Use what you've got to get what you need.

If you've had a stroke, your spinal cord still works fine. The spinal cord takes over some aspects of movement. The first step in this process of the spinal cord taking over is spasticity. The brain can't move you, so spasticity, generated in the spinal cord, takes over. And as much as we hate spasticity, things could be worse. Spasticity is better than nothing. "Nothing" in this case would be a completely flaccid affected ("bad") side. And being flaccid is worse than being spastic. Trust me on this.

But if we go a step beyond spasticity towards recovery there is an intermediate step. This intermediate step is known as synergy. The spinal cord basically allows for basic movements. The brain is not working, the spinal cord takes over, and the spinal cord allows very basic movements.

The synergies, although often disparaged by clinicians, are brilliant. In the upper extremity, synergy allows for the most important movement you can imagine: 

 

Feeding. It looks like this...

 

In the lower extremity the flexor synergy looks very much like a stepping pattern.

Clinicians have, for 40 or 50 years or so, said that synergies are bad. I disagree. Synergies can be used in a way that replicates good coordinated movement. Synergies give you the ability to at least attempt to replicate a normal movement. Enough attempts and the brain rewires and the synergies are discarded.

Watch this video. This stroke survivor (Brian Redd) is on the right track... use what you have to get more. 

(At 2:35 he provides a stellar description of the flexor and extensor synergies of the leg).

List of Post-Stroke Sequelae. Stroke symptoms.

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Sequelae: Plural of Sequela. 

A pathological condition resulting from a disease. An aftereffect of disease.

Body Including Limbs 
Sensory impairment including tactile,  pressure, Proprioception
Hemiplegia
Hemiparesis
Subluxation
Shoulder hand syndrome/RSD
Flaccidity (hypotonicity)
Balance problems
Apraxia
Hemineglect 
Altered walking gait
Vertigo
Neurogenic bladder
Eyes
Hemieposia
Eating
Dysphagia is difficulty in swallowing.
Aphagia – Inability or refusal to swallow.
Risk of aspiration
Seizures
Spasticity
Soft tissue shortening/contracture
Genu recuvatm
Speaking
Dysphasia: Impairment of speech.
Aphasia: Language disorder (defect or loss of the power of expression by speech, writing, or signs.
Dysphasia and aphasia are synonymous terms.  They mean a language disorder with impairment of speech and comprehension of speech. 
Physchosocial
Depression
Decrease sexuality
Indifference, inappropriateness, depression, mania 
"Other"
Recurrent stroke

Repetitive Practice Stroke

What is the key to recovery? Everybody now: Repetition! I've written about this before here, here and here (journal article; co-author).

Everybody knows that repetitive practice (also known as repetitive task practice) is the way to reestablish executive (brain) control over the body. To regain control of an arm and hand repetitive practice can be used to reestablish that control. To regain control over a leg during walking, repetitive practice (walking) can be used to reestablish control over walking.

It's not rocket science. And it's not brain science, until it is.

The thing that they don't tell you is how many repetitions you have to do. The first person to talk about the power of repetitive practice was Randolph J. Nudo. You pretty much can't read any journal article on stroke rehab research that doesn't involve a reference to this guy. His suggestion was that 2500 repetitions would begin to change the brain enough to make that movement better. In constraint induced therapy there is approximately 200 repetitions per therapy session. In typical rehab there's about 32 repetitions or therapy session. It looks as if the number may be approximately a total of 1200 reps. That would require about three hours per day.

As you can imagine, these numbers are rather variable. The amount of focus brought to each repetition would be one variable. The complexity of the movement that you're trying to relearn would be another variable. The number of joints that the movement required would be a variable. The number of directions that that limb would have to move in order to carry out the task would be a variable.

But I think we can all agree that most stroke survivors don't attempt these numbers of repetitions. 

Here is the other question: How do you do all the repetitions you need to do without driving yourself crazy? 

Here is the only possible answer: Tie it to something that you care about.

Get cracking.

I'm not drunk, "retarded", or mentally unstable

Its a pretty simple calculus: If you don't use it you lose it. But there's a corollary: If you don't try it you can't possibly gain it. For example, if you use an AFO to walk during the early days after stroke, you'll not easily not use the thing again. 

And if I choose not to play violin- an instrument I've never played- I'll not get better at violin. So, both learning for anyone and relearning after stroke involves taking your brain (where learning happens) out of your brain's comfort zone.

Which leads me to spouses. I've met a ton of 'em. The wife is aphasic, the husband loves her, knows what she's trying to say and finishes the sentence for her. (When its men I always get the feeling they're saying to themselves, "Finally, I get to do the talking!") The spouse can become the exact thing they don't need. 

I always liked talking to folks who are aphasic. I usually get trampled by conversations because I'm slow in the think department. Aphasic folks give me a chance to ruminate a bit. Try it. Slow the conversation.

But "I've gotta get on with my life. How is it good to have my wife talk slowly when we're trying to check out (or ask directions, or talk to the gas station attendant)?"

Here's how its good. Do you know anyone who doesn't stumble and bumble their way through conversations? OK, a few people are so verbally dexterous that they don't really have this problem, ever. But nobody likes those people.

Why shouldn't someone who has a language deficit struggle as much as we do? They should struggle. Once they don't struggle, you know whats that's called?

A plateau. 
Beside, aphasia can be fetching. 

Stretching reduces spasticity. Yeah, no.

OK class, here's your quiz:

1. Stretching decreases spasticity T/F

2. Stretching increases the length of spastic muscles T/F

3. Stretching reduces the chance of contracture (muscle stuck at a shortened length) T/F

4. Stretch helps make joints more mobile T/F

First of all, why stretching is good: 

Stretch is good for joints. Every time we move, joints are "lubricated." That is, joints require movement in order for the fluid in the joint (synovial fluid) to be properly distributed. Stroke survivors, because they are typically weak on one side, don't get the joints on the "bad" side to move enough. How much is enough? Look at it this way, on the "good" side your joints, all of them, will be moved through their entire arc of movement (called range of motion) dozens if not hundreds of times per day. How many times are your "bad" side joints moved? Because they have trouble moving, it is wise to move them either with the "good" side doing the work, or a caregiver doing the work. This is called passive ranging.

But while stretching may be good for joints, the affect of stretch on muscles and other soft tissue (ligaments, blood vessels, fat, etc.) is, so far as the science says, negligible. So the answer to your quiz is F, F, F, and F.

I know this is hard to believe. And it is counter to what some therapists think. But it is confusing. There is an immediate effect of stretch on spasticity, everyone knows that. But this is one of the many reasons stroke is so devious; what is true now may not be true 5 minutes from now.

This is a frustration for many clinicians. You observe something is true (i.e. spasticity wanes with stretch) only to find that with the next big movement by the survivor, spasticity comes right back.

Further reading from this blog on spasticity here and here.