Electrical Stimulation after Stroke MADE EASY

Lets say you wanted to do electrical stimulation (eStim) to help your recovery. But....

There are 2 things stopping you:

1. You don't know what to do

2. eStim is really expensive

Let me help you with that... 

eStim is easy and cheap.

First the EZ part: How do you do it.

There are 3 parts to any eStim setup:

1. Machine

2. Lead wires

3. Electrodes

Put 2 electrodes (they're usually sticky) over the muscle you want to work. Typically, after stroke there are two sets of muscles that everyone focuses on:

1. The wrist and finger extensors. These will pull the wrist up and open the fingers.

2. The muscles that lift the foot to (hopefully) end drop-foot.

So, where do the electrodes go again?

Wrist/ fingers:

The muscles that lift the foot:

As EZ as ABC!A. Attach the lead wires from the machine to the electrodes.B. Stick the electrodes on according to the images, above. Optimal placement will vary from person to person because everyone's anatomy is different. And, after stroke, every survivor's deficit will require slight changes in electrode placement-- according to their needs.C. Turn up the eStim. If you are getting the movement you want, take a photo of the electrode placement, or put a pen mark on you skin, so you can remember where then "perfect" electrode spot is.How long should I do it for?I've been involved in a lot of what is called "dosing" clinical trials for eStim (here are a few). Figuring dosing for eStim is just what like figuring dosing for a drug: How much should I take? Is it different for every survivor? Yes. Does it depend on how much brain damage there was? Yes. Does it depend on other things as well? Yes.  Let me give you the EZ bottom line here...The only way you'll learn how much eStim you need and learn how to use the machine... is to use the machine. Manuals and rules are nice, but practice is better. Put the electrodes on and turn up the estim slowly. Once you get the movement you want, note the amount of eStim you used (measured in milliamps or mA).Two important notes (this gets a bit technical, but you can handle it!)1. Make sure you gradate up the eStim. Basically, its the same as any exercise program: Start slowly, and work up to more over time. Why gradate up? When eStim is used and there is muscle contraction, that muscle is being worked. It is firing, and just like with any muscle work you can end up sore (or worse) if you do too much too soon. So gradate up something like this:Day 1: 2 minutes. 
Day 2: 4 minutes.
Day 3: 6 minutes.
Day 4: 10 minutes.
Day 5: 5 minutes twice a day.
Day 6: 8 minutes twice a day.
Day 7: 10 minutes twice a day. And so on... until you hit the optimal dose and then stay there. This will give your muscles time to build gradually. If you get sore- reduce the dose.

2. Make sure you ramp up up the eStim. (A little more technical, sorry!). When eStim makes your muscle fire it does not just effect that muscle. It also effects that muscle's antagonist (the muscle that moves in the opposite direction). Example: Elbow flexors (benders) and extensors (straighteners). If you eStim the muscles that straighten the elbow, the muscles that bend the elbow will be forced to relax. And I think you'd agree, in most survivors where the elbow is always bent, it would be good (great!) to relax the muscles that bend the elbow. (Note: this phenomenon—when one muscle the contracts—its opposing muscle relaxes was discovered by one of my neuroscience heroes: Sir. Charles Sherrington.)

 

So that's good: You use eStim to contract one muscle and relax the opposite muscle. But there is one problem...

If the eStim is put on so that the highest amount of eStim that is set happens all at once, a paradoxical thing happens. The muscle that should relax (the opposite or antagonist muscle) actually fires. So now both muscles are firing and essentially fighting each other. 

So make sure the "ramp up time" is at least 2 seconds. The machine will let you control the amount of ramp up time. Make it 2-5 seconds. This extra time will give the antagonist muscle time to not feel threatened and relax. 

So it will look something like this:

PRECAUTIONS:

1. First, get an appropriate healthcare worker involved. An OT or PT will work. Have them read this blog entry and help you set it up- first time at least.

2. There are a bunch of precautions for eStim. You can find them here... but they can be misinterpreted so always: get an appropriate healthcare worker involved.Price: Cheap!eStim is cheap. Below are some examples. You're looking for NMES (where the muscle actually fires) not TENS (where you can feel it but the muscle does not fire).HERE, HERE and HERE

Get an MRI of your brain. Keep a copy.

