xiPreface
I wrote this book because I couldn’t figure out why it hadn’t already been written. So much has been discovered about recovery in the last two decades, but the information wasn’t getting to survivors. If you search magazines and the Internet you might get a smattering of related information, but there was no singular source. Stronger After Stroke is a “field manual” of information unifying and simplifying most of what is currently known about recovery. The word most is emphasized because one of the clear messages of this book is held within the proverb: “Give a man a fish, feed him for a day. Teach a man to fish and feed him for a lifetime.” Recovery requires knowing the latest and greatest research. The Resources section includes quick and easy ways of discovering what is new and effective in stroke recovery research.
Billions have been spent on stroke recovery research. You should benefit.
The first edition of Stronger After Stroke (2008) had a simple message: When it comes to recovery, stroke survivors are in control. Only survivors can leverage the power of brain plasticity for recovery. Stronger After Stroke wasn’t the first source to advocate a “neuroplastic model of stroke recovery.” It was, however, the first to pull the idea from scientific journals and books, explain it so everyone could understand it, and bundle it with tools survivors could use. The second edition expanded the same theme. This third, fully revised and updated new edition continues this tradition with new insights from psychology, psychiatry, rehabilitation science, exercise science, and, most importantly, neuroscience. But don’t blink. Scientists from around the world are adding their voices and expanding our understanding of how to rewire to recover. To catch a glimpse of this ever-expanding perspective, have a look at this book’s companion website (Google: Stronger After Stroke blog.)
Beyond the science, there is a very human aspect to the information in this book. I have done hundreds of talks across the United States, many at the most respected rehabilitation hospitals in the United States. Ideas are xiiexchanged with thousands of therapists during these talks. Many of the ideas in this book reflect those discussions—their best ideas for recovery, presented to you.
It is clear that stroke survivors have taken the message this book presents to heart. And the message is spreading— since the first edition it has been translated into several languages. Stronger After Stroke has also changed the way stroke is talked about, and it’s easy to track its influence. Prior to the publishing of the first edition, people who had a stroke were written about in the press (popular and scientific) as either patients or victims. When I wrote the first edition I knew many survivors who were neither patients nor victims, and reflected that by exclusively using the word survivors. Now survivors are almost always referred to as survivors. There have been other concepts from Stronger that have been generally accepted by both survivors and clinicians. Some examples are deemphasizing the plateau, focus on brain plasticity, the neuroplastic model of spasticity reduction, etc.
There has been another phenomenon surrounding this book as well: plagiarism. Either word for word plagiarism, or as a sort of reverse engineering of the whole sections of the book. Even the title has been ripped off. Since the first edition the Journal of the American Academy of Neurology, University of Tennessee Medical Center, and Emerson Hospital, and many others have all called articles in print or on line “Stronger After Stroke.”
The fact that this book has a big footprint is a good thing because I have only one hope for this book.
I hope it helps.
HOW FASCINATION WITH THE BRAIN HAS HELPED SURVIVORS
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Hippocrates was the first to define stroke—2,400 years ago. For most of the time since, rehabilitation was a patchwork of techniques based on clinical expertise and educated guesses. Within the last couple of decades, these techniques have been forced to give way to rigorous scientific consideration. Sheer curiosity has driven scientists to stroke recovery. Recovery from stroke provides a unique perspective on the capability of the brain. And that’s the hook: Science finds the brain a world of wonderment. At the same time, xiiia huge amount of other (non-stroke) brain science research is going on. This research, into the brain and into recovery from brain injury, will rapidly continue to provide new insights. In the meantime, the extent to which the brain is able to rewire is not yet known. What we do know is that every time the brain is asked to do extraordinary things, it responds. That’s the good news. The bad news is that the response takes a tremendous amount of hard work. This book celebrates and gives the scientific justification for that hard work.
THE SUPER-SURVIVOR
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Every stroke survivor has a certain level of potential recovery. Few reach that potential. Stroke survivors who do reach their potential do so because they have no choice. This breed of “super-survivor” is so unwilling to let go of career independence, personal passions, family commitments, and so on, that they are compelled to recover. They intertwine recovery with what they love to do. Sometimes recovery is so much a part of what they love doing that they don’t even notice they’re recovering.
For the super-survivor, recovery is a vision quest. The challenge of recovery is no different from other challenges they’ve conquered in life. They get on with it. They put in the time. They fall in love with the process. It’s much the same reason athletes, dancers, and muscians are driven to always get better. Stroke survivors who recover the most see the process of recovery as an opportunity for growth.
This book is not for stroke survivors who are okay with where they are. This is a book for stroke survivors who want to get better.
