 |
| Developed by Pete Levine Click for more info! |
You're supposed to do repetitive practice. But how are you supposed to repeat a movement when you can't move?
The ArmTran can help. It turns small amounts of strength into large movements!
Dec 15, 2015
$39 total. Because recovery should not cost an arm and a leg.
The ArmTran can help. It turns small amounts of strength into large movements!
Spasticity II: The Explanation
So how can you explain spasticity to patients and their significant others in a way that is easy to understand and scientifically valid?
Here is the story of spasticity. Spasticity happens because of a set of circumstances caught in an endless closed loop. The players in this story are the brain, the spinal cord and the spastic muscle (SM).
There is an injury to the brain. The brain can no longer control the SM. Muscle spindle sensitivity then develops because the flaccidity resulting from the lack of brain control causes overstretch of the SM.
The muscle spindle then sends a "Help, I'm being overstretched!" signal to the spinal cord. The spinal cord then sends the message to the brain. The brain would normally send down a mix of facilitory and inhibitory signals to stabilize the muscle. But the brain is not responding. So the spinal cord does.
The spinal cord says, "SM, do that thing you do!" The SM only does one thing: Flex. So flex it does. These messages go on and on during during most waking hours and for some who suffer from spasticicty, during all but the deepest of sleep. Eventually, the SM starts to lose sarcomeres (the contractile units in muscle) and the SM and other area muscles that are kept in a shortened position, lose length. The shortened muscle perceives everything as an overstretch and the alarm signals to the spinal cord proliferate. The process repeats itself in an endless cycle until contracture sets in.
Most therapeutic interventions therapists typically use are, at best, nominally effective against the symptoms of spasticity, and do little to address the underlying issues causing spasticity. Consider stretching. Stretching reduces spasticity, right? Stretching does retain soft tissue length and for that reason should be done often to spastic muscles. But research of the effectiveness of stretching in the reduction of spasticity, either through weight bearing, isotonic stretch without weight bearing as well as isokinetic stretching, is equivocal at best. Typically used modalities like cold and heat have a nebulous, short-term effect. There is strong evidence that splinting is ineffective in reduction of spasticity and contracture formation. Facilitory and handling techniques? Also no demonstrated effect.
Here is the story of spasticity. Spasticity happens because of a set of circumstances caught in an endless closed loop. The players in this story are the brain, the spinal cord and the spastic muscle (SM).
There is an injury to the brain. The brain can no longer control the SM. Muscle spindle sensitivity then develops because the flaccidity resulting from the lack of brain control causes overstretch of the SM.The muscle spindle then sends a "Help, I'm being overstretched!" signal to the spinal cord. The spinal cord then sends the message to the brain. The brain would normally send down a mix of facilitory and inhibitory signals to stabilize the muscle. But the brain is not responding. So the spinal cord does.
The spinal cord says, "SM, do that thing you do!" The SM only does one thing: Flex. So flex it does. These messages go on and on during during most waking hours and for some who suffer from spasticicty, during all but the deepest of sleep. Eventually, the SM starts to lose sarcomeres (the contractile units in muscle) and the SM and other area muscles that are kept in a shortened position, lose length. The shortened muscle perceives everything as an overstretch and the alarm signals to the spinal cord proliferate. The process repeats itself in an endless cycle until contracture sets in.
Most therapeutic interventions therapists typically use are, at best, nominally effective against the symptoms of spasticity, and do little to address the underlying issues causing spasticity. Consider stretching. Stretching reduces spasticity, right? Stretching does retain soft tissue length and for that reason should be done often to spastic muscles. But research of the effectiveness of stretching in the reduction of spasticity, either through weight bearing, isotonic stretch without weight bearing as well as isokinetic stretching, is equivocal at best. Typically used modalities like cold and heat have a nebulous, short-term effect. There is strong evidence that splinting is ineffective in reduction of spasticity and contracture formation. Facilitory and handling techniques? Also no demonstrated effect.
Brain + Comfort Zone = No Gain
The key to recovery is challenge. Heck, the key to learning anything new is challenge. (For stroke survivors movements that need to be re-learned are "new.")
So how much challenge is needed? Let's put it this way, one of the treatments used to improve quality and speed of walking that seems very promising is called "speed dependent treadmill training." How challenging is it? Check this out…
The survivor gets on a treadmill and harnessed to the ceiling with a strap around their chest, just under their arms. The strap doesn't do anything – it's just a safety belt so if they fall, they don't fall- if you fall oh. (heh heh- still got it!)
