Young Survivors: You may look great AND struggle.

A couple of bits of bad news for younger stroke survivors. First, a look at this article.

My interpretation: Young people who have insomnia are at a much higher risk of stroke. And by much higher I mean more than 8 times the risk. 

That's valuable information. But. There's a not-so-subtle intimation that a lot of young stroke survivors complain about. Namely, that young people are out doing drugs (and other bad things) which keep them awake. 

The second bit of bad news

There's a new article out with a not-so-subtle name "Poor Long-Term Functional Outcome After Stroke Among Adults Aged 18 to 50 Years." Its bottom lines may come as some surprise to clinicians: many young survivors stroke survivors struggle with everyday tasks. 

After 10 years, 1 in 8 patients (12.9%) was not able to function independently. 

When interviewed the author's seem to suggest that, young survivors often don't show severe outward signs of problems related to stroke. For instance, they would struggle much less with walking than older survivor. But that does not mean that these everyday tasks are not problems. One author Frank-Erik de Leeuw, Ph.D., put it this way "Even if patients seem relatively well recovered with respect to motor function, there may still be immense 'invisible' damage that leads to loss of independence." 

I've heard this before from young survivors. People will come up to then say "You look great!" And they think to themselves, "I don't feel great." 

 One interesting note: Almost all the popular press has reported that this article suggests that "one-third" of young stroke survivors are having problems. I've read the article. It's one in eight. I'm not great at math. I'm pretty sure that's not one third.

Falls. Bad.

Here is your challenge: 

In the comments section, write everything that this survivor could do better in order to get up the stairs more safely. 

We all know that falls are bad. 

Falls can kill you. For survivors, falls are especially bad. Stroke affects balance, coordination, strength, and any number of other things that can lead to an increased risk of falls. On top of that, survivors tend to fall towards their affected side. In the affected side tends to be more osteoporotic. So have at it. This is good place to start as anywhere. What is this gentleman doing wrong? How do you do differently? What can you suggest?

The neuroplastic model of hypersensativity reduction after stroke for fun!!

Hypersensativity after stroke can come in two basic flavors:

1. A touch (or some other stimulus that normally does not hurt) hurts. A lot. This is called allodynia.

2. Something that usually does hurt hurts a lot more that it should. In other words, it hurts a lot more than it might on the unaffetced side. This is called hyperalgesia.

So how might you treat this. Lets go to the never-ending neuoplastic well, shall we? We know that stroke damages the brain which may cause the altering and amplifiying of sensation. So what if we used the same process to reverse it? These are hypothetical (although some have been tested) so keep that in mind. So what are the neuroplastic model to treat? Possibilities include...

1. TENS (mild electrical stimulation). Dosage here.
2. A placebo. An example would be suggesting a manual therapy (like message or manipulation of the extremity) will help reduce it. Discussion here.
3. Comparison. Put the gel on the unaffected side and say, "See, its just a bit cold. We'll take exactly the same gel (it can even be done at the same time)and put it on the 'bad' side and they'll-hopefully-feel the same.
4. Mirror therapy. Set it up like this: Have him look only at the unaffected side as either the survivor or someone else gives the "good" limb the stimulus which is painful to the "bad" limb. It will look like its getting put on the affected side, but with no pain.

Further reading here.  Duscussion of the difference between hyperalgesia and allodynia here.

Pfft!

Why Dynasplint is half dead (and all dead for survivors)

Do you have muscles tightened by spasticity? 

Sarcomeres are the small units in muscle that contract when your muscles contract. (Great image here. Look at the bottom right corner.)  Sarcomeres will increase in numbers when muscle is put through a prolonged stretch. Increasing sarcomeres is how muscles are lengthened. Lengthening of muscle and increasing sarcomeres increases flexibility. Which is a good thing because we can talk about neuroplasticity until the cows come home but if your arm (or whatever) "won't go that way," all bets are off.

 
OK. So how might you increase the number of sarcomeres? One way that many clinicians think works is called "dynamic splinting." The idea is that you'd wear something that would hold you in a position that would stretch you. If you could wear it at that posture for 2-3 hours, the clinician would "dial in" a more "aggressive" range of motion. Over time you'd gain sarcomeres which would allow you to have more range of motion. 

Sounds groovy, right?

It works for, say, marital artists who want flexibility so they can KICK ASS.

Stretching ROCKS! Sometimes!

You stretch, you get a longer muscle, everybody's happy!

But yeah. That whole science thing gets in the way. Don't you just hate science?

