The NOGGINS AND NEURONS Podcast
What Doesn’t Work II

What Doesn’t Work II

June 29, 2021

What Doesn't Work II

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PETE: Here’s one for you...acupuncture may not be helpful for improving  functional ambulation, spasticity and activities of daily living for the lower extremity. Again we’re still talking about the lower extremity. Here’s one that may not surprise you...Neuro Aid may not be beneficial for improving stroke severity

DEB: Huh! That’s interesting. It made it in here, into the EBRSR

PETE: Yeah. How about this one? Stimulants may not be beneficial for improving motor function. Do you remember when stimulants were all the rage for people with brain injury because it was thought that they would somehow get better if they had...what’s the big one again?

DEB: Ritalin...

PETE: Adderall

DEB: oh Adderall yeah... Ritalin’s the one that I seem to remember somebody talking about a lot at the hospital

PETE: For brain injury recovery?

DEB: I think so because it was a stroke center

PETE: How about this one...have you ever heard of wholebody vibration?

DEB: Yeah!

PETE: Yeah? Wholebody vibration may not be beneficial for improving balance, functional ambulation, and muscle strength. How ‘bout them apples?

DEB: How ‘bout them apples?

PETE: Yeah...

DEB: Is that going to come up again in what does work?

PETE: That’s a good question because I know for acupuncture there are some things where it does work

DEB: Yeah...I do too.

PETE: You can have that. You can have stuff that doesn’t work for one thing but where it works for another. Yeah, absolutely

DEB: Maybe we should’ve done a comparison what does this intervention work for, what doesn’t it work for?

PETE: That is the third one...so we have what doesn’t work, what does work and what’s the comparison for things that do work and don’t work and when do they work and not work? This is a lot of work!

EPISODE SUMMARY: In this episode of NOGGINS & NEURONS: Stroke and TBI Recovery Simplified, Pete and Deb talk about more of What Doesn’t Work. We discovered:

  • There’s mixed evidence around bilateral training
  • How clinical reasoning works and why it’s important in the rehab process
  • The literature is mixed about music therapy, telerehabilitation, arm/shoulder robotics for arm recovery
  • Neuro Aid engages in shady practices and it may not improve spasticity
  • Research supports that recovery does NOT occur from proximal to distal – it is indeed a myth!
  • Yet again the importance of bringing meaning into recovery
  • Acupuncture, Botox, exoskeleton systems, whole body vibration and stimulants may not be effective for lower extremity recovery
  • It’s important to look closely at evidence available for treating spatial neglect
  • That hyperbaric oxygen therapy isn’t effective for stroke recovery

Pete and Deb infuse clinical reasoning and stories into this interesting conversation about stroke and brain injury interventions that don’t work. People who have experienced stroke or brain injury are smart. They are also in a vulnerable space and may be susceptible to being taken advantage of. This why all of us, survivors, caregivers and healthcare providers must do our research to ensure they receive high quality interventions that work.

As always, we want to hear your top takeaways! 

LINKS TO ARTICLES, BOOKS AND OTHER IMPORTANT INFORMATION:

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What Doesn’t Work I

What Doesn’t Work I

June 27, 2021

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PETE: “Stem cells are gonna shine in the future. There’s no FDA approval. You can’t get it anywhere in the United States. You can’t get it anywhere in Europe. There are places that you can get it and I’m gonna put a link in the show notes to two places that do it. Both of them are in China. I had a survivor, that when I wrote about this in my blog, report that he went to China to get this done and it cost him about 16,000 U. S. dollars to do it and this....it makes it difficult. You know, the Chinese are doing it but we’re not doing it. You know...it’s tough to standardize things unless nations across the world agree to the standardization. I have to say, and the reporting back that I got from the blog, it didn’t seem to work that well. But, you know, you never know. So I think there’s great hope for stem cells for people with brain injury, and a lot of other neurological diseases...You know, Amyotrophic Lateral Sclerosis, MS, there’s a bunch of stuff out there that could probably benefit from this stuff. It’s just not there yet.”

DEB: “Yeah...Well, from the information I read it seems to play a role in decreasing inflammation which is a big problem following brain injury.”

PETE: “I think stem cells are gonna shine in the future...People are freaked out. Look, my dear loved one went down. And then you go online and you go, ‘stem cells...boom, we gotta get ‘em. Let’s go to China. I’ll do anything for my spouse. You know, whatever it takes.’ And this is part of the problem here...This is a very vulnerable population and it’s a very vulnerable time in their life. If you’ve ever been a caregiver, you know. You’re just like desperate for answers. And then somebody’s coming by saying ‘yeah we got this thing. Oh, but by the way, it’s not FDA approved but they do it in China,’ you know it’s just a dangerous situation.”

EPISODE SUMMARY: In this episode of NOGGINS & NEURONS: Stroke and TBI Recovery Simplified, Pete and Deb talk about What Doesn’t Work. This turned out to be a big topic, so we turned it into two episodes. In part I we talk about:

  • Conventional therapy – what it looks like since it’s referred to in the research but not clearly defined
  • An eclectic intervention approach appears to be the best way to promote recovery
  • Challenges in reading the research and deciding whether or not certain interventions or certain aspects of interventions actually work
  • Interventions that don’t work and are harmful or dangerous, those that don’t work and don’t seem to be harmful and the ones that work but better options might be available
  • Stem cells, how it works and researcher reports that stretch the truth about outcomes and more
  • How the research shows there are some effective aspects of NDT but in general doesn’t stand up well compared to other approaches

Pete and Deb share exciting news about upcoming guest interviews at the beginning of the episode before they talk about stem cells and brain injury recovery; Pete’s curiosity around word choices used in the EBRSR – it may, it may not, it can, etc. that leaves us clinicians confused, and his plan to ask Dr. Teasell to clear that up for us; and the lack of research on Neurodevelopmental Treatment (NDT), a highly thought of and used intervention.

As always, we want to hear your top takeaways!

