Exercise helps recovery because it strengthens what?

Interesting video, below, by one of my favorite neuroscientists, Dale Corbett.  For the record: There is no one I know up doing a better job of translating what neuroscientists have to offer to stroke recovery. Have a watch. The insights really start at 1:40 in. I'll post my critique below the video.  

The overall message is important. Exercise is essential. It is unfortunate that the message is sort of convoluted in this video. They're talking first about TIA, and how if you have a TIA you should use exercise as a way to lessen the chance of a full-blown stroke. Then the discussion takes an obtuse tangent into how exercise is important to recovery, and then with no real explanation doubles back to talking about TIA again. Still, while maybe the messages should have been separated, both are important. 

1:50 Another person, besides Corbett, whose interviewed in this video is William Mcillroy, who like Corbett is a PhD. I quibble a bit with Mcillroy's statement that exercise can be started "...as short as two weeks after stroke." Charitably, this is highly debatable. Once a patient is medically stable, intensity should be increased to tolerance. There is no one-size-fits-all timeline for every survivor that is rigid enough to predict that someone can start exercise "as short as two weeks after stroke." In fact, it could be much shorter. For instance, in a survivor who is medically stable day 4, waiting another 10 days to start a progressively rigorous exercise program would allow learned nonuse to take hold. 

2:20 Both PhD's talk about how exercise is good for the brain. Corbett talks about how exercise helps cognition, and points out exercise also helps sensory motor recovery. I would remind anyone who is willing to listen: sensation and motor behavior are cognitive. We learn sensation and movement the same way we learn French, or trumpet, or algebra. That is, changes in motor and sensory behavior happen involve the same brain processes as any other kind of learning.

2:50 I'm not sure that there should be such an unequivocal endorsement of balance retraining using biofeedback. Certainly the research is not there yet. 

Having said all that, I think this is a really great video with some really essential points. Interviews can be misrepresented because the person being interviewed is not doing the editing. The points these guys were making may have been a ton more cogent in the original interviews. 

The best line is by Dr. Corbett: 

 "It's still early days and you know we're nowhere near to the level that I think we can get to. And if we can understand what the mechanisms are then we might be able to optimally better design exercise programs to improve stroke recovery." 

"Until then, anyone trying to sell you certainty is after your wallet," he didn't add.

Is walking right after stroke good?

I've been involved in stroke recovery research for a long time. And I do a lot of seminars on stroke recovery. A lot of clinicians that come to the seminars take this posture: Just tell me what the treatment options are and how to do them. This demand assumes that there are a lot of treatment options. It also assumes that those treatment options are "proven." And it assumes that things can be made simple and immediately clinically applicable.

Overall the posture suggests Dunning Kruger effect. The Dunning Kruger effect is simple and measurable:

1. The less you know about a subject, the more you estimate you know.
2. The more you know about a subject, the less you estimate you know.

The Dunning Kruger effect in action: You ask two people about galaxies; one is an astrophysicist, the other is a six-year-old. The astrophysicist says, "There so much more that we need to discover. We're not even sure how many there are." You ask a six-year-old and he says, "I know all about galaxies. There is a moon, and he goes up and down, and it squiggles, and then there's the Earth and the sun goes around and around and you can take a spaceship to it."

The Dunning Kruger effect in post stroke rehabilitation
 
We don't know much about what helps stroke survivors recover. There. I said it. That there is a lot of confusion about what helps stroke survivors recover does not sit well with rehabilitation clinicians. And one of the reasons it does not sit well is that there are a lot of folks that try to sell treatment options that are "proven." This mucks up the waters. Let's say you're a therapist looking for answers. Are you going to listen to the person who says "Well, we really don't know, we're not really sure, none of this is proven, but this is what we think..." or are you going to listen to the person who says, "I have this great thing that works and it's super fantastic and it works all the time." The folks who are real sure that their treatment option is the bees knees of stroke rehab are often out to sell something. Like a machine, or a "pay us to learn" technique. But those of us in the research game are more equivocal.

In other words, the thing that research does, which is discover things layer by layer in a slow plodding scientific process, is not very satisfying.

Let me give you an example. I got an e-mail recently from a therapist who had been to the seminar. This therapist asked a very specific question: "Is very early mobilization after stroke good or not?"

Mobilization means "Getting them up and walking." "Very early" is a designation that means within the first 24 hours of the first symptoms of stroke. Simple question, right? The answer should either be yes. Or it could be no.

