Half out of it: What you can do about unilateral neglect

Unilateral neglect is a phenomenon where the survivor does not/ cannot attend to the "bad" (affected) side. Here is a visual explanation...

If a survivor with unilateral neglect is asked to bisect a line at the midpoint they'll do this: 

If a survivor with unilateral neglect is asked to cross out every instance of a given item they'll do this:

If a survivor with unilateral neglect is asked to fill in the numbers on a clock face they'll do this:

Here I'll discuss two options for, hopefully, decreasing unilateral neglect. And decreasing it is important: If the arm is not payed attention to, the survivor will not use it. And you know the brain... its very use it or lose it. 

The 2 options: Limb activation, and taping. These are not the only options. For more options go here and search for the word unilateral.

Limb activation. 
Typically, clinical studies of this treatment have used a "Limb Activation Device." 

These machines cue the survivor to pay attention by buzzing, making a sound, or lighting up. So, there's the problem: You need a machine. You could buy a watch that vibrates and set it for every minute or so. When it vibrates the survivor knows to do a movement with that arm. This is different from most treatments for unilateral neglect. Usually, the survivor is told to attend to the affected side (turn their head, and find their affected side). But that is the head finding the arm. With vibration, the arm reminds the head.

Or you could just touch the survivor's affected side at a set interval, and the survivor then moves that limb.

There is quite a bit of research that limb activation works.

Taping

This is one I got from a therapist at one of my seminars. Although its much less evidenced based, its much simpler, and worth a try.

The survivors neck is taped with Kinesio Tape (also known as KT Tape or TheraTape). 

You know the stuff, athletes wear colorful tape on their body and its supposed to reduce pain, or increase performance. Many of these claims are questionable.

In a survivor with unilateral neglect the tape would be used to provide a pull towards the affected side. The tape is stretchy, so if the survivor turns towards the "good" side, they would be reminded by the feeling of stretch to turn towards the "bad" side. This would be the approximate line of tape (and line of pull).

Clever, huh? 
Therapists are clever.

Boring stats

795,000 Americans have a stroke per year and unilateral neglect occurs in approximately 30% of individuals who experience a CVA. Left unilateral neglect is more prevalent, affecting 40-50% of left hemis.

Defined as a failure to report, respond, or orient to sensory stimuli presented to the side contralateral to the stroke lesion. Unilateral neglect (UN) is found in about 23% of stroke patients. • More common in patients with Right sided lesions (42%) than Left sided lesions (8%) and is more persistent with Right sided strokes. • Recovery of UN common; most recovery occurs in 1st 6 months and later recovery is less common. • UN associated with negative prognosis for functional outcome, poorer mobility, longer LOS in rehab, and slower rates of improvement; tend to be more functionally disabled at discharge.

This looks cool...

This blog gets a lot of attention from folks trying to sell stuff. Machines, products, services. I'm pretty selective about advocating anything where the balance between the manufacturer, book author, video producer, etc.— and the best interest of stroke survivors— does not exist. I got an email from the stroke survivor producing this video. It looks cool, and is deserving of support. 

Have a click, have a look!

Do Bleed Strokes Have a Penumbra? Nope.

 

I explain the penumbra after stroke fully here (with pictures!) and explain how important it is after stroke. 

But a question kept coming up in my clinical talks: Do hemorrhagic strokes have a penumbra?

Just some quick background:

After a block (ischemic) stroke, there is an area that the stroke kills (infarct) ("Stroked" in the image below). 

Then there's another LARGE area that, hopefully, comes back on line: The penumbra.

But what about a bleed stroke:? There is no penumbra in bleed (hemorrhagic) stroke.

There was a long debate about this, but as more experimentation was done, and as brain scanning has gotten better: Bleed stroke: No penumbra.

If you'd like a more science-y take:

The first thing to make clear is that hemorrhagic stroke is different to ischaemic stroke. In ischaemic stroke, all the fuss... is about perfusing and salvaging the penumbra of ischaemic brain tissue, surrounding the dead central tissue. This penumbra doesn’t exist around hemorrhagic tissue.