The speed of the treadmill is turned up until either the therapist or the stroke survivor freaks out. Trust me, I'm only nominally paraphrasing here.
The survivor gets on a treadmill and harnessed to the ceiling with a strap around their chest, just under their arms. The strap doesn't do anything – it's just a safety belt so if they fall, they don't fall- if you fall oh. (heh heh- still got it!)
The speed of the treadmill is turned up until either the therapist or the stroke survivor freaks out. Trust me, I'm only nominally paraphrasing here.
The "freak out" speed is considered the survivor's top speed. The survivors then rests for about five minutes. Then he gets back on the treadmill, harnessed again, and the speed of the treadmill is brought to half of his top speed for two or three minutes – as a warm-up.
The speed of the treadmill is then increased to their top
speed. If they can handle their top speed for 10 seconds, the speed of the treadmill is increased 10%. If they can handle that, there speed is increased another 10%. If they stumble it comes down 10%. But if they can then handle that for 10 seconds it increases 10%.
For this treatment, if speeds are plotted on a graph it looks kind of like the stock market – you have peaks and valleys but your speed is quicker at the end then at the beginning.
Think about that. The level of challenge is increased so much that it's defined by the person stumbling. This is where the brain operates. A safe brain does not grow. The brain has to be brought way outside it's comfort zone or doesn't change. True for anyone trying to learn anything. True for stroke survivors.
Guide recovery of walking after stroke
Here is a flowchart used to guide recovery of walking after stroke...
Boy, that's complicated!
How do we learn how to walk in the first place- as infants? Does it involve "treatments" that span from "Task Specific Training" to orthotics?
Stroke recovery is hurt by complexity. When rehab options become too complicated the stroke survivor is separated from their own recovery because they don't know what to do.
Forget survivors for the moment... At some point stroke recovery can become so complicated that even clinicians don't understand it. Or they don't understand the technology in the complicated system because they never interface with that complicated technology.
Have a look at the algorithm above. I would argue the whole thing is not only way too complicated, it's also incorrect.
I would like to rewrite the entire algorithm like this...
Do Doctors Know?
Medical doctors. MDs. They can be your best friend. If you’ve had a stroke they spent a lot
of their decade-plus of schooling training to save your life and save as much of your brain as they possibly could. When some MDs show up at the Pearly Gates, St. Peter is going to provide velveteen pathways to the VIP room.
 |
Sherrington:
A great MD/Scientist
that advanced stroke recovery
|
BUT.
Let’s be clear about this, your doctor is probably not a scientist. Very few are. The ones that are usually work at major academic institutions. Think Johns Hopkins.
A few quick points here…
1. Without a doubt, a rare few MDs do great, great scientific work that promotes medicine.
2. Almost all medical science is developed by neuroscientists, biologists, chemists, etc. Scientists develop treatments (from x-ray
 |
| Taub: A great psychologist who advanced stroke recovery. |
to antibiotics) and MDs make it illegal for anyone beyond themselves to prescribe them. Sometimes they make great gatekeepers, but they often screw it up.
In fact, assuming your MD is even committed to the science may be a bit of folly. "Only a fraction of what physicians do is based on solid evidence from Grade-A randomized, controlled trials; the rest is based instead on weak or no evidence and on subjective judgment. When scientific consensus exists on which clinical practices work effectively, physicians only sporadically follow that evidence correctly." (Scientific American)
Most MDs don’t do science, don’t do clinical trials and are not qualified as scientists. Many MDs are not qualified to interpret the science they need to do their jobs, especially if they are not specialized in the area in question. Asking a GP about leading-edge rheumatoid arthritis treatment is like asking a soccer player about basketball’s triangle offence; they may know, but they probs don’t. Even asking, say, a neurologist about, say, migraine is a mistake. How many pathologies do neurologists treat? Countless, that’s how many. Will they be an expert on migraine? Maybe.
So what does this mean to you, dear survivor? It means you have to do your own research, and find your own experts.
There is a bit of good news…if you are willing to work a bit. If you go to PubMed and ask it your questions (i.e.: aphasia stroke recovery) articles by scientists who are experts will bubble up and from there it’s just a hop-skip and jump to their email address. Ask the scientists on the bleeding edge your question. (Hint; be clear, specific and respectful for the best results.) Hack through the pseudo-scientific gobbledygook of medicine (haven’t you exhausted that already anyway?) and get to the extraordinary.
Off you go…