Walking Faster Means Walking Better

      When it comes to walking most folks (survivors and therapists) focus on one thing: Distance walked. The distance you can walk is important. For instance you might need enough stamina to be able to get out of the car walk 50 yards to the supermarket, walk another couple hundred yards through the supermarket, and walk back another 50 yards to your car. That's 300 yards of walking. So its important to be able to nail the distance that you can walk.

But there is another element of walking that's at least as equally important as distance walked: The speed of walking.

Measuring distance walked is easy enough. You can measure out a certain distance across the floor. If you can walk further you can base distance on the number of times you can go around a track (in United States its usually 400 yards). Further than that and you can measure the distance walked using Google maps.

The standardized way of measuring the speed of walking is very simple. All you need is 20 meters in a straight line, and a stopwatch.

Perpendicular to the 10 meter line you mark off four lines: The starting line, 5 meters in, 15 meters in, and at the end of the 20 meters. (See diagram below)

 

There is a chair at the beginning and at the end of the 20 meters. The survivor gets out of their chair and walks the first 5 meters. The person who is timing (it can easily be the stroke survivor themselves) clicks the stopwatch when they get to the 5 meter line. The survivor then walks the intermediate 10 meters, and the stopwatch is clicked again at the end of that 10 meters. The survivor then decelerates during the last five meters.

There are a few other rules...
1. The survivor usually does two passes, and the two times are averaged.
2. The survivor is asked to walk at a "comfortable speed," not, for instance, as fast as they can. Just a safe and comfortable speed. This is called "self-selected speed."
3. The 10 meter walk test is done over an arc of time to see if speeds increase over that arc. For this reason it is important to make all the tests apples to apples. The survivor should be timed at the same time of day, wearing the same clothes, wearing the same shoes and AFO, same cane, across the same floor, etc. etc.

So what does your hard work tell you? A ton. For instance, walking speed can be used to determine the effectiveness of a particular rehabilitation treatment option. That is, walking speed can be used as a surrogate for quality of gait; the faster the walking, generally speaking, the higher the quality of gait. Higher walking speed is generally associated with less falls, and less fear of falling.

• (Note: If you are over 75 -- whether you've had a stroke or not -- walking speed is eerily predictive of how long you will live.)

                                                  
©Stronger After Stroke Blog

Stretching reduces spasticity. Yeah, no.

OK class, here's your quiz:

1. Stretching decreases spasticity T/F

2. Stretching increases the length of spastic muscles T/F

3. Stretching reduces the chance of contracture (muscle stuck at a shortened length) T/F

4. Stretch helps make joints more mobile T/F

First of all, why stretching is good: 

Stretch is good for joints. Every time we move, joints are "lubricated." That is, joints require movement in order for the fluid in the joint (synovial fluid) to be properly distributed. Stroke survivors, because they are typically weak on one side, don't get the joints on the "bad" side to move enough. How much is enough? Look at it this way, on the "good" side your joints, all of them, will be moved through their entire arc of movement (called range of motion) dozens if not hundreds of times per day. How many times are your "bad" side joints moved? Because they have trouble moving, it is wise to move them either with the "good" side doing the work, or a caregiver doing the work. This is called passive ranging.

But while stretching may be good for joints, the affect of stretch on muscles and other soft tissue (ligaments, blood vessels, fat, etc.) is, so far as the science says, negligible. So the answer to your quiz is F, F, F, and F.

I know this is hard to believe. And it is counter to what some therapists think (this statement: Prolonged stretching can lengthen muscles to help decrease spasticity)

But it is confusing. There is an immediate effect of stretch on spasticity, everyone knows that. But this is one of the many reasons stroke is so devious; what is true now may not be true 5 minutes from now.

This is a frustration for many clinicians. You observe something is true (i.e. spasticity wanes with stretch) only to find that with the next big movement by the survivor, spasticity comes right back.

Further reading from this blog on spasticity here and here. 
                                                     ©Stronger After Stroke Blog

Are you frail and elderly?

(The following is a paraphrasing of writing by Janet Carr and Roberta Sheppard in their stellar book "Stroke Rehabilitation.")

"Frail elderly." This is the way most stroke survivors are treated, and it's not good. It is important for stroke survivors to engage in strengthening and cardiovascular training. It is also important to do a lot of intensive and repetitive practice. The problem with both training and a lot of practice is that they cause fatigue. And when the survivor is perceived as being fatigued they'll be asked to rest. But exercise is safe after stroke. Intensive rehabilitation improves not only muscle and heart/lung strength, it also improves movement.

To promote intensity in rehabilitation goals should be set. Goals can include increasing the speed of a task, increasing number of repetitions of the task is done, and improving the performance of the task. The stroke survivor can benefit from these parameters being graphed. Graphing of improvements in performance can provide type of feedback to the clinician, and can be motivating the survivor.
                                                                          ©Stronger After Stroke Blog

I'm not drunk, "retarded", or mentally unstable

Its a pretty simple calculus: If you don't use it you lose it. But there's a corollary: If you don't try it you can't possibly gain it. For example, if you use an AFO to walk during the early days after stroke, you'll not easily not use the thing again. 

And if I choose not to play violin- an instrument I've never played- I'll not get better at violin. So, both learning for anyone and relearning after stroke involves taking your brain (where learning happens) out of your brain's comfort zone.

Which leads me to spouses. I've met a ton of 'em. The wife is aphasic, the husband loves her, knows what she's trying to say and finishes the sentence for her. (When its men I always get the feeling they're saying to themselves, "Finally, I get to do the talking!") The spouse can become the exact thing they don't need. 

