Deans' stroke musings

Changing stroke rehab and research worldwide now.Time is Brain!Just think of all the trillions and trillions of neurons that DIE each day because there are NO effective hyperacute therapies besides tPA(only 12% effective). I have 493 posts on hyperacute therapy, enough for researchers to spend decades proving them out. These are my personal ideas and blog on stroke rehabilitation and stroke research. Do not attempt any of these without checking with your medical provider. Unless you join me in agitating, when you need these therapies they won't be there.

What this blog is for:

Shortly after getting out of the hospital and getting NO information on the process or protocols of stroke rehabilitation and recovery I started searching on the internet and found that no other survivor received useful information. This is an attempt to cover all stroke rehabilitation information that should be readily available to survivors so they can talk with informed knowledge to their medical staff. It's quite disgusting that this information is not available from every stroke association and doctors group.
My back ground story is here:http://oc1dean.blogspot.com/2010/11/my-background-story_8.html

Wednesday, March 30, 2011

hbot as a stroke therapy

There are numerous clinics touting the benefits of Hyperbaric Oxygen Treatment. And I have heard of personal stories relating what seemed like miraculous recoveries.
However research seems limited and if you think about the claims that saturating the blood with oxygen brings back dying neurons, then if would seem logical to only expect this to work in the early hours after stroke onset.
Mayo clinics take:
http://www.mayoclinic.com/health/stroke-therapy/AN01697
Agency Research for Healthcare and Quality:
http://www.ahrq.gov/clinic/epcsums/hypoxsum.htm

Overview

Hyperbaric oxygen therapy (HBOT) is the inhalation of 100 percent oxygen inside a hyperbaric chamber that is pressurized to greater than 1 atmosphere (atm). HBOT causes both mechanical and physiologic effects by inducing a state of increased pressure and hyperoxia. HBOT is typically administered at 1 to 3 atm. While the duration of an HBOT session is typically 90 to 120 minutes, the duration, frequency, and cumulative number of sessions have not been standardized.
HBOT is administered in two primary ways, using a monoplace chamber or a multiplace chamber. The monoplace chamber is the less-costly option for initial setup and operation but provides less opportunity for patient interaction while in the chamber. Multiplace chambers allow medical personnel to work in the chamber and care for acute patients to some extent. The entire multiplace chamber is pressurized, so medical personnel may require a controlled decompression, depending on how long they were exposed to the hyperbaric air environment.
The purpose of this report is to provide a guide to the strengths and limitations of the evidence about the use of HBOT to treat patients who have brain injury, cerebral palsy, and stroke. Brain injury can be caused by an external physical force (also known as traumatic brain injury, or TBI); rapid acceleration or deceleration of the head; bleeding within or around the brain; lack of sufficient oxygen to the brain; or toxic substances passing through the blood-brain barrier. Brain injury results in temporary or permanent impairment of cognitive, emotional, and/or physical functioning. Cerebral palsy refers to a motor deficit that usually manifests itself by 2 years of age and is secondary to an abnormality of at least the part of the brain that relates to motor function. Stroke refers to a sudden interruption of the blood supply to the brain, usually caused by a blocked artery or a ruptured blood vessel, leading to an interruption of homeostasis of cells, and symptoms such as loss of speech and loss of motor function.
While these conditions have different etiologies, prognostic factors, and outcomes, they also have important similarities. Each condition represents a broad spectrum, from barely perceptible or mild disabilities to devastating ones. All three are characterized by acute and chronic phases and by changes over time in the type and degree of disability. Another similarity is that the outcome of conventional treatment is often unsatisfactory. For brain injury in particular, there is a strong sense that conventional treatment has made little impact on outcomes.
Predicting the outcome of brain injury, cerebral palsy, and stroke is difficult. Prognostic instruments, such as the Glasgow Coma Scale (GCS) for brain injury, are not precise enough to reliably predict an individual patient's mortality and long-term functional status. Various prognostic criteria for the cerebral palsy patient's function have been developed over the years. For example, if a patient is not sitting independently when placed by age 2, then one can predict with approximately 95 percent confidence that he/she never will be able to walk. However, it is not possible to predict precisely when an individual patient is likely to acquire a particular ability, such as smiling, recognizing other individuals, or saying or understanding a new word.
Mortality and morbidity from a stroke are related to older age, history of myocardial infarction, cardiac arrhythmias, diabetes mellitus, and the number of stroke deficits. Functional recovery is dependent on numerous variables, including age, neurologic deficit, comorbidities, psychosocial factors, educational level, vocational status, and characteristics of the stroke survivor's environment.
The report focuses on the quality and consistency of studies reporting clinical outcomes of the use of HBOT in humans who have brain injury, cerebral palsy, or stroke. This information can be used to help providers counsel patients who use this therapy and to identify future research needs.

Findings

Brain Injury

  • For traumatic brain injury, one randomized trial provided fair evidence that HBOT might reduce mortality or the duration of coma in severely injured TBI (traumatic brain injuries) patients. However, in this trial, HBOT also increased the chance of a poor functional outcome. A second fair quality randomized trial found no difference in mortality or morbidity overall, but a significant reduction in mortality in one subgroup. Therefore, they provide insufficient evidence to determine whether the benefits of HBOT outweigh the potential harms.
  • The quality of the controlled trials was fair, meaning that deficiencies in the design add to uncertainty about the validity of results.
  • Due to flaws in design or small size, the observational studies of HBOT in TBI do not establish a clear, consistent relationship between physiologic changes after HBOT sessions and measures of clinical improvement.
  • The evidence for use of HBOT in other types of brain injury is inconclusive. No good- or fair-quality studies were found.
And a more positive but maybe biased look:
http://www.thehealinginstitute.net/Hyperbaric_Oxygen_Therapy.asp


General rule, ask your doctor.

compelled weightbearing and gait rehab

I wonder how this would compare to split-belt treadmill training?
http://www.ncbi.nlm.nih.gov/pubmed/10847573

Abstract

The hypotheses have been tested that 1) symmetry of weightbearing in persons who have sustained a stroke could be improved by the addition of a lift to the shoe on the non-paretic lower limb and 2) compelled weightbearing resulting from the addition of a lift in conjunction with targeted exercise helps to overcome the learned disuse of the paretic limb. Weightbearing on the paretic side was measured in eight persons with hemiparesis during quiet standing and in conditions of compelled weight shift. Compelled weight shifts were applied with special lifts to the shoe on the non-paretic limb of the subjects. An increase in symmetrical weightbearing was recorded in conditions of compelled weight shifts: 10-mm lift provided the best symmetry of bipedal standing. We suggest that improved symmetry of bipedal standing obtained with the lift of the non-paretic limb would help in overcoming the learned disuse of the affected limb. Pre- and post-test results of a person with hemiparesis who was wearing a shoe lift on the non-paretic limb during a 6-week physical therapy program showed statistically significant improvement of walking speed, stride length, and weightbearing. Such findings support the idea of using compelled weightbearing via lifting and targeted exercise during treatment.

Only to be done with your doctors supervision, I could easily see this causing falls.

SK3 Channel/nWASP/Abi-1 Complex and neurogenesis

This doesn't help us do-it-yourselfers but you can at least take some hope for future members of our club.
http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0018148

Abstract 

Background

The stabilization or regulated reorganization of the actin cytoskeleton is essential for cellular structure and function. Recently, we could show that the activation of the SK3-channel that represents the predominant SK-channel in neural stem cells, leads to a rapid local outgrowth of long filopodial processes. This observation indicates that the rearrangement of the actin based cytoskeleton via membrane bound SK3-channels might selectively be controlled in defined micro compartments of the cell.

Principal Findings

We found two important proteins for cytoskeletal rearrangement, the Abelson interacting protein 1, Abi-1 and the neural Wiskott Aldrich Syndrome Protein, nWASP, to be in complex with SK3- channels in neural stem cells (NSCs). Moreover, this interaction is also found in spines and postsynaptic compartments of developing primary hippocampal neurons and regulates neurite outgrowth during early phases of differentiation. Overexpression of the proteins or pharmacological activation of SK3 channels induces obvious structural changes in NSCs and hippocampal neurons. In both neuronal cell systems SK3 channels and nWASP act synergistic by strongly inducing filopodial outgrowth while Abi-1 behaves antagonistic to its interaction partners.

Conclusions

Our results give good evidence for a functional interplay of a trimeric complex that transforms incoming signals via SK3-channel activation into the local rearrangement of the cytoskeleton in early steps of neuronal differentiation involving nWASP and Abi-1 actin binding proteins.

If someone could translate this into layperson terms that would be great.

Monday, March 28, 2011

exosomes delivering drugs to brain

This might make it easier to deliver a lot of the drugs I mentioned in earlier posts to the brain.
http://www.bbc.co.uk/news/health-12776222
A new way of delivering drugs to the brain has been developed by scientists at the University of Oxford.
They used the body's own transporters - exosomes - to deliver drugs in an experiment on mice.
The authors say the study, in Nature Biotechnology, could be vital for treating diseases such as Alzheimer's, Parkinson's and Muscular Dystrophy.
The Alzheimer's Society said the study was "exciting" and could lead to more effective treatments.
Research barrier

One of the medical challenges with diseases of the brain is getting any treatment to cross the blood-brain barrier.
The barrier exists to protect the brain, preventing bacteria from crossing over from the blood, while letting oxygen through.
However, this has also produced problems for medicine, as drugs can also be blocked.

