The Resonating Arm Exerciser: design and pilot testing of a mechanically passive rehabilitation device that mimics robotic active assistance

I'm sure your therapist could create something similar using Theraband.
http://www.jneuroengrehab.com/content/10/1/39/abstract

Abstract (provisional)

Background

Robotic arm therapy devices that incorporate actuated assistance can enhance arm recovery, motivate patients to practice, and allow therapists to deliver semi-autonomous training. However, because such devices are often complex and actively apply forces, they have not achieved widespread use in rehabilitation clinics or at home. This paper describes the design and pilot testing of a simple, mechanically passive device that provides robot-like assistance for active arm training using the principle of mechanical resonance.

Methods

The Resonating Arm Exerciser (RAE) consists of a lever that attaches to the push rim of a wheelchair, a forearm support, and an elastic band that stores energy. Patients push and pull on the lever to roll the wheelchair back and forth by about 20 cm around a neutral position. We performed two separate pilot studies of the device. In the first, we tested whether the predicted resonant properties of RAE amplified a user's arm mobility by comparing his or her active range of motion (AROM) in the device achieved during a single, sustained push and pull to the AROM achieved during rocking. In a second pilot study designed to test the therapeutic potential of the device, eight participants with chronic stroke (35 +/- 24 months since injury) and a mean, stable, initial upper extremity Fugl-Meyer (FM) score of 17 +/- 8 / 66 exercised with RAE for eight 45 minute sessions over three weeks. The primary outcome measure was the average AROM measured with a tilt sensor during a one minute test, and the secondary outcome measures were the FM score and the visual analog scale for arm pain.

Results

In the first pilot study, we found people with a severe motor impairment after stroke intuitively found the resonant frequency of the chair, and the mechanical resonance of RAE amplified their arm AROM by a factor of about 2. In the second pilot study, AROM increased by 66% +/- 20% (p = 0.003). The mean FM score increase was 8.5 +/- 4 pts (p = 0.009). Subjects did not report discomfort or an increase in arm pain with rocking. Improvements were sustained at three months.

Conclusions

These results demonstrate that a simple mechanical device that snaps onto a manual wheelchair can use resonance to assist arm training, and that such training shows potential for safely increasing arm movement ability for people with severe chronic hemiparetic stroke.

The complete article is available as a provisional PDF. The fully formatted PDF and HTML versions are in production.

Visuomotor learning by passive motor experience

Ask your doctor what the hell this means.
http://journal.frontiersin.org/article/10.3389/fnhum.2015.00279/full?

Takashi Sakamoto^† and Toshiyuki Kondo^*†

• Department of Computer and Information Sciences, Graduate School of Engineering, Tokyo University of Agriculture and Technology, Tokyo, Japan

Humans can adapt to unfamiliar dynamic and/or kinematic transformations through the active motor experience. Recent studies of neurorehabilitation using robots or brain-computer interface (BCI) technology suggest that passive motor experience would play a measurable role in motor recovery, however our knowledge of passive motor learning is limited. To clarify the effects of passive motor experience on human motor learning, we performed arm reaching experiments guided by a robotic manipulandum. The results showed that the passive motor experience had an anterograde transfer effect on the subsequent motor execution, whereas no retrograde interference was confirmed in the ABA paradigm experiment. This suggests that the passive experience of the error between visual and proprioceptive sensations leads to the limited but actual compensation of behavior, although it is fragile and cannot be consolidated as a persistent motor memory.

1. Introduction

Previous studies of human motor learning have shown that we can adapt to unfamiliar environments with dynamic and/or kinematic transformations through the active motor experience. Active motor learning has been widely investigated based on various motor tasks, such as mirror drawing (Adams, 1987; Basteris et al., 2012), shift prism (Luauté et al., 2009), visuomotor rotation (Krakauer et al., 1999; Imamizu et al., 2000; Caithness et al., 2004; Kondo and Kobayashi, 2007; Saijo and Gomi, 2010), and virtual force fields (Shadmehr and Brashers-Krug, 1997; Tong et al., 2002; Caithness et al., 2004; Bays et al., 2005; Ito et al., 2007). These studies showed that the central nervous systems (CNS) generates internal models; forward models predict future states according to the current state and action, whereas inverse models calculate an appropriate motor command based on a desired motor plan (Wolpert et al., 1995; Kawato, 1999), thereby facilitating fast and accurate movements via active interactions with the environment.

