What is stress and how does it impact stroke recovery? In this episode, I talk with Speech Language Pathologist, Wellness coach, and endocrinology expert Michelle rusk about the nature of stress and the role of Cortisol in our bodies.

Modern life is stressful enough without contending with stroke and recovery. Add more mundane and major sources of stress to our lives on a daily basis drives out bodies to a continuous state of Fight, Flight, or Freeze. Overtime, that causes more health problems, which introduces more stress to the system

Breaking the cycle of stress requires that we understand more about it and  just how it impacts our bodies.

If you don't see the audio player below, visit http://Strokecast.com/Stress to listen to the conversation

Who is Michelle Rusk?

Michelle Rusk is a North Carolina based Speech Language Pathologist, licensed to treat patients in North Carolina and Virginia. She is also a Wellness Coach and Dutch Test practitioner working with clients from all over.

She owns and operates Coastal Speech Therapy and Wellness. Coastal Speech Therapy & Wellness is a private practice offering virtual therapy throughout Virginia and North Carolina for those with brain injury. She serves patients as a therapist, certified brain and hormone health coach, and DUTCH test practitioner.

What is Cortisol?

Cortisol is one of the body's stress hormones. When an emergency arises, the body dumps cortisol into the system to increase blood pressure, blood sugar, and other mechanisms that give us extra resources to run away or fight a threat.

Humans have been around for about 100,000 years. Up until the last hundred years or so, that system worked fine. Modern life though, for all the wonderful and amazing things it offers, introduces a lot of low level stress that builds and builds.

In response, our bodies push more cortisol into the system. We end up living with a higher level of cortisol than we were ever meant to. That contributes to a whole array of health issues.

As Michelle explains, the way to address that is with lifestyle changes,

What is the Dutch test?

Michelle uses the Dutch test with her wellness patients. It's a urine test that assesses the levels of hormones in a person's system, with cortisol being the big one.

The company actually offers a variety of tests that work in different ways to assess hormone levels. You collect the samples at home, send them off to the lab, and then get the detailed results.

You can learn a lot more about the tests and see sample reports at http://DutchTest.com.

Once you get results, you should discuss them with your doctor or medical team. Actually, it's probably a good idea to talk with your medical team first because these tests can cost several hundred dollars and generally won't be covered by health insurance.

Social Wellness Groups

Michelle's comments on social wellness groups are also interesting.

An online or in person stroke support group is a powerful thing. There's a lot of value in connecting with other survivors. It's not just about getting tips for living with stroke or learning about local resources, though.

It's about the community.

Often we can go through our days isolated. Most of the people we talk to have not experienced a stroke. They can't understand our experience.

In a support group, though, we're around people who do "get it." And that's a big deal.

A social wellness group takes that to another level. There are the benefits of the community, sure, but there's the added benefit of the instructor led skill development. Michelle is able to coach conversational norms, among other things, to help reduce the sense of isolation out in the real world.

Michelle on Discharge Day

Michelle mentioned how amazing discharge day is, even if it is tinged with sadness as the relationship changes. Here's the post she mentioned: https://www.instagram.com/p/CcQuULsOABh/

Mimi Hayes Kick Starter

Mimi Hays survived a stroke shortly into her first job as a teacher in her twenties. She had a ridiculous amount of trouble getting treatment which still makes me angry. So naturally, she turned to a career in comedy, and she's a delight. We talked all about her adventures here: http://Strokecast.com//mimi

Mimi has performed all sorts of places, including the massive Edinburgh Fringe Festival in Scotland. Now she's trying to get back to Fringe and

Often we tend to think of "patients" and "providers." While sometime we may accuse medical teams of forgetting that their patients are whole human beings and not just a wrist band and chart in a hospital bed, it works the other way, too. We sometimes forget that our doctors are more than white coats adjusting out medications and asking who the president is -- again.

But doctors are, in fact, human. And they can create art. And they can have strokes.

Dr. Bevan Choate, MD, was a surgeon and urologist just enter the heart (or kidney) of his career. One morning, everything changed. He shares his story of the past 18 month in this episode.

(If you don't see the audio player below, visit http://Strokecast.com/Bevan to listen.)

Who is Dr. Bevan Choate, MD?

Bevan was bornin 1985 in San Angelo, TX.  What do you do when you are born in San Angelo, TX? You grow up on a horse. As Bevan says:

"I grew up in a cattle ranching family.  Cowboying since I could ride a horse but perhaps due to the Waylon and Willie song, they didn’t want me to grow up to be a cowboy. So, I was given all the odd and less glamorous jobs.

I realized about midway through undergrad that I wanted to be a doctor.  I was always a science geek at heart, and figured medicine to be a pure and noble application of science.

I excelled in medical school and completed my five-year Urology residency in Albuquerque at the University of New Mexico Hospital.  It was the roughest five years of my entire life.  Being a sleepless subordinate for almost two thousand days is a tough pill to swallow.  Nonetheless, I persevered and began practicing Urology in Albuquerque.  It was my calling.  I love it.  I love my patients and some of them even love me.  I did quite a bit of oncologic surgery and got good at robotic surgery using the Da Vinci robot. "

Things changed for Bevan on December 3, 2020. That's when a left vertebral artery dissection threw a clot that lodged in the left part of his cerebellar and proceeded to kill millions of valuable brain cells.

