Don't worry, therapists...

I was doing a series of talks- on stroke recovery, natch- in Georgia last week. Someone brought up a concern about my talk that I also heard last time I did a series of talks. Here's a paraphrasing of that concern:

"You're saying that a lot of what we do in the clinic is shown to be ineffective in research. Payers (insurance/Medicare/Medicaid) are going to hear about this and then... I'm afraid we're going to get paid less and have fewer treatment options."

And I laughed. On the inside because out loud would have been rude. But: How silly! To think that insurance companies are listening to researchers about what is and is not effective! Insurance cares about shareholders and Medi"care" cares about keeping costs as low as possible. One thing they care little about: the science.

Therapists, fret not. Things that research indicates are ineffective are still paid for. Consider splinting. These are the rigid pieces of plastic that keep a joint in a certain position.  They are believed to reduce muscle shortening in patients that posture in a flexed potion.

So people like this:

Get one of these...

Governmental clinical guidelines suggest splints don't work, and may make things worse. Its usually stated like this....

For stroke survivors at risk of or who have developed contractures and are undergoing comprehensive rehabilitation, the routine use of splints or prolonged positioning of muscles in a lengthened position is NOT recommended.

Is splinting paid for. Let's put it this way.

So relax therapists. Don't worry, they're not listening to researchers!

And not only will they pay for stuff that does not seem to work, they won't pay for stuff that does work yay!

Take constraint induced therapy (CIT). We've known for a while that is particularly effective for some stroke survivors. In fact, CIT shows up on every set of clinical guidelines in the English speaking world. Here for example, are the clinical guidelines for OT in Australia. Open it, and search (Ctrl+F) for the word "constraint."

Is CIT paid for? No. There is not even a "code" for it (a code is the numbers used to bill for a particular treatment). 

"stroke recovery expert"

Use your hand. Now.

Even if you can't open your “bad” hand, you should use it. 

You can release your hand by using the “good” hand to bend the “bad” wrist. This maneuver typically opens the fingers. Once the fingers are open you can use the hand to stabilize, grasp, and even exercise. Grasping objects is, generally speaking, good for the hemiparetic hand. Squeezing objects, as well, is good for the hemiparetic hand.

One way you can quickly get the hand back in the game is using gripping aids. One company that makes a gripping aid that is very easy to use is Active Hands. (Full disclosure, Active Hands a sponsor of this blog).

Using a gripping aid has two immediate benefits after stroke:

1. The “bad” hand can be used to augment your available grip to make gripping safer. The gripping aids would be just that; and aid. As much as you can, use the grasp you have to hold items. But the gripping aid can support your active grasp adding safety and functionality to the grasp.
2. The hand, now “in the game” with the gripping aid, will now use the rest of the arm (shoulder, elbow, forearm rotation). In this way, the rest of the arm is used, which is good for recovery of the rest of the arm. The primary reason for the existence of the arm is to get the hand to where it needs to be, so a (a-HEM!) active hand leads to an active arm. And an active arm is one that is likely to recover.
   

Socializing, Play and Moving Helps Drive Recovery

Part of your recovery may depend on how much fun your having while you recover.

Enriched environments (EE) are what we all want. It's why we send our kids to good schools, why we seek out new experiences and why we travel.  It turns out that enriched environments are very good for the brain. One of the main enrichments of environment that humans have is social interaction.

What do enriched environments have to do with stroke recovery? A ton.

What hurts social interaction? A stroke.

It turns out that there's pretty good evidence that stroke survivors engaged in enriched environments recover more. More than what,you may ask. Survivors involved in environments rich in social interaction, physical activity, and interesting experiences recover more than survivors who are not in enriched environment.

There is one caveat… Most of this research has been done on animals. The reason was done in animals is that it would be impossible to do the same sort of research and humans. Imagine a human study like this would go…

You would have to groups:

The control group: survivors would be involved in a highly social environment in which there were a lot of games played, a lot of conversations and a lot of physical activity.

The experimental group: survivors would be put in a cell where they were fed well, but did not engage any other humans in anyway.

A study like that on humans would be considered… What's the word? Unethical. That's the word: Unethical.

