Why Dynasplint is half dead (and all dead for survivors)

Do you have muscles tightened by spasticity? 

Sarcomeres are the small units in muscle that contract when your muscles contract. (Great image here. Look at the bottom right corner.)  Sarcomeres will increase in numbers when muscle is put through a prolonged stretch. Increasing sarcomeres is how muscles are lengthened. Lengthening of muscle and increasing sarcomeres increases flexibility. Which is a good thing because we can talk about neuroplasticity until the cows come home but if your arm (or whatever) "won't go that way," all bets are off.

 
OK. So how might you increase the number of sarcomeres? One way that many clinicians think works is called "dynamic splinting." The idea is that you'd wear something that would hold you in a position that would stretch you. If you could wear it at that posture for 2-3 hours, the clinician would "dial in" a more "aggressive" range of motion. Over time you'd gain sarcomeres which would allow you to have more range of motion. 

Sounds groovy, right?

It works for, say, marital artists who want flexibility so they can KICK ASS.

Stretching ROCKS! Sometimes!

You stretch, you get a longer muscle, everybody's happy!

But yeah. That whole science thing gets in the way. Don't you just hate science?

It turns out that the way to elongate (add sarcomeres)  "normal" muscle is nothing like the way you'd do it in spastic muscle. To stretch spastic muscles so they gain length, the stretch must be held at least 48 hours. And dynamic splints are not kept on for anywhere near that long; a few hours, max. 

And here's another little interesting tidbit. The 600 pound gorilla of dynamic splints is a company call DynaSplint (get it?) and they've had a little bit of trouble lately. The kind of trouble where they may have defrauded the Federal Govmint. And they laid off 500 workers in one day. Which makes sense since it was a DynaSplint salesperson that was the whistle-blower that brought the whole company down. Which then triggered their bank to stop their operating budget.

And while I have no idea of any of those problems are warranted, one thing I do know is that they are fraudulent in another way. Again and again they claim that their splinting systems help folks with spasticity. They also claim they increase muscle length. Don't buy it!

The neuroplastic model of hypersensativity reduction after stroke for fun!!

Hypersensativity after stroke can come in two basic flavors:

1. A touch (or some other stimulus that normally does not hurt) hurts. A lot. This is called allodynia.

2. Something that usually does hurt hurts a lot more that it should. In other words, it hurts a lot more than it might on the unaffetced side. This is called hyperalgesia.

So how might you treat this. Lets go to the never-ending neuoplastic well, shall we? We know that stroke damages the brain which may cause the altering and amplifiying of sensation. So what if we used the same process to reverse it? These are hypothetical (although some have been tested) so keep that in mind. So what are the neuroplastic model to treat? Possibilities include...

1. TENS (mild electrical stimulation). Dosage here.
2. A placebo. An example would be suggesting a manual therapy (like message or manipulation of the extremity) will help reduce it. Discussion here.
3. Comparison. Put the gel on the unaffected side and say, "See, its just a bit cold. We'll take exactly the same gel (it can even be done at the same time)and put it on the 'bad' side and they'll-hopefully-feel the same.
4. Mirror therapy. Set it up like this: Have him look only at the unaffected side as either the survivor or someone else gives the "good" limb the stimulus which is painful to the "bad" limb. It will look like its getting put on the affected side, but with no pain.

Further reading here.  Duscussion of the difference between hyperalgesia and allodynia here.

Falls. Bad.

Here is your challenge: 

In the comments section, write everything that this survivor could do better in order to get up the stairs more safely. 

We all know that falls are bad. 

Falls can kill you. For survivors, falls are especially bad. Stroke affects balance, coordination, strength, and any number of other things that can lead to an increased risk of falls. On top of that, survivors tend to fall towards their affected side. In the affected side tends to be more osteoporotic. So have at it. This is good place to start as anywhere. What is this gentleman doing wrong? How do you do differently? What can you suggest?

Young Survivors: You may look great AND struggle.

A couple of bits of bad news for younger stroke survivors. First, a look at this video (on the right side of the site).

My interpretation: Young people who have insomnia are at a much higher risk of stroke. And by much higher I mean more than 8 times the risk. 

That's valuable information. But. There's a not-so-subtle intimation in this video that a lot of young stroke survivors complain about. Namely, that young people are out doing drugs (and other bad things) which keep them awake. 

