From Our Print Archives

Using What Works

A manual for the stroke survivor's brain

Vol. 19 • Issue 25 • Page 24

I've just taken three years to write a book about stroke recovery. For the first two years I was writing the book for therapists. Then I got a publishing deal. The publisher asked me to simplify it for stroke survivors. Who knew "simple" could be so. complicated?

It is one thing if you tell a therapist that X works because it reduces spasticity. But if you say the same thing to a stroke survivor you first have to explain what causes spasticity, the specific effect of spasticity on movement, the impact on soft tissue and finally, how X helps spasticity wane. You also have to make all your explanations easy to understand and scientifically accurate. It was quite the monumental challenge.

There was one great upside to this challenge, however. It made me focus on what really matters. I had to condense and simplify everything I've learned in 10 years of clinical stroke recovery-specific research into 200-odd pages. So I got to thinking, what if I condensed it even more? What if I had just 10 minutes to summarize what (really) works to recover from stroke. What would I say?

I guess the first thing I'd say is: As complicated as it is, keep it simple. Neuroplasticity ("brain-rewiring"), the unequivocal foundation for all recovery, involves a tremendous amount of hard work. Stroke survivors will not commit to the hard work needed to rewire their brains without first understanding why all the hard work is necessary. My most recent column in ADVANCE addresses this issue. The brain may have a 100 billion neurons and a quadrillion (1015) synapses, but it responds to pretty basic commands. Here are "quick hits" that can drive robust neuroplastic change and realize the highest possible level of recovery.

"We are what we repeatedly do." Aristotle could have been talking about stroke recovery. Repetitive practice (RP) drives neuroplastic change. As neuroscientists put it, "Neurons that fire together wire together." With each movement attempt neurons migrate toward each other, sprout new dendrites and form pathways to place more neuronal firepower behind the movement.

One of the questions that crops up about RP is "How many repetitions are needed to drive neuroplastic change?" There is no single answer. We know that for "normals" to become expert in a movement (i.e., basketball jump-shooting, carpet weaving, violin playing) the number of repetitions needed is in the millions. The number 10,000 is commonly accepted as enough to drive robust neuroplastic change. Determining the amount of RP needed in individual stroke survivors will always be an educated guess based on a complicated algorithm that includes:

• The complexity of the movement(s) being learned;

• The amount of AROM currently available;

• The level of focus the stroke survivor brings to each effort.

When RP does begin to pay off, results are obvious. Accurate outcome measures allow for a "poor man's MRI" as the extremities provide a window to neuroplastic change. The problem with repetitive practice has always been the level of boredom it can inspire.

There is good news, however. Emerging technologies like robotics, EMG-based gaming and virtual reality (i.e., the Wii) alleviate the boredom of RP by turning the mundane into fun. Also, when stroke survivors understand the process of neuroplasticity and see an upward spiral of recovery, the drudgery of RP becomes much more acceptable.

Meaningful tasks drive recovery. Practice should be task-specific. That is, tasks or component parts of a task should be practiced. Help survivors choose tasks that are very meaningful. The more meaningful the task, the more motivated they will be. The more motivated, the more effort will be brought to bear. The more effort exerted, the more neuroplastic change will be driven.

Keep it challenging. Whatever is practiced, it must be challenging. In research, an 80-percent threshold is generally used. For instance, if a stroke survivor can successfully turn the pages in a magazine 80 percent of the time, the challenge can be increased by turning the pages of a newspaper. Since turning pages of newspaper requires increased excursion of the shoulder and elbow, the increased AROM will "trickle down" to easier tasks such as turning pages in books and magazines, card flipping and laundry folding.

Measuring progress propels progress. Measurement determines what's working and what's not. Early in recovery, changes are obvious-they couldn't walk and then they could, they couldn't toilet and then they could, and so on. But as time goes on, changes become less obvious and progress more incremental. While less dramatic, small changes add up. Small pieces of the recovery puzzle tend to assemble and a more complete recovery portrait is revealed. These small gains may not be appreciated nor noticed if not measured. Here are a few suggestions for measuring incremental progress.

Videotaping different tasks. Video provides a visual record that is easily evaluated and sensitive to the subtle and nuanced steps toward recovery. Video also provides a permanent and rolling historical account that allows for a perspective into the entire arc of recovery. Each video session should be consistent in terms of task, environment, clothing, footwear and so on. This will allow for an "apples-to-apples" comparison through the span of trials. In the clinic, capturing video is as easy as a cheap digital camera and viewing and storage on a PC. A word of caution: Videotaping clients may have implications regarding HIPAA. Mirrors, as well, may be particularly effective in providing "immediate feedback" to people with unilateral neglect and/or apraxia.

Timing. You can time anything from speaking a sentence to walking a specific distance. In research, efforts are usually timed at two different speeds-as fast as possible and at a "self-selected" (comfortable) speed. Doing tasks at self-selected speeds will generally provide an increase in quality of movement.

Measuring length/distance. Examples of distances that can be measured include distance reached by the hand (i.e., up, forward, out to the side), distance walked and the length of a step. There are many other examples of measurement of progress. The point is to make sure that the measurement done is sensitive enough to incremental gains or losses. Measurement of progress will help separate the interventions that are working from those that are a waste of time. Measurement also provides motivation because nothing motivates like success.

Do it yourself (DIY). Stroke survivors will recover to the highest level when they have a DIY focus. It is neither possible nor necessary to have a therapist available during every effort toward recovery. Many of the therapies that best feed the neuroplastic beast require hours per day of practice. Even if the survivor is currently in therapy, efforts toward recovery are most effective if the survivor can extend work during his time without the therapist(s). Once discharged from therapy, stroke survivors benefit most from a robust home recovery program that automatically triggers increases in levels of challenge. The home recovery program will benefit from incremental visits with therapists who can help track progress, suggest new challenges and ensure safety.

There is one other element to recovering from stroke that should be emphasized. I call it "banking energy." Muscle strengthening (even on the unaffected side) and cardio work (i.e., walking, stationary recumbent bike, upper-body ergometers) are essential to provide the underlying "banking" of energy. The banked energy is essential because banked energy provides the fuel needed to do the hard work of recovery. The average stroke survivor has half the amount of cardiovascular strength as age-matched "couch potatoes." But most ADLs take twice as much energy. In other words, stroke survivors have half the energy to do twice the work.

The foundation of all recovery from stroke involves neuroplastic "rewiring" of the brain. And while the energy needed to drive neuroplastic change has not been measured, one thing is for sure-neuroplasticity takes a lot of energy.

Up to 70 percent of stroke survivors suffer from severe fatigue. Many survivors consider fatigue the worst comorbidity caused by their stroke. Banking energy goes a long way toward fighting fatigue.

Peter G. Levine is the author of Stronger After Stroke: Your Roadmap To Recovery and a regular contributor to ADVANCE. He can be reached at


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