So would this help get
tPA in;
nicotine;
marijuana;
magnesium;
viagra;
nitric oxide;
anti-depressants
tgf alpha;
lobster shells;
tumeric;
niacin;
caffeinol;
xenon gas;
drug that activated the sigma-1 receptor;
Docosahexaenoic acid (DHA), a component of fish oil?

All these possibilities just waiting to be further tested. Ask your doctor which ones s/he believes has the most promise and when they are going to start a clinical trial. Come on lets start the guilt trips on our medical staff.

Regent Suit and stroke rehabilitation

See even Russia can come up with good ideas, now will we allow ourselves to mimic them and make it better.
http://www.ncbi.nlm.nih.gov/pubmed/21417139
G Ital Med Lav Ergon. 2011 Jan-Mar;33(1):74-83
Efficacy of the Regent Suit training during a post-acute stroke rehabilitation process: description of a case report


Abstract

In Western industrialized Countries, stroke constitutes a major cause of motor disability. According to rehabilitative principles, propríoceptive stimulations appear to positively influence postural control and ambulation recovery. This case report describes the application of the Regent Suit, a rehabilitative device developed by the Institute of Biomedical Problems of the Russian Academy of Sciences in Moscow, to improve the gait performances of a patient severely affected by stroke, in its post-acute phase. During the in-hospital period, the patient attended to 20 rehabilitation sessions divided into 2 phases: the former based on motor passive/active exercises and the latter based on gait training wearing the Regent Suit. We introduced different outcome measures to investigate motor performances (Berg Balance Scale, 6-min WT, Gait Analysis, ADL restrictions (Barthel Index, FIM scale) and Suit acceptability (Global Perceived Effect). At the end of the rehabilitation process, we found encouraging improvements in all of the parameters investigated, in particular those mostly related to gait abilities. To confirm the collected data, we suggest to start a randomized, controlled trial with a long-term follow-up.

This one even has the references in Russian
http://www.medlit.ru/medeng/fbr/fbr10e0216.htm

Or do you want to read it in Italian:
http://www.gimle.fsm.it/33/1/08.pdf
You will have to look in this PDF if you want to see a picture of what a Regent suit looks like.

I wonder if I couldn't duplicate this by wearing my full body wetsuit. I really want to get my proprioception better.
Remember your therapist should know about this, ask them when it will be available for general use.

5 stages of grief - my take on stroke

Denial, Anger, Bargaining, Depression and Acceptance :thumbsd:

I am still in denial that I won't recover, I refuse to accept that compensation is the best I can do. Anger still exists against the medical establishment that has not set forward a strategy for stroke rehabilitation for all survivors. Bargaining I never did. Depression was from the total lack of communication about what recovery looks like. My vision was that in 6 months I would be canoeing again. With no discussion from any medical staff that this was impossible, depression was inevitable. I haven't accepted my physical limitations because I know I will eventually get them back. I have enough drive ,persistence, pugnacity and smarts to move my brain functions around. In any event I set myself a goal to change stroke rehab worldwide, this is probably an insane belief. And the way to do that is to research and plan what needs to be done. Blogging is my starting point and from some of the responses it's doing a good job. :Tantrum:

Sunday, March 27, 2011

Haptics and stroke rehabilitation

This doesn't seem too much different than regular video game rehab except for using sensation to help fire the muscles. They could have just used the word proprioception.
http://www.sciencedaily.com/videos/2008/0405-new_hope_for_stroke_survivors.htm
April 1, 2008 — Using a technology called haptics, mechanical engineers can design physical therapies that reestablish motor pathways broken down by strokes. A motorized joystick guides patients to move their hands in the direction dictated by graphics on a television screen. This feedback helps the patients regain motion that had been previously lost.

There are more than four million stroke survivors living in the United States. It's been a standard prognosis for almost all of them -- whatever motor skills you didn't get back right away may be lost forever; but now, new technology is proving that even stroke rehab is better late than never.
Judy Walsh is proud grandmother and a stroke survivor. "I just couldn't believe it," Walsh recalls. "Here I am, 54. I never thought I would have this problem."
But now at age 64, ten years post stroke, Walsh is still feeling the effects. "My left side of my leg, my left arm, my speech and my swallowing," Walsh describes.
For many stroke patients, functions that aren't relearned in the first few months after their stroke are nearly impossible to get back. Regaining motor skills is a frustrating process that makes even the simple things in life difficult.
"Getting dressed, putting socks on … that's a two-handed deal too," Walsh says.
But mechanical engineer Marcia O'Malley is determined to help stroke patients continue on their road to recovery, no matter how far out they are. "If we continue to deliver therapy, they're going to see continued improvement," Marcia O'Malley, of Rice University in Houston, told Ivanhoe.
Using the same technology found in video game controllers, she's using a technology called haptics, which relies on the perception of touch, allowing patients to feel their environment while being guided through correct movements.
"We know that repetitive practice -- high intensity practice -- can improve outcomes for rehabilitation, and robots are really well suited to that," O'Malley explains.
By repeating exercises over and over, patients regain motion. Mike Dixon was able to get the results he was looking for, four years after his stroke. "Things show that I'm improving on a regular basis," Dixon says.
This joystick therapy could be in high demand, but that's something O'Malley and her team has already thought about. "A robotic device might enable one therapist to oversee numerous patients at the same time," O'Malley explains. Giving more patients like Walsh the freedom to move as they please.
This joystick technology can also potentially be used by patients at home, allowing them to continue rehab on their own schedule.

Its been three years since this came out. What is the current use of this? Does anybody know or care?

Brain-computer implant for stroke patient has passed 1000-day milestone

I'm glad she can control a cursor with her mind but a more functional test would be to have her control her paralyzed limbs directly.
http://www.newscientist.com/blogs/shortsharpscience/2011/03/power-of-thought-neural-implan.html
A paralysed woman was still able to accurately control a computer cursor with her thoughts 1000 days after having a tiny electronic device implanted in her brain, say the researchers who devised the system. The achievement demonstrates the longevity of brain-machine implants.
The woman, for whom the researchers use the pseudonym S3, had a brainstem stroke in the mid-1990s that caused tetraplegia - paralysis of all four limbs and the vocal cords.
In 2005, researchers from Brown University in Providence, Rhode Island, the Providence VA Medical Center and Massachusetts General Hospital in Boston implanted a tiny silicon electrode array the size of a small aspirin into S3's brain to help her communicate better with the outside world.
The electrode array is part of the team's BrainGate system, which includes a combination of hardware and software that directly senses the electrical signals produced by neurons in the brain which control the planning of movement.
The electrode decodes these signals to allow people with paralysis to control external devices such as computers, wheelchairs and bionic limbs.
In a study just published, the researchers say that in 2008 - 1000 days after implantation - S3 proved the durability of the device by performing two different "point-and-click" tasks by thinking about moving a cursor with her hand.
Her first task was to move a cursor on a computer screen to targets arranged in a circle and select each one in turn. The second required her to follow and click on a target as it moved around the screen in varying sizes.
Leigh Hochberg, visiting associate professor of neurology at Harvard Medical School and director of the BrainGate trial, told the website Medical News Today:
This The electrode array is part of the team's BrainGate system, which includes a combination of hardware and software that directly senses the electrical signals produced by neurons in the brain which control the planning of movement.
The electrode decodes these signals to allow people with paralysis to control external devices such as computers, wheelchairs and bionic limbs.
In a study just published, the researchers say that in 2008 - 1000 days after implantation - S3 proved the durability of the device by performing two different "point-and-click" tasks by thinking about moving a cursor with her hand.
Her first task was to move a cursor on a computer screen to targets arranged in a circle and select each one in turn. The second required her to follow and click on a target as it moved around the screen in varying sizes.
Leigh Hochberg, visiting associate professor of neurology at Harvard Medical School and director of the BrainGate trial, told the website Medical News Today:
However, the device did not perform perfectly - fewer electrodes were recording useful neural signals than they did when tested six months after implantation.
The researchers say there is no evidence of any fundamental incompatibility between the sensor and the brain. Instead, they believe the decreased signal quality over time can largely be attributed to engineering issues. Ongoing research means these issues are now less of a problem than they were when S3 received her implant.
Speaking with Brown University's news service, lead author John Simeral, assistant professor of engineering at Brown, said that they would like to further improve the sensitivity of the device:

surgery transformation into scientific facts

I just finished the book The Knife Man, The extraordinary Life and
Times of John Hunter, Father of Modern Surgery by Wendy Moore.
Prior to his times, surgeons still relied on medieval traditions.  His approach was to try the traditional method, analyze the outcome, form a hypothesis on how to improve, implement his results. This was his scientific method, based on reasoning, observation and experimentation. He started practicing in 1748. As far as I can tell stroke rehabilitation is still in medieval times, the scientific method has barely been broached for this.  If we had a place to put and read about stroke rehab case studies that would help tremendously.  I can correlate anything to stroke rehab, maybe I should try the book, Everything I know I learned about in Kindergarten.

My transformation from victim to survivor

It started quite slowly, I was waiting for my medical staff to give me some concrete information on rehabilitation and then I could follow that and recover. That never occurred, I don't think my doctors in 30+ years of practice had ever figured out anything about stroke rehab. Since my cognitive abilities were spared, as soon as I got access to a computer I found a number of stroke forums and everyone on them was looking for information that no-one had gotten from their doctors. It became painfully obvious that all stroke survivors are on their own, they need to figure out their own therapy protocols. Of the 5 stages of grief:
Denial, Anger, Bargaining, Depression and Acceptance
I am still in denial that I won't recover, I refuse to accept that compensation is the best I can do. Anger still exists against the medical establishment that has not set forward a strategy for stroke rehabilitation for all survivors. Bargaining I never did. Depression was from the total lack of communication about what recovery looks like. My vision was that in 6 months I would be canoeing again. With no discussion from any medical staff that this was impossible or even any information at all, depression was inevitable. I haven't accepted my physical limitations because I know I will eventually get them back. I have enough drive ,persistence, pugnacity and smarts to move my brain functions around. In any event I set myself a goal to change stroke rehab worldwide, this is probably an insane belief. And the way to do that is to research and plan what needs to be done. This blog is my starting point and from some of the responses its doing a good job.

