Stroke Recovery, Stroke Rehabilitation: A Message to Therapists

There you sit, face to face with a stroke survivor. Only a few days ago he was a vibrant, energetic community member... employee... family member and now is sitting in front of you…. aphasic… hemiparetic …scared. The family sits anxiously behind him. They’re eager to get their loved one back and now they look to you. “When?” they ask. “How?” they inquire. And make no mistake, no matter who has talked to them before and no matter how blunt other health professionals have been, they hold hope for full recovery. Between their expectations and their slowly materializing nightmares, you are the last line of defense.

This is not a good time to ask, “Are my skills up to this?”

What if you simply want to do what is the best neurological therapy available? What if you want to treat based on the best available scientific evidence. What if you don't want to be influenced by the wide variety of competing schools of neurorehabilitation, each with their own books and seminars and cult of personality leaders? 

Want to scrape all the BS away? Go here: meta-analysis.

A meta-analysis is simply a study of studies. Researchers take all the available pertinent studies and then determine which studies are worthy of inclusion based on a variety of criterion. Then, of the studies that make the cut, each is given a certain weight depending on the number of participants (more is generally better), if they are blinded, the quality of outcome measures, and so on. All the available data is run through an algorithm and voila! Meta-analyses provide a “box score”. Simplified, it will look like this:

Therapy “XYZ” = -8.5

Therapy “123” = 9.3

Therapy “EFG” = 7.2

Therapy “ABC” = 27.6

Therapy “ABC” looks best, doesn’t it? Are you using “ABC”?

But trust in meta-analyses assumes trust in the scientific method. Phrases like evidence based and best practice are contingent on an inherent belief in the scientific method as related to rehabilitation research. 

(There is actually a remarkable amount of resistance to the scientific method, not just in rehabilitation but everywhere... deniers of global warming, human existence in the current form for the last quarter million years, evolution, a man on the moon, etc. etc. I was find it interesting that folks that are willing to deny science embrace it wholeheartedly if they are diagnosed with cancer. Oncology; based in science.)

Rehabilitation clinicians, in all their forms, graduate from colleges and colleges within universities that are usually called something like "College of allied health science." 

With regard to rehabilitation research for stroke, what exactly is involved in the scientific method? How do medical and research doctors come to conclusions about what does and does not work?

As with many things medical, it started with Hippocrates. Hippocrates was the first to describe stroke, transient ischemic attacks and aphasia. Hippocrates, however, provided no clues on how to rehab stroke survivors and for more than 2400 years little was written and we know of few interventions used to facilitate recovery from stroke.

Fast-forward to the period from the early 1950’s until the early 1980’s. Individual therapists armed with “keen observational skills”, pencil, paper and a goniometer published their observations and claimed it an effective therapeutic intervention. During this period, therapists could reasonably say, “I know it works because I’ve seen it work in my patients.” or “There are no better alternatives”. Now, anyone armed with the power of meta-analysis can refute these claims with a simple statement.

“Prove it.”

In many ways clinical rehabilitation research can trace it’s genesis to widespread hospital usage of functional magnetic resonance imaging (fMRI) in the 1980’s. Suddenly researchers were able to see the fruit of their therapy by simply examining before/after images of brains of study participants. Why is this so important? Because if fMRI shows activity during purposeful movement and that activity did not exist prior to the intervention, then there is reasonable proof of neuroplasticity. And neuroplasticity is the foundation of all lasting change in the ability to move.

Research and medical doctors have used cutting edge diagnostics including kinematics, electromyography, brain imaging, and the most reliable and valid outcome measures to completely reshape the world of stroke rehabilitation. In fact, it’s not a world at all. It’s an expanding universe.

And why is stroke rehabilitation it expanding so rapidly? A basic understanding of the sheer enormity of dollars provides some insight.

• $52 billion is spent on stroke care each year. 
• The projected costs for stroke for the next 45 years: $2 Trillion.
• There are 50 million stroke survivors worldwide. (In a global  economy.)

Enter entrepreneurs. Entrepreneurs have completely changed the way stroke rehabilitation is conceptualized, researched, and administered. Medical device companies, business minded bioengineers, electrical engineers, biological and clinical neuroscientists, doctors and therapists are aggressively seeking a piece of the burgeoning multi-trillion dollar stroke rehabilitation pie. This explosive increase in the number of gizmos and treatment techniques has created a total mutation of the paradigm for rehabilitation for stroke. The resultant technological tsunami will force an unprecedented marriage between patient and technology while forging a massive adaptation by universities that train therapists, and facilities that want to continue treating stroke survivors.

