Saturday, January 24, 2015

What my Doctor Should Have Told me About Stroke Recovery

Dean Reinke
Deans’ Stroke Musing
Thursday, August 12, 2010

After four years this is what I expected during my hospital stay, with my therapists working on pieces to meet those needs. I received no information on stroke rehabilitation or even what the damage from stroke consisted of from my physiatrists. This is what I believe I should have received. If the medical profession is not willing to critique their own information delivery then we will have to do it for them. Some of these references probably didn't exist 4 years ago but if the same stroke happened today this is what a good doctor should be able to give you.

If your doctor doesn't give something like this to you, Point blank ask him/her 'Who can I go to that will give me hope/answers?' Remember the detriment of the nocebo effect.

You had a massive stroke affecting your right cerebral cortex, a clot plugged your middle cerebral artery at this location - shows me a three dimensional map of a brain and points out the location. This area here is the epicenter of the stroke, it includes the motor cortex, the part that controls your muscles on the left upper half side of your body. The pre-motor cortex was also destroyed, this does the planning for complicated muscle movements. The sensory cortex does not seem to have died. Your cognitive abilities were spared.

Because you had an ischemic stroke(clot) you will be started on warfarin, a blood thinner, eventually we will get you down to just using aspirin.

There are two types of damage to the brain, First is the epicenter, this area is dead, the second is called the penumbra, which is the area surrounding the epicenter that was partially damaged during your stroke. Recovery of the penumbra area usually spontaneously recovers in 6-12 months. This does not mean you can sit back and just wait for recovery to happen. The ability to move muscles in this area is fairly limited, in order to recover them to something close to pre-stroke levels, you will need to try very hard to move them even if they barely work. This may require thousands to millions of repetitions. The statement you will sometimes hear in regard to this is, 'Use it or lose it'. Any minimal movement you have will need to be diligently worked at. This is what can be called the easy neuroplasticity

The recovery of functions that were controlled by the areas that are now dead is much harder and will require you to neuroplastically move control to another location in your brain. Call this hard neuroplasticity. You do not have unused areas of your brain, the 10% brain use is a myth.

Neuroplasticity is the most important term for you to understand, read about and believe in. These books give a good explanation of this concept:
  • The mind and the Brain : neuroplasticity and the power of mental
  • force / Jeffrey M. Schwartz and Sharon Begley.
  • Train Your Mind, Change
  • Your Brain: How a New Science Reveals Our Extraordinary Potential to
  • Transform Ourselves by Sharon Begley
  • The brain that changes itself : stories of personal triumph from the frontiers of brain science / Norman Doidge.
  • Stronger After Stroke by Peter Levine, This one is worth buying.
CIMT (Constraint Induced Movement Therapy) is a way to get movement back. The concept is your working side, usually your arm/hand is prevented from moving you will retrain your non-working side to be able to do the movement needed. This is quite useful for areas that are in the penumbra on the stroke.

If you find that your sense of touch is not up to pre-stroke levels this document will give you a good idea of what needs to be done.

Researchers found that cycles of heat and cold significantly enhanced the
sensory and motor function in the arms and hands of stroke survivors after a few weeks of therapy.

For recovering the functions that were in the dead area there are a number of possibilities. Here are printouts of research studies. None of these are far enough along to have therapy protocols but this is the best we can do right now
  1. Passive Movement, moving the affected limb with the good limb. The effects of repetitive proprioceptive stimulation on corticomotor representation in intact and hemiplegic individuals.
  2. Mental imagery, Imagining doing something like playing the piano or whatever you used to be able to do with the affected side but can't now. Efficacy of motor imagery in post-stroke rehabilitation: a systematic review. Andrea Zimmermann-Schlatter, Corina Schuster, Milo A Puhan, Ewa Siekierka and Johann Steurer. Using Motor Imagery in the Rehabilitation of Hemiparesis, Archives of Physical Medicine and Rehabilitation , Volume 84 , Issue 7 , Pages 1090 - 1092. J . Stevens Mental imagery for promoting relearning for people after stroke: A randomized controlled trial, Archives of Physical Medicine and Rehabilitation , Volume 85 , Issue 9 , Pages 1403 - 1408 K . Liu , C . Chan , T . Lee , C . Hui-Ch. Mental practice and imagery: a potential role in stroke rehabilitation. Author's reply. R VAN LEEUWEN, JT INGLIS, J RAVEY - Physical therapy reviews, 1998 -
  3. Mirror-box therapy, This is watching your good hand/arm arm in a mirror. The reflected image looks like the affected hand/arm is moving. This tricks the mind into believing the affected arm is being used. Rehabilitation of hemiparesis after stroke with a mirror. Altschuler EL, Wisdom SB, Stone L, Foster C, Galasko D, Llewellyn DME, Ramachandran V. The Lancet - Vol. 353, Issue 9169, 12 June 1999, Pages 2035-2036
  4. Music therapy, music has been proven to help initial recovery, So while you are in the hospital you will have a selection of music to listen to.
One of the main deficits that survivors complain about is the fatigue that seems constant. We do not have any solutions for this but to suggest that you try to increase your cardiovascular capacity.

The second major deficit survivors complain about is spasticity, abnormal stiffness of your affected side. You will need to stretch those muscles. Stretching does not cure the spasticity but it does prevent contractures, which is the permanent shortening of tendons and muscles.

Some of the recommended interventions for spasticity are stretching, general muscles relaxants, ITB(Intra Thecal Baclofen Therapy), botox, phenol, serial casting, tendon rearrangement, tendon snipping. None of these are cures, they tackle the side effects of spasticity. The cure is to get brain control of those muscles again. The best way to do that is to exercise the muscles that are spastic.

Recovery is a long drawn out processs, brains do not recover like other parts of your body. You will need to work at this for years. The only way you will not get better is if you decide that you are satisfied with where you are at and stop working at your recovery therapies.

Changes will barely be able to be noticed after one year so you will need to stay persistent and positive about your recovery work.

Your Physical, occupational and speech therapists will give you rehabilitation exercises to follow both here and at home. Doing them will not easily bring back your lost functions but they will bring back more than you have today.

If you get depressed, come back we can provide some medications that can help.

Good luck and keep in touch.

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