Neuroaid: Scam

So. It turns out that in the largest clinical trial ever of the drug, neuroaid was  "statistically no better than placebo in improving outcomes." Who'da thunk? Oh yeah, we did!

So how do you think neuroaide spun it? Not real well. "Researchers found NeuroAiD, a stroke treatment based on Traditional Chinese Medicine, increases the odds of achieving a better functional outcome." "We are totally full of crap," they did not add.

Use what you love to recover what you love

I've said this before, but it bears repeating:

Recover so you can do what you love and use what you love to recover.

This is the hidden secret of recovery. It’s hidden because it has nothing to do with rehab or rehab science or physiatry or even neurology. It has to do with neuroscience; the neuroscience of the human brain

Here's the rule: Your brain will rewire (not just for stroke but for anything you learn) if you care about what you are rewiring for. Rewiring= learning. In neuroscience learning = "Changing the structure and/or function of neurons"= "brain rewiring."

But unless you care about what you learning you won't learn it.

Take math. How many adults have used an algebraic equation in the last year? Probably about 2%. And 95% of that 2% used algebra because they had to take an algebra course to graduate. Don't get me wrong, math is important. But the math most of us see as important can be done on a dollar stroke calculator. But algebra? You never really learned it because it has no importance to your everyday life. Now consider something like texting or using a new cell phone. We learn it in a matter of days because it’s important.

The same is true for stroke recovery. Many of the "ADLs"  (activities of daily living) that are used to rehab people after stroke are dry and boring. Things like dressing, grooming, bathing etc. are all necessary, but they're not very interesting to the brain.

Here's my suggestion: as much as possible, focus on things that you really care about. If it's important to you it will be important to your brain. The more pertinent is to you, the more brain rewiring can flower.

The following video is a good example of this. It's unusual example because the guy uses what he loves to "stay in the game," not rehab in the traditional sense. Have a look at the video. His right arm is still not working. But his love of music is.

The telling shot is approximately 50 seconds in. That, my friends, is "dense hemiparesis."

 Click the photo for the full story⇩⇩⇩⇩

This entry is dedicated to Mike Chambers 

Thanks for Todd Jasko for the idea!

Two Roads Diverged...

There are two ways to go after stroke: 
1. Compensation (technically: The compensatory approach)
2. Recovery (technically: The restorative approach)

Compensation involves getting on with your life by any means necessary. If your right hand doesn't work, you do everything with your left hand. If you can't walk because your foot drops, you put on an AFO. If you have trouble speaking, there's an app  for that.

Recovery involves using the intact part of the brain to take over for the "stroked" part of the brain.

It would be nice to say that the focus of clinical rehabilitation is on recovery. But for the most part, managed care only pays for compensation. Insurance companies want to get the survivor safe, functional, and out the door. Why do they want the survivor safe? Because an unsafe survivor will cost them more money down the road (think falls). Why do they want the survivor out the door? Because every day in any clinical setting costs a ton of money. But while survivors also want to be safe, and out the door, is it in their best interest to be "functional"?

On the face of it, sure, survivors want to be able to function. "Function" is a catchall word that means "getting on with your life." And it's seductive. Everyone wants to be functional. Everyone wants to be independent, and able to function.

But there is a problem with function. And it's not just a generalized idea that if you "focus on function" you'll ignore recovery. It's a very specific concept based in neuroscience.

It would make sense that if you focus on learning compensation, you would spend less time on recovery. And this would mean that you would become better at compensation, but less recovered. But it's more than just a time issue. It's a brain issue.

It turns out that something special happens to the brain after stroke. The brain is in an almost "infantile state" after stroke (in fact, after any brain injury). And "infantile state" is a good thing. The brain, through a release of special proteins is "primed" for learning— like an infant's brain. But what will it learn?

Well, it could learn to compensate. If you are right-handed and you have limited use of your right hand after stroke, the brain could learn to compensate. Your left hand would be doing a whole bunch of things never did before. The left hand is now handwriting, attempting to tie shoes, brushing the hair and teeth, and dressing. And it's doing it all alone — no right hand to help. So during this period in which the brain is "primed" for learning, the left hand does all the learning.

But if the focus is not compensation, but recovery, there will be more recovery. The brain is "primed" for learning, and it learns to recover.

NSAIDs Increase Risk of Stroke

Do over the counter pain relievers cause stroke? Some do, some don't. Might some pain relievers also cause heart problems and other cardiovascular problems? Same deal: Some do, some don't.