Or even nerdier!:

The most important finding of these studies is that different from ischemic strokes from proximal or distal middle cerebral artery occlusion a penumbra following the territory of arterial branches does usually not exist after intracerebral hemorrhage.

A Problem with the F.A.S.T test? Yes and no.

The FAST test (Face, Arm, Speech, Time) is used to tell if somebody is having a stroke. 

The problem is, it doesn't pick ~15% of strokes. Worldwide, that is ~2 million stroke not captured. 

The article referenced above, written in 2014, essentially adopted recommendations published in Stronger After Stroke in 2009. Here it is in a nutshell...

One thing they added, I kinda disagree with. "Leg" which involved a walking test. Which, you know, getting someone having a stroke to get up and walk may not be prudent?

Overall, it helps if everyone knows the symptoms of stroke.

In 90% of all people having a stroke, medical attention was sought by a bystander! Yay bystanders! Maybe we should call them bydoers!

Just over a third of all stroke survivors will have a another stroke within 10 years of their first stroke – a one in three chance.

Every stroke survivor knows that if they're having a stroke time is brain. The quicker you can get to the emergency room, the more options the doctors have. More options = more brain saved.

But how do you know if you're having another stroke? What if the symptoms are different than the last stroke? What if last time you had numbness and weakness in your left arm, and this time you have a blinding headache? Will you know? Will caregivers know?

The common wisdom is to use the FAST test. 

But there's a problem with the fast test. 3/4 of all "block" (ischemic) strokes have sudden weakness or numbness on one side of the body. But that same symptom drops to less than half in "bleed" (hemorrhagic) strokes. On the other hand, headache happens in 40% of bleed strokes, but less than 20% of block strokes. 

Don't get me wrong, the FAST test has been useful and effective. For instance in the UK, after the FAST TV campaign was rolled out, the time to hospital was reduced. The time from the stroke (the first symptom) to the hospital dropped by 66 minutes. That's amazing. 

Adolf "Woody" Hitler: If I had a stroke in 1937
it woulda been a good thing schlieben!

Had a stroke? Have daughters? You're in luck!

If you've had a stroke, and have daughters, you are more likely to go home than to an institution. (article here)

In fact, the more daughters you have, the more likely you are to go home!

As Sarah Silverman says: Sorry, its a boy!

You're welcome.

   (3rd ed.,      2nd ed.,     Malaysian,    1st ed.,   Japanese,  Korean.)

Since the 2nd edition (2012) of Stronger After Stroke, I've been advocating basing survivor's recovery plan on the phase of recovery they're in. So, you might do "Recovery option Y" with someone who is 2 months after the stroke. 

But if you did the same with someone 3 days after the stroke, you could make the infarct (brain killed by the stroke) worse. 

2 months, good; 3 days, bad.

There was only one problem: Nobody had defined the timing of the phases. I was able to do so after considerable research of textbooks, articles, and expert opinion. So far as I know, my book is the first and only resource that actually specifically delineates post-stroke phases. (The book outlines two ways; a "one size fits all timeline", and a more nuanced perspective based on the fact that survivors are never on the same timeline.) The best place to learn about the post-stroke phases is the book. But you can get a thumbnail here.

Its nice to know clinical research has caught up (where y'all been?). This article (2016)(It references an article on which I'm a coauthor jus' sayin') puts it this way: Rehabilitation interventions targeting at improving a stroke patients' performance should be implemented according to the phase of neurological recovery.

Even the word phases instead of the classic stages is telling, because that is the exact term Stronger used since the 1st edition-- 2008 (although I had not yet defined the phases). 

Stronger has changed the conversation, not only among survivors and caregivers (although motivated survivors were the first adopters). More recently researchers, and scientific organizations, have come aboard. This is the way I put it in the 3rd edition:

There has been another phenomenon surrounding this book as well: plagiarism. Either word for word plagiarism, or as a sort of reverse engineering of the whole sections of the book. Even the title has been ripped off. Since the first edition the Journal of the American Academy of Neurology, University of Tennessee Medical Center, and Emerson Hospital, and many others have all called articles in print or on line “Stronger After Stroke.” 

The fact that this book has a big footprint is a good thing because I have only one hope for this book. 

I hope it helps.