And make no mistake; entrepreneurs are marketing directly to stroke survivors. If you want insight into this process have a look at the advertisements in the two major free magazines for stroke survivors; the magazine of the National Stroke Association Stroke Smart and Stroke Connection magazine, published by the American Stroke Association.

And what of stroke survivors? Have they not always strived towards full recovery? Unfortunately, the history of stroke survivors is story of warehousing and lowered expectations. But don’t blink: things are changing fast. Baby boomer’s increased economic clout and heightened expectations intersecting with the mushrooming middle class in less developed countries has and will continue to create a new breed of stroke survivor who will want, need and expect more recovery.

And all this leads to more high quality stroke rehabilitation research.

Rapid technological change has led to ever more accurate determination of an intervention’s effectiveness and if effective, how effective.  The force of a flood of dollars, both public and private, has changed the way stroke rehabilitation research is realized. Modern research often involves hundreds of specifically randomized participants and involves medical personnel (often including therapists) with degrees specific to their responsibilities within the study. Further, there are institutional review boards to guarantee ethical standards within the research trails, federal (FDA) oversight, and precise handling of collected data. Private, for profit companies, with and without the aid of public funding (NIH, NINDS, public and private universities) are spending hundreds of millions of dollars, on a variety of modalities and therapeutic interventions designed to ameliorate the residual aspects of stroke.

And all of that is only half the battle. In order for studies to be distributed in a manner that is respected by the medical community at large, it has to be published in peer-reviewed journals. Even once the study is done there is an expectation that the same or similar studies will follow that speak directly to reliability (the ability for an intervention to have the same or very similar results over and over.) Once a critical mass of research is done on a therapeutic intervention meta-analysis is done to, essentially, provide a numerical “score” that pits therapy against therapy and declares a winner.

 “I will continue with diligence to keep abreast of advances in medicine.” So says the Hippocratic Oath. Medical doctors have endeared themselves to the public for centuries, millennia really, by accepting a direct influence of science on their professional practice. Therapists and assistants should do the same.

This is not a good moment to ask,  “Are my skills up to this?”

Unless they are.

Fish oil may help recovery.

Note: With regard to any supplementation -- Ask your doctor first. Ask your doctor first. Ask your doctor first. Thank you.

Fish oil may help many aspects of recovery from stroke. In my book (now in the second edition, available for pre-order, just sayin') I put it this way:

 

 Fish oil may help stroke survivors in two ways:
 

1. DHA and EPA may help to reduce swelling in the brain after stroke.
2. Fish oil helps overall function of the nervous system and is considered “neuroprotective” (a substance that protects the nervous system).

Fish oil helps promote the neuroplastic process and appears to help the brain recover after stroke. Fish oil helps restore a neurotransmitter after traumatic brain injury. It may do the same after stroke.

Fish oil "treatment is able to facilitate functional recovery after (stroke)." It probably also reduces mortality after stroke.

Great general discussion of fish oil here. It turns out that cheap fish oil is just as good as the expensive stuff.

Remember, always ask your doctor first!

Repetitive Recovery and Rehabilitation

Modern clinical rehab research has confirmed what many rehabilitation clinicians have assumed to be true: Post-stroke motor recovery requires repetitive practice (RP). Many clinicians use RP as a tool to restore movement. But as is true with many core concepts in stroke recovery is also true with regard to RP. Namely, what rehab research reveals and what rehab clinicians use are two very different things. Bottom line: The fly in the ointment is the amount. Clinicians in rehab don't encourage enough repetitions.

The absolute minimum number of repetitions needed to drive cortical changes (brain rewiring) for a single joint movement is approximately 2,000. If it's a multiplanar, multi-joint movement, the numbers are in the tens of thousands if not hundreds of thousands of repetitions. Researchers in neuroscience talk about more than that; often the number of repetitions needed for quality movement is in the millions.

How many repetitions do clinicians in rehabilitation typically ask stroke survivors to perform per session? Studies in which clinicians are observed as they work with stroke survivors show that patients typically attempt approximately 50 repetitions in the average therapy session. A stroke survivor would need 40 sessions to get enough RP for a single joint.

I strongly advocate offloading much of the work to the person who owns the nervous system in question-the survivor. That is, to get enough RP to provide robust enough brain rewiring to promote quality movement, much of the work must be done when the survivor is not with the clinician. And this is a problem because many clinicians believe that if stroke survivors are encouraged to move without proper guidance, they'll use the stereotypical patterns available (called synergistic movement). If used enough, so the thinking goes, these movement patterns will be ingrained and the "incorrect" movement will never be unlearned. This perspective, reduced, sounds weird: "The more you move, the worse you'll get." It sounds weird because it erodes a foundational belief of the therapies: Exercise helps the brain and body heal.