In these studies, transfer or interference of the internal models were examined because the efficient acquisition of motor skills is of general interest for human movement science research. In particular, the consecutive learning of mutually conflicting motor tasks (A and B) is known to be difficult because of retrograde interference, i.e., the motor skill required for the first task (A) cannot be retained as an internal model after 24-h rest period due to interference from a secondary task (B) experienced immediately after the first motor learning session (Brashers-Krug et al., 1996; Shadmehr and Brashers-Krug, 1997; Krakauer et al., 1999; Tong et al., 2002; Bays et al., 2005). The methodology employed in these studies is referred to as the ABA paradigm. Using the paradigm, we can investigate how a motor experience is consolidated as an internal model in our brain.

These studies demonstrate that the adjustment of feedforward motor commands is based mainly on the error between re-afferent sensory feedback and the prediction of the forward model; thus, active motor process is considered to be indispensable for motor learning. However, recent studies on robot-assisted motor experience suggest that robotic intervention facilitates the acquisition of novel motor skills (Reinkensmeyer and Patton, 2009; Bara and Gentaz, 2011; Basteris et al., 2012; Beets et al., 2012) and might also improve the motor function of hemiparesis patients (Aisen et al., 1997; Krebs et al., 1998; Riener et al., 2005; Kahn et al., 2006; Vergaro et al., 2010). In addition, brain-computer interface (BCI) based neurorehabilitation research has hypothesized that passive motor experience via a robotic exoskeleton or a functional electrical stimulation (FES) would play a measurable role in motor recovery if it is coupled to a voluntary motor intention (Takahashi et al., 2012). These studies indicate that even a passive sensorimotor experience might be effective in improving motor skills; however, our knowledge of motor learning through the passive motor experience is still insufficient compared with the active one.

To clarify the effect of passive motor experience on human visuomotor learning, we performed two motor learning experiments that comprised arm reaching tasks during visuomotor rotations guided by a robotic manipulandum. The first experiment evaluated the anterograde effect of passive motor experience on successive active motor learning. The second experiment used an ABA paradigm to investigate both anterograde and retrograde interference via passive motor experience.

More at link.

Mechanical Design of an Affordable Adaptive Gravity Balanced Orthosis for Upper Limb Stroke Rehabilitation

Have your doctor get this paper and see what your therapists can use to recover your upper limb.
http://eprints.soton.ac.uk/376692/

Cannella, G., Laila, D.S. and Freeman, C. T. (2015) Mechanical Design of an Affordable Adaptive Gravity Balanced Orthosis for Upper Limb Stroke Rehabilitation. Mechanics Based Design of Structures and Machines, An International Journal (In Press).

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Description/Abstract

In this paper a novel design of non-powered orthosis for stroke rehabilitation is reported. Designed for home based use, it is the first low-cost, passive design to incorporate an assistive level that can be adaptively varied within a closed-loop control scheme. This allows the device to be integrated with a dual robotic and electrical stimulation control scheme, to thereby enable full exploitation of the motor relearning principles which underpin both robotic therapy and Functional Electrical Stimulation (FES) based stroke rehabilitation. This embeds the potential for more effective treatment. The paper focuses on the mechanical design of the non-powered orthosis, providing detailed design and dynamics analysis and evaluation.

Item Type:	Article
Divisions:	Faculty of Engineering and the Environment > Engineering Sciences > Electro-Mechanical Research Group Faculty of Physical Sciences and Engineering > Electronics and Computer Science > EEE
ePrint ID:	376692
Date Deposited:	30 Apr 2015 16:00
Last Modified:	30 Apr 2015 16:00
Further Information:	Google Scholar
URI:	http://eprints.soton.ac.uk/id/eprint/376692

What Dr. Richard Harvey of RIC should have said to Julia

I put this together since this is all readily available for anyone with a modicum of stroke knowledge and smarts.  If the RIC were anything close to the #1 stroke rehabilitation hospital out there, this would be the minimum I would expect from them.  With a team of 5 people and a couple of years Dr. Harvey could have accomplished this, or just me in a couple of hours. Why didn't he?

The RIC episode fiasco as explained in a letter to them here;
http://mycerebellarstrokerecovery.com/2014/01/26/julia/
RIC failed miserably in point #2 from here. My opinion only since I'm not seeing any facts proving their competency.

How to tell you have an incompetent stroke doctor or hospital

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Pedro Bach-y-Rita had a stroke in 1958, it destroyed a large portion of his brain stem and yet over the last 7 years of his life he recovered most of his faculties. We have the methods he used, we should be able to modify them to help you.
http://oc1dean.blogspot.com/2011/05/brainstem-stroke-recovery.html

 If you have spasticity in your hand the only way I think its possible to stop spasticity is to exercise the spastic muscles, thus telling the brain that it has control and stop listening to those contract messages from the spinal cord. As Peter Levine talks about here;
http://physical-therapy.advanceweb.com/Article/The-Magic-Cure-for-Spasticity-Reduction.aspx
That does require the ability to grasp and close your hand

Since your control area for your fingers is probably dead, the next step is to find a new location for that control area, this is where the Good, the Bad and the Ugly come in. We really have no idea on how to accomplish that yet.

