Brain Remapping After Stroke


After a stroke, do nearby nerve cells take over the function of dead nerve cells as folks regain function? That's what we would expect, but new research from Dr. William Zeiger suggests that is not the case. After giving very specific strokes to mice, they used advanced imaging techniques to understand just what was happening in those little mouse brains. It was not what they expected.

We talk about that research, brain remapping after stroke, the importance of constraint induced therapy, and more in this episode.


Dr. William Zeiger professional head shot. He wears a white doctor's coat against a gray background as he looks at the camera

Dr. Zeiger is a physician scientist in the Department of Neurology at UCLA. Clinically, Dr. Zeiger works as a neurologist specializing in movement disorders, particularly Parkinson disease and atypical parkinsonian disorders. Dr. Zeiger also runs a neuroscience research lab focused on investigating cortical circuit dysfunction in neurological disorders.

The Study

You can read the paper Dr. Zeiger and his team produced here: https://www.nature.com/articles/s41467-021-24211-8

You can read an article about the study here. It's how I learned about the research and is a little more accessible: https://www.eurekalert.org/pub_releases/2021-06/uoc--hbc062521.php

Basically, researchers gave mice strokes in a specific part of the brain to stop a single whisker from working. They use a technology called 2-Photon Microscopy to examine the brains of these mice. They wanted to see if other nerves would simple take on responsibility for that whisker. That did not happen.

Then they removed all the other whiskers from the mice. Once they did that, mice began recovering function in that remaining, stroke affected whisker. Essentially, it was a form on Constraint Induced Therapy for the mice.

This gives us some interesting information about neuroplasticity. It's hard to extrapolate to humans, but it does point toward the needs for ongoing research into just what is happening during brain recovery.

The Neuro Nerds

The Neuro Nerds is one of my favorite podcasts. Host Joe Borges was a guest on this show back in episode 65.

This week, I was Joe's guest on The Neuro Nerds. We talked stroke stories, nerd stuff, Doctor Who, podcasting, the brain injury community, and much more. You can listen in your favorite podcast app or right here by pressing play.

Hack of the Week

One of the biggest risks for stroke survivors and Parkinson's Disease patients is falls. Falling is of course even more likely at night because it's dark and we're tired. And many of those late night falls happen during late night trips to the bathroom.

If you're a fall risk, one solution is a bedside commode or a urinal jug (sorry that doesn't help you, ladies). It may not be pretty or something you want in your bedroom, but if it means you don't fall and pick up another brain injury or other injury, it's probably worth it.


Where do we go from here?

Here is the latest episode of The Strokecast


Can you treat depression with Tai Chi?

Recent research shows that doing Tai Chi after a stroke may reduce depression. We talk with the author of the study in this episode.

It's a nice complement to our previous episode where we talked about the nature of Post Stroke Depression. Depression is an insidious illness that undermines recovery, healing, relationships and the joy we could find in life.

Traditional treatments may include talk therapy and/or medication. There are also a host of new treatments being studied. And there's a bunch of snake oil or scam treatments out there, too. Plus there's a whole bunch of stuff in between.

Dr. Ruth Taylor-Piliae has been working in the stroke field and with Tai Chi for a long time. Her research is a promising starting point for exploring the potential of ancient Tai Chi practices to treat Post Stroke Depression.


From the University of Arizona College of Nursing

Dr. Ruth Taylor-Piliae poses for a headshot in front of a golden brown backdrop

Dr. Ruth Taylor-Piliae is an Associate Professor in the College of Nursing at the University of Arizona. The goal of her research is to increase physical activity among older adults with heart disease and stroke through the implementation of innovative interventions such as Tai Chi, to improve physical functioning, reduce fall rates and improve quality of life.

Dr. Taylor-Piliae received her B.S.N. from California State University Fresno, her M.N. from the Chinese University of Hong Kong, and her Ph.D. from the University of California San Francisco. She completed a 2-year post-doctoral fellowship in cardiovascular epidemiology and prevention at Stanford University. Dr. Taylor-Piliae has received funding as a principal investigator from the American Heart Association/American Stroke Association, Hospital Authority of Hong Kong, National Institute of Health, and the Robert Wood Johnson Foundation.

She reviews for professional journals and has had over 70 peer-reviewed manuscripts published in top-tiered journals both within nursing and inter-professional journals. She is highly cited for her work (citations>3600, h-index=30, i10-index=54).

For more details, see https://www.nursing.arizona.edu/rpiliae

Should you do Tai Chi?

