The STROKE-O-MATIC 76

When it comes to selling stroke-recovery machines to therapists, the phrase "another tool in the toolbox" is all the rage. Vendors (sellers) use the toolbox idea to soft-peddle to therapists. Here's how the pitch goes...

"We have this great new machine. It works great. Now, I'm not saying to pitch what you use. I'm just saying that this machine of mine is...another tool in the toolbox." But therapy time is very (very), very limited. So, Ms. Therapist, if you use their machine, there'll be no time for what you have been using. And the vendor knows this. 

But the vendor is scared to say their version of the truth which is, "My machine works better than what you have been using" because that suggests the therapist has been providing something less than the best. (And you don't insult the client, right?) But that's exactly what they are saying. My machine works better than what you usually use... Instead, the vender, fearing being considered condescending treats the clinician like a child and says, "You're doing just fine. This is just another tool for your toolbox." Its like telling a child, "I love Joey, your (stinking, puked-on) Teddy bear  too. But lets just get another Teddy. You can keep Joey too (in the garbage!) but we'll buy you this new one."

I find this even more condescending to therapists than giving it to them straight. Vendors, if you think your thingy works better, say so. Not to is spineless because you've not stepped up for the people who need you. No, not therapists (your bank account or your boss). You've not stepped up for survivors. If your thing works, get behind it. And if you are truly behind it, soft-peddling just makes you someone who'd rather make the sale than do the right thing.

Of course, if you want $ over integrity, you'll get neither.

Allergic to milk... right.

There are so many stories that survivors have written about their recovery. But this one is special because it comes from a survivor that knows the experience from every angle, and exceeded expectations in every way.

My Story of Striving in the Post Stroke World
By Mitch Raymond
 

When most people think of stroke, they think of it happening to people 50+ years of age in the latter half of life due to a blood clot or hemorrhage in the brain. People are absolutely shocked when I tell them that it can happen at any age of life. Take me for example, I had my stroke during my childhood and in the beginning, I was very debilitated.  It was an uphill battle filled with many twists and turns but I was able to make it from being a debilitated child to being a fully functioning adult with a wife, two children, and a successful career to support them by the time I got around to typing up/voice dictating this story 30 years later.       

The career that I chose, and currently practice today is Physical Therapy. This allows me to integrate my personal stroke rehab experience with my PT knowledge and clinical experience.  In turn, that allows me to better help my clients improve their functional abilities.  Some may ask how I was able to achieve this level of success.  Well, it did take open-mindedness, curiosity, will power, perseverance, determination, research, and a lot of life experience, but I did not achieve this alone.  With the guidance of therapists, teachers, friends, colleagues, fellow people with disabilities, and of course my loving family, I was able to overcome many of the obstacles that stood in my way toward success.

I had my stroke back on January, 17th 1989 when I was 6 years old. I had a benign brain tumor that was a birth defect. By the time I was five, the tumor was golf ball sized and it had made itself one with my left middle cerebral artery. Up until the tumor was found, I was having seizures that were getting worse and worse. In the beginning, they were just daydreaming spells. But they gradually became more involved. My mom eventually took me to the local doctor when I was four years old. It was determined that I was allergic to milk without anything more than the most superficial of diagnostic observations. By the time I was five, the seizures consisted of the following. I would be playing with my older brother when all of the sudden I would go into a trance. I would then proceed to walk toward my mother and sit in her lap, stand by her side, or walk in circles for a minute or two. She would frantically try to get me to respond during that time, but I could not answer or I would answer in incoherent babble. I would then proceed to walk toward the bathroom, vomit and collapse. Allergic to milk... right.

The last photo that was taken of Mitch
before tumor removal surgery

My parents could only trust the original doctor so far and then decided to get a second, third and even fourth opinion to make sure the real diagnosis was found and sound. When the tumor diagnosis was confirmed at UMass Medical via CT scan and MRI, I was sent to Boston Children's Hospital for surgery. 