Except it's neither. It's "We don't know." In the few studies that have been done on this subject (there are ongoing studies which might provide more clarity) the conclusion is, we don't know. On one hand, it is commonly believed that many problems early after stroke are caused by immobilization. Problems caused by lack of early movement/walking include infections (especially in the lungs) and blood clots breaking off and causing all kinds of vascular problems. Further, getting somebody up and walking after stroke, especially in animal experiments, seems to help promote brain plasticity.

The problem is that the brain is very vulnerable after stroke. And one of the things it's vulnerable to is decreased blood flow. And when somebody is in an upright position is decreased blood flow to the brain. 

A quick review of lit...

• The Cochrane review: At present there is insufficient evidence to support or refute the effects of routine very early mobilisation after stroke.
• An article looking at quality of life: Conclusions. Very early mobilization may help improve long-term quality of life after stroke, particularly in relation to functional independence, but this requires further examination.
• An article where they interviewed therapists, docs and nurses: Conclusion: Our study shows that most clinicians had concerns in relation to early mobilisation of stroke patients and more clinicians had concerns for haemorrhagic than for ischaemic 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 mobilisation after stroke.
• A Very Early Rehabilitation Trial for Stroke (AVERT): Conclusions: Very early mobilzation of patients within 24 hours of acute stroke appears safe and feasible.  
• The LEAPS trial (the largest study ever done on post-stroke rehab): "patients who received early locomotor training experienced more multiple falls."

There. Does that clear things up?

Bobath: The more you move, the worse you'll get

I've made my position on Bobath/NDT pretty clear (hint, I'm not a devotee). One of the many things Bobath was clearly wrong about was the effect of effort on spasticity. Bobath weirdly believed that using spastic muscles would increase spasticity. The way she put it in her book Adult Hemiplegia was, "Effort leads to an increase in spasticity." This is the way the thinking goes: Since movement poststroke requires effort, movement increases spasticity. Distilled, the philosophy was pretty clear: The more you move, the worse you'll get. Later in her book she doubled down on this concept. "The use of effort... will only reinforce the existing released tonic reflexes and, with it, increase spasticity."
 Wrong. Wrong. Wrong.  
(Here are the references...)

Note: CIT requires a lot of effort.

And it's more than just wrong, it obfuscates the issue for clinicians trying to find answers. I'm guessing, but at least 80% of all seminars for stroke recovery revolve around the Bobath/NDT. So clinicians learn it. And it wastes researcher's time, effort and funding. Because clinicians learn and believe it, researchers often have to go and "prove the negative." Researchers have successfully debunked the concept that effort increases spasticity. Because effort reestablishes cortical control over spastic muscles, spasticity is actually reduced. 

"This evidence is not compatible with the underlying assumptions of the Bobath approach." 
(From the 3rd article referenced, above) 

  ©Stronger After Stroke Blog 

How to walk when you can't (and walk better when you can).

Challenge. Challenge causes change in the body. For instance, challenge changes muscle. Once they are challenged (i.e. resistance training) muscles "micro tear." This tearing (after some days of aching muscles)  increases the thickness of muscles, which makes them stronger.

Challenge also changes the brain. 

Challenge is the way that you learn; you go to school, you're asked to do things that are hard to do, and your brain changes. Challenge is the stuff that learning is made of. Without going outside of the brain's "comfort zone" the brain will not change. You've probably heard the saying, "use it or lose it" when it comes to the brain. If you don't use a skill your ability to do that skill will get worse. And why does it get worse? Because the part of the brain that controls doing that skill gets smaller. So, maybe the saying should be "If you don't use it you'll lose it." The flipside would be: "Challenge it and gain it." The brain will only rewire the it is challenged enough to necessitate rewiring.

Challenge and walking.

Challenging walking after stroke only has one downfall: a potential downfall. (Info on reducing the risk of falls, here.) Falling strikes terror in survivors and clinicians alike. A fall by a survivor in their care can be a black mark on the clinician's career. If someone falls while under their care,  a cascade of emotional pain follows. There is a ton of paperwork and a formal review of what caused the fall. People have been known to lose their job. Not only that, a lawsuit can sometimes follow. 

For their part, managed care (insurance) hates falls because falls cost tons of $$$. The cost of fall related injuries was $23.6 billion in 2005.

Survivors are afraid of falls because hitting the ground is never fun. But when you're in a weakened state after stroke falls can be especially dangerous. Stroke survivors tend to fall towards the weak side. The weak side in stroke survivors is often more osteoporotic (weak bones) strong side. So survivor is more likely to fall towards the side of his weaker muscles, and on bones that are weaker.

