Does "X" aid recovery after stroke?

What works and what doesn't work to help recover after stroke? Research has revealed three broad categories:
1. It works
2. It doesn't work
3. We don't know yet

There is tons we don't know about stroke recovery. Stroke recovery is a million different puzzle pieces, with no picture on the front of the box to help out. But there are some resources to help answer some of the questions (at least)...

There is one website that answers, in layman's terms, what works and what doesn't work. Although the list is far from complete, it's a start. Thank you Canada!

 

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Stroke Recovery. Its About Time.

Stroke survivors are given such a short time to recover. For everyone "motor learning" takes repeated attempts in order to rewire the brain. How much more effort must motor learning take in folks who have billions of neurons killed by their stroke? The numbers get very large. I've heard "2000 for a single joint" and " 140,00" "and "10,000" and "Tens of thousands" and" millions." But guess what? Every stroke is different. So the numbers for you and how you are trying to move are different than her and what she is trying to move. I think I've come up with the perfect number for everyone. This is based on my dozens of peer-reviewed coauthored studies, and clinical research at both the Kessler Institute and the U of Cincinnati. But the number is algorithmic and gets very complicated. Ready? Here's the number...

"A lot."

It is commonly and scientifically accepted that that it takes at least 10 years to become an expert in any field. We ask stroke survivors to relearn difficult tasks such as walking within a few months to a few years of their stroke. And all this difficult motor learning is done against a backdrop in which portions of the brain that is usually used for walking is deceased. And then there's all the other variables like other health issues, depression, lack of energy, natural aging and on and on.

Anyone who has children and has gone through boxes and boxes of Band-Aids and knows that motor learning is a challenge. Skinned knees and elbows attest to this. It takes years for children to learn how to walk. How much time do we give stroke survivors whose primary neuronal circuitry for walking has been taken off-line —6 months? Stroke survivors are best served through a combination of personal empowerment and guidance from therapists. No matter how ugly, no matter how synergistic, no matter how submerged in spasticity, each volitional movement should be encouraged. People with acquired brain injury will only drive their own neuroplastic rewiring through repeated volitional attempts, that “nip at the edges” of their ability. Therapists have traditionally focused more on quality of movement and functional relevance than on a confluence of gained active range of motion. No matter how incremental, increased active range of motion in all pivots and planes provides a template for any and all future movements.

Video games+Tennis balls+ Anger=Recovery

A great article in the British newspaper The Telegraph. The article is by a stroke survivor who recovered well after an ischemic (block) stroke. He's hit on some very core ideas. Here are the most important points (comments in red are mine):

• "...nobody in the hospital was going to tell me how to get better ..."
• "I had to get out of hospital and cure myself."
• "...found that major strides had been made in America in treating stroke victims." (USA! USA! USA!)
• "Research there showed that damaged neural pathways could be re-routed" (Taub! Taub! Taub!)
• "The key was speed. After three or four weeks, the brain seemed to start a permanent shut-down on these pathways." Not true. But the guy is a "High Master" which I think is a principal. He can be forgiven.
• "I decided to bounce a tennis ball 2,000 times a day off the kitchen floor, missed catches not counting." Obsessive repetitive practice. I love it.
• "The first day it took four hours to reach the target." Ambitious repetitive practice.
• "...wrote out the alphabet, one line per letter, for two hours a day." Brilliant, I think the British say.
• "I vowed to (type) 10 pages a day, typing out my corrections on my latest book with one finger. The first 10 pages took three days." I love this guy.
• "I decided to recite the poems of Andrew Marvell for two hours a day..." Fighting aphasia by using something meaningful. This guy may have missed his calling: neuroscience.
• "I marched up and down the stripes on the lawn for two hours a day." Very Monty Python.
• To reestablish I coordination he used "a computer game flying a virtual F15 jet - or, in my case, crashing it thousands of times on the runway before finally landing it - after 40 hours' "flying" time." I think this is great. The idea of doing something fun to recover. When else in the middle of somebody's career are they allowed to play 40 hours of any game?
• "I came close to giving up the grind of rehab. But by choosing tasks like writing the alphabet or counting how many times I could walk down the lawn without crossing a stripe, I could monitor my own progress." Okay, two things: close to giving up. But not giving up. And second: being able to "monitor progress" is essential to recovery because if you don't monitor things closely how do you know if you are getting any better?
• "The difference between success and failure was...a deep anger that I was not offered more help to start with" You know, even Gandhi was not against anger. He just said you should use it wisely because it's very powerful. I'd say using anger to recover from stroke is using anger wisely. 
•  Gandhi on Anger  "I have learned through bitter experience the one supreme lesson to conserve my anger, and as heat conserved is transmuted into energy, even so our anger controlled can be transmuted into a power which can move the world." 