LINKS TO ARTICLES, BOOKS AND OTHER IMPORTANT INFORMATION:

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Subluxation and Shoulder Pain

Subluxation and Shoulder Pain

June 20, 2021

Subluxation and Shoulder Pain

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“And my problem with taping generally is, it’s kind of band-aidy because as soon as you take it off the arm could fall right back out. However, if you could get that to reduce pain and then have them do stuff, which then activates the SITS muscles and the deltoid and it brings that humerus back into where it needs to go, in the meantime because they are doing stuff...they’re driving cortical change, which reduces spasticity, which may indicate more movement and now we get this upward spiral of recovery that could be quite helpful. So taping may be a temporary thing but it might be a good temporary thing.”

EPISODE SUMMARY: This episode of NOGGINS & NEURONS: Stroke and TBI Recovery Simplified covers subluxation and pain. In this episode we learn:

  • That moving the hand engages the shoulder and the muscles that reduce subluxation
  • The proximal to distal arm recovery notion is a myth
  • That approximately 80% of stroke survivors experience shoulder subluxation
  • The importance of proper arm positioning to prevent shoulder subluxation and soft tissue damage
  • Pete’s and Deb’s opinions of overhead pulley use by stroke survivors - again
  • Ways to measure subluxation
  • About treatment strategies for supporting the shoulder, improving subluxation and reducing pain

Join Pete and Deb as we talk about subluxation statistics, how to prevent shoulder subluxation and/or soft tissue damage and the importance of safely moving a hemi-paretic shoulder. We discuss several braces that are commonly used to support the shoulder as well as common challenges experienced when donning and doffing them.  We also cover e-stim, NMES, functional e-stim, TENS, stretching, and taping as effective methods for addressing subluxation. We learned that brain controlled interfacing (BCI) with e-stim (which incorporates action observation and motor imagery) results in greater improvements in reducing subluxation and pain, than when functional e-stim is used alone.

As always, we want to hear your top takeaways!

LINKS TO ARTICLES, BOOKS AND OTHER IMPORTANT INFORMATION:

Comley-White, N., Mudzi, W., & Musenge, E. (2018). Effects of shoulder strapping in patients with stroke: A randomized control trial. South African Journal of Physiotherapy, 1-11. ISSN. (Online) 2410-8219, (Print) 0379-6175.

Hartwig, M., Gelbrich, G., & Griewing, B. (2012). Functional orthosis in shoulder joint subluxation after ischaemic brain stroke to avoid post hemiplegic shoulder-hand syndrome: a randomized clinical trial. Clinical Rehabilitation 26 (9) 807-816. DOI: 10.1177/0269215511432355 cre.sagepub.com

Jang, Y., Kim, T., Lee, B. (2016). Effects of brain–computer interface-controlled functional electrical stimulation training on shoulder subluxation for patients with stroke: A randomized controlled trial. Occupational Therapy International, 23(2), 175–185. https://doi.org/10.1002/oti.1422

Chatterjee, S., Hayner, K., Arumugam, N., Goyal, M., Midha, D., Arora, A. (2016). The California tri-pull taping method in the treatment of shoulder subluxation after stroke: A randomized clinical trial. North American Journal of Medical Sciences (8)4

Kate Hayner's Calif Tri Pull Taping Method video

Where electrodes should be placed for NMES and subluxation

Products to help subluxation and shoulder pain:

OmoTrain

GivMohr Sling 

StimRouter

Research:

A randomized controlled trial on the immediate and long-term effects of arm slings on shoulder subluxation in stroke patients

Effect of arm sling application on gait and balance in patients with post-stroke hemiplegia: a systematic review and meta-analysis

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Mirror Therapy

Mirror Therapy

June 15, 2021

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“I have to say, out of all the therapies that rehab can do, mirror therapy seems like it’s the most robust. The EBRSR and other meta-analyses get behind mirror therapy so much I’m amazed. And this is just because I’ve known you and we started doing this podcast, I’ve been keeping an eye on mirror therapy, thinking ok it’s a good thing...apparently it’s not a good thing, it’s a great thing...Unlike a meta-analysis that is done where you might look at a meta-analysis from 2016...well, it’s been a while since 2016. The EBRSR is updated every year so you’re always getting the latest and greatest in meta-analysis form and here’s some of the stuff they say...’mirror therapy on its own or in combination with other interventions can improve many aspects of upper limb function following stroke.’  Now you might think that that’s a pretty mild statement, but it says can improve and the word can there is bizarre for the EBRSR cuz they never say can. They say, ‘it may, it may not, it doesn’t seem to, it may, maybe, kinda, sort of’ but this is the one they say ‘it can.’ And that stuck out because there’s only like that and nothing else where they are willing to go out on a limb and say ‘it can.’ And it showed strong evidence, Level 1A, the best, the highest evidence to support the use of mirror therapy to improve unilateral spatial neglect in the subacute phase of stroke recovery and improve upper extremity kinematics and motor function...

EPISODE SUMMARY: This episode of NOGGINS & NEURONS: Stroke and TBI Recovery Simplified is all about mirror therapy. We talked about:

  • The history of mirror therapy and V. S. Ramachandran
  • Mirror neurons, empathy and brain activity
  • What research says about mirror therapy improving sensation, hemi-inattention/neglect and pusher syndrome
  • Pusher syndrome explained and what it looks like in real life
  • Mirror therapy and complex regional pain syndrome
  • The strong evidence supporting use of mirror therapy as an intervention following stroke
  • Mirror therapy protocols & home programs
  • Noggins And Neurons Podcast listener discounts

Join Pete and Deb as we discuss the ways that mirror therapy can be used to help many of the problems faced by stroke and brain injury survivors.

As always, we want to hear your top takeaways!

