Building the Recovery Wall

Scott Gallagher posted a comment to a previous blog post. I'll paste that comment at the bottom.

What caught my eye in his comment is the conflict between repetition and quality. The conflict goes like this: If you do a ton of repetitions you may not concentrate on quality. If you concentrate on quality you may not hit enough repetitions.

I do a lot of talks about stroke recovery to clinicians. There is a small but vocal group of therapists who believe that if you don't focus on quality you may as well not practice. "Perfect practice means perfect recovery." I completely disagree. What if the survivor doesn't move perfectly? The answer by these clinicians is "I use hand over hand techniques to make sure that they do." Basically, they move the stroke survivor in the proper arc of movement. (BTW: the original quote was, "Practice does not make perfect. Only perfect practice makes perfect." - Vince Lombardi. Vince Lombardi was dealing with professional athletes. If he was coaching peewee football his quote would've been "We're not asking for perfection, we're asking you practice.")

There's several problems with stroke recovery put to this "If its not perfect, don't bother" philosophy. First of all, who's to say what "good" movement is after stroke? If somebody's trying to learn golf and they suck, nobody stands behind them and says, "You're doing it wrong." The more you practice golf, the better you'll get. Should you practice proper technique? Yes. But stroke survivors know proper technique. They've been doing these movements for all the years prior to their stroke. And even if they forgot they can model with the unaffected side.

 strongerafterstrokeblogpants

Second, this philosophy suggests a therapist. "Don't move unless I'm there to help you move." Alternatively this can be expressed as, "The more you move the worse you'll get." But therapists can't be with the survivor all the time, and the survivor doesn't have enough money in their pocket to pay for endless therapy. There is some good news... "The more you move the worse you'll get." Hogwash. Moving a lot on your own leads to better movement as long as you make the movements challenging (always reaching beyond you present ability).

Third, when's the last time you saw a coach with their hands all over a player? When's the last time you saw a music teacher with their hands overlapping the hands of the trumpet player? Learning movement involves mistakes corrected.

Scott Gallagher puts it this way "...any time I tried to insert control or effectiveness into my program, whether it would be with walking or with the hand, it would drive the repetition numbers down and my recovery would stall." And I know that is taken out of context, but as it stands as a quote I agree with it.

Scott Gallagher: If complete recovery is the goal, one problem might be in the sheer numbers involved. I have no reason to think that my stroke was anything but whatever might be considered a normal stroke, but currently in measured distance I'm at 5,112 walking miles. I'm so close to recovered, I'd say 5,000 miles is what it took for me to fully walk normally again. I tried speed walking, but the problem I was having was that any time I tried to insert control or effectiveness into my program, whether it would be with walking or with the hand, it would drive the repetition numbers down and my recovery would stall. My strategy, then, became one of brute force: keep it simple and push those repetition numbers up. But even if I had effectively used speed walking, how effective could it be? Even if it took 3,000 miles off my total distance, that would still leave 2,000 miles left to cover. I only made it through by switching from an exercise-based program to a mind and motivation-strengthening program. For all but a very, very few the repetitions required for full stroke recovery may make it, although possible, simply unfeasible. Come to think of it, though, your post may have been intended for a less hardened recovery program. Thanks.

Thank you Scott! 

                                                                                            ©Stronger After Stroke Blog

Cerebellar stroke

Somebody gave my book a crappy review because there's nothing specifically about  cerebellar strokes. But there is. A stroke can happen in the cerebrum, cerebellum or brain stem. I don't have anything specifically about the cerebrum or brain stem strokes or cerebellar strokes. I just have stuff about stroke. 

Is there something inherently different about cerebellar stroke vis-a-vie strokes in the cerebrum or brain stem? No. What about a stroke that hits the posterolateral thalamus? Maybe the folks who have had a stroke that hit the posterolateral thalamus (or was exclusive to white matter or only hit the pituitary gland, or any of the other dozens of structures in the brain) should get their own chapters or books.  Actually, I'd love to see that happen. In the mean time, my book is a review of the neuroplastic process that encompasses all of those. Recovery from all of them fall under the same neuroplastic model of stroke recovery.

I don't like the template for recovery being contingent on where the stroke is. Again and again I stress that the view that the brain is NOT cordoned off into specific compartments that necessarily control specific functions. This notion, that the brain is sectioned off into independent exclusive sections is called the "mechanistic view of the brain". In fact, in my book there is a whole section (NEUROPLASTICITY AND HOW SCIENCE GOT IT WRONG) about this (brain=machine) mistaken perspective. 

Is there something inherently different about cerebellar stroke? No. 

What does the cerebellum do?

Cerebellum is Latin for "little brain." It sits at the bottom and back of the brain (3D animation here). The cerebellum is involved in providing precision and coordination movement. The cerebellum is said to "calibrate" movement. It doesn't initiate movement, it just makes movement smooth and coordinated. People who have had a cerebellar stroke often have an uncoordinated tremor. For example, if they were to reach out and try to touch target in front of them, and then their nose they would have difficulty targeting towards both. As the person got closer to the target end to their nose tremor in the targeting finger would increase. This phenomenon, called ataxia, is very similar to a phenomenon known as intention tremor. Find a possible neuroplastic option for the treatment of intention tremor here.

Notes about the cerebellum and cerebellar stroke.

