Pfft!

Great Question!

I get a lot of questions about stroke recovery and try to answer the best I can given the fact that I have rarely met the folks I'm giving advice to. Here is an email I got recently. Hope the following exchange helps some folks!

Dear Mr. Levine, 

In March of 2014 my friend had a stroke. She is 59, very gifted and motivated. She has received physical and occupational therapy from local facilities since then and has made a lot of improvement. We have obtained a Neuromove unit and recently got a Walkaide device for her foot, but it is looking like we are reaching the limit of local expertise to help her push forward. She has been very motivated up to now, but upon not satisfactorily acheiving some of her 6 month goals, has hit a rough patch. So we are just searching for anything that might spur her on at this point. We have looked into constraint induced programs locally, but not impressed with what we have found. Also, she is very reluctant to undergo the frustration she thinks this therapy will be. We don't want to encourage her to do something difficult without knowing it has a good chance of helping her. I am writing to you because your book has been a huge help in "coaching" her, and I thought you might know someone in New England who we could go to for help.

"Joan"

Hi "Joan,"

A couple quick things; it looks like you're doing the right thing re: NeuroMove, and the walkaid. I'm a pretty big fan of both of those. 

Secondly, if she is plateauing, that's to be expected. The general philosophy is that once the plateau has taken place, gains can continue to be made, but of course, the gains are much more conservative given an equal amount of work.

Sometimes it helps to work towards specific goals. For instance, your friend may walk great with the walkaid, but may not walk fast enough to make getting around outside useful. So increasing the speed of walking would be the goal. In fact, quickness can generally be used as a goal; upper body dressing, cooking a specific dish, making a bed etc. can all be goals were speed is worked on.

In terms of finding a place in New England, of course there are quite a few good ones. Find the link on this blog on the right hand column [-->] you'll see something that says "FIND A STROKE CENTER NEAR YOU?" Click on that, put in your ZIP Code, and all the hospitals that are supposed to be good at stroke recovery will come up- they should be able to direct you to the best rehab options. There's other links on there (on the right side column [-->]) to help you look for aggressive physiatry and other rehab clinicians.

One last thing, and this is a tough one… But your friend may be simply at the end of recovery. This is one thing I struggled with in my book… And in fact had somebody else write it; Kathy Spencer. I'll attach and image of her quote to this email (bottom of this blog entry). And she talks about the point at which living your life gets in the way of recovery. At some point there's not enough justification for the hard work given the amount of gains that are made. It's a decision that everybody has to make for themselves.

Have you looked into the saeboflex? It may be appropriate.

But, again,there's no magic algorithm here, it's just more work.

Please let me know if you have any other comments, insights, etc.

Best,     
Pete

(CLICK ON TEXT BELOW TO MAKE IT LARGER!)

The Brain Science Podcast: The brain brought to you by the people who actually study it.

First, a bit of a acknowledgement: 

Ginger Campbell wrote a very nice review of my book which

Ginger Campbell, MD

ended up on the book's cover. I asked her to write it because I love her podcast; The Brain Science Podcast. 

The podcast, which is usually in interview form, is an incredible resource for anyone interested in the brain. Ginger Campbell, the creator/director, interviews lions of neuroscience at the top of their game. I rarely find myself lost in her question and answer tête-à-tête. She strikes the perfect middle ground where you understand what they're talking about but it's not simplified into mush.

In the negotiation to get her to write a blurb for my book, she floated the idea of me being interviewed on the Brain Science Podcast, to which I spat my coffee all over the computer screen. Sure, interview a whole bunch of people who are teetering on the verge of a Nobel, and then interview me. I've decided I'm a "science communicator." And in this regard me and Dr. Campbell have a lot in common. She's not a neuroscientist, she's not a neurologist, as I understand it she's an ER MD (see her update to this, below). So it's been sheer curiosity that has driven her to the brain. And we have that in common. Every other organ in the body is known-- right down to its molecular structure, we know what's going on. But the brain is not only unknown, it's really unknown. 

Stroke has been the fascination of scientists since Hippocrates. Dr. Campbell has done several episodes on stroke but almost all the episodes has something relatable to stroke.

Please note, there is a link to the podcast on the right hand column (→) 

Here is Dr. Campbell's input on this entry...

"After spending over 20 years as an emergency physician I am now doing a Fellowship in Hospice and Palliative Care Medicine at the University of Alabama School of Medicine.

However, I do need to clarify the difference between Free and Premium episodes, which I hope you will pass on to your readers.

The 25 most recent episodes are ALWAYS free. This represents about 2 years of content. Free episodes are available in iTunes, Stitcher, and most other podcasting apps.

There is some limited Premium Content in iTunes, but this is from 2010 when I was experimenting with making Premium versions of new episodes. (I also had CD's of these but they didn't sell so I quit after 3 episodes (65-67).