LINKS TO ARTICLES, BOOKS AND OTHER IMPORTANT INFORMATION:

 

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Constraint Induced Therapy: Part II

Constraint Induced Therapy: Part II

June 12, 2021

CONSTRAINT INDUCED THERAPY II

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OVERVIEW: Pete: Yeah, although be forewarned that if you have questions, we may read it on the air and, uh...on the air! Are we on the air? I don’t even know...

Deb: Like WKRP In Cincinnati.

Pete: Hey ‘now for the big sounds of the big town where the daddy-o of the radio in a city so nice they named it twice. New York, New York.’ I was communications....

Deb: You’ve been waiting your whole life for this opportunity!

Pete: I used to practice that...  

EPISODE SUMMARY: This episode of NOGGINS & NEURONS: Stroke and TBI Recovery Simplified is part 2 of Constraint Induced Therapy (CIT). Part 2 begins with Pete reiterating important points covered in Episode 1, including:

  • Commitment is required for participation in a CIT program
  • When NOT to wear the constraint: when ambulating, navigating stairs, bathing/washing, toileting and driving
  • Review of frequently asked questions about CIT including compliance, dropout rate; that CIT is not an easy intervention but is worth it, hand dominance, location of infarct, use in acute stroke

The conversation further evolved into:

  • Research on the use of CIT at the acute stage and the VECTORS trial
  • When it’s safe to begin CIT
  • Using Constraint Induced Therapy during the chronic phase – plateaus, taking breaks and having a strategic recovery plan
  • What happens to the weaker side when the training focus is on the stronger side during the first 10 days following brain injury and why it’s important to limit compensation
  • What happens to the brain with intense exercise during the first 7 days – what intensity looks like and examples of how to determine intensity levels
  • Using CIT with children
  • Reimbursement for modified Constraint Induced Therapy
  • Socialization, Groups, friendly competition and CIT
  • Starting a CIT program: benefits to survivors and clinics
  • All about lower extremity CIT, including how it’s done and figuring out who it’s appropriate for

This engaging conversation goes deeper into Constraint Induced Therapy. Survivors, caregivers and clinicians alike will benefit...

As always, we want to hear your top takeaways!

LINKS TO ARTICLES, BOOKS AND OTHER IMPORTANT INFORMATION:

 

MUSIC

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Constraint Induced Therapy: Part I

Constraint Induced Therapy: Part I

June 5, 2021

Constraint Induced Therapy: Part I

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OVERVIEW: Pete: And I asked whoever answered the phone, may I please speak to Dr. Ince. And he goes ‘hello’ and I’m in a panic because I’m like this is the guy! It took me three days to find him! And I’m like, ahh, Dr. Ince my name is Pete Levine and I’m doing a book on ah Constraint Induced Therapy and um Dr. Taub said that you were the first human to ever do it on humans and I’m really excited to talk to you... and he goes ‘I can’t hear you. There doin’ construction outside. Wait, let me close the door.’ Boom! Door slams and he comes back and he tells me this fantastic story. 

Pete quoting Dr. Ince: In 1967, I’m in a Macy’s and I’m standing there next to this guy. I don’t know who he is, and ah, we’re at a table with toys and our wives are gone doing something, I don’t what they were doing. And he was fooling with this toy...’

Pete: I always imagine this toy was the monkey with the two cymbals going like shika tik tik.

Pete quoting Dr. Ince: ‘And he was foolin’ with this toy and we got to talking and I’m a physiatrist and he was doing this stuff and he invited me to his lab in Brooklyn...’

Pete: And this is my best NY accent...I’m so sorry...you know I was born in Manhattan, so I have a little bit of right to do this.

Pete quoting Dr. Ince: ‘And um, and I asked him: What you're doing with these monkeys... Can I do it with humans? And what I found was that it could be done with people. We did the experiment. We were the first to publish about it and with some people it was successful, with some people not so successful, and some people it was a total failure.’

Pete: And that’s still where we are today. Constraint Induced Therapy is not for everyone. I think you would agree.

Deb: Yes. That’s fascinating! What a cool life you have!

Pete: I know! Lawrence Ince... he was so cool with me. Once he saw that I wasn’t calling him to sell him life insurance or something...you know he was willing to talk. So, he was great. It was just great. It sends shivers up my spine still...

 

EPISODE SUMMARY: This episode of NOGGINS & NEURONS: Stroke and TBI Recovery Simplified is all about Constraint Induced Therapy (CIT). CIT is a big topic and we talked for a long time – enough for two full episodes. In this part 1 section we:

  • Heard about the history of CIT - that it began with Nobel Prize winner, Sir Charles Sherrington 
  • Learned that Sir Charles Sherrington coined the words ‘synapse,’ and ‘neuron,’ and he talked about ‘neural networks.’ That's not all, he drew neurons and synapses! Listen to learn why this is a BIG DEAL...
  • Reviewed dorsal root rhizotomy and went deeper into it, including the procedure and process – according to Pete, it's a really great tool for spasticity treatment
  • Learned about reflexes and movement
  • Talked about the role of Operant Conditioning in CIT
  • Compared differences between research done by Dr. Edward Taub and that performed by Dr. Stephen Page & Pete Levine
  • Tied in the importance of home programs and clinic follow up for client follow through

This episode begins with a bit of fascinating neuroscience history to include Nobel Prize winner Sir Charles Sherrington. There’s no rabbit hole involved as it ties right into the topic of Constraint-Induced Therapy! Pete takes us along a journey into the research using his artful way of telling a story that keeps everyone captivated.  We transition smoothly from the early days of CIT into Dr. Edward Taub’s work, and then onto detailed information around the modified version of CIT with our very own Peter G. Levine’s work.

As always, we want to hear your top takeaways!

LINKS TO ARTICLES, BOOKS AND OTHER IMPORTANT INFORMATION:

  • A journal article about the first time constraint induced therapy was tried in humans, by Lawrence Ince, MD.

    • Ince J. Escape and avoidance conditioning of response in the plegic arm of stroke patients; a preliminary study. Psychonom Sci 1969; 16: 49-50.

