One of the most severe and life altering injuries a body can go through is a stroke, encephalitis (brain swelling) or other traumatic brain injury. The effects can be profound; from erasing memories, changing personality, or highly specific things like no longer being able to recognize facial expressions, or use/hear emotions in voice. Given my focus as a neurological specialist, it would surprise few that these are among my favorite cases to work on because of their often complicated nature and the particular expertise required to help them which needs to be more common and available. However, for some aspects of brain injury recovery, it’s not necessarily highly complicated, but nonetheless can be highly challenging in other ways.
By this, I’m speaking about one of the most frequent concerns across many of these injuries; difficulties with walking or even the full loss of the use of a limb. In a brain injury we can easily damage portions of the brain which are responsible for knowing that a given limb even exists, and then how to use it. While, yes, there will be complicated aspects of what specifically was injured and how that’s affecting your ability to move, and how we approach it in office (which will be much more complicated, and won’t be discussed here), but the demands on the patient themselves are pretty straight forward: repetition. Repetition every day, often for months, with none, and then slow progress, with apparent plateaus spread throughout.
When a portion of the brain has been damaged in this kind of way, the foundation of our approach is to show the brain, over and over, that this limb exists and that we do in fact need to use it! We do this in a few main ways, mixed between stimulating the limb in a sensory fashion, simulating movement, and actively trying to move the limb. The first is done by simply offering a range of stimulation to the limb. Rubbing it while looking at it (eye contact is important for all of these) throughout the day is our foundation, working through the joints like ankles/wrists, fingers/toes. Introducing other stimuli to it like mild warmth and cold, different textures, and so on is also important. These stimuli give a signal for the brain to start recreating it’s ‘bodymap’ of what parts are where through the sensory nerves spread throughout the limb. As though the brain were exploring a new land for the first time, this is slow and takes time and constant dedication.
Similarly having the limb passively move it (either the patient, or someone else) around in space stimulates the nerves in the muscles and joints. Gently bending fingers, toes, ankles and wrists in different directions, taking them through their full ranges of motion (definitely being careful not to over do it, since you often won’t be able to feel them going too far). As with all of these, it’s very important to look at the limb during this process, and really focus on the process, with no distractions. While the limb is moving you should be thinking through the movement, willing the movements that you are seeing it go through, like you were making the limb move with your brain. This and the following two give an impulse for the brain to start rewiring and connecting the circuits needed to actually control limbs.
We also love the use of mirror boxes! Invented to help with phantom pains after the loss of a body part, we’ve also found it very helpful to simulate the movement of the limb for the brain. Making your own mirror box is doable at home, and can make a good addition to your stroke rehab process. How mirror boxes work is a bit of a topic by itself, but in short we have ‘mirror neurons’ in our brain that activate when we see an action like someone using a tool, or hear someone speaking. The mirror neurons activation is very similar to our brain actually carrying out the action itself, and so is vital for observation based learning, helping our brain create the wiring to carry out these movements ourselves. So we are able to use this function of the brain with a mirror box to help rewire and activate the affected limb. From simple movements to more complex tasks like picking up coins and putting them in a jar while watching the mirror, or drawing letters with the movement of the foot, and so on. A demo can be seen here.
Lastly, is directly attempting to move the affected limb(s). This is different from the passive movement, though you’ll combine the two, and is the most important in many ways. You must intensely, with full focus, try to move the limb. Imagine it moving in a certain way and try to make it happen. It will take a fairly long amount of time where you see no results at all, but the bottom line is that if you’ve lost the use of a limb, you will not regain its use unless the brain is constantly shown that the limb exists and is needed. The approaches discussed here seek to do just that and it’s all fairly straight forward. Despite that general straight forward nature I will say that with my patients throughout the years this can be one of the most maddening parts of recovery because you have to keep up the constant effort for weeks, to potentially months before we see much of any improvement at all. But, with a combination of other necessary therapies, it can get you there.
When someone is unable to go through this process, for whatever reason, the result is what we call ‘learned non-use’. This is where the body and brain adapts to that limb not being used. If the limb was never going to be used again, like an amputation, this is definitely a good and necessary thing, but when you’re trying to get it back into function, it can be quite counter productive. The longer rehabilitation of the limb waits after the inciting injury, the closer we are to a state of learned non-use and the longer and harder the rehab process itself is. So naturally, we try to get it started to some degree as soon as the patient is able and go from there. Learned non-use can be overcome, but again, the road becomes longer and harder the more time goes by.
