Emerging Stroke Recovery Treatments? Yeah NO.

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Just caught this over at Dean's stellar stroke-recovery site:

An article called "Emerging Treatments for Motor Rehabilitation After Stroke."  They include:
1. mirror therapy
2. motor imagery or mental practice
3. constraint-induced movement therapy
4. noninvasive brain stimulation 
5. selective serotonin reuptake inhibitor medications

A coupla itzy problems: These treatment options have been around for at least a decade and at least one has little proven efficacy.

Let's get the 5th one out of the way; these meds (SSRIs) are things like prozak and paxil and they usually treat depression. They've been used forever to treat depression in survivors. Do they help depression, yeah. Do they help you recover, no. SSRI's effectiveness-- if you take JAMA's word for it: meh. BTW, Mild to moderate depression is probably better treated with exercise. (A review here from Harvard.) And exercise is what survivors ought to be doing anyway, so its a two-fer! 

The 2nd and 3rd I've been involved in published clinical trials and have written about in my book, blog entries and magazine articles. In fact, our group, led by our fearless leader Stephen J. Page, was the first to do a modification of constraint induced therapy, and the first to look at motor imagery post stroke. And this goes back to the late 90s. "Emerging Treatments." Yeah. No. I've written about it extensively in every edition of my book as well as magazine articles, journal articles and every talk I've ever done.

Mirror therapy has been around for stroke, again, since the late 90s. I've written about it in this blog, in my book and in every talk.

Noninvasive brain stimulation is nonspecific but they're talking about Transcranial Magnetic Stimulation (TMS), which has been around for quite some time. Our group has done

a lot of work with the "next gen" of this called Navigated Transcranial Magnetic Stimulation -- basically its more accurate. But there is no research that shows that sapping the "stroked" brain with TMS does anything--yet. Promising, maybe, but not much there...yet.

So we have 3 "emerging" treatment option that have been around for more than a decade, one option that probs does not work and one that we're not sure what it does or how to use it. 

Poor taste public service announcement!

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Have a look at this cartoon. In poor taste, yes. But it manages to raise awareness and it does it in a way that is comically accurate. Here is your quiz: Watch the vid and then do this: Just below the cartoon, highlight the invisible text by right clicking and dragging to the bottom of the post. Therein lies my observation of what the cartoon gets right. If you'd like me to add anything I've missed, put it in the comments or email me.

Highlight text below↓↓↓↓↓↓↓↓↓↓↓↓↓
1. Drop foot 
2. Inability to clear ground during swing phase of gait 
3. Flaccid left upper 
4. Lack of sensation left upper 
5. Caregiver concern regarding driving 
6. Difficulty with spacial issues while driving 
7. Left hemiparesis, no aphasia! 
8. "Stroke! Stroke! Stroke!" Its a public service announcement! More of the episode here...

In the comments section Jim Sparks points to a part in the episode where a treatment that is not proven to work, works!

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Stroke = Dog Tired

As many as 70% of stroke survivors complain about fatigue. Many stroke survivors think that fatigue is the worst thing caused by their stroke. 

Stroke survivors should be four times as tired as everyone else, and I can prove it. Research shows that, when you compare survivors to age-matched “couch potatoes," the stroke survivors are in half as good cardiovascular health. Research also shows that most everything (i.e. walking, dressing, bathing etc.) takes twice as much energy after a stroke. Mathematically… 

(Twice as much energy needed) 
x (half as much energy available) 
= (I need a nap)

The best thing you can do is stay in good cardiovascular and muscular shape. This means resistance training and cardio work. It may be counter-intuitive, but exercise increases energy. Other things that will help increase energy levels include 

• Eating well 

• drinking plenty of water 

• sleeping well

"stroke recovery blog"  "stroke blog"  "stronger after stroke blog"

Walking in Rhythm

During stroke recovery "the good trains the bad." This is known as "bilateral training." In anyone, stroke or not, it is true "the good trains the bad." Here's an example: I'm a drummer. I'm right-hand dominant. If I try to tap my left hand as fast as I can it is not as fast as if I tap it alternately with the right dominant hand. Research has found that my left hand will not only be quicker, but it will be more accurate when I do the movement with my right hand. So I will be both faster and hit the drum where it should be hit.

In stroke survivors bilateral training can be used to begin the recovery process. And it can be used to help stroke survivors with very little movement. Survivors with very little movement are sometimes called "lower-level." (This designation says nothing about the ability to think, only the ability to move.) The reason bilateral training works for lower-level stroke survivors is because the way bilateral training may work. And I say may, because nobody's really sure. Bilateral training may work because the two limbs communicate with each other even when that communication does not go through the brain. It's the reason infants step even before they can walk.

