Neuroplasticity and recovery with Peter Levine

Episode 27, 10 August 2021

Peter LevineFor the 5th anniversary of the EnableMe podcast series we're revisiting one of our most popular topics: neuroplasticity, the ability of the brain to change and the basis of recovery after stroke.

To find out what's new in neuroplasticity and how to use it in your own life, we talk to medical researcher Peter Levine, author of the book Stronger After Stroke, which has helped stroke survivors worldwide.

We also speak to young stroke survivor Saran Chamberlain, founder of the YESS SA network and engagement coordinator for the Stroke Foundation's Young Stroke Project, and to physiotherapist Katherine Yong from StrokeLine.

 

Podcast transcript

Announcer: Welcome to the EnableMe podcast series, where we bring together stroke survivors, health professionals and researchers, providing you with practical advice to enable you on your journey to reclaim your life after stroke. The advice given in this podcast is general in nature, and you should discuss your own personal needs and circumstances with your healthcare professionals. You can join the conversation at enableme.org.au. This series is presented by Australia's Stroke Foundation, working to prevent, treat, and beat stroke.

Chris: [00:35] The EnableMe podcast series is now five years old, and we've spoken to a lot of people who've had strokes, and we've covered a lot of topics in stroke recovery. One of the most popular topics we've done was in our very first episode, when we talked about neuroplasticity. This is the ability of the brain to change, and it's the basis for recovery after a brain injury like a stroke. Now we thought since it's our five-year anniversary, what better time to revisit neuroplasticity and find out a bit more about what's new and how to use it in your own life.

And how better to do that than by talking to someone who has helped a lot of people worldwide understand about neuroplasticity for stroke recovery. So we're very pleased to have with us Peter Levine, a medical researcher and author of the book Stronger After Stroke. He's joining us on the line from Cincinnati, Ohio. Pete, it's an honour to have you on our podcast.

Peter: Well, it's an honour to be here, and I love talking about this stuff, so probably at some point, you're going to have to shut down my mic.

Chris: Well, we're going to have a challenge to control ourselves as well, because I have helping me with this conversation today, young stroke survivor Saran Chamberlain. Now Saran, she has also helped a lot of other stroke survivors. She founded the YESS SA network, which stands for Young Enabled Stroke Success South Australia, and she currently coordinates engagement for the Stroke Foundation's Young Stroke Project. Welcome, Saran.

Saran: Thank you very much for having me.

Chris: And last but not least, we also have physiotherapist Katherine Yong, from the Stroke Foundation's StrokeLine. Great to have you here, Kath.

Kath: Thanks, Chris. Great to be here too.

Chris: [02:06] Now, Pete, a lot of people may have already heard about you and your book, but for those who haven't, could you tell us a bit about your background and how you came to write Stronger After Stroke?

Peter: [02:15] Well, I get this question a lot and I'm always sort of flummoxed about where I should start. So I guess, I'll start with my first college degree. I went to George Mason University, which is just outside of Washington DC, and got a degree in communication. But during my high school years and my college years, I was very interested in being a drummer in rock bands, and being the hyperactive person that I am. So after college, I moved to Austin, Texas, which is a big music town, a big college town here in the States and in the great state of Texas, and almost immediately got into a band that almost immediately got signed to a major label and TV, touring, the whole thing. And I'm not just mentioning this because I want you to know that I was a nominal, very small rock star at one time, but rather because a lot of what I know about recovery from stroke comes directly from my experience as a musician.

Musicians, athletes and stroke survivors all have the same ambition in mind, they want to get better. And there's nothing new under the sun, I think there's a lot of people in rehab, there's a lot of people, physiatrists, neurologists, a lot of very smart people that try to complicate things up. We've been doing skilled stuff since about 70,000 years ago when we started building tools. And everything that drives cortical change, that drives brain changes, we've known about for very long periods of time. We've been really good. As humans, we're really good at this stuff.

So anyway, so get back to the story. After a while, being in a band that was touring throughout the United States, I decided that the lifestyle just wasn't for me and I went back to school, got a degree in physical therapy, worked in skilled nursing for a few years, what you guys might call a nursing home, and then got a job at the Kessler Institute in their research department. And Kessler is a very highly ranked rehab hospital here in the United States on the East Coast, and had three bosses at the time, something I don't recommend. During this period, we were absolutely on the bleeding edge of everything that was coming down the pipe with regard to stroke recovery. And I thought it was a good time for me to maybe think about writing a book.

And I had been writing about stroke recovery for quite some time. I had a column in a trade magazine, in a physical therapy trade magazine, and I'd written an article called "10 Things That Stroke Survivors Can Do To Recover". And I thought, "Well, if I can come up with 10 things, I wonder if I can come up with 100 things, or 101 things?" So, the working title for a long time was "101 Things That Stroke Survivors Can Do To Recover". The problem I had was I stalled around number 40. I couldn't think of any more than that. There was nothing else that was proven in clinical research and it had to be proven in clinical research for me to include it. And so, I changed the name to "Stronger After Stroke". It's now in its third edition, it's been published in a few different languages, and I think that pretty much takes us up to speed.

Chris: [05:38] That is fantastic, and it's really interesting to hear about your music career because I guess we can genuinely talk about you as a rockstar in stroke. But also fascinating to hear how neuroplasticity, as you said, is fundamental to learning all skills, including I guess, relearning skills after a brain injury like a stroke. So, I guess, we really need to know a little bit more. Can you tell us a bit more about neuroplasticity and how it works?

Peter: [06:04] Yeah. Because I am probably one of the bigger purveyors of this idea that neuroplasticity drives everything in stroke recovery, I should probably push back on that. I've evolved on this concept relatively recently. So, what happens after a stroke is there's a portion of the brain that's infarcted, let's just go with an ischaemic stroke, that is a block stroke, and that portion of the brain dies. It's gone, it's never coming back. And it actually cavitates and fills with cerebrospinal fluid. There's an area around the area of brain damage called the penumbra, and during the first three months or so after a stroke, the penumbra starts to come back online. That is the majority of the recovery that happens in that very important first three-month period.

So, what happens is as that penumbra, this peri-infarct area, the neurons that are still alive, right after the stroke, they're stunned, they're said to be stunned. It's a process known as cortical shock and the neurons that are ... It's much bigger than the area that's infarcted, they're alive. They're just not doing anything for the first little while after the stroke, and the first few months. So, the predominance of recovery comes from this brain that wasn't online, coming back online and doing exactly what those neurons had done prior to the stroke. And so, this is an interesting time in physical and occupational and speech therapy, because it's often the time that therapists want to get the person safe and functional and out the door. They want to put orthotics on them and make stuff easier for them so that they can be functional.