Saturday, March 26, 2011

GRASP PROGRAM FOR HAND AND ARM THERAPY

This is one of the few studies that actually had the protocol exercises, but I had to get them from another stroke forum.
Here is the full study:
http://stroke.ahajournals.org/cgi/reprint/40/6/2123
abstract here:

A Self-Administered Graded Repetitive Arm Supplementary Program (GRASP) Improves Arm Function During Inpatient Stroke Rehabilitation

A Multi-Site Randomized Controlled Trial

Jocelyn E. Harris, MSc; Janice J. Eng, PhD; William C. Miller, PhD; Andrew S. Dawson, MD
From the Department of Physical Therapy (J.E.H., J.J.E.), the Department of Occupational Science and Occupational Therapy (W.C.M.), and the Department of Medicine (A.S.D.), University of British Columbia, Vancouver, Canada.

Correspondence to Janice Eng, PhD, Department of Physical Therapy, University of British Columbia, 212-2177 Wesbrook Mall, Vancouver, British Columbia, Canada, V6T 1Z3.
Background and Purpose— More than 70% of individuals who have a stroke experience upper limb deficits that impact daily activities. Increased amount of upper limb therapy has positive effects; however, practical and inexpensive methods of therapy are needed to deliver this increase in therapy.
Methods— This was a multi-site single blind randomized controlled trial to determine the effectiveness of a 4-week self-administered graded repetitive upper limb supplementary program (GRASP) on arm recovery in stroke. 103 inpatients with stroke were randomized to the experimental group (GRASP group, n=53) or the control group (education protocol, n=50). The primary outcome measure was the Chedoke Arm and Hand Activity Inventory (CAHAI), a measure of upper limb function in activities of daily living. Secondary measures were used to evaluate grip strength and paretic upper limb use outside of therapy time. Intention-to-treat analysis was performed. Group differences were tested using analysis of covariance.
Results— At the end of the 4-week intervention (approximately 7 weeks post stroke), the GRASP group showed greater improvement in upper limb function (CAHAI) compared to the control group (mean difference 6.2; 95% CI: 3.4 to 9.0; P<0.001). The GRASP group maintained this significant gain at 5 months post stroke. Significant differences were also found in favor of the GRASP protocol for grip strength and paretic upper limb use. No serious adverse effects were experienced.
Conclusion— A self-administered homework exercise program provides a cost-, time-, and treatment-effective delivery model for improving upper limb recovery in subacute stroke.

Exercises here:
http://www.rehab.ubc.ca/jeng/Our_Exercise_Manuals/GRASP.htm
I was still disappointed in the baseline because they never specified the penumbra or the dead brain area and as a result I don't believe this is scientifically reproducible.

Thursday, March 24, 2011

Spasticity intervention for stroke rehab?

Spasticity interventions include FES - Functional Electrical Stimulation, This is usually applied to the antagonist muscle, the one opposite the spastic one. In fingers the flexors are usually spastic causing clenched fingers, the FES is applied to the opposite muscle, the extensors.

Why? If the problem is the flexors why aren't we working on sending electrical signals to them telling them to relax? There has to be some kind of electrical signal telling them to relax. I don't have a good enough background to even see if this has been thought of and discarded or never thought of.
Doing FES is usually thought of as reducing spasticity when it actually does nothing of the sort. It fires the antagonist muscle to overpower the agonist muscle.

Tuesday, March 22, 2011

Apoplexy Rehabilitation Instrument

From China, I could never figure out what this is doing, so ask your doctor to explain it to you.

http://www.china-lifecare.com/products/Apoplexy-Rehabilitation-Instrument-122419.html
The appraisal mission judges that the Apoplexy Rehabilitation Instrument has succeeded to the rich experience of apoplexy rehabilitation by acupuncture and massage, drawn lessons from the modern rehabilitation theory, and got it realized by electronics and software high technology, worked out some innovative achievements:
1.Optimization and fixation of the acupuncture
points and massage sites make it possible for patients and their families to freely master the rehabilitation that was previously handled only by doctors.
2. Realization of the neuromuscular facilitation technology guided by specialized rehabilitation doctor through a set of medical gymnastics, and it is made into VCD for patients’ own exercise.
3. It lightens social and family burden, and arise the patient’s positive attitude toward rehabilitation. Through the application of the instrument, the patients will not feel that they are burden of others, and thus it is possible that the disease is cured and the patients become healthy.
4. The Apoplexy Rehabilitation Instrument is the mark product of modernization and standardization of traditional acupuncture and massage therapies. It increases the maneuver ability of apoplexy rehabilitation, and becomes the evangel for the patients to get healthy and return to the society.
The scientific research personnel from Research Institute of Acupuncture & Moxibustion and Meridian, Anhui Institute of Traditional Chinese Medicine, have formed a subject-tackling team, and under the coordination of some colleges and research units all over China, they finally obtained the delightful achievement: Apoplexy Rehabilitation Instrument.
Taking National Torch-plan Project in 2000 “Human Body Bioelectricity Simulation” as its platform, and based on the proved recipe of predecessor’s application of acupuncture and massage to treat hemiplegia from apoplexy, the project ream has not only mastered the unique frequency and waveform of acupuncture, as well as maneuver and strength curve, but also scientifically screened Shuxue and muscle group used fro apoplexy rehabilitation. At the same time, the microelectronic and embedding software technology have been applied to realize the simulation of acupuncture and massage maneuver. The clinical trials have made it clear that the Apoplexy Rehabilitation Instrument has achieved the same effect as that treated by acupuncture doctors and massagists

astrocytes in central nervous system regeneration

This was also referred to in the Willis lecture.
http://jrm.medicaljournals.se/article/abstract/10.2340/16501977-0084
Abstract:
Rehabilitation medicine is entering a new era, based on the knowledge that the central nervous system has a substantial capacity for repair and regeneration. This capacity is used in 3 distinct but overlapping situations: (i) routine housekeeping throughout life (i.e. taking care of normal wear-and-tear); (ii) older age, when functional reserves of various kinds are depleted, resulting in cognitive, motor, and other deficits; and (iii) contexts in which a neurological deficit reflects an acute or chronic pathological process, such as neurotrauma, stroke, or neurodegenerative disease. The positive message here is two-fold. First, some aspects of regeneration occur even in the adult and ageing brain and spinal cord, and we are starting to unravel the underlying molecular mechanisms. Secondly, novel therapeutic approaches and targets are emerging that will substantially increase the efficiency and efficacy of rehabilitation and will transform rehabilitation into a discipline focusing both on its traditional domain and on prevention, ultimately across all the age categories. This review attempts to sum up the present knowledge about an enriched environment, currently the single most efficient plasticity- and regeneration-promoting paradigm. It also summarizes research showing that astrocytes – considered only years ago merely to nurse and support neurones – are a novel and highly interesting target for regenerative strategies in the brain and spinal cord.
Picture here:http://blustein.tripod.com/Astrocytes/astrocytes.htm
What they do:Astrocytes are star shaped glial cells that perform a variety of functions in the CNS.  Astrocytes provide physical support to neurons and clean up debris within the brain.  They also provide neurons with some of the chemicals needed for proper functioning and help control the chemical composition of fluid surrounding neurons.  Finally, astrocytes play a role in providing nourishment to neurons.
In order to provide physical support for neurons astrocytes form a matrix that keep neurons in place.  In addition, this matrix serves to isolate synapses. This limits the dispersion of transmitter substances released by terminal buttons; thus aiding in the smooth transmission of neural messages.
Astrocytes also perform a process known as phagocytosis.  Phagocytosis occurs when an astrocyte contacts a piece of neural debris with its processes (arm of the astrocyte) and then pushes itself against the debris eventually engulfing and digesting it.
Astrocytes provide nourishment to neurons by 1) receiving glucose from capillaries 2) breaking the glucose down into lactate (the chemical produced during the first step of glucose metabolism) 3) releasing the lactate into the extra cellular fluid surrounding the neurons.  The neurons receive the lactate from the extra cellular fluid and transport it to their mitochondria to use it for energy.  In this process astrocytes store a small amount of glycogen, which stays on reserve for times when the metabolic rate of neurons in the area is especially high.

It does leave the question open as to how to use this knowledge to rehabilitate.

Recumbent stepping and stroke rehab

Maybe I'll have to figure out what recumbent stepping is. Maybe it is a recumbent elliptical.
Recumbent stepping has similar but simpler neural control compared to walking

Abstract

The purpose of this study was to compare muscle activation patterns and kinematics during recumbent stepping and walking to determine if recumbent stepping has a similar motor pattern as walking. We measured joint kinematics and electromyography in ten neurologically intact humans walking on a treadmill at 0 and 50% body weight support (BWS), and recumbent stepping using a commercially available exercise machine. Cross correlation of upper and lower limb electromyography patterns between conditions revealed high correlations for most muscles. A principal component analysis revealed that the first factor accounted for more muscle activation signal content during recumbent stepping (81%) than during walking (70%). This indicates that the motor pattern during walking is more complex than during stepping. Cross correlation analysis found a high correlation between factors for recumbent stepping and walking (R = 0.54), though not as high as the correlation between factors for walking at 0% BWS and walking at 50% BWS (R = 0.68). There were substantial differences in joint kinematics between walking and recumbent stepping, most notably in hip, elbow, and shoulder motions. These results suggest that although the two tasks have different kinematic patterns, recumbent stepping relies on similar neural networks as walking. Individuals with neurological impairments may be able to improve walking ability from recumbent stepping practice given similarities in neural control between the two tasks.
Ask your therapists about this, this didn't come from me.