The dissection has no "attributable etiology." That's how doctors write a shoulder shrug emoji. No one knows why it happened. Bevan just got lucky.

The surgeons who were not Bevan got to work. His procedures included a ventricular shunt, a craniectomy, and a left cerebellar strokectomy (surgical excision of infarcted brain tissue post-stroke with preservation of skull integrity, distinguishing it from decompressive hemicraniectomy).

As Bevan says, "Yep, I have about 80-85% of a brain.  Not playing with a full deck"

Following this adventure, Bevan contended with:

• Acute Deficits
  • Double vision
  • Visual impairment
  • Vertigo
  • Left-sided ataxia
  • Loss of left fine motor function
  • Inability to walk or balance
• Chronic Deficits
  • Loss of left fine motor function
  • Balance issues
  • Right sided stroke neuropathy
  • Left-sided ataxia

Since then, he's accomplished some impressive things, not the least of which are living and walking. He's also become a published author and a professional artist.

He's also still practicing medicine and seeing patients. The laser may need to wait a little while though.

It's been quite the year and a half.

Typing around a Stroke

People approach their stroke recovery in different ways. Bevan and Michael Schutt both launched their writing projects to learn to type with their affected side again.

My approach to typing was the opposite. Instead of forcing my left hand to the keyboard, I wanted to get faster more quickly. I taught myself to type more quickly with one hand. I'm currently at about 34 wpm (average for two-handed typists is about 44 wpm).

Has that slowed my recovery? Maybe. Recovery is a delicate balance of accepting a disability and fighting that disability. Too far in one direction is not great for living the best life possible for many folks.

Of course, every stroke is different. I can admire the approach others took without feeling mine was wrong. Especially since my fingers are still (slowly) coming back.

And if they don't, that's fine, too.

Why write?

Bevan started writing his book to collect anecdotes. It's so easy to forget the details of an event with time, especially if we don't realize at the moment how important they might be. The very acting of writing or typing them out gives them a stronger hold in our memory. Every time we read them again, we can reinforce that hold they have. We can extract more incite from them.

You don't have to write a book, though. When I was in the hospital, I tried to post at least one anecdote from the day every day to Facebook. Part of that was to keep people informed of my status. Part was my compulsion to entertain folks and make sure they got value from check in on me (that's something I should probably unpack at some point). Part of it was to chronicle what I was going through for future reference.

In Be

June 3, 2022, was my fifth Strokeaversary.

It's an important milestone. My risk for a second stroke is now statistically lower, but that not why this matters. It's not about celebrating experiencing a stroke. It celebrating survival and recovery. It's about coming back from a battle with my own blood vessels both damaged and enriched.

It's complicated. But that blood clot on the morning of June 3, 2017, changed the direction of my life for good.

In this solo episode I share some more thoughts and feelings about my experience.

If you don't see the audio player below, visit http://Strokecast.com/Five

Don't get best…get better

I end every episode and nearly every blog post with this line, but what does it mean?

It means that constantly trying to be the best is a flawed path. To be the best at something means that everyone else has to be worse. It is an approach that actively discourages people from working together to help one another. The experiences of these past few years show us just how much we do need to work together and support one another.

Instead of focusing on being the best, focusing on just being a tiny bit better every day. Make the effort to consistently improve just a tiny bit. Help others to improve just a tiny bit, too.

Those little bits of improvement -- of growth -- add up over the days, weeks, months, and years. It can take you so much further that just focusing on the win/lose yes/so succeed/fail dichotomy that a focus on being the best promotes.

Where is my recovery today?

My recovery is ongoing. It didn't stop at the 6 month mark. Or the 12 month mark. Or the 24 month mark. Recovery doesn't stop on some artificial timeline.

My fingers are still getting better. I'd say I have about 15% of the use of my left hand back at this point. I can use it for practical stuff. Not in the same way I did before the stroke of course, but it will get there given enough time and work.

Right now my legs are tired because of an unplanned Costco shopping excursion where they were out of electric mobility carts. And since it was unplanned, I didn't wear my AFO so it was a lot more work. But I did it. And I wouldn't have been able to 3 years ago.

I also recently got my latest thrice yearly Dysport injection (a BOTOX alternative) . This medication treats the tone and spasticity in my left arm. My doctor was able to use less this time and treat fewer muscles. Again, it's another example of progress.

It's not all perfect, of course. I'm still living with fatigue, exacerbated by my recent COVID experience. So that's fun. And it's part of the reason I'm getting this episode out a week later than I had planned.  Adapting is what we do, though.

Going forward

I still have lots of projects to pursue as I go forward. I'm working on a book right now. Actually, I've been working on it for a year and a half and had to start over somewhere in the middle. I look forward to sharing more details on that later in the year.

