Don't forget the Yang

If movement is the yin, sensation is the yang. Try to zip up your zipper with gloves on. Its hard to even find the zipper! Part of the finding and the zipping is being able to feel. The feeling of the zipper tells you where the zipper is, how much force it will need to be pulled up, the angle of pull that is the most efficient, etc., etc.

For many survivors, its more than just losing the feeling of the zipper between their fingertips, its also the feeling of the entire arm and hand that may either be diminished or lost. If you think its hard to pull up a zipper because you can't feel the zipper, imagine how hard it is to pull up a zipper if you can't tell where your hand is! This ability to feel where the extremity is in space (without looking at it) is called proprioception. Proprioception, when intact, is a constant feedback loop. 

Little organs in your muscles, tendons and joints tell your brain where your limbs are without you looking at them. You adjust your movement according to this information. As you adjust your position, your muscles continue to tell you where you are! 

All this information runs through your nerves (from muscles to brain and back) at about 300 feet per second. But it may all "fall on deaf ears." If the portion of the brain that "listens" to proprioception is killed by the stroke, none of that information will get through.

Is proprioception retrainable?

Anyone who reads this blog, or my book, or practically any article I've written knows that I think the whole darned system is retrainable. The research is somewhat unclear because its hard to measure proprioception. You can measure movement, but how do you measure feeling? But. There is a lot of research that says, basically, the more you move, the better your movement becomes. And, there is a general belief that better movement requires two things:

1. Better control over muscles
2. Better proprioception

So, if you are moving better, we can assume that you are probably feeling the movement better.

And "use it or lose it" is in play. We know that if a survivor moves less, the area in the brain that controls that movement shrinks. But the areas in the brain involved in proprioception also shrink. 

So move! A lot! Its a twofer! If you move you regain control over movement and the feeling of movement! That then gives you a wider palette of movement! And, if you work really hard (and are lucky) your movement will be integrated into your everyday! And that's the holy grail of stroke recovery!

More tips to recover proprioception here.

The STROKE-O-MATIC 76

When it comes to selling stroke-recovery machines to therapists, the phrase "another tool in the toolbox" is all the rage. Vendors (sellers) use the toolbox idea to soft-peddle to therapists. Here's how the pitch goes...

"We have this great new machine. It works great. Now, I'm not saying to pitch what you use. I'm just saying that this machine of mine is...another tool in the toolbox." But therapy time is very (very), very limited. So, Ms. Therapist, if you use their machine, there'll be no time for what you have been using. And the vendor knows this. 

But the vendor is scared to say their version of the truth which is, "My machine works better than what you have been using" because that suggests the therapist has been providing something less than the best. (And you don't insult the client, right?) But that's exactly what they are saying. My machine works better than what you usually use... Instead, the vender, fearing being considered condescending treats the clinician like a child and says, "You're doing just fine. This is just another tool for your toolbox." Its like telling a child, "I love Joey, your (stinking, puked-on) Teddy bear  too. But lets just get another Teddy. You can keep Joey too (in the garbage!) but we'll buy you this new one."

I find this even more condescending to therapists than giving it to them straight. Vendors, if you think your thingy works better, say so. Not to is spineless because you've not stepped up for the people who need you. No, not therapists (your bank account or your boss). You've not stepped up for survivors. If your thing works, get behind it. And if you are truly behind it, soft-peddling just makes you someone who'd rather make the sale than do the right thing.

Of course, if you want $ over integrity, you'll get neither.

Since when is “productive” fun?

When it comes to stroke recovery, no clinician, no matter how skilled, can "do it for them." Recovery from stroke is dependent on repetitive and demanding practice by the owner of the damaged nervous system—the survivor. If done correctly repetitive and demanding practice drives cortical plasticity ("brain rewiring") robustly enough to be evident in increased quality of movement. 

But this sort of repetitive practice is boring! Repetitive practice does not necessarily involve functional activity. For example, a clinician, seeing a deficit in the last 15 or 20° of dorsiflexion, may have the patient repetitively practice dorsiflexion, irrespective of ambulation. At least in that example the end goal, whether it's stated or not, is obvious; walking. In the upper extremity repetitive practice of single joint movements may or may not relate to any particular everyday activity. Instead repetitive practice may be used just to increase active range of motion in those joints. Because it does not involve anything functional, repetitive practice can be inherently boring.  And what makes it even more boring is that stroke survivors aren't even working on anything novel; there relearning movement that they used to do perfectly well. So where's the motivation? 

The motivation ends up being a conjuring. Some of this motivation may come from the minds of clinicians. OTs, PTs and speech therapists should try to make repetitive practice as interesting as possible. But some of this motivation comes from the survivor. The survivor needs the imagination enough to understand how this hard and boring work will help realize potential.

Yes! Stretch!

The small units that make up muscles are called sarcomeres.

Help! Stretch me!

Sarcomeres shorten when we contract our muscles. When we stretch for a long time, there is an increase in the number of sarcomeres. Literally, muscles get longer.

For example, increased flexibility is directly related to an increased number of sarcomeres. One of the ways that the number of sarcomeres can increase happens to all of us: Growth from birth to out 21st year. Growth in the length of bones during childhood provides a prolonged stretch of muscles. As muscles are stretched to their physiological limit they react by developing an increase number of sarcomeres. Stretch has to be of sufficient duration for this remodeling of muscle to occur.

The opposite is true as well. When muscles are left in shortened position, the number of sarcomeres decreases. Nothing provides a prolonged shortening of muscles like spasticity after stroke and brain injury.

So all the rules of stretching are thrown out the window when the muscle is spastic.

How is spastic muscle different than normal muscle? Let me count the ways...

Spastic muscles... 

•have lost some (if not all) communication with the brain.

•are often kept in a shortened position on the "bad" side for long periods of time.

•are not subject to the same rules of stretch. (That rule: The more you stretch the longer the muscle will become.)

Spasticity after brain injury keeps muscles (on the "bad" side) in a shortened position long enough to lose sarcomeres.

It comes as some surprise to most therapists, but there is very little scientific evidence that stretching muscle reduces spasticity. In the very short term there is a small reduction in spasticity. But spasticity is not reduced in any lasting way by stretching because spasticity is not caused by muscles. Spasticity is caused by brain injury. Brain injury causes the brain to cede muscular control to spinal reflexes. Increasing the number of sarcomeres will not reduce spasticity. If it did, every case of spasticity would be eliminated by a regimented stretching program. And wouldn't that be nice?

Soooooo... Should you not stretch? No! I mean yes! I'm confused! Yes, you should stretch!

Why should you stretch? Because even if stretch has no lasting effect on spastic muscle, there are several reasons to do it anyway. Stretch... 
•feels good 
•reduces spasticity for a sort amount of time 
•is good for joints 
•may be good for other tissue besides muscle (ligaments, veins/arteries, nerves, skin, etc.)

Wanna write a book?

From the publisher of my book...You can email her directly (contact info, below) if you're interested. Best, -pete

"I’ve been thinking about two possible new books on stroke for our list and I wondered if you might know of anyone who might be interested in writing them:

 

A Caregiver’s Guide to Stroke: a handbook to help the caregiver, addressing all of the issues and best practices they should know about: creating and managing a health care team, dealing with the various physical, emotional and cognitive issues, etc. The right author would most likely be a social worker, therapist, or professional caregiver.

 

Myths vs. Facts on stroke: a book aimed at dispelling the myths/misinformation about the causes, treatment, physical and cognitive impact of stroke." 

Julia Pastore
Executive Editor, Demos Health Publishing

jpastore@demoshealth.com