Click here: See a baby walk before it can walk

It's why, in animal experiments, you can sever the spinal cord but the back legs will automatically go into walking pattern when they're put on a treadmill. It has to do with neural networks that are in the spinal cord. These networks are collectively called the central pattern generator (CPG). The CPG allows for limbs to communicate from the fingertips of one hand to the fingertips of the opposite hand (or "toe to toe"), right through the spinal cord.

In the arms and legs, bilateral training is relatively straightforward. In the arms you would have each arm trying to hit a target. You could have both hands attempting to alternate to hit a target. You could also have it set up so the "good "hand has to hit a target that much further away than the "bad" hand. You can also do this with a rhythm. The idea would be to use a metronome (click, click, click, rhythmically) or music where the drumbeat would dictate when each hand would have to meet the target.

In the lower extremity it similar: there is a rhythmic component. You would try to take exactly the same step length with the "good" and "bad" legs. A rhythmic component is added the same way as the arms: music, or a metronome is used to establish be in each footfall happens on each beat. It is thought that reestablishing the rhythmicity of gait will help reestablish the symmetry of gait.

As I said in a PT trade mag...

"A simple metronome either heard through headphones or carried by the therapist next to the stroke survivor can be used to promote the re-establishment of rhythmicity of gait. Plugging the ears using standard noise-reducing plugs can boost the volume of footfall to make that obvious to the survivor. The trick is then to match the footfall to the beat."

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What do doctors know?

Show me a neurologist or physiatrist who does not know that recovery can continue after a year and I'll show you someone who should lose their license.

In some ways doctors are forced by the Hippocratic Oath to lowball any estimate of recovery. If a doctor says you won't recover, and then you do, they can say “Great!” If a doctor says, "You can expect a great recovery” and you don't, they have done you harm.

In terms of having a doctor understand rehabilitation per se, it's probably not going to happen. The responsibility for rehabilitation is offloaded to therapists. The one exception to this may be physiatrists. However, although they may be very aware of various recovery options, they are not trained in rehabilitation techniques.

Of course, MDs can be a driving force towards recovery. Each clinician (MD, therapist) has a unique role to play. Some MDs are not very well versed in all things recovery. If you want to find aggressive MDs and therapists, click this link >>> 

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Reading to Recover

Ever want trip up a therapist? Ask this question: What's the latest stroke recovery research say? The answers will be, politely, inconsistent. Some therapists actually know a lot. Others haven't read their professional journals, ever. Look for facilities and therapists that are "evidence-based" (basing treatment on the best available scientific evidence). Being evidence-based is sort of like having a GPS.

Imagine you have two people; one person has an absolutely stellar sense of direction. They never seem to get lost. The other person has no sense direction at all. They get lost in their own neighborhood. Let's say the “neighborhood looser” buys a GPS. Now who has a better sense of direction?

Imagine you have two therapists; one therapist is very smart, intuitive, conscientious, and caring. Everyone says they are a great therapist. The other therapist is sloppy, snotty and disorganized. Let's say snotty therapist reads a lot of stroke recovery research and implements what he reads. Now who is the better therapist?


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Simple. Brain. Recovery. Game.

Stroke recovery involves neuroplasticity. You can slice it and you can dice it but the bottom line always comes back to stroke as brain injury -- and how to overcome it. If you can't get the brain to reorganize around the injury, recovery is toast.

• Spasticity: caused by brain damage.

• Inability to feel the movement: caused by brain damage.

• Unilateral neglect (decreased attention to the “bad” side): caused by brain damage.

• Lack of control over the affected arm and leg: caused by brain damage.

• Aphasia: caused by brain damage

• Vision problems: caused by brain damage

• And much more!: caused by brain damage

So the answer to the question “… how might movement problems be overcome?” is simple: Rewire your brain.

And it is good that it is simple because only the stroke survivor can do it. A therapist could have a double major physical and occupational therapist PhD from Harvard school of Super Duper Rehab summa cum laude with postdoctoral training as a Rhodes Scholar and they still can't do it for you. You know the old Smokey the Bear poster: "Only you can prevent forest fires"? For stroke survivors the poster should say: "Only you can drive neuroplastic change". Fortunately, the rules for rewiring your brain are very, very simple. Unfortunately, rewiring takes a tremendous amount of hard work.

And what does it take? Repetitive practice.

Repetitive practice is boring.
So try spicing up with a video game yay!