I've also been doing more talks with survivor groups, students, and more to share my story and to help others share their stories. I plan to do more of that in the coming year. If you're looking for a speaker for your support group, reach out and let me know.

Storytelling

That brings me to the importance of storytelling. It's a theme that comes up again and again in my work. Professionally, I help journalists use Microsoft tools to tell stories more efficiently. I tell stories as part of that training process. Strokecast itself is built around empowering survivors and professionals tell their stories to educate and encourage the entire stroke community. Those stories help build connections across the silos of expertise and experience we find ourselves living in.

In sales and marketing, we say, "Facts tell; stories sell." Talking about stroke isn’t just about drilling into the biological details (though that is important). It's about telling the stories of real people or processes to connect those facts the lived experience we have. It's about helping patients, doctors, researchers, therapists, and commercial partners all experience one another as real people instead of just a bullet point list of details.

People don't want to go to a lecture on facts. They do want to go hear someone's story. That's how people connect with material.

Our earliest cultural touchstones in Western Civilization are based around storytelling -- from the ancient greek mythology to the slightly less ancient Homeric tales to the Christian bible where Jesus instructs his followers not with just precepts, but with parables -- stories -- that make the point.

The Brothers Grimm didn't just make a list of rules for safety and moral codes. The collected, recorded, and refined the fairy tales to serve as warnings to children about the dangers of the world.

My story and your story are how we can talk about stroke with others. That we can explain what it is, what to do, how to spot it, and potentially, how to avoid it. And even more importantly, that stroke and brain injury doesn't need to be an end. It can be a change -- a new beginning to a new phase in life. We may lose somethings while we gain so many more.

Was stroke a blessing or a curse?

I ask this question of most of my guests because it's one I struggle with myself. Most of my guests say it was a blessing. I'm not so sure.

For my detailed thought process on this question, though, I encourage to you listen to the episode or check out the transcript.

How can you support me?

There are a few things you can do to support me and the Strokecast. These are all things that help to grow the platform so more people can experience that value that you experience. Growing the platform will be a big help to me.

First, tell people about the show or tell them about your favorite episodes. The single best way to get more people to listen to a podcast is word of mouth from trusted friends and colleagues. They can find it in their favorite app, or they can just go to http://Strokecast.com

Second, subscribe to the Strokecast newsletter so you get updates and news when I'm able to share them via email.

Third, follow me on Instagram where I am @Bills_Strokecast. I post a lot of quotes from previous episodes and a few personal updates.

Fourth, invite me to speak to your virtual or local stroke support group. My webcam is always ready. Or hire me to speak at your conference or professional event/meeting. Just email me at [email protected]

Deb Shaw was at the top of her career, selling cybersecurity technical products to government customers for a silicon valley powerhouse. Things were going great. Then she had a stroke. And then she had another stroke. And then she had a third stroke, paired with a concussion.

Since then, she started a nonprofit with her husband and has produced more than 10 booklets for stroke survivors to help them navigate their new lives.

Recently, the American Heart Association named Deb their latest Survivor Hero.

Deb shares her journey in this conversation.

If you don't see the audio player below, visit http://Strokecast.com/deb to listen to the conversation.

About Deb Shaw

Deb Shaw is an inspirational three-time ischemic stroke survivor and the Founder & President of a nonprofit who remains steadfastly upbeat, despite her ongoing difficulties. Deb channeled her energy into creating “Champion the Challenges,” a nonprofit organization that helps motivate stroke survivors to pursue her three P’s of a successful recovery: Patience, Positivity, and Practice. Be patient in everything, have a positive outlook, and practice your exercises every day.

Deb founded and launched ChampiontheChallenges.org, a rapidly growing 501c3 focused on helping stroke survivors reimagine their stroke rehabilitation journey.  The website is filled with inspirational content, therapy ideas, and success stories all designed to encourage.  Deb has written 11 Quick Read Booklets ™ that are geared to inspire and educate the stroke community. The booklets are available on-line as flipbooks, or in print editions, all compliments of Deb.

“Champion the Challenges” was started during Covid because she wanted to share the inspiration, motivation, technology, and helpful stroke ideas, all in one website. This is her way to give hope to many people needing to discover their inner strength.

3Ps

Deb's approach to recovery is based on the three Ps:

1. Patience
2. Positivity
3. Practice

Patience with yourself is critical. While we are all trying to recover, it doesn't always happen as quickly as we would like. Sometimes we can't do things yet that we feel like we ought to be able to do. That's okay. It happens. Getting angry and frustrated with ourselves may be natural in the moment, but ultimately is not helpful. We need to be patient with our brains and our bodies to give them the space they need to heal and to relearn our lives.

Positivity helps us get through the day. Negative feelings are natural and okay in the moment, and long term they can become a problem. Living in and dwelling in the negative is not going to get us where we need to be. A positive attitude and approach to our tasks and lives may not guarantee success, but I have never heard of someone succeeding while dwelling in a cloud of negativity.

