"My son" loves the show "The Flash" and lo and behold, he (Mr. Flash) was wearing a Saeboflex in tonight's episode! 
Dec 14, 2015
10 Things That Work Against survivors.
2. Fault: MDs. Once in the hospital stroke is often misdiagnosed. For instance: I cannot tell you how many young survivors who have told me that, once they got to the hospital all anyone asked them about was their drug use. Over and over again. Sometime that's a germane; you want to know about potential meds interactions. But often the MD misdiagnosed the stroke as a potential affect of illegal drugs.
3. Fault: managed care. Survivors are often rushed from the hospital without the clinicians involved being able to take the time to figure out what the next best step is. How
4. Fault: managed care, clinicians. Survivors are often sent from hospital to sub optimal situation. And where survivors are sent next will impact not only recovery, but also is predictive of how much longer they'll live. Ref1 ... Ref2
5. Fault: managed care, clinician. Too much therapy too soon within rehabilitation hospitals can be dangerous to the recovering brain. Survivors are often discharged from hospitals to rehab hospitals. Rehab hospitals require a minimum of 3 hours a day of rehab. Because survivors are discharged soon after their stroke (see #4., above) they are forced to do "too much, too soon" and this can hurt the recovering brain.
6. Fault: managed care, clinicians. Survivors, especially within the first week of their stroke, are often not given enough opportunity and tools to get decent sleep. Decent
7. Fault: clinicians. Rehabilitation clinicians are sometimes very well trained in the best treatment for stroke recovery. But they are often not trained nearly enough. Clinicians treat many pathologies – and stroke is only one of them. Survivors would be best served by being sent to facilities designed and trained to be the best for stroke.
8. Fault: managed care, clinicians. Stroke survivors are often discharged from therapy once there is a perceived "plateau". But this plateau is often more an artifact of poor outcome measures than actual potential for progress.
9. Fault: clinicians. What survivors will do "with the rest of their life" after they are discharged from therapy is often left to happenstance. Clinicians would serve survivors well by working with the survivor immediately "from the first session" as to what the plan should be once their discharge.
10. Fault: stroke survivors. Survivors often do not work particularly hard after therapy ends. This is usually because the survivor doesn't believe that they can get any better. They don't believe that they can get any better for two reasons: a. Because they've "plateaued" the survivor does not believe they can get any better b. Clinicians often lead the survivor to believe that once they are discharged from therapy – partly because they plateaued and partly because they're no longer under the care of the therapist – they won't get any better. How to combat that here.
How Instant Gratification Can Hurt Recovery
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.
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.” 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.
Splinting After Stroke? Why?
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. The granddaddy of all metas, the Cochrane review, has looked at splinting after stroke. The review states,
“Nine studies with a total of 391 participants investigated the effects of splinting. The mean effect 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.
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.
Freeing and Removing an IOL
removing an IOL can be tricky. first you have to free the IOL from its capsular adhesions. then you have to get it out. here i will share a few tips on removing IOLs.
freeing the IOL from the capsule. The ease of IOL removal is mostly dependant on how long the IOL has been in the bag. IOLs which have been in the bag for a few weeks are very easy to free from the bag. IOLs that have been in the bag for years can be very hard to remove. Removing an IOL with an intact posterior capsule is far easier than when the patient has had a YAG capsulotomy.
the first step is to somehow get a visco dissection plane started between the IOL and the capsule. I like to use dispersive OVD especially when the posterior capsule is not intact. with IOLs that have been in place for a while i like to use a 27 gauge needle attached to viscoat and use the sharp end to get under the capsule and then inject the viscoat. then i will sometimes use the Duet micro forceps (as shown in the video) to lift the capsule to get a canula under for more viscodissection. I also like to use a flat hydrodissction cannula for visco dissection as the flat surface makes it easier to get between the capsule and the IOL. most of your attention should be directed to freeing up the haptics with viscodissection. If the posterior capsule is intact the viscoat will often track around the optic and free it from it posterior attachments. after the capsular adhesions are freed try to spin the IOL clockwise to allow the haptics to spin free. sometimes the haptics are just too stuck and must be cut to free separately or are even left in the bag.
removing the IOL can be done through a small incision (refolding or cutting) or by extending the incision to the size of the optic.
The high index of refraction acrylic IOLs (eg. MA60, SA 60) can be refolded within the eye either using the folding forceps or the henderson technique. The standard refolding technique uses a paracentesis across from the main wound (3.5 mm) to introduce a spatula to place under the optic while using an open IOL insertion forcep above the optic in the anterior chamber. while lifting with the spatula and coming down on top of the optic with the open insertion forceps the IOL can be folded inthe anterior capsule. once folded the optic is simply removed through a 3.5 mm or so wound please use lots of OVD during this process. refolding the IOL only works well with thin acrylic IOLs likem the SNWF, SA60, MA60 and in my hands is virtually impossible with thick acrylic IOLs like the AR40 and the slippery IOLs like the silcon three piece IOLs. see video of refolding.