Mirror Therapy Promotes Recovery From Severe Hemiparesis

Finally a protocol for one of the rehab therapies, but don't do anything with this dangerous therapy unless your doctor approves.
http://nnr.sagepub.com/content/23/3/209.abstract
Abstract
Background. Rehabilitation of the severely affected paretic arm after stroke represents a major challenge, especially in the presence of sensory impairment. Objective. To evaluate the effect of a therapy that includes use of a mirror to simulate the affected upper extremity with the unaffected upper extremity early after stroke. Methods. Thirty-six patients with severe hemiparesis because of a first-ever ischemic stroke in the territory of the middle cerebral artery were enrolled, no more than 8 weeks after the stroke. They completed a protocol of 6 weeks of additional therapy (30 minutes a day, 5 days a week), with random assignment to either mirror therapy (MT) or an equivalent control therapy (CT). The main outcome measures were the Fugl-Meyer subscores for the upper extremity, evaluated by independent raters through videotape. Patients also underwent functional and neuropsychological testing. Results. In the subgroup of 25 patients with distal plegia at the beginning of the therapy, MT patients regained more distal function than CT patients. Furthermore, across all patients, MT improved recovery of surface sensibility. Neither of these effects depended on the side of the lesioned hemisphere. MT stimulated recovery from hemineglect. Conclusions. MT early after stroke is a promising method to improve sensory and attentional deficits and to support motor recovery in a distal plegic limb.

Or this trial:

Motor Recovery and Cortical Reorganization After Mirror Therapy in Chronic Stroke Patients

A Phase II Randomized Controlled Trial

Abstract

Objective. To evaluate for any clinical effects of home-based mirror therapy and subsequent cortical reorganization in patients with chronic stroke with moderate upper extremity paresis. Methods. A total of 40 chronic stroke patients (mean time post .onset, 3.9 years) were randomly assigned to the mirror group (n = 20) or the control group (n = 20) and then joined a 6-week training program. Both groups trained once a week under supervision of a physiotherapist at the rehabilitation center and practiced at home 1 hour daily, 5 times a week. The primary outcome measure was the Fugl-Meyer motor assessment (FMA). The grip force, spasticity, pain, dexterity, hand-use in daily life, and quality of life at baseline—posttreatment and at 6 months—were all measured by a blinded assessor. Changes in neural activation patterns were assessed with functional magnetic resonance imaging (fMRI) at baseline and posttreatment in an available subgroup (mirror, 12; control, 9). Results. Posttreatment, the FMA improved more in the mirror than in the control group (3.6 ± 1.5, P < .05), but this improvement did not persist at follow-up. No changes were found on the other outcome measures (all Ps >.05). fMRI results showed a shift in activation balance within the primary motor cortex toward the affected hemisphere in the mirror group only (weighted laterality index difference 0.40 ± 0.39, P < .05). Conclusion. This phase II trial showed some effectiveness for mirror therapy in chronic stroke patients and is the first to associate mirror therapy with cortical reorganization. Future research has to determine the optimum practice intensity and duration for improvements to persist and generalize to other functional domains.

Monday, March 21, 2011

Have less than 24 teeth? Watch out for stroke!

This is probably one of thoses observational studies that can't prove cause and effect. I think I have 28 teeth, less my 4 wisdoms taken out.
http://ibnlive.in.com/news/have-less-than-24-teeth-watch-out-for-stroke/146624-19.html

nostrums for apoplexy cure

This was so fascinating I had to research some more. And all these 10 wonderful cures for apoplexy from the late 1800's to early 1900's. I wonder what happened to them all. And if you die from apoplexy just take, Dr. Sibly's Re-Animating Solar Tincture.
The word derives from the Greek word apoplēxia (ἀποπληξία). Hippocrates used the word in his day to describe stroke.
Dr.Greene's Nervura sold for apoplexy along with 29 other afflictions

Dr. A. Upham's Valuable Electuary - remedy for paralysis, apoplexy and measles

Paul Gage’s Tonic Antiphlegmatic Elixir

As well as worms and the more likely coughs, colds and asthma, the Elixir would cure apoplexy, scrofula, gout, dropsy, palpitations, skin conditions and ‘diseases of women.’


Dr. Munyon’s Homoeopathic Home Remedy Company The Wonderful X-Ray machine---It is medical electricity. Cures nervous prostration,overworked brains and broken-down systems, stiff joints, paralysis, pains in any part of the body.
Sounds like it could help my apoplexy


Dr Junod's Exhausting Apparatushttp://thequackdoctor.com/index.php/dr-junods-exhausting-apparatus/
Important Notice to the Afflicted
ALL Persons suffering from PARALYSIS, SPINAL
AFFECTIONS, RHEUMATISM, NEURAL-
GIA, ASTHMA, Pain in the Head, or all cases of INFLAM-
MATION or CONGESTION, should at once try Mr G. W.
Gedney’s VACUUM APPARATUS, by Dr. Junod, which has
been practised with great success for upwards of 40 years.
Testimonials of the highest character on application to
Mr. G. W. GEDNEY,
64, Victoria Street, London Road, Ipswich.

Dr Williams' Pink Pills for Pale People
The same medicine cures
rheumatism, sciatica, neuralgia, paralysis, locomotor
ataxy, nervous headache, scrofula, chronic erysipelas,
and influenza

Allcock's Porous Plasters http://thequackdoctor.com/index.php/allcocks-porous-plasters/
The plasters were not only supposed to to help lumbago – other adverts suggested using them for such varied disorders as quinsy (you had to put a strip of plaster under your chin, stretching from ear to ear), diabetes, St Vitus’s Dance, epilepsy, dyspepsia, diarrhoea, coughs and colds, asthma, pleurisy, whooping cough, consumption, ruptures, sciatica, paralysis, rheumatism, tic douloureux and kidney problems.

GAMJEE’s ORIENTAL SALVE
CURES Burns, Sores, Piles, Rheumatism, Paralysis, Lumbago, Stiff Joints, White Swellings, Wens, Hip Disease, Chest and Lung Complaints, &c., &c.
Allan's Anti-Fat
Some adverts claimed it also cured dyspepsia, palpitations, rheumatism and gout, and prevented heart disease, apoplexy and paralysis.


Mormon Elder’s Damiana Wafers

Actually creates new Nervous Fluid and Brain Matter by supplying the Blood with VEGETABLE PHOSPHATES, its Electric Life Element, the very core and center of the Brain itself—Restoring the fullest and most Vigorous conditions of Robust Health of Body and Mind, so that all the Duties of Life may be pursued with Confidence and Pleasure, and whilst pleasant to the taste never fails to Purify and Enrich the Blood, and thoroughly invigorate the Brain, Nerves, and Muscles. Its energising effects are shown from the first day of its administration by a remarkable Increase of Nerve and Intellectual Power, with a Feeling of Courage, Strength and Comfort, to which the Patient has long been unaccustomed

And something for my baldness:
http://thequackdoctor.com/index.php/you-neednt-be-bald/

Dr. Sibly's Re-Animating Solar Tincture - So use this to prevent death from 1793

In all circumstances of suicide, or sudden death, whether by blows, fits, falls, suffocation, strangulation, drowning, apoplexy, thunder and lightning, assassination, duelling, &c., immediate recourse should be had to this medicine, which will not fail to restore life, provided the organs and juices are in a fit disposition for it, which they undoubtedly are much oftener than is imagined.
I do wonder how you successfully get the medicine down the throat of a 'perishing' person.
http://thequackdoctor.com/index.php/dr-siblys-re-animating-solar-tincture/

Just think, these nostrums may come back as the height of medical intervention if our medical insurance/HMOs price everyone out. Remember to ask your doctor about the validity/efficacy of these, you are not to self-medicate.

porch swing as stroke rehab

Now that the snow is melting and the swing becoming exposed again I can do this when I come home from work.
A couple of years ago we had a garage sale so there was lots of sitting around. We have a porch swing installed in our arbor which was just the right height for my feet to reach the ground. So I used that to hold my foot down on the ground and use my hamstring muscles to pull the swing forward and then let it back. At times I had to use my good leg to help holding it down. This mimcs what my PT tried to do with me way back when I was still in the hospital. He put my foot on a wheeled board and had me trying to pull it toward me. At the time I didn't have those muscles working at all. Later the idea changed to sitting on a chair with wheels and trying to move the chair forward by contracting my hamstrings. This didn't work because the chair was on a rug and my muscles needed an extremely light weight to work with. The swing right now is just the right resistance.
If I can get this working better, it will help in walking when you lift your foot up behind you. This is one of my ideas, breaking down movements into tiny pieces and figuring out how to do them. Eventually it will be to put them together into functional movement. This goes totally against what your therapists are taught, which is to work on complete functional movements. So ask your therapist what to do.

