Neuroaid: Scam

So. It turns out that in the largest clinical trial ever of the drug, neuroaid was  "statistically no better than placebo in improving outcomes." Who'da thunk? Oh yeah, we did!

So how do you think neuroaide spun it? Like punks, natch. "Researchers found NeuroAiD, a stroke treatment based on Traditional Chinese Medicine, increases the odds of achieving a better functional outcome." "We are totally full of crap," they did not add.

Predicting hand recovery by infarct size -- not.

Interesting work here by my colleague Stephen J. Page.

It seems like in "no-brainer." The more brain destroyed by the stroke, the greater the disability. Right? Except that when it comes to arm and hand movement, that may not be true.

"Historically, lesion size been thought to influence recovery, but we didn't find that to be the case when looking at regaining arm and hand movement," Steve put it.

There is no way to stare at your brain scan and A.) know what the deficit is gonna be B.) know how profound any deficit will be C.) predict recovery. 


(Find the published article here)

One other note: I've always disliked the term "massive stroke." Most doctors, and therefore survivors, claim that any stroke is a massive stroke. I've heard the claim that the word massive means "likely fatal." But if that is true then it has nothing to do with the mass (size) of the infarct. Thus, the word massive is meaningless. It is a superlative to add when the word "stroke" is somehow not enough.

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.