The Good, the Bad and the Ugly - neurons

The area that controlled your hand is probably dead, this means none of the standard therapies will work, but since we are #1 we have studied possibilities that show promise in bringing back those functions.
1. Mirror therapy
Mirror Therapy for Improving Motor Function After Stroke
Systematic Review on the Effectiveness of Mirror Therapy in Training Upper Limb Hemiparesis after Stroke
Regardless we have come up with some protocols to follow.

2. Action observation
From action representation to action execution: exploring the links between cognitive and biomechanical levels of motor control

Modulating the motor system by action observation: Implications for stroke rehabilitation

We have thousands of animated gifs and videos of hundreds of muscle movements.

3. Mental imagery
Motor Imagery As A Tool For Stroke Rehabilitation Improvement
 We believe this works even though some research suggests it doesn't.
4. Passive movement
Exoskeleton hand gives you robo-powered fingers
We are working on getting a prototype of this in RIC.

5. Thermal stimulation
Facilitation of Sensory and Motor Recovery by Thermal Intervention for the Hemiplegic Upper Limb in Acute Stroke Patients
Basically 15 seconds warm 30 seconds cool.

6. Lucid dreaming
Lucidity Research, Past And Future - dreaming

7. Extra sensation
According to Margaret Yekutiel  in the book, Sensory Re-Education of the Hand After Stroke in 2001 sensation is a great precursor to movement.


You have to hope that your executive control areas are strong enough to resist being taken over.

We have been studying the hundreds of neurogenesis research papers and while there is no defined standard of care for this yet we have some ideas worth trying. This is fairly far out there so we don't even have any reported successes yet.

Stem cells are not even close to any brain application.
We have the ability to get you closer to where you want to be.

Contact me RIC if you want even more innovative ideas to keep your #1 ranking.  Its obvious Dr. Harvey is not.

My theory on motor recovery - stroke rehab

I put this out there with no professional background, borrowed from Cassalita and my original OT on eccentric vs. concentric contractions.Most therapists focus on functional recovery because that's what they are paid for. From some questions directed to me, a lot of survivors have a specific movement they want to recover - not necessarily functional. And no one is giving them any help in planning out how to recover that.  And as Steven Wolf says, 'Stroke patients need to rely more on their own problem solving to regain mobility', Prerequisites are a decent muscle anatomy or body-building book or anatomy software that shows the complete range of movement of the muscles you are interested in. My example is the bicep.
1. First you need to see where you have some control. straighten your arm out, see if you can exert force at any point in the contraction phase, this might entail having someone lift your arm up bit by bit to see if you have some muscle control at any point, try this standing and lying down. That determines if you have some concentric contractions. Then get the lower arm to 90 degrees to your body and try to lower it. You may need someone to pull on your hand to tell if you can resist. That determines if you have eccentric contractions.
2. If you have control at any point, start there and move it back and forth, thousands to millions of times.
3. If that doesn't produce anything it's time to go to the dead brain recovery options - these are not really proven yet and some can be quite dangerous(videos and mirrors)
    a. Mental imagery
    b. Passive movement
    c. Mirror therapy
    d. Thermal therapy
    e. Action observation
4. If 3 works go back and repeat 1 and 2.

Remember, this is not for personal use, ask your doctors and therapists for validation first.

If your doctor or therapist has given you something better, please post it, it must be worth a lot since it is not public information.

Exoskeleton hand gives you robo-powered fingers

Someone could easily repurpose this for finger therapy - passive movement.

Festo's prototype robo-hand can operate machine manipulators from afar, and could help stroke victims regain use of their hands

Exoskeleton hand gives you robo-powered fingers

 full article and video at the link.