• Compared to the rest of the brain, damage to the cerebellum is a little "backwards." In most strokes, if the stroke affects the right side of the brain, the left side of the body is weak or paralyzed, and vice versa. With the cerebellum is the stroke is on the right side, the right side of the body is affected.
• Cerebellar strokes are unusual. About 2% of all strokes are cerebellar.
• It would be well and good to assume that the cerebellum is only involved in coordinating movement. However, like much of the brain, the cerebellum is poorly understood. It is now believed to have at least some role in higher level thinking as well as emotions. 
• (Find an interesting piece on a cerebellar stroke survivor here.)

How do I rehab after cerebellar stroke?

It turns out that the same rules of plasticity available to the rest of the  brain are available to the cerebellum as well. Here's my suggestion: Forget about where the stroke was. Instead, focus your efforts on sequalae.

The Orthopedic Card

I'm about sick of what I'm starting to call "movement elitism." The idea is that, unless you move perfectly, you shouldn't move. Because… you'll ingrain "pathological movement patterns." I've railed against this before. And here it goes again...

Curious Person (CP)

Clinical Movement Elitist (CME)

CP: Why should a stroke survivor not move when they're alone? 

CME: Because they move wrong.

CP: What will moving wrong do?

CME: Make it so they'll never move right.

CP: So what should the survivor do to practice movement?

CME: Wait until there's a clinician around to tell them how to move.

CP: Won't the survivor run out of money eventually?

CME: It’s worth every penny because bad movement is bad. It will make moving right harder.

CP: Don't we all learn to move by correcting mistakes?

CME: Yes but survivors need guidance.

CP: Couldn't they sit in front of a mirror and model the movement of the "good" side?

CME: Yes, but they'd fail in the execution.

CP: So they need to be perfect right out the box?

CME: Yup.

CP: What if they can't move right?

CME: I move them.

CP: Doesn't that defeat the purpose any "productive struggle"?

CME: Survivors shouldn't struggle too much.

CP: Why should they not struggle?

CME: They'll move even worse.

CP: Survivors need lots and lots of repetitions to recover moment, right?

CME: Yup.

CP: And that has to do with forging new pathways in the brain?

CME: Yup. It takes thousands of repetitions to get the brain to regain control over muscles.

CP: How long do you typically see a patient?

CME: About an hour a day.

CP: How many repetitions do you have survivors do in a typical session?

CME: A lot...as many as we can.

CP: Did you know that the number of repetitions done in a typical stroke rehab session has been counted?

CME: I did not. Know.

CP: The average number of repetitions in a typical session for the arm is 18 and for the leg its 38

CME: It will take a while.

CP: How do you reckon the survivor will get to the thousands of repetitions they need?

The movement elitist may seem cornered, but they have an ace…

CME: Even if they could practice on their own, and even if that practice is beneficial, the bad movement will cause orthopedic problems like bad joint movement and pain. It may be good for their brain but it’s gonna be bad for their body.

CP: Couldn’t the improved movement and the better brain control lead to less ortho problems?
---

What if you made it harder?

There are a lot of things out there that can help make the life of the survivor easier. Assistive devices that can aid in everything from walking to eating, for instance. There are apps to help aphasic folks communicate. There are even books that give you "Tips for Making Life Easier. " 

There are really really good reasons to have these "helpers." One of those reasons is safety. Take AFOs, for example. I've been an advocate of attempting to "walk out of" the AFO. AFOs help folks who can't lift their foot, walk. And if its a safety issue then, by all means, keep it!! But if a set of muscles is not used it will atrophy. In the case of the AFO, the orthotic eliminates the need to use the dorsi flexors which lift the foot. But that muscles will atrophy is only half the problem.

The other thing that atrophies is the portion of the brain that controls that movement.  In short order (weeks) the number of connections between neurons in the brain rapidly decreases. Is that what we want? Generally, no (but for safety, yes, maybe.)

So all this time is spent on making life easier but making life harder is the place to be.  Find suggestions here and here and here.

Clinical research indicates you are smarter if you don't buy lumosity

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Lumosity is a scam. It costs $15 a month and it will change your brain. What does it do to your brain? It makes your brain better at playing the lumosity games.

Really you don't need fancy software and a computer interface to do what human brains have been doing for the last 200 thousand years. 

Heck, these guys don't even use the word neuroplasticity right. Their tagline is "Lumosity is based on the science of neuroplasticity." But neuroplasticity is not science. 

(note: The previous link was to luminosity's website. But they must've gotten enough flak about the whole "science of neuroplasticity" thing that they took it off their website. However, others have found, and recorded, the same statement.)

Neuroscience is a science. Biology, chemistry, zoology -- these are sciences. Saying neuroplasticity is a science is like saying E=MC2 is a science. In fact, both E=MC2 and neuroplasticity are theories. Given the fact that lumosity has a huge stable of neuroscientists, you think they'd be able to figure the nomenclature.

The fact is, the best way to "train your brain" is to challenge your brain. This challenging of the brain -- also called learning -- changes neurons. Learning stresses out neurons which react by creating new dendrites, that then form new synaptic connections. The best way to rewire your brain to learn something new is the old-school stuff; learning a new language, learning a new musical instrument, learning a new sport, etc.

I'm not sure I could put it better than this: "The (lumosity) scam is a pretty smart one because it melds together not just one but two classic plays in the world of conning – the idea that you don’t have to work hard for something because there’s a hidden shortcut, and the inherent belief that you could be brilliant if only you could tap some hidden skillset lurking somewhere in your brain-case."

How can stroke survivors drive this sort of change in their brain? It involves a lot of hard work. The work has to be very challenging. The bottom line is, there is no game, or machine or pill that will help you learn. And there's no game, machine or pill that will help you recover from stroke.

More up-to-date blog entry on "brain games" here.