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When all you have is a hammer everything looks like a nail

I got an email from an author the other day. He’s written a book about stroke recovery. He said that he’d heard that I did “...not like presenting other peoples' work as helpful for stroke survivors." I explained to him my position this way:

I work in rehab research; have since the 90's. All of that research has been stroke-specific. One of the things I've learned is that clinicians had made the mistake over and over and over (for decades) of buying into completely ineffective treatment options. They did this for 2 reasons:

1. The treatment had/has a charismatic leader
2. Clinicians in rehab don't typically read research.

So even if large studies came out and say "Those things don't work" clinicians just kept/keep on doing (and promoting, and selling books about, and teaching) them. And then there are categories of "treatments" that have no research (standardized, controlled trials) at all supporting them. So in my talks (I do many) I start by saying "Most of what has been used for stroke recovery is ineffective or untested. Here's what we think we know…” And most clinitians get it. They're pros. They want better tools.

I actually promote (when appropriate) a bunch of people and ideas. But anything endorsed is evidenced based and what that means is very specific: Has the treatment option reached meta-analysis and did that meta-analysis show efficacy? If it has and it does I'm all in.

If not, I let people know.

What I find from survivors is that they want us to hash this stuff out. They want us to have these discussions and not just stick with the same old because it’s what we feel comfortable.

E-Stim. If dude can do it, so can you.

Electrical stimulation after stroke is the single most important modality there is for recovery. A modality is...application of something therapeutic like a hot pack or cold gel or...e-stim. Part of the reason e-stim is so important is that it does so many different things. 

Drunk smoking guys use e-stim for fun!

But here's some funny: Some OTs (occupational therapists) cannot do e-stim clinically. Why? It turns out that in some States OTs have to get a special post-secondary education certification to do it. Which was always weird to me. You know that ad where you can use the stim "ab-exerciser" that’s supposed to give you ripped abs while you lounge around because the e-stim builds muscle? And who’s ordering that? Some drunk guy at 2 in the morning. HE can do it, but OTs can't? Weird. 

E-stim does so much that its lack of use clinically for survivors has flummoxed me for years. The reasons given for not doing it clinically tend to be of the "Its too complex to set up" variety. "It’s too expensive." is another thing. Some e-stim machine are expensive. But even the cheap gizmos can do the job. Most of the reason it’s  not done is because no one wants to figure out the machine.

Jesse says: 
E-stim is not just for 
drunk folks and kids!

Enter my 10 year old son, Jesse. I have a lot of e-stim machines stored in my basement. I've accumulated them over time in various ways. And boys will be boys and boys (and their friends) will go into the basement and put electrodes all over themselves and turn up the stim and see what pops. And they figure the machine out. Because e-stim works like this: Put on the electrodes (they stick to your skin) and turn up the stim. And see what happens. And that’s it.

And yet many clinicians shy away from e-stim. They shy away from something that can do everything from help recovery of sensation, to stretching to building muscle to starting the neuroplastic process. So talk to 'em. And if they have any questions, tell 'em to email me.

Note: There are some serious contraindications to doing estim in some folks. i.e., they can mess up pacemakers and other electronic devices. So always ask your doc first!

The perfect time to have a stroke?

I'd argue that the "best" age to have a stroke is 27. The entire brain is fully wired (the frontal lobe wires in the 26th year). You're young enough to undertake the rigors of recovery (recovery is statistically better the younger you are). But you're old enough to have your brain wired "normally" (recovery in children is often a mixed bag because the brain is not yet fully developed).

But what is the best day to have a stroke? Any day but the weekend. Turns out the having a stroke on the w/e means lower quality care than during the week. 

Will and imagination

I do a ton of talks on stroke recovery. I come from the world of research. So my perspective is a bit different to the rehab clinicians I talk to. I do my best to ease them into the world of research. I explain where they can find leading edge stroke rehab info for themselves. I describe where we are in researching stroke recovery (not very far I’m afraid). I explain how the stuff from research can be used with their patients.

And there’s the rub. Therapists and other folks in rehab sometimes have a bit of difficulty imagining how to transfer the research to their practice.

"I'm in acute care (or skilled nursing, or an outpatient clinic, or in home care, or in long term care, etc.).  I can't implement this stuff. It takes too much time (or we don't have the equipment, or don't know how to bill for it, or nursing won't follow through, etc.). This stuff can't be used on my patients because they're not motivated enough (or have too many other medical problems, or are too "low level", or are too old, etc.)"

The core concepts of relearning how to move after stroke are simple. These concepts don’t have to be done clinically the way they’re done in research. In fact, they are often more effective in the clinic. They may be more effective because clinicians can change the treatment to fit individual survivors.  Research involves a one-size-fits-all implementation. Therapists can add and subtract, slow down and speed up, skip or add more treatments.  In research all those screw up consistency.