Recovery shouldn't cost an arm and a leg.

I'm pretty scandalized by some of the stuff on the market that claims to help survivors. I'll not name names, but I will say, stuff that costs a lot can usually be done cheaper. And cheaper is good (hasn't the stroke cost you enough??). 

When you're about to buy something expensive, ask yourself this: Can I do basically the same thing without all the flashing lights, cool colors, and fetching website? You can do it cheaper, almost always. And by almost always, I mean always.

(Warning: self promotion!)

I have something on the market. Its cheap (sorry: inexpensive) and it'll do the same basic stuff that the expensive stuff will do. 

Reduce Risk of Stroke: Vitamins and Coffee!

Two interesting studies:

1.  Stroke is an indicator of damage to blood vessels. Vit D3 may reverse that damage.

2. More coffee drinking probably reduces risk of  stroke.

Stroke is a hellish cat...

Stroke is a hellish cat gnawing its way through different disparate parts of the brain. Let's see how!!

The average stroke kills less than 3% of the total number of neurons in the brain. And that is way worse than it sounds. That small area of infarct insidiously exports itself to all reaches of the brain.

The first part of this process happens in two areas: The "stroked area" (the area killed by the stroke), and the penumbra (the area that surrounds the stroked area" that is still alive immediately after the stroke). The longer it takes to remove the clot, the more brain is "dragged into" the stroked area". 

Once the clot is removed, you're left with a stable stroked area" and a stable penumbra. The MDs (hopefully) have done a great job making sure as much brain as possible is saved. 

But in rehab, this is where the wheels tend to fall off. Rehab tends to focus on function. This too often means that therapists work on the "good" side so the survivor can "be functional" (able to live their life—whatever that means). This focus on function means the part of the brain the doctors saved is never used. Rehab is expensive, and insurance companies want to save money, so they'll get you out of the rehab hospital ASAP. How much is spent on rehab in a typical stay after a brain injury? "...almost $1600 per day and about $46,000 each (patient)" So how are survivors rushed out of the hospital? Focus on all the tricks and compensations and orthotics needed to get you back "home," wherever that will be (i.e. home, skilled nursing, nursing home, or long term care.) The focus is less on recovery (getting back what you lost) and more on "function" (getting out the door). So while the MDs may have done a good job of saving your brain, no one uses the part of it that remains alive. It takes too long to recover. This sets the survivor up for "learned nonuse."

The recovery of the brain is slow. And how that recovery reveals itself is subtle (through what clinicians may call "non-functional" movement). As the survivor is rushed through the process of rehab, the area surrounding the stroke is not used (learned nonuse). And it is usually not used for the rest of the person's life. 

So– now we have a dead area, surrounded by a much larger area that lies fallow. 

But the insidious nature is of stroke is not yet fully realized.

Many different areas of the brain outside of the dead zone and the penumbra are dragged into the mayhem. A process known as diaschisis takes over, exporting damage throughout the brain. Why does this happen? The entire brain is interconnected, and when one system goes down (the part of the brain killed by the stroke, as well as the penumbra) all the other areas connected to that those areas also become either less functional or non-functional. Look at it this way: The classic neuroscience way of putting the way the brain operates is this: "neurons that fire together wire together." That means one part of the brain, if it communicates with a completely different part of the brain, they'll both grow. If an area of the brain is not used (as in stroke) other connected areas will become less activated. Those areas (and they can be on completely opposite sides of the brain) shrink. But diaschisis is not the end of the story. 

The rambling and insidious nature of stroke marches on…

The next issue has to do with the strokes affect on survivors' life. After their stroke, survivors will typically become less socially engaged, less employable, less mobile, etc. The bad news is that the brain is designed to be socially engaged, productive, and to explore new things. The upshot of a less engaged brain is this: The entire brain goes through a literal "pruning." In fact, neuroscientists call this process a "pruning of the dendritic arbor." Throughout the brain neurons no longer used for the daily skills they once were, disengage from each other. In a sort of bad neuroplasticity, the brain becomes less capable. But, you guessed it, we're not done yet…

The final, and one of the worst and most insidious effects of the stroke is this: Through a series of direct communication and chemical reactions, the "reptilian brain" is dragged into the evil march of stroke. Areas like the hippocampus and limbic system – areas that are responsible for emotions, and mood regulation, are also wracked by the stroke.