It turns out that the way to elongate (add sarcomeres)  "normal" muscle is nothing like the way you'd do it in spastic muscle. To stretch spastic muscles so they gain length, the stretch must be held at least 48 hours. And dynamic splints are not kept on for anywhere near that long; a few hours, max. 

And here's another little interesting tidbit. The 600 pound gorilla of dynamic splints is a company call DynaSplint (get it?) and they've had a little bit of trouble lately. The kind of trouble where they may have defrauded the Federal Govmint. And they laid off 500 workers in one day. Which makes sense since it was a DynaSplint salesperson that was the whistle-blower that brought the whole company down. Which then triggered their bank to stop their operating budget.

And while I have no idea of any of those problems are warranted, one thing I do know is that they are fraudulent in another way. Again and again they claim that their splinting systems help folks with spasticity. They also claim they increase muscle length. Don't buy it!

SEMINAR STUFF

REPETITIVE — CHALLENGING — MEANINGFUL

• The number of repetitions typically done in a rehab session I
• The number of repetitions typically done in a rehab session II
• The number of reps that can be performed I. if therapy focus is on repetitive practice
• The number of reps that can be performed II. if therapy focuses on repetitive practice
• fMRI data collected from survivors doing hundreds of repetitions of grasp, release.
• The Importance of Salience (Meaningful) in Stroke recovery
• The Importance of Challenging (Intensity) in Stroke recovery
• How parenting radically changes your brain. #1
• How parenting radically changes your brain. #2

TREATING

Electrical Stimulation (E-Stim)

• Upper limb electrical stimulation exercises
• E-Stim for subluxation of shoulder post stroke
• All The Things E-Stim Can Do For Stroke Recovery 
• General considerations for E-Stim
• Videos: How to E-Stim any muscle group!
• Great simple review of EStim; large section for stroke
• Articles showing how surface E-Stim changes the brain 
• In healthies
• In stroke and dystonia
• hand
• tibialis anterior

Rhythmic Bilateral ARM Training 

• BATRAC (Bilateral Arm Training with a Rhythm) (see "TRAINING" for clinical dose) 

Rhythmic Bilateral LEG Training 

• Cerebellar stroke: Metronome cueing ↓'s variability for step, stance, double support times & joint kinematics
• Stroke: Effects of  rhythmic auditory cueing on gait. A systematic review with dosage included

Mirror Therapy

• Make a mirror box cheap!
• Mirror Therapy
• Mirror Therapy II
• Mirror Therapy for Intention Tremor

Increasing walking speed 

• Speed-Dependent Treadmill Training 
• Double walking speed with verbal encouragement (QUICK READ)
• Double walking speed with verbal encouragement (FULL STUDY)

Constraint Induced Therapy (CIT)

• Lower Extremity Modified CIT
• Compelled Weight bearing (shoe lift)
• 2 versions of Compelled Weight bearing: shoe lift vs. knee immobilizer

CIT early after stroke may not be a good idea

• The "VECTORS" trial 

Amazing CIT dissertation by STACY L. FRITZ that includes:

• MOTOR ACTIVITY LOG (MAL) Manual, WOLF MOTOR FUNCTION TEST, FUGL-MEYER Upper Extremity Motor score sheet, CIT HOME DIARY, CIT DAILY ACTIVITY LOG, BEHAVIORAL CONTRACT FORM

Sensation Recovery

• Lower extremity
• Upper extremity

Why task specific practice important in neurorehab

• Task Specific Practice in Neuro Rehab 

Ataxia

• Educational webinars about Ataxia

REDUCTION OF SPASTICITY

Electrical Stimulation (E-Stim)

• Effects of Electrical Stimulation on Spastic Muscles After Stroke
• E-Stim to Reduce Spasticity in the Leg

 Evidence for the "neuroplastic model of spasticity reduction".

• "The Neuroplastic Model of Spasticity Reduction" in a nutshell
• Motor learning therapy increased spastic muscle's contralesional cortical motor regions leading to decreased spasticity
• Intensive training in patients with increased muscle tone improves function without exacerbating spasticity 

 CIT decreases spasticity and “pathological” synergies

• CIT reduces spasticity 2017
• CIT reduces spasticity 2013
• CIT reduces spasticity and increases functional use
• CIT increases strength and decreases spasticity

Resistance training does not increase  spasticity 

• Power training does not exacerbate of spasticity 
• Resistance training ↑s strength, gait speed, and functional outcomes without exacerbation of spasticity.