MUSIC

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Neuroplastic Beats Spastic

Neuroplastic Beats Spastic

June 2, 2021

OVERVIEW: Now the one thing that they do have is finger flexion. And often therapists think you cannot let them flex their fingers because if you do you will strengthen the overwhelmingly strong flexors; and if you do that you will make the spasticity worse – which is NOT true. Spastic muscles are weak so even if you strengthen them it wouldn’t be the end of the world. But you’re not trying to strengthen them; you’re just trying to activate them. How are you gonna re-establish brain control over the finger flexors if you don’t allow them to flex the fingers? But what about a ball – a squishy ball? Who doesn’t like a squishy ball? You squish into the ball, it re-establishes brain control over the flexors thereby reducing spasticity. That’s the whole thing.

EPISODE SUMMARY: This episode of NOGGINS & NEURONS: Stroke and TBI Recovery Simplified is all about spasticity. In this deep dive we learn:

  • What spasticity is and is not
  • That spasticity is under-treated
  • The impact of untreated spasticity on the body and survivor quality of life
  • Understanding spasticity from the Neuroplastic Model

Pete shares his in-depth knowledge about spasticity in this informative episode of Noggins And Neurons. Deb’s brain kicks into OT gear and attempts to process information Pete shares – some of it as she hears it for the first time. This must listen episode will change the way some of us think about spasticity while also giving everyone ways to think about it that will ultimately benefit the survivor.

As always, we want to hear your top takeaways!

LINKS TO ARTICLES, BOOKS AND OTHER IMPORTANT INFORMATION:

Evidence for the "neuroplastic model of spasticity reduction"

 CIT decreases spasticity and “pathological” synergies

  • Questions and Comments about the podcast:
  1. NogginsAndNeurons@gmail.com
  2. NogginsAndNeurons: The Website

MUSIC

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Research for Recovery

Research for Recovery

May 30, 2021

Research for Recovery

OVERVIEW: “So here's a little fun fact: In a lot of these articles the contact information for the researchers is made available. And I have been known to reach out to researchers over the course of my career and they do respond to me and oftentimes they're very happy—very happy—to share their information and some of their PowerPoint slides and stuff that will help you in your practice. It goes back to what you were saying in the beginning. Researchers want us using their information.” 

EPISODE SUMMARY: This episode of NOGGINS & NEURONS: Stroke and TBI Recovery Simplified gets into research for recovery. We talk about research in terms that everybody can understand. In this episode we talk about:

  • What to look for when starting off on a research path
  • Systematic Reviews & Meta-Analyses as a good sign that your topic is well investigated
  • The history about how to discern evidence-based practice – good for clinicians who engage in patient-driven care as well as survivors and caregivers for assessing the care received
  • Reasons to be evidence-based...because it’s fun and satisfies one’s rebellious nature? – Why, YES!
  • Detailed information to guide researchers. NOTE: anyone who wants to know about the evidence is a researcher – survivors, caregivers, students and clinicians...
  • Where to start to your research journey
  • More...

To help offset fears and symptoms of research, Pete and Deb discuss their personal investigative styles that make research fun for them! Neither one experiences migraines or nausea whenever engaging in this exciting aspect of their work and don’t think you should either...Pete goes into history around evidence-based medicine and speaks from his research background while Deb talks from her clinical and teaching experiences. We hope you find great value in both the conversation and the show notes. HINT: There’s more in the notes than we talked about during our time together.

Pete and Deb agree that applying evidence to practice is essential for optimal recovery outcomes following stroke and TBI. We understand that knowing where, how and why can be challenging and cause procrastination, which is the reason for covering this much needed topic. We hope this RESEARCH FOR RECOVERY episode helps steer you in a right direction as you take the next step, whatever the reason for investigating stroke and TBI recovery.

As always, we want to hear your top takeaways!

LINKS TO ARTICLES, BOOKS AND OTHER IMPORTANT INFORMATION:

  • Evidence Pyramid: There are many available online. This link highlights the EBM Pyramid used by University of California Irvine. It includes information about the TRIP database that I learned about through net, a good resource.
  • TRIP Medical Database – free and premium access to medical information/journal articles
  • Knowledge Translation for Disability and Rehabilitation Research (KTDRR) Website – org – “The purpose of the Center on Knowledge Translation for Disability and Rehabilitation Research (KTDRR) is to make it easier to find, understand, and use the results of research that can make a positive impact on the lives of people with disabilities.” (ktdrr.org, 2021)

ResearchMatch helps match volunteers researchers and their studies at institutions across the country.

NIH-sponsored clinical trials that are currently accepting participants.

The National Institutes of Health (NIH) Clinical Center Search the Studies site 

Find clinical trials from around the world.

The number of medical articles published  per year 

Find all of the following under "RESEARCHING" in the middle of the web page:

Evidence-based review of stroke rehabilitation

StrokEngine: Tons of info for therapists and survivors

PubMed Central: Free Journal Articles (NIH)

MedlinePlus Simple and Free bottom line reviews

Bookshelf: free online books and docs (NIH)

Cochrane Database of Systematic Reviews

Bio med central free open-access articles

TRIP Database: a smart, fast tool to find high quality clinical research evidence

Hindawi Free Access to Journals

Directory of Open Access Journals (DOAJ)

 

CONNECT WITH US:

  • Questions and Comments about the podcast:
  1. NogginsAndNeurons@gmail.com
  2. NogginsAndNeurons: The Website

MUSIC

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How Repetition Rules Recovery

How Repetition Rules Recovery

May 25, 2021

How Repetition Rules Recovery

OVERVIEW: "What we all want at the end of the day is better quality, fluid, coordinated movement. But sometimes we don't get there. I would suggest to therapists: Don't make the perfect the enemy of the good. We're not trying to make them perfect, we're just trying to get them better. And better is good.