Note: As a group these meds are called Nonsteroidal anti-inflammatory drugs or "NSAIDs" (pronounced: NAY-sads). (List of all NSAIDs here)

In 2011 rather large study of this issue was completed. This study was a meta-analysis. A meta-analysis is a study of all the available studies. Although this is not news (it did come out in 2011) it is important for folks with chronic pain. If for instance you have frequent headaches and you take certain painkillers for that headache pain it could increase your risk of stroke and heart problems. Ibuprofen, for instance, tripled the incidence of stroke. 

Keep in mind, this study was not done with people who have had stroke. The statistics may be different if you've already had a stroke.

And "dying from heart trouble was four times greater" when using some NSAIDs.  As Consumer Reports puts it: "...all (NSAIDs) except naproxen were associated with similar increased risks..."

Here's my suggestion: Ask your medical doctor about this research.

PT/OT invented rehab - not.

A scene from 
Walking with Cavemen.

Rehab is not new. It goes back -- not hundreds of years but back to the earliest humans. We’ve been "rehabbing" for hundreds of thousands of years. And what we did to recover, all those thousands of years ago, may have been more effective than most of what's been developed since. 

Consider the stroke-rehab ideas coming from recent neuroscience (and to a lesser degree, OT, PT and Speech therapy). This recent work has more in common with "rehab" tens of thousands of years ago, than it does with the decades between 1920 and 2000. What has this recent research and our deep ancestral rehabbing have in common? Researchers now call it "intensity." But back then they called it something else: Survival 

There's a lot of folks, therapists mostly, who think that rehab started in 1918 or so. They'll tell you that PT was developed in response to polio and WW I. They'll tell you that, in the US anyway, its champion was Mary McMillian, the first PT, credited with starting the first legitimate PT training school in the US. Some of them may even know that Pehr Henrik Ling developed and codified the concept that exercise=health in the 1800s. Ling went further, developing a standardized way of promoting rehabilitation and recovery. 
 

But what of “Rehab=Survival=The Latest Research"?

Imagine a survivor trying to rehab 150,000 years ago. Let's call our stroke survivor “Magch” and his mate-pair “Youngh.” It seems as if we probably had language even then. This is the way the conversation probably went…

Youngh: “How many times do I have to tell you to stop leaning to your good side?”

Magch: (leaning towards his "bad" side): “Yes honey.”

Is that rehab? Yes! If Magch did that movement tens of thousands of times until it felt natural, today's neuroscientists would call him a genius.

Our ancestors knew a thing or two about rehab. Read about it here.

How to walk when you can't (and walk better when you can).

Challenge. Challenge causes change in the body. For instance, challenge changes muscle. Once they are challenged (i.e. resistance training) muscles "micro tear." This tearing (after some days of aching muscles)  increases the thickness of muscles, which makes them stronger.

Challenge also changes the brain. 

Challenge is the way that you learn; you go to school, you're asked to do things that are hard to do, and your brain changes. Challenge is the stuff that learning is made of. Without going outside of the brain's "comfort zone" the brain will not change. You've probably heard the saying, "use it or lose it" when it comes to the brain. If you don't use a skill your ability to do that skill will get worse. And why does it get worse? Because the part of the brain that controls doing that skill gets smaller. So, maybe the saying should be "If you don't use it you'll lose it." The flipside would be: "Challenge it and gain it." The brain will only rewire the it is challenged enough to necessitate rewiring.

Challenge and walking.

Challenging walking after stroke only has one downfall: a potential downfall. (Info on reducing the risk of falls, here.) Falling strikes terror in survivors and clinicians alike. A fall by a survivor in their care can be a black mark on the clinician's career. If someone falls while under their care,  a cascade of emotional pain follows. There is a ton of paperwork and a formal review of what caused the fall. People have been known to lose their job. Not only that, a lawsuit can sometimes follow. 

For their part, managed care (insurance) hates falls because falls cost tons of $$$. The cost of fall related injuries was $23.6 billion in 2005 (Update: $50 billion in the USA in 2015. And that's only in people over 65).

Survivors are afraid of falls because hitting the ground is never fun. But when you're in a weakened state after stroke falls can be especially dangerous. Stroke survivors tend to fall towards the weak side. The weak side in stroke survivors is often more osteoporotic (weak bones) strong side. So survivor is more likely to fall towards the side of his weaker muscles, and on bones that are weaker.