My diagnosis of stroke

This is a problem with my stroke. I think too much about all things stroke related. I was never given any detailed diagnosis of my stroke, just told it was an ischemic one. And from reading thousands of stroke related forums I don't think anyone else has either. It would be like getting a diagnosis of cancer and not telling you where the cancer is located. With no diagnosis there is no chance of getting appropriate therapy because the therapists are only working with the symptoms rather than the underlying cause. And as a result I can never compare my therapy to what should be a standard therapy for a specific diagnosis. PMR doctors hand off the patients by just giving them to the OTs and PTs a prescription for ET, Evaluate and Treat.  This is a total abandonment of their responsibilities.
This is suggesting that therapist teachings for stroke rehab is all wrong.

Ignore me, I should never presume to know more than my medical staff, even though I do.

stroke survivors and OCD

Obsessive-Compulsive Disorder, OCD, is an anxiety disorder and is characterized by recurrent, unwanted thoughts (obsessions) and/or repetitive behaviors.
This is not really a disease for survivors but I would say we have to work on the repetitive behaviors without fail.  I open and close my fingers while riding in a car, watching TV or a movie, while listening to someone talk to me. going to sleep. Other movements are not quite so obvious but they continue regardless of the situation. My therapy is more important than the disapproving stares of people.
These are actually wanted thoughts and behaviors.
Keep them up.

Sunday, March 20, 2011

Was your stroke preventable?

My dad had blockage in one of his carotid arteries of 85%. It has now been cleaned out. If his doctor had told him to have his children get neck ultrasounds because of his blockage, Or if my doctor had asked me if any of my parents had arterial blockages. I could have easily gotten an ultrasound and cleaned out my bad artery. But I didn't think about it, mainly because I am 30 years younger and was in excellant physical shape with no symptoms.
And obviously neither of the doctors involved did. There should be a way that survivors could provide case studies to medical staff. Our observations could easily be used to prevent strokes and point to rehab successes.
Tilting at windmills again.

therapy intervention reason

I follow lots of stroke survivor blogs but only one therapist other than Pete Levine and that is Toni, she is a neuro therapist and works mainly with stroke patients and has wonderful insights.
http://community.advanceweb.com/blogs/pt_2/default.aspx?p=2
She talks about evidence based therapy vs. clinical experience. You as a patient should know the distinction because if your therapist can only use evidence-based therapy then they may not be able to point you to clinical trials in Phase I or II. Toni only seems to need to do that for classes. The more you know the better you will make your therapists. Consider it on-the-job training.
From Toni:
Every course I've taken has required me to produce evidence to support my interventions. I could use clinical experience to decide which intervention but not to support my decision. My experience with the treatment could not be cited. Unless I had a study supporting my decision, the intervention was acceptable.
There are two schools of thought. One stresses the evidence over everything else. The other ignores the evidence and relies on what has worked in the past. Ideally we want a patient-focused happy medium. Somewhere along the line, clinical experience came to be looked down on because it is intangible and not always reproducible. Skill level has an effect on this. Someone who is skilled in a technique is going to have better outcomes than someone just learning it.

Can you dance?

Last summer I went to the  5 day Winnipeg Folk Festival, camping at the Birds Hill Provincial Park outside Winnipeg, Manitoba. Each night the main acts would usually get the crowd dancing. My attempts were pretty limited. I could do the head bob and fist pump from the 'Rock Star Movements' of the Blue Man Group but couldn't manage any of the jumping up and down movements.
For video of blue man group - http://www.youtube.com/watch?v=rqQnHETW_D0
One of the main stage acts was Cat Empire from Melbourne and OKA from Australia was also there on some of the smaller stages. It was a tossup between Cat Empire and Peatbog Fairies from Scotland which was my favorite.  I have even tried holding onto the footboard of the bed to see if I can get both feet off the ground at the same time. No such luck. This does not fall under any of the ADLs so there is no therapist I could ask about this.

Saturday, March 19, 2011

knowledge of phase trials

You should educate yourself about the meaning of the research trials I mention.
http://clinicaltrials.gov/ct2/info/glossary
BASELINE: 1. Information gathered at the beginning of a study from which variations found in the study are measured. 2. A known value or quantity with which an unknown is compared when measured or assessed. 3. The initial time point in a clinical trial, just before a participant starts to receive the experimental treatment which is being tested. At this reference point, measurable values such as CD4 count are recorded. Safety and efficacy of a drug are often determined by monitoring changes from the baseline values.
This is why I think most stroke research is a naked emperor. None of the baselines I've seen has distinguished between easy penumbra recovery and difficult dead brain function recovery.
http://oc1dean.blogspot.com/2010/10/is-stroke-rehab-research-emperor.html

PHASE I TRIALS: Initial studies to determine the metabolism and pharmacologic actions of drugs in humans, the side effects associated with increasing doses, and to gain early evidence of effectiveness; may include healthy participants and/or patients.
PHASE II TRIALS: Controlled clinical studies conducted to evaluate the effectiveness of the drug for a particular indication or indications in patients with the disease or condition under study and to determine the common short-term side effects and risks.
PHASE III TRIALS: Expanded controlled and uncontrolled trials after preliminary evidence suggesting effectiveness of the drug has been obtained, and are intended to gather additional information to evaluate the overall benefit-risk relationship of the drug and provide and adequate basis for physician labeling.
PHASE IV TRIALS: Post-marketing studies to delineate additional information including the drug's risks, benefits, and optimal use.

Ask your doctors and therapists to document the trials that pointed to the therapies they are working with you on.

microscope captures 3D movies of living cells

I wonder how many would be willing to volunteer to open a flap to their brain to allow researchers to prove their therapies work on a cellular level vs. using micro-optics

http://www.gizmag.com/3d-microscope-movies-living-cells/18138/
In some cases, looking at a living cell under a microscope can cause it damage or worse, can kill it. Now, a new kind of microscope has been invented by researchers from the Howard Hughes Medical Institute that is able to non-invasively take a three dimensional look inside living cells with stunning results. The device uses a thin sheet of light like that used to scan supermarket bar codes and could help biologists to achieve their goal of understanding the rules that govern molecular processes within a cell.
    View all
Veteran microscope innovator Eric Betzig says that the field of microscopy has been hindered by the fact that many techniques require cells to be killed and fixed before being viewed. Light produced by microscopes used for live-cell techniques can, in some cases, actually cause damage to the cells. The light also floods the whole area being examined, not just the small portion that's in focus – producing blur from the out-of-focus regions.
Two years after arriving at HHMI's Janelia Farm Research Campus, Betzig started working ways to overcome these problems.
"The question was, is there a way of minimizing the amount of damage you're doing so that you can then study cells in a physiological manner while also studying them at high spatial and temporal resolution for a long time?" said Betzig.


First developed around a 100 years ago, plane illumination microscopy involves shining light through the side of a sample rather than from the top. While offering some promise, Betzig's group found that the technique still exposed too much of the sample. A much thinner sheet of light was produced using by sweeping a Bessel beam – a kind of non-diffracting light beam – across the sample but the light produced by this form of plane illumination microscopy proved to be somewhat weak, making the pattern of illumination look somewhat like a bullseye.
Working with postdoctoral researchers Thomas Planchon and Liang Gao, Betzig has spent the last couple of years refining the process to try and overcome the problem. First, instead of sweeping the Bessel beam across the sample, the group rapidly switched it off and on – a method known as structured illumination. Then by concentrating the light to a narrow central part of the Bessel beam using something called two-photon microscopy, they were able to build 3D stacks of the sample at nearly 200 images per second to generate movies of processes like cell division in stunning detail.
Betzig says that Bessel beam plane illumination microscopy will prove a powerful tool for cell biologists, since it non-invasively images the rapidly evolving three-dimensional complexity of cells.
The research is described in detail in a paper entitled Rapid three-dimensional isotropic imaging of living cells using Bessel beam plane illumination, which was recently published in the journal Nature Methods.

I can't help myself, I have to suggest options for researchers even though they might be smarter than me, although I doubt it.

Friday, March 18, 2011

Rehabilitation glove uses artificial muscles

I know this is actually meant for quadraplegics but it could easily be used for stroke rehab. And it would be a lot less conspicious than the SaeboFlex
http://www.gizmag.com/go/3437/
from Oct. 2004 I wonder what happened to it? There is a tremendous need for something like this. As a joke I once mentioned to someone that I needed little motors for each of my fingers to passively flex and extend them thousands of times daily. Two problems with this; no thumb, getting a glove on a spastic hand is nigh impossible. Where did the prototype end up?
I found this one by backtracking a search hit on my blog that led to a Polish search engine looking for rehabilitation gloves.
A rehabilitation glove powered by artificial muscles has won the recent AUD $10,000 British Council Eureka Prize for inspiring science. Designed by the Quadriplegic Hand Research Unit at the Royal North Shore Hospital, the invention will help people with permanent hand-movement loss to perform the daily functions most of us take for granted.
The Australian design is the first medical application to use dynamic actuators that contract when stimulated in a similar way to normal muscles. It opens up new therapeutic possibilities for those suffering from paralysed hands and future applications may even see artificial muscles implanted in the body to enable bionic functionality.
Currently one of the most effective ways to rehabilitate damaged hands or to maintain supple conditions for paralysed hands is by a gentle, continuous motion of hand joints. This often requires intensive attention over long periods, making it unfeasible for a therapist to be continuously present.
With the rehabilitation glove each joint can be independently moved to a desired angle. Portable control software allows the therapist to program desired force, speed and range of motion for each of the15 finger/ thumb joints in the hand, giving continuous passive joint movements for hours at a time.
The Rehabilitation Glove will provide a light hand grasp with a controllable holding force. For people with paralysed hands, this function can be triggered using an external switch. This beneficial feature allows the device to control and maintain a grasp force, thereby securing the grip on objects held.