THERAPEUTIC EXERCISE and Range of Motion ROM Exercises

I know this is mainly for therapists but you need to know about this also.
diagrams and explanations at the link.
http://pt-rehabilitation.com/2012/04/therapeutic-exercise-and-range-of-motion-rom-exercises.html?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+---physiotherapyOnline+%28Physiotherapy+online%29

A Pilot Study to Assess Use of Passive Extension Bias to Facilitate Finger Movement for Repetitive Task Practice After Stroke

I want to know how to duplicate this for myself.
http://thomasland.metapress.com/content/016784161j578037/

Abstract

Background and Purpose: The purpose of this study was to investigate whether active range of finger motion could be increased through the introduction of passive, external extension joint torques in stroke survivors. Participants: Five chronic stroke survivors with severe hand impairment resulting from hemiparesis took part in the study. Method: Participants completed 2 experimental sessions in which hand movement and function were assessed. In one session, they wore a custom orthotic glove (X-Glove) that passively supplied extension torques to the joints of the fingers. In the second session, they performed the same tasks as in the other session, but without the glove. Outcome measures consisted of active range of motion, distance of the fingertip from the hand, selected tasks from the Graded Wolf Motor Function Test (GWMFT), and the Box and Blocks (BB) test. Primary results with and without the glove were compared using paired t tests with a Bonferroni correction. Results: Active range of motion improved significantly by over 50%, from 4.4 cm to 6.7 cm, when the X-Glove was worn (P = .011). The distance of the fingertip from the metacarpophalangeal joint increased by an average of 2.2 cm for 4 of the subjects, although this change was not significant across all 5 subjects (P = .123). No significant differences were observed in the BB or GWMFT whether the X-Glove was worn or not. Discussion and Conclusion: Introduction of passive extension torque can improve active range of motion for the fingers, even in chronic stroke survivors with substantial hand impairment. The increased range of motion would facilitate therapeutic training of the hand, potentially even in the home environment, although the bulk of the orthosis should be minimized to facilitate interactions with real objects.

arm-hand stroke exercises by madfit

Madfit has posted these on several stroke forums. They are so good they need to be distributed again. You won't get something like this from your therapist so since this is a non-medical source it is not worth listening to.
http://www.stroke-survivors.co.uk/forum/viewpostsbyuser.aspx?UserID=106

When you read these you can see that she covers the therapy needed for those muscles that still partially work, and goes to passive movement to neuroplastically get functions that were in the dead area moving again. She also worked on sensations which has been proven to help movement.

Here are the exercises:
1. Take your arm, and with the other hand massage the affected arm, trying to loosen the muscles. If you keep doing this, eventually it will loosen up. In rehab this method is called Miofacial Release. The therapist did for me and I continued to do it at home. It really worked on me. Ask at Rehab if they offer it.
2. Stengthen your whole arm including your fingers, by taking a plastic grocery bag and put a few groceries, adding more and more weight when you think you can. You'll be surprised, by carrying the bag with 2 or 3 fingers, you'll see how strong both the fingers and arm become and the muscles will loosen up.
3. With the affected hand, pull the fingers on the opposite hand, one at a time, and keep stretching them out. Stretch each joint on the finger, the 3 joints on every finger. I constantly did this. My hand used to be like a claw. You should see it now. I am even touch typing this note using every finger on both hands. It takes a strong will, perseverance and a lot of work.
Take the good hand and pull on the thumb stetching it, farther and farther from the index finger. After a while, you'll notice you can separate the thumb from the index finger until it is normal like your good hand.
4. Then when you have accomplished this, just try opening and closing the fingers, over and over until they become strong.
5. Use a tight springed clothes pin, and keep pressing it open, this will also give strength to the fingers.
6. Put some small type shaped pasta or marbles in a bowl and try picking one at a time up. This gives coordination.
7. Did they give you puddy in therapy? That was also good to build strength.
8. It's very important to do exercises all the time. Just relaxing in bed, sitting in a chair or anyplace. I even used to do this when someone took me by car shopping, after a while it will be instinctive. I can personally attest to these exercises helping.
9. Use the squeeze ball method to gain strength, while watching TV, in a car, etc.
Now I touch-type, that is using both hands and all fingers, I do everything with the affected hand. The only thing I cannot do well is write. The precise coordination which is needed in the wrist I still don't have for writing. It takes alot of hard work, a strong will, and dedication every day, as well as prayers. But it does work.
I had a pretty bad stroke in October 2002, when I was 55 years old with a good job. I was totally paralyzed on my right side (leg and arm). I had about 3 months in-patient therapy, and 2 months outpatient therapy. Eventually went home in a wheelchair.
I was told I probably would walk eventually with a cane, but several doctors told me I would never have function of my right arm and hand. I told them I don't accept their prognosis. I might add that I am a right-handed person, so that made it even worse. I had to learn to write and do things with my left hand.
Hope this helps you! Good luck.

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'.

What therapy-exercise worked best for your stroke rehab?

Therapists ask me what therapies have worked in my rehab. I can understand why because they want to add that therapy to their roster of abilities.

Survivors ask me what exercises worked in my rehab. They are hoping that if they can just find the right exercise to do they will recover.

