Recovery depends on neuroplasticity? Yeah...not entirely.

There's this notion among many clinicians and survivors that recovery is all about neuroplasticity. It's the thesis of my book, the focus of the work of me and fellow lab rats (colleagues), as well as much of our stuff in journal articles. But it's not 100% true. A lot of recovery comes from stuff other than neuroplasticity.

Healing First, Neuroplasticity Later

To explain this, let's nail down two things:
1. What neuroplasticity is
2. When neuroplasticity is important

What is neuroplasticity, and where does it happen?
Neuroplasticity–the simplest definition: Changing the structure and/or function of neurons in the brain. Actually, this is not entirely true. Neuroplasticity can happen anywhere in the nervous system. Even peripheral nerves can change in terms of structure and function. This is why, when it comes to stroke, researchers often talk about "cortical plasticity." They are being very specific about where the plasticity is happening: in the cortex of the brain. 

The cortex is where all the "learning" neurons are. The cortex is where all the neuroplastic action is.

The definition of neuroplasticity as a relates to stroke is this: Changing the structure and or function of neurons in the cortex of the brain.

When is neuroplasticity important?
The first thing to do is figure out when neuroplasticity is not that important. The cortex of the brain is constantly rewiring in all of us–all of the time. But it is only robust enough to make a difference in a stroke survivor once they are chronic. The chronic phase is generally defined as "after the first three months after stroke." But probably a better way to define it is: the point after the plateau. So once a survivor has plateaued from then to the end of their life they are considered chronic.

During the chronic phase neuroplasticity is vitally important to recovery. It is only through forging new pathways a chronic stroke survivor learn to move better. "Forging new pathways" is neuroplasticity.

This will tell you where to focus on all phases of recovery.

So neuroplasticity is vital to recovery during the chronic phase. And make no mistake: for most very successful stroke survivors recovery done during the chronic phase is represents a huge part of their recovery.

However, most recovery, for most survivors happens during the subacute phase (from 7 days to 3 months, average). But during the subacute phase neuroplasticity is not the predominant driver of recovery.

So what is the primary driver during the subacute phase?

To put it simply, recovery during the subacute phase has to do with healing (more technically "reengaging the penumbra").

The penumbra is the portion of the brain that surrounds the area that was killed by the stroke. NOT using the whole penumbra is the essence of learned nonuse.

So, to review:

SUBACUTE PHASE (~7 DAY TO ~3 MONTHS): Most recovery during this phase is what would be called "spontaneous recovery" or "natural recovery." CHRONIC PHASE ~3 MONTHS UNTIL THE END OF LIFE) Recovery comes from the hard work of the survivor driving their own brain towards recovery neuroplastically.

I miss my old self (too)

One of the laments that I hear a lot from survivors is "I miss my old self." But please, survivors, keep in mind – we all miss our old self.

I feel 
grrrreat!

I am as 
indestructible 
as I feel!

We often tend to look at the past fondly simply because we were young. But we're all getting older, slower, achier – and, as if tipping our hand of our aging interior – our looks take a hit.

So let's say a stroke survivor had their stroke 10 years ago – when they were 40. Now they're 50, and they "Miss their old self." It is true that stroke ages you immediately. The stroke ages you at least five years. That is, your brain is five years older, your body is five years older, etc. – all within the first 24 hours of stroke. So when survivor say "I miss my old self," I can dig it.

Doing well!

I haven't had a stroke, but I can tell you, 60 ain't 50, and 50 ain't 40. That is, you wouldn't be how you remembered irrespective of the stroke. So when you compare, compare to the projection of yourself given the added age.

So, like the rest of us, as you work against the deficits of the stroke you are also working against father time (or mother nature).

Crap I didn't 
even know 
I had aches.

I do know some stroke survivors who are in some of the best shape of their life after their stroke because this was really the first time in their life that they look after themselves.

So what can you do against age related decline? I'll let the great neuroscientist Michael  Merzenich tell you here:

$39 total. Because recovery should not cost an arm and a leg.

Developed by Pete Levine
Click for more info!

You're supposed to do repetitive practice. But how are you supposed to repeat a movement when you can't move?

The ArmTran can help. It turns small amounts of strength into large movements!

Use your hand. Now.

Even if you can't open your “bad” hand, you should use it. 