One thing I recommend to every survivor: Get an MRI of your brain and keep a copy.

Why? 

First of all, an MRI can tell you a lot about what parts of your brain were damaged. Knowing where the damage was can give you insight into potential recovery. 

And an MRI (probably) comes with good news: You probs didn't suffer from as much brain damage as you thought you did. In fact, the average stroke (stress average) kills about 2% of the brain. And the brain is a highly resilient and transitory environment. It is very plastic. So that's good news, not much damage in an environment that can make up for its own weaknesses. 

What is a massive stroke?

MDs often describe a stroke as massive. The problem is, there is no definition for that word when it comes to stroke.

What a free book? Here's you quiz...
Here I will offer a challenge. (If I lose, I will recant and send you a free signed copy of my book- yay!?). When a stroke is defined as massive, how much of the brain has to die to be considered massive? I'll take a % or a # of neurons, or any other quantifiable definition. 

Here's what I suspect: The word massive has never been defined at all for stroke. MDs use the word like they use many words: to define what they can't define. Massive tells you nothing, as does hemiparesis, cognition, unilateral neglect, etc., etc. These are terms that are used a lot but provide no quantitative measurement. Take hemiparesis. This term runs the span from someone who can barely lift their shoulder to someone who you'd not recognize as having a stroke at all. And poorly defined terms like massive end up providing a self-fulfilled prophecy. "I had a massive stroke." It sounds bad and it may be bad. But because its not well defined, it may not be bad. It may be pretty small. How small? Get you an MRI of your brain, or if you had one (you probably did) get a copy. And embrace it. Frame it and put it on your wall. It might be the most inspiring piece of art you have.

Is it too late for you to get better - no.

Let's say you're a chronic stroke survivor. You know "chronic" – it's the time after your plateau. Typically the chronic phase goes from 3 months to the end of the stroke survivors life. Do you still have a chance to get better during the chronic phase? 

Yes.

Seriously? 

Yes.

There's actually good scientific reason to believe that you can get better after the plateau – once you are chronic.

And here it is…

Typically survivors are forced through rehab as soon as possible. Facilities are expensive and home is cheap, so off you go! The problem is that to get the survivor out the door, compensatory strategies are implemented. Things like AFOs and using the good arm to get everything done. It makes sense, these things do get people out of the system. The problem is those same strategies also hurt the survivors brain.

In fact, if compensation is taught during the first 10 days after stroke it hurts future function of the "bad" side.

OK, but how does this all help the chronic survivor? It sounds like it would hurt recovery.

Here's why: Since the survivor is encouraged to use the "good" side, the "bad" side of the brain sits fallow- doing nothing. The upshot is that many survivors have a huge portion of the brain, usually adjacent to the area damaged by the stroke, that is on vacation. You've heard of 'use it or lose it'? Well, they've lost it. BUT, it can be regained. How?
Here & here & here & here are some ideas.

Enriched Environments help recovery after stroke

What is an enriched environment (EE)?

An EE is something that forces you to learn. Forced to learn. You have to be forced to learn. Learning can be forced by everything from curiosity to circumstance. 

In fact, the brain will not learn (change) unless its forced. Why would your brain change if it is comfortable? What if the brain changes while you're comfortable? It may change to the point where you are no longer comfortable. 

And a lack of comfort is icky.

Travel is an EE because it forces you to learn. When you are somewhere other than home you don't know whats around the next corner. You are challenged into something new and different. You are forced by your new (enriched) environment to learn. 

But how can stroke survivors use EE to recover?

Travel is not the only form of EE. Lets take a big driver of EE in humans: Social interaction. Sure, it easier to ignore everyone and hope no one talks to you. Especially after stroke when, according to the research, you're about a million times more likely to "socially isolated." In the long run it may be a heck of a lot more comfortable not to engage whats-his-name (what the heck is his name??) than to engage in conversation. But if you do engage in conversation your brain is in for a hell of a ride. 