What ends up happening is a process known as learned non-use. Basically, these neurons come back, but because the stroke survivor's being taught compensatory movement, they often do everything with their good side, and the brain is very use it or lose it, and what ends up happening is something called a pruning of the dendritic arbour. Those neurons are coming back online, but they're not used, and because they're not used, they're lost. And that huge portion of the brain then lies fallow for the rest of that stroke survivor's life. So, this is a long-winded way of saying that the first push in the brain is just brain coming back online. After that, and we know it's after that, because there's this really big thing that happens in stroke survivors' lives, they plateau.

After the plateau, everything after that is neuroplastic change in the brain. So, you have brain coming back online, you ride that, what I call it, riding the wave of natural recovery, and they get a very steep incline in recovery, and then there's that plateau. After that plateau, that portion of the brain's back online, they have to borrow neurons, or they have to add synaptic connections in the peri-infarct area. But that's where neuroplasticity really comes in, it comes in during what we call the subacute phase. Typically, after the first three months after stroke. Now, what is brain plasticity? It's just this incredible ability for the brain, very quickly to go through massive rewiring in order to turn the brain into whatever its owner wants it to be. It can be as fast as post-traumatic stress disorder. Somebody comes into your house and blows a couple of holes through your wall with a shotgun, that's going to be something that happens immediately, but you'll never forget it. Your first kiss, a broken leg, these things stick with you forever. It doesn't have to take a long time to make this stuff happen.

Of course, in brain injury, what you're trying to do is get people to not have post-traumatic stress disorder, but rather to drive a lot of cortical change so that they can get on with their life. But there is a downside to neuroplastic change, right? So, things like OCD, and depression, and anxiety, and drug addiction, and bigotry, and sexism, and all these other things are neuroplastic too. We always talk about the mind and the brain, the mind is you, what you want to be, who you love, what your ambitions are. The brain is just the machine that carries it out. I would say that it's probably not that important to know too much about brain plasticity to make it happen. We all make it happen in our lives every single day.

I would be super careful, just for anybody who hasn't had a stroke and people who have had a stroke, be real careful about the things, especially the things that you think repeatedly, because those things will leave an imprint on your brain. And this is, as I said, the essence of things like bigotry and sexism and all these other problems that keep human beings from being decent to each other.

Chris: [11:25] Well, I guess, like any powerful tool, there are going to be ... you do have to be careful about how you use something like neuroplasticity. But it is promising to hear that it can give you that long-term changes in your brain for stroke recovery. I guess, I'd like to get another perspective on that. Saran, I'd love to hear your own experience of long-term recovery after your stroke, but to start with, could you tell us a bit about your stroke story?

Saran: [11:48] Sure. I had a stroke eight years ago. I was 37 at the time. I had an ischaemic stroke, which affected my sensory, premotor, and motor cortex of my hand and fingers, but I lost completely my left side. And it's funny, Peter, the way you're explaining neuroplasticity, I've read lots of books and I've read yours, that explanation of neuroplasticity and the recovery, it's so simple and really makes sense. And when I was listening to your book, I was wishing that not only were stroke survivors, but also other allied health professionals listen to it. So, it's really great. I love your book, by the way.

But I suppose, I started walking around the five-week mark and didn't really get any shoulder movement for about a year and a half. But from a therapy and rehabilitation side of things, I was determined to, and still am determined to try and get as much back as I can. So, a lot of it is repetition, a lot of it mainly is visualisation, to be honest, because there's nothing in my hand or arm that I can really do. So, I've been lucky enough to have really good therapists that can help me understand what parts of my body or what parts of my arm move my wrist, for example, and things like that. But yeah, it's certainly hard work and a lot of repetition and just constant improvement.

Chris: [13:30] Yeah look, it is really interesting to hear what you said too, about how some of the techniques in Pete's book, that you wish that allied health professionals knew a little bit more about. So, it's probably a good time to ask Kath about this. As a physiotherapist, what do you think about allied health professionals like physiotherapists, like occupational therapists, speech pathologists, and others, do you think they are becoming more aware of these principles and techniques?

Kath: [13:56] Yes, I do believe that allied health professionals are becoming more aware of neuroplasticity. I think it is used in our therapy a lot these days, and I think it's also not okay not to know about this anymore. We get taught that the brain can rewire and change and adapt, and that practising and encouraging practice of exercises and meaningful exercises will help to regain movement. We do always try to encourage practice and repetitions of meaningful exercise with our stroke survivors. And sometimes, the challenge can be in trying to find an increase in the amount of reps that stroke survivors are doing, and also what they can do independently. I think that can sometimes be the challenge, and I know that health professionals, allied health professionals can't be with their patients 24/7. So, finding ways to encourage the practice outside of scheduled therapies is what our big focus is to try to help to promote neuroplasticity.

I think allied health professionals are getting better at also explaining neuroplasticity to stroke survivors. I think, like Pete says, that that way of describing it through music or through athletics as well, is something that can really help a stroke survivor. And I think that with understanding that the brain is not fixed and that it can adapt even after this plateau period of spontaneous recovery, I think that's so important for a stroke survivor. And if our message gets across to stroke survivors, I think that does provide a lot of hope.

Chris: [15:47] Now, Pete, your book was first published in 2008, but I believe it's currently on the third edition, which was released in 2018. I imagine, like us, who've been doing this podcast for a few years, you've seen quite a few changes in that time. So, you've told us a little bit about that, some of the new way of thinking you have about the way the brain recovers and rewires, but what other new developments in neuroscience and in recovery treatments, have you seen in that time?

Peter: [16:14] Well, our lab has been really on the bleeding edge of this for quite some time. I know you sent me a link for an article about transcranial magnetic stimulation, TMS. And we have that as a technology, we're not super knowledgeable about how quite to use it yet. There's stem cell research, in which stem cells are injected into the brain right around the area of infarction, in order to have those stem cells differentiate into new neurons. That's another one that we're waiting for it to show its real promise. I think TMS falls in that category as well. What I've always been interested in is, and I think Kath touched on this when she talked about how you're really looking for stuff that people can do at home because there's just not enough therapy time, and therapists are expensive, and therapy is expensive, and you can't just run to the clinic every time you need to get better. You've got to do it on your own at some point.