When possible, one approach to combating learned non-use is not allowing you to use the good limb, such as when you can’t use your right arm, you bar the use of the left and try to use only the right instead. Obviously this isn’t going to be functionally successful, but presenting the brain with a problem over and over (like needing to open a door in front of you) and taking away its ability to use it’s fully functioning limb gives it a lot of direct motivation to connect the affected limb and use it! When my patients start regaining the use of their affected limb, this becomes a heavily used strategy to get it functioning much faster, and start integrating it’s use with the rest of the body again instead of simply trying to get it to ‘turn on,’ by itself. Similarly, developmental movements (the core movements we learn as infants to toddlers to navigate the world) work extremely well for these purposes, with baby crawling being my favorite.
There is one more concept that should be mentioned here. While the first barrier in returning the use of a limb is often ‘waking’ it up in the first place, many processes involved in stroke recovery will run into an ‘automation’ phase, which will look like progress has simply stopped when it hasn’t. For many many years therapists and doctors in stroke recovery would work with a patient and see ongoing progress, up until a point when it simply stopped. At this junction, it was assumed that the damage which was incurred in the injury had left permanent limitations and the rehab process had met that barrier. In many cases, however, this is not what’s going on.
When we were born, we only had reflexive movements, we didn’t really control any of them ourselves. Everything we did, from turning our head intentionally, to crawling, sitting up, and then standing and walking were long learning processes requiring a lot of conscious trial and error. You don’t likely remember any of this, but conscious attention was definitely needed, just like would be required as an adult learning to play the piano. Once we learn how to do a movement, we start a phase where we learn how to do it without thinking. You had to focus intensely on walking at first as a toddler, and getting distracted could easily lead you to fall! But then your brain learned how to do this task more on autopilot, so that you didn’t have to pay attention to all the parts involved in taking each step without falling. This is how entertainers can play a complicated guitar piece while also singing, and do it with precision.
So too, in stroke recovery it will look like progress has plateaued when the brain is actually working on automating this task. Giving it some more time while going through the same tasks at that level of complexity lets the brain ‘work through the problem’ long enough to do it in a more autopilot fashion, and then make further improvements or move onto a new task. This can be frustrating to experience as you see the progress stop, but can be a very good sign.
So on the whole, I like to be up front about this part of the stroke rehab process. It can be maddening for a while where you have to keep up strong focus and dedication in your homework without seeing many results. It can be boring even when it starts working, and the plateaus, no matter how good a sign they are, can be horribly obnoxious. But these approaches to stroke recovery can be highly effective, let alone simply necessary, and you can often do them on your own. More situation specific homework definitely helps, but these make a strong foundation.
Each situation does vary, and so I cannot make specific recommendations for anyone reading, but I would often have patients starting with just a couple minutes of each of these approaches, a couple times a day, depending on their overall health situation at that time (how severe the stroke was, how long it was since the stroke, other complicating health factors, and their own priorities for therapy) and build from there. I hope the information here helps give you some ideas of the possibilities for you, or those in your life who are on the road to recovery from a brain injury. As always, I strongly suggest running by any rehabilitative exercises you try with supervising medical professionals to ensure they are safe and effective for your situation. If you are local to us, and want to see what we can do to help you or a loved one through their own recovery from a brain injury, feel free to get in touch for a no cost consultation where we can go over our approach, and your health situation in more depth.
After my spouse got home from the hospital because of severe brain swelling, he was left without the ability to take care of himself in any real sense, and has been stuck for more than two years with so little progress. He could barely walk, could not even stand in place without support. He had severe nightmares, thought everyone hated him or didn't like him anymore, even our daughter, because he couldn't stop negative thoughts. He would yell at strangers he'd pass by thinking they were thinking bad things about him, and he'd go into fits of angry rants or crying. The list goes on. But working with Thrive, every part of his recovery finally started moving forward again. The nightmares started going away, fits of anger were getting less frequent, less severe, and easier to get out of. Walking and balance have been getting so much better, and chunks of memory are even coming back. We've hit a real turning point.