Here is a list of what we think social interaction does for the brain after stroke:

• Reduces death rate
• Increases total recovery of functional skills
• Increases speed of recovery of functional skills
• Redice risk of risk of developing depression 
• Increases post-stroke quality of life
• Increases speed of recovery of walking

But social interaction is not the only (fun!) way to use EE to recover. Here are some other ways:

• Do something with your hands. The hands are very important to the brain. The hands take up huge swaths of the brain because the hands have so much responsibility. My suggestion? Do something with your hands that you enjoy, even if you have to do it with your "good" side.
• Exercise is considered an enrichment of environment.

Mental Practice in stroke

Stroke survivors, quick question...

In your dreams, have you had a stroke? 

Your answer is probably no. 

What if you were able to access that memory for your recovery?

You can.

Not everything that will help stroke survivors recovery is a therapy - per se. Some things you can do benefit your brain so much that they help recovery as well. An example is Mental Practice.

Mental practice - 

We've published on this one a lot. The idea is pretty simple - do what athletes and musicians do... Practice mentally. You get the idea, you sit back and imagine a movement, and then when you go to actually do the movement it's better. 

There are a few things that you should know if you want to undertake mental practice:

• Mentally practice what you are actually practicing. For example, let's say you're working on walking in therapy. During that same set of weeks or months you would also do mental practice of walking when you are at rest. And that brings up another very important point... 
• Only mentally practice what you're good at. The good news is, a stroke survivor trying to get back what they've lost, is already an expert at the moment that they're trying      to relearn. Consider walking. At one point in time, almost every stroke survivor walked perfectly fine. And if you ever ask a stroke survivor - in your dreams have you had a stroke? - they always tell you the same thing: no. The AFO may be in the corner as a metaphor for something awful— or the wheelchair may show up in the dream somewhere— but they were moving and walking and talking perfectly fine. That's what mental practice is all about— you try to get into that dream-like state— but while you're awake. Because while you're awake you'll be able to really focus on what you're trying to relearn unlike a dream, where you may or may not be able to control it. 
• When you mentally practice something the muscles involved in actually doing that movement fire. And they fire in exactly the same order as if you were to actually do the movement. They just fire very minutely. Think about the muscle jerk that you might get during a dream as you're trying to run away from the monster . those are imagined movement manifested in physical movement. So, getting back to why you should only practice stuff you know well... If you mentally practice movements you don't know well, it will make your movements worse. 

But, again, the good news is that stroke survivors will be mentally practicing things that they used to do perfectly well.

Don't believe the hype -OR- Have you been lowballed? -OR- Clinician fulfilled prophecy

Bottom line: 
What the therapist predicted: Very little
What the survivor achieved: A lot

Let me tell you about a stroke survivor I worked with a year or so ago. I'll call him "Sam."

I was working in a skilled nursing facility. The physical therapist (PT) did Sam's evaluation.  The PT then told me Sam would be added to my caseload. 

I read the PT evaluation and it was pretty shocking. One thing stuck out: The "long-term goals" were one thing: "bed mobility." 

There it was. The best that Sam was expected to do was to be able to roll around in his bed. He wouldn't be able to stand. And walking was beyond belief.

The day Sam was to have his first treatment I went to the nurses station to read his chart before I met him. Nursing facilities often have a cluster of patients in wheelchairs right around the nurses station. It's where all the action is.

As I began to read Sam's chart I asked one of the nurses to point Sam out to me. She pointed to a gent in a wheelchair. "That couldn't be him"- I thought. If he could not get around the bed, how did nurses get him in a wheelchair?  The nurse: "That's him. He came in yesterday." 

This was the guy who's long-term goals were "bed mobility."
That day he took his first step. Two weeks later he was lapping the facility several times, without an AFO, and beginning to walk outside. Yes, we were both a "hot mess" by the end of treatments, but it was fun. Sam would get called out by staff "Amazing! Keep going Sam! Lookin' good!" In fact, some of the folks with dementia thought it was some sort of conga line so by the end of our walk we'd have a parade! 

P.S: There may be several reasons for the physical therapist lowballing expectations. Maybe Sam was exhausted by the experience of being transferred from hospital to skilled nursing. Maybe his meds had changed. Maybe he was admitted so late that by the time the therapist got there he was asleep and the therapist had to wake him and he was very tired. 

Or maybe: 

Some clinicians are so concerned with deficits that they miss potential.