Both of these questions are invalid because the first thing to understand is how recovery occurs and where you are in the process. Until you know that can you select a therapy or exercise to work on. If you are working on penumbra recovery in the first 6-12 months then you take the little pieces of movement you do have and keep extending them longer and farther. If you are trying to get back functions that were in the dead brain area then you need to work on neuroplastic therapies that move those functions; try passive movement, mental imagery, thermal stimulation, action observation. All of these are discussed in other posts on my blog.

Until we get the whole concept of what needs to be done to recover changed from this specific therapy or exercise will we finally come up with a therapy model for stroke rehab. So don't enable the doctors and therapists by accepting a therapy or exercise without them specifying how it meets the protocol of recovery. See my blog on restructure stroke rehab model and theoretical basis of stroke rehab for my ideas. I actually think they are pretty good.

Standard response to stroke rehab questions

Since I post in numerous forums and there are lots of questions on what to do next I came up with this standard response. Of course this does contradict what you will hear from your medical staff; 'All strokes are different, all stroke recoveries are different.'

The whole problem here is that the medical world does not have any clue as how to approach getting stroke survivors back to full recovery. They are hoping that your spontaneous recovery in 6-12 months is enough to satisfy you. What needs to be done is identify the penumbra and those functions, these are helped by standard therapy protocols because you still have a limited ability to do those functions and repetition will help recover them. The second part is to identify the dead brain area and the functions they covered. This requires a totally different approach, mainly you need to neuroplastically move those functions to another part of your brain. Some therapies than might be able to accomplish that are; mental imagery, passive movement, mirror-box therapy, thermal therapy. I would say your crucial answer is to completely understand neuroplasticity and find therapists who understand how to do that. But what the hell do I know, I'm just a stroke-addled survivor,

dead brain recovery options

Since I have huge amounts of dead brain these are the therapies I am using to try to get them moved to another location. This is not actually recovering the dead brain, it is trying to move the functions that area of brain controlled to another place. This is probably the hardest thing to do, especially with no research guidance or medical support on how to do this. So this is just my opinion only, try your doctors to see if they have anything better and then reply here.

mental imagery:
Andrea Zimmermann-Schlatter*1,2, Corina Schuster2,3, Milo A Puhan4,
Ewa Siekierka5 and Johann Steurer4
http://www.jneuroengrehab.com/content/pdf/1743-0003-5-8.pdf
Using Motor Imagery in the Rehabilitation of Hemiparesis ,
Mental imagery for promoting relearning for people after stroke: A randomized controlled trial1 , *1 .
Archives of Physical Medicine and Rehabilitation , Volume 85 , Issue 9 , Pages 1403 - 1408

Mirror-box therapy: Rehabilitation of hemiparesis after stroke with a mirror
Altschuler EL, Wisdom SB, Stone L, Foster C, Galasko D, Llewellyn DME, Ramachandran V
The Lancet - Vol. 353, Issue 9169, 12 June 1999, Pages 2035-2036

Passive movement: http://www.ncbi.nlm.nih.gov/pubmed/15003755
The effects of repetitive proprioceptive stimulation on corticomotor representation in intact and hemiplegic individuals.

Thermal therapy: http://stroke.ahajournals.org/cgi/content/full/strokeaha;36/12/2665
researchers found that cycles of heat and cold significantly enhanced the
sensory and motor function in the arms and hands of stroke survivors after a few weeks of therapy.
Music therapy: I am way too late for this to help but this should be part of every survivors' therapy in the hospital.
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/
https://web.archive.org/web/20090726073749/http://hubpages.com/hub/Music-Therapy-Healing including Kenny Rogers
I don't think I could have handled Kenny in the hospital.
Lucid dreaming: This one is just my completely off-the-wall idea. Why waste the time spent sleeping. Of course I have no proof/research that supports this. I try to dream using my pre-stroke abilities.
Do not take any of this as medical advice

24 hour-a-day stroke rehab therapy

My therapy seems to continue 24 hours a day.  There is nothing here that is clinically proven but I believe that even minimal tries every day will eventually produce neuroplastic change.
This knowledge came from reading lots of books, mostly Stronger After Stroke by Peter Levine. Everything I do has to be looked at in terms if it will help my recovery. I'm left side affected with at least half of my motor cortex dead and all of my pre-motor cortex dead, no real damage to my sensory cortex. This diagnosis did not come from my doctor since he never even showed me my MRI, I figured this out myself by joining a research study that did an fMRI scan on my brain. My sensory cortex supposedly was not affected but is less than before so I am assuming that it was routed thru the motor cortex across the central sulcus to get to the correct nerve endings. And since the motor cortex is mostly dead I have to find a new pathway to those nerves. This is rather depressing that I have to do all this self-diagnosis myself.
Since I am 4 years out I am way past the normal spontaneous recovery of the penumbra of the stroke. This means that all the work I am doing is to neuroplastically move control of dead areas to another location in the brain. The concept I am working on is to at least get some movement by passively moving body parts that don't work. Passive movement does have some research backing it up. http://www.ncbi.nlm.nih.gov/pubmed/15003755