Thursday, March 17, 2011

caveperson stroke rehab

Now since I am not a medical person, this is not advice, just something interesting to think about.

I ascribe to the Peter Levine theory that in caveman days, stroke survivors rehabilitated faster because they had to. You didn't eat, you starved, you couldn't keep up with the tribe, you were left behind. The motivation was great for getting yourself rehabilitated.
http://recoverfromstroke.blogspot.com/2008/05/ive-long-believed-that-amount-of.html
And this referenced video is interesting to watch,
http://recoverfromstroke.blogspot.com/2009/09/ghead-click-article.html, although I did tweak Mr. Levine about that it was a TBI instead of a stroke. The caveman got bashed in the head with a rock but still came up with an irrigation idea to save the tribe.

Wednesday, March 16, 2011

showering and stroke rehab

There is no place that you can't do rehab.  I started out by using my right hand to hold my left hand and touch all the 4 in. square tiles in front of me. About 8 rows by 7 columns. This was to get both my bicep and pec to relax. I started this while still using the shower bench, I now do it while standing. Entering the shower I lift my left foot over  and back the 4 in. high threshold 10 times, trying to keep my lower leg hanging straight down. I hold my left hand under the spray trying to overstimulate the senses.

My most painful experience in the shower was when I was still using the shower bench.  I had an ingrown toenail on my left big toe. I sneezed and violently kicked the left foot into the wall six inches away. The big toe led the way, the tile wall was not fazed. It's amazing the speed you can generate in 6 inches, if I tried to do it willfully it would have been a love tap.

Ask your therapist for their recommendations in the shower, and make sure you ask for research proof that it is effective.

Tuesday, March 15, 2011

spasticity during sleep, does it exist?

I was asked by Peter Levine once if I thought I had spasticity while sleeping. I think my left calf is spastic during sleep, when I get up I have to immediately stretch it out before I can walk. This is really only provable when there is a quantitative measure of muscle spasticity I think when I wore a night splint those fingers also were spastic during the night. The gel Yoga toes I wore for awhile were uncomfortable after 5 hours so those toes were defintitely being spastic at night. What are your experiences?

sleeping and necessary therapy

I used to sleep face down.
This used to be the normal way I slept, with my face at the edge of the bed in order to get the maximum exposure to the air in the room. I have not been able to do this since my event. I tried this past weekend and managed to get on my stomach by rolling over my affected arm. Due to the spasticity in my pectoral and bicep muscles the arm was attempting to burrow under my body. I lasted for all of 5 minutes before I gave up.
Trying to roll over my good arm to my stomach doesn't work because my affected arm gets under my body before I can complete the roll.
I changed this now to grasp one of the spindles at the head of the bed. It takes about 5 minutes to force open my hand and get it around the spindle before my wrist turns down and slips my fingers off. The arm is then bent at a right angle above my head. This really keeps my pectoralis stretched out. The bicep is contracted but the pec needs more work, I don't worry about the curled fingers.
The other thing I try sometimes is to put a pillow on the floor at the left side of the bed. I can then lay on my stomach with the left arm dangling in a fist on the pillow. I can't lift my arm up except by rolling on my back.

This is obviously something you should be getting from your therapists so don't try this without such permission.

15 Million Americans Now Caring for Loved One With Alzheimer’s

I know this isn't directly related to stroke but I can correlate anything to stroke.
http://www.doctorslounge.com/index.php/news/hd/18571
At least the chief medical officer of the Alzheimer's Association can put out decent press releases keeping that disease in front of the American people.
If we compare the 5.4 million people in the United States have Alzheimer's disease, and their 14.9 million caregivers provided a total of 17 billion hours of unpaid care, valued at more than $200 billion, according to the report. With 6 million stroke survivors the numbers could be close to the same. Who is speaking up for the stroke survivors? I don't see either the ASA or NSA stepping up to the plate, at least as far as survivors are concerned. Tell me who is or the excuses that someone isn't.

Patient's Subjective Experience in Stroke Rehabilitation

This would have really helped me in the first days and weeks in the hospital, rather than telling me nothing. Something to add to the stroke rehab protocol.
http://www.ncbi.nlm.nih.gov/pubmed/21371977
Abstract
Kaufman's observation that the patients' reactions to their impairments and disabilities need to be addressed in stroke rehabilitation has been shown to be an accurate and perceptive statement. In this article, 3 levels of stroke rehabilitation are outlined, and the importance of focusing on the third level (the level of subjective experience) is emphasized. Identification of the patients' subjective experience allows one to understand what is most frustrating to them. After addressing those frustrations, patients are more eager to engage the rehabilitation process. Within the context of this rehabilitation process, helping patients clarify what their subjective or phenomenological state is as it relates to their stroke is crucial in having them not only engage the rehabilitation process, but ultimately find meaning in life in the face of their stroke. This can be a difficult task because patients often do not have the words to clarify what their inner psychological experiences are following a stroke. Helping to provide guidelines for this can result in a meaningful experience for both the patient and the therapists involved in their care.

Monday, March 14, 2011

moral test of government

This came from my senator and former VP of the US.
"The moral test of government is how it treats those who are in the dawn of life . . . the children; those who are in the twilight of life . . . the elderly; and those who are in the shadow of life . . . the sick . . . the needy . . . and the disabled."
-- Hubert Humphrey
As someone from Australia asked me about health care reform in the US. My reply was;
The people shouting the loudest hate it but I really think they just want complete anarchy. Survival of the fittest and all, and since I no longer am in that category I should probably just reduce myself as part of the surplus population.

problem solving for stroke rehab

This comment from a rehabilitation stroke expert pretty much follows what I am trying to accomplish.
http://www.ottawasun.com/news/ottawa/2010/04/12/13560141.html
Stroke patients need to rely more on their own problem solving to regain mobility, says a leading international expert on stroke therapy. Dr. Steven Wolf, a rehabilitation stroke expert and professor at Emory University School of Medicine in Atlanta.
This one contradicts everything you are taught, that you need to rely on your medical staff for what to do. And I probably should tell you to discuss this line of circular reasoning with your doctor and see which one of you starts screaming first.
Good luck, as my wife once said to me, You're on your own now.

viagra and stroke rehab

Well I'm sure they could get lots of male human volunteers. I wonder what the rats thought about it?
Sildenafil (Viagra) Induces Neurogenesis and Promotes Functional Recovery After Stroke in Rats
http://stroke.ahajournals.org/cgi/content/full/33/11/2675

No self-medicating here. This is definitely something to ask your doctor about.

Stroke Rehabilitation: What is the point?

This is an article by Sarah Tyson from 1994.
senior lecturer in physiotherapy, Department of Health Studies, Brunel University College, Borough Road, Isleworth, Middlesex
She seems to have channeled Hipprocrates from 2400 years ago, 'It is impossible to cure a severe case of apoplexy and difficult to cure a mild one.'

http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B7CVK-4HCDTJ0-3&_user=10&_coverDate=08%2F31%2F1995&_rdoc=1&_fmt=high&_orig=gateway&_origin=gateway&_sort=d&_docanchor=&view=c&_searchStrId=1678658776&_rerunOrigin=google&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=c026b31aff4059214885ae156232ebd0&searchtype=a

I am certainly not going to buy it for $31.50
Summary here:

Rehabilitation has been defined as the restoration of optimal physical, psychological, and emotional ability. The ineffectiveness of stroke rehabilitation in the light of these terms is highlighted, and the experience of people with stroke after discharge is described. Reasons for the apparent lack of true rehabilitation are suggested, and the dichotomy between health care professionals' and patients' goals and perceptions is discussed.

Key Words: Stroke rehabilitation; physical outcome; social activity; psychological outcome

This article is adapted from one presented at the Wessex Regional Postgraduate Continuing Medical Education Programme in Elderly Care, 1994.

hand opening and stroke rehab

I probably spend an hour or two each day just flexing my hand open with my good hand. At a stroke meeting someone joked about seeing all the survivors flexing their hands open and closed. I know there is some science behind passively moving your muscles to start neuroplasticity. See here -
http://www.ncbi.nlm.nih.gov/pubmed/15003755 With hand function probably being the most requested item to recover I wish there was some actual fact-based information on what needs to be done to recover it. It seems we are once again left hanging with 'We don't know, try something yourself'. As Sargent Schultz used to say, 'I know nuthing'.

finger gloves and stroke rehab

Since I have spasticity in my finger flexors getting a glove on is usually an almost impossible task. During my canoe trip 3 years ago I ended up rubbing my left palm raw with a half-dollar size skin removal. After taping that up the trip leader asked if I had brought along paddling gloves, I had and for some reason I even brought the left glove. He proceeded to roll down the glove until the entry holes for each of the fingers was open. I then flattened my hand and started feeding each of the fingers into the holes. After much tugging and pulling we were able to get the glove on my hand. The trip leader related that he learned of this trick when he was a PCA for a CP patient. For the next 9 days I tried this and on 2 days I was able to even get it on by myself although when people helped it went much faster, I did have to be sitting down when doing this and alloting 15 minutes to accomplish it

inversion of the ankle stroke rehab

I was wrong, the picture is actually inversion not eversion. Told you you shouldn't listen to the blatherings of an idiot.
This is something your PT should be explaining to you. But if you want to learn on your own read this.
Here is a link to an article that explains which muscles are used in inversion.
http://www.massagetoday.com/mpacms/mt/article.php?id=13429
This picture is a great example it came from http://www.rehabanklesprain.com/rehab-ankle-sprain.html?hop=31702 This is my main reason for wearing an AFO, if I wear solid shoes I can prevent inversion, going barefoot does not work. When I went cross-country skiing without an AFO I rolled my foot dozens of times barely missing a sprained ankle. Now I ski with an AFO even though my toes are squashed.