So, those are the ones that have always fascinated me and maybe this will help Saran as well. So, one of the things that I've been focused on recently is, our lab did a lot of the seminal work with regard to mental practice after stroke. And mental practice is something that musicians, athletes, do all the time. It's this idea of pre-imagining an event.

So, if you imagine a movement that you do well, the portion of the brain that lights up is exactly the same portion as the portion when you actually do it. Not only that, but the muscles involved in the thing that you're imagining, the movement that you're imagining, those muscles will fire in the same duration and in the same order as if you actually do it. They just fire very minutely, almost like a dreamlike twitch, they'll have. It wouldn't be visible, nobody would be able to feel it, but with electromyography, you'd be able to pick it up. So, if you imagine a movement, the portion of the brain dedicated to that movement lights up, and the muscles fire in the same duration and in the same order as if you actually do it.

Then there's this other thing that's been coming down the pipe, that's very much related to mental practice, and it's called action observation. The idea is that you watch somebody do something, the portion of your brain dedicated to what they're doing lights up. And this is one of the things that I'm sure you guys have heard of, mirror neurons, mirror neurons have to do with empathy. So, you actually feel what that other person is doing through their movement.

A great example is if you've ever watched kids play soccer and you see the parents on the sideline, especially if they're little kids and they really don't know what they're doing, the kid's standing right in front of the goal, and he's just not kicking the ball into the goal. And you see all the parents say, "Kick it." And their legs are moving out. They're empathising with the movement that they want that child to do. If you're a musician, a good way to become a better musician is by watching musicians that are better than you. So, when you observe that action, that portion of the brain, in your brain, that would do that action will light up and the muscles will fire.

So, you have three situations that you can use in order to drive cortical change, even before you move. One is mental practice. One is action observation, where you observe somebody else. And the other one that drives cortical change as well is movement itself, and lots of repetitions of movement.

I would say, for Saran, the other option is ... Because I think I heard her mention that she isn't moving yet, but another thing that you can do is mirror therapy, where you look in the mirror at your unaffected side. So, imagine taking a mirror and splitting yourself left and right, but the reflective part of the mirror is focused towards your good side. If you don't mind me calling it the good side. And you do something in the mirror and you look in the mirror and you can see your good side moving, but it looks like your bad side moving, that also drives cortical change. So, you would get changes in the portion of the brain dedicated to the bad limb, simply by looking at the good limb in a mirror. So, there's three options, mental practice, action observation, and mirror therapy, that can be used as a precursor to jumpstart the brain so that then you can go into a lot of repetitive practice.

Chris: [21:21] Saran, does any of this resonate with you? Or I should say, ask maybe are your neurons lighting up accordingly?

Saran: [21:29] They are certainly. I do a lot of visualisation of moving my left hand and fingers. So, I work my way down, visualising my bicep, tricep, forearm, wrist, and then I get to my hand. And I've been doing it for quite some time. And again, there's no movement at all. I can feel the different muscles actually starting to fire off in my arm, that actually move those fingers. So, I have been feeling more, or should I say visualising more, which is really exciting.

And here in South Australia, we have some video software that we are trying to get some funding for where it could take photos of people moving and taking the still shots of them. And what I worked out was that as soon as I did it, I felt my left side completely lighten. I've got a lot of pain and heaviness in my left side of my body. It was really quite amazing. And the more often I did it, the longer that feeling of lightness lasted. The brain can do amazing things. And I've found out obviously, the harder way, but I am just hoping one day that it kicks in enough that it will take over what that part of my brain and my left arm could do.

Chris: [22:56] Okay. Now, one of the questions I wanted to ask you, Pete, I guess, is this, it sounds like it is a long journey. It's a lifelong journey, a stroke recovery, and some of the treatments, some of the exercises and things that we've heard from you and from Kath, and from Saran, requires a lot of practice and a lot of repetitions, which must require quite a bit of motivation to keep going. How do people stay motivated through this journey?

Peter: [23:22] I bet Saran would probably be a better person to ask. This is another thing I punted on in my book. I actually got a stroke survivor to explain to me what it was that made her stop trying to get better. And she said that she had gotten so much better, that she was able live her life to the point that she didn't have to obsess about getting better. So, it's this nexus, right? Where you're living your life to the point where you don't need to recover anymore to live your life, and for different people, that's a question that they have to answer. At some point, some people don't get better and of course, we're all hedging against our natural ageing as well. So, even if a stroke survivor is not getting better specifically, they still have to work in order to keep away ageing itself.

I would like to though, if I very quickly go over the number of repetitions that we think it takes in order to drive cortical change after a brain injury. And I'll give you three numbers, 1200, 30, and 400. So, 1200 is the least amount of repetitions that you would have to do in somebody who's had a brain injury, in order for two things to happen. First of all, they get more active range of motion, that is measurable movement. And the second thing is that the portion of the brain dedicated to that movement hypertrophies, we use functional magnetic resonance imaging for that. So, you need 1200 repetitions.

The second number I'll give you is 30. That's the average number of repetitions that is vectored into a stroke survivor per session. So, they figured this out by basically following therapists around and counting the number of repetitions they were having stroke survivors do. So, in occupational therapy, more upper extremity stuff, it was about 25 repetitions. In the lower extremity, the numbers got quite a bit higher with physical therapy, or what you guys would call physiotherapy, because walking is inherently repetitive. So, it's baked right into the main thing that physical therapists are focused on.

But in any case, you have this deficit of numbers because you're only getting 30 repetitions, but you need at least 1200 just to start the process. And remember, the 1200 is in a single joint. Something like walking involves, oh, tons of joints, in all kinds of different directions. So, you have this deficit, you need a lot of repetitions, there's just not a lot of time in rehab to do those repetitions. What researchers have found, and this doesn't come from our lab, but they found that if you say to a therapist, "Look, all we want you to do is get as many repetitions into that stroke survivor as possible." The number of repetitions per hour jumps from between three to 500 repetitions.

Now, obviously, it depends on how strong the stroke survivor is. Kath for instance, might be laughing at this number of three to 500 repetitions in a single session, because for all I know she works in a rehab hospital, or she works in a hospital where somebody's just woken up after their stroke. But for chronic stroke survivors or somebody that's subacute, the therapist can hyper-focus on these number of repetitions and hit these very high numbers that you have to hit in order to drive the kind of cortical change and get the movement that you need to.