Practice is the other key element. A positive attitude may make recovery a possibility, but it's practice that can turn that possibility into actual success. Neuroplasticity is a powerful force in recovery, and building those new neural pathways requires thousands of repetitions of activities. It takes practice and then more practice.

2022 Stroke Hero Awards: Survivor Hero – Deb Shaw

Llamas and Alpacas

For my Girlfriend's birthday, we went to Topstall Farm to visit play with llamas and alpacas. It's a short 1.5-2 hour drive from Seattle.

The person who runs the farms limits groups to 6 people so we get a personal experience. She told us all about the critters and explained how they care for them.
 

Then we got up close and personal. We walked into the paddock and got to feed them by hand. One thing that amazed me was how soft the alpacas lips were as they took the pellets right from my palm. They were aggressive about getting to the food but gentle about taking it.

After we fed the alpacas, we took the llamas for a walk. It was 2 people per llama. Cathy and I got to take Armando on a half mile hike around the property.  Armando wasn't terribly interested in the walk, but he went along with it. Every 20 or 30 feet or so he would stop and bend down to start snacking on some grass, as though to convince us he hadn’t eaten in FOREVER. We weren't buying that however.

The walk itself was a challenge because it wasn't a paved path or smooth trail. The ground was uneven and muddy in places, as you would expect. I managed pretty well with my cane (I used the cheap one), but I certainly got my PT in for the day.

Sophie Salveson survived a stroke at 19. It's not the way any freshman wants to end their first year of college. She was a writer, actor, and singer. The stroke stole her right side limbs, her speech, and her access to language.

Over the past 10 years she fought back through PT, OT, speech therapy. She learned to stand, walk and speak again. And she continues to make progress.

In the previous episode (http://strokecast.com/ExpandedPractice) I spoke with Marabeth Quinn, Sophie's Mom, and Danielle Stoller, one of Sophie's Physical Therapists. This week, we hear from Sophie and Marabeth and learn more about Sophie's journey.

If you don't see the audio player below, visit http://Strokecast.com/Sophie.

Song

Many people with aphasia find it easier to sing than to speak. Early treatment sometimes involves getting folks to sing their name or sing a greeting. Or even sing a song deeply embedded in their memory, like Happy Birthday.

It has to do with the way music and song live in different part of the brain.

Aphasia isn't the only place music as an impact. In episode 106, I spoke with Brian Harris of Medrhythms about his work using music to bypass limitations of the motor cortex and help people significantly improve their gait.

This is an amazing video of Sophie from 2020. You can hear her sing, "A Change in Me" from Beauty and the Beast.

Now, I really want to hear Sophie's Eponine.

Maggie and Michael

Sophie isn't the only stroke survivor with a passion for theater.

I talked with Maggie in episode 38. Since then she has acted in a theater company fill with folks with disabilities. She continues to make progress on her documentary, The Great Now What. Here's the trailer:

Michael Schutt was on the show in episode 124 talking about creating his solo show to share his stroke story. COVID lock downs meant planned performances didn't happen. He pivoted it into a radio play available on line. You can listen at http://ALessonInSwimming.com.

Sophie's Book Recommendations

The first book Sophie really read for pleasure after her stroke was "Shatter Me," by Tahereh Mafi.* It came with a powerful endorsement -- her sister's. And connecting about the book with her sister was a powerful incentive to read it, no matter what it took.

Sophie's current favorites include "Good Girl's Guide to Murder," by Holly Jackson and "Elsewhere," by Gabrielle Zevin. * Pick up a copy or find them at your library and tell Sophie what you like about her favorites.

Hack of the Week

Keep trying. Speaking with aphasia is tough, but the only way out is through the key is to keep trying and to keep working on it.

I've found it best top to try doing a thing with my affected hand three times before switching to my unaffected side. By trying three times, I'm reminding my brain that my left hand is still there and has a job to do. By stopping after three failed attempts, I stave off frustration and can try again another day.

Links

Where do we go from here?

• Connect with Sophie on Instagram or email and check out the links above.
• Share Sophie's story with someone you know by giving them the link http://Strokecast.com/Sophie
• Subscribe to the Strokecast newsletter at http://Strokecast.com/New
• Don't get best…get better.

"Communication is the process by which shared meaning is created." 

CO 101

That's the first lesson we learned in Communications class back in college.

Communication isn't spoken words or written words of photos or symbols or sounds or touches. Or even scents or tastes.  Those are all just vehicles for communication. They are the trucks intended to carry the freight of meaning from one person to another.

After stroke, some of those trucks are no longer available. Aphasia and dysarthria may interfere with speech. Hemiparesis may interfere with writing or gestures. Sensory overload and attention challenges may interfere with listening.

And yet communication continues. Because the other lesson we learned in the class CO101 is, "You can't not communicate."

Combine those principles with the idea that your actions always speak louder than your words, and we have deeper understanding of how important it is for clinicians to think deliberately about the things they say and do when working with clients.

Marabeth Quin and Physical Therapist Danielle Stoller joined me in this episode to share their stories and how they came to develop Expanded Practice -- a training program for clinicians that helps them tune their communication strategies to build better relationships with their patients.