So sometimes the beauty is not in the beauty but in the ugliness of the movement. Let it be ugly. Let it be sweaty. Look— if you don't think that this has value, here's what you need to do: Go to a music store and get yourself a viola, and let me know how that doesn't sound like a dozen doing cats for the next six months. ‘Cause it’s gonna! Take up golf! It's gonna be— it's not supposed to be beautiful. It's supposed to be ugly. You got to enjoy the stuff."

EPISODE SUMMARY: This episode of NOGGINS & NEURONS: Stroke and TBI Recovery Simplified explains the importance of repetition for regaining movement. We talk about:

  • Repetition and where it fits in the trifecta of brain rules
  • What getting better means
  • The number of repetitions required for a person to get better
  • Variables that impact motor recovery, including survivors age, area and size of infarct, medication use, survivor motivation and movement intricacies
  • Survivor and Clinician perceptions on intensity
  • Importance of leadership in supporting new protocol and program development

Pete and Deb discuss the real-world motor and physiological effects of stroke and how thoughts impact behaviors. Pete explains research that details the challenges around determining a specific number of repetitions survivors need to perform to get better. He stresses the importance of incorporating meaning into interventions.

We found great research that looks at survivor and therapist perceptions around intensity that should help everyone feel more comfortable and confident in developing rehab programs with appropriate intensity levels that facilitate functional change. 

As always, we want to hear your top takeaways!

LINKS TO ARTICLES, BOOKS AND OTHER IMPORTANT INFORMATION:

How many repetitions does it take to drive brain changes and movement changes in folks with brain injury/ stroke?

This study showed that there were similar outcomes under three dosages of repetitive practice...

There were four groups:

  • Group A (the control) received 3 hours of traditional therapy consisting of passive movement, therapeutic positioning, and weight bearing on the affected limb. Throughout study the score increased ~3 points for the Fugl-Meyer.
  • Group B: Modified constraint induced therapy consisting of 3 hours of shaping practice per day, and a constraint on 90% of all waking hours. Throughout study the score increased ~17 points for the Fugl-Meyer.
  • Group C: 300: repetitions per day, 5 days per week, increases across all outcomes (FM, MAL, WMFT, etc.) started at 2 weeks and the trajectory continued throughout the study. Throughout study the score increased ~17 points for the Fugl-Meyer.
  • Group D: Same as Group C, but double the number of repetitions. Throughout study the score increased ~19 points for the Fugl-Meyer.
  1. Janssen, J., Klassen, T., Connell, L., & Eng., J. (2020). Factors influencing the delivery of intensive rehabilitation in stroke: Patient perceptions versus rehabilitation therapists perceptions. Physical Therapy 100:307-316.
  2. Rosenfeldt, A., Linder, S., Davidson, S., Clark, C., Zimmerman, N., Lee, J. & Alberts, J. (2019). Combined aerobic exercise and task practice improve health-related quality of life postroke: A preliminary analysis. Archives of Physical Medicine and Rehabilitation. 100: 923-30.
  3. Study findings from University of Colorado School of Medicine broaden understanding of neuroscience (Motor learning promotes remyelination via new and surviving oligodendrocytes). June 2, 2020. Life Science Weekly
  4. Bacmeister, C., Barr, H., McClain, C., Thornton, M., Nettles, D., Welle, C. & Hughes, E. (2020). Motor learning promotes remyelination via new and surviving oligodendrocytesNature Neuroscience. July ; 23(7): 819–831. doi:10.1038/s41593-020-0637-3 

CONNECT WITH US:

  • Questions and Comments about the podcast:
  1. NogginsAndNeurons@gmail.com
  2. NogginsAndNeurons: The Website

MUSIC

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Motor Learning Simplified

Motor Learning Simplified

May 20, 2021

OVERVIEW: "Something I try to tell therapists all the time.... when you take all the neuroscience and you look at it all I swear neuroscientists say "Wow we think repetitive practice works—who does a lot of that?" And they look down that long hallway and they see therapists already doing it and having done it since the early 1900s.  And they go "Well it should be challenging. Who vectors in challenge?" And they see a therapist down there and they've been doing it since the early 1900s. And then they go, "It should be repetitive, and challenging... and it should be meaningful. Who does that? OTs do that!" So you guys are in the perfect position to leverage the great neuroscience that we have and... I swear I think neuroscientists are like jealous or maybe they're angry or—I don't know. But every time they turn around they see a therapist having done it for decades and decades and decades.  Here's what I would say... if you want to know in a neuroscience would say about rehab they'd say "We agree with everything you're doing just put it on steroids."  That's it. Don't overthink it."

EPISODE SUMMARY: This episode of NOGGINS & NEURONS: Stroke and TBI Recovery Simplified brings the concepts of motor learning to light in ways everyone can understand. Pete and Deb talk about:

  • Principles of Motor Learning
  • Real life examples of what motor learning looks like
  • Reasons why Motor Learning Theory should be accessible to clinicians
  • Things that get in the way of understanding and implementing these concepts
  • The importance of meaningful activity as it relates to the brain’s ability to change
  • Enriched environments and recovery
  • How therapists are perfectly leveraged for using Motor Learning Concepts in practice

We dove pretty deep into the principles of motor learning. Pete and Deb highlighted research around difficulties with implementing these concepts and also how clinicians are already using aspects of this theory.  We discussed the roles of cognition, emotional health, and socialization related to motor learning. There are a lot of components involved and we’re sure everyone already knows this at some level. This podcast episode brings to light the fact that people can’t be reduced to component parts; rather we must incorporate all aspects of a person for optimal motor recovery.

We hope our conversation makes this important topic digestible and more understandable in ways that help you add to your practice, support or recovery.

As always, we want to hear your top takeaways!