Maybe. Ask your doctor.

Before engaging in any new exercise program or treatment, ask your doctor to make sure you can do it safely.

I am not a doctor. I say it all the time. I'm just a marketing guy who knows way more about neurology and neuroplasticity than any marketing should know.

That said, let's run Tai Chi through my snake oil filter.

Is Tai Chi safe?

For the most part, yes. Of course if you have balance or movement challenges, an adaptive for may be more appropriate. Take steps to make sure you don't fall. Falling is probably the biggest risk, but it should be an easy one to mitigate,

Is it expensive?

Generally, it's probably not that costly. It's not going to cost you tens of thousands of dollars. With some searching, you can find free or low cost options.

Will it interfere with traditional therapies?

It doesn't have to. If you have the time and energy, you can do Tai Chi in addition to PT, OT, Speech, or Mental Health therapy. If you decide to do Tai Chi as part of your recovery, this random guy on the internet suggests to do it in addition to, rather than instead of regular therapy.

Will it actually help your recovery?

Maybe. As Ruth and I discussed, her research shows it does reduce Post Stroke Depression. Granted, it's a small study.

There are a lot of things survivors are encouraged to do to help recovery. Move. Exercise. Practice patterns. Learn stuff. Connect with other people. Find things you enjoy doing and do them. Those are just a few, but Tai Chi does support those.

Final analysis

Especially if you enjoy doing Tai Chi and your doctor says its safe, then go for it. There appears to be a potential benefit and no significant downside. That's a win by my math.

Paralympic Games

The 2020 Paralympic Games will take place in Tokyo between August 24th and September 5. You can learn more about the games from the main site here. You can also learn more about the US team of 200+ athletes here.

Check out their stories. Try to catch some of the games on TV or online. These are athletes who are competing with disabilities and showing what can be possible. Perhaps there's a sport you would like to become more involved in. These athletes may show you a way.

Check out the athletes' stories and follow your favorites on social media. What an you learn from them that you can apply to your own life?

And maybe there's not a life-changing takeaway other than, "That was awesome!" And you know what?

That's okay, too.

Hack of the Week

You don't need specialized grippers for jars and containers. Simple rubber band can make handling things with weak hands much simpler. They're cheap and come in a variety of sizes. Here's a listing on Amazon.*


Where do we go from here?

Here is the latest episode of The Strokecast


Ep 137 - Get the Arm Back with Vagus Nerve Stimulation

A lot of the attention in stroke research is paid to the acute phase. How can we treat a stroke in the ER? What can we do so it doesn't get worse? How can we prevent strokes from happening? What can we do in inpatient rehab to help folks get better?

Those are all important things,  and the stunning innovations happening around us are amazing, newsworthy, and truly impacting people's lives in a meaningful way.

But there's not as much attention given to chronic stroke. Sure, there's some. There are people working really hard to help stroke survivors recover even years after stroke. But not as much makes it into the news.

That's one reason I was interested in Dr. Jesse Dawson's work at the University of Glasgow. The recently published a study in the Lancet about using Vagus Nerve Stimulation to drive recovery in patients years after stroke. And their procedure looks promising.


Dr. Jesse Dawson headshot. He directly faces the camera against a white background

Dr. Jesse Dawson is a Professor of Stroke Medicine and Consultant Physician in the Queen Elizabeth University Hospital. His research portfolio includes prevention and rehabilitation clinical trials in stroke survivors. His main interest is in improving the long-term outcome after stroke. Dr. Dawson holds a BHF/Stroke Association programme grant, HTA NIHR funding and NIH funding and runs a large outcomes adjudication system for multi-national stroke trials. He is the NHS Research Scotland lead for stroke research and sits on the editorial board of Stroke.

Dr. Dawson is currently researching the role of xanthine oxidase inhibition as a novel preventative treatment after stroke. This is the focus of a UK wide clinical trial, funded by a programme grant from the BHF/Stroke Association.

He is also studying novel treatments for upper limb weakness after stroke, including vagus nerve stimulation and robotic therapy. These studies included a large NIHR funded study, funding from Chest Heart Stroke Scotland and a collaboration with industry. 

Dr. Dawson is the Medical Outcomes Manager for the endpoint committee of the large NIH funded CLEAR III trial, the NIH funded MISTIE III study, the European Union FP-7 funded EuroHYP study and the international SITSOPEN collaboration. This involves review of all trial endpoints and co-ordination of the endpoint adjudication process for these large phase III studies.