Note: This isn’t the first time I talked about communication in an academic context. This was also something I talked about with Drs. Sara Parsloe and Patricia Geist-Martin in episode 111 at http://Strokecast.com/process.

If you don't see the audio player below, visit the original post at http://Strokecast.com/ExpandedPractice.

Who are Danielle and Marabeth?

Danielle Stoller is a neuro physical therapist who helps stroke and brain injury survivors improve their lives through a holistic rehab approach.  Marabeth Quin uses the experiences and insights she has gained from her daughter’s stroke recovery to improve therapist’s understanding of the mental and emotional aspects at play in the recovery process.  Together they co-founded Expanded Practice.

Expanded Practice

Expanded Practice is the training organization that Danielle and Marabeth started  once they saw the need to help therapists connect more effectively with their patients.

Their goal in part is to go beyond the technical details of the tasks that go into a session and to help therapists think more about the client experience -- to connect to the clients as individuals with specific therapeutic, emotional, and psychological needs. That's not about providing counseling per se; it's about understanding the patient and building a trusting relationship with them to promote a more effective session.

In some ways it parallels the work I've done as a corporate training help folks learn how to sell technology products. It's not about the high-tech features of the product. It never is. It's about what those features and those products will do for the customer. Effective salespeople ask themselves, "How will this product or service make THIS customer's life better? How will this benefit them?"

To answer that, they have to talk to their customers and ask questions. They put the focus on the customers' lives.

That focus on the client is something Danielle and Marabeth teach to. As we talked about in the episode,  they teach therapists about the environment they create. If the therapist appears rushed or tense, that will affect the client's perception of what is happening. That increase in tension makes a session less effective.

Here's how Marabeth and Danielle describe the program:

Expanded Practice teaches physical, occupational, and speech therapists to start utilizing the power of positive mindsets and expectations in the recovery process so they can connect with their patients on a more significant level and help them reach greater recovery potentials.  Expanded Practice is passionate about improving the rehab experience for patients and therapists so both thrive and achieve the highest possible outcome.

Stroke Awareness Month

May is Stroke awareness month in the US.

What does that mean for you? Well, whatever you want it to.

It's a month when many survivors will share their stories or post on social media about how to recognize a stroke or just have personal conversations with others they are close to.

Some may choose more subtle signs, like adding a stroke awareness frame to a Facebook avatar or wearing a red ribbon.

Some may give a talk at school, church, or work to help raise awareness.

And many folks will choose to treat it like any other month.

What matters most is to treat it in the way that best supports your needs, goals, and recovery.

And if you want to do something, but you're not sure what, you can always tell folks about your favorite stroke related podcast :).

Or find a new stroke podcast to listen to at http://Strokecast.com/strokerelatedpodcasts.

Hacks of the week

Two guests again means 2 hacks.

Marabeth makes a point of reminding us to keep going. The thing about recovery -- whatever part you're in -- is that it can be easy to stop and give up. It seems so enticing to do that somedays. It really does.

But then you stop getting better. And you may get worse. Even when it's hard, you have to keep going. That's the only way to get to the better days that are coming.

Olga and her husband were having the vacation of a lifetime. They hooked up a teardrop trailer to their Subaru in NJ and headed out west. The planned to explore the gorgeous landscapes of the Washington State parks before jumping on ferry to Alaska.

On July 19, 2021, at a campground in Deception Pass State Park on the Washington State Peninsula, things started to unravel.

Olga had a brain stem stroke. She felt tingling up and down one side of her body and could not stop vomiting. She felt it was a stroke. Her husband called 911 and they made it out of the woods to a fire house.

The EMT said she wasn't having a stroke.

The ambulance that arrived said she wasn't having a stroke.

The ER staff said she wasn't having a stroke.

The neurologist said she probable wasn't having a stroke and specifically discouraged the tPA that could have solved the problem

And no one sent her to the more advanced hospitals in Seattle for stroke treatment.

The window for tPA came and went.

This whole time, Olga was having a stroke.

Olga shares her story in this conversation.

If you don't see the audio player below, visit http://Strokecast.com/Olga

Who is Olga Wright?

Olga is a married mother, grandmother, and recently retired educator. She lives in central New Jersey, where she practices extreme gardening.

She and her husband recently returned from a six-month, 24,000-mile road trip to Alaska and back, with their ultra-light, solar-powered camper.

Her goal is to educate the public and medical professionals at all levels to recognize nausea, vomiting, and tingling as stroke symptoms so that no one else is misdiagnosed as she was.

Olga can be reached at [email protected]

Deception Pass

Deception Pass State Park is a gorgeous corner of the state. It's filled with hiking trails (including accessible trails), lakes, salt water shoreline, and campgrounds.

It's also just an amazingly beautiful part of the state. It seems remote but it's also within just a couple hours of Seattle to the Southeast and 90 minutes from Canada to the north.

It's easy to see why Olga and her husband chose to camp there.