But we're talking about a lot of repetitions. And when Saran is talking about doing this work, she says, "Yes, it's very simple." It is simple. I mean, the concept of doing repetitive practice are simple, you do repetitive movement into the stuff that you can't do. You're always chipping away at your present active ranges of motion. You're trying to do stuff you can't do, because if you keep doing stuff that you can do, you're not getting any better.

That's the easy part. The hard part for the stroke survivor is, you got to do these tons of repetitions. And it's great when you're a musician and you're doing tons of repetitions because you're learning something new every day, it's the joy of learning. If you're an athlete, you're getting better at the skill. If you're learning how to paint, you're getting ... But what does stroke survivors have? All they're doing is relearning what they used to do perfectly well. So, now we've come full 360 on this. The motivation becomes a big problem after a while. And I don't blame stroke survivors for at some point saying, "You know what? I've recovered enough." Or, "This is all the recovery I'm going to get. I need to get on with my life now."

Chris: [28:34] Now, Saran, I suppose this is a good time to ask you about some of this as well, and I guess not only your own experience, but as I said before, you work with a lot of other young stroke survivors, do you see these different attitudes, or people at different stages in their recovery journey, and how they can manage to fit in the therapy in their lifestyle?

Saran: [28:56] Oh, definitely. I mean, from people who are, I suppose, really high achievers or have literally OCD, I'm a bit obsessed about just doing it. It now is second nature to me. I just tend to do it automatically because I've been trying for so long. But certainly, if you're not actually improving ... Because I think a lot of people do find that they have quite an increase, as Peter was saying, in those first few months. And I did in my first 12 months, I was ending up being able to walk, so I assumed that, well, my arms should come back the same sort of timing. I was very wrong, obviously.

And it is hard. I think, everyone has dips, but a lot of what we're trying to put across for people that I suppose are further on down the track like myself, is that you celebrate the small wins and that perhaps helps you go, "Okay, well last month I was only able to walk five minutes, whereas this month I've done 15." And I think in some ways, that actually really helps to help with that motivation, because it is, it's hard. And you think, "Surely there's going to come an end goal here," but it's a journey and it continues on.

Chris: [30:24] What do you think is next for you on your recovery journey?

Saran: [30:27] I don't think it's a next, I think it's just a continuation of being able to just continue on. I suppose, from my perspective, realising that you're not alone is huge. And I think, from my perspective, and it helps my recovery, is actually helping other people on their journey or at least walking alongside them. But certainly, I will still continue to work at trying to get my arm better, as well as my whole body, I'm completely off-centre, those kind of things, but I make sure I enjoy life. So, I'll ride the jet ski, even though it's with one hand, or do modifications so I can kneeboard behind the boats, and still enjoy life. And that's the thing, is making sure that you can still do as much as you can through your journey, but still be involved in, for me, for my family's life.

Chris: [31:30] Excellent. That is some great advice and a great attitude to continue being part of the community. Pete, we don't have much time left, so could you ... I don't know, it's a very big question, what would be the main message that you would give a stroke survivor?

Peter: [31:47] Yeah. So, that is a big question. It depends on the stroke survivor. For Saran, right now, what I would say is, there is this technology called electromyography and I'm talking about surface electrodes. And if you can get ahold of that technology, electromyography or EMG, so that you can prove to yourself that those messages that you think that you're hearing or you're feeling, or that lightness that you describe, maybe that is happening in the muscles. It's just so low level that it's not showing anything. I am absolutely amazed that you jet ski, I'm afraid of those things. So, that's great.

But yeah, I would say, it doesn't matter where you are in recovery, we're all getting older, we're all fighting ageing and other pathologies. Just because you've had a stroke doesn't mean other things won't hit you in the future. Look, even if you are done recovering and you're satisfied with your recovery, you've still got to stay active and keep pushing the situation. And the brain plasticity works for any kind of growth that you're trying to find in your life. Just keep going. Look, you'll have plenty of time to sleep when you're dead. So, keep the things rolling while you're still here.

Chris: [33:10] Brilliant, that is a very good general advice for life, of course. Kath, finish up with you. We just want to summarise what we've talked about here. What are StrokeLine's top tips for long-term recovery?

Kath: [33:24] I would say, I'm going to take a little bit of what Saran said actually, and to know that there are those dips of up and downs, but to celebrate the small wins. I think that was a really great line that Saran used. I also think that doing things that are meaningful to yourself in life and try to incorporate practice into life is really important. And yeah, as Peter said as well, to keep going, but know that there is support there as well. So, StrokeLine is here if you need support. And there's also health professionals, if you're finding that you're having a plateau and that you want to continue to create improvements, there are health professionals that might be able to help you in that circumstance as well. Yeah.

Chris: [34:14] Great. Thank you very much, Kath. Now, as Kath said there, you can actually call StrokeLine and speak to a health professional like herself. The number is 1800 787 653 or one 1800 STROKE. Or you can go on to the EnableMe website and ask a question and get a response from health professionals and other stroke survivors.

And if you want to find out more about Peter Levine, that's L-E-V-I-N-E, I should have spelled that at the beginning, and his book Stronger After Stroke, the book is available to order through bookstores or online, or you can go to his website, which is recoverfromstroke.blogspot.com. Are there any other avenues that people can find out more, Pete?

Peter: [34:59] So, everything's under one umbrella, "Stronger After Stroke". So, if you want to find the blog, you just Google "Stronger After Stroke blog" and you'll find it. The book is called Stronger After Stroke. And feel free to email me as well, I'm at strongerafterstroke@yahoo.com.

Chris: [35:17] Brilliant. Thank you very much, Pete. Now, if you like what you've heard today, please give us a good rating and review on your podcast app, as that will help lift us up in the search ranking so that other people can find our podcast. And I want to thank once again, all our guests, Peter Levine, Saran Chamberlain, and Katherine Yong.

Announcer: [35:36] That's all for today's EnableMe podcast. You can find out more on this topic and continue the conversation or listen to other podcasts in the series at enableme.org.au. It's free to sign up, and you can talk with thousands of other stroke survivors, carers, and supporters. You can also suggest a topic or provide feedback on this podcast.

EnableMe has qualified health professionals from StrokeLine who can answer your questions and give evidence-based advice. The advice given here is general in nature, and you should discuss your own personal needs and circumstances with your healthcare professionals.

The music in this podcast is "Signs" by stroke survivor Antonio Iannella and his band The Lion Tamers. It's recorded at Antonio's studio, which you can find out more about at facebook.com/studiofour99. This EnableMe podcast series is produced by the Stroke Foundation in Australia, working to prevent, treat and beat stroke. See strokefoundation.org.au.