I am having major spasticity with that and an AFO is the common solution. I want to try to strengthen those muscles. Latest research has shown that exercising spastic muscles does NOT increase spasticity, contrary to what your therapists have probably told you. Exercise actually increases your control of the muscles reducing your spasticity.

Remember these are the blatherings of an idiot, talk to your therapist or doctor.

observational study, trial or experiment?

I also have not distinguished between these. From GarySchwitzer, director of the Duke Stroke Center at Duke University Medical Center  and his blog on
http://getbetterhealth.com/coffee-and-stroke-another-study-the-media-got-wrong/2011.03.14

Coffee And Stroke: Another Study The Media Got Wrong

It was a big study, but an observational study. Not a trial. Not an experiment. And, as we say so many times on this website that you could almost join along with the chorus, observational studies have inherent limitations that should always be mentioned in stories. They can’t prove cause and effect. They can show a strong statistical association, but they can’t prove cause and effect. So you can’t prove benefit or risk reduction. And stories should say that.

So be forewarned and ask your doctors what these mean.

Sunday, March 13, 2011

Nitric oxide and stroke

http://www.nottingham.ac.uk/~nszwww/enos//
The 'Efficacy of Nitric Oxide in Stroke' (ENOS) study is a collaborative, international, multicentre, prospective, randomised, single-blind, blinded endpoint, parallel-group, controlled trial designed to test the safety and efficacy of:
(i) transdermal glyceryl trinitrate (a nitric oxide donor) or control; and
(ii) continuing or temporarily stopping prior anti-hypertensive medication.
3,500+ patients with acute ischaemic or haemorrhagic stroke will be enrolled within 48 hours of the onset of stroke and treatment will be given for 7 days. The primary outcome is shift in death or dependency (modified Rankin Scale) determined at 90 days by observers blinded to treatment.
Power point presentation, V1.0 (Powerpoint, size=3.9MB)
http://www.nottingham.ac.uk/~nszwww/enos//enostalkgenericv10.ppt
Brief Information for patients & relatives about the trial, V1.1 (PDF file, MREC approved)
http://www.nottingham.ac.uk/~nszwww/enos//enosinfopatrelv11.pdf
Full information for patients, V2.11 (PDF file, MREC approved)
http://www.nottingham.ac.uk/~nszwww/enos//enospisv211.pdf
Nobel prize is awarded for NO discovery
http://circ.ahajournals.org/cgi/content/full/98/22/2365
Nitric oxide was named "Molecule of the Year" in 1992 by the journal Science, but it took another 6 years for those responsible for the major discoveries surrounding it to win the Nobel Prize. Three US scientists—Robert F. Furchgott, PhD, Louis J. Ignarro, PhD, and Ferid Murad, MD, PhD—will receive the 1998 Nobel Prize for Physiology and Medicine on December 10, 1998, in Stockholm, Sweden.
The discovery of nitric oxide's signaling role in the cardiovascular and nervous systems is now nearly 20 years old, but its clinical use is only beginning. Dr Furchgott, a distinguished professor of pharmacology at the State University of New York (SUNY) at Brooklyn, began the studies that led to the identification of nitric oxide as a biological agent in 1980. At that time, he was trying to reconcile the contradictory effects drugs had on blood vessels. He concluded that endothelial cells produce an unknown signal molecule that makes vascular smooth muscle cells relax. He called the signal molecule EDRF, or endothelium-derived relaxing factor.
In unrelated experiments, Dr Murad, now chairman of the integrative biology department at the University of Texas Medical School at Houston, was analyzing how nitroglycerin works. In 1977, while at the University of Virginia, he found that nitrates release nitric oxide, which relaxes smooth muscle cells, resulting in vasodilation. He was fascinated that the colorless, odorless gas could act as a signaling molecule.
Dr Ignarro, now a professor of pharmacology at UCLA School of Medicine in Los Angeles, California, through a series of analyses concluded in 1986 that EDRF was identical to nitric oxide. His work, done independently and together with that of Dr Furchgott, prompted an increase in research activities in many areas of the world.

I have no idea if this is just for acute or rehab. I was taking NO prior to the event, a combination of L-Carnatine and L-Arginine, but I have quit due to the size of the pills. Talk to your doctor on this.

protocols for stroke rehab - nonexistant

For something that affects hundreds of thousands each year, its rather pathetic that no stroke related association has done anything.
However for less disabling injuries/diseases there are some:

In 2007 the American Heart Association (AHA) stated that for most people, taking antibiotics for routine dental procedures was no longer recommended. Based on this recommendation, the American Dental Association (ADA) followed suit that same year, changing its prophylactic antibiotic protocol.
http://www.cancerprotocol.com/
The information found in this website is primarily directed towards those patients who have been given poor prognosis and their medical oncologist who have run out of treatment options. At a recent meeting, in Amsterdam, Netherlands, which was sponsored by the National Cancer Institute and the European Organization for Research in Treating Cancer, cautious hope emerged. A revolutionary new view of treatment protocols was put forth.
Presbyterian's Heart Attack Protocol Recognized as a Blueprint for Success
http://www.presbyterianmdlinks.org/site/news_and_publications/news_releases2/Presbyterian_VHA_Heart_Attack_Blueprint.html
Instead in the stroke world you get these bland statements.
From the American Stroke Association:
Under your doctor's direction, rehabilitation specialists provide a treatment program specifically suited to your needs. Physicians who specialize in rehabilitation are called physiatrists. The number of services you receive will depend on your needs. Services may include:
•Rehabilitation nursing   
•Physical therapy   
•Occupational therapy   
•Speech-language pathology   
•Audiology   
•Recreational therapy   
•Nutritional care   
•Rehabilitation counseling   
•Social work   
•Psychiatry/Psychology   
•Chaplaincy   
•Patient/Family education   
•Support groups
Vocational evaluation, driver's training and programs to improve your physical and emotional stamina so you can go back to work also may be part of your rehabilitation program

From the National Stroke Association:
During all phases of your rehabilitation and recovery, you will most likely work with a team of professionals from different specialties. It’s important that you get to know your health care team and feel comfortable addressing any recovery issue with them.
Services delivered during rehabilitation may include physical, occupational, speech and language therapies, therapeutic recreation, and specialty medical or psychological services.

From the World Stroke Association:
Unable to find, probably because the WSO has no interest in helping survivors.

Even a cut finger down to the bone has a protocol;  Modified Duran Protocol
http://www.scribd.com/doc/13709371/Handbook-of-Orthopedic-Reahabilitation
Chapter One has the description if you are interested.

Did just find an OT one here:
http://www.scribd.com/doc/21483160/Ot-Guidelines-Stroke-Rehab-Protocol-Final
Still disappointed because it has no therapies and why to chooose such therapies. A consequence of the PMR doctor not giving a damage diagnosis.

All the stroke ones use weasel words, there has to be enough smart people out there working on this that they could at least try to write up a protocol. Or do we need to put together our stroke-addled brains and do the job ourselves.?

 But first we have to break though the comment 'All strokes are different, All stroke recoveries are different'.

Proprioception and stroke rehab

I have been looking for years for a writeup on recovering proprioception and this is the first one I've seen.
Its pretty useless for a do-it-yourself program like mine, but hey, its a start.
http://www.webmedcentral.com/wmcpdf/Article_WMC001721.pdf
It talks about a podcast but I couldn't find it.

Friday, March 11, 2011

What's your perfect world of stroke rehab?

Today we are barely better off than 2400 years ago when Hippocrates said, 'It is impossible to cure a severe case of apoplexy and difficult to cure a mild one'. I have some very opinionated ideas but I'm trying to put them together in an opinion article to the New York Times. I thought I would start at the top. Put something together for your local paper.

neurotransmitter reboxetine could improve post-stroke rehabilitation

http://www.mpg.de/1206132/noradrenaline_stroke?filter_order=L
In many patients, fine motor skills remain impaired after a stroke. A recent study has shown that the neurotransmitter noradrenaline may be able to reduce such deficits. This finding could result in the development of a new therapeutic approach to the post-stroke rehabilitation of patients.
 Brain connectivity following the administration of reboxetine
© C. Grefkes, MPI for Neurological Research As part of the study carried out by Christian Grefkes from the Max Planck Institute for Neurological Research in cooperation with scientists from the Institute of Neurosciences and Medicine of the Forschungszentrum Jülich and the Department of Neurology of the University Hospital of Cologne, eleven stroke patients (between 42 and 74 years old) with fine motor deficits carried out a range of motor tasks which involved the determination of maximum grip power and finger-tapping frequency and the execution of pointing movements.
The researchers influenced the dwell time of the naturally released neurotransmitter noradrenaline by administering reboxetine (RBX) to the patients. This substance slows down the reuptake of the transmitter by neurons and hence extends its stimulating effect on coupling within the cortical motor network. As a control condition, some patients were given a pill that looked the same, but contained no active substance (placebo).
On the behavioural level, the extended dwell time of the noradrenaline prompted an improvement in the patients’ performance of simple motor tests: while grip power in the affected hand increased by a factor of four on average, the finger-tapping frequency doubled – this represents a remarkable improvement from both the patients’ and neurologists’ point of view. As indicated by functional magnetic-resonance imaging scans (fMRI), the improvements in motor performance were associated at cortical level with a normalisation of the previously abnormally increased brain activity – particularly in the motor areas of the damaged brain hemisphere. These processes were accompanied by greater communicative efficiency between the hand area and the brain’s motor control centres.
Max Planck junior scientist Christian Grefkes is optimistic about the results: “The findings of our study could provide a starting point for the development of a promising new therapeutic approach to the correction of defects in brain networks and improvement of hand motor functions following a stroke”. The plan is now to test reboxetine on a larger group of patients over a period of several weeks to establish the sustainability of the improved effects.

