Emerging Stroke Recovery Treatments? Yeah NO.

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Just caught this over at Dean's stellar stroke-recovery site:

An article called "Emerging Treatments for Motor Rehabilitation After Stroke."  They include:
1. mirror therapy
2. motor imagery or mental practice
3. constraint-induced movement therapy
4. noninvasive brain stimulation 
5. selective serotonin reuptake inhibitor medications

A coupla itzy problems: These treatment options have been around for at least a decade and at least one has little proven efficacy.

Let's get the 5th one out of the way; these meds (SSRIs) are things like prozak and paxil and they usually treat depression. They've been used forever to treat depression in survivors. Do they help depression, yeah. Do they help you recover, no. SSRI's effectiveness-- if you take JAMA's word for it: meh. BTW, Mild to moderate depression is probably better treated with exercise. (A review here from Harvard.) And exercise is what survivors ought to be doing anyway, so its a two-fer! 

The 2nd and 3rd I've been involved in published clinical trials and have written about in my book, blog entries and magazine articles. In fact, our group, led by our fearless leader Stephen J. Page, was the first to do a modification of constraint induced therapy, and the first to look at motor imagery post stroke. And this goes back to the late 90s. "Emerging Treatments." Yeah. No. I've written about it extensively in every edition of my book as well as magazine articles, journal articles and every talk I've ever done.

Mirror therapy has been around for stroke, again, since the late 90s. I've written about it in this blog, in my book and in every talk.

Noninvasive brain stimulation is nonspecific but they're talking about Transcranial Magnetic Stimulation (TMS), which has been around for quite some time. Our group has done

a lot of work with the "next gen" of this called Navigated Transcranial Magnetic Stimulation -- basically its more accurate. But there is no research that shows that sapping the "stroked" brain with TMS does anything--yet. Promising, maybe, but not much there...yet.

So we have 3 "emerging" treatment option that have been around for more than a decade, one option that probs does not work and one that we're not sure what it does or how to use it. 

Lumosity: NOT generalizable.

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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...

A Consensus on the Brain Training Industry from the Scientific Community 

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."

More here

Poor taste public service announcement!

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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!

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"Instant gratification and how it may hurt you" OR "It works great (and that's the problem)"

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You want to eliminate drop foot? 

Use an AFO, done!

You want the elbow to straighten?

Tap the triceps, done! 

  

You want the hand to stay open? 

Put a splint on, done!

You want to improve balance? 

Give 'em a walker, done!

You want to have them talk better? 

Give them a language aid, done!

You them to swallow better? 

Feed them thickened liquids, done!

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.

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The rules of recovery

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.