Spasticity and sleep

• Spasticity wanes during sleep

Mirror therapy reduces spasticity

• Ashworth score declines

Stretch (any form, duration, or arc of time) does not decrease Spasticity

• Cochrane Review

Selective dorsal rhizotomy (SDR) success in adults

• Functional Outcome of Adulthood Selective Dorsal Rhizotomy
• One woman's experience with a SDR done in adulthood

Botox strength increased, and uptake time decreased with EStim

• Rationale, & State of the Art

PRIMING THE BRAIN FOR RECOVERY

ACTION OBSERVATION VIDEOS

1. A Variety of Acton Observation Videos
2. Upper Body Dressing

• Motor Priming in Neurorehabilitation: An Overview
• Moving, mental practice, and action observation activates similar parts of the brain (great images!) 
• Action observation leads to measurable muscle activity
• Action observation of swallowing activates swallowing muscles in observer. 
• Cortical change with action observation in hospitalized  moderate to severe TBI
• The mighty Cochrane Review found that AO therapy resulted in better arm and hand function

VIDEO

• Taping for genu recurvatum
• How a Baclofen Pump Works
• GRAPHIC: Selective Dorsal Rhizotomy (starts @ 2 min in)
• GRAPHIC: The Unfixed Brain: What your brain really looks like
• GRAPHIC: Surgery for Acute Subdural Hematoma
• Brilliant vid on the great work MDs do to lessen the effects of stroke-- fantastic graphics!
• Great ideas for survivors to self-recover by "super-survivor" Kathy Spencer 
• Kahn Academy: types of ischemic stroke

RESEARCHING

Researching Stroke Recovery

• Evidence-based review of stroke rehabilitation
• StrokEngine: Tons of info for therapists and survivors
• PubMed Central: Free Journal Articles (NIH)
• MedlinePlus Simple and Free bottom line reviews
• Bookshelf: free online books and docs (NIH)
• Cochrane Database of Systematic Reviews
• Bio med central free open-access articles
• TRIP Database: a smart, fast tool to find high quality clinical research evidence
• Hindawi Free Access to Journals
• Directory of Open Access Journals (DOAJ) 

Clinical Guidelines from around the World

• New Zealand
• UK
• Australia
• USA/VA/DoD
• Scotland 

Information About Other Forms of Brain Injury

• Evidence-Based Review of Brain Injury
• Overview: Chronic Traumatic Encephalopathy (CTE/Football/concussion)

Find Stroke-Recovery Research in Your Area

• National Institute of Health 

Two Free Stroke-Specific Magazines

• StrokeSmart Magazine
• Stroke Connection Magazine

MEASURING

Measuring Recovery

• The best Rehab Outcome Measure search engine EVER!
• Calculator to score patients accurately for G-Code Med. B (Claims-Based Outcomes Reporting [CBOR])
• TONS MORE stroke recovery tests
• Nottingham Sensory Assessment
• Walking Speed: the Sixth Vital Sign
• 10m Walk Test: What Does the Data Mean?
• FUGL- MEYER: Rules for UE and LE
• FUGL- MEYER: Score sheet for UE and LE
• Motor Activity Log (MAL) Manual
• The Modified Ashworth: U.E and L.E 

Cognitive (mental) Tests

• Mini-Mental Exam (copyrighted)
• VA SLUMS Exam

Posterior Pusher Syndrome (or) posterior pelvic tilting

• Treatment ideas

REFERENCING

• References for information used in the seminar

BDNF

• BDNF produced by aerobic exercise
• BDNF produced by resistance exercise
• Aerobic Exercise increases BDNF in neuro patients
• BDNF levels after TBI are predictive of recovery

Walking within within 24 hours after stroke: help or hurt?

·  An article where they interviewed therapists, docs and nurses: Conclusion: Our study shows that most clinicians had concerns in relation to early mobilization of stroke patients and more clinicians had concerns for hemorrhagic than for ischemic 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 mobilization after stroke.

· A Very Early Rehabilitation Trial for Stroke (AVERT): Conclusions: 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."

The curious case of NDT.

• Neuro-Developmental Treatment: maybe.

the most important gizmo for recovery is you

I do stroke recovery talks to PTs and OTs (and a mix of other clinicians, survivors and caregivers) all over the US. Today I'm in Cheyenne, WY. 