Normal day, going to work.
Breakfast is pretty much a one-handed affair. I don't have finger extension yet to be able to hold my bowl of cereal with my left hand.  I can't keep my arm on the table due to spasticity constantly pulling it off, My OT tried to use opening the refrigerator door with my left hand as a therapy goal but since the fingers still haven't opened that one is still a failure. Zipping up a coat is still a challenge with the limited pinch grasp I have. I walk 2 blocks to the bus stop with my cane. I use a cane to get to work because the Messenger bag I carry pulls me off balance. At the corner waiting for the bus I lift my left foot up to the top of an 18 inch high rock. this mimics the stair stepping my PT always had me doing.After that I stand on my right leg and pull my left leg back until it rests on my left toes, this is trying to get my hamstring to fire. Then comes standing on my left leg and stepping back and forth with the right leg, good for all the little muscles that fire in your legs to keep you balanced, if necessary I use the cane in my right hand for balance. This came from a Tai Chi class I took. I add using my cane for PROM movements of my shoulder. On the bus ride itself I have to decide if I should work on keeping my arm straight, trying to stop the spasticity in my bicep, or flex my fingers open and closed with my good hand.
At work, I use my good hand to guide me bad hand with a single finger pointing down to type. Sitting in my work chair I pull my left leg under me, trying to fire my hamstring muscles.I try to dangle my arm over the side of the chair to let it know that it can relax and hang straight. Washing my hands at the sink I have to open and close the single lever faucet with my bad arm/hand. Then I go to the stairwell and do a set of 50 toe raises.
Waiting at the bus stop at night I raise and lower my lower arm 50 times. Next is knee bends on the left side, just going down enough to unlock the knee and then straightening it out again. On the way home I stop at one of our apple trees in our yard and put the affected hand around a limb that is at shoulder height, push and pull with the biceps/triceps. Sitting on a couch reading requires either sitting on my flattened hand or keeping the whole arm straight next to my leg.
While sitting I rotate my arm outward from my leg, even if it is only 3 inches at a time.
Eating at the table I just put my left hand flat on the table next to my plate, just trying to keep it in one place is a workout quieting down my spastic pectoralis and bicep muscles. I sneezed once at the table and swept all my dishes to the floor, so now I grab my affected hand as soon I notice a sneeze coming. In the shower at night I put my affected hand directly under the shower head trying to stimulate the sensations. This idea came from Sensory Re-education of the Hand After Stroke by Yekeutiel, Margaret. I also have a small fingernail brush that I use on my affected hand. The other trial I work on is hot and cold water on the hand from http://myweb.ncku.edu.tw/~fzshaw/ ASA.pdf
Researchers found that cycles of heat and cold significantly enhanced the
sensory and motor function in the arms and hands of stroke survivors after a few weeks of therapy.
At night I have to decide if I want to sleep on my back which requires putting my affected fist under my butt, or sleep on my side with my affected hand flattened out under my pillow.
Other therapies during a regular day. Riding in a car means either flexing my fingers of my affected hand or straightening my left arm and just holding it straight.
Every time I stop walking I have to consciously tell my left arm to relax and hang straight by my side. This is rather embarassing for a guy walking around to have his bent arm constantly banging into his crotch. As much as possible I try to come up with exercises that engage my triceps to keep my arm straight. I also work on exercising my biceps because exercising spastic muscles does not increase spasticity as your therapist probably told you.
None of this is intended to be medical advice, Just my opinion that if you are going to recover you need to consider it a constant job, either with exercises or mental imagery of those exercises.
My suggestion is that you take whatever movement you do have and work at the outer limits of that movement.
What I have to do is think every single moment of the day if there is some movement I should practise or should I be thinking about that movement. What this means is that I have to do everything the hard way to get to recovery rather than compensatory movements.
This book, The survivors club : the secrets and science that could save your life / Ben Sherwood, was interesting in that it broke down survivors of disasters into 3 groups. 10% would actively become leaders, 80% would follow the leaders, 10% would do nothing. I try to apply this to my stroke survivorship and am working on being in the top 10%.
In further posts I will detail the work I do for rehab.

No rest for the wicked.

