List of Post-Stroke Sequelae. Stroke symptoms.

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Sequelae: Plural of Sequela. 

A pathological condition resulting from a disease. An aftereffect of disease.

Body Including Limbs 
Sensory impairment including tactile,  pressure, Proprioception
Hemiplegia
Hemiparesis
Subluxation
Shoulder hand syndrome/RSD
Flaccidity (hypotonicity)
Balance problems
Apraxia
Hemineglect 
Altered walking gait
Vertigo
Neurogenic bladder
Eyes
Hemieposia
Eating
Dysphagia is difficulty in swallowing.
Aphagia – Inability or refusal to swallow.
Risk of aspiration
Seizures
Spasticity
Soft tissue shortening/contracture
Genu recuvatm
Speaking
Dysphasia: Impairment of speech.
Aphasia: Language disorder (defect or loss of the power of expression by speech, writing, or signs.
Dysphasia and aphasia are synonymous terms.  They mean a language disorder with impairment of speech and comprehension of speech. 
Physchosocial
Depression
Decrease sexuality
Indifference, inappropriateness, depression, mania 
"Other"
Recurrent stroke

Repetitive Practice Stroke

What is the key to recovery? Everybody now: Repetition! I've written about this before here, here and here (journal article; co-author).

Everybody knows that repetitive practice (also known as repetitive task practice) is the way to reestablish executive (brain) control over the body. To regain control of an arm and hand repetitive practice can be used to reestablish that control. To regain control over a leg during walking, repetitive practice (walking) can be used to reestablish control over walking.

It's not rocket science. And it's not brain science, until it is.

The thing that they don't tell you is how many repetitions you have to do. The first person to talk about the power of repetitive practice was Randolph J. Nudo. You pretty much can't read any journal article on stroke rehab research that doesn't involve a reference to this guy. His suggestion was that 2500 repetitions would begin to change the brain enough to make that movement better. In constraint induced therapy there is approximately 200 repetitions per therapy session. In typical rehab there's about 32 repetitions or therapy session. It looks as if the number may be approximately a total of 1200 reps. That would require about three hours per day.

As you can imagine, these numbers are rather variable. The amount of focus brought to each repetition would be one variable. The complexity of the movement that you're trying to relearn would be another variable. The number of joints that the movement required would be a variable. The number of directions that that limb would have to move in order to carry out the task would be a variable.

But I think we can all agree that most stroke survivors don't attempt these numbers of repetitions. 

Here is the other question: How do you do all the repetitions you need to do without driving yourself crazy? 

Here is the only possible answer: Tie it to something that you care about.

Get cracking.

I'm not drunk, "retarded", or mentally unstable

Its a pretty simple calculus: If you don't use it you lose it. But there's a corollary: If you don't try it you can't possibly gain it. For example, if you use an AFO to walk during the early days after stroke, you'll not easily not use the thing again. 

And if I choose not to play violin- an instrument I've never played- I'll not get better at violin. So, both learning for anyone and relearning after stroke involves taking your brain (where learning happens) out of your brain's comfort zone.

Which leads me to spouses. I've met a ton of 'em. The wife is aphasic, the husband loves her, knows what she's trying to say and finishes the sentence for her. (When its men I always get the feeling they're saying to themselves, "Finally, I get to do the talking!") The spouse can become the exact thing they don't need. 

I always liked talking to folks who are aphasic. I usually get trampled by conversations because I'm slow in the think department. Aphasic folks give me a chance to ruminate a bit. Try it. Slow the conversation.

But "I've gotta get on with my life. How is it good to have my wife talk slowly when we're trying to check out (or ask directions, or talk to the gas station attendant)?"

Here's how its good. Do you know anyone who doesn't stumble and bumble their way through conversations? OK, a few people are so verbally dexterous that they don't really have this problem, ever. But nobody likes those people.

Why shouldn't someone who has a language deficit struggle as much as we do? They should struggle. Once they don't struggle, you know whats that's called?

A plateau. 
Beside, aphasia can be fetching. 

Stretching reduces spasticity. Yeah, no.