He supervises several PhD and MD students, including students with competitive government and charitable funded fellowships. He co-directs a large MSc programme in Clinical Pharmacology and is Director of the Vertical Theme for Clinical Pharmacology and Therapeutics for the MBChB programme. He is a regular MRCP PACES examiner and external higher degree examiner for several UK univeristies.

The Research

This is a fascinating study because even though they are stimulating the Vagus nerve, they are not actually treating it. Instead they are using it as a messenger to the brain to say, "Wake up! It's time to learn something." Essentially, it's trying to get the brains attention so traditional Occupational and Physical Therapy can work. And it seems to be working. It will be interesting to see if in future studies they can get similar results with Speech Therapy.

The other important take away here is that this work with chronic stroke survivors -- folks who had strokes years ago -- even in the control group. Granted the experimental group that got the Vagus Nerve Stimulation got better results.

The point is, though, that intense physical and occupational therapy gets results even years after as stroke, demonstrating once again that the 6 or 12 month caps on recovery are complete and utter nonsense.

Hack of the Week

Pick a small thing to focus on. Perhaps it’s a small task. Or part of a small task. Or maybe it's a new goal you haven't done before but it seems within reach. Do that. Focus on that. Achieve that. The look for more small challenges. Lots of wins on small challenges adds up to big success in the long run.


Where do we go from here?

Here is the latest episode of The Strokecast

Understanding Post Stroke Depression


Surviving a stroke is not the end of a medical issue. It's the start of a new journey, with new challenges. Major depression is often one of those challenges. It interferes with recovery, rehab, adjusting to a new life, and maintaining relationships.

In short, it's big problem. And it's pretty common.

According to new research by Dr. Laura Stein from the Icahn School of medicine, depression after stroke is twice as likely to occur as depression after heart attack. There's something unique about stroke that leads to depression.

On top of that, if a person lived with Generalized Anxiety Disorder before stroke, they are 1.7 x as likely to experience Major Depression after stroke.

In this conversation, Dr. Laura Stein talk about her research and what survivors, caregivers, and medical practitioners need to know.


Dr. Laura Stein smiles at the camera while wearing a white doctor's coat against a gray back drop

Laura K. Stein, MD, MPH is an Assistant Professor of Neurology at the Icahn School of Medicine at Mount Sinai and attending physician at the Mount Sinai and Mount Sinai Queens Stroke Centers. She is board certified in Neurology and Vascular Neurology by the American Board of Psychiatry and Neurology. Dr. Stein received a BA from Amherst College and her MD and MPH from the Icahn School of Medicine at Mount Sinai. She completed her internship, neurology residency, and vascular neurology fellowship at Mount Sinai. 

Dr. Stein's interests are in stroke clinical care, stroke outcomes research, and medical education. She is the Neurology Residency Associate Program Director and precepts first year medical students in the Art and Science of Medicine preclinical skills course. Dr. Stein received the Department of Neurology Resident Class of 2020 Award of Appreciation for Dedication & Commitment Towards Excellence in Mentorship and 2020 Institute for Medical Education Excellence in Teaching Award. 

The Research

Dr. Stein's research was part of the American Stroke Association’s virtual International Stroke Conference. You can read the paper here.

You can read the article where I first encountered her work here.

The approach of looking at depression after heart attack vs looking at depression after stroke is an interesting one. It's a nice way of controlling for other potential causes.

The research looked at Medicare recipients, Medicare is a US government health insurance program, generally for folks 65 and older. It lets researchers draw from a rich collection of data. There are two significant tradeoffs, of course.

First, it's restricted to the US so there's no international representation in the study. Obviously, depending on the research question in particular, that may or may not be an issue.

Second, it's restricted to folks 65 and older. Can we say that the results of this study apply to younger stroke survivors?



We don't know. And this study was not designed to answer that question. I'd say it does get us closer, though, and it opens up an opportunity to do further research that asks different but related questions.

That's what good studies do. The answer specific question with solid evidence and clear analysis. And the result can introduce new questions for researchers to explore in different studies.

In the meantime, it's likely safe to say, that regardless of age, stroke survivors are probably more likely to experience depression, and the community needs to be vigilant for the signs of depression and seek treatment accordingly.