Neuroplasticity and recovery with Peter Levine

Episode 27, 10 August 2021

Peter LevineFor the 5th anniversary of the EnableMe podcast series we're revisiting one of our most popular topics: neuroplasticity, the ability of the brain to change and the basis of recovery after stroke.

To find out what's new in neuroplasticity and how to use it in your own life, we talk to medical researcher Peter Levine, author of the book Stronger After Stroke, which has helped stroke survivors worldwide.

We also speak to young stroke survivor Saran Chamberlain, founder of the YESS SA network and engagement coordinator for the Stroke Foundation's Young Stroke Project, and to physiotherapist Katherine Yong from StrokeLine.

 

Podcast transcript

Announcer: Welcome to the EnableMe podcast series, where we bring together stroke survivors, health professionals and researchers, providing you with practical advice to enable you on your journey to reclaim your life after stroke. The advice given in this podcast is general in nature, and you should discuss your own personal needs and circumstances with your healthcare professionals. You can join the conversation at enableme.org.au. This series is presented by Australia's Stroke Foundation, working to prevent, treat, and beat stroke.

Chris: [00:35] The EnableMe podcast series is now five years old, and we've spoken to a lot of people who've had strokes, and we've covered a lot of topics in stroke recovery. One of the most popular topics we've done was in our very first episode, when we talked about neuroplasticity. This is the ability of the brain to change, and it's the basis for recovery after a brain injury like a stroke. Now we thought since it's our five-year anniversary, what better time to revisit neuroplasticity and find out a bit more about what's new and how to use it in your own life.

And how better to do that than by talking to someone who has helped a lot of people worldwide understand about neuroplasticity for stroke recovery. So we're very pleased to have with us Peter Levine, a medical researcher and author of the book Stronger After Stroke. He's joining us on the line from Cincinnati, Ohio. Pete, it's an honour to have you on our podcast.

Peter: Well, it's an honour to be here, and I love talking about this stuff, so probably at some point, you're going to have to shut down my mic.

Chris: Well, we're going to have a challenge to control ourselves as well, because I have helping me with this conversation today, young stroke survivor Saran Chamberlain. Now Saran, she has also helped a lot of other stroke survivors. She founded the YESS SA network, which stands for Young Enabled Stroke Success South Australia, and she currently coordinates engagement for the Stroke Foundation's Young Stroke Project. Welcome, Saran.

Saran: Thank you very much for having me.

Chris: And last but not least, we also have physiotherapist Katherine Yong, from the Stroke Foundation's StrokeLine. Great to have you here, Kath.

Kath: Thanks, Chris. Great to be here too.

Chris: [02:06] Now, Pete, a lot of people may have already heard about you and your book, but for those who haven't, could you tell us a bit about your background and how you came to write Stronger After Stroke?

Peter: [02:15] Well, I get this question a lot and I'm always sort of flummoxed about where I should start. So I guess, I'll start with my first college degree. I went to George Mason University, which is just outside of Washington DC, and got a degree in communication. But during my high school years and my college years, I was very interested in being a drummer in rock bands, and being the hyperactive person that I am. So after college, I moved to Austin, Texas, which is a big music town, a big college town here in the States and in the great state of Texas, and almost immediately got into a band that almost immediately got signed to a major label and TV, touring, the whole thing. And I'm not just mentioning this because I want you to know that I was a nominal, very small rock star at one time, but rather because a lot of what I know about recovery from stroke comes directly from my experience as a musician.

Musicians, athletes and stroke survivors all have the same ambition in mind, they want to get better. And there's nothing new under the sun, I think there's a lot of people in rehab, there's a lot of people, physiatrists, neurologists, a lot of very smart people that try to complicate things up. We've been doing skilled stuff since about 70,000 years ago when we started building tools. And everything that drives cortical change, that drives brain changes, we've known about for very long periods of time. We've been really good. As humans, we're really good at this stuff.

So anyway, so get back to the story. After a while, being in a band that was touring throughout the United States, I decided that the lifestyle just wasn't for me and I went back to school, got a degree in physical therapy, worked in skilled nursing for a few years, what you guys might call a nursing home, and then got a job at the Kessler Institute in their research department. And Kessler is a very highly ranked rehab hospital here in the United States on the East Coast, and had three bosses at the time, something I don't recommend. During this period, we were absolutely on the bleeding edge of everything that was coming down the pipe with regard to stroke recovery. And I thought it was a good time for me to maybe think about writing a book.

And I had been writing about stroke recovery for quite some time. I had a column in a trade magazine, in a physical therapy trade magazine, and I'd written an article called "10 Things That Stroke Survivors Can Do To Recover". And I thought, "Well, if I can come up with 10 things, I wonder if I can come up with 100 things, or 101 things?" So, the working title for a long time was "101 Things That Stroke Survivors Can Do To Recover". The problem I had was I stalled around number 40. I couldn't think of any more than that. There was nothing else that was proven in clinical research and it had to be proven in clinical research for me to include it. And so, I changed the name to "Stronger After Stroke". It's now in its third edition, it's been published in a few different languages, and I think that pretty much takes us up to speed.

Chris: [05:38] That is fantastic, and it's really interesting to hear about your music career because I guess we can genuinely talk about you as a rockstar in stroke. But also fascinating to hear how neuroplasticity, as you said, is fundamental to learning all skills, including I guess, relearning skills after a brain injury like a stroke. So, I guess, we really need to know a little bit more. Can you tell us a bit more about neuroplasticity and how it works?

Peter: [06:04] Yeah. Because I am probably one of the bigger purveyors of this idea that neuroplasticity drives everything in stroke recovery, I should probably push back on that. I've evolved on this concept relatively recently. So, what happens after a stroke is there's a portion of the brain that's infarcted, let's just go with an ischaemic stroke, that is a block stroke, and that portion of the brain dies. It's gone, it's never coming back. And it actually cavitates and fills with cerebrospinal fluid. There's an area around the area of brain damage called the penumbra, and during the first three months or so after a stroke, the penumbra starts to come back online. That is the majority of the recovery that happens in that very important first three-month period.

So, what happens is as that penumbra, this peri-infarct area, the neurons that are still alive, right after the stroke, they're stunned, they're said to be stunned. It's a process known as cortical shock and the neurons that are ... It's much bigger than the area that's infarcted, they're alive. They're just not doing anything for the first little while after the stroke, and the first few months. So, the predominance of recovery comes from this brain that wasn't online, coming back online and doing exactly what those neurons had done prior to the stroke. And so, this is an interesting time in physical and occupational and speech therapy, because it's often the time that therapists want to get the person safe and functional and out the door. They want to put orthotics on them and make stuff easier for them so that they can be functional.