Bravo High Master of stroke recovery!

Find the article here.

Stroke Recovery. Are You Up for the Challenge?

Keeping it challenging...

Whatever is practiced, it must be challenging. In research, an 80-percent threshold is generally used. For instance, if a stroke survivor can successfully turn the pages in a magazine 80 percent of the time, the challenge can be increased by turning the pages of a newspaper. Since turning pages of newspaper requires increased excursion of the shoulder and elbow, the increased AROM will "trickle down" to easier tasks such as turning pages in books and magazines, card flipping and laundry folding.

What is usually done

Compensation (learning to "get by" with the "good" side). As "Dean's" puts it: Compensation being doing whatever is necessary to accomplish a goal. Recovery is using the muscles as intended to accomplish the same goal. Insurance wants you to use compensation whenever possible because it is faster and cheaper. 

Faster and cheaper

Faster and cheaper is good because its faster and cheaper. You could go to a State University. Or you could get a degree from a degree mill. You could make a a salad, but you could get the same amount of calories from a pop tart. But even as fast and cheap as they are, you'll still feel gypped.

AFO: You can check out anytime you like, but can you ever leave?

I often get questions about ankle foot orthoses (AFOs), and how to get out of them. I'm not a big fan of AFOs because they encourage a sort of "learned nonuse." It's actually more like "learned disuse." (Learned disuse: You're not learning to not use the body part, but you learning to use body part incorrectly.) And keep in mind, every movement you make changes the way your brain is wired. So it's very easy to get used to an AFO. Let's put it this way:

It's easy to walk into an AFO. It's hard to walk out.

In any case, I get a lot of e-mails about this subject. Here's an example:

 

I wear a big brace on my right leg. I am paralyzed on the right side. I walk with a one-point cane. I walk with an open hinge (articulating) AFO.

 

They opened the hinges on my old brace several years ago. I walk around my apartment with the old one. But when I go out I use the bigger brace which isn't open at hinges.

 

I read on Deans' Stroke Musings that you recommend the Air Cast. Which one for stroke survivor do you like? They have a lot of different ones on their website. 

Here's my answer:

First of all, the disclaimer:

(Warning: ENDING THE USE OF AN AFO CAN LEAD TO FALLS AND INJURIES.

Never discontinue the use of an orthotic without first consulting the appropriate health care provider. Then call your doctor. Then have your doc talk to any other providers as needed. Then discuss it some more. Thank you.)

Wear a brace on the ankle that satisfies two things:

1. Keeps you safe

2. Challenges* you

*Challenge: Walking naturally challenges you to lift your foot. If you can lift your foot up and down to stay safe (not trip) then you might consider questioning an orthotic that helps lift the foot. 

Gradation would usually be something like this:

1. Rigid AFO

2. Articulating AFO (where the ankle joint moves just a little bit)

3. A stirrup (stabilizes both sides the ankle but allows the ankle to move up and down freely)

4. A high top shoe (like a basketball shoe)

5. Nothing

There are a wide variety of other options between a rigid AFO and barefoot. Here are some. Some help bring the ankle up during gait, others support the ankle. The stirrup is usually associated with one particular company: AirCast.

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Know a good doc or therapist?

I get this all the time:

"How does one go about looking for a neurologist or physiatrist or therapist who is familiar with the practices outlined in your book?"

You'll notice a link on the right column. Or you can click here. Either way, if you live in the USA,  you'll find resources to help find aggressive healthcare providers for your recovery team.

Then  next questions is "Where do I find an OT or PT or speech therapist who knows?" You find a resource for that too.

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NEWS FLASH: There's No Way to Prepare For Life After Stroke

Surprise!

A recent study seems to sum up much of the whirlwind shock of life post stroke. I can't say it any better, so let me quote the authors:

There are 3 phases in the continuum from acute care to inpatient rehabilitation to home: 3 phases of this trajectory: 
1. the stroke crisis
2. expectations for recovery
3. the crisis of discharge
Stroke survivors and their caregivers faced enormous challenges as they moved through 3 phases of the trajectory. As caregivers move through the phases of the trajectory, they do not have a good understanding of the role to which they are committing. Survivors are often underprepared to take on even the basic tasks to meet the patients' needs on discharge

Conclusion: Stroke survivors and their caregivers do not have adequate time to deal with the shock and crisis of the stroke event, let alone the crisis of discharge and all of the new responsibilities with which they must deal.

