xviiIntroduction
We are what we repeatedly do.
—Aristotle
In the last decade or so, stroke-recovery research has focused on a few basic core concepts. Understanding these building blocks of recovery will help you decide which of the growing number of treatment options is right for you. All of the following will provide insight into developing a great recovery plan.
ELEMENTS ESSENTIAL TO RECOVERY FROM STROKE
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Mixing the following elements has been shown to the drive neuroplastic (brain rewiring) change necessary for recovery:
Repetitive. Pick options that use repetitive practice. Movements that you want to relearn should be performed over and over. For instance, if you want to lift your foot better, then you would concentrate on doing that movement repeatedly and with the highest possible quality of movement. Use of repetition requires “nipping at the edges” of your current ability. With each attempt, try to extend beyond your present ability a little bit more. Repetitive practice changes the part of the brain that controls movement. But how many repetitions are needed to change the brain? Let’s consider elbow extension (going from the elbow bent to the elbow straight). Approximately 1,200 repetitions are needed to make the brain better at controlling that movement. Not perfect, but better. And that’s for a single-joint movement.
Most of the movements we make involve many joints moving in a variety of directions. So how many repetitions are needed to do complex “every day” movements? The number of repetitions needed gets very large very quickly. Most practical everyday movements will require tens of xviiithousands, if not hundreds of thousands, of repetitions. This is one of the reasons that working only when a therapist is around is not practical. There is simply not enough time with therapists to accomplish the number of repetitions needed.
New and Challenging. Work on movements that are novel (new) to you. Of course, the movements are not really new. You may have been doing the movements for 50 years prior to your stroke, but it is considered novel if it has yet to be learned since your stroke. Researchers use the word “novel,” but a better word may be “challenging.” Focus on relearning challenging movements. Attempting movements that are too easy will not help you recover. As soon as you can perform a movement at a quality that reaches about 80 percent of your pre-stroke ability, move on to something new and challenging.
Meaningful. Neuroplastic (brain rewiring) change is much more likely to occur if the movement you are trying to relearn is part of a real-world task. The task has to be meaningful (important, essential, engaging) to you. The more important the task is to you, the more it will drive recovery. For instance, if you are trying to regain the ability to pick up objects, make it part of a real-world task that is meaningful to you.
Use what you care about to drive recovery. Recover to do what you care about.
If you love to paint, practice picking up a paintbrush. But what if you can’t pick up a paintbrush? You only need to practice a portion of the task. It is not necessary to have the ability to accomplish the entire task to make it task specific. If the task is picking up a paintbrush, you may only be able to get the hand to the table but not be able to actually grasp the brush. As you bring the hand up to the table, have the paintbrush there to provide a meaningful goal.
THE P.E.N.S. CONCEPT
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The P.E.N.S. concept provides an effective way to decide whether or not an option is worthy of consideration. It includes:
xixP is for Patient driven.
• Can you do the therapy by yourself, or does it require supervision?
• Is it intuitive, or does it require a lot of training? Is it expensive or is it affordable?
• Is it available in your area or do you have to travel to get to it?
Lean toward options that have the potential to be used at home, relatively easily, and with little cost and set-up.
E is for Evidence based. Has the option been researched? The amount of scientific testing of recovery options is highly variable. Some …
• Have never been tested
• Have been tested in small, poorly run studies
• Have been tested by people who will make money if the product sells
• Have done poorly in well-run studies
• Have done poorly in multiple well-run studies
• Have done well in well-run studies
• Have done well in multiple well-run studies
When researching the recovery option, ask the question: Did it shine or was it a lemon? In the Resources section of this book there are websites and other sources of information to help you pick and choose.
N is for Neuroplastic. Does the recovery option promote neuroplastic change? That is, will it rewire the brain in a way that helps recovery? The problem is, science may not have yet proven that the option you’ve chosen actually rewires the brain. There are few recovery options that have been tested this way. Try to determine if the therapy has all the earmarks of neuroplasticity included in Essential Elements of Recovery From Stroke, discussed previously.
S is for Simulations vectors. This is a fancy way of saying, “Consider multiple options as you plan your recovery.” There is no one magic bullet for stroke recovery. Therapists tend to use a small group of therapies that they know well. Researchers tend to focus on a small group of related treatment options. Both therapists and researchers bring important perspectives to stroke recovery. xxBut in some ways, both lack a sufficiently broad perspective. When stroke recovery is viewed globally, a hidden secret emerges: It’s not anything, it’s everything. Imagine stroke recovery as a picture puzzle. Solving the stroke-recovery puzzle involves using the puzzle pieces (recovery options) to build as complete a picture as possible (recovery). If the puzzle is done correctly, the highest possible level of recovery is achieved. The stroke-recovery puzzle has two added dimensions that picture puzzles don’t:
1. The number of pieces (treatment options) is continually changing. This is a result of increased research, including research of new technologies. At the same time, research is sifting out other, ineffective treatments.
2. The background picture (where you are in the recovery arc) changes.
Figuring out . . .
• what puzzle piece fits
• when it fits
• and how it fits
. . . is essential to an effective recovery plan.
GOOD NEWS AND BAD NEWS
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Recovery takes hard work and commitment. It’s not easy. It will most likely be the hardest thing you’ve ever done. But the process is simple.
• The bad news: Recovery takes a lot of hard work.
Note: If someone is telling you that they can help you recover without hard work, grab your wallet and leave!
• The good news: The process of recovering from stroke is both intuitive and simple.
Note: If someone is telling you to do something to recover but they can’t explain why in simple language—it is cause for suspicion!
ONE LAST BIT OF HOUSEKEEPING . . .
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While limbs on one side of the body are most impacted, research has found that all four limbs are affected by the brain damage caused by stroke. xxiBecause all four limbs are affected, researchers use the terms “more affected” and “less affected” when describing the relative deficit in the limbs after stroke. Please note that for the sake of brevity and simplicity, this book sometimes uses the following terms:
• “Bad”—the limbs more affected by the stroke.
• “Good”—the limbs less affected by the stroke.
These terms are not meant to reflect the potential for recovery, nor the relative importance of the limb.xxii