The Orthopedic Card

I'm about sick of what I'm starting to call "movement elitism." The idea is that, unless you move perfectly, you shouldn't move. Because… you'll ingrain "pathological movement patterns." I've railed against this before. And here it goes again...

Curious Person (CP)

Clinical Movement Elitist (CME)

CP: Why should a stroke survivor not move when they're alone? 

CME: Because they move wrong.

CP: What will moving wrong do?

CME: Make it so they'll never move right.

CP: So what should the survivor do to practice movement?

CME: Wait until there's a clinician around to tell them how to move.

CP: Won't the survivor run out of money eventually?

CME: It’s worth every penny because bad movement is bad. It will make moving right harder.

CP: Don't we all learn to move by correcting mistakes?

CME: Yes but survivors need guidance.

CP: Couldn't they sit in front of a mirror and model the movement of the "good" side?

CME: Yes, but they'd fail in the execution.

CP: So they need to be perfect right out the box?

CME: Yup.

CP: What if they can't move right?

CME: I move them.

CP: Doesn't that defeat the purpose any "productive struggle"?

CME: Survivors shouldn't struggle too much.

CP: Why should they not struggle?

CME: They'll move even worse.

CP: Survivors need lots and lots of repetitions to recover moment, right?

CME: Yup.

CP: And that has to do with forging new pathways in the brain?

CME: Yup. It takes thousands of repetitions to get the brain to regain control over muscles.

CP: How long do you typically see a patient?

CME: About an hour a day.

CP: How many repetitions do you have survivors do in a typical session?

CME: A lot...as many as we can.

CP: Did you know that the number of repetitions done in a typical stroke rehab session has been counted?

CME: I did not. Know.

CP: The average number of repetitions in a typical session for the arm is 54 and for the leg its 75

CME: It will take a while.

CP: How do you reckon the survivor will get to the thousands of repetitions they need?

The movement elitist may seem cornered, but they have an ace…

CME: Even if they could practice on their own, and even if that practice is beneficial, the bad movement will cause orthopedic problems like bad joint movement and pain. It may be good for their brain but it’s gonna be bad for their body.

CP: Couldn’t the improved movement and the better brain control lead to less ortho problems?
---

Spasticity reduction in dystonia and stroke

So, here's the deal. I'm a member of the FB young stroke survivors group.  If you are not, I'd suggest you join. These folks do not pull punches and most are robustly and actively  engaged in their recovery. (Many have the same posture as Dean of Deans' stroke musings. (Put his blog in your faves. Now.)  The group as a whole reminds me very much of many spinal cord injured people who I've worked with; no BS, been there done that, laid bare.

I'm also a member of the "Neuronauts" group on FB. This group has a pathology that causes a spastic pull on muscles called dystonia. The muscles that are affected can be pretty much anywhere and can jam body parts into themselves and into other body parts. I'm not generally Mr. Empathetic, but the Neuronauts will break your heart. Shocked, sad helpless is the way their stories sometimes make me feel. Stories of living with a complete and painful betrayal of their bodies. Short term excruciating pain and long term injuries often result. 

Dystonia is caused by injury to the basal ganglia (which can be caused by stroke). The basal ganglia is a "gang" of structures deep in the brain. "The basal ganglia... monitors the speed of movement and controls unwanted movements"

Examples of dystonia

    
Spasticity

Spasticity is uncontrolled reflexes. Reflexes exists in all of us all the time. But you usually never see them. They are only "unloaded" when there's an emergency. Like, when you burn yourself and you hand ends up by your ear and you wonder how it got there. Or when you step on a sharp stone walking barefoot and your hip and knee quickly bends. Or when you lose your balance and your arms fly around wildly without your consent in an effort to keep you on your feet. These are all emergency situations. There is simply no time to consult the brain. The reflexive impulse goes from receptors on periphery of the body, to the spinal cord (where reflexes reside) and back. Its about speed because its an emergency.