Zofran and the Brain

Zofran is a medication I was not familiar with, and it's what finally got Olga's vomiting under control.

It's typically used to help treat nausea associated with chemotherapy. In Olga's case, it was used to treat a malfunctioning brain that was sending the signal of, "OKAY! Everyone out the way you came in!" even though there was nothing left.

The brain tries to protect us in lots of ways. Sometimes those threats are real and sometimes they are not. In Olga's case, her dying brain stem knew something was wrong but didn't know what. It went to an early reflex for poison and just kept trying the expulsion solution because it didn't know what else to do. Meanwhile, Olga's higher level brain functions were still working and trying to seek medical treatment for the stroke.

And this conflict is an illustration that the brain is not one, cohesive unit. It's different parts grabbing different pieces of data and attempting to execute a solution based on the tools at its disposal. The brain does not always work as a single unit.

But back to Zofran. One of the interesting things I learned while reading about it is that Serotonin, one of the brain's "happy" chemicals is also responsible for the vomiting function/command. Zofran works by suppressing Serotonin.

And that makes me wonder how its use as an antiemetic impacts things like depression. I suppose that will be a future research project.

Swedish ARU

The reason Olga and I connected is that she spent her inpatient rehab time at Swedish Medical Center. It's the same place I lived for the month following my stroke. You can learn more about the Acute Rehab Unit here.

Olga was lucky enough to work with OT Emilee who told her about the Strokecast. Emilee was also one of my OTs 4 years before Olga made it there. I interviewed Emilee in episode 20. You can hear that conversation here: http://Strokecast.com/Emilee

I've stayed engaged with members of my rehab team over the years. I've also met other folks on the stroke team at Swedish. Here are some other interviews I've done with the team at Swedish: http://strokecast.com/Swedish

Licensing for PT and OT

The pandemic has brought a dramatic increase in the availability of telemedicine. This is great because a lot of follow up appointments really don't need to be in person. I'd much rather do a 15 minute video appointment versus a 15 minute in person appointment I have to travel to and back from.

In Olga's case, it almost worked out for Outpatient PT. She would be able to continue her travels after leaving the hospital and get therapy on the road via the internet!

It’s a great idea, but it didn't work. Not because of technolog

More than 80% of strokes are caused by blood clots. These strokes are called "ischemic" because the clot block the flow of blood through a blood vessel, starving brain cells of oxygen and nutrients. My own stroke was ischemic.

There are new treatments to clear the clot and restore blood flow and we talk about them a lot on this show. What we don't usually discuss is the nature of clots themselves and how that impacts patient recovery.

So this episode is a little different. We go deep into understanding the biologfy of blood clots with Michael Gilvarry and Dr. Patrick Brouwer from Cerenovus, a Johnson & Johnson company.

Cerenovus commits a lot of research and resources to understanding clots because they make equipment used in Mechanical Thrombectomy and reduce the impact of stroke on thousands of patients a year.

You can listen to the conversation here or in your favorite podcast app. If you don't see the audio player below, visit http://Strokecast.com/Clots

Meet Dr. Patrick Brouwer and Michael Gilvarry

Dr. Patrick Brouwer, Head, Worldwide Medical Affairs - CERENOVUS

Dr. Patrick Brouwer is a clinician and scientist who has made significant contributions in the field of interventional neuroradiology and endovascular surgery.

Before joining CERENOVUS as Head of Worldwide Medical Affairs, he served in senior staff positions for over 20 years as a neurointerventionalist at various university hospitals in Europe. As a key opinion leader in his field, Patrick has published close to 100 scientific papers and book chapters and lectured, including for invited professorships, on more than 400 occasions around the world on a variety of topics related to neurointervention.

Patrick has additionally contributed by serving in various board positions across key societies, such as the European Society of Minimally Invasive Neurological Therapy (ESMINT) and the World Federation of Interventional and Therapeutic Neuroradiology (WFITN).

He received his medical degree, with honors, from the Free University in the Netherlands.

Connect with Dr. Brouwer on LinkedIn.

Michael Gilvarry, General Manager, CERENOVUS Galway

Michael Gilvarry is the General Manager of CERENOVUS in Galway. With a distinguished career in research and development (R&D) spanning over 20 years, Michael leads the CERENOVUS campus in Galway which is a key hub for producing world-class leading research on stroke and clot science, as well as R&D for the business’ product pipeline.

He leads a distinguished team who informs new innovations and the development of medical devices to address real-world challenges faced by neurovascular physicians in the treatment of stroke. This work has led to many international research projects in collaboration with universities and hospitals in the field of acute ischemic stroke.

He is the recipient of a Johnson Medal, the most prestigious award for R&D excellence within Johnson & Johnson, and is a named inventor on over 60 U.S. patents.

Connect with Michael on LinkedIn.

Cerenovus

CERENOVUS, part of Johnson & Johnson Medical Devices Companies, is an emerging leader in neurovascular care. Our commitment to changing the trajectory of stroke is inspired by our long heritage and dedication to helping physicians protect people from a lifetime of hardship. CERENOVUS offers a broad portfolio of devices used in the endovascular treatment of hemorrhagic and ischemic stroke. For more information, visit www.cerenovus.com and connect on LinkedIn and Twitter.