OK class, here's your quiz:

1. Stretching decreases spasticity T/F

2. Stretching increases the length of spastic muscles T/F

3. Stretching reduces the chance of contracture (muscle stuck at a shortened length) T/F

4. Stretch helps make joints more mobile T/F

First of all, why stretching is good: 

Stretch is good for joints. Every time we move, joints are "lubricated." That is, joints require movement in order for the fluid in the joint (synovial fluid) to be properly distributed. Stroke survivors, because they are typically weak on one side, don't get the joints on the "bad" side to move enough. How much is enough? Look at it this way, on the "good" side your joints, all of them, will be moved through their entire arc of movement (called range of motion) dozens if not hundreds of times per day. How many times are your "bad" side joints moved? Because they have trouble moving, it is wise to move them either with the "good" side doing the work, or a caregiver doing the work. This is called passive ranging.

But while stretching may be good for joints, the affect of stretch on muscles and other soft tissue (ligaments, blood vessels, fat, etc.) is, so far as the science says, negligible. So the answer to your quiz is F, F, F, and F.

I know this is hard to believe. And it is counter to what some therapists think. But it is confusing. There is an immediate effect of stretch on spasticity, everyone knows that. But this is one of the many reasons stroke is so devious; what is true now may not be true 5 minutes from now.

This is a frustration for many clinicians. You observe something is true (i.e. spasticity wanes with stretch) only to find that with the next big movement by the survivor, spasticity comes right back.

Further reading from this blog on spasticity here and here. 
                            

Building the Recovery Wall

Scott Gallagher posted a comment to a previous blog post. I'll paste that comment at the bottom.

What caught my eye in his comment is the conflict between repetition and quality. The conflict goes like this: If you do a ton of repetitions you may not concentrate on quality. If you concentrate on quality you may not hit enough repetitions.

I do a lot of talks about stroke recovery to clinicians. There is a small but vocal group of therapists who believe that if you don't focus on quality you may as well not practice. "Perfect practice means perfect recovery." I completely disagree. What if the survivor doesn't move perfectly? The answer by these clinicians is "I use hand over hand techniques to make sure that they do." Basically, they move the stroke survivor in the proper arc of movement. (BTW: the original quote was, "Practice does not make perfect. Only perfect practice makes perfect." - Vince Lombardi. Vince Lombardi was dealing with professional athletes. If he was coaching peewee football his quote would've been "We're not asking for perfection, we're asking you practice.")

There's several problems with stroke recovery put to this "If its not perfect, don't bother" philosophy. First of all, who's to say what "good" movement is after stroke? If somebody's trying to learn golf and they suck, nobody stands behind them and says, "You're doing it wrong." The more you practice golf, the better you'll get. Should you practice proper technique? Yes. But stroke survivors know proper technique. They've been doing these movements for all the years prior to their stroke. And even if they forgot they can model with the unaffected side.

 strongerafterstrokeblogpants

Second, this philosophy suggests a therapist. "Don't move unless I'm there to help you move." Alternatively this can be expressed as, "The more you move the worse you'll get." But therapists can't be with the survivor all the time, and the survivor doesn't have enough money in their pocket to pay for endless therapy. There is some good news... "The more you move the worse you'll get." Hogwash. Moving a lot on your own leads to better movement as long as you make the movements challenging (always reaching beyond you present ability).

Third, when's the last time you saw a coach with their hands all over a player? When's the last time you saw a music teacher with their hands overlapping the hands of the trumpet player? Learning movement involves mistakes corrected.

Scott Gallagher puts it this way "...any time I tried to insert control or effectiveness into my program, whether it would be with walking or with the hand, it would drive the repetition numbers down and my recovery would stall." And I know that is taken out of context, but as it stands as a quote I agree with it.

Scott Gallagher: If complete recovery is the goal, one problem might be in the sheer numbers involved. I have no reason to think that my stroke was anything but whatever might be considered a normal stroke, but currently in measured distance I'm at 5,112 walking miles. I'm so close to recovered, I'd say 5,000 miles is what it took for me to fully walk normally again. I tried speed walking, but the problem I was having was that any time I tried to insert control or effectiveness into my program, whether it would be with walking or with the hand, it would drive the repetition numbers down and my recovery would stall. My strategy, then, became one of brute force: keep it simple and push those repetition numbers up. But even if I had effectively used speed walking, how effective could it be? Even if it took 3,000 miles off my total distance, that would still leave 2,000 miles left to cover. I only made it through by switching from an exercise-based program to a mind and motivation-strengthening program. For all but a very, very few the repetitions required for full stroke recovery may make it, although possible, simply unfeasible. Come to think of it, though, your post may have been intended for a less hardened recovery program. Thanks.

Thank you Scott! 

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