Saturday, October 31, 2015

The 2 Minute Survivor Exam That Tells You a Ton

Peter G. Levine
Stronger After Stroke
Thursday, October 15, 2015

I've been involved in a lot of trials that have involved brain scanning. (example).

But I've never been a big fan of using brain scans to try to predict the deficit. In school we were taught to look at the artery that was blocked. The artery that was blocked leading to the brain or in the brain was supposed to give you some indication about what deficits were.

I would suggest this is where neurology and physiatry on one hand-- and neuroscience on the other-- kind of disagree. The neurologist and phsyiatrist say that this info (brain scan and/or artery blocked) helps determine the deficit, and even the chance of recovery.

But neuroscientists would suggest that, because the brain wiring is "random access" (that any part of the brain may be wired to any other part of the brain), looking at a brain scan maybe grossly predictive, but really tells you not much at all.

In all my seminars I suggest that the thing to do is to examine the patient in a very limited way.

Here's suggestions that will give you global insight into the potential for recovery:

1. Can they move their hand? First, let's define "hand movement." I would suggest that hand movement is any movement from the wrist to fingers, in any direction. The easiest movement for most survivors is closing (fist) the hand. The problem is that many strokes survivors think that they can't close their hand. If they think they can't, do this:
  • Bend (technically: Flex) the wrist. This will allow you to open the fingers. 
  • Put the elbow in more than 90° of extension (more straight than a"shake hands" position) 
  • With your fingers inside the palm ask the survivor to try to touch their chin. 
  • This will force the flexor synergy into play, and if they are able, the fingers will flex and you'll feel the pressure on your fingers. Voilà: they have hand movement! From that you can determine potential for recovery of the hand. (Hint: there is potential).

2. Brush both forearms lightly with your fingertips. Ask the survivor if they feel the same, and if not, how they feel different. If they do feel different, this suggests that sensation has been hit. Try to get them to give you a percentage ("My bad arm feels about 25% of my my good arm feels"). There is a general association between tactile (brushing your fingertips) and proprioception (feeling where that limb is in space). And proprioception has huge implications for recovery.

3. Vision: Can they follow the tip of a pen with their head held straight in front of them all the way towards their affected side? If they tend not to follow things on the affected side, this suggests a hemi field cut and possibly “unilateral neglect" – an inability to attend to the affected side.

4. Speech: can they speak; do they understand what's being said?

5. Are they walking, how well, how fast are they walking?

There-- now you have global insight into that stroke survivor. Isn't that more important than knowing that an occlusion of the inferolateral arterial group infarcted the posterolateral thalamus?

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