Symptoms of Major Depression

Diagnosing depression involves identifying symptoms from a couple lists. To "earn" a depression diagnosis, a patient needs 5 symptoms from list 1 and all 4 from list 2. They are:

List 1 (Pick 5 or more)

  • Depressed Mood (most days)
  • Loss of Interest or pleasure
  • Weight loss or gain
  • Insomnia or hypersomnia (nearly every day)
  • Psychomotor agitation or limitation
  • Fatigue (nearly every day)
  • Feelings worthless or experiencing inappropriate guilt
  • Decreased concentration (nearly everyday)
  • Thoughts of death or suicide

List 2 (All 4)

  • Symptoms cause significant distress or social/professional impairment
  • Symptoms not attributable to a substance or medical condition
  • Symptoms not explained by another disorder
  • No history of manic episodes

You can read more details about the symptoms here.

You can probably see one of the issues. Many of those symptoms may be directly attributed to the disabilities and brain damage of the stroke without it being Major Depression. That's why it's important to work with a medical professional to tease them apart.

Symptoms of Generalized Anxiety Disorder

Generalized Anxiety Disorder is about more than feeling nervous. It's more complicated and severe.

The National Institute of Mental Health describes it this way:

People with generalized anxiety disorder (GAD) display excessive anxiety or worry, most days for at least 6 months, about a number of things such as personal health, work, social interactions, and everyday routine life circumstances. The fear and anxiety can cause significant problems in areas of their life, such as social interactions, school, and work.

Generalized anxiety disorder symptoms include:

  • Feeling restless, wound-up, or on-edge
  • Being easily fatigued
  • Having difficulty concentrating; mind going blank
  • Being irritable
  • Having muscle tension
  • Difficulty controlling feelings of worry
  • Having sleep problems, such as difficulty falling or staying asleep, restlessness, or unsatisfying sleep

You can read more about the condition here.


While most psychologists and psychiatrists can help stroke survivors and others with depression and other conditions, there is a specialty that may be even more helpful -- neuropsychology.

A while back, I talked with Dr. Karen Sullivan from I Care For Your Brain. She wrote the "Interactive Stroke Recovery Guide."*  You can listen to that conversation or learn more at http://Strokecast.com/Karen

A neuropsychologist has additional, specialized training to work specifically with folks who have brain injuries. They dive deep into the details of the injury to provide the best customized treatment plan, leveraging expertise that generalists don't have.

They work with folks with a wide array of functionality and challenges.


As long as we are talking about depression, we should also talk about antidepressants a little -- specifically SSRIs and how the relate to stroke.

In 2011, the FLAME study was published in the Lancet. In short, it demonstrated that stroke survivors who took Prozac (Fluoxetine) experienced stronger motor recovery. Many hospitals saw those results and began putting more stroke survivors on Prozac because, well, why not? If the patient tolerates it well, and it can help folks work better, it's probably a good idea. And if it reduces or prevent post stroke depression (or other depression) that's a solid win.

I talked with Dr. Nirav Shah about this back in November of 2018. You can listen to that episode here.

That's how I started on an SSRI in my stay. They originally tried Prozac with me, but I had a not great reaction to it. It apparently gave me an anxiety attack. So we quickly stopped that (thank you, Xanax, I think). We talked about it some more and tried again with a different SSRI -- Lexapro (Escitalopram) because I had tolerated it well during a tough time some years earlier.

Cheap, no negative side effects, and potentially helpful is win.

A month after my interview with Nirav, and a year and a half after my stroke, the FOCUS study came out, attempting to duplicate the results of the FLAME study on a bigger scale.

It failed.

The scientific consensus now is that SSRIs do not help with motor recovery. They do still help with depression.

The hospital no longer recommends SSRIs as part of the motor recovery protocol.

So what does that mean for folks like me?

I asked my doctor last year if that meant I should stop taking them. We talked about it and she explained I could certainly stop if I wanted to.

"But, dude -- it's 2020."

And she had a valid point.

(Okay, maybe I paraphrased that)

And that's why Escitalopram still has a place in my pill organizer.

As always, everyone's stroke and circumstances will vary, so talk to your doctor before making any changes to your medication.

Hack of the Week

Get a dog.

A dog can be helpful after stroke, whether it's a service dog or simply a companion animal.

When you have a dog, you have a responsibility to take care of it. You have to feed it, walk it, groom it, and give it cuddles.

Sometimes that may be reason enough to get out of bed and get moving for the day.


Where do we go from here?

  • If you think there's a chance you might be experiencing depression, talk to your medical team
  • Share this episode with someone you know with the link http://Strokecast.com/depression
  • Subscribe to the free, monthly Strokecast email newsletter at http://Strokecast.com/news
  • Don't get best…get better.

Here is the latest episode of The Strokecast