It is heartening, and it certainly is a point of view that I have promoted over the years, that the average stroke is really small. And the stroke sits in a highly redundant, and highly changeable (plastic) environment. All of that seems like good news. You have a small area of death, surrounded by a large family of neurons willing to take over for those that are killed by the stroke.

But the more I learn about stroke the more I understand that the stroke is not just the stroke. Echoes of that small area reverberate. The ripple effect of that small area wraps its tentacles around—and through—the entire brain. 

DIY Mirror Therapy Box

Final mirror box

Mirror therapy is great. Even if the survivor cannot move the "bad-side" limb at all, using a mirror will fool the brain into thinking the "bad" limb into think it is moving. And because the brain is fooled, the brain changes.

Click here for a quick start guide to mirror therapy.

How do you do mirror therapy? Click here to find out!

How do you make a mirror box cheaply and easily? Here are instructions...

What you need to buy
(click here)

What you need to make
(click here)

Heaven on Wheels...

Tissue Plasminogen Activator (tPA) is a clot-busting drug. It can radically reduce the physical problems after stroke. tPA has been used for years, but not enough. There are 2 things that get in the way of tPA being used more:

1.There is reluctance among some MDs to administer it; they think they may get sued for causing a worse stroke (Note tPA is only for "block" ischemic stroke, but would make a "bleed" hemorrhagic stroke worse).

2. Survivors often miss the "window" of time tPA is thought to be effective (~3-4 hours). Only about one third of all survivors call 911 after their stroke. That is, very few survivors access emergency care that would be required to administer tPA.

The first issue, above, is discussed here. Irony: MDs are more likely to get sued if they don't administer tPA!

The second issue, this may change. There is new technology and it’s on wheels! Have a look at this vid.

More videos here.

How much does it cost to have a stroke?

The cost of having a stroke is variable. For instance, in the United States, stroke can easily bankrupt you-- or not, depending on your insurance, your wealth, and the combination of both. In Europe it is much less of a burden. Or, lets say, the burden is more shared. But it does not matter where you are, almost always there are extra expenses along with less income.

But the data is scarce. You'd think the amount having a stroke might cost someone would be well studied. It is not. At least not lately (most studies were done in the 90s). There is a lot of research on the macro issue; how much of a burden it is on a country or a national health care system. But not much on the individual's burden. The best estimate is this: 

The long-term costs of stroke The lifetime cost of a first stroke occurring in 1990 (not including lost wages) was estimated to be $228,030 ($462,126 today, adjusted for inflation) for an ischemic (block) stroke. There is one more recent study that suggests the amount is $140,048 ($283,821.68 today). In Germany the cost estimate is 43,129 EUR.

But both of these estimates seem low. 

Finally, there is no way to estimate the cost. How do you estimate what might have been?

If you are struggling with the issue of expenses after stroke-- at least here in the US, there is a resource that may help.

It is the FINANCES AFTER STROKE GUIDE.

Motor Relearning After Stroke: Hardwiring Recovery

Motor learning is what everyone does to learn any new movement. Motor relearning is what stroke survivors do to recover any lost movement. In some ways learning movement and relearning movement after stroke are the same; they both rely on the neurons in the brain to control movement. In some ways learning and relearning a movement are inherently different because a new and different part of the brain is used to control the movement. And there is a more obvious and less science-heavy difference: Learning a movement is fun. Relearning a movement is fraught with frustration.

Motor Learning And Motor Relearning: The Differences.

For stroke survivors, the part of the brain that was used their entire lives to control particular movements is dead. The dead portion of the brain becomes a fluid-filled cavity (called an infarct). Some of the neurons used in the pre-stroke movement may be reengaged. But those neurons will have to create novel relationships with other neurons to recover the pre-stroke movement. There is no potential to relearn a movement in the same way it was originally learned.