Very interesting but I wonder if this is just for acute or could I as a chronic survivor benefit from this?  This one says it is for chronic
http://www.ncbi.nlm.nih.gov/pubmed/17277911
Who's willing to follow up with more detailed human testing?

brain plasticity and stroke rehabilitation 1999

http://stroke.ahajournals.org/cgi/content/full/31/1/223
The Willis Lecture
Presented as the Willis Lecture at the 24th American Heart Association International Conference on Stroke and Cerebral Circulation, Nashville, Tenn, February 4, 1999
Current Concepts on Brain Plasticity
Sections:
Introduction
Current Concepts on Brain Plasticity
Possible Mechanisms Behind Brain Plasticity
Spontaneous Events and Training Effects
Enriched Environment and Neurotrophic Factors
Pharmacological Interventions
What Is the Possible Role of Neurogenesis?
Transplantation
Clinical Evidence for Reorganization of Cortical Networks
Stroke Units and Early Training
Age and Plasticity
Concluding Remarks
References

For something that was so farsighted 12 years ago we finally seem to be getting back to it with Clarkes' and Moskowitz theories. My doctors obviously never got the memo; neither did anyone else. At least from what survivors write about, we have millions that are in the dark. My solution to that is to put a cognitive survivor in charge, this every person for themselves is an exercise in stupidity.

Role of Cerebrospinal Fluid in Brain Stem Cell Development

http://www.prnewswire.com/news-releases/study-illuminates-role-of-cerebrospinal-fluid-in-brain-stem-cell-development-117740298.html
I know this is way out of my league but brain stem cells sounds like a good idea for stroke survivors.
Of course there might be a side effect of tumors. Ask your doctor to weigh in on this.


BOSTON, March 10, 2011 /PRNewswire-USNewswire/ -- Cerebrospinal fluid (CSF), the fluid found in and around the brain and spinal cord, may play a larger role in the developing brain than previously thought, according to researchers at Children's Hospital Boston. A paper published online March 10th by the journal Neuron sheds light on how signals from the CSF help drive neural development. The paper also identifies a CSF protein whose levels are elevated in patients with glioblastoma, a common malignant brain tumor, suggesting a potential link between CSF signaling and brain tumor growth and regulation.
The study, led by senior investigator Christopher Walsh, M.D., Ph.D., chief of the Division of Genetics at Children's, adds to a very small body of literature on the normal physiological roles of CSF in neural development. It harkens back to ancient and medieval thinking about CSF – not the brain itself -- as the locus of the mind.
Walsh and colleagues became aware of the role of the CSF while studying how stem cells in the brain establish polarity -- distinct regions within a cell. All stem cells in the brain contain groups of proteins, known as apical protein complexes, that work together to establish polarity. They also play a role in telling stem cells whether to continue dividing or to become neurons.
The researchers noticed that these apical proteins are expressed on the parts of the stem cell that are in contact with the CSF, and that stem cells actually send tiny protruding processes called cilia, that act almost like antennae, directly into the CSF. They suspected that signals to initiate or curb stem cell growth were coming from the CSF. But how?
They found that two proteins within the apical complex, Pals1 and Pten, were interacting with the Igf1 receptors in the stem cells, relocating the receptors to the boundary between the stem cells and the CSF. This allowed the receptors to be stimulated by the CSF protein Igf2. When Pals1 or Pten were disrupted, the cell's ability to receive signals from the CSF was impaired, and stem cell growth was altered.
"When we deleted Pals1 in mice, we disrupted the normal assembly of the apical complexes, which then led to loss of polarity in the stem cells," said Maria Lehtinen, Ph.D., in Walsh's laboratory, one of the study's first authors. "This disruption of polarity impaired the stem cells' ability to divide appropriately."
This, in turn, dramatically curtailed brain development. "These mice essentially have no cortex," Lehtinen said.
Pten, they found, has the opposite effect: its disruption caused the creation of too many stem cells, an effect previously associated with tumor formation.
When the Children's team interbred the mutant Pals1-deficient mice with Pten-deficient mice, they were able to reactivate stem cell growth in the brain artificially. "We saw a nearly complete restoration of brain size," said Lehtinen.
The team then focused its attention on the CSF, showing that the Igf2 concentration in CSF regulates the rate of stem-cell proliferation. Moreover, they found that the concentrations of Igf2 and hundreds of other CSF proteins change over time, peaking near birth in rats and mice. The Igf2 peak occurs at the time when the cortex is most actively developing.
The researchers explored these dynamic fluctuations by floating young brains in old CSF and old brains in young CSF.
"We found that the stem cells really behaved according to what CSF they were in," said Walsh. "The CSF is really telling the brain what to do. It's telling the stem cells to either divide a lot if you're in the embryonic brain, or if you're in the adult brain, just rest, and we'll tell you if we need you."
A better understanding of the Igf2 signaling pathway, the stem cell's apical complex proteins that interact with it, and the temporally-driven changes in the CSF could lead to increased understanding of some brain tumors, including glioblastoma.
"It may be that too much Igf2 in the CSF sets up an environment that promotes tumorigenesis, adding to genetic changes in the brain tumor stem cells themselves," said Walsh.
In principle, the CSF is accessible for treatment purposes, so it could potentially be altered to inhibit brain tumorigenesis. This study did not explore direct clinical applications, however.
"One insight we found is that the CSF seems to have all the stuff in it that you need to regulate stem cells – to keep them alive and to tell them whether to proliferate or rest," said Walsh. "That gives us the potential to really understand much more clearly how we want to regulate those stem cells, acting through this medium. Hopefully we can soon get a better understanding of how to control brain stem cells so we can use them for many experimental or therapeutic applications."
Mauro W. Zappaterra of Children's Hospital Boston and Harvard Medical School was co-first author of the paper. The study was supported by a Sigrid Juselius Fellowship, an Ellison/AFAR Postdoctoral Fellowship, grants from the National Institutes of Health, a Stuart H.Q. & Victoria Quan Fellowship, an NIH MSTP grant, the Child Neurology Foundation, the A Reason To Ride research fund, a UNC-CH Reynolds Faculty Fellowship, the Manton Center for Orphan Disease Research, Simons Foundation, the NLM Family Foundation, the Intellectual and Developmental Disabilities Research Centers and the Howard Hughes Medical Institute.

music listening and stroke rehab

There has been a number of studies suggesting music during acute phase is good for you. I'm not sure I would have been able to stay awake regardless of the music played. This falls into the enhanced stimulation being good for you
http://brain.oxfordjournals.org/cgi/content/full/131/3/866
Music listening enhances cognitive recovery and mood after middle cerebral artery stroke
http://www.therapytimes.com/content=0402J84C48968A84406040441
Music Therapy Speeds Post-Stroke Recovery
music therapy
http://www.msnbc.msn.com/id/35502970/ns/technology_and_science-science/
http://www.epsychology.us/rhythm-of-life-music-shows-potential-in-stroke-rehabilitation/
http://hubpages.com/hub/Music-Therapy-Healing including Kenny Rogers, I couldn't have handled this. Ask your doctors if you can listen to music to make sure it doesn't have negative side effects.

Wednesday, March 9, 2011

drop foot options and stroke rehab

I put this together a few years ago so I'm not sure all the links work. This is really stepping on PT toes especially since you will only get the AFO option or maybe one of the estim/FES options.
Read up on Peter Levines discussion of why an AFO may prevent recovery.
http://recoverfromstroke.blogspot.com/2010/11/make-them-walk-funny-and-look-lousy-in.html

An AFO seems to be the only standard protocol for anything in stroke rehab. This piece contradicts the 'all strokes are different, all stroke recoveries are different.
Ah yes, no consistency in rehab.
drop foot options lack of ankle dorsiflexion
The standard seems to be a rigid plastic AFO, sometimes with a built-in hinge. This is also helpful in preventing foot rolling to the outside, which is my problem.
Other possibilities (to be discussed with your providers) are;
1. Soft brace - http://www.3tailer.com/shop/freedomandreg-soft-footdrop-brace
2.. Musmate a strapping and bungee sytem - http://www.musmate.com/
3. x-strap a bungee sytem from the ankle - http://www.x-strap.com/
4. eStim sending signals through the peroneal nerve to activate dosiflexion.
5. Malleoloc Ankle Brace - http://www.achillesmed.com/Malleoloc_Ankle_Brace.html?gclid=CJyWoMu3kKACFQsNDQod12P0dw
6 Walk Aide - an expensive commercial version of eStim - http://www.walkaide.com/
7. Bioness L300 a commercial version of eStim - http://www.bioness.com/NESS_L300_for_Foot_Drop.php
8. surgery This one is definitely to ask your doctor about. http://www.drnathfootdrop.com/
9. And last is just exercise. I have been doing this one for years and while I have excellent dorsiflexion when I focus just on that, my Premotor cortex needs to be reprogrammed someplace else to get the timing and multitasking working correctly.