Anyone who knows arteries knows how fragile they are, especially when a tumor has to be extruded off of one. Thus, when the tumor was surgically extruded, my left middle cerebral artery hemorrhaged leading to my stroke.

When I exited out of the OR (I don't remember this, mind you), I stared up at my parents and then to the surgeon who had just saved my life and said "I... hhate... yoou." He smiled up at my parents and said "no big deal, I get that all the time." He was a doctor with a great sense of humor, along with just being a great doctor in general, because he saved my life.
 
My affected side (right side), was totally flaccid (paralyzed) post-operation.  I could not even support my own posture to sit in a regular wheelchair. They ended up having to put me into a special wheelchair that put me into a propped up but laying down position. On top of that, I had double vision and anomic aphasia. 

Textbook characteristics of anomic aphasia include trouble using correct names for people, places or things; speaking hesitantly because of difficulty naming words; difficulty finding words may be evident in writing as well as speech; reading ability may be impaired; and having knowledge of what to do with an object, but still unable to name the object. I had every one of these characteristics at first, but I was able to work through most of them through speech therapy, which I had for six years after the stroke.  After that 6 year period of speech therapy, word retrieval fluency was the only residual deficit from the anomic aphasia.  

After the tumor extrusion surgery, the doctors told my parents that I may never walk again. The keyword there was "MAY," but my parents took it as "Will." That was until I started rehab. My PT was the first therapist I saw and my parents

told her that the doctor said I WILL never walk again. The PT smiled and said "we'll see about that; no prognosis is set in stone when it comes to stroke rehab." This was by report from my parents later in life when I could comprehend such things.

It was through PT that within three months I could walk again and within six months I could run and play with the other kids with a significant limp. I kept having PT until sixth grade, when my playing sports took priority over PT.   

In school sports, I always felt subpar due to my weak right side.  That was until I joined the Vermont Special Olympics (VTSO).  It was through the swimming and skiing competitions that I realized that it was possible for people/kids to be more disabled than I was and still outperform someone like me through hard work, through a significant amount of practice, and determination.  

I practiced for, and competed in, the VTSO from 1992 to 1997.  By 1997, I was competing well and had built up enough confidence in the sport of downhill skiing that I started coaching other kids with disabilities to compete in the winter VTSO games. I credit the VTSO with giving me the confidence boost I needed to become a successful adult.

In school from elementary school into high school, writing/typing narratives for school assignments was agonizing due to my residual word retrieval fluency problems on top of having to write with my formerly non-dominant left hand and type with only one hand as well.  I had this difficulty right up until high school when a new piece of technology came my way. 

In sophomore year of high school, I was introduced to Dragon Naturally Speaking voice dictation software.  At first, it was terribly difficult to train and use due to the accuracy issues of the program combined with my difficulty efficiently retrieving words.  However, after a year or two of using it, two remarkable things happened. One was the program became more used to my speech patterns and two was that the residual word retrieval fluency problems that I had were significantly reduced.  This occurred due to the need to speak in complete sentences in order to get the program to transcribe the correct words on to the document that I am writing.  To this day I still use Dragon Naturally Speaking and other voice dictation software to more efficiently perform word processing projects and it has made a world of difference.

My biggest regret from my childhood was in regards to my neglect of my right hand.  I did have one period of late in the game progress when my mom signed me up for Constraint Induced Movement Therapy for two weeks one summer while in high school. I retained my thumb and forefinger pincher grasp through this therapy, but I still neglected the use of my hand into my first year at college.

I went to Boston University for one semester of Aerospace Engineering and then one semester Astrophysics. All the while spasticity was actually increasing in my elbow, forearm/wrist and hand muscles out of neglect. I saw this and also saw that my life wasn't going the way I wanted it to. I ended up withdrawing from BU and taking a year off to re-assess my life.