Motor relearning after stroke has another distinction from motor learning. Most motor learning that we do is derived from play. The joy of learning a new skill propels us the development of that skill. Consider skiing. You start out and you fall (and fall and fall) and you get very wet and very cold. And then you do something right and that feeling of making the turn and carving the snow becomes the carrot at the end of the motor learning stick. But stroke survivors are not learning new skills; they’re simply relearning movements that they used to do perfectly well as they attempt to cajole new neurons to do old tricks. Where’s the fun in that?

The fact that motor relearning is not necessarily fun provides a supreme challenge to the coaching abilities and motivational skills of therapists as they shepherd stroke survivors, not towards the joy of playful motor learning, but towards the monumental task of motor relearning.

Motor Learning And Motor Relearning: The similarities.

In some ways relearning to move after stroke and “regular” motor learning are similar. Both require neuroplastic rewiring of the motor and sensory portions of the brain. Both types of learning require the learner to do the hard work (or play) of learning. No therapist, no matter how talented, can learn it for them. This is where the coaching skills of clinicians are tested. Motor relearning only happens if the stroke survivor remains motivated to move. And stroke survivors will only remain motivated if they know why they're doing what they're doing. The neuroscience is clear: only through the volitional movement of the stroke survivor does neuroplastic brain rewiring take place. Providing stroke survivors with a nervous system “user’s manual” complete with “instructions” and even “troubleshooting tips” is vital to the process of recovery. And just like any good manual, the simpler the better.

Motor learning simplified

Therapists usually think about the nervous system in terms of upper motor neuron vs. lower motor neuron, brain vs. spinal cord or central nervous system vs. peripheral nervous system. There is another way to view the part of the nervous system that impacts motor learning: front vs. back.

Consider the following thought experiment. You decide you will scratch your head, but you don’t want to mess up your hair, so you need a single nail to fall on the exact epicenter of itchiness. You begin by estimating where your arm and hand is in space (proprioception). Messages from the muscle spindles, Golgi tendon organs and other proprioceptors provide the feeling of the position of the hand and arm. That feeling becomes a sensory impulse that enters the back (dorsal root) of the spinal cord. The impulse travels up the spinal cord and ends up in the back of the brain, in the sensory portion of the cortex, just behind the central sulcus, a large fissure that separates the front of the brain from the back. The impulse, with “fine-tuning” by other parts of the brain, jumps to the anterior portion of brain and provides a movement strategy. These instructions descend the spinal cord and exit the front of the spinal cord. The impulse then goes into peripheral nerves which terminate at the target muscles that power the movement. To review:

The impulse goes from the proprioceptors in the limb 
toàthe back of the spinal cord 
toà the back of the brain 
toà the front of the brain 
andà out the front of the spinal cord.

Back to front. You scratch your head. But let’s say you miss your target and your nails land in the wrong place. You use this feedback to self-correct and you again send an impulse from the back to the front of your nervous system. Your nails target the exact point of itchiness. The adjustment that you’ve made is the essence of motor learning. In this thought experiment each attempt was felt and each feeling was used to mitigate the next attempt.

          Now let's continue the thought experiment with a more complicated movement. Consider typing. Typing involves precise and delicate movements of the fingers. Learning how to type involves feeling the position of the fingers (proprioceptive input) followed by repeated attempts to hit the correct keys on the keyboard (motor output). Each time the pinky finger makes a foray towards the “enter” key the feeling of a correct attempt is processed by the brain. If enough repeated attempts are successful, the movement is learned. If the learned movement is done over weeks or months or years, it is seared as a neuronal pathway into the brain. This is why we never forget how to ride a bike or swim even if we haven't done either in years. The motor strategies are “hardwired”. Hardwiring useful patterns of movement in stroke survivors is motor relearning.

Shocking Subluxation

Electrical stimulation for subluxation. There's a lot of info out there, and its confusing. That's where I come in!

Here ya go...

From Stronger After Stroke:

There has been some debate about where electrodes should be placed for NMES and subluxation. Traditionally, the placement has been the deltoid and supraspinatus. However, it has been pointed out that the placement over the supraspinatus is problematic because the supraspinatus is covered by the upper trapezius. It is thus unlikely that the supraspinatus can be activated by surface stimulation. A better choice is the deltoid and the infraspinatus and teres minor.

So...