If there is no emergency the brain dampens the reflexes down. But if there is a brain injury the dampening stops and the reflexes are unloaded. This unloading causes muscles to fire even though there's no emergency. This constant firing of the muscles is spasticity.

There are many treatments for spasticity. Most of them fall into 3 catigories: 

1. Don't work. 
2. Work but are a band-aid (work until you take them away). 
3. Work and are permanent.

Examples of #1 above are splinting and hot packs. Examples of #2 above are drugs and stretching. An example of the 3rd category: Dorsal root rhizotomy.

Dorsal root rhizotomy (DRR)
A Dorsal root rhizotomy (aka selective dorsal rhizotomy, aka DRR) is a delicate surgery where some of the little hair-like "rootlets" that go into the spinal cord are surgically cut. (GRAPHIC: Selective Dorsal Rhizotomy...starts @ 2 min in).

And I don't want to white wash it...it is a surgery. But it is a very small incision and recovery is quick. The reduction of spasticity after DRR is permanent. For the life of me, I don't know why it is not more often used. I've seen sores the size of steaks- life threatening sores- created by spastic limbs crushing the skin.The DRR would elevate this. It also reduces pain in the area. It is done very selectively. The neurosurgen will test ever nerve rootlet to see what it does before cutting. In this way, the amount of spasticity is gradated. If more spasticity is helpful (some people use their "tone" to help them function) it is left.

Does it work for dystonia and the spasticity that results? Yes. Will insurance pay for it? Sometimes. Does it work for spasticity post stroke? Yes, but it can be tricky in the legs.

Cerebellar stroke

Somebody gave my book a crappy review because there's nothing specifically about  cerebellar strokes. But there is. A stroke can happen in the cerebrum, cerebellum, or brain stem. I don't have anything specifically about the cerebrum strokes or brain stem strokes or cerebellar strokes. I just have stuff about stroke. 

Is there something inherently different about cerebellar stroke vis-a-vie strokes in the cerebrum or brain stem? No. What about a stroke that hits the posterolateral thalamus? Maybe the folks who have had a stroke that hit the posterolateral thalamus (or was exclusive to white matter or only hit the pituitary gland, or any of the other dozens of structures in the brain) should get their own chapters or books.  Actually, I'd love to see that happen. In the mean time, my book is a review of the neuroplastic process that encompasses all of those. Recovery from all of them fall under the same neuroplastic model of stroke recovery.

I don't like the template for recovery being contingent on where the stroke is. Again and again I stress that the view that the brain is NOT cordoned off into specific compartments that necessarily control specific functions. This notion, that the brain is sectioned off into independent exclusive sections is called the "mechanistic view of the brain". In fact, in my book there is a whole section (NEUROPLASTICITY AND HOW SCIENCE GOT IT WRONG) about this (brain=machine) mistaken perspective. 

Is there something inherently different about cerebellar stroke? No. 

What does the cerebellum do?

Cerebellum is Latin for "little brain." It sits at the bottom and back of the brain (3D animation here). The cerebellum is involved in providing precision and coordination movement. The cerebellum is said to "calibrate" movement. It doesn't initiate movement, it just makes movement smooth and coordinated. People who have had a cerebellar stroke often have an uncoordinated tremor. For example, if they were to reach out and try to touch target in front of them, and then their nose they would have difficulty targeting towards both. As the person got closer to the target end to their nose tremor in the targeting finger would increase. This phenomenon, called ataxia, is very similar to a phenomenon known as intention tremor. Find a possible neuroplastic option for the treatment of intention tremor here.

Notes about the cerebellum and cerebellar stroke.

• Compared to the rest of the brain, damage to the cerebellum is a little "backwards." In most strokes, if the stroke affects the right side of the brain, the left side of the body is weak or paralyzed, and vice versa. With the cerebellum is the stroke is on the right side, the right side of the body is affected.
• Cerebellar strokes are unusual. About 2% of all strokes are cerebellar.
• It would be well and good to assume that the cerebellum is only involved in coordinating movement. However, like much of the brain, the cerebellum is poorly understood. It is now believed to have at least some role in higher level thinking as well as emotions. 
• (Find an interesting piece on a cerebellar stroke survivor here.)