Nature of clots

Most folks who encounter clots only experience them on the surface of the body or when they come out of the body, but we don't think too much about their nature, especially wqhen they stay inside the body.

At the most basic levels, the structure of a clot is determined by the ratio of fibrin to red blood cells. Clots that are high in fibrin tend to be "tougher" and more compact, thanks to the way platelets help tighten them up. That also makes them easier to remove with Mechanical Thrombectomy.
 Clots that are higher in red blood cells may be softer and less dense, but they are also more fragile. Pulling one out of a blood vessel in one piece is a lot harder.

An environment with higher sheer forces is more likely to generate a high-fibrin clot. What is a high sheer environment? Think about a river with a strong, fast flowing current. One way to get a high sheer environment is with high blood pressure. With high blood pressure, blood is coursing through less flexible vessels with greater speed and strength.

A high red blood cell clot is more likely to be formed in a turbulent environment. AFIB, or atrial fibrillation is one such environment. A space where blood flows unevenly or pools can lead to a clot like this which can then travel to the brain.

Clots can also be different shapes. It's not like they are just a disk that closes off a blood vessel. They could be in the shape of a cylinder blocking a blood vessel. The can easily be longer than 8 mm.

Cerenovus recently presented a paper at the American Heart Association's International Stroke conference looking at the impact of clot composition on patient outcomes in mechanical thrombectomy. They showed that thrombectomy had better patient outcomes with high-fibrin clots.

Of course, today there really isn't a way from a neuro-interventionist to know the type of clot before they go in to get it. In the f

Again and again, we learn the secret to stroke recovery is repetition. It's about doing the same movement or behavior again and again -- tens of thousands of times.

In a typical session with an OT or PT, a patient might do the same exercise 30-60 times, which is a good start. But what if a therapist could crank that up to 1,000 reps an hour, or one every four seconds? Now you've got some interesting possibilities for recovery.

Bionik, Inc makes devices and software that do just that. This week I talk with CEO Rich Russo about the InMotion Hand and InMotion Arm devices and how they work in conjunction with a therapist to help patients recover.

Listen to the conversation here or in your favorite podcast app. If you don't see the media player below, visit http://strokecast.com/Bionik

Who is Rich Russo?

From the Bionik website:

Mr. Russo Jr. has over 15 years of finance and accounting leadership experience and is a Certified Public Accountant.

From March 2017 through November 2020, Mr. Russo was the Vice President of Finance and United States Chief Financial Officer, of IcarbonX, a privately held digital health management company specialized in artificial intelligence and health data, and a predecessor PatientsLikeMe. While there, he was responsible for, among other things, the merger of three companies, fundraising, and the ultimate dissolution of certain affiliated companies.

From 2007-2016, Mr. Russo held various key leadership roles for Nasdaq-listed companies in life sciences, pharmaceutical and medical device industries. From September 2015 to October 2016, he served as Corporate Controller for Pieris Pharmaceuticals, Inc., a clinical stage biotechnology company, and prior to that, he had roles at Juniper Pharmaceuticals, a woman’s health company focused on developing therapeutics, and Cynosure, a medical device company focused on aesthetic treatment systems. In each of these roles, Mr. Russo was responsible for all finance activities and SEC reporting, including partnering closely with management to ensure effective and efficient financial procedures throughout the organizations. Mr. Russo started his career in 2005, where he served as an auditor at Pricewaterhouse Coopers in the assurance group.

Mr. Russo is a graduate of Bridgewater State University in Bridgewater, MA, where he graduated from a dual degree program, receiving his Bachelor of Science in Accounting and his Masters in Management and Accounting.

Other Inpatient Solutions

The Bionik system is one for hospitals and rehab units. The rapid reps help in partnership with the rehab professional.

In that respect, it's similar to devices from Restorative Therapies. I talked with the team at Restorative Therapies in episode 92. You can find that episode here. 

The key difference is that Restorative Therapies uses Functional Electric Stimulation (or FES) to activate a patients muscles. The Bionik solutions provide physical assistance to help the patient complete motions. They are different ways to stimulate the brain, increase repetitions, and drive the neuroplasticity that is so key to recovery.

They are also both intended for use in a hospital or rehab facility with the help of a trained therapist.

The other devices I talk about often, like those from sponsor Motus Nova and previous guests with Neofect and Racoon Recovery are for at home use, as a supplement to therapy provided at a medical facility, or as an alternative when those services are not available, for whatever reason. You can learn more about those devices by clicking the links on their names above or from the link table at the bottom of this post.

The point of all these solutions is the same -- drive patient recovery through increased movement and repetitions to neureoplastically teach to brain how to access that limb once again.

Hack of the Week

Wear comfy socks.

It's such a simple thing, but the right socks can make a big difference in how you feel. The right socks can wrap your feet well and wick away perspiration. They can protect your foot from rubbing against an AFO or the heel of your shoe.