How do you find rats that have had a stroke? You give them one. Researchers surgically cause a stroke in the rats. (video here) 

They then separated the rats into an experimental 

and control group. 

(Note: the idea of enriching environments is beginning to be tested in human survivors. It is made ethical by letting one group do what they normally would do while the experimental group got an increase in physical, cognitive, and social activity.)

What does the research show about the effect of enriched environments on stroke recovery? The rat stroke survivors in the enriched environments had better proprioception (sense of movement) than the rats that were left to themselves. 

Also...

• EE plays an important role in the recovery of damaged neural function
• Housing rats in an enriched environment can enhance functional outcome after focal brain ischemia
• Significant improvements in sensorimotor function

Recovery depends on neuroplasticity? Yeah...not entirely.

There's this idea among many clinicians and survivors that when it comes to recovery it's all about neuroplasticity. Certainly, my book as well as many of my articles support this concept. But it's not 100% true. Some of recovery comes from stuff other than neuroplasticity.

To explain this, let's nail down two things:
1. What neuroplasticity is
2. When neuroplasticity is important

What is neuroplasticity?
Neuroplasticity – the simplest definition: Changing the structure and/or function of neurons in the brain. Actually, this is not entirely true. Neuroplasticity can happen anywhere in the nervous system. Even peripheral nerves can change in terms of structure and function. This is why, when it comes to stroke, researchers often talk about "cortical plasticity." They are being very specific about where the plasticity is happening: in the cortex of the brain. 

The cortex is where all the neuron cell bodies are, and therefore where all the neuroplastic action is.

So very specifically the definition of neuroplasticity as a relates to stroke is this: Changing the structure and or function of neurons in the cortex of the brain.

Okay. We have neuroplasticity nailed down. Now let me nailed down when neuroplasticity is important after stroke.

When is neuroplasticity important?
The first thing to do is figure out when neuroplasticity is not that important. The cortex of the brain is constantly rewiring in all of us -- all of the time. But it is only robust enough to make a difference in a stroke survivor once they are chronic. The chronic phase is generally defined as "after the first three months after stroke." But probably a better way to define it is: the point after the plateau. So once a survivor has plateaued from then to the end of their life they are considered chronic.

During the chronic phase neuroplasticity is vitally important to recovery. It is only through forging new pathways a chronic stroke survivor learn to move better.

So neuroplasticity is vital to recovery during the chronic phase. And make no mistake: for most very successful stroke survivors who recover a lot the recovery done during the chronic phase is represents a huge part of their recovery.

However, most recovery, for most survivors happens during the subacute phase (from 7 days to 3 months, average). But during the subacute phase neuroplasticity, by and large, is not the predominant driver of recovery.

So what is the primary driver during the subacute phase?

To put it simply, recovery during the subacute phase has to do with "using the penumbra."

The penumbra is the portion of the brain that surrounds the area that was killed by the stroke. NOT using the whole penumbra is the essence of learned nonuse.

I miss my old self (too)

One of the laments that I hear a lot from survivors is "I miss my old self." But please, survivors, keep in mind – we all miss our old self.

I feel grrrreat!

I am as indestructible as I feel!

We often tend to look at the past fondly simply because we were young. But we're all getting older, slower, achier – and- as if tipping our hand of our aging interior – our looks take a hit.

So let's say a stroke survivor had their stroke 10 years ago – when they were 40. Now they're 50, and they "Miss their old self." It is true that stroke ages you immediately. The estimate I read recently is that the stroke itself ages you at least five years. That is, your brain is five years older, your body is five years older, etc. – all within the first 24 hours of stroke. So when survivor say "I miss my old self," I can dig it.

Doing well!

I haven't had a stroke, but I can tell you, 50 ain't 40. That is, you wouldn't be how you remembered irrespective of the stroke. So when you compare, compare to the projection of yourself given the added age.

So, like the rest of us, as you work against the deficits of the stroke you are also working against father time.

Crap I didn't even know I had aches.

I do know some stroke survivors who are in some of the best shape of their life after their stroke because this was really the first time in their life that they look after themselves.