So here's the question: How can you challenge walking after stroke, when walking is inherently dangerous?

For a long time the hope was partial weight supported walking (PWSW).

With PWSW the survivor is harnessed from above while they walk. So if they fell, they wouldn't fall (if you follow). The problem with PWSW is that it's laborious to set up (it often takes more than one therapist to administer) and the equipment is expensive. Plus, the research into PWSW was not very flattering. Or, as the NIH put it: "In the largest stroke rehabilitation study ever conducted in the United States, stroke patients who had PT at home improved (paraphrased) just as much as the people who got PWSW." It should be noted that some therapists believe that there was a flaw in the research into PWSW. Specifically, the amount of time on used in research is seen by clinicians as too much. In research PWSW was typically used for 20 to 30 minutes. In the clinic, therapists will often use it for as little as five minutes.

PWSW does have some advantages. Therapists will often use PWSW (where available) when patients are "pre-ambulatory." Pre-ambulatory is a fancy way of saying that these patients are right on the cusp of being able to walk. They just need a little bit of help. Therapists will often use it for people that are bariatric (obese) because these patients can be difficult to manage, especially if they are about to fall! 

Another option is aquatic treadmills. This allows the survivor to simulate land-based walking but with a reduction in bodyweight. Again, not very available, and very expensive.  

There are much less expensive options that fall into the PWSW category. Here is one example that allows for challenge, and eliminates the fear of falling (another form of PWSW).

There are also other things that can help "unweight" and  reduce fear of falling:
  
What if you're walking, but want to walk better?
If you are able to ambulate without these devices, the best way to add challenge is to add speed. There is a particular technique to get you there, and you can find my blog entry on this technique here.

Bobath: The more you move, the worse you'll get

I've made my position on Bobath/NDT pretty clear (hint, I'm not a devotee). One of the many things Bobath was clearly wrong about was the effect of effort on spasticity. Bobath weirdly believed that using spastic muscles would increase spasticity. The way she put it in her book Adult Hemiplegia was, "Effort leads to an increase in spasticity." This is the way the thinking goes: Since movement poststroke requires effort, movement increases spasticity. Distilled, the philosophy was pretty clear: The more you move, the worse you'll get. Later in her book she doubled down on this concept. "The use of effort... will only reinforce the existing released tonic reflexes and, with it, increase spasticity."
 Wrong. Wrong. Wrong.  
(Here are the references...)

Note: CIT requires a lot of effort.

And it's more than just wrong, it obfuscates the issue for clinicians trying to find answers. I'm guessing, but at least 80% of all seminars for stroke recovery revolve around the Bobath/NDT. So clinicians learn it. And it wastes researcher's time, effort and funding. Because clinicians learn and believe it, researchers often have to go and "prove the negative." Researchers have successfully debunked the concept that effort increases spasticity. Because effort reestablishes cortical control over spastic muscles, spasticity is actually reduced. 

"This evidence is not compatible with the underlying assumptions of the Bobath approach." 
(From the 3rd article referenced, above) 

  ©Stronger After Stroke Blog 

Is walking right after stroke good?

I've been involved in stroke recovery research for a long time. And I do a lot of seminars on stroke recovery. A lot of clinicians that come to the seminars take this posture: Just tell me what the treatment options are and how to do them. This demand assumes that there are a lot of treatment options. It also assumes that those treatment options are "proven." And it assumes that things can be made simple and immediately clinically applicable.

Overall the posture suggests Dunning Kruger effect. The Dunning Kruger effect is simple and measurable:

1. The less you know about a subject, the more you estimate you know.
2. The more you know about a subject, the less you estimate you know.

The Dunning Kruger effect in action: You ask two people about galaxies; one is an astrophysicist, the other is a six-year-old. The astrophysicist says, "There so much more that we need to discover. We're not even sure how many there are." You ask a six-year-old and he says, "I know all about galaxies. There is a moon, and he goes up and down, and it squiggles, and then there's the Earth and the sun goes around and around and you can take a spaceship to it."

The Dunning Kruger effect in post stroke rehabilitation
 
We don't know much about what helps stroke survivors recover. There. I said it. That there is a lot of confusion about what helps stroke survivors recover does not sit well with rehabilitation clinicians. And one of the reasons it does not sit well is that there are a lot of folks that try to sell treatment options that are "proven." This mucks up the waters. Let's say you're a therapist looking for answers. Are you going to listen to the person who says "Well, we really don't know, we're not really sure, none of this is proven, but this is what we think..." or are you going to listen to the person who says, "I have this great thing that works and it's super fantastic and it works all the time." The folks who are real sure that their treatment option is the bees knees of stroke rehab are often out to sell something. Like a machine, or a "pay us to learn" technique. But those of us in the research game are more equivocal.