Splinting after stroke? Why?

The research into splinting stroke survivors is clear: It does not work. Let’s have a look. 

Forget individual studies… they don’t count for much. Rather, let’s look at the meta-analyses (or “metas”). Metas are studies of all the studies available and will quickly tell you if something works. Or at least its the best tool we have to come as close as possible to "the truth." 

The granddaddy of all metas, the Cochrane review, has looked at splinting after stroke. The review states, 

"A total of 787 participants were included in the analyses.  The mean difference of splinting on joint mobility was 0°."

Ouch.

...

After stroke there are a number of reasons that you’re supposed to splint the wrist/hand/fingers. Here is the logic:

The survivor tends to posture with the wrist and fingers flexed (bent at the wrist and the fingers in a fist). Why do survivor’s posture like that? It has to do with the brain injury. Because the brain is no longer in full control, the stronger of the two muscle groups takes over. Imagine you have a ping pong paddle in your hand… what movement do you think is stronger: The wrist extended (like the follow through in a ping pong backhand), or the wrist forward (like the follow through in a ping pong forehand)? It’s actually the forehand/ flexion posture. OK, that’s why the wrist flexes (down, towards the forearm). What about the fingers? Same thing… the moment of the fingers to close the fingers (fist) is stronger than the movement to open the hand.

But why does this natural posture in survivors suggest to therapists that the hand and wrist be splinted? In some ways, it has to do with the same philosophy that scientific medicine has about treating everything. If she has a fever, try to cool the her down. If she can’t sleep, give her sleeping meds. If she’s nauseous, give her a pill to reduce the nausea.  Of course, there is the opposite view. For instance we know that the immune system works better when the body is feverish, so maybe we should let the fever run its course. If someone can’t sleep, maybe there is a reason and the person should exercise. If there is nausea, maybe what the body is trying to rid itself of… should uh... be expelled.  

Let’s get back to splinting of the wrist/hand… What does the joint want to do? Flex. So the scientific perspective would be: do the opposite-- extend. What keeps joints in an extended position? Splints. So when therapists splint, they’re taking the scientific medical perspective. But as shown by the Cochrane meta, above, the science disagrees. 

One last thing; I’m sure I will hear it from the pro-splinting lobby. Please save your time if you have anecdotal “splinting worked great for me” “evidence.” Unless you are willing to collect data using high reliability/validity outcome measures and have that data accepted as a result of the peer reviewed process, it is not evidence. On the other hand, you may just be an outlier and splinting did work on you. I'd suggest, however, if you do think it worked on you, you establish that it did in fact, work. What and how did you measure? Was your measurement accurate? Was your test valid and reliable? These are the things we sweat in research. In fact, I'd suggest that if you are measuring the two things splints purport to effect, range of motion and spasticity (i.e. goniometery and the modified Ashworth), that you have a partner given that both of these tests have to be done by someone other than the tested. 

How Instant Gratification Can Hurt Recovery

(Note: The following is a fleshing out of a previous blog entry)
Instant gratification can hurt stroke recovery. Here’s how…

Let’s say you want to retain soft tissue length in finger and wrist flexors. What do you do? How about a static splint?

It makes sense; you hold the soft tissue in a lengthened position and the soft tissue won’t shorten, right? There’s only one problem: The evidence suggests static hand/ wrist splinting does not improve movement, function, reduction of spasticity, nor does it retain soft tissue length. So what does splinting do? It provides instant gratification. The therapist can claim they’ve done something and the stroke survivor believes something is being done.

Here are some other options that play the same trick… 

• Stretching to reduce spasticity
• Handling techniques
• Tapping a tendon to get a muscle to fire

All of the above are good and bad

• The good: Instant gratification
• The bad: no evidence of long term efficacy.

Then again, what’s the harm? If a therapist wants to progress the leg during gait by tapping the quads, why is that bad? It’s not bad, but it may be… unhelpful, confusing to the survivor and a waste of therapy resources. Using the same the same example, tapping the quads to progress the leg here’s how it may be unhelpful:

A survivor with footdrop is in the parallel bars (II bars to the rehab nerds). The therapist taps the quads, progressing the tibia at the knee. The tapping puts a quick stretch which the golgi tendon organ perceives as potentially damaging to the quad which, through spinal reflexes, contracts to protect itself, progressing the tibia. The survivor is able to take a step.