That summer, I began to design my own therapy regimen with everyday household items (PVC Pipe, a basketball, pen and paper, cups, utensils, etc). With this I started to see some of my control returning and started to develop an interest for the first time in the rationale behind the rehabilitative therapy interventions I had been through. I then started shadowing local Physical Therapists to see what rehab was like from the perspective of the therapist. I was fascinated by their descriptions of the rationales behind their interventions. I wanted to know more both for myself and potentially for others to see if I was able to accomplish what it took to become a therapist. Thus, I started applying to and visiting colleges again and finally got into the Quinnipiac University Master of Physical Therapy (MPT) program.
 

PT school was one of the most difficult challenges that I have ever put myself through.  Not only was it mentally challenging due to the amount of information that I had to cram into my memory banks for each test, but it was physically challenging as well on a neuromuscular level.  Almost every single hands on technique that we learned and practiced needed to be adapted to my physical capabilities with my stroke affected right upper extremity.  In the beginning, this was hard not only mentally, but socially and emotionally as well due to the fact that my adaptive techniques made me stand out amongst my peers with my different approaches to the text book ways we were learning each technique.  This made me feel somewhat of an outcast amongst my fellow students because a lot of them did not want to get confused by my alternative approaches to the text book techniques that they were trying to master.

I even dealt with a select few of my instructors who were hesitant to allow me hands on experience with clients in the field due to being insecure about my physical capabilities.  One time, one of my neurorehab professors allowed every single member of my lab group to get hands on with a stroke survivor from facilitating balance work to transfer, gait and stair training; everyone except for me of course.  I know now that I could have been hands on with that client in the field lab and been totally safe with him if I had been given a chance to be hands on.  I was so put off by this experience that I reported this incident to the heads of my department and vowed to never let it happen again.

Being a student of PT also had its perks. I got to learn from some of the greatest PT minds in the field with regard to their educated and well researched perspective to my case as a stroke survivor. I also had the privilege of being a subject of a graduate PT study on the application of Saebo Splint products. I even got Botox injections to tone down my spasticity in my forearm and hand so that it could be easier to stretch and work my hand with the Saebo stretch and the Saebo flex splints that I got to practice with. Unfortunately, the project was cut short due to my catching Mono during my week trip down to New Orleans in 2005 to be a part of the Katrina Relief effort.After 5 years of schooling, a year of clinical affiliations, and hundreds of hours studying PT baseline knowledge and skill sets, I finally sat down to the PT Board exams and passed 1st time around.

Today, I am a PT licensed in the state of New York, a husband to my wonderful soul mate, and father to my 2 loving sons. Since 2010, I have worked in all aspects of inpatient rehab as well as in home care. I currently work in a home care agency in upstate New York.  I also lead a local stroke support group called Friends and Family Stroke Recovery Group. It is through PT that I have accomplished many of my life's goals. It is also through PT that I still work on my ongoing goal of continuing to regain the control and use of my right hand. As a PT, I work hard every day to help people achieve their goals of regaining their functional mobility through applied evidence based practice, education given to each patient about my approaches to each of their cases, and empathy. Some people believe stroke is a curse. For me, my stroke was a blessing because it made me who I am today, a Physical Therapist who can truly empathize with the hard but rewarding work of rehabilitation through my life as a Physical Therapy patient and professional status post stroke.

If anyone has questions or comments, you can send them to the following email and mitch will reply when he can.  Email: mitchraymond614@gmail.com

Don't forget the Yang

If movement is the yin, sensation is the yang. Try to zip up your zipper with gloves on. Its hard to even find the zipper! Part of the finding and the zipping is being able to feel. The feeling of the zipper tells you where the zipper is, how much force it will need to be pulled up, the angle of pull that is the most efficient, etc., etc.

For many survivors, its more than just losing the feeling of the zipper between their fingertips, its also the feeling of the entire arm and hand that may either be diminished or lost. If you think its hard to pull up a zipper because you can't feel the zipper, imagine how hard it is to pull up a zipper if you can't tell where your hand is! This ability to feel where the extremity is in space (without looking at it) is called proprioception. Proprioception, when intact, is a constant feedback loop. 

Little organs in your muscles, tendons and joints tell your brain where your limbs are without you looking at them. You adjust your movement according to this information. As you adjust your position, your muscles continue to tell you where you are! 