LINKS TO ARTICLES, BOOKS AND OTHER IMPORTANT INFORMATION:

  1. The guy (George Bush, PhD.) who discovered where emotions are processed in the brain. 
  2. Article discussing where embarrassment is processed in the brain.
  3. Similarities in brain activation during mental practice, action observation (observing someone else do the movement, and actual movement).
  4. Kafri, M. & Atun-Elny, O. (2019). From motor learning theory to practice: A scoping review of conceptual frameworks for applying knowledge in motor learning to physical therapy practice. Oxford University Press.
  5. Dahms, C., Brodoehl, S., Witte, O. & Klinger, C. (2019). The importance of different learning stages for motor sequence learning after stroke. Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany. Biomagnetic Center, Jena University Hospital, Jena, Germany. DOI: 10.1002/hbm.24793

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Stop Falling!

Stop Falling!

May 15, 2021

OVERVIEW: "Carr and Shephard are two Aussie physical therapists. They were the first to dovetail modern motor learning with rehab which was a sea change from the neurofacilitation crowd. Janet Carr, one of them, passed away in 2014. But they wrote this great book, I think it’s called, “Stroke Rehabilitation.” I think that’s what it’s called. I wrote a review on Amazon, you can read it, it’s just glowing because I just, I adore this book...But they make it very, very clear...There’s four situations in which you’re most likely to fall. And this is especially for people with brain injury, but also for anybody. Starting to walk, so right when you start the acceleration of walking; when you stop walking...you know...can you come to a full stop and not lose your balance? Turning – a whole bunch of problems with turning because you know, you have to shift your gaze constantly, you have to shift your feet constantly...and then uneven surfaces. So when you’re out walking and you’re thinking “Wow, I don’t want to be afraid of walking, I want to get out and I want to see things and I want to see people and I want to do my life, think about those four situations - When you start walking, when you stop walking, when you’re turning and then any sort of uneven surfaces – be really hyper-focused on those four situations."

EPISODE SUMMARY: This episode of NOGGINS & NEURONS: Stroke and TBI Recovery Simplified is all about not falling...Pete and Deb talk about helping people not to fall. We started and ended with the rabbit hole topic of Deb’s anthropology degree and bipedalism – super fun part of the conversation! Climbing out of the hole, Pete and Deb then talked about:

  • The relationship of medications to fall and the Paper Bag Test
  • Risk factors for falls in stroke survivors
  • Downward health spiral that can occur if survivors fall
  • What to do if you see someone fall
  • Home safety tips for fall prevention

This meaningful conversation gets into the literature, preventing falls, the negative impact of fear of falling, assessments and home safety. We share tips and tricks from the PT and OT perspectives. We hope survivors, caregivers and clinicians all find value in this conversation.

As always, we want to hear your top takeaways!

LINKS TO ARTICLES, BOOKS AND OTHER IMPORTANT INFORMATION:

  1. Fall Risk Assessment Tool - Johns Hopkins Medicine  
  2. Xu, T., Clemson, L., O’Loughlin, K., Lannin, N., Dean, C., & Koh, G. (2018). Risk factors for falls in community stroke survivors: A systematic review and meta analysis. Archives of Physical Medicine and Rehabilitation. 99:563-573.
  3. Cho, K., Yu, J., & Rhee, H. (2015). Risk factors related to falling in stroke patients: a cross-sectional study. Journal of Physical Therapy Science. 27: 1751-1753.

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Super Survivor Kathy Spencer On Successful Recovery

Super Survivor Kathy Spencer On Successful Recovery

May 13, 2021

Super Survivor Kathy Spencer On Successful Recovery

OVERVIEW: Kathy - Well, when I got in the arm study, I was like ten or eleven months out and my I could barely— I couldn't move my wrist, my hand, or my fingers. All I could do is clench but that was it. And I thought, if I just believe that I would have given up and I wouldn't be recovered today. So, I always tell people— and Pete's book is outstanding on the plasticity of the brain— but doctors don't tend to tell us that. I went around talking to certain groups around here a while back and people were crying, they said, "You know I believed the doctor" and they gave up on their therapy.

I said: You are never done unless you quit.

Deb - Something that you said caught my attention...what your OT said to you when you were being discharged. Remind me what she said and I want to know how that made you feel because a lot of what we do in occupational therapy has to do with that rapport that we build with people and I’m just curious to know how that made you feel. It sounds like you knew more about yourself than the therapy team.

Kathy:  I loved, loved, loved my OT. We laughed every day...because I would laugh at myself.

EPISODE SUMMARY: This episode of NOGGINS & NEURONS: Stroke and TBI Recovery Simplified is an ear-gripping conversation with Super Survivor Kathy Spencer. She graciously shares her story of having and recovering from an ischemic stroke. We hope you enjoy listening as much we loved being a part of this time with her. Join in the learning as Kathy:

  • Reminds us that recovery never ends
  • Shares strategies that work to improve hand function
  • Describes how to harness the power of the mind for optimal recovery
  • Explains the importance of self-advocacy and what that looks like

Kathy shares her lived experience from when the stroke occurred, her rehab journey and beyond. Strategies that worked for her include evidence-based interventions such as repetitive practice, mental imagery/visualization and journaling for self motivation. Kathy learned how perseverance plus patience equals peace, and tells inside details about this puzzling equation. Lastly, she reminds us that while repetition might be boring, recovery is not! This is a must listen for anyone who works with stroke survivors, knows a survivor or is a survivor.

As always, we want to hear your top takeaways!

LINKS TO ARTICLES, BOOKS AND OTHER IMPORTANT INFORMATION:

  1. Kathy’s blog article: Bouncing Back From Stroke by Katie D. Neal on February 24, 2011
  2. Kathy’s Youtube Video:
  3. Bioness Website

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Measuring Recovery

Measuring Recovery

April 28, 2021

OVERVIEW: “This episode was largely geared towards the survivors at home...once they’re at home doing this and some very simple strategies for how to do it and I LOVE the video recording piece. I know some people are shy and afraid to look at themselves on camera but you don’t have to show it to anybody...You know...And the people that love you won’t care any way. They will be happy to see your progress...”