I always liked talking to folks who are aphasic. I usually get trampled by conversations because I'm slow in the think department. Aphasic folks give me a chance to ruminate a bit. Try it. Slow the conversation.

But "I've gotta get on with my life. How is it good to have my wife talk slowly when we're trying to check out (or ask directions, or talk to the gas station attendant)?"

Here's how its good. Do you know anyone who doesn't stumble and bumble their way through conversations? OK, a few people are so verbally dexterous that they don't really have this problem, ever. But nobody likes those people.

Why shouldn't someone who has a language deficit struggle as much as we do? They should struggle. Once they don't struggle, you know whats that's called?

A plateau. 
Beside, aphasia can be fetching. 

Repetitive Practice Stroke

What is the key to recovery? Everybody now: Repetition! I've written about this before here and here.

Everybody knows that repetitive practice (also known as repetitive task practice) is the way to reestablish executive (brain) control over the body. To regain control of an arm and hand repetitive practice can be used to reestablish that control. To regain control over a leg during walking, repetitive practice (walking) can be used to reestablish control over walking.

It's not rocket science. And it's not brain science, until it is.

The thing that they don't tell you is how many repetitions you have to do. The first person to talk about the power of repetitive practice was Randolph J. Nudo. You pretty much can't read any journal article on stroke rehab research that doesn't involve a reference to this guy. His suggestion was that 2500 repetitions would begin to change the brain enough to make that movement better. In constraint induced therapy there is approximately 200 repetitions per therapy session. In typical rehab there's about 32 repetitions per therapy session. It looks as if the number may be approximately a total of 1200 reps. That would require about three hours per day.

As you can imagine, these numbers are rather variable. The amount of focus brought to each repetition would be one variable. The complexity of the movement that you're trying to relearn would be another variable. The number of joints that the movement required would be a variable. The number of directions that that limb would have to move in order to carry out the task would be a variable.

But I think we can all agree that most stroke survivors don't attempt these numbers of repetitions. 

Here is the other question: How do you do all the repetitions you need to do without driving yourself crazy? 

Here is the only possible answer: Tie it to something that you care about.

Get cracking.

List of Post-Stroke Sequelae. Stroke symptoms.

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Sequelae: Plural of Sequela. 

A pathological condition resulting from a disease. An aftereffect of disease.

Body Including Limbs 
Sensory impairment including tactile,  pressure, Proprioception
Hemiplegia
Hemiparesis
Subluxation
Shoulder hand syndrome/RSD/CRPS
Flaccidity 
Hypotonicity
Balance problems
Apraxia
Hemineglect 
Altered walking gait
Vertigo
Neurogenic bladder
Eyes
Hemianopsia
Eating
Dysphagia is difficulty in swallowing.
Aphagia – Inability or refusal to swallow.
Risk of aspiration
Seizures
Spasticity
Soft tissue shortening/contracture
Genu recurvatum
Speaking
Dysphasia: Impairment of speech, and understanding language. 
Aphasia: Loss of the power of expression by speech, writing, or signs. 
(Dysphasia and aphasia are sometimes used interchangeably;  language disorder with impairment of speech and comprehension of speech.)
Psychosocial
Depression
Decrease sexuality
Indifference, inappropriateness, depression, mania 
"Other"
Recurrent stroke

Use what you've got to get what you need.

If you've had a stroke, your spinal cord still works fine. The spinal cord takes over some aspects of movement. The first step in this process of the spinal cord taking over is spasticity. The brain can't move you, so spasticity, generated in the spinal cord, takes over. And as much as we hate spasticity, things could be worse. Spasticity is better than nothing. "Nothing" in this case would be a completely flaccid affected ("bad") side. And being flaccid is worse than being spastic. Trust me on this.

But if we go a step beyond spasticity towards recovery there is an intermediate step. This intermediate step is known as synergy. The spinal cord basically allows for basic movements. The brain is not working, the spinal cord takes over, and the spinal cord allows very basic movements.

The synergies, although often disparaged by clinicians, are brilliant. In the upper extremity, synergy allows for the most important movement you can imagine: 

 

Feeding. It looks like this...

 

In the lower extremity the flexor synergy looks very much like a stepping pattern.

Clinicians have, for 40 or 50 years or so, said that synergies are bad. I disagree. Synergies can be used in a way that replicates good coordinated movement. Synergies give you the ability to at least attempt to replicate a normal movement. Enough attempts and the brain rewires and the synergies are discarded.

Watch this video. This stroke survivor (Brian Redd) is on the right track... use what you have to get more. 

(At 2:35 he provides a stellar description of the flexor and extensor synergies of the leg).

Predicting hand recovery by infarct size -- not.

Interesting work here by my colleague Stephen J. Page.

It seems like in "no-brainer." The more brain destroyed by the stroke, the greater the disability. Right? Except that when it comes to arm and hand movement, that may not be true.

"Historically, lesion size been thought to influence recovery, but we didn't find that to be the case when looking at regaining arm and hand movement," Steve put it.

There is no way to stare at your brain scan and A.) know what the deficit is gonna be B.) know how profound any deficit will be C.) predict recovery. 


(Find the published article here)

One other note: I've always disliked the term "massive stroke." Most doctors, and therefore survivors, claim that any stroke is a massive stroke. I've heard the claim that the word massive means "likely fatal." But if that is true then it has nothing to do with the mass (size) of the infarct. Thus, the word massive is meaningless. It is a superlative to add when the word "stroke" is somehow not enough.

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.