How do I rehab after cerebellar stroke?

It turns out that the same rules of plasticity available to the rest of the  brain are available to the cerebellum as well. Here's my suggestion: Forget about where the stroke was. Instead, focus your efforts on sequalae.

The Vanillaization of Your Recovery

I'm not a big fan of WebMD. I'm not even sure why people read it. I guess if you just "Google it" -- whatever "it" is, WebMD is one of the first things to show up. But imagine if you had to rely on this site for serious information about anything medical? It seems that everything I read on it is a sort of a whitewashed, dated, vanilla attempt.
 

For example: I read an article on WebMD recently entitled, "Stroke Recovery and Arm Rehab: Important Questions." Poststroke arm rehab is one of my areas of interest, so I at least wanted to see what it said. Here's what the article says: Nothing about: arm rehab. Which you think it would've said something about arm rehab. Because it's in the title.

What I found instead was a bunch of, you guessed it, whitewashed, dated vanilla. The article is in a question and answer format. Below, I paraphrase them, and then add my 2¢.

1. What caused my stroke?
What WebMD says, paraphrased: Types of stroke, relative incidence, etc.

What I say: This is the same information that can be found everywhere on the web. By the time most stroke survivors leave the hospital they are going to know most of this stuff.

2. Am I at risk for a second stroke?
What WebMD says, paraphrased: Yes, you are, talk to your doctor.
What I say: Yawn

3. What is the stroke recovery process?
What WebMD says, paraphrased: Your rehab program will be tailored to you. You'll do "assisted exercises" in the hospital. Then you may go to a rehab hospital, and then home. Rehabilitation takes place for 3-6 months. But "patients" can continue to make gains after this if you "... practice the skills (you) learned in rehabilitation."

What I say: "Assisted exercises" is meaningless. In the hospital survivors will generally be called upon to do whatever it is that they can do, assisted or otherwise. The article does say that you "may go to an inpatient rehab facility" but it does not add "if you are lucky." It also says that you'll go home. Nursing homes are full of people that didn't make it that far. 

The idea that you will continue to make progress if you practice the skills that you learned in rehabilitation is nonsense. The reason that people plateau is because they continue to practice the same thing in the same way.

4. How long will my recovery from stroke take?
What WebMD says, paraphrased: Recovery is different for everyone, but for most it's a lifelong process.

What I say: If it's a lifelong process you're doing it wrong. Recovery ends at the point in which you have recovered enough to spend too much time living to spend more time recovering. Maybe they mean that exercise should continue through the end of life.

5. Am I at risk for depression after a stroke?
What WebMD says, paraphrased: Becoming depressed after stroke is common because of the changes in the brain and because of the lamenting of losses caused by the stroke. Depression can be treated with medication and/or counseling.

What I say: You know what else is a great treatment for mild to moderate depression? Exercise. I would think that's pretty germane to this article. Just sayin'.

6. What medications will I be taking and do they have any side effects?
What WebMD says, paraphrased: You'll probably be put on a blood thinner. Talk to your doctor.

What I say: Hopefully you are not reading an article to find out about post stroke medications.

7. When should I call my doctor?

What WebMD says, paraphrased: If you have symptoms of a stroke. They then list the symptoms.

What I say: No quarrel with this one.

So there it is. Now you know how to use your arm again. Off you go!

Acute stroke care, environmental complexity, and the damned cell phone

In a recent seminar I was talking about how, in a general sense, the more complex the environment after stroke, the better. The idea is that "environmental complexity" leads to further recovery.

Hospitals are the real problem. In the hospital survivors are not much engaged after their stroke. Compared to prior to their stroke survivors have less conversations, less time to play, learn and socialize. And the brain hates this comparative social isolation. The brain hates it so much that the brain ends up learning movement less than if the survivor was engaged. Bottom line, have the survivor involved in conversations (as best they can) play with objects (tinker), play games, etc.