Between Casper and Cheyenne

I've had many conversations with therapists over the years. One of the things that's remarkable is how little consistency  there is in the tools therapists have. Some therapists have every gizmo known to man, others have little other than their creativity and a few standard tools. Imagine the difference between working in a leading-edge rehab hospital vs. an on-the-road home care therapist.

That's me. The king of PowerPoint.

Do "stroke recovery machines" make a difference? Within reason, no. There are a few tools that may be essential. For instance, electrical stimulation, parallel bars and a mirror may be essential at some points in some survivor's recovery. Really, much more important is the training of the therapist. This is not just true in stroke rehab but in many areas of medicine; outcomes are directly tied to the training of the clinician. For most survivors, the knowledge of the therapist is the most important gizmo. 

But remember, they'll "discharge" you at some point and then the most important gizmo for recovery is you (and caregivers!).

Don't stop. Don't stagnate. Don't let a lull convince you recovery has ended.

What about "Long-Term Rehab Management of Stroke"? What do we know about stroke recovery as we get into months and years and decades? 

What does this post have
to do with this girl?
Nothing!

The first thing we know is that its nonsense to believe that recovery has some sort of expiration date. I like the idea of someone coasting for a month or longer and then recommitting themselves to recovery. Its never too late.
 

What does tend to happen is "adaptation." The word refers to the notion that if you do the same techniques you get the same results. Survivors and therapists can both cause adaptation. Therapists can get used to what they use and go automatic and unimaginative with treatments. Survivors can get lazy and not push against their present abilities. 

Bottom line: There is good  evidence in the research that so-called "chronic" survivors can continue to make progress.

Don't stop. Don't stagnate. Don't let a lull convince you recovery has ended.

Wanna write a book?

From the publisher of my book...You can email her directly (contact info, below) if you're interested. Best, -pete

"I’ve been thinking about two possible new books on stroke for our list and I wondered if you might know of anyone who might be interested in writing them:

 

A Caregiver’s Guide to Stroke: a handbook to help the caregiver, addressing all of the issues and best practices they should know about: creating and managing a health care team, dealing with the various physical, emotional and cognitive issues, etc. The right author would most likely be a social worker, therapist, or professional caregiver.

 

Myths vs. Facts on stroke: a book aimed at dispelling the myths/misinformation about the causes, treatment, physical and cognitive impact of stroke." 

Julia Pastore
Executive Editor, Demos Health Publishing

jpastore@demoshealth.com

Yes! Stretch!

The small units that make up muscles are called sarcomeres.

Help! Stretch me!

Sarcomeres shorten when we contract our muscles. When we stretch for a long time, there is an increase in the number of sarcomeres. Literally, muscles get longer.

For example, increased flexibility is directly related to an increased number of sarcomeres. One of the ways that the number of sarcomeres can increase happens to all of us: Growth from birth to out 21st year. Growth in the length of bones during childhood provides a prolonged stretch of muscles. As muscles are stretched to their physiological limit they react by developing an increase number of sarcomeres. Stretch has to be of sufficient duration for this remodeling of muscle to occur.

The opposite is true as well. When muscles are left in shortened position, the number of sarcomeres decreases. Nothing provides a prolonged shortening of muscles like spasticity after stroke and brain injury.

So all the rules of stretching are thrown out the window when the muscle is spastic.

How is spastic muscle different than normal muscle? Let me count the ways...

Spastic muscles... 

•have lost some (if not all) communication with the brain.

•are often kept in a shortened position on the "bad" side for long periods of time.

•are not subject to the same rules of stretch. (That rule: The more you stretch the longer the muscle will become.)

Spasticity after brain injury keeps muscles (on the "bad" side) in a shortened position long enough to lose sarcomeres.

It comes as some surprise to most therapists, but there is very little scientific evidence that stretching muscle reduces spasticity. In the very short term there is a small reduction in spasticity. But spasticity is not reduced in any lasting way by stretching because spasticity is not caused by muscles. Spasticity is caused by brain injury. Brain injury causes the brain to cede muscular control to spinal reflexes. Increasing the number of sarcomeres will not reduce spasticity. If it did, every case of spasticity would be eliminated by a regimented stretching program. And wouldn't that be nice?

Soooooo... Should you not stretch? No! I mean yes! I'm confused! Yes, you should stretch!

Why should you stretch? Because even if stretch has no lasting effect on spastic muscle, there are several reasons to do it anyway. Stretch... 
•feels good 
•reduces spasticity for a sort amount of time 
•is good for joints 
•may be good for other tissue besides muscle (ligaments, veins/arteries, nerves, skin, etc.)