OK, we have the instant gratification done. Now, what about the next step? Another tap? What happens when the survivor wants to take a step on their own? They felt their own muscles contracting when the therapist tapped them, but can the survivor do the same thing to himself? That’s confusing. And what is the carryover of the tendon tapping? Is there any physiological advantage the next day, the next hour, the next step? 

Most of the rehab and neuroscience research suggests having the survivor struggle to get their leg to through swing, by hook or by crook, utilizing whatever they have. This sort of “productive struggle” is what drives neuroplasticity post-stroke. If there’s one thing we know about brain plasticity its this: it won’t happen if it’s easy. Tapping makes it easy, but there is no long term benefit. Further, it is confusing to the patient. "Wow, I did that!"- they may think. If you elicit one of your spinal reflexes, yes, it is your muscles doing the movement. But it is not voluntary movement. The only way to get that movement again is to elicit the reflex again.

The same is true with stretching to reduce contractures and/or spasticity. Does stretch have a short term effect? Sure. Might that effect have some clinical usefulness? Sure. Will the impact of a single stretching session or even long term program of stretching reduce spasticity? Again, there is neither supporting research nor long term efficacy.

And handling techniques like NDT? Instant gratification, yes because you can get a survivor who can’t move to move and move without “pathological movement patterns” because, basically, the clinician is moving the survivor. But there is a bit of skepticism among researchers. Here is the Wikipedia take on it.  Here's my take on NDT. 

My suggestion is for clinicians to ask, “What will be the effect after the next associated reaction (laughing, sneezing, getting up from a chair), later the same day, later in the week, 6 months later, and so on?”

And survivors should be asking the same question.

Saebo: Faster than ever!

"My son" loves the show "The Flash" and lo and behold, he (Mr. Flash) was wearing a Saeboflex in tonight's episode! 

The 2 minute survivor exam that tells you a ton

I've been involved in a lot of trials that have involved brain scanning. (example)

But I've never been a big fan of using brain scans to try to predict the deficit. In school we were taught to look at the artery that was blocked. The artery that was blocked leading to the brain or in the brain was supposed to give you some indication about what deficits were.

I would suggest this is where neurology and physiatry on one hand-- and neuroscience on the other-- kind of disagree. The neurologist and phsyiatrist say that this info (brain scan and/or artery blocked) helps determine the deficit, and even the chance of recovery.

But neuroscientists would suggest that, because the brain wiring is "random access" (that any part of the brain may be wired to any other part of the brain), looking at a brain scan maybe grossly predictive, but really tells you not much at all.

In all my seminars I suggest that the thing to do is to examine the patient in a very limited way.

Here's suggestions that will give you global insight into the potential for recovery:

1. Can they move their hand? First, let's define "hand movement." I would suggest that hand movement is any movement from the wrist to fingers, in any direction. The easiest movement for most survivors is closing (fist) the hand. The problem is that many strokes survivors think that they can't close their hand. If they think they can't, do this: 

• Bend (technically: Flex) the wrist. This will allow you to open the fingers. 
• Put the elbow in more than 90° of extension (more straight than a "shake hands" position) 
• With your fingers inside the palm ask the survivor to try to touch their chin. 
• This will force the flexor synergy into play, and if they are able, the fingers will flex and you'll feel the pressure on your fingers. Voilà: they have hand movement! From that you can determine potential for recovery of the hand. (Hint: there is potential).

2. Brush both forearms lightly with your fingertips. Ask the survivor if they feel the same, and if not, how they feel different. If they do feel different, this suggests that sensation has been hit. Try to get them to give you a percentage ("My bad arm feels about 25% of my my good arm feels"). There is a general association between tactile (brushing your fingertips) and proprioception (feeling where that limb is in space). And proprioception has huge implications for recovery.

3. Vision: Can they follow the tip of a pen with their head held straight in front of them all the way towards their affected side? If they tend not to follow things on the affected side, this suggests a hemi field cut and possibly "unilateral neglect" – an inability to attend to the affected side.