The second bit of bad news

There's a new article out with a not-so-subtle name "Poor Long-Term Functional Outcome After Stroke Among Adults Aged 18 to 50 Years." Its bottom lines may come as some surprise to clinicians: many young survivors stroke survivors struggle with everyday tasks. 

After 10 years, 1 in 8 patients (12.9%) was not able to function independently. 

When interviewed the author's seem to suggest that, young survivors often don't show severe outward signs of problems related to stroke. For instance, they would struggle much less with walking than older survivor. But that does not mean that these everyday tasks are not problems. One author Frank-Erik de Leeuw, Ph.D., put it this way "Even if patients seem relatively well recovered with respect to motor function, there may still be immense 'invisible' damage that leads to loss of independence." 

I've heard this before from young survivors. People will come up to then say "You look great!" And they think to themselves, "I don't feel great." 

 One interesting note: Almost all the popular press has reported that this article suggests that "one-third" of young stroke survivors are having problems. I've read the article. It's one in eight. I'm not great at math. I'm pretty sure that's not one third.

Institute of Neurological Recovery. B-level scam.

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Anyone looking online for a magic bullet to help reverse stroke will end up with the same group of scams. There's the neuroaid scam. The wheatgrass scam. The Neuro-IFRAH scam.

There's two kinds of "stroke recovery" scams:

A-level scams: I sell you a "treatment." Does it work? Who cares!? I'm Selling! A-level scams tend to not last very long. If it doesn't work and it's harmless, the public will soon lose interest. And if the "treatment" hurts people the scammer will be sued into oblivion.

B-level scams: I sell you a "treatment." I really really really really believe it works. But I have no legit whatchamacallit... science... science behind the "treatment." How do I prove it works? A video! And a lot of stories from a lot of people that really like it a lot! 

What's so fun about all the B-level scams is that they're so easy to investigate. Really, this inter-web thing is great!

(I Think B-level scammers think we don't have access to the interweb!)

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Institute of Neurological Recovery 

Up until now my favorite scam has been neuroaid. And not just because my blog entry on neuroaid is the most read blog entry in SAS-blog evah! No, neuroaid was my fav because their conflict of interest was so obvious (the people on their scientific advisory board were also doing the research).

But my new fav is the Institute of Neurological Recovery. Although I feel a bit lame here because so many before me have pointed this scam out. Here as well. Hilarious radio commercial here.

Basically the scam is, you come in-- even years past your stroke-- they give you a shot (1st shot ~ $6,800- info from a recent patient) and you're better (video here) (another here). And they have research. Check out their "research" page. See the first 3 links? They all point to articles whose lead author is one Dr. Tobinick.

Dr. Tobinick owns the Institute of Neurological Recovery. Done!

Where's the challenge in that? They're not even trying! They even suck at obfuscation! Does the injection work? I don't know! But neither do they!

BTW, their "big" study involved looking at charts of patients and, based on no standardized tests said, "Yeah, all these people got better."

In some ways, B-level scams are worse. B-level scammers are often clinicians, and clinicians should treat using things that have scientific evidence specific to that treatment. Occasionally there are treatments that are missed by science, but shortly there reaches this critical mass of interest in the treatment. Once that critical mass is met, researchers get very interested, and they investigate. So, a good indication that a scam is a scam is that only the folks involved in the scam have investigated. So the scam is never investigated with anything close to science because, they're scammers, not scientists.

B-level scammers posture as scientists. But they're not scientist. The first thing a scientist would do when they say "my thing works" is to recuse themselves from the testing. It's called blinding. It's science 101. You want to make sure whoever is doing the testing is unaware which group (control/expiremental/different dosages, etc etc) the participants are in. Otherwise there's a clear conflict of interest. Otherwise, they'll say "My thing works great! I just tested my thing! And my thing works great!"

P.S. The Institute of Neurological Recovery has tried this before, with Alzheimers. Here is an article on it. My fav line? "Edward Tobinick ... has been active in laser hair removal prior to developing an interest in the use of etanercept for CNS indications. The hair removal clinic at which Tobinick is medical director, the Institute of Laser Medicine, is in the same building as the Institute for Neurological Research..."