What ends up happening is a process known as learned non-use. Basically, these neurons come back, but because the stroke survivor's being taught compensatory movement, they often do everything with their good side, and the brain is very use it or lose it, and what ends up happening is something called a pruning of the dendritic arbour. Those neurons are coming back online, but they're not used, and because they're not used, they're lost. And that huge portion of the brain then lies fallow for the rest of that stroke survivor's life. So, this is a long-winded way of saying that the first push in the brain is just brain coming back online. After that, and we know it's after that, because there's this really big thing that happens in stroke survivors' lives, they plateau.

After the plateau, everything after that is neuroplastic change in the brain. So, you have brain coming back online, you ride that, what I call it, riding the wave of natural recovery, and they get a very steep incline in recovery, and then there's that plateau. After that plateau, that portion of the brain's back online, they have to borrow neurons, or they have to add synaptic connections in the peri-infarct area. But that's where neuroplasticity really comes in, it comes in during what we call the subacute phase. Typically, after the first three months after stroke. Now, what is brain plasticity? It's just this incredible ability for the brain, very quickly to go through massive rewiring in order to turn the brain into whatever its owner wants it to be. It can be as fast as post-traumatic stress disorder. Somebody comes into your house and blows a couple of holes through your wall with a shotgun, that's going to be something that happens immediately, but you'll never forget it. Your first kiss, a broken leg, these things stick with you forever. It doesn't have to take a long time to make this stuff happen.

Of course, in brain injury, what you're trying to do is get people to not have post-traumatic stress disorder, but rather to drive a lot of cortical change so that they can get on with their life. But there is a downside to neuroplastic change, right? So, things like OCD, and depression, and anxiety, and drug addiction, and bigotry, and sexism, and all these other things are neuroplastic too. We always talk about the mind and the brain, the mind is you, what you want to be, who you love, what your ambitions are. The brain is just the machine that carries it out. I would say that it's probably not that important to know too much about brain plasticity to make it happen. We all make it happen in our lives every single day.

I would be super careful, just for anybody who hasn't had a stroke and people who have had a stroke, be real careful about the things, especially the things that you think repeatedly, because those things will leave an imprint on your brain. And this is, as I said, the essence of things like bigotry and sexism and all these other problems that keep human beings from being decent to each other.

Chris: [11:25] Well, I guess, like any powerful tool, there are going to be ... you do have to be careful about how you use something like neuroplasticity. But it is promising to hear that it can give you that long-term changes in your brain for stroke recovery. I guess, I'd like to get another perspective on that. Saran, I'd love to hear your own experience of long-term recovery after your stroke, but to start with, could you tell us a bit about your stroke story?

Saran: [11:48] Sure. I had a stroke eight years ago. I was 37 at the time. I had an ischaemic stroke, which affected my sensory, premotor, and motor cortex of my hand and fingers, but I lost completely my left side. And it's funny, Peter, the way you're explaining neuroplasticity, I've read lots of books and I've read yours, that explanation of neuroplasticity and the recovery, it's so simple and really makes sense. And when I was listening to your book, I was wishing that not only were stroke survivors, but also other allied health professionals listen to it. So, it's really great. I love your book, by the way.

But I suppose, I started walking around the five-week mark and didn't really get any shoulder movement for about a year and a half. But from a therapy and rehabilitation side of things, I was determined to, and still am determined to try and get as much back as I can. So, a lot of it is repetition, a lot of it mainly is visualisation, to be honest, because there's nothing in my hand or arm that I can really do. So, I've been lucky enough to have really good therapists that can help me understand what parts of my body or what parts of my arm move my wrist, for example, and things like that. But yeah, it's certainly hard work and a lot of repetition and just constant improvement.

Chris: [13:30] Yeah look, it is really interesting to hear what you said too, about how some of the techniques in Pete's book, that you wish that allied health professionals knew a little bit more about. So, it's probably a good time to ask Kath about this. As a physiotherapist, what do you think about allied health professionals like physiotherapists, like occupational therapists, speech pathologists, and others, do you think they are becoming more aware of these principles and techniques?

Kath: [13:56] Yes, I do believe that allied health professionals are becoming more aware of neuroplasticity. I think it is used in our therapy a lot these days, and I think it's also not okay not to know about this anymore. We get taught that the brain can rewire and change and adapt, and that practising and encouraging practice of exercises and meaningful exercises will help to regain movement. We do always try to encourage practice and repetitions of meaningful exercise with our stroke survivors. And sometimes, the challenge can be in trying to find an increase in the amount of reps that stroke survivors are doing, and also what they can do independently. I think that can sometimes be the challenge, and I know that health professionals, allied health professionals can't be with their patients 24/7. So, finding ways to encourage the practice outside of scheduled therapies is what our big focus is to try to help to promote neuroplasticity.

I think allied health professionals are getting better at also explaining neuroplasticity to stroke survivors. I think, like Pete says, that that way of describing it through music or through athletics as well, is something that can really help a stroke survivor. And I think that with understanding that the brain is not fixed and that it can adapt even after this plateau period of spontaneous recovery, I think that's so important for a stroke survivor. And if our message gets across to stroke survivors, I think that does provide a lot of hope.

Chris: [15:47] Now, Pete, your book was first published in 2008, but I believe it's currently on the third edition, which was released in 2018. I imagine, like us, who've been doing this podcast for a few years, you've seen quite a few changes in that time. So, you've told us a little bit about that, some of the new way of thinking you have about the way the brain recovers and rewires, but what other new developments in neuroscience and in recovery treatments, have you seen in that time?

Peter: [16:14] Well, our lab has been really on the bleeding edge of this for quite some time. I know you sent me a link for an article about transcranial magnetic stimulation, TMS. And we have that as a technology, we're not super knowledgeable about how quite to use it yet. There's stem cell research, in which stem cells are injected into the brain right around the area of infarction, in order to have those stem cells differentiate into new neurons. That's another one that we're waiting for it to show its real promise. I think TMS falls in that category as well. What I've always been interested in is, and I think Kath touched on this when she talked about how you're really looking for stuff that people can do at home because there's just not enough therapy time, and therapists are expensive, and therapy is expensive, and you can't just run to the clinic every time you need to get better. You've got to do it on your own at some point.