Left hand stroke therapy

Getting something into my left hand is an interesting exercise in patience. While my hand is not curled into a fist the fingers are not hanging loose. Anything larger than a bottle of soda is impossible to grasp. The top also needs to be sealed, an unopened can or bottle is only possible because I need to be able to tilt it on its side prior to forcing my fingers open. Open glasses will not work because I can't hold it upright and pry my left hand fingers open at the same time. Soft sided styrofoam or cardboard cups are also out. My basic therapy for this is passively flexing my fingers open and closed with my right hand. I used to have a plastic hand splint for nighttime use to keep my fingers straight and splayed but after three years of continous use the plastic rotted.

Stroke research questions

I started compiling a simple list of questions that I think stroke researchers need to address regarding stroke rehabilitation. I consider them to be easy questions with difficult answers. Without these answers we are just stumbling in the dark.

1. What is the correlation between cognitive ability before the stroke and complete recovery from the stroke deficits?
2. What amount of cognitive ability is needed after the stroke to get to complete recovery?
3. Can neurons in the brain control two different processes at the same time? ie. Can the area for toe control also be used for finger control?
4. If the previous question is false then how is it decided which functions of the brain are thrown out to neuroplastically recover damaged functions? This assumes that 100% of the brain is in use and the 10% use of the brain is a myth.
5. How many persons go insane while recovering from a stroke? This is a serious question.
6. How does brain reserve get built up again?
7. Why has no one folowed up on Brunstroms six stages of recovery to map exactly what needs to be done to get from stage to stage?
8. How much sensation is needed to fully recover motor ability?
10. What needs to be done to bring back proprioception?
11. Which therapy is best for getting a new area to start performing functions from a dead area? Passive movement, mirror-box therapy, or mental imagery?
12. How many passive movements are required to start neuroplasticity?
13. Does the laying down of new functions facilitate related functions nearby? If shoulder muscle control relocates, does that make it easier for arm and hand control to relocate nearby?
14. What is the order that recovery should work on? Should complete leg work be done before working on arm/hand issues? Or can therapy be interspersed?
15. Has the spasticity issue finally been resolved? Should spasticity be treated? From 2004-5 there were a number of researchers stating we should not treat spasticity, it was a normal protection effect of the stroke.
16. Do new neurons grow into the dead area? Where does neurogenesis lay down the new neurons?
17. Would cell homing be useful as a pointer for stem cells?
18. Which technolgy has been proven to be better, c3A peptides or NOGO receptors?
19. In 20 years when the boomers are fully into having strokes, what will you tell them about complete recovery from a stroke? They will not accept 'I don't know' for an answer.
20. How many years after a stroke is the tumor necrosis factor (TNF) is still around in the brain? In regards to the use of etanercept.
21. Is anyone researching white matter recovery vs. gray matter?

I eventually will keep going on these questions. As a lark I once said I could come up with 1000, with a little help that wouldn't be hard. Someday I will figure out how to get these to NINDS.

What my doctor should have told me about stroke recovery

After four years this is what I expected during my hospital stay, with my therapists working on pieces to meet those needs.
I received no information on stroke rehabilitation or even what the damage from stroke consisted of from my physiatrists. This is what I believe I should have received. If the medical profession is not willing to critique their own information delivery then we will have to do it for them. Some of these references probably didn't exist 4 years ago but if the same stroke happened today this is what a good doctor should be able to give you.
If your doctor doesn't give something like this to you, Point blank ask him/her 'Who can I go to that will give me hope/answers?'     Remember the detriment of the nocebo effect.



You had a massive stroke affecting your right cerebral cortex, a clot plugged your middle cerebral artery at this location - shows me a three dimensional map of a brain and points out the location. This area here is the epicenter of the stroke, it includes the motor cortex, the part that controls your muscles on the left upper half side of your body. The pre-motor cortex was also destroyed, this does the planning for complicated muscle movements. The sensory cortex does not seem to have died. Your cognitive abilities were spared.
Because you had an ischemic stroke(clot) you will be started on warfarin, a blood thinner, eventually we will get you down to just using aspirin.
There are two types of damage to the brain, First is the epicenter, this area is dead, the second is called the penumbra, which is the area surrounding the epicenter that was partially damaged during your stroke. Recovery of the penumbra area usually spontaneously recovers in 6-12 months. This does not mean you can sit back and just wait for recovery to happen. The ability to move muscles in this area is fairly limited, in order to recover them to something close to pre-stroke levels, you will need to try very hard to move them even if they barely work. This may require thousands to millions of repetitions. The statement you will sometimes hear in regard to this is, 'Use it or lose it'. Any minimal movement you have will need to be diligently worked at. This is what can be called the easy neuroplasticity
The recovery of functions that were controlled by the areas that are now dead is much harder and will require you to neuroplastically move control to another location in your brain. Call this hard neuroplasticity. You do not have unused areas of your brain, the 10% brain use is a myth.
Neuroplasticity is the most important term for you to understand, read about and believe in.
These books give a good explanation of this concept:
The mind and the Brain : neuroplasticity and the power of mental
force / Jeffrey M. Schwartz and Sharon Begley.
Train Your Mind, Change
Your Brain: How a New Science Reveals Our Extraordinary Potential to
Transform Ourselves by Sharon Begley
The brain that changes itself : stories of personal triumph from the frontiers of brain science / Norman Doidge.
Stronger After Stroke by Peter Levine, This one is worth buying.
CIMT (Constraint Induced Movement Therapy) is a way to get movement back. The concept is your working side, usually your arm/hand is prevented from moving you will retrain your non-working side to be able to do the movement needed. This is quite useful for areas that are in the penumbra on the stroke.
If you find that your sense of touch is not up to pre-stroke levels this document will give you a good idea of what needs to be done.