It is true that repetitive practice of wrong movement will lead to more wrong movement. In athletes the idea of "bad practice leads to bad performance" is well known. This is why athletes strive to practice with perfect form. Stroke survivors are no different. Unless there is a precise evaluation of movement deficits, there's no way to tell what should be practiced. When it comes to movement, quality matters. And quality matters for many reasons, because bad movement:

• Takes more energy than good movement;

• Takes more time than good movement;

• Can lead to injuries;

• Can lead to a lack of enjoyment of a wide range of activities;

• Looks bad, which has social implications.

So how does a stroke survivor reverse "bad practice leads to that movement?" That is, how do you do "good practice" that leads to "good movement?"

My lab work has focused on stroke-specific outcome measures testing post-stroke movement. I used a laundry list of these outcome measures. 

They are often complicated and require special equipment. We also use movement analysis laboratories that collect thousands of bits of data to determine whether movement is increasing or decreasing in quality. Finally, we use technologies like functional magnetic resonance imaging and transcranial magnetic stimulation to determine whether the part of the brain dedicated to movement is expanding.

But what of my earlier suggestion of offloading much of the work onto the survivor? Because it takes so many repetitions to drive robust change, they are to do much of the work. So stroke survivors must evaluate their own movement. And once they evaluate the movement, they must adjust according to the evaluation. For the stroke survivor trying to improve quality of movement, some of the simplest "data collection" works quite well.

• Using mirrors to provide real-time feedback can be helpful. Using a mirror at the end of a treadmill can provide insight into the quality of gait. 
• In the upper extremity, it is helpful to use the "good" side to remind yourself what "normal" looks like.
• Videotaping specific movements throughout the arc of recovery can be helpful as well. Video provides a chronological log of where you were and where you are now, and can suggest what to work on next.

It comes down to a lot of the right kind of practice. As Vince Lombardi put it, "Practice does not make perfect. Only perfect practice makes perfect."

Neuro-Developmental Treatment: meh.

I'm going to copy some of my favorite quotes about NDT/Bobath. The quotes themselves are links that will take you to the reference.

"The NDT approach was not found effective in the care of stroke patients in the hospital setting. Health care professionals need to reconsider the use of this approach."

"There is now a growing body of research and opinion saying Bobath is out of date and obsolete, not least because of emerging data from neurosciences and should be abandoned in favour of an evidence-based approach."

"Families continue to be advised that they should seek Bobath- or NDT-trained therapists and avoid those who are not, which unfairly and, I would contend, unethically discredits those therapists and programs providing evidence-based treatment but are not using NDT."

"The Bobath concept is now so diverse that it can be difficult to know where it came from and what it is: there are so many derivatives of it that it could be considered a disservice to ... Bobath to continue to practise under the Bobath name."

(NDT trained therapists) "talk about quality of motor control and motor performance, but they do not understand how to measure quality... observation is not an appropriate way to say this works."

"It is hard to justify continuing to use Bobath nowadays, when the evidence to support other treatments is so much stronger.’

"It is almost impossible to define what Bobath/NDT is in current times given that the approach has become so diverse, and in all probability, one needs to go back to the original Bobath ideas to understand what it is."

"Results show no evidence proving the effectiveness of NDT or supporting NDT as the optimal type of treatment..."

"There was no evidence of superiority of Bobath on sensorimotor control of upper and lower limb, dexterity, mobility, activities of daily living, health-related quality of life, and cost-effectiveness."

The following quote is my personal favorite. NDT has a long history of taking the hard work of researchers and exclaiming "That's NDT!" They then proceed to screw up a perfectly good treatment option by smearing Bobath/NDT all over it.

"I refer to (followers of Berta and Karel Bobath) as the ‘torch carriers’, likening them to those who ‘carry a torch’ for someone in a romantic sense, something which is typically not reciprocated or based in present day reality."

"A disconcerting facet of the torch bearer approach is that therapy principles and programs developed by other innovative clinical researchers or scientists are now considered an integral part of NDT or Bobath. Why does this method have the right to pull in everything that comes into its path like a supernova that becomes a black hole?"

Study
systematic review
systematic review
systematic review
a great non-scientific discussion here

Neuro-Developmental Treatment. That's a lot of syllables. Very scientific sounding. It was developed by Berta Bobath, and for a long time was called The Bobath concept. Let’s just call it NDT/Bobath.

