—measuring small improvements is necessary. A bunch of small improvements = large improvement.
4. You have to do it yourself (DIY). This DIY concept is essential in 2 ways:
5. Only you can rewire your brain.
6. If you have to rely on therapists and other clinicians to reach you highest level of potential recovery, you’ll run out of time and money before you’re done.

Focus on 2 things;

1. Making sure that you are not allowing soft tissue to shorten. If it shortens permanently, it doesn’t matter how much “recovery” you get, the joint will not be able to move.
2. Driving brain rewiring change towards recovery. How do you know if your brain is changing? A “Yes” to the following questions will help determine if you are rewiring your brain:
• Are your limbs moving better?
• Can you feel your limbs more?
• Is your balance getting better?
• Is your hand able to grasp wider objects?
• Are you walking faster?
• …and much more will tell you if you are rewiring your brain. Remember, the foundation of relearning movement is changes in the brain, not in the limbs. Although the limbs get credit, it’s the brain moving those limbs. The limbs tell us what is going on in the brain.

The basics of recovery from stroke are simple. The work required is difficult. Recovery from stroke, even years after the event, is available to any stroke survivor. The key is to bring your focus and power to your own quest for recovery.

Electrical stimulation can be used to help stroke survivors recover in many ways including:

1. Keeping soft tissue (including muscle, blood vessels and nerves) elongated (see "Electrical stimulation (E-Stim)" bottom of the post HERE).
2. Jump starting movement in survivors who have little or no movement
3. Reestablishing sensation in survivors who have sensation loss
4. Building strength in muscles that are not quite ready to move on their own

Pusher Syndrome

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.

How? Read on...

2 welcome mentions...

Click to make larger!

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.

Go Pats!


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A Rare non-stroke recovery entry: Hand washing

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 (née 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.

Propylene Glycol, Tocopheryl Acetate, Aminomethyl Propanol, Carbomer, Fragrance, Glycerin, Isopropyl Myristate, Propylene Glycol, Tocopheryl Acetate, Aminomethyl Propanol, Carbomer, Fragrance (Parfum), Blue 1 (CI 42090), Yellow 5 (CI 19140). (Thanks Sanjay!)
So I choose straight alcohol. But unlike the former governor of Kansas , I am not an expert in this field. So trust your doctor!

Stroke Recovery and Rehabilitation: A Head Game.

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.

But this is the big kahuna.


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G'head. Click the article.

Extry!


Extry!

Rewiring Around Dysphasia

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.

METANEUROPLASTIFICATION

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.

See me Heal me Touch me Feel me

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.

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The National Stroke Association endorses Stronger After Stroke

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.

We can make him better. Stronger. And with increased elbow extension.

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.

An appreciated review

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. 

Neuroplastification RAWK

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.

                    Click on image for video.

Good press. Always nice.

Click on any image to make ginormous.

Better late than never yay!

Me and a bunch o' my fellow labrats homeslices are speaking at this shindig which I should have blogged before but didn't because insert excuse.

A cool concept: lets get all the stroke nerds together to talk about the impact of technology which will eventually turn us all into Sony robots.

If yer in to this whole technology thang, click here. DANGER DANGER DANGER: YOU WILL FOREVER GET LOST IN THIS SITE!







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