So, those are the ones that have always fascinated me and maybe this will help Saran as well. So, one of the things that I've been focused on recently is, our lab did a lot of the seminal work with regard to mental practice after stroke. And mental practice is something that musicians, athletes, do all the time. It's this idea of pre-imagining an event.

So, if you imagine a movement that you do well, the portion of the brain that lights up is exactly the same portion as the portion when you actually do it. Not only that, but the muscles involved in the thing that you're imagining, the movement that you're imagining, those muscles will fire in the same duration and in the same order as if you actually do it. They just fire very minutely, almost like a dreamlike twitch, they'll have. It wouldn't be visible, nobody would be able to feel it, but with electromyography, you'd be able to pick it up. So, if you imagine a movement, the portion of the brain dedicated to that movement lights up, and the muscles fire in the same duration and in the same order as if you actually do it.

Then there's this other thing that's been coming down the pipe, that's very much related to mental practice, and it's called action observation. The idea is that you watch somebody do something, the portion of your brain dedicated to what they're doing lights up. And this is one of the things that I'm sure you guys have heard of, mirror neurons, mirror neurons have to do with empathy. So, you actually feel what that other person is doing through their movement.

A great example is if you've ever watched kids play soccer and you see the parents on the sideline, especially if they're little kids and they really don't know what they're doing, the kid's standing right in front of the goal, and he's just not kicking the ball into the goal. And you see all the parents say, "Kick it." And their legs are moving out. They're empathising with the movement that they want that child to do. If you're a musician, a good way to become a better musician is by watching musicians that are better than you. So, when you observe that action, that portion of the brain, in your brain, that would do that action will light up and the muscles will fire.

So, you have three situations that you can use in order to drive cortical change, even before you move. One is mental practice. One is action observation, where you observe somebody else. And the other one that drives cortical change as well is movement itself, and lots of repetitions of movement.

I would say, for Saran, the other option is ... Because I think I heard her mention that she isn't moving yet, but another thing that you can do is mirror therapy, where you look in the mirror at your unaffected side. So, imagine taking a mirror and splitting yourself left and right, but the reflective part of the mirror is focused towards your good side. If you don't mind me calling it the good side. And you do something in the mirror and you look in the mirror and you can see your good side moving, but it looks like your bad side moving, that also drives cortical change. So, you would get changes in the portion of the brain dedicated to the bad limb, simply by looking at the good limb in a mirror. So, there's three options, mental practice, action observation, and mirror therapy, that can be used as a precursor to jumpstart the brain so that then you can go into a lot of repetitive practice.

Chris: [21:21] Saran, does any of this resonate with you? Or I should say, ask maybe are your neurons lighting up accordingly?

Saran: [21:29] They are certainly. I do a lot of visualisation of moving my left hand and fingers. So, I work my way down, visualising my bicep, tricep, forearm, wrist, and then I get to my hand. And I've been doing it for quite some time. And again, there's no movement at all. I can feel the different muscles actually starting to fire off in my arm, that actually move those fingers. So, I have been feeling more, or should I say visualising more, which is really exciting.

And here in South Australia, we have some video software that we are trying to get some funding for where it could take photos of people moving and taking the still shots of them. And what I worked out was that as soon as I did it, I felt my left side completely lighten. I've got a lot of pain and heaviness in my left side of my body. It was really quite amazing. And the more often I did it, the longer that feeling of lightness lasted. The brain can do amazing things. And I've found out obviously, the harder way, but I am just hoping one day that it kicks in enough that it will take over what that part of my brain and my left arm could do.

Chris: [22:56] Okay. Now, one of the questions I wanted to ask you, Pete, I guess, is this, it sounds like it is a long journey. It's a lifelong journey, a stroke recovery, and some of the treatments, some of the exercises and things that we've heard from you and from Kath, and from Saran, requires a lot of practice and a lot of repetitions, which must require quite a bit of motivation to keep going. How do people stay motivated through this journey?

Peter: [23:22] I bet Saran would probably be a better person to ask. This is another thing I punted on in my book. I actually got a stroke survivor to explain to me what it was that made her stop trying to get better. And she said that she had gotten so much better, that she was able live her life to the point that she didn't have to obsess about getting better. So, it's this nexus, right? Where you're living your life to the point where you don't need to recover anymore to live your life, and for different people, that's a question that they have to answer. At some point, some people don't get better and of course, we're all hedging against our natural ageing as well. So, even if a stroke survivor is not getting better specifically, they still have to work in order to keep away ageing itself.

I would like to though, if I very quickly go over the number of repetitions that we think it takes in order to drive cortical change after a brain injury. And I'll give you three numbers, 1200, 30, and 400. So, 1200 is the least amount of repetitions that you would have to do in somebody who's had a brain injury, in order for two things to happen. First of all, they get more active range of motion, that is measurable movement. And the second thing is that the portion of the brain dedicated to that movement hypertrophies, we use functional magnetic resonance imaging for that. So, you need 1200 repetitions.

The second number I'll give you is 30. That's the average number of repetitions that is vectored into a stroke survivor per session. So, they figured this out by basically following therapists around and counting the number of repetitions they were having stroke survivors do. So, in occupational therapy, more upper extremity stuff, it was about 25 repetitions. In the lower extremity, the numbers got quite a bit higher with physical therapy, or what you guys would call physiotherapy, because walking is inherently repetitive. So, it's baked right into the main thing that physical therapists are focused on.

But in any case, you have this deficit of numbers because you're only getting 30 repetitions, but you need at least 1200 just to start the process. And remember, the 1200 is in a single joint. Something like walking involves, oh, tons of joints, in all kinds of different directions. So, you have this deficit, you need a lot of repetitions, there's just not a lot of time in rehab to do those repetitions. What researchers have found, and this doesn't come from our lab, but they found that if you say to a therapist, "Look, all we want you to do is get as many repetitions into that stroke survivor as possible." The number of repetitions per hour jumps from between three to 500 repetitions.

Now, obviously, it depends on how strong the stroke survivor is. Kath for instance, might be laughing at this number of three to 500 repetitions in a single session, because for all I know she works in a rehab hospital, or she works in a hospital where somebody's just woken up after their stroke. But for chronic stroke survivors or somebody that's subacute, the therapist can hyper-focus on these number of repetitions and hit these very high numbers that you have to hit in order to drive the kind of cortical change and get the movement that you need to.