The wrong socks will keep you too hot or too cold. The wrong size will leave you with an uncomfortable wrinkle you walk on all day. If they're too slippery, you've got an additional safety hazard to contend with.

The hospital socks they gave me in the hospital were terrible. The had the no slip dots, which was great, but they kept falling down and rotating around my foot. Part if it was they were likely the cheapest that met minimum standards. The other part is that I have large feet for my height (size 12). So my partner ordered me better hospital socks from Amazon,* which helped.

For air travel after stroke, I have made a change to my wardrobe. I now wear knee-high compression socks.* They do a good job of preventing swelling in my feet and legs during long flights. And that helps to prevent DVT or deep vein thrombosis, which is where a clot forms in the legs and causes problems there, or breaks loose and lodges elsewhere in the body. That's how Ted Baxter had his stroke. I talked with Ted back in Episode 34.

Relatively speaking, good socks are still fairly cheap. Try different ones until you find the socks that are best for your feet and life style.

Good socks are worth it.

If you have a hole in the middle of your heart and it's not supposed to be there, is that a problem? Should it be fixed? The answer is a resounding, "Maybe."

Dr. David Thaler and his colleagues looked at the impact of PFO closure on stroke patients and found that often, the best solution is to leave it alone. They developed a scoring system to help neurologists and cardiologist make the best decision on a patient-by-patient basis.

Dr. Thaler joins me in this conversation to talk about the research and recommendations.

(If you don't see the audio player below, visit http://Strokecast.com/PFO)

About Dr. Thaler

Dr. David Thaler, MD, PhD, FAHA, is the Neurologist in Chief at Tufts University Medical school. He is the Chairman and an active professor in the Department of Neurology.

Additionally, he continues to treat patients and is a clinician focused on stroke care. He  continues to work to advance the field with a research focus on acute management of cerebrovascular disease, secondary stroke prevention, cryptogenic stroke and patent foramen ovale (PFO).

Dr. Thaler's training involves work at:

• Oxford University
• John Radcliffe Hospital, UK
• Brigham and Women's Hospital
• St. Elizabeth's Medical Center

He is a Board Certified specialist in Neurology and Vascular Neurology.

Stroke Basics with Dr. David Thaler

Dr. Thaler works on projects ranging from advance neurological  research to the fundamentals of stroke education. This video is an excellent, short introduction to stroke  that is also sharable:

One of the things that is especially interesting about this video is that in describing the symptoms of stroke the first one he mentions is tingling on one side of the body. This usually isn't mentioned as a stroke symptom by most warnings.

In episode 156, coming up in a few weeks, I talk with a survivor who had this exact symptom and was told by first responders that she definitely wasn't having a stroke and by emergency room personnel that she probably wasn't having a stroke. It turns out she was having a stroke.

BEFAST and AHORA are excellent starting points for recognizing the signs of a stroke, but they are not comprehensive. They do not cover every sign of stroke. They are just a useful short hand.

What is a PFO?

A PFO is a hole in the heart. Roughly 25% of the population has one. I have one. Guests Misha Montana and Christine Lee both had PFOs that led to their strokes.

After we are born, our blood follows a path through the heart. It comes in the right side. When the heart beats, the blood on the right side heads out of the heart to the lungs. There, it drops of CO2, picks up oxygen, filters out clots, and heads to the left side of the heart. It will pour into the left side and when the heart beats, it sends that oxygen-rich blood on to the brain and other parts of the body. Then that blood drops off its oxygen, picks up CO2, and heads back to the right side of the heart to start the whole cycle over.

Before we are born, though, the process is different. While we are developing in our mothers' uteruses, we don't breath air. All the oxygen and nutrients we need to build fingers and toes and kidneys and hearts and brains comes from the umbilical cord.

Since we're not breathing air, there's no point in sending blood to the lungs. Instead, in utero it goes straight from the right side of the heart to the left side of the heart through a hole in the middle. That hole is called a Patent Foramen Ovale, or a PFO. It normally closes on its own shortly after we are born.

A quarter of the time it doesn't close after birth, and that allows unoxygenated, unfiltered blood to sneak across the heart, skip the lungs and drag a blood clot to the brain.

So, if you've had a stroke, and you have a PFO, should you have surgery to close that hole? Maybe.

Christine and Misha had their PFOs closed. I did not

Dr. Thaler's research helps doctors make the best recommendation for the patient: to close or not?

Neurology, Illustrated

When you visit the doctor's office, what do you see on the walls? Probably posters showing the warning signs of stroke or heart attack. Maybe information about COVID-19 protection and policies. Probably lots of important, useful, stressful, and boring text.

If you visit the Neurology department at Tufts Medical Center, you'll have a different experience. There you'll see art all about neurology -- from centuries old brain drawings to photos reflecting the impact of stroke on world events to modern pieces exploring the diversity of the brain and nervous system we live with today.

You can also see these images and read more about them at  Neurology, Illustrated on the Tufts website.

Here's a video of Dr. Thaler explaining the program.