In other words, the thing that research does, which is discover things layer by layer in a slow plodding scientific process, is not very satisfying.

Let me give you an example. I got an e-mail recently from a therapist who had been to the seminar. This therapist asked a very specific question: "Is very early mobilization after stroke good or not?"

Mobilization means "Getting them up and walking." "Very early" is a designation that means within the first 24 hours of the first symptoms of stroke. Simple question, right? The answer should either be yes. Or it could be no.

Except it's neither. It's "We don't know." In the few studies that have been done on this subject (there are ongoing studies which might provide more clarity) the conclusion is, we don't know. On one hand, it is commonly believed that many problems early after stroke are caused by immobilization. Problems caused by lack of early movement/walking include infections (especially in the lungs) and blood clots breaking off and causing all kinds of vascular problems. Further, getting somebody up and walking after stroke, especially in animal experiments, seems to help promote brain plasticity.

The problem is that the brain is very vulnerable after stroke. And one of the things it's vulnerable to is decreased blood flow. And when somebody is in an upright position is decreased blood flow to the brain. 

A quick review of lit...

• The Cochrane review: At present there is insufficient evidence to support or refute the effects of routine very early mobilisation after stroke.
• An article looking at quality of life: Conclusions. Very early mobilization may help improve long-term quality of life after stroke, particularly in relation to functional independence, but this requires further examination.
• An article where they interviewed therapists, docs and nurses: Conclusion: Our study shows that most clinicians had concerns in relation to early mobilisation of stroke patients and more clinicians had concerns for haemorrhagic than for ischaemic stroke.
• An article looking at very early mobilization and depression: Conclusion: Very early mobilization may reduce depressive symptoms in stroke patients at 7 days post-stroke.
• Early mobilization out of bed after stroke may be all good: Conclusion: It seems to reduce severe complications but not cerebral blood flow:
• Early mobilization out of bed after stroke, maybe: Conclusions: Insufficient data are available to prove the beneficial effects of early mobilisation after stroke.
• A Very Early Rehabilitation Trial for Stroke (AVERT)2008: Conclusions: Very early mobilzation of patients within 24 hours of acute stroke appears safe and feasible.  ADDENDUM: This was updated once the study was over (2015) and it "proved" the negative: Fewer patients in the very early mobilisation group had a favourable outcome than those in the usual care group.
• The LEAPS trial (the largest study ever done on post-stroke rehab): "patients who received early locomotor training experienced more multiple falls."

There. Does that clear things up?

Exercise helps recovery because it strengthens what?

Interesting video, below, by one of my favorite neuroscientists, Dale Corbett.  For the record: There is no one I know up doing a better job of translating what neuroscientists have to offer to stroke recovery. Have a watch. The insights really start at 1:40 in. I'll post my critique below the video.  

The overall message is important. Exercise is essential. It is unfortunate that the message is sort of convoluted in this video. They're talking first about TIA, and how if you have a TIA you should use exercise as a way to lessen the chance of a full-blown stroke. Then the discussion takes an obtuse tangent into how exercise is important to recovery, and then with no real explanation doubles back to talking about TIA again. Still, while maybe the messages should have been separated, both are important. 

1:50 Another person, besides Corbett, whose interviewed in this video is William Mcillroy, who like Corbett is a PhD. I quibble a bit with Mcillroy's statement that exercise can be started "...as short as two weeks after stroke." Charitably, this is highly debatable. Once a patient is medically stable, intensity should be increased to tolerance. There is no one-size-fits-all timeline for every survivor that is rigid enough to predict that someone can start exercise "as short as two weeks after stroke." In fact, it could be much shorter. For instance, in a survivor who is medically stable day 4, waiting another 10 days to start a progressively rigorous exercise program would allow learned nonuse to take hold. 

2:20 Both PhD's talk about how exercise is good for the brain. Corbett talks about how exercise helps cognition, and points out exercise also helps sensory motor recovery. I would remind anyone who is willing to listen: sensation and motor behavior are cognitive. We learn sensation and movement the same way we learn French, or trumpet, or algebra. That is, changes in motor and sensory behavior happen involve the same brain processes as any other kind of learning.