Some therapists have no problem with implementing this stuff. Some go well beyond what I suggest. For instance, they may dovetail suggested treatment options in a mix that is beyond anything researched. (Note to clinicians who do this: make sure you use valid and reliable outcome measures to prove to yourself that these things work.)

Whats the difference between those who can and those who can't?

Will and imagination.

A test that predicts when survivors may die

A test of mental ability after stroke can predict how long a survivor will live (Find the study here.)

Poor performance on these tests can predict mortality in stroke survivors, a full decade before death. Previous tests have shown a link between heart disease and dementia after stroke and mortality. This is the first to show small amounts of cognitive decline correlating to mortality.

Here are the tests that they used.

The longer it takes to do the tests the more "impaired psychomotor speed." Participants that were the slowest third of the group for both tests were more likely to die.

In this study, the mean result for TMT A was 47 seconds and for TMT B, 119 seconds.

Also a decline in mental function before a stroke can be an indicator of an impending stroke.

Good luck!

What else can I do?

There is an inaccuracy in a recent Amazon review of Stronger After Stroke that I must correct... 

BULL

Here is part of the review:

"I have not read the book, but one of the reasons my father in law suffered a stroke was because he's blood pressure was too high due to alcohol consumption. In this book it says it's ok to have 4 oz of alcohol a day so my father in law has started drinking again. So I'm hoping I didn't start up the drinking with him by giving him this book."

Actually, there is no mention of alcohol at all, any place in the book. But the author of the review hadn't read the book, so how would they know?

Here's a part of the story that may be interesting only to me: I contacted Amazon, asking them to consider taking the review down. Amazon will only take down a review "If it in violation of one of Amazon's posted guidelines." One of posted guidelines is: "Customer reviews should be relevant to the product in question." The reviewer is clearly reviewing hearsay, not a book. In any case, I was amazed that Amazon has declined to take the review down. I'm a huge fan of Amazon! I'm disappointed.

I'm not an advocate of drinking after stroke.

Thank you.S

Demanding Repetition

I do a lot of talks on stroke recovery. From Alaska to Florida, from New Hampshire to San Diego I'm all over the place all the time. I do these talks  for therapists; OT, PT, speech. Survivors and their caregivers show up as well. Also, medical device people, nurses, physiatrists, etc. So I get to talk to a lot of people about stroke. I always do the best I can to make things as simple as possible. Here is a really simple but profound way to look at stroke recovery...

Repetitive.
Demanding.

That's it. Repetitive practice of the movement or sound or walking or skill or whatever. Of course repetitive practice has the habit of doing two things: 1) causing people to repeat things that they can do pretty well, over and over. 2) Plateau. People plateau (don't get any better) because they keep doing what they can do pretty well over and over.

That's where demanding comes in. Repeatedly practice the skill in a way that "nips at the edges" of your current ability.

Repetitive without demanding and progress will slow to a crawl.
Demanding without enough repetition will halt progress."the stroke blog" "The stroke recovery blog"

Meaningful: Driving Stroke Recovery

When practicing to relearn movement effort should be task-specific. That is, tasks or component parts of a task should be practiced.  Choose tasks that are very meaningful. The more meaningful the task, the more motivation available. The more motivated, the more effort will be brought to bear. The more effort exerted, the more neuroplastic (brain rewiring) change will be driven. 

What motivates you? Fear? Friends not dropping by because you can't play cards anymore? Clients not trusting you because you've had a stroke? Recovery is not supposed to be comfortable. A dash of desperation is necessary.

A great sentiment but...

The question becomes, what to do next? An important question every time you ask it. Even if mistakes are made, even if the wrong choice is made, keep making decisions. Even if you are not absolutely OBSESSIONAL about recovery, forever dedicate a part of yourself to the question...  

What to do next? 

Whatever the answer, make it outside the comfort zone.* Or, to put it another way: 

"Intensity of practice after stroke: More is better."

*While remaining safe.

Fish oil may help recovery.

Note: With regard to any supplementation -- Ask your doctor first. Ask your doctor first. Ask your doctor first. Thank you.

Fish oil may help many aspects of recovery from stroke. In my book (now in the second edition, available for pre-order, just sayin') I put it this way:

 

 Fish oil may help stroke survivors in two ways:
 

1. DHA and EPA may help to reduce swelling in the brain after stroke.
2. Fish oil helps overall function of the nervous system and is considered “neuroprotective” (a substance that protects the nervous system).

