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.
(Warning: ENDING THE USE OF AN AFO CAN LEAD TO FALLS AND INJURIES.
Never discontinue the use of an orthotic without first consulting the appropriate health care provider. Then call your doctor. Then have your doc talk to any other providers as needed. Then discuss it some more. Thank you.) For years I've been pointing out how whatclinicians focus on can hurt recovery. Clinicians focus on having the patient be safe and functional (able to do everyday tasks). Clinicians have the "safe and functional" mantra running through their heads constantly. There are two other things that influence what clinicians will to use to help survivors recover:
1. What managed care will pay for
2. What therapists know about stroke recovery
This leaves a very small group of available options. These options may or may not lend themselves to promoting the highest level of recovery. Recovery, yes. But not necessarily the highest level of potential recovery.
I think the best example of this is the AFO.
Before I get too technical, let me ask you a hypothetical.... Let's say you're a survivor. Your ankle is not moving well after stroke. But you know that recovery is unpredictable.
Here's my question: During the time in which your ankle is trying to come back, would you put it in a cast? Probs not. If you casted it and the ankle tried to come back it wouldn't be able to. It would be stuck in one position by the cast. This is where clinicians lose the plot (as the English say). They see this ankle issue as an ankle issue. But its not an ankle issue! Its a brain issue. And what's the first rule of the brain? What's the one rule that everybody knows about the brain? Use it or lose it.
Now this (casting example) is only a slight exaggeration of what happens when stroke survivors are put into an AFO.
Generally, AFOs are prescribed by clinicians waaaay too early. The brain has not revealed what it's capable of doing during the first few months after stroke. This phase, known as the subacute phase, typically last from 3 to 6 months. Clinicians will often prescribe the AFO in the first, second or third month after stroke.
And even before that... sometimes within the first 2-3 weeks after stroke, there is an effort to somehow bind the ankle in such a way that it is not required to move.
These all essentially lock the joint, disengaging the ankle muscles from what they've been using to lift the foot at the ankle since that survivor was born.
So why do clinicians do it?
Simple; They don't focus on what the brain needs. They're more... peripheral in their perspective. They're about muscles and bones and tendons and ligaments. You you can't see neurons, can't see the brain, can't see the brain "reawaken" after stroke, and you can't see cortical plasticity. The mind, for many clinicians, is out of sight out of mind.
And who do they listen to? Orthotists. And what do orthotists make? AFOs. So will the orthotist say to a clinician suggesting an AFO, "Naw, AFOs lead to learned nonuse." Probs not.
It's not that clinicians mean to do you harm. They want you to be safe and functional. They want you to be where you want to be: home. So there is a trade-off: Put you in an AFO and get you home safe and early, or wait and see what develops. Here's one thing that managed care won't pay for: Waiting to see what develops.
Its the instant gratification thing. Put an AFO on and survivors walk better instantly! But they also promote muscle atrophy, lock the joint (which joints hate because they like to move) and may lead to learned nonuse.
AND AFOs discourage walking.
"Hey mom, dad didn't put his ankle thingy on!"
"OK, lets just take the wheelchair!"
(Wanna know how hard it is to put on an AFO with one hand? This hard! ↓↓↓)
Oh, and one more thing... once the AFO is on there, its on for life. Why? Because an AFO will atrophy both the neurology and the muscles involved in walking. Further, it will so change your "gait kinematics" that NOT wearing will become a risk.
BTW: I'm not saying AFOs are never appropriate. Its just that they are not appropriate too early and they're not appropriate for everyone. Further reading: Here.
Stroke survivors are given such a short time to recover. For everyone "motor learning" takes repeated attempts in order to rewire the brain. How much more effort must motor learning take in folks who have billions of neurons killed by their stroke? The numbers get very large. I've heard "2000 for a single joint" and " 140,00" "and "10,000" and "Tens of thousands" and" millions." But guess what? Every stroke is different. So the numbers for you and how you are trying to move are different than her and what she is trying to move. I think I've come up with the perfect number for everyone. This is based on my dozens of peer-reviewed coauthored studies, and clinical research at both the Kessler Institute and the U of Cincinnati. But the number is algorithmic and gets very complicated. Ready? Here's the number...
"A lot."
It is commonly and scientifically accepted that that it takes at least 10 years to become an expert in any field. We ask stroke survivors to relearn difficult tasks such as walking within a few months to a few years of their stroke. And all this difficult motor learning is done against a backdrop in which portions of the brain that is usually used for walking is deceased. And then there's all the other variables like other health issues, depression, lack of energy, natural aging and on and on.
Anyone who has children and has gone through boxes and boxes of Band-Aids and knows that motor learning is a challenge. Skinned knees and elbows attest to this. It takes years for children to learn how to walk. How much time do we give stroke survivors whose primary neuronal circuitry for walking has been taken off-line —6 months? Stroke survivors are best served through a combination of personal empowerment and guidance from therapists. No matter how ugly, no matter how synergistic, no matter how submerged in spasticity, each volitional movement should be encouraged. People with acquired brain injury will only drive their own neuroplastic rewiring through repeated volitional attempts, that “nip at the edges” of their ability. Therapists have traditionally focused more on quality of movement and functional relevance than on a confluence of gained active range of motion. No matter how incremental, increased active range of motion in all pivots and planes provides a template for any and all future movements.
Got a good question the other day about resistance training the other day. Please see the Q&A, below...
Q
I am a 43 year old stroke survivor(2010). I walk ok(not too pretty), can do light manual work, and can't run. My left affected side is considerqbly weaker than my dominnant, nonaffected right side.
I want to return to higher impact activities one day, but I just don't think I have the physical strength to do so.
I have read several articles by Sroke survivors who benefitted greatly from barbell-base systematic weight training as a means to advance recovery.
One writer mentioned (book) as a good place to begin. It emphasizes combination weight exercises that employ multiple muscle groups and run through a full range of motion.
Do you have any opinions or clinical experiences on the subject of Strength Training following Stroke or could direct me towards some materials to get started?
A
I did a quick review of the literature (example) and found that there's a general consensus that resistance training is a good thing post stroke. A really good thing. But there seems to be no consensus on what type of resistance training it should be. Keep in mind: Resistance training can injure. There are a ton of questions before you begin, like...
How stable is your "bad" shoulder?
Will you have the strength and coordination to hold whatever (barbell, band, etc) and not drop it?
Do you have sensation enough to know if you are injuring the limb?
One concern that therapists mistakenly have is that if you use muscles that have spasticity you will increase the spasticity. This is wrongheaded, and not true. So don't worry about using spastic muscles to help move you.
I have seen people who've had a stroke run again. They're almost always young (younger than 60). I would think that as long as you are okay with "a new normal" the sky is the limit.