NDT/Bobath has been used on stroke survivors for decades and decades. When I was in school professors talked about it as if it was the most awesomest thing that had ever been awesome. It was the pinnacle. But it was complicated. It was so complicated you couldn't even learn it in school. You have to learn it from other NDT/Bobath practitioners. You could've gone to the Harvard school of physical therapy (if there was one -- which there isn't) and you still couldn't learn NDT/Bobath. Which is a red flag right there. If it works so well it would be required.

Instead, after graduating you have to go and get "certified" by NDT/Bobath gurus. Those gurus would've learned from other gurus, and up the pyramid it goes. NDT/Bobath training is expensive. We're talking about thousands of dollars and weeks of a therapist's life.

What could they possibly be teaching for that amount of time and money? 

NDT/Bobath uses "patient handling" where if you touch the patient in a particular way the patient would get better. Which makes no sense. If you could touch somebody and make them better that would be really nice. Touching is great. "Hands-on" is something that no therapist seems to be able to get enough of. But does this hands-on treatment work for stroke? Is NDT/Bobath effective?

No and not really.

And how do I know this? Systematic reviews.  Systematic reviews can be used to figure out if anything is effective for anything -- at least in medicine. If you want to be sure that something is effective you turn to systematic reviews. It's basically a study of all the qualified studies of whatever the subject is. This study of studies either says the thing works, the thing doesn't work, or they don't know yet.

NDT/Bobath always does poorly in systematic reviews. And that should be the end of it, right? It doesn't work. Goodbye. But not so fast.

Imagine if you'd spent thousands of dollars and weeks of your life in training. And in some fancy underpantsy researcher comes up and says "That doesn't work." What would you do? I've been doing talks for years to therapists. I've heard every justification for continuing NDT/Bobath.

Here are some arguments made by NDT/Bobath therapists:

1. "There's research that says it works, and research that says it doesn't work. Its 'he said she said' I choose to believe the research that says it works."

There are individual studies that say that NDT/Bobath works. But this is why scientists insist that studies be replicated. Individual studies prove little. The real question is, what do all the studies say? Large groups of studies, from researchers around the world, can be looked at and analyzed en masse. These "studies of studies" are called meta- analyses and systematic reviews. For NDT/Bobath there are quite a few; links below. They all come to the same conclusion: NDT is not particularly effective.

2. "NDT incorporates all the latest research into NDT. Therefore NDT is research-based."

I call this the "Horshella." 

Person 1: "I love horseradish."  
Person 2: "Well I love Nutella!" 
Person 1: "Oh, horseradish tastes great with Nutella." 

Maybe. But we should probably test it before we market "Horshella". Smearing NDT/Bobath all over well run clinical trials does not make NDT/Bobath research-based. In fact, it destroys the original research by adding a debilitating confounding variable. Adding NDT/Bobath to a well researched intervention may make that intervention better, worse, or not affect it at all. But the original research was never done with NDT/Bobath, so we'll never know. Stealing other people's research and glomming it does not make your intervention research-based. All you've done is hijacked well run clinical trials, and in the process made everyone look bad.

3. "I don't need research to tell me something works. I've seen it work."

The world is flat. And I can prove it. Look out the window. See? I know global warming is not happening. When I got out of the shower this morning I was freezing! The point is: Clinicians are not blinded, they don't gather and analyze data, they don't have a control group, there is no elimination of confounds and on and on. Simply: Clinical observation won't tell you if A works better than B.


4. "Research doesn't know what works so I can use anything I want."

Here is the American Heart Association Scientific Statement on the Rehabilitation Care of the Stroke Patient. It mentions constraint induced therapy, electrical stimulation, robotics, etc. It not only doesn't recommend NDT, it doesn't even mention NDT.

5. "What do I use for very low level survivors? They can't move and/or can't follow directions. So, I move them. At least I'm doing something."

Nothing else stops the plague so we're sticking with leeches. (The difference is that leeches may actually do harm. NDT does not do harm except in the sense that it leeches (!) $$ that could be better spent elsewhere.) 

Remember: There are only two kinds of true paralysis after stroke: Spastic and flaccid. Most survivors can move. Many, however are told not to move on their own because its bad movement, and will cause more bad movement. And who suggested bad movement will cause more bad movement (which is not true)? Bobath! Bobath called the movement after stroke "pathological" and insisted it be suppressed.  I call this the "The more you move the worse you'll get" philosophy.

Here are my suggestions:

• If you have a therapist that's doing NDT/Bobath, have them read this blog entry. 
• If you're a therapist doing NDT/Bobath, consider the evidence.

