Stretching After Stroke

Address soft tissue shortening.

Until soft tissue shortening is addressed (i.e. muscle tightness), the chronic (post 3 month) survivor has no chance of functional recovery. You can do a ton of hard work but if the muscle length is not there, that's as far as you'll go. It's that simple. This is particularly true of the tendency toward the shortening of soft tissue in the elbow, wrist, finger flexors in the arm and hand. In the leg and foot the main concern is the calf muscle. This muscle often shortens because the calf often has spasticity. Spasticity keeps the foot pointed down in that position, if held long enough will shorten the muscle.

There is a tendency for patients with chronic stroke to limit their stretching of at-risk joints to a few times a day. I would suggest that, given no pathological or orthopedic reasons not to, stretching should be done often. (Always: check with you friendly neighborhood PT or OT!)

Any therapist who works with any patient population with spasticity should know the implications of Botox and intrathecal baclofen, the range of oral medications as well as splinting. The anti-spasticity qualities of these medications are beyond the scope of this article, but they are important in the treatment of spasticity. And therapists are often the clinicians who can redirect patients back to physiatrists and neurologists. These docs then can suggest appropriate meds.

Upon discharge, therapists should "read the riot act" to stroke survivors. Therapists should inform them of the dangers of soft tissue shortening, including decreased function, less chance for future rehabilitation, pain and contracture.

(Note: There is considerable debate about the effectiveness of stretching out spastic muscles. This debate is not among clinicians as much as waged within the world of rehabilitation research. However, even though the scientists are not yet fully convinced, there's reasons to stretch outside of retention of tissue length. For example, the number one cause of poststroke shoulder pain is not subluxation (shoulder separation due to weakness of the shoulder muscles). The number one causes adhesions that build up in the capsule the shoulder. What keeps these adhesions at bay? Stretching. Or at least "ranging." "Ranging" is a term that therapists use to mean not necessary to be stretching, but taking the joint through its full range of motion. Ranging is done passively, as his stretching. That is, stroke survivors limb is moved through its available painless range of motion, but some outside force does it. It might be clinician, a caregiver, or the survivor themselves ranging the joint.)

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Stroke Recovery: One Myth, Two MDs

Assume no plateau.

Time and time again, the idea of a plateau in post-stroke recovery has been refuted, both in research and anecdotally. It is the responsibility of the therapist to let the patient know that the culmination of therapy this is not the beginning of the end, but the end of the beginning. The patient's rehabilitative efforts after discharge can be confusing, frustrating and not always entirely fruitful. But motivated patients can make gains if they are willing to try new ideas, adapt and research new techniques.

 Know the role of the physiatrist and neurologist.

I've asked physiatrists how often they suggest that their patients should schedule an appointment with them, once they've been discharged from therapies. Their answers tend to be all over the place. "If there is a change in function," or "If the patient is having an issue with meds," or "Once a year." But when a typical patient with stroke, who is perhaps five years post-stroke, is asked, "Who is your physiatrist?" the usual answer is, "I don't have any problems with my feet."

The fact is that patients with stroke often lose touch with their physiatrists because many don't see the need for a doctor who directed their acute rehabilitation. They know they've "plateaued"—so why would they need the "stroke doctor" (as physiatrists and neurologists are often called)? But there are good reasons to reintroduce yourself to your physiatrist. Only physiatrists and neurologists are trained to measure nuanced change, know about the latest applicable medications, and understand the true breadth of rehabilitative care as it relates to patients with stroke.

Stroke Survivors Are...

Athletes

There are two populations of patients who usually recover from stroke faster than others (or, at least, have a great advantage): Athletes (incl. dance, yoga, martial arts, etc.) and musicians. 

There are three reasons for this...

Reason one: There may very well be hypertrophy of the motor portions of the brain in both athletes and musicians. We know that massed practice will reconfigure the brain, with new neurons recruited and new pathways developed. And which populations are, by definition, involved in massed practice? Athletes and musicians. 

Reason two: As anyone who is either an athlete or a musician knows, both these populations know how to train. And I don't mean just, "Yeah, I did my therapy today" kind of training. I mean the "I dream about therapy, wake up and plan my day around therapy and dedicate most of my time to therapy," kind of training. 

Reason three: Athletes and musicians are often extremely motivated to get back to their instrument or their sport.

Both athletes and musicians understand all the factors that are important to stroke rehab. They know how to practice with vigor and focus. They know the commitment of time and resources that such practice involves. And they know that if their practice routine changes, they will get different results.

Stroke survivors are true athletes. Lower level athletes playing a higher stakes game. But on the other hand, they have the most devoted fans in sport: Their loved ones. And their families and friends have every reason, both altruistic and self-serving, to coach, cajole, encourage, support and embolden their athlete toward success.

A great sentiment but...

The question becomes, what to do next? An important question every time you ask it. Even if mistakes are made, even if the wrong choice is made, keep making decisions. Even if you are not absolutely OBSESSIONAL about recovery, forever dedicate a part of yourself to the question...  

What to do next? 

Whatever the answer, make it outside the comfort zone.* Or, to put it another way: 

"Intensity of practice after stroke: More is better."

*While remaining safe.

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.