2:50 I'm not sure that there should be such an unequivocal endorsement of balance retraining using biofeedback. Certainly the research is not there yet. 

Having said all that, I think this is a really great video with some really essential points. Interviews can be misrepresented because the person being interviewed is not doing the editing. The points these guys were making may have been a ton more cogent in the original interviews. 

The best line is by Dr. Corbett: 

 "It's still early days and you know we're nowhere near to the level that I think we can get to. And if we can understand what the mechanisms are then we might be able to optimally better design exercise programs to improve stroke recovery." 

"Until then, anyone trying to sell you certainty is after your wallet," he didn't add.

Try: to attempt to do or accomplish

Here is clarification of a paragraph in the previous post:

Of course, there's a fine line between the exercise and movement needed to relearn movement. But the emphasis on trying to build muscle is as mistaken as changing the oil in a car with no gas: Its a good thing, but hardly the main issue.

This difference between exercise and repetitive practice (movement needed to relearn movement) may seem like a distinction without a difference. In fact, both build muscle and both drive plastic changes in the brain. The distinction is in the focus. Repetitive practice paradigms focus on driving changes in the motor and sensory cortices of the brain, not specifically in changes in muscle strength. Sure, muscles will build. But focusing on strengthening is like climbing a ladder to the top only to find the ladder is leaning against the wrong building. Stroke is brain damage. And, unlike most other forms of acquired brain injury, stroke involves just one part of the brain. So if a survivor is, say, 2 years post-stroke and they can’t open their hand and then, later they can, that is not a reflection of muscular strength. It is a clear indication of a change in the brain. The muscles have been there all along. Muscle strengthening is the easy part. 

Clinicians often sweat the fact that survivors have limited energy for therapy. But does it need to be very strenuous to be beneficial? No! The ability to open the hand (or lift the foot or straighten the elbow or move the mouth) can be done while sitting in a comfy chair. Each attempt should be focused and deliberate. The very ends of the movement should be the point of focus. Each attest is measured as a success if it is just beyond the previous attempt.

Details are the devil

Because it involves the brain, stroke recovery is complicated. The brain is complicated, so anything that involves the brain is complicated as well.

Except that's not true. And it's more than not true. Complexity, when it comes to stroke recovery, is evil. 

Of course, complexity is out there if you want it. There are "treatment options" that force therapists to spend thousands of dollars and weeks of their life getting trained in the devil in the details. Some of these treatment options have been around for 40 years, but new ones are invented every year. Do these therapies work? They generally fall into two categories; 1. Been around forever, the data doesn't look good. 2. They're completely untested.

Anyhoo... with regard to stroke, complexity is evil. Complexity separates the survivor from recovery. Why? It turns out that no matter what any clinician is telling you, only you can make you better. Remember the old-fashioned way of saying "teach me?" It was "learn me." Learn me to do math. No one can you learn you stuff. You have to learn it. That seems rational to just about everyone when it comes to learning that involves the brain; things like learning math and chemistry and French. But for some reasons when we talking about movement, its not considered learning. But it is.

• Learning math involves changes in the structure and function of neurons in the brain. So does learning how to move.
• Learning math involves neurons in the cortex (the outer shell of the brain). So does learning how to move.
• Learning math involves repeated attempts towards the correct outcome. So does learning how to move.
• Learning math increasing complexity. So does learning how to move.

How complexity kills recovery.

• If instructions from a clinician are complicated ("Move your arm up but keep you shoulder down now turn your hand blah blah blah") movement performance gets worse.
• If the pieces that go into recovery are complicated the survivor will not be able to drive their nervous system towards recovery. Complexity make it impossible for survivors to work towards recovery on their own.
• Learning complicated treatment options ties up clinician's scarce education resources (time and money).

In every sense of the word, regaining the ability to move after stroke is learning. People, especially clinicians, want to talk about muscle weakness. "These exercise will help you move better." No they won't. What helps you relearn how to move after stroke is moving, not exercise. Of course, there's a fine line between the exercise and movement needed to relearn movement. But the emphasis on trying to build muscle is as mistaken as changing the oil in a car with no gas: Its a good thing, but hardly the main issue.

Recovery with a Beat

With the lower extremity "function" is inherently bilateral. That is, because the primary function of the lower extremities is ambulation, bilaterality is inherent. 