You can release your hand by using the “good” hand to bend the “bad” wrist. This maneuver typically opens the fingers. Once the fingers are open you can use the hand to stabilize, grasp, and even exercise. Grasping objects is, generally speaking, good for the hemiparetic hand. Squeezing objects, as well, is good for the hemiparetic hand.

One way you can quickly get the hand back in the game is using gripping aids. One company that makes a gripping aid that is very easy to use is Active Hands. (Full disclosure, Active Hands a sponsor of this blog).

Using a gripping aid has two immediate benefits after stroke:

1. The “bad” hand can be used to augment your available grip to make gripping safer. The gripping aids would be just that; and aid. As much as you can, use the grasp you have to hold items. But the gripping aid can support your active grasp adding safety and functionality to the grasp.
2. The hand, now “in the game” with the gripping aid, will now use the rest of the arm (shoulder, elbow, forearm rotation). In this way, the rest of the arm is used, which is good for recovery of the rest of the arm. The primary reason for the existence of the arm is to get the hand to where it needs to be, so a (a-HEM!) active hand leads to an active arm. And an active arm is one that is likely to recover.
   

Any questions?

Brain + Comfort Zone = No Gain

The key to recovery is challenge. Heck, the key to learning anything new is challenge. (For stroke survivors movements that need to be re-learned are "new.")

So how much challenge is needed? Let's put it this way, one of the treatments used to improve quality and speed of walking that seems very promising is called "speed dependent treadmill training." How challenging is it? Check this out…


The survivor gets on a treadmill and harnessed to the ceiling with a strap around their chest, just under their arms. The strap doesn't do anything – it's just a safety belt so if they fall, they don't fall- if you fall oh. (heh heh- still got it!)

The speed of the treadmill is turned up until either the therapist or the stroke survivor freaks out. Trust me, I'm only nominally paraphrasing here.

The "freak out" speed is considered the survivor's top speed. The survivors then rests for about five minutes. Then he gets back on the treadmill, harnessed again, and the speed of the treadmill is brought to half of his top speed for two or three minutes – as a warm-up.

The speed of the treadmill is then increased to their top speed. If they can handle their top speed for 10 seconds, the speed of the treadmill is increased 10%. If they can handle that, there speed is increased another 10%. If they stumble it comes down 10%. But if they can then handle that for 10 seconds it increases 10%.

For this treatment, if speeds are plotted on a graph it looks kind of like the stock market – you have peaks and valleys but your speed is quicker at the end then at the beginning.

Think about that. The level of challenge is increased so much that it's defined by the person stumbling. This is where the brain operates. A safe brain does not grow. The brain has to be brought way outside it's comfort zone or doesn't change. True for anyone trying to learn anything. True for stroke survivors.

Don't worry, therapists...

I was doing a series of talks- on stroke recovery, natch- in Georgia last week. Someone brought up a concern about my talk that I also heard last time I did a series of talks. Here's a paraphrasing of that concern:

"You're saying that a lot of what we do in the clinic is shown to be ineffective in research. Payers (insurance/Medicare/Medicaid) are going to hear about this and then... I'm afraid we're going to get paid less and have fewer treatment options."

And I laughed. On the inside because out loud would have been rude. But: How silly! To think that insurance companies are listening to researchers about what is and is not effective! Insurance cares about shareholders and Medi"care" cares about keeping costs as low as possible. One thing they care little about: the science.

Therapists, fret not. Things that research indicates are ineffective are still paid for. Consider splinting. These are the rigid pieces of plastic that keep a joint in a certain position.  They are believed to reduce muscle shortening in patients that posture in a flexed potion.

So people like this:

Get one of these...

Governmental clinical guidelines suggest splints don't work, and may make things worse. Its usually stated like this....

For stroke survivors at risk of or who have developed contractures and are undergoing comprehensive rehabilitation, the routine use of splints or prolonged positioning of muscles in a lengthened position is NOT recommended.

Is splinting paid for. Let's put it this way.

So relax therapists. Don't worry, they're not listening to researchers!

And not only will they pay for stuff that does not seem to work, they won't pay for stuff that does work yay!

Take constraint induced therapy (CIT). We've known for a while that is particularly effective for some stroke survivors. In fact, CIT shows up on every set of clinical guidelines in the English speaking world. Here for example, are the clinical guidelines for OT in Australia. Open it, and search (Ctrl+F) for the word "constraint."

Is CIT paid for? No. There is not even a "code" for it (a code is the numbers used to bill for a particular treatment). 

"stroke recovery expert"

Probs should do it now.

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