“Stronger After Stroke” is one of the most recommended books for stroke survivors by stroke survivors. It is a roadmap for recovery after leaving the hospital. Peter G. Levine talks about the importance of repetition to neuroplasticity. He dives deeply into Dr. Edward Taub’s Constraint Induced Therapy, and what stroke survivors can learn from musicians and athletes.
And Levine joins us in this episode of the Strokecast.
Bio
(From Pete’s Amazon author page)
Peter G. Levine is a researcher, author, clinician, adjunct professor, and science communicator. His career in clinical research has been dedicated to finding and reporting on the best systems for driving post-stroke brain plasticity.
For two decades Levine has tested emergent stroke neurorehabilitation options including EMG-based gaming, wearable robotics, mental practice, functional electrical stimulation, transcranial magnetic stimulation, and modified constraint-induced therapy (mCIT). He was the lab co-director at the University of Cincinnati Academic Medical Center, and a Research Associate at Kessler Institute for Rehabilitation. He continued his clinical research with The Ohio State University B.R.A.I.N. lab.
Levine communicates what he’s learned in research through his blog, dozens of magazine and journal articles, hundreds of professional talks on stroke recovery and brain injury, as well as his book, Stronger After Stroke.
Constraint Induced Therapy
Constraint Induced Therapy (CIT) at the most basic level, is about encouraging the survivor to use an affected limb by forcing its use. At one level, we all know we’re supposed to use our affected limbs as much as possible. Of course it’s not always easy.
In my case, I try to do something like flip a switch or open a door three times with my left hand. After three tries, I let myself use my unaffected limb. That way I get the practice and I don’t get too frustrated when I can’t do something yet.
CIT takes that to the next level. It involves restricting the unaffected limb with a sling or other mechanism to force the use of the affected limb for hours a day of therapy. It should be done under the supervision of a therapist because there is certainly a risk of falling or other injury when the unaffected limbs we rely on more than ever are suddenly restricted.
But forcing deliberate use of an affected limb is the best way to bring it back on line.
Practice
One of the key themes we talked about was the importance of practice and repetition. Musicians and athletes (like Peter G. Levine and Stephen Page) know the importance of repetitive, deliberate practice.
Professionals and amateurs who want to be the best they can, practice. And the enjoy it. Spending hour after hour working on a segment of a song or to shave half a second off a run is how they build the skills they need and want to acquire.
Malcom Gladwell in his book “Outliers” popularized the idea that to develop expertise in something takes 10,000 hours of practice. And deliberate practice at that. It’s a theory based on the work described in The Cambridge Handbook of Expertise and Expert Performance.
Developing skills and particular motions after stroke is similar. It requires more and more repetitions. As Pete shares, it takes 1200 repetitions to develop a single motion in a single joint. Of course walking requires dozens of joints, muscles, and motions. So multiply all those 1200s against one another, and get to work!
Homunculus
The homunculus is a representation of the brain and various parts of the body. The more you use a part of the body, the more neurons it takes up in the brain. For example, the hands and tongue take up more space in the than the elbow and pinkie toe.
The more time and energy you dedicate to something, the more space in your brain is dedicated to that task. For example, a homunculus of my brain would likely show a much larger segment dedicated to speaking than to throwing a baseball.
One way I think about how this applies to survivors (and I may be stretching the homunculus analogy) is that a skill from the prestroke days that a survivor was an expert at may come back before a skill one had limited experience with simply because despite the damage there were simply more nerves dedicated to it.
As you continue to work on a skill post stroke, a larger portion of the brain will be dedicated to it. More nerves, dendrites, and synapses will become involved. This is neuroplasticity at work.
Four Lessons for Recovery
Pete summed up his approach and book in 4 lessons.
- Recovery takes a lot of repetitive practice.
- Recovery takes a lot of visualization.
- Don’t expect miracles.
- Don’t let the perfect be the enemy of the good.
Hack of the Week
Pete uses a strap with Velcro as a simple, low-cost AFO. It’s a tool that helps lift the toe to make walking smoother and combat foot-drop.
The nice thing about a solution like this is that it also gives you access to a wider assortment of shoes while reducing the risk of tripping.
Links
| Stronger After Stroke Blog | |
| Stronger After Stroke on Amazon | |
| Pete on Research Gate | |
| Stephen Page | https://www.medbridgeeducation.com/instructors/stephen-page-ot/ |
| Kessler Institute | |
| Taub Therapy Clinic | https://www.uabmedicine.org/patient-care/treatments/ci-therapy |
| Dr. Edward Taub | https://www.uab.edu/cas/psychology/people/faculty/edward-taub |
| Dr. Jill Whitall | |
| Signe Brunnström on Wikipedia
| |
| Brunnstrom Stages of Stroke Recovery | https://www.neofect.com/us/blog/understanding-the-brunnstrom-stages-of-stroke-recovery |
| Modified Ashworth Scale | https://www.sralab.org/sites/default/files/2017-06/Modified%20Ashworth%20Scale%20Instructions.pdf |
| Homunculus | |
| Brian Harris on Strokecast |
Where do we go from here?
- So check out Pete’s book here and blog here.
- To get better, continue practicing and doing those exercises your PT and OT recommended.
- If you think you reached a plateau, try some different exercises, and keep going.
- Share this episode with someone you know by giving them the link http://Strokecast.com/StrongerAferStroke
- Don’t get best…get better
Strokecast is the stroke podcast where a Gen X stroke survivor explores rehab, recovery, the frontiers of neuroscience and one-handed banana peeling by helping stroke survivors, caregivers, medical providers and stroke industry affiliates connect and share their stories.
*Amazon links are affiliate links. I may receive compensation for purchases made through them.
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