(By "advantage" I do not suggest that I buy into the concept that the lower extremities come back before the upper extremities post-stroke. This is common wisdom in rehab, but it may be incorrect. The only way to prove the lower extremity comes back before the upper extremity would be to measure the most distal element of both: the fingers and toes. Measuring toe extension in comparison to finger extension has, to my knowledge, never been done.)

Beyond bilaterality, ambulation is also inherently rhythmic. The rhythm after stroke is disrupted and made unequal. And rhythm is what bilateral leg training with rhythmic auditory cueing attempts to re-establish in the lower extremity.

That is, if you re-establish the rhythm of gait, you will go a long way to re-establish symmetry of both step length and step timing.

There are commercial systems that use a heel switch so that the moment of heel strike is radio-delivered to headphones. The patient hears their own heel strike through the headphones, as well as a beat that they have to match with each heel strike.

But as is true with many technologies purported to help stroke survivors relearn movement, no special system is really needed to bring the idea of rhythmicity into gait.

A simple metronome either heard through headphones or carried by the therapist next to the stroke survivor can be used to promote the re-establishment of rhythmicity of gait. Plugging the ears using standard noise-reducing plugs can boost the volume of footfall to make that obvious to the survivor. The trick is then to match the footfall to the beat. 

Intention tremor, and a possible neuroplastic treatment

In stroke intention tremor is caused by damage to the cerebellum. 

The cerebellum is important in fine coordination. If the stroke damages the cerebellum fine motor coordination suffers. 

(Note: Intention tremor is different from essential tremor, often found in Parkinson's) 

It is called intention tremor because the tremor happens when somebody moves intentionally. So let's say the intended movement is touching the nose with a fingertip. With intention tremor, the trajectory toward the nose is good until the finger gets close to the nose (closer to the intended target) and the tremor begins. As the New York Times put it:

Intention (or kinetic) tremors: These tremors occur at the end of a purposeful (intended) movement, such as writing, pressing a button, or reaching for an object. The tremor will often disappear while the affected body part is at rest.

Outside of stroke it is often seen in long-term alcoholics. So here's my first suggestion: If you have intention tremors, don't drink. Other drugs can cause tremors as well. So, the "Brown Bag Medication Review" may help in reducing tremors.

How has intention tremor typically been treated? 

Intention tremor is notoriously difficult to treat. There are several drugs that are used for treatment, but they all work for some of the people some of the time. (Here's an example of an herbal "remedy.")

Other things that had been tried:

Physical therapy: In some people it works great to temporarily reduce tremors. It's not cure.
 

Meditation, yoga, deep breathing exercises, biofeedback have all been used with varying levels of success.

The neuroplastic model
So what is the neuroplastic model for overcoming intention tremor? I guess the first question is: Is there a neuroplastic model? Is there anything that can be done to rewire the brain "around" this movement disorder?

We will wait for neuroscience to catch up to that question. It could take decades, it could take centuries. On the other hand, somebody could come up with a really good way of applying the brain's inherent plasticity tomorrow. So you never know.

Having said all that, I still have some suggestions that may very well rewire the brain to help overcome this issue. Here are my suggestions:

Mirror therapy. This is the way that mirror therapy would be applied:

Just like in mirror therapy for movement recovery, you look only at the "good" side. That is, you only see the flawless movement of the unaffected side.

Bimanual training. This option involves having the "good" train the "bad." It's a simple enough concept; whatever the good hand does, the bad hand attempts to copy.

Your meds are probably wrong. And its probably gonna hurt.

The statistics about medications and falls are pretty clear. The more medications, the more chance of falls. This is as true in stroke survivors as anybody else. 

But stroke survivors automatically have two additional things going against them:
1. They are usually on more medications
2. They are more likely to fall in the first place

But there are other reasons to reconsider medications. In 2008 almost 2,000,000 people became ill or injured because of the use of prescription drugs. These are from "medication errors." 

So how do you go about reconsidering medications? The "Brown Bag Medication Review." And you should do it. (My favorite line: “Out of 10-15 brown bag reviews, only 2 were accurate.”) About 50% of the time the meds will, in some way, be wrong.
The idea is you throw all your medications in a brown paper bag.
 

In the bag should be... 

• All prescription medicines (including pills and creams).
• All over-the-counter medicine they take regularly.
• All vitamins and supplements.
• All herbal medicines.

All medications are placed on the counter in the exam room. The physician or pharmacist, with your help, decides which meds to keep, which to pitch and which dosages to tweak. Also decided...