EPISODE SUMMARY: This episode of NOGGINS & NEURONS: Stroke and TBI Recovery Simplified is all about ways to measure change along the recovery journey. There are different reasons for measuring from insurance reimbursement to deciding how long a person remains on a skilled therapy program to just wanting to know if what’s being done is working. Pete does most of the talking in this episode (and Deb is fine with that – she’s an introvert at heart and sometimes, when she’s learning, thinking makes her happy).  Keep listening for more great information as we:

  • Explain reasons for taking measurements
  • Discuss the difference between validity and reliability
  • Explain aphasia and dysarthria and ways to measure changes in the motor aspects of speech
  • Talk about the importance of standardizing measurements
  • Review simple ways for survivors to measure change at home, starting with a baseline and maintaining consistency over time.
  • Learn what it means when there’s no change in measurements and what to do when that happens. Hint: It’s not time to quit!
  • Delve into some interesting history about  Signe Brunnström, and Axl Fugl-Meyer

Join us as we start the conversation with reasons for taking measurements. The conversation takes a quick turn as we talk about a simple strategy – using time to establish baseline measurements and progress for walking, while also being mindful of safety. Pete introduces “self selected walking speed” and use of assistive devices and tells us how to be consistent over time. Other activities that can be measured with time include buttoning, zipping and putting a jacket on/taking it off. Quality of movement, fatigue and other factors also need to be taken into consideration when tracking change. It is important to note that it’s not time to quit when it looks like there’s a plateau as Pete reminds us to think like an athlete or musician when this occurs.

We learn about the vast respect Pete has for  Signe Brunnström as he digs deep into history and explains the genius scoring she developed (that was later credited by name to Axl Fugl-Meyer) which has become the gold standard in outcome measures for people who’ve had stroke.

As always, we want to hear your top takeaways!

LINKS TO ARTICLES, BOOKS AND OTHER IMPORTANT INFORMATION:

  1. Is gait speed or walking distance a better predictor for community walking after stroke?
  2. Testing Spasticity: The Modified Ashworth Scale
  3. The Arm Motor Ability Test

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Bilateral Training for the Arm, and Leg

Bilateral Training for the Arm, and Leg

April 26, 2021

OVERVIEW: "Antiphase would be right hand forward right hand back, left hand forward left hand back...you get the idea. So, there’s a million things that you can do within the...This could be fun! It should be fun! Yeah....Put the “fun” back in function! Exactly! The lower extremity’s super easy to do...Here’s the thing about the lower extremity – one of the things that messes up in people that have gait problems after a brain injury is the rhythmicity of walking....put in ear plugs one time and walk. It’s almost like a shuffle beat (Pete adds sound effects). It has all that beat going on. in. it. And so if you can re-establish the rhythmicity of gait you start to re-establish stride length, kinematics, hip rotation, the amount of knee flexion...it’s just something that’s not used by clinicians very often and I’m flummoxed as to why. Get a metronome...get it on your phone...use it and see if you can’t get people to re-establish their rhythmicity of gait."

EPISODE SUMMARY: This third episode of NOGGINS & NEURONS: Stroke and TBI Recovery Simplified is all about bilateral training. We jump right into the massive benefits of this intervention and learn immediately that bilateral training isn’t one of the top rehab go-to interventions by PT’s and OT’s! There’s good news for you if you’re someone who hasn’t used this intervention – you aren’t ALONE! Keep listening for more great information as we:

  • Describe bilateral training in depth – including important Google search information that can leave you confused and wondering if you’re just getting started with this technique
  • Experience the power of bilateral training with a fun activity
  • Observe what it’s like for Deb when she’s put on the spot! We’re pretty sure it will make some of you feel more at home in your own skin
  • Learn about Bilateral Arm Training with Rhythmic Auditory Cues (BATRAC) and Jill Whithall’s research
  • Talk about the Tailwind and how to get one – maybe – FYI...the price is higher than Pete thought
  • Discover good research and rationale supporting the justification of bilateral training (OT’s and anyone involved in UE rehab – pay attention – this might be just what you need to enhance your documentation skills)
  • Talk about a common clinical strategy that is NOT appropriate for use in Bilateral Training interventions and why

Join us in this engaging and insightful conversation about bilateral training. We encourage listeners to set aside preconditioned notions and beliefs about stroke rehab – this includes letting go of judgment and beliefs about how rehab should be done.  We look at the research around bilateral training and experience first-hand what it feels like – a must for any rehab professional to try. We share important information around Jill Whitall’s research with this topic and Pete gives us some real life strategies to try. We’re wondering why this intervention isn’t used more often in rehab settings. Knowing that it’s never too late to change, Deb openly admits lack of clinic use may begin with classroom instruction. She plans to up her intervention instruction game for the fall ’21 semester.

If you are using bilateral training in the clinic or as a home program, PLEASE share that with us! If you aren’t using it and think you might start, we want to hear about that too! Let’s start a conversation that improves the rehab and stroke recovery experience.

We always want to hear your top takeaways!

LINKS TO ARTICLES, BOOKS AND OTHER IMPORTANT INFORMATION:

  1. Article Referenced: McCombe Waller, S., & Whitall, J. (2008). Bilateral arm training: why and who benefits?.  
  2. Additional Tailwind Information:
  1. Pete’s Book-Bilateral Training: pp. 118-125
  2. Choosing Wisely Campaign
  3. American Occupational Therapy Association & Choosing Wisely  
  4. Metronome Apps:

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THE CLARIFICATION

THE CLARIFICATION

April 23, 2021

OVERVIEW: There’s another important component to us as humans and that is our level of motivation and building habits for recovery...And I think that’s an important role that therapists play in the rehab phase for a person...and really talking with them about it, the survivor if they understand. If they’re struggling to understand it’s time to bring in the caregivers...where is this person going when they leave our level of care...and talking about the importance of establishing whatever this habit, routine is towards recovery and explaining clearly the benefits of getting in the groove now.