4. Speech: can they speak; do they understand what's being said?

5. Are they walking, how well, how fast are they walking?

There-- now you have global insight into that stroke survivor. Isn't that more important than knowing that an occlusion of the inferolateral arterial group infarcted the posterolateral thalamus?

The Wrong Question

"What is the single most important thing you should know about stroke rehab treatments?"

That's easy: You're asking the wrong question.

If you are talking about rehabilitation treatments you are talking clinical stuff. You are talking about a clinician-- usually a therapist-- in a clinical setting. And both clinician and clinic are great but they are not enough during two time periods:

1.  Every day

2. Once you're discharged from therapy.

Let's consider why clinical stuff "every day" is not enough. How much therapy might you get? An hour-- two-- three? Recovery is a full time job during the first few months after stroke and it is the first few months after stroke that you're still seeing therapists. So even when therapists are there, there almost always not there enough.

OK, now lets take "Once your discharged from therapy." Discharged from therapy is in and of itself the very definition of not enough therapy, because you've been discharged. Discharged like a bullet from a gun, off you go! So once you are discharged you are definitely not getting enough clinical stuff.

So maybe the question ("What is the single most important thing you should know about stroke rehab treatments?") is wrong. What if instead the question was "What is the single most important thing you should know about stroke recovery options?"

Isn't that freeing? You are no longer under the rules of managed care because managed care does not care if you try, on your own, to take on your recovery using whatever options you can find. You can spend as much time as you want. And even if recovery options are an adjunct to rehabilitation treatments, they expand the opportunities for recovery.

So, "What is the single most important thing you should know about stroke recovery options?"

Sweat equity. That's it. The more you put in, the more you make your brain uncomfortable and force it to change. The more repetitions, the more challenge, the more focus— the more recovery.

Oh dear blog, how I have neglected thee!

Oh dear blog, how I have neglected thee!

But I have a good excuse. In fact I have many. But let me just give you the two big hits:

1. As usual, I'm on the road a lot, doing talks on stroke recovery. If you a are a survivor, please note that my talks are available at a discounted rate. Jus' sayin'. Love to see you there. We'd probably use you as a guinea pig, so be forewarned.

2. At the beginning of last summer I was offered work as a consultant for a lab at Ohio State. It's a long story, but this lab is the latest iteration of the lab that I've worked for— or with— for the last 15 years.

And in all those 15 years, I've been involved in all kinds of cool stroke recovery studies. I've been involved in studies of constraint induced therapy. I've been involved in studies of mental practice (imagery), electrical stimulation machines, as well of the song whole host of other gizmos. I was lucky enough to also be involved in a transcranial magnetic stimulation (TMS) study. Boy! That was a cool study! Basically we were able to touch stroke survivor's brains, without having to go through the messy business of opening up part of the skull.

I could write much more than this blog entry can hold about TMS. But I'd like to tell you a little bit about the latest study I've been involved in. It's the coolest!

A pharmaceutical company run by neuroscientists, called Dart Neuroscience, thinks it may have come up with a pill to help stroke survivors recover.

This pill is thought to help the brain produce BDNF (brain derived neurotrophic factor). BDNF is called by some

neuroscientists "miracle grow for the brain." It is produced by the brain for the brain during times in which the brain needs to learn.
For instance, BDNF comes out right after birth. And you can imagine why – the infants brain is trying to figure out what that smell is, who that face belongs to, how to use their hand, and on and on. So the brain needs help, so it produces BDNF to make all that stuff easier to learn.BDNF is also produced by the brain after brain injury – including stroke.

This is one of the reasons that the stroke survivor's brains are said to be in in "infantile state" — because, like an infant's brain, the stroke survivors brain is awash in BDNF.

But if there was a pill that produced BDNF in survivors it would help in two ways:

1. Typically BDNF is only available in the brain for about a three month period after the stroke. If a pill would produce even more BDNF it would open a larger window of opportunity for recovery.

2. Some stroke survivors just don't produce BDNF— at all— after their stroke. This medication would help those people. A lot.

To get a study like this off the ground involves a pretty monumental effort by dozens of people. I am one of those people.

So, dear blog, I apologize! 

But I'm back!