• Tips for safe and effective medication use
• Answers to your questions about medications 

Once the whole thing is  figured out you are given a card that has all the information on it. This information would be available for you to review, and for you to hand to doctors, dentists, etc. who may need to know your medications at a glance.

More info here.

Hell Yes.

Can someone get better after they "plateaued?" Hell yes.

What is the plateau? 

It's the point at which all of the neurons that were "stunned" by the stroke have come back online. Why were the neurons stunned in the first  place? The stunning of neurons is known as "cortical shock." Neurons, right after the stroke, are fighting a battle to survive. And while they're fighting this battle, they don't work. These neurons eventually come back online. They usually come back online between one week and three or four months after the stroke. This is known as the subacute phase. (Note: there is no "one size fits all" timeline for these events. Two stroke survivors can have radically different timelines.)

In any case, at some point these neurons come back online. Recovery is sometimes very rapid and relatively "easy" during this phase. This kind of recovery, stunned neurons coming back online, is known as natural recovery, or spontaneous recovery. In other words, "Not a lot of work, but a lot of recovery."
 

Eventually, all of the neurons that were stunned are back online. The survivor "plateaus" and the chronic phase of stroke begins. Once this happens there is a discernible reduction in the rate of recovery. The reduction is because there's no neurons to come back online and help the process along. But recovery can still happen.

It's just that recovery takes a different form. Now neurons from around the brain have to be recruited in order to make up for the neurons killed by the stroke. This makes recovery a much different (and effortful) process during the chronic phase, than during subacute phase.

But... you hear this all the time. I even hear this from therapists. They'll say something like, "We ended therapy with this guy, 14 months later he walks through the door and he can do stuff that he couldn't do when he was discharged!" This sort of recovery can then trigger more rehab. Remember, rehab ends when the person plateaus. (Its a managed care thing.) So if there are changes in the ability to move, therapy can be justified. So you could go through the cycle where you work your butt off to get a little bit better, which then triggers more therapy. 

It's a beautiful cycle, and it can continue for decades.

~

Exercise. Energy. Recovery.

There are good reasons for muscle strengthening after stroke, of course. But therapists know these reasons well. For instance, the muscles on the affected side, even the ones that are the most spastic and seem overwhelmingly strong, are usually no more than half as strong as the unaffected side. Because spasticity is such an issue after stroke, some clinicians believe that strengthening "tight" spastic muscles will exacerbate spasticity. Research has shown that this is untrue; exercising muscles does not increase spasticity. It is important to focus on the muscles that are the weakest, of course. For instance, most stroke survivors have no problem at all bending their elbow, but extending their elbow is often very difficult, especially at the end of the range of motion. In this case it would be wise to work the triceps because it is the weaker of the two muscle groups. 

The other form of exercise that therapists focus on is cardiovascular. Unfortunately stroke survivors get a double whammy: They are in half as good cardiovascular shape as age-matched couch potatoes, but everything they do takes twice as much energy. A good example is walking. Before stroke, walking takes very little energy. Most of the energy is expended in small bursts of muscle power, perfectly timed to use momentum forces and gravitational pull. After stroke, gait loses its subtlety and coordination. The gait that is typically left in the wake of stroke uses twice as much energy as prior to the stroke.

So cardio and muscular strengthening are important, but viewed as more of a "pre-process" than the process itself. In fact, many of the leading-edge treatment options (i.e., repetitive practice, CIT, forced use) are considered "intensive." They require that the survivor "hits the ground running" and be able to withstand the rigors of the intensity right from the get-go. In this regard there is a necessity for the survivor to be in pretty good cardiovascular and muscular shape prior to the initiation of treatment. Once the survivor has the stamina, the focus comes off the body and shifts to the brain.

Why a little means a lot

10°. 

10° is all you need to qualify for constraint induced therapy. Just a tiny bit of movement. Just a little bit of movement in the fingers and a little bit of movement in the wrist. This would be movement that many clinicians would call "nonfunctional" movement. That is, many clinicians make the unfortunate mistake of thinking that a small amount of movement is not helpful. The thinking is, small amounts of movement won't help you live your life, so who cares?

But every bit of neuroscience is very clear about this: a little bit movement can lead to more movement through repetitive and demanding practice. Move as much as you can. It may be ugly, it may be "incorrect," it may be "nonfunctional," and it may be "useless." But this is probably more true: Small amounts of movement may turn into something beautiful, something correct, something functional, and something useful. If someone is telling you that your movement is unimportant, or harmful, or irrelevant, politely don't listen.