Thermal therapy speeds limb recovery after stroke

November 2005

researchers found that cycles of heat and cold significantly enhanced the
sensory and motor function in the arms and hands of stroke survivors after a few weeks of therapy.
For recovering the functions that were in the dead area there are a number of possibilities. Here are printouts of research studies. None of these are far enough along to have therapy protocols but this is the best we can do right now
1. Passive Movement, moving the affected limb with the good limb.
http://www.ncbi.nlm.nih.gov/pubmed/15003755
The effects of repetitive proprioceptive stimulation on corticomotor representation in intact and hemiplegic individuals.
2. Mental imagery, Imagining doing something like playing the piano or whatever you used to be able to do with the affected side but can't now.
Efficacy of motor imagery in post-stroke rehabilitation: a systematic
review
Andrea Zimmermann-Schlatter*1,2, Corina Schuster2,3, Milo A Puhan4,
Ewa Siekierka5 and Johann Steurer4
http://www.jneuroengrehab.com/content/pdf/1743-0003-5-8.pdf
Using Motor Imagery in the Rehabilitation of Hemiparesis , .
Archives of Physical Medicine and Rehabilitation , Volume 84 , Issue 7 , Pages 1090 - 1092
J . Stevens
Mental imagery for promoting relearning for people after stroke: A randomized controlled trial1 , *1 .
Archives of Physical Medicine and Rehabilitation , Volume 85 , Issue 9 , Pages 1403 - 1408
K . Liu , C . Chan , T . Lee , C . Hui-Ch
Mental practice and imagery: a potential role in stroke rehabilitation. Author's reply
R VAN LEEUWEN, JT INGLIS, J RAVEY - Physical therapy reviews, 1998 - cat.inist.fr
3. Mirror-box therapy, This is watching your good hand/arm arm in a mirror. The reflected image looks like the affected hand/arm is moving. This tricks the mind into believing the affected arm is being used.
Rehabilitation of hemiparesis after stroke with a mirror
Altschuler EL, Wisdom SB, Stone L, Foster C, Galasko D, Llewellyn DME, Ramachandran V
The Lancet - Vol. 353, Issue 9169, 12 June 1999, Pages 2035-2036
4. Music therapy, music has been proven to help initial recovery, So while you are in the hospital you will have a selection of music to listen to.
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

One of the main deficits that survivors complain about is the fatigue that seems constant. We do not have any solutions for this but to suggest that you try to increase your cardiovascular capacity.

The second major deficit survivors complain about is spasticity, abnormal stiffness of your affected side. You will need to stretch those muscles. Stretching does not cure the spasticity but it does prevent contractures, which is the permanent shortening of tendons and muscles.
Some of the recommended interventions for spasticity are stretching, general muscles relaxants, ITB(Intra Thecal Baclofen Therapy), botox, phenol, serial casting, tendon rearrangement, tendon snipping. None of these are cures, they tackle the side effects of spasticity. The cure is to get brain control of those muscles again. The best way to do that is to exercise the muscles that are spastic.

Recovery is a long drawn out processs, brains do not recover like other parts of your body. You will need to work at this for years. The only way you will not get better is if you decide that you are satisfied with where you are at and stop working at your recovery therapies.

Changes will barely be able to be noticed after one year so you will need to stay persistent and positive about your recovery work.

Your Physical, occupational and speech therapists will give you rehabilitation exercises to follow both here and at home. Doing them will not easily bring back your lost functions but they will bring back more than you have today.
If you get depressed, come back we can provide some medications that can help.
Good luck and keep in touch.