But we're talking about a lot of repetitions. And when Saran is talking about doing this work, she says, "Yes, it's very simple." It is simple. I mean, the concept of doing repetitive practice are simple, you do repetitive movement into the stuff that you can't do. You're always chipping away at your present active ranges of motion. You're trying to do stuff you can't do, because if you keep doing stuff that you can do, you're not getting any better.

That's the easy part. The hard part for the stroke survivor is, you got to do these tons of repetitions. And it's great when you're a musician and you're doing tons of repetitions because you're learning something new every day, it's the joy of learning. If you're an athlete, you're getting better at the skill. If you're learning how to paint, you're getting ... But what does stroke survivors have? All they're doing is relearning what they used to do perfectly well. So, now we've come full 360 on this. The motivation becomes a big problem after a while. And I don't blame stroke survivors for at some point saying, "You know what? I've recovered enough." Or, "This is all the recovery I'm going to get. I need to get on with my life now."

Chris: [28:34] Now, Saran, I suppose this is a good time to ask you about some of this as well, and I guess not only your own experience, but as I said before, you work with a lot of other young stroke survivors, do you see these different attitudes, or people at different stages in their recovery journey, and how they can manage to fit in the therapy in their lifestyle?

Saran: [28:56] Oh, definitely. I mean, from people who are, I suppose, really high achievers or have literally OCD, I'm a bit obsessed about just doing it. It now is second nature to me. I just tend to do it automatically because I've been trying for so long. But certainly, if you're not actually improving ... Because I think a lot of people do find that they have quite an increase, as Peter was saying, in those first few months. And I did in my first 12 months, I was ending up being able to walk, so I assumed that, well, my arms should come back the same sort of timing. I was very wrong, obviously.

And it is hard. I think, everyone has dips, but a lot of what we're trying to put across for people that I suppose are further on down the track like myself, is that you celebrate the small wins and that perhaps helps you go, "Okay, well last month I was only able to walk five minutes, whereas this month I've done 15." And I think in some ways, that actually really helps to help with that motivation, because it is, it's hard. And you think, "Surely there's going to come an end goal here," but it's a journey and it continues on.

Chris: [30:24] What do you think is next for you on your recovery journey?

Saran: [30:27] I don't think it's a next, I think it's just a continuation of being able to just continue on. I suppose, from my perspective, realising that you're not alone is huge. And I think, from my perspective, and it helps my recovery, is actually helping other people on their journey or at least walking alongside them. But certainly, I will still continue to work at trying to get my arm better, as well as my whole body, I'm completely off-centre, those kind of things, but I make sure I enjoy life. So, I'll ride the jet ski, even though it's with one hand, or do modifications so I can kneeboard behind the boats, and still enjoy life. And that's the thing, is making sure that you can still do as much as you can through your journey, but still be involved in, for me, for my family's life.

Chris: [31:30] Excellent. That is some great advice and a great attitude to continue being part of the community. Pete, we don't have much time left, so could you ... I don't know, it's a very big question, what would be the main message that you would give a stroke survivor?

Peter: [31:47] Yeah. So, that is a big question. It depends on the stroke survivor. For Saran, right now, what I would say is, there is this technology called electromyography and I'm talking about surface electrodes. And if you can get ahold of that technology, electromyography or EMG, so that you can prove to yourself that those messages that you think that you're hearing or you're feeling, or that lightness that you describe, maybe that is happening in the muscles. It's just so low level that it's not showing anything. I am absolutely amazed that you jet ski, I'm afraid of those things. So, that's great.

But yeah, I would say, it doesn't matter where you are in recovery, we're all getting older, we're all fighting ageing and other pathologies. Just because you've had a stroke doesn't mean other things won't hit you in the future. Look, even if you are done recovering and you're satisfied with your recovery, you've still got to stay active and keep pushing the situation. And the brain plasticity works for any kind of growth that you're trying to find in your life. Just keep going. Look, you'll have plenty of time to sleep when you're dead. So, keep the things rolling while you're still here.

Chris: [33:10] Brilliant, that is a very good general advice for life, of course. Kath, finish up with you. We just want to summarise what we've talked about here. What are StrokeLine's top tips for long-term recovery?

Kath: [33:24] I would say, I'm going to take a little bit of what Saran said actually, and to know that there are those dips of up and downs, but to celebrate the small wins. I think that was a really great line that Saran used. I also think that doing things that are meaningful to yourself in life and try to incorporate practice into life is really important. And yeah, as Peter said as well, to keep going, but know that there is support there as well. So, StrokeLine is here if you need support. And there's also health professionals, if you're finding that you're having a plateau and that you want to continue to create improvements, there are health professionals that might be able to help you in that circumstance as well. Yeah.

Chris: [34:14] Great. Thank you very much, Kath. Now, as Kath said there, you can actually call StrokeLine and speak to a health professional like herself. The number is 1800 787 653 or one 1800 STROKE. Or you can go on to the EnableMe website and ask a question and get a response from health professionals and other stroke survivors.

And if you want to find out more about Peter Levine, that's L-E-V-I-N-E, I should have spelled that at the beginning, and his book Stronger After Stroke, the book is available to order through bookstores or online, or you can go to his website, which is recoverfromstroke.blogspot.com. Are there any other avenues that people can find out more, Pete?

Peter: [34:59] So, everything's under one umbrella, "Stronger After Stroke". So, if you want to find the blog, you just Google "Stronger After Stroke blog" and you'll find it. The book is called Stronger After Stroke. And feel free to email me as well, I'm at strongerafterstroke@yahoo.com.

Chris: [35:17] Brilliant. Thank you very much, Pete. Now, if you like what you've heard today, please give us a good rating and review on your podcast app, as that will help lift us up in the search ranking so that other people can find our podcast. And I want to thank once again, all our guests, Peter Levine, Saran Chamberlain, and Katherine Yong.

Announcer: [35:36] That's all for today's EnableMe podcast. You can find out more on this topic and continue the conversation or listen to other podcasts in the series at enableme.org.au. It's free to sign up, and you can talk with thousands of other stroke survivors, carers, and supporters. You can also suggest a topic or provide feedback on this podcast.

EnableMe has qualified health professionals from StrokeLine who can answer your questions and give evidence-based advice. The advice given here is general in nature, and you should discuss your own personal needs and circumstances with your healthcare professionals.

The music in this podcast is "Signs" by stroke survivor Antonio Iannella and his band The Lion Tamers. It's recorded at Antonio's studio, which you can find out more about at facebook.com/studiofour99. This EnableMe podcast series is produced by the Stroke Foundation in Australia, working to prevent, treat and beat stroke. See strokefoundation.org.au.