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Herding Spastic Cats: electrical stimulation

There's a lot of great things to be said about e-stim after stroke. E-stim can be used to do a number of things to help survivors recover. But let me review one: Stretching.

About 30% of the time stroke survivors have "severe" spasticity. How is "severe" defined? Severe is considered "≥ to 3 in the modified Ashworth scale." What does that mean? It means that if you move the joint through its range of motion it is tough to move. The force that used is an outside force; someone other than the survivor moves it (passively).

Severe spasticity in the upper extremity can lead to a fisted hand. In the lower extremity it leads to the foot pointing down at the ankle (plantarflexion). 

So how should you stretch spastic muscles? One way is manually. In the ankle is pretty easy. Stand up. This is called a "weigtbearing" stretch. But in the upper extremity... ah, it can be difficult to stretch a fisted hand. It's not just that you're dealing with stretching over all of the joints of the fingers (12 in all). If that you can't fully stretch the fingers without also stretching the wrist. The reason they have to do both gets technical. The muscles that control the fingers, also control the wrist. So to get everything fully stretched you have to extend both the wrist and fingers. "Extend" means that the fingers would be perfectly straight, and the wrist would be pushed back as far as possible.

There was a very influential neuroscientists and Nobel laureate named Sir Charles Sherrington. Sherrington made many discoveries about the nervous system. One of the things that he discovered is that for one set of muscles to contract, the other set of muscles would have to relax. Let's use that hand as an example. For the muscles to open the hand to work properly the muscles that close the hand after relax. Otherwise those muscles would be fighting themselves. Which Sherrington discovered was that in a healthy (non-stroke) situation, when there was an attempt to open the hand the muscles that close the hand would relax. If you want to get technical, it's called reciprocal inhibition.

Trying to stretch the fingers into an open position, while also extending the wrist with a spastic stroke survivor is a bit like herding cats. It's tough to get all of those joints (were up to 13 now) going in the right direction. This is where e-stim can come in.

Because e-stim makes the finger extensors and the wrist extensors fire, it also forces the wrist and finger flexors to relax (reciprocal inhibition). In this case, the electrodes would be put on the back of the forearm with the muscles that open the hand and wrist are. Again, the e-stim would go through the electrodes into the back of the forearm fire the muscles that extend the fingers and wrist. And... at the same time... relax the muscles that close the fingers and wrist.

Talk to your therapist. If you have a lot of spasticity this is something that you can do at home, once trained. The technology tends to be relatively inexpensive, and can be used for an extended period of time. But again, talk to a therapist, and get them to figure out what the right settings and dosage or for you, and then e-stim away!

DIY Stroke Recovery

There is a common suggestion among many in the "alternative medicine" industry expressed in the question: "If it means less business, why would your doctor want you to be healthy?" A strict emphasis on healthy lifestyle including diet and exercise would be like the proverbial "apple a day" - keeping the doctor away.

Doctors who do this - who keep themselves away as much as they can - are the best doctors. And therapists who "keep themselves away" are the best therapists.

Many pathologies allow for a definitive discharge point. The patient who has had a knee replacement gets therapy, and then goes home to live the rest of his life. But neurological disorders are different. Many, from Parkinson's disease to multiple sclerosis, are progressive. But what of non-progressive neurological disorders like stroke and traumatic brain injury? Does this "apple a day" philosophy work? Is there a point at which these populations no longer need therapists?

Many patients with brain injury (including stroke) believe that they will always need therapists. Most see therapists as essential to the recovery process, no matter how long (months, years, decades) it takes for them to achieve their highest level of potential recovery. But this view is incorrect.

There is a point at which therapists are no longer the fulcrum for recovery. Nor should they be, for reasons that range from financial to practical. At discharge stroke survivors are, and should be, in complete control of their own recovery. During the chronic phase of recovery from stroke, the speed of recovery slows. The physiological action of recovery is based on a lot of self-directed hard work. Much of what is required is relatively simple, and revolves around the broad concept of repetitive practice. In order to take charge, stroke survivors need to be given the tools to initiate and follow an "upward spiral of recovery." This term is used to describe the path to the highest level of potential recovery. The "upward spiral of recovery" is driven by real-life demands for everything from coordination to cardiovascular strength.