But. There may be a limit.

I was talking to a therapist at one of my seminars and she was saying that she agreed that increasing environmental complexity was a good thing. But, she said, often caregiver descend on the survivors room but are so engaged with their cells and iPads that the survivor gets a lot of cacophony and little engagement. Folks visit but they don't necessarily help.

Just sayin'.

Perfect not.

Should practice of movement after stroke concentrate on perfection. I guess. But what stroke survivor is going to be perfect? This was addressed in an earlier entry. To quote that entry: "There is a small but vocal group of therapists who believe that if you don't focus on quality you may as well not practice."

Why should the practice be perfect when the next step should be better. If you look way up to perfect there's too much room to say "Forget it. Too hard." And you have every excuse to forget it because it will be too hard.

Focus on the small goals ahead of you, not perfection. 

There is a great blog called Seth's Blog. He has an entry that might be helpful. In it he says,

"Growth is messy and dangerous. Life is messy and dangerous. When we insist on a guarantee, an ever-increasing standard in everything we measure and a Hollywood ending, we get none of those."

 In another entry he quotes someone as saying, "I find myself getting uninterested/unmotivated on projects that I start. The emotion of deciding to start has faded and the results are slow to keep me motivated." He answers this plateau by saying, "The real work comes after the novelty wears off." Like me, Seth is not a big fan of perfection mostly because it gets in the way of forward movement. Here are some more Seth quotes about perfection and perfect:

• Perfection is overrated, particularly if it keeps you from trying things that are interesting.
• Perfect doesn't mean flawless. Perfect means it does exactly what I need it to do.
• The object isn’t to be perfect. The goal isn’t to hold back until you’ve created something beyond reproach. I believe the opposite is true. Our birthright is to fail and to fail often, but to fail in search of something bigger than we can imagine. To do anything else is to waste it all.
• Perfect is the enemy of good. [Voltaire] No doubt about it.

And on and on... Still some readers of this blog have chimed in and what they say has value (as pulled from the comments section)...

Blogger Linda said... ...if not precision perhaps focus seems like a good idea to me. 

Pete: Agree! Head towards challenging, not perfection.

Scott Gallagher said... If I'm ever going to get someone to do what it might take, I'm going to have to convince them that “thousands of miles” and “millions of repetitions” is unremarkable enough (and it is) for them to go ahead and spend a few short years to knock 'em out.

Pete: Is there anything to be said for that "few years" beyond "I practiced." Was it interesting in any way? Was there a spiritual element? Did it test you in new ways that helped you grow or know yourself (or others) better?

Barb Polan said...Give me reps over quality anytime. remember: some stroke survivors can't do ANYTHING. the expectation of high quality is absurd. And damaging.

Pete: Forgive therapists; they've not had a stroke. The expectation of high quality is absurd, for most survivors. And for survivors who are nudging up against high quality movements, then great! But most survivors will not hedge high quality but the rules remain the same: Get better.

Therapists are not like oncologists.

Therapists are not like oncologists.

Imagine an oncologist who has no idea what the latest treatment is. Imagine now that they are trying to cover their butts. "You have cancer, but I have something that works in my patients." "Something that works in your patients?" Even in your distress something seems odd about that statement. "Does it work in all patients or just in yours?" Its one of those questions you think twice about asking an MD because it smacks of sarcasm and hints a possible incompetence. But it is exactly the most rational question.

Of course, of an oncologist you'd not have to ask this question because oncologists are required by law to use the most effective treatment. If they do not do the latest and greatest they can get sued. Into oblivion.

People die of cancer. People generally don't die of bad therapy.

Now imagine your therapists says this... "You've had a stroke but I have something that works in my patients." "Does it work in all patients or just in yours?" There are 2 possible answers:

1. I have a lot of clinical experience, and in my experience it works.

2. Actually, its not ME saying it works in MY patients, but the research says it works in patients with your sequalae (symptoms).

