I've said before and I'll say it again, "brain training" games -- like those developed by lumosity -- have very little proven
efficacy. Do they change the brain? Yes. But so does just about everything else. Let me explain... there was a story that we used to tell in the lab and it went like this...
"If I throw you a set of keys, and you catch it, there will be neuroplastic change.
If I throw you a set of keys, and you try catch it drop it, there will be neuroplastic change.
If I throw you a set of keys, and you just watch the keys hit the floor, there will be neuroplastic change."
So do "brain traing " games change your brain? Yes. The change your brain to be better at the games. If the end result you want is to be better at the games, have at it, and become better at those games. But are the skills that you gain from these games generalizable to anything else in your life? Not that we know of.
Here is a recent article that says... well, let's put it this way... if you work for luminosity, you'll hate it...
Again, the key word here is "generalizable." Here's another article that makes the same point: "The authors conclude that memory training programs appear to produce short-term, specific training effects that do not generalize."
Have a look at this cartoon. In poor taste, yes. But it manages to raise awareness and it does it in a way that is comically accurate. Here is your quiz: Watch the vid and then do this: Just below the cartoon, highlight the invisible text by right clicking and dragging to the bottom of the post. Therein lies my observation of what the cartoon gets right. If you'd like me to add anything I've missed, put it in the comments or email me.
Highlight text below↓↓↓↓↓↓↓↓↓↓↓↓↓ 1. Drop foot 2. Inability to clear ground during swing phase of gait 3. Flaccid left upper 4. Lack of sensation left upper 5. Caregiver concern regarding driving 6. Difficulty with spacial issues while driving 7. Left hemiparesis, no aphasia! 8. "Stroke! Stroke! Stroke!" Its a public service announcement!More of the episode here...
In the comments section Jim Sparks points to a part in the episode where a treatment that is not proven to work, works!
In every case, and many more, short-term "instant gratification" often gets in the way of a more complete recovery.
Why and how?
The irony of stroke is that deficits to lifting the foot, swallowing, balance, etc. are exactly what needs to be embraced to promote recovery. So instead of throwing an external aid at the problem, sometimes its best to challenge the challenge.
If you want to speak French better, do you get an app?
If you want to learn how to work on your car do you hire a better mechanic?
If you want to be better at driving directions do you get a GPS?
In stroke, sometimes it is better to use the aid, no doubt. But choose your acquiescence wisely.
There's a difference – in my mind – between recovery and rehabilitation. Recovery is getting back what the stroke took. Rehabilitation is a medical model that may or may not help recovery.
I'm a fan of rehab for the most part. Good rehab from (approximately) the first week, through the first year in a system with folks who are trained and with the fundamental equipment needed to promote recovery, represents the best that can be done. But for most, this in not close to the reality.
But instead of trashing the system and the people in that system, let me focus on recovery. The rules of recovery are simple. The process is dauntingly difficult, but the rules are simple.
What are the rules of recovery?
The rules of recovery are the same as deeply learning anything arduous; lots of hard work, lots of repetition, lots of planning and constantly looking for breakthroughs.
Of course, there are a few flies in the ointment. What of spasticity? What about the classic stroke Catch-22-- if you can't move, how do you repeat a movement? If the ability to be rational is gone, can the level of effort needed be achieved? And then there is the huge number of other issues that can get in the way. Issues of balance and vision and sensation and all the other illnesses that may befall us, and finally, aging.
The rules of recovery are the rules of every effort and every success. Let's not make it complicated.
(Warning: ENDING THE USE OF AN AFO CAN LEAD TO FALLS AND INJURIES.
Never discontinue the use of an orthotic without first consulting the appropriate health care provider. Then call your doctor. Then have your doc talk to any other providers as needed. Then discuss it some more. Thank you.) For years I've been pointing out how whatclinicians focus on can hurt recovery. Clinicians focus on having the patient be safe and functional (able to do everyday tasks). Clinicians have the "safe and functional" mantra running through their heads constantly. There are two other things that influence what clinicians will to use to help survivors recover:
1. What managed care will pay for
2. What therapists know about stroke recovery
This leaves a very small group of available options. These options may or may not lend themselves to promoting the highest level of recovery. Recovery, yes. But not necessarily the highest level of potential recovery.
I think the best example of this is the AFO.
Before I get too technical, let me ask you a hypothetical.... Let's say you're a survivor. Your ankle is not moving well after stroke. But you know that recovery is unpredictable.
Here's my question: During the time in which your ankle is trying to come back, would you put it in a cast? Probs not. If you casted it and the ankle tried to come back it wouldn't be able to. It would be stuck in one position by the cast. This is where clinicians lose the plot (as the English say). They see this ankle issue as an ankle issue. But its not an ankle issue! Its a brain issue. And what's the first rule of the brain? What's the one rule that everybody knows about the brain? Use it or lose it.
Now this (casting example) is only a slight exaggeration of what happens when stroke survivors are put into an AFO.
Generally, AFOs are prescribed by clinicians waaaay too early. The brain has not revealed what it's capable of doing during the first few months after stroke. This phase, known as the subacute phase, typically last from 3 to 6 months. Clinicians will often prescribe the AFO in the first, second or third month after stroke.
And even before that... sometimes within the first 2-3 weeks after stroke, there is an effort to somehow bind the ankle in such a way that it is not required to move.
These all essentially lock the joint, disengaging the ankle muscles from what they've been using to lift the foot at the ankle since that survivor was born.
So why do clinicians do it?
Simple; They don't focus on what the brain needs. They're more... peripheral in their perspective. They're about muscles and bones and tendons and ligaments. You you can't see neurons, can't see the brain, can't see the brain "reawaken" after stroke, and you can't see cortical plasticity. The mind, for many clinicians, is out of sight out of mind.
And who do they listen to? Orthotists. And what do orthotists make? AFOs. So will the orthotist say to a clinician suggesting an AFO, "Naw, AFOs lead to learned nonuse." Probs not.
It's not that clinicians mean to do you harm. They want you to be safe and functional. They want you to be where you want to be: home. So there is a trade-off: Put you in an AFO and get you home safe and early, or wait and see what develops. Here's one thing that managed care won't pay for: Waiting to see what develops.
Its the instant gratification thing. Put an AFO on and survivors walk better instantly! But they also promote muscle atrophy, lock the joint (which joints hate because they like to move) and may lead to learned nonuse.
AND AFOs discourage walking.
"Hey mom, dad didn't put his ankle thingy on!"
"OK, lets just take the wheelchair!"
(Wanna know how hard it is to put on an AFO with one hand? This hard! ↓↓↓)
Oh, and one more thing... once the AFO is on there, its on for life. Why? Because an AFO will atrophy both the neurology and the muscles involved in walking. Further, it will so change your "gait kinematics" that NOT wearing will become a risk.
BTW: I'm not saying AFOs are never appropriate. Its just that they are not appropriate too early and they're not appropriate for everyone. Further reading: Here.