All this information runs through your nerves (from muscles to brain and back) at about 300 feet per second. But it may all "fall on deaf ears." If the portion of the brain that "listens" to proprioception is killed by the stroke, none of that information will get through.

Is proprioception retrainable?

Anyone who reads this blog, or my book, or practically any article I've written knows that I think the whole darned system is retrainable. The research is somewhat unclear because its hard to measure proprioception. You can measure movement, but how do you measure feeling? But. There is a lot of research that says, basically, the more you move, the better your movement becomes. And, there is a general belief that better movement requires two things:

1. Better control over muscles
2. Better proprioception

So, if you are moving better, we can assume that you are probably feeling the movement better.

And "use it or lose it" is in play. We know that if a survivor moves less, the area in the brain that controls that movement shrinks. But the areas in the brain involved in proprioception also shrink. 

So move! A lot! Its a twofer! If you move you regain control over movement and the feeling of movement! That then gives you a wider palette of movement! And, if you work really hard (and are lucky) your movement will be integrated into your everyday! And that's the holy grail of stroke recovery!

More tips to recover proprioception here.

What if you made it harder?

There are a lot of things out there that can help make the life of the survivor easier. Assistive devices that can aid in everything from walking to eating, for instance. There are apps to help aphasic folks communicate. There are even books that give you "Tips for Making Life Easier. " 

There are really really good reasons to have these "helpers." One of those reasons is safety. Take AFOs, for example. I've been an advocate of attempting to "walk out of" the AFO. AFOs help folks who can't lift their foot, walk. And if its a safety issue then, by all means, keep it!! But if a set of muscles is not used it will atrophy. In the case of the AFO, the orthotic eliminates the need to use the dorsi flexors which lift the foot. But that muscles will atrophy is only half the problem.

The other thing that atrophies is the portion of the brain that controls that movement.  In short order (weeks) the number of connections between neurons in the brain rapidly decreases. Is that what we want? Generally, no (but for safety, yes, maybe.)

So all this time is spent on making life easier but making life harder is the place to be.  Find suggestions here and here and here.

Clinical research indicates you are smarter if you don't buy lumosity

Lumosity is a scam. It costs $15 a month and it will change your brain. What does it do to your brain? It makes your brain better at playing the lumosity games. 

(If you're interested in games and gaming that may actually help you recover, see this link.)

Really you don't need fancy software and a computer interface to do what human brains have been doing for the last 200 thousand years. 

Heck, these guys don't even use the word neuroplasticity right. Their tagline is "Lumosity is based on the science of neuroplasticity." But neuroplasticity is not science. 

(note: The previous link was to luminosity's website. But they must've gotten enough flak about the whole "science of neuroplasticity" thing that they took it off their website. However, others have found, and recorded, the same statement.)

Neuroscience is a science. Biology, chemistry, zoology -- these are sciences. Saying neuroplasticity is a science is like saying E=MC2 is a science. In fact, both E=MC2 and neuroplasticity are theories. Given the fact that lumosity has a huge stable of neuroscientists, you think they'd be able to figure the nomenclature.

The fact is, the best way to "train your brain" is to challenge your brain. This challenging of the brain -- also called learning -- changes neurons. Learning stresses out neurons which react by creating new dendrites, that then form new synaptic connections. The best way to rewire your brain to learn something new is the old-school stuff; learning a new language, learning a new musical instrument, learning a new sport, etc. I'm not sure I couldn't put it better than this: The (lumosity) scam is a pretty smart one because it melds together not just one but two classic plays in the world of conning – the idea that you don’t have to work hard for something because there’s a hidden shortcut, and the inherent belief that you could be brilliant if only you could tap some hidden skillset lurking somewhere in your brain-case.

How can stroke survivors drive this sort of change in their brain? It involves a lot of hard work. The work has to be very challenging. The bottom line is, there is no game, or machine or pill that will help you learn. And there's no game, machine or pill that will help you recover from stroke.

More up-to-date blog entry on "brain games" here.

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'.