E=Recovery

Banking energy is essential to recovery. Muscle strengthening (even on the unaffected side) and cardio work, i.e. walking, recumbent steppers, upper-body ergometers) are essential to provide the underlying "banking" of energy. The banked energy is needed to provide the fuel needed to do the hard work of recovery. The average stroke survivor has half the amount of cardiovascular strength as age-matched "couch potatoes." But most ADLs (walking is what is usually measured) take twice as much energy. In other words, stroke survivors have half the energy to do twice the work.

The foundation of all recovery from stroke involves neuroplastic "rewiring" of the brain. And while the energy needed to drive neuroplastic change has not been measured, one thing is for sure-neuroplasticity takes a lot of energy. The buzz word in rehab research is intensity. But how can you do intensive without enough energy?

Up to 70 percent of stroke survivors suffer from severe fatigue. Many survivors consider fatigue the worst aspect of post- stroke life. Banking energy goes a long way toward fighting fatigue.

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Meaningful: Driving Stroke Recovery

When practicing to relearn movement effort should be task-specific. That is, tasks or component parts of a task should be practiced.  Choose tasks that are very meaningful. The more meaningful the task, the more motivation available. The more motivated, the more effort will be brought to bear. The more effort exerted, the more neuroplastic (brain rewiring) change will be driven. 

What motivates you? Fear? Friends not dropping by because you can't play cards anymore? Clients not trusting you because you've had a stroke? Recovery is not supposed to be comfortable. A dash of desperation is necessary.

Stretching After Stroke

Address soft tissue shortening.

Until soft tissue shortening is addressed (i.e. muscle tightness), the chronic (post 3 month) survivor has no chance of functional recovery. You can do a ton of hard work but if the muscle length is not there, that's as far as you'll go. It's that simple. This is particularly true of the tendency toward the shortening of soft tissue in the elbow, wrist, finger flexors in the arm and hand. In the leg and foot the main concern is the calf muscle. This muscle often shortens because the calf often has spasticity. Spasticity keeps the foot pointed down in that position, if held long enough will shorten the muscle.

There is a tendency for patients with chronic stroke to limit their stretching of at-risk joints to a few times a day. I would suggest that, given no pathological or orthopedic reasons not to, stretching should be done often. (Always: check with you friendly neighborhood PT or OT!)

Any therapist who works with any patient population with spasticity should know the implications of Botox and intrathecal baclofen, the range of oral medications as well as splinting. The anti-spasticity qualities of these medications are beyond the scope of this article, but they are important in the treatment of spasticity. And therapists are often the clinicians who can redirect patients back to physiatrists and neurologists. These docs then can suggest appropriate meds.

Upon discharge, therapists should "read the riot act" to stroke survivors. Therapists should inform them of the dangers of soft tissue shortening, including decreased function, less chance for future rehabilitation, pain and contracture.

(Note: There is considerable debate about the effectiveness of stretching out spastic muscles. This debate is not among clinicians as much as waged within the world of rehabilitation research. However, even though the scientists are not yet fully convinced, there's reasons to stretch outside of retention of tissue length. For example, the number one cause of poststroke shoulder pain is not subluxation (shoulder separation due to weakness of the shoulder muscles). The number one causes adhesions that build up in the capsule the shoulder. What keeps these adhesions at bay? Stretching. Or at least "ranging." "Ranging" is a term that therapists use to mean not necessary to be stretching, but taking the joint through its full range of motion. Ranging is done passively, as his stretching. That is, stroke survivors limb is moved through its available painless range of motion, but some outside force does it. It might be clinician, a caregiver, or the survivor themselves ranging the joint.)

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Stroke Recovery: One Myth, Two MDs

Assume no plateau.

Time and time again, the idea of a plateau in post-stroke recovery has been refuted, both in research and anecdotally. It is the responsibility of the therapist to let the patient know that the culmination of therapy this is not the beginning of the end, but the end of the beginning. The patient's rehabilitative efforts after discharge can be confusing, frustrating and not always entirely fruitful. But motivated patients can make gains if they are willing to try new ideas, adapt and research new techniques.

 Know the role of the physiatrist and neurologist.

I've asked physiatrists how often they suggest that their patients should schedule an appointment with them, once they've been discharged from therapies. Their answers tend to be all over the place. "If there is a change in function," or "If the patient is having an issue with meds," or "Once a year." But when a typical patient with stroke, who is perhaps five years post-stroke, is asked, "Who is your physiatrist?" the usual answer is, "I don't have any problems with my feet."

The fact is that patients with stroke often lose touch with their physiatrists because many don't see the need for a doctor who directed their acute rehabilitation. They know they've "plateaued"—so why would they need the "stroke doctor" (as physiatrists and neurologists are often called)? But there are good reasons to reintroduce yourself to your physiatrist. Only physiatrists and neurologists are trained to measure nuanced change, know about the latest applicable medications, and understand the true breadth of rehabilitative care as it relates to patients with stroke.

Stroke Survivors Are...

Athletes

There are two populations of patients who usually recover from stroke faster than others (or, at least, have a great advantage): Athletes (incl. dance, yoga, martial arts, etc.) and musicians. 

There are three reasons for this...

Reason one: There may very well be hypertrophy of the motor portions of the brain in both athletes and musicians. We know that massed practice will reconfigure the brain, with new neurons recruited and new pathways developed. And which populations are, by definition, involved in massed practice? Athletes and musicians. 

Reason two: As anyone who is either an athlete or a musician knows, both these populations know how to train. And I don't mean just, "Yeah, I did my therapy today" kind of training. I mean the "I dream about therapy, wake up and plan my day around therapy and dedicate most of my time to therapy," kind of training. 

Reason three: Athletes and musicians are often extremely motivated to get back to their instrument or their sport.

Both athletes and musicians understand all the factors that are important to stroke rehab. They know how to practice with vigor and focus. They know the commitment of time and resources that such practice involves. And they know that if their practice routine changes, they will get different results.

Stroke survivors are true athletes. Lower level athletes playing a higher stakes game. But on the other hand, they have the most devoted fans in sport: Their loved ones. And their families and friends have every reason, both altruistic and self-serving, to coach, cajole, encourage, support and embolden their athlete toward success.