Mirror Therapy Stroke Recovery

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     Most recovery from stroke requires neuroplastic "rewiring" of the brain. Forging neuroplastic change in the cortex, the outer shell of the brain where much of neuroplastic action takes place, involves an incredible amount of effort on the part of the stroke survivor. 

It also takes time and resources dedicated to that effort. There are, however, recovery options that stroke survivors can use that to not burn through a lot of resources.  These recovery options can be added as a simple and effective adjunct to traditional therapy.

One example of such a recovery option is mirror therapy. Much research remains to be done to fully prove efficacy of mirror therapy. But for some stroke survivors mirror therapy appears to be a promising and effective option for reestablishing cortical control over wayward limbs.

Mirror therapy

·        requires very little training

·        is easy to set up

·        requires inexpensive equipment

·        is not taxing to the patient.

Mirror therapy for the upper extremity.

The stroke survivor is seated. A mirror is aligned to intersect with the patient's body in the sagittal plane at chest level. This is usually done by placing the mirror on a table with the hands resting on the table on either side of the mirror. The reflective part of the mirror faces the unaffected side. As the patient looks into the mirror, all they see is the unaffected side. The mirror blocks the view of the unaffected side of the body. The patient gazes into the mirror reflecting the "good" hand. When the "good" hand is moved the mirror gives the illusion that the "bad" hand is moving perfectly well.

Often, a "mirror box"—usually about twice the size of a shoebox—is used.  On one outside surface of the box is a mirror, which faces the unaffected side. The patient places the affected hand in the box so it is covered on all sides. The stroke survivor attempts to copy the movement of the “good” arm and hand with the hemiparetic arm. In other words, the movements are done symmetrically, like conducting an orchestra. However, the stroke survivor only sees the reflection of the good hand.

Mirror therapy for the lower extremity.

The stroke survivor can be either in long sitting on a plinth or seated on a chair. The advantage of the plinth is that the lower extremity is more easily viewed. The advantage of the chair is that it may be more comfortable for some patients. In either case, a mirror is placed the between the patient's legs to intersect patient's body in the sagittal plane. As with the upper extremity, the mirror is facing the unaffected side. The patient is instructed to plantar and dorsiflex the unaffected side ankle, and at the same time attempting to do the same movement with the unaffected side. The speed of the movement is self-selected.

Dosage.

For both the upper and lower extremity the dosage is 30 minutes a day, five days a week for four weeks.

How and why does it work?

There are two explanations for why mirror therapy seems to show efficacy in clinical research. The first is technical. The second explanation is better suited for patients who are less interested in the science and more interested in efficacy.

The scientific basis seems to be in what is activated when we are presented with the illusion of seeing both limbs when, in reality, we are only seeing one. Transcranial magnetic stimulation studies with mirror therapy reveal something remarkable; when the left hand is moving the left motor cortex is excited, and vice versa. Normally, of course, when the left hand moves, the motor cortex on the right side is activated. So if the stroke survivor has right-sided hemiparesis, viewing the "false” right hand in the mirror will activate the portion of the brain that controls the hemiparetic hand. If the stroke survivor is trying to activate the motor cortex for the affected side limb, research suggests that mirror therapy can be used to initiate that activation.

The simple explanation. But just like any other neuroplasticity-driving treatment option, it is primarily through the effort of the stroke survivor that rewiring takes place. For that reason it is essential that stroke survivors are educated on what works and how it works. Stroke survivors need to know why they're doing what they're doing in order to have them on board for the process. The challenge of making things scientifically accurate and easy-to-understand is essential to any patient education. Mirror therapy is no exception. The following can be used to describe the essence of mirror therapy to patients considering this option:

·        The reflection of the good arm superimposes normal sensory signals on the brain.

·        Mirror therapy provides proper visual input because the reflection helps them think that their affected arm is moving correctly.

·        The reflection, perceived to be accurate movement is thought to reorganize the way the brain is wired.

·       This fooling of the brain stimulates the brain to help with control of limb movement.

Here is a vid that will give you a general idea of how it works. I would suggest that the skill this therapist is suggesting (handwriting) may not be the best for this patient for 2 reasons:
1. Handwriting is a skill usually only done by the dominant hand. This patient cannot adequately perform handwriting with his non-dominant hand. So his left hand may not be the best teacher. This patient would probably be better served by working on something that the left hand can do flawlessly and that the right hand can learn from.
2. What movement should be chosen? I would suggest working on whatever movement the "bad" hand is on the cusp of doing. So if the survivor is on the cusp of opening the hand, work on that. Simple, basic movements seem to work best.