The Premium subscription ($5/month) gives people unlimited to all the back episodes PLUS episode transcripts. Details at http://brainsciencepodcast.com/premium. I also offer all these episodes and transcripts for $1 each. These have been more popular than expected.

Access to the Premium content is via a special webpage and/or via the mobile APP, which is now free.

I have gotten a few complaints about putting some of my content behind a Pay wall, but many more listeners appreciate having an easy way to support my work. I don't make that much but since I took a 50% paycut to pursue my Fellowship in Palliative Medicine, every little bit helps!

One other thing: even the premium episodes contain Audible ads because there is no easy way to remove this."

"Science. Confusing everyone since the 1500s!"

Girl. 
For no particular reason.

An interesting article came out recently in the popular press. Bottom line: Oral contraceptives (OC) can increase risk of stroke. OC can also increase risks for other diseases as well.

Let's talk about stroke first. Current use of OC increases chance of a clot breaking of somewhere in the veins/arteries and causing stroke. Interesting side-note: Chances go up with the amount of estrogen in the OC. Nerdy way of saying this: "... the risk is directly proportional to the amount of estrogen present in the pill." 

The article also says there is an increase in brain and breast cancers. Brain cancer chance IS doubled but the type of brain cancer they're talking about is very rare so a doubling still makes it ... very rare. 

Breast cancer is increased but only if you are a recent user (within the prior year). 

And what of the affect of oral contraceptives (OC) on stroke? "Current OC use increases risks of venous thromboembolism and ischemic stroke. However, women of reproductive age are at low baseline risk, so the chances are small."

Hemianopsia (visual field cut) after stroke: The Neuroplastic model

Note: There are two free resources for retraining vision after stroke. Both are on the right hand column of this site (-->). Click on "Vision Problems? Click Here!" and/or "Tx for hemianopia and spatial neglect".

Sometimes survivors "neglect" their bad side. Survivors who have neglect don't pay attention (don't see or even recognize as their own) the "bad" side. In fact, it can be so bad that they don't even look at the "bad side" half of the world.

There are a ton of terms for this phenomenon. Unilateral neglect is the most common. Other terms are... 

• unilateral spatial agnosia 
• unilateral visual neglect 
• hemi-inattention
• hemi-imperception

This inattention may be caused by visual deficits on the neglected side— a problem of the eyes and eyesight. The problem with eyesight that cuts off half the world is called hemianopsia.

Or it may be a matter that the brain is not processing information coming from that side, including vision. Or it could be both of those (vision and a brain problem) together. 

Unilateral neglect and the brain 

What do we pay attention to? There's lots of stuff in this great big world so we make choices about what we attend to. But someone with unilateral neglect can't/won't pay attention to their "bad" side.  

The "neuroplastic model of stroke recovery" was a term I coined based on the observation that, no matter what deficits are left the survivor there are groups of researchers trying to develop "brain rewiring" treatments to reverse those deficits.

The neuroplastic model for Unilateral neglect becomes really clear if you look at it as more of a "won't" issue and less of a "can't" issue. If a survivor won't, it suggest that they could. Because if they won't then maybe their perspective can be changed so they will. So reducing inattention can be helped by paying more attention. 

With unilateral neglect inattention to the affected side is bad for obvious reasons. But Inattention is also bad, because, as this book points out: Inattention results in confusion, and confusion increases inattention. So what can be done? How do you get someone or yourself, to attend; to pay attention? 

Therapists contend that you should approach and do everything on the affected side so that the stroke survivor attends this affected side. However, it's a good idea to start off on the good side, otherwise, you may not know if the survivor is even paying attention to what you're trying to communicate with them. For instance the survivor may not understand instructions, context, spacial issues, etc. So do all the early teaching stuff on the good side.

To start with, survivors can be encouraged to turn their head towards the neglected side. Eventually, the survivor should be encouraged not to turn their head, but to move their eyes towards the neglected side.

It happens more often with people where the left side of their body is the "bad side." This may have something to do with the fact that we tend to be "right eye dominant." That is just in the normal course of human events, the right eye is the one that we more trust, and use.

Using tactile stimulation can help survivors be aware of the neglected side. You can use touch on the affected side, or rough cloth, a vibrator, etc.

It's a good idea for survivors to understand that they have neglected side. If it's a vision problem, be aware that you have vision loss on that side. Examples in the room around them can be used. You might say how many chairs in this room, and the survivor would only count half of them as they would neglect half the room, and therefore have the chairs.

Don't deny...

 "...unaware of the complete nature of the disability and even deny it, blaming the problem on eyeglasses that are too weak or a room that is too dark."

Nerdy take:

 "To enhance the integration of scanning behavior during functional tasks such as gait and dressing, the client should be reminded of scanning principles and carried through a series of scanning exercises before initiation of the activity. If inattention reappears during the activity, the therapist should stop and assist the client in becoming reoriented before the activity is resumed."