The henderson (bonnie henderson boston ma) technique for folding soft IOLs such as the IQ single piece acrylic is very slick. dr henderson's technique is to simply pull on an externalized haptic (with 0.12 or similar toothed forcep) while pushing on the optic 180 degrees across from the wound (inside the eye) with a hook (eg. Kuglen) amazingly the IOL folds itself and pops out of the eye. see video.
There a few ways to cut an IOL to get the optic small enough to remove through a small incision. One classic technique is to only cut about 2/3 through the IOL and make what looks like a Pac Man and rotate the IOL out through the wound as shown in the video.
You can also cut the IOL completely in half or into thirds and bring out the pieces. i like to use the Osher mildly serrated cutter from Duckworth and Kent as shown in this video. you can usually keep the IOL from flopping around too much by holding the externalized haptic with this cutter. if you are in a bind you can even use Vanna scissors to cut the IOL.
i also think the Duet forceps and IOL cutters can be handy to cut IOLs and haptics. you can use the Duet forceps through a paracedntesis to stop the IOL from flopping about and hitting the cornea. both the cutter and the forceps can pass through a paracentesis. here the Duet system forcep is used to hold an IOL while cutting in the video.
freeing the IOL from the capsule. The ease of IOL removal is mostly dependant on how long the IOL has been in the bag. IOLs which have been in the bag for a few weeks are very easy to free from the bag. IOLs that have been in the bag for years can be very hard to remove. Removing an IOL with an intact posterior capsule is far easier than when the patient has had a YAG capsulotomy.
the first step is to somehow get a visco dissection plane started between the IOL and the capsule. I like to use dispersive OVD especially when the posterior capsule is not intact. with IOLs that have been in place for a while i like to use a 27 gauge needle attached to viscoat and use the sharp end to get under the capsule and then inject the viscoat. then i will sometimes use the Duet micro forceps (as shown in the video) to lift the capsule to get a canula under for more viscodissection. I also like to use a flat hydrodissction cannula for visco dissection as the flat surface makes it easier to get between the capsule and the IOL. most of your attention should be directed to freeing up the haptics with viscodissection. If the posterior capsule is intact the viscoat will often track around the optic and free it from it posterior attachments. after the capsular adhesions are freed try to spin the IOL clockwise to allow the haptics to spin free. sometimes the haptics are just too stuck and must be cut to free separately or are even left in the bag.
removing the IOL can be done through a small incision (refolding or cutting) or by extending the incision to the size of the optic.
The high index of refraction acrylic IOLs (eg. MA60, SA 60) can be refolded within the eye either using the folding forceps or the henderson technique. The standard refolding technique uses a paracentesis across from the main wound (3.5 mm) to introduce a spatula to place under the optic while using an open IOL insertion forcep above the optic in the anterior chamber. while lifting with the spatula and coming down on top of the optic with the open insertion forceps the IOL can be folded inthe anterior capsule. once folded the optic is simply removed through a 3.5 mm or so wound please use lots of OVD during this process. refolding the IOL only works well with thin acrylic IOLs likem the SNWF, SA60, MA60 and in my hands is virtually impossible with thick acrylic IOLs like the AR40 and the slippery IOLs like the silcon three piece IOLs. see video of refolding.
The henderson (bonnie henderson boston ma) technique for folding soft IOLs such as the IQ single piece acrylic is very slick. dr henderson's technique is to simply pull on an externalized haptic (with 0.12 or similar toothed forcep) while pushing on the optic 180 degrees across from the wound (inside the eye) with a hook (eg. Kuglen) amazingly the IOL folds itself and pops out of the eye. see video.
There a few ways to cut an IOL to get the optic small enough to remove through a small incision. One classic technique is to only cut about 2/3 through the IOL and make what looks like a Pac Man and rotate the IOL out through the wound as shown in the video.
You can also cut the IOL completely in half or into thirds and bring out the pieces. i like to use the Osher mildly serrated cutter from Duckworth and Kent as shown in this video. you can usually keep the IOL from flopping around too much by holding the externalized haptic with this cutter. if you are in a bind you can even use Vanna scissors to cut the IOL.
i also think the Duet forceps and IOL cutters can be handy to cut IOLs and haptics. you can use the Duet forceps through a paracedntesis to stop the IOL from flopping about and hitting the cornea. both the cutter and the forceps can pass through a paracentesis. here the Duet system forcep is used to hold an IOL while cutting in the video.