 

EPISODE SUMMARY: This second episode of NOGGINS & NEURONS: Stroke and TBI Recovery Simplified, emerged as Pete and Deb realized additional clarifications were warranted. Not surprisingly, more insights come about as the conversation unfolded! In this episode we:

Share Pete’s clarification’s which take us on a deeper dive into differences between diseases affecting the brain & acquired brain injury; differences between hemorrhagic & ischemic strokes.

  • Learn of Pete’s discovery that not all published research is necessarily the most recent!
  • Uncover the truth about neuroplasticity in subacute and chronic phases.
  • Are reminded that no 2 brain injuries are alike. Ever. This is because all brains are unique!
  • Consider the importance of motivation & habit and how they are underutilized at the subacute level. Let’s remember to include the survivor’s loved ones at this early stage for max benefit.
  • Answer the first listener question!

Join us as we continue to unpack stroke, brain injury and learned non-use. Pete reminds us there is a difference between acquired brain injuries and other diagnoses such as Alzheimer’s and Parkinson’s Diseases. He dives into further detail about hemorrhagic strokes and the ways they differ from ischemic strokes, referring to a well-known survivor, Jill Bolte-Taylor’s experience. Deb’s brain went into overdrive a couple times, bringing the conversation a bit deeper into real life recovery and the importance of building good recovery habits at the subacute stage, including how practitioners are uniquely positioned to help move survivors and caregivers in that direction. Pete also discovered that other researchers attempted to stage recovery phases after he did, bringing to light that researchers can miss really important information (Pete’s did the work first, in this case!). Perhaps this is a reminder to always do our best to be thorough while also realizing that with the vastness of the world, not all work is original or copied. Even though no 2 brains are alike multiple people can think similarly!

We also answered our first listener question from Ingrid Kanics, OTR/L, FAOTA, President of  ­­­­­Kanics Inclusive Design Services. Ingrid asked for more information about what goes on inside the brain regarding dendritic pruning, the penumbra and neuroplasticity. Thanks for asking, Ingrid!

Please share your top takeaways!

LINKS TO ARTICLES, BOOKS AND OTHER IMPORTANT INFORMATION:

  1. Bernhardt J, Hayward KS, Kwakkel G, Ward NS, Wolf SL, Borschmann K, Krakauer JW, Boyd LA, Carmichael ST, Corbett D, Cramer SC. Agreed definitions and a shared vision for new standards in stroke recovery research: The Stroke Recovery and Rehabilitation Roundtable taskforce. Int J Stroke. 2017 Jul;12(5):444-450. doi: 10.1177/1747493017711816. PMID: 28697708.
  1. My Stroke of Insight by Jill Bolte Taylor
  1. Stronger After Stroke: Your Roadmap to Recovery 3rd Edition by Peter G. Levine

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Learned Non-use

Learned Non-use

April 11, 2021

OVERVIEW: ...So hyper-acute, acute, subacute and chronic, those are the 4 phases...The way that you tell it’s time to start is look for subacute, spontaneous recovery and then, once they plateau, after that you’re not waiting for this easy ride of the brain coming back online...It’s all neuroplastic change after that. You’ve got to borrow from some other part of the brain that’s still intact and so then it becomes real learning....

EPISODE SUMMARY: In this first, full episode of NOGGINS & NEURONS: Stroke and TBI Recovery Simplified, Pete and Deb discuss the perplexing phenomenon of Learned Non-Use. This engaging conversation will help you understand:

  • How, when and why learned non-use it occurs
  • Common deficits and rehab approaches that contribute to learned non-use
  • An introduction to interventions and strategies to help thwart and reverse it

Join us as we start to unpack this fascinating topic. As you’ll soon discover, learned non-use and other concepts that occur in and around stroke or acquired brain injury are inter-relational. As Pete eludes to in the podcast, no 2 strokes or brain injuries are the same. Our engaging conversation is a great foundational episode as we define stroke and brain injury, discuss the 4 phases of stroke, the concept of too much too soon and the sweet spot of the subacute phase. There are some interesting implications for everyone – from those who provide care at any level for survivors, occupational and physical therapy practitioners, to the survivor’s and more. Please share your top takeaways!

LINKS TO ARTICLES, BOOKS AND OTHER IMPORTANT INFORMATION:

  1. Learned Non-Use Article: Barth, J., Geed, S., Mitchell, A., Lum, P. S., Edwards, D. F., & Dromerick, A. W. (2020). Characterizing upper extremity motor behavior in the first week after stroke. PloS one15(8), e0221668. https://doi.org/10.1371/journal.pone.0221668
  1. V S Ramachandran and his work with mirror therapy: http://cbc.ucsd.edu/ramabio.html  
  1. The Brain That Changes Itself by Normal Doidge, MD https://www.penguinrandomhouse.com/books/291041/the-brain-that-changes-itself-by-norman-doidge-md/
  2. Documentary – The Brain That Changes Itself https://www.youtube.com/watch?v=VIdWFuuZaxw
  3. The Mind and the Brain: Neuroplasticity and the Power of Mental Force by Jeffrey Schwartz https://jeffreymschwartz.com/
  4. The Brain Science Podcast - https://brainsciencepodcast.com/

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Intro Episode: Stroke and TBI Recovery Simplified

Intro Episode: Stroke and TBI Recovery Simplified

April 11, 2021

NOGGINS & NEURONS: Stroke and TBI Recovery Simplified: Intro Episode

Peter G. Levine and Debra Battistella discuss the heart and soul of this endeavor and you will learn how quickly they go down a rabbit hole! We discuss our passion for filling in gaps and the single, most important goal of this podcast...To simplify everything around stroke and brain injury so that survivors, caregivers and loved ones, therapists, the medical team and students understand the recovery process better. Better understanding can make for a better recovery experience. We look to the future and share our thoughts on next topics to include such as core concepts around optimal recovery and why applying them is sometimes tough. Debra summed it up when she said, “If we can be the agents of change for simplifying things to enable people to have a good rehab experience, to have good continued recovery, then I think we’re doing what we set out to do.”

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