If you are not a stroke survivor, this book may have meaning for you as well. The same thing that drives recovery from stroke can drive any form of learning. Learning involves the most important scientific discovery since fire: neuroplasticity. Humans have always used their plastic brain. But the discovery of how the brain changes allows us to wonder: How much more can we make it change? How plastic is it? Answering these questions will help develop the best ways to recover from stroke. It will also help anyone trying to learn any new skill.
xivNEUROPLASTICITY AND HOW SCIENCE GOT IT WRONG
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In the mid-1800s, scientists began mapping the brain. Each portion of the brain was sectioned off. Each section was proclaimed as the only possible site for everything—from the ability to do math to wiggling your toes. One section, on the left side of the brain, always controls speech. Another section, near the top of the brain, controls the hand. The back of the brain processes vision; the front solves problems. These early attempts defined the brain as static. Sure, in our youth, perhaps before five years old, there were some changes in the brain. But after that initial wiring the brain was fixed, frozen, and locked. This was bad news for stroke survivors. What happened if the stroke killed the language portion of the brain? Because science thought the brain unchangeable, attempting to use different parts of the brain for language was, well … unthinkable. Once language, or limb movement, or sensation, or anything else was knocked out by the stroke, it was gone. Forever.
There is good news, however: These early attempts to define the brain were wrong.
Scientists had a “mechanistic view” of the brain. Galileo and Copernicus had mechanized the heavens and Leonardo da Vinci had mechanized pretty much everything else. Our fascination with machines profoundly influenced our study of the human body. Scientists viewed the body as a machine, with smaller machines inside. Muscles were pulleys, bones were levers, the kidneys were filters, the heart was a pump, and so on. Certainly the brain was some sort of machine as well. Scientists tended to compare the brain to whatever the latest technology was: “The brain is like a clock.” “The brain is like an engine.” “The brain is like a calculator.” Whatever the latest technology was, that's what the brain was like.
And then, in the mid-1900s, scientists started to realize that the brain did not operate like any other machine. Consider computers. If you ask two identical computers to do the same thing, they’ll do the same thing in exactly the same way over and over and over again. But if you asked the same person the same question, once on Monday and once on Wednesday, they may very well give you different answers. They’ve “changed their mind.” That change was actually a physical, measurable change in the brain. Neurons change structure and/or function.
xvMost of the work challenging the idea that “the brain is just another machine” came from neuroscience. Neuroscience studies the entire nervous system but is fascinated with the brain. Neuroscientists are especially interested in developing and testing ways of rewiring the brain neuroplastically. And this is good for folks that have brain injury, including stroke. Neuroplasticity is at the core of recovery. Neuroscience will lead the way in developing systems to drive neuroplasticity.
The ability the brain has to change, the ability to learn, comes at a cost. Our brain is inconsistent. A computer might always express A = B = C. We might say “A = C but I left out B because I’m in the process of adding D.” As neuroscientists Sam Wang and Sandra Aamodt put it, the brain is less like machine and more like a busy Chinese restaurant. If you’ve ever been in a crowded Chinese restaurant, it’s chaos. Some people are getting their orders taken, other people are being seated, orders are being yelled, food is being eaten, and plates are clanging.
But everything gets done.
Your brain is less like a computer and more like a busy Chinese restaurant. As new connections between neurons are made in the brain, different answers, different perspectives, and different solutions to problems are created. What we lose in the linear (A always = B, which always = C) we gain in the ability to do what other machines can’t: Learn. And that’s the point: Brains change, machines don’t. As you read this book you may associate exercise with neurons and neurons with recovery and recovery with your own personal story. The brain can associate anything with anything else. Machines can only associate what you tell them to associate. Simply, brains learn, machines don’t.
NEUROPLASTICITY: SIMPLICITY IN A BOX
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The brain can be rewired and, under certain conditions, radically rearranged. It turns out that the brain, 100 billion neurons strong, can be changed into whatever kind of tool we want. And there is more good news: Some of the best tools needed for rewiring the brain after stroke are very simple. Although the brain is the most complex entity in the known universe, it responds and rewires according to simple instructions. All a person needs to change his or her brain is a whole lot of focused and dedicated practice. And it happens fast. xviLarge portions of our brains can be rewired in a matter of hours, days, or weeks. Understand: This is not some sort of vague “new-age” concept; this is an actual physical event, measurable by brain-scanning technology. From learning to control emotions to hitting a baseball, the core of change involves rewiring the brain.
You might suspect that there is a bit more to it, and there is. While the idea of “practice makes perfect” is simple, how to practice is more complicated. This book defines the elements needed to drive neuroplastic change.
Beyond focused and dedicated practice, rewiring the brain also involves another rather large pink elephant in the room: motivation. Neuroplasticity takes a tremendous amount of work. It does not necessarily involve a long period of time, just a lot of focused effort. Your hard work is the most essential aspect of successful recovery. Clearly, the most important person involved in the recovery from stroke is the survivor. Much of the work can be done at home with help from family and friends while under the guidance of doctors and therapists. While clinicians are essential to the recovery process, you and your caregivers should not wait for health professionals to chaperon you toward your highest level of potential recovery. There is no doctor, therapist, minister, guru, or shaman in a better position to run your master recovery plan. There is no one who cares as much. Accept the challenge, empower yourself, focus on recovery, work hard, don’t give up, and watch an upward spiral emerge that allows for the highest level of recovery.