So here's the question: How can you challenge walking after stroke, when walking is inherently dangerous?

For a long time the hope was partial weight supported walking (PWSW).

With PWSW the survivor is harnessed from above while they walk. So if they fell, they wouldn't fall (if you follow). The problem with PWSW is that it's laborious to set up (it often takes more than one therapist to administer) and the equipment is expensive. Plus, the research into PWSW was not very flattering. Or, as the NIH put it: "In the largest stroke rehabilitation study ever conducted in the United States, stroke patients who had PT at home improved (paraphrased) just as much as the people who got PWSW." It should be noted that some therapists believe that there was a flaw in the research into PWSW. Specifically, the amount of time on used in research is seen by clinicians as too much. In research PWSW was typically used for 20 to 30 minutes. In the clinic, therapists will often use it for as little as five minutes.

PWSW does have some advantages. Therapists will often use PWSW (where available) when patients are "pre-ambulatory." Pre-ambulatory is a fancy way of saying that these patients are right on the cusp of being able to walk. They just need a little bit of help. Therapists will often use it for people that are bariatric (obese) because these patients can be difficult to manage, especially if they are about to fall! 

Another option is aquatic treadmills. This allows the survivor to simulate land-based walking but with a reduction in bodyweight. Again, not very available, and very expensive.  

There are much less expensive options that fall into the PWSW category. Here is one example that allows for challenge, and eliminates the fear of falling (another form of PWSW).

There are also other things that can help "unweight" and  reduce fear of falling:
  
What if you're walking, but want to walk better?
If you are able to ambulate without these devices, the best way to add challenge is to add speed. There is a particular technique to get you there, and you can find my blog entry on this technique here.

PT/OT invented rehab - not.

A scene from 
Walking with Cavemen.

Rehab is not new. It goes back -- not hundreds of years but back to the earliest humans. We’ve been "rehabbing" for hundreds of thousands of years. And what we did to recover, all those thousands of years ago, may have been more effective than most of what's been developed since. 

Consider the stroke-rehab ideas coming from recent neuroscience (and to a lesser degree, OT, PT and Speech therapy). This recent work has more in common with "rehab" tens of thousands of years ago, than it does with the decades between 1920 and 2000. What has this recent research and our deep ancestral rehabbing have in common? Researchers now call it "intensity." But back then they called it something else: Survival 

There's a lot of folks, therapists mostly, who think that rehab started in 1918 or so. They'll tell you that PT was developed in response to polio and WW I. They'll tell you that, in the US anyway, its champion was Mary McMillian, the first PT, credited with starting the first legitimate PT training school in the US. Some of them may even know that Pehr Henrik Ling developed and codified the concept that exercise=health in the 1800s. Ling went further, developing a standardized way of promoting rehabilitation and recovery. 
 

But what of “Rehab=Survival=The Latest Research"?

Imagine a survivor trying to rehab 150,000 years ago. Let's call our stroke survivor “Magch” and his mate-pair “Youngh.” It seems as if we probably had language even then. This is the way the conversation probably went…

Youngh: “How many times do I have to tell you to stop leaning to your good side?”

Magch: (leaning towards his "bad" side): “Yes honey.”

Is that rehab? Yes! If Magch did that movement tens of thousands of times until it felt natural, today's neuroscientists would call him a genius.

Our ancestors knew a thing or two about rehab. Read about it here.

NSAIDs Increase Risk of Stroke

Do over the counter pain relievers cause stroke? Some do, some don't. Might some pain relievers also cause heart problems and other cardiovascular problems? Same deal: Some do, some don't.

Note: As a group these meds are called Nonsteroidal anti-inflammatory drugs or "NSAIDs" (pronounced: NAY-sads). (List of all NSAIDs here)

In 2011 rather large study of this issue was completed. This study was a meta-analysis. A meta-analysis is a study of all the available studies. Although this is not news (it did come out in 2011) it is important for folks with chronic pain. If for instance you have frequent headaches and you take certain painkillers for that headache pain it could increase your risk of stroke and heart problems. Ibuprofen, for instance, tripled the incidence of stroke. 

Keep in mind, this study was not done with people who have had stroke. The statistics may be different if you've already had a stroke.

And "dying from heart trouble was four times greater" when using some NSAIDs.  As Consumer Reports puts it: "...all (NSAIDs) except naproxen were associated with similar increased risks..."

Here's my suggestion: Ask your medical doctor about this research.