STROKE CAREGIVERS HANDBOOK (free)

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Swallowing Trouble: Dysphagia

My son Jesse, swallowing.

Dysphagia:  difficulty swallowing.

Stroke is the leading cause of dysphagia.

Approximately 60% of stroke survivors develop dysphagia at some point after stroke. Dysphagia is the most frequent cause of pneumonia poststroke. It can also delay other parts of recovery. (It's hard to recover when you can't swallow.)

 The treatment for dysphagia may follow the same neuroplastic rules as every other form of post stroke recovery. For example, repetitive practice of wrist extension will change the brain to make wrist extension easier as time goes on. But repetitive practice of wrist extension has no downside. The worst thing that can happen is that you get tired. But if you repeatedly practice swallowing there may be a risk. What happens if you can't swallow whatever it is you're trying to swallow? You choke! You may aspirate. Aspiration involves having whatever you attempt to "swallow" go "down the wrong pipe". Instead of going down the esophagus to the stomach, the material goes down the trachea to the lungs. Once lodged and lungs it can cause pneumonia. Why does it cause pneumonia? Because the lungs hate having foreign matter inside. So the lungs try to fight the foreign matter. The lungs attempt to fight the foreign matter is the very definition of infection. An infection in the lungs is called pneumonia.

There is a tendency for clinicians to undertreat patients with dysphagia. These clinicians feared that there is a risk of aspirating.

So, if repetitive practice works, but repetitive practice of swallowing is dangerous, what can you do? If a particular skill is not used (in this case swallowing), the portion of the brain that controls that skill will shrink. As that portion of the brain shrinks, the skill gets even worse. As the skill gets worse, that portion shrinks further... and a downward spiral is initiated. If the dysphagia patient is not swallowing, or not swallowing enough, the portion of the brain dedicated to swallowing will get smaller, and the skill will suffer. 

The movements involved in swallowing have been traditionally viewed as reflexive in nature. But swallowing also follows the same basic "repetitive practice equals more movement" rule.  But what if the person can't yet swallow safely in order to practice swallowing?

There is emerging literature that electrical stimulation may initiate the neuroplastic process. Again, this is not only true for the hand and foot emerging research indicates that the same is true for swallowing. Electrical stimulation may provide the "X” factor that provides small amount of movement on which to build more robust movement. This same continuum of care (e-stim to repetitive practice) is used by clinicians in rehabilitation hospitals around the country to reestablish nominal movement. Although not functional swallowing, electrical stimulation provides early steps towards regaining the ability to swallow.

In terms of the repetitive practice itself, the generally accepted way of safely repeating swallowing is called the "The Frazier Water Protocol". 

For a bit more science-y perspective, click here.

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Bleed Vs. Block: Who Can Expect Better Recovery?

 

       Survivors who have a hemorrhagic (bleed) stroke average better recovery than survivors who have an ischemic (block) stroke. But bleed strokes usually have more disability to begin with. In other words, “bleeds”  start out lower but end up higher. The difference has to do with the different ways these types of stroke affect neurons:

“Block” stroke: neurons die because blood flow is blocked. No blood, no O_2.   No O_2, neurons die.
  

“Bleed” stroke: much of the damage comes from the compression on the brain by the buildup of blood in the skull. Once the compression is resolved there is less overall neuronal damage.

Bottom line: The effect of efforts towards recovery can be expected to be less for ischemic vs. hemorrhagic stroke. Rehab strategies that work well for bleed stroke will typically have less rehab potential for survivors with a block stroke.

This is one of my problems with books about survivors who've had a bleed stroke.  Some of the  books give the impression that they a) had more will, b) are smarter, c) have come up with a new and special technique. Again, on average, they start out lower but end up higher. So the recovery process is scary and arduous, but ultimately more fruitful. And it is more fruitful because there is less brain damage. 

Of course, the prime example of this fudging of the facts is Jill Bolte-Taylor's book My Stroke of Insight.  She had a bleed stroke on the left side of the brain.  Have a look at this video. Does anyone see any deficit in either the right arm/hand or in her speech?

Almost 90% of all stroke are blocks, not bleeds.

Want the science-y perspective?

"If 2 patients at the beginning of rehabilitation had the same basal neurological severity, same basal functional disability, same age, same sex, and same OAI, hemorrhagic patients showed better neurological and functional prognosis compared with ischemic ones."

And to be clear: Bleed strokes are terrible. You have a greater chance of dying from a bleed than a block. And recovery from any stroke is to be celebrated. 

But beware of inflated expectations suggestions by survivors of a bleed stroke. What they suggest may work for them but it is clear: their recovery will usually be higher given the same amount of effort.

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