Fish oil helps promote the neuroplastic process and appears to help the brain recover after stroke. Fish oil helps restore a neurotransmitter after traumatic brain injury. It may do the same after stroke.

Fish oil "treatment is able to facilitate functional recovery after (stroke)." It probably also reduces mortality after stroke.

Great general discussion of fish oil here. It turns out that cheap fish oil is just as good as the expensive stuff.

Remember, always ask your doctor first!

EXTRY! PT HELPS SURVIVORS RECOVER!

So here is a bit of good news: PT helps survivors recover. Which you woulda thought had already been proven, but here's some funny: Very little has been proven with rehab vis-à-vis stroke. And then there is the little problem of a pretty long tradition of clinicians in rehab deeply believing in therapies that, once examined in the light of well run research, looked very meh. And speaking of such...

This article reviewing the effectiveness of PT on stroke recovery is a gem (and not just because it references more than 10 articles on which I'm a co-author!). It doesn't just comment broadly on PT post-stroke, it nuances it. Some things work, some things don't. Guess what goes in the "doesn't work bin?" Guess. Here's a hint, this blog has said this for a long time... Like here. And here. Thats right...

NDT!

As the authors put it:

NDT has an unfavorable effect on length of stay, motor function (synergy), muscle strength of the arm, walking speed, spatiotemporal gait pattern functions like stride length, muscle tone, range of motion, balance, walking ability, arm-hand activities, and basic ADL. Insufficient evidence was found for NDT benefiting muscle strength of the leg, grip strength, muscle tone, brain activity, walking ability. 

But. The overall message of this article bodes well for PT and for survivors. Namely: There is strong evidence for PT interventions... in all phases poststroke.

An Open Letter to "Payers" Regarding Stroke recovery: You're Doing it Wrong

Dear Insurance Providers, 

I'm sure you want to help stroke survivors. A survivor that is home in the pursuit of happiness is healthier and cheaper. 

But there's a problem... The systems that insurance companies and Medicare ("payers") have developed is a hodgepodge based on a patchwork of incorrect assumptions and old science.

The following are some recommendations to better align insurance regulations with the aspirations of survivors.

1. Make immediate screening for TPA mandatory, even in the most rural hospitals.

2. Where a survivor goes for therapy matters. Unfortunately, the decision determining where the lion's share of recovery will take place is made within the first few days post-stroke— way too soon. Given the emerging healing in the brain acutely there is simply no way for any clinician to predict where that survivor is going to be, functionally, in a week, let alone a month – or several months out. 

There are some who believe that future movement can be predicted within the first week post stroke. However, those predictions are accurate only because they force a self-fulfilling prophecy. Based on the algorithmic prognosis, survivors are put in less than optimal rehabilitation settings. Thus, they do not reach the highest level of recovery  providing justification for the original in-hospital prediction.

Instead of forcing therapists to make this decision in the first few days, wait until day 14. By then the resolution of the penumbra will have revealed true future potential-- at least in ischemic strokes. Hemorrhagic strokes take even longer to predict.

3.  Clinicians are forced to discharge survivors once they have plateaued. However, given the massive potential brain plasticity, it is now known that plateau is a slowing, not an ending, of recovery. Given the potential for recovery into the chronic phase of stroke, complete disengagement from therapy is a mistake. I would strongly suggest maintenance visits with therapist, introduction to well-trained stroke specific exercises at local gyms and workout facilities, as well as distance (i.e. phone calls) with therapist.

Sincerely,

Peter G. Levine

Recovery is done in three phases.

Recovery from stroke is done in three phases.

ACUTE    SUBACUTE    CHRONIC

1. The acute phase (~day 1 to day 7 [note all time periods are highly variable]). This is usually done in the hospital. In terms of recovery your main responsibility is to keep yourself healthy. Therapists will typically focus on helping you do what you can do. This is a time for convalescence.

2. The subacute phase (~day 7 to 3 months). This is usually done with some help from therapists. You will experience the most recovery during this phase. This is the time that rehabilitation should "put the pedal to the metal." This is where the hard work begins. During the subacute phase the brain is "primed" to recover. Make the most of this phase because it is a window of opportunity to reach the highest level of recovery.Squander it and squander the highest level of potential recovery.

3. The chronic phase (~3 months to the end of life). Typically the survivor has very little contact with rehabilitation professionals during the chronic phase. This is the time to implement a "do-it-yourself" plan for recovery. Recovery comes at fits and starts and is much more difficult than during the subacute phase. Still, important gains can be made during this phase. Up to very recently it was thought that no recovery could be made during the chronic phase. We now know, however, because of the brain's amazing ability to rewire itself, essential progress can be made during the chronic phase.