I feel safer with #2.

#1 could have an unspoken "...but I've never really collected data or analyzed data or compared it to a control group or blinded myself during your measurement, or done anything else that science does to make sure that my data is "clean"."

"Does it work in all patients or just in yours?" is really the question, "Is there research that says it works?"

Encourage therapists to have a look at their diploma. It'll say, clear as day "Associate's of applied SCIENCE," "Bachelors of SCIENCE," "Masters of SCIENCE," and so on. The the notion that they base treatment solely on clinical experience is dangerous. One of the biggest determinants of recovery is the therapist sitting in front of you. Do yourself a favor, and do them a favor: Call them on the evidence.

Building the Recovery Wall

Scott Gallagher posted a comment to a previous blog post. I'll paste that comment at the bottom.

What caught my eye in his comment is the conflict between repetition and quality. The conflict goes like this: If you do a ton of repetitions you may not concentrate on quality. If you concentrate on quality you may not hit enough repetitions.

I do a lot of talks about stroke recovery to clinicians. There is a small but vocal group of therapists who believe that if you don't focus on quality you may as well not practice. "Perfect practice means perfect recovery." I completely disagree. What if the survivor doesn't move perfectly? The answer by these clinicians is "I use hand over hand techniques to make sure that they do." Basically, they move the stroke survivor in the proper arc of movement. (BTW: the original quote was, "Practice does not make perfect. Only perfect practice makes perfect." - Vince Lombardi. Vince Lombardi was dealing with professional athletes. If he was coaching peewee football his quote would've been "We're not asking for perfection, we're asking you to practice.")

There's several problems with stroke recovery put to this "If its not perfect, don't bother" philosophy. First of all, who's to say what "good" movement is after stroke? If somebody's trying to learn golf and they suck, nobody stands behind them and says, "You're doing it wrong." The more you practice golf, the better you'll get. Should you practice proper technique? Yes. But stroke survivors know proper technique. They've been doing these movements for all the years prior to their stroke. And even if they forgot they can model with the unaffected side.

 strongerafterstrokeblogpants

Second, this philosophy suggests a therapist. "Don't move unless I'm there to help you move." Alternatively this can be expressed as, "The more you move the worse you'll get." But therapists can't be with the survivor all the time, and the survivor doesn't have enough money in their pocket to pay for endless therapy. There is some good news... "The more you move the worse you'll get." Hogwash. Moving a lot on your own leads to better movement as long as you make the movements challenging (always reaching beyond you present ability).

Third, when's the last time you saw a coach with their hands all over a player? When's the last time you saw a music teacher with their hands overlapping the hands of the trumpet player? Learning movement involves mistakes corrected.

Scott Gallagher puts it this way "...any time I tried to insert control or effectiveness into my program, whether it would be with walking or with the hand, it would drive the repetition numbers down and my recovery would stall." And I know that is taken out of context, but as it stands as a quote I agree with it.

Scott Gallagher: If complete recovery is the goal, one problem might be in the sheer numbers involved. I have no reason to think that my stroke was anything but whatever might be considered a normal stroke, but currently in measured distance I'm at 5,112 walking miles. I'm so close to recovered, I'd say 5,000 miles is what it took for me to fully walk normally again. I tried speed walking, but the problem I was having was that any time I tried to insert control or effectiveness into my program, whether it would be with walking or with the hand, it would drive the repetition numbers down and my recovery would stall. My strategy, then, became one of brute force: keep it simple and push those repetition numbers up. But even if I had effectively used speed walking, how effective could it be? Even if it took 3,000 miles off my total distance, that would still leave 2,000 miles left to cover. I only made it through by switching from an exercise-based program to a mind and motivation-strengthening program. For all but a very, very few the repetitions required for full stroke recovery may make it, although possible, simply unfeasible. Come to think of it, though, your post may have been intended for a less hardened recovery program. Thanks.

Thank you Scott! 

                                                                                            ©Stronger After Stroke Blog

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.