why is Not to, “ Not Use” good limbs so highly

difficult for stroke subjects?

By
Rajul vasa B. Sc .P T
Applied movement scientist
Mumbai [India]
www.brainstrokes.com
 Common assumptions

 Stroke patient and their family assumes that rest is

important after such major illness.
 A lot of time is spent on resting and recouping and waiting
for some therapeutic and medical help to take care of paretic
limbs.
 Recovery takes weeks and months and years, is a common
assumption.
In the mean time……
Selforganizing brain begins to take actions to prioritize safety
of balance of body i.e. COM [centre of mass] of the body
without waiting for any medical or therapeutic help !
 Safety of COM is a priority for all

Safety of balance i.e. of COM of the body is a priority for

all. For you for me and for all the stroke subjects as much
and more because one side is paretic and weak and not
able to support itself. Under the circumstances…….

 Selforganizing brain begins to take action to control

COM with use of good limbs to sit, stand and walk when
paretic limbs not only cannot combat the force of gravity
but pose huge threat to the safety of balance without any
discrimination of who the stroke victim is, whether he is
from developed nation or from developing nation !
 Getting on with life

 Stroke subjects automatically and spontaneously uses

good hand and the leg to get on with life and for
activities of daily living like, to sit up in bed, to stand
up from bed and to eat, drink and write etc. in short,
good limbs are used for all postural and supra
postural activities.
 Selforganizing brain triggers instant plastic changes
following stroke to enable the stroke subject to use
good side of the body automatically to control COM
[centre of mass] and to restore and regulate COM.

 Consistent non use of paretic limbs triggers loss of

neurons in affected hemisphere with passage of time.
 Structural changes in CNS.

 It has been shown in the research studies that plastic

structural changes takes place in the non lesioned
hemisphere of CNS [central nervous system] from experience
dependant plasticity.
 Consistent use of good limbs for postural and supra
postural activities lead to experience dependant
structural plastic changes.
 These structural changes further facilitate the stroke
subject to use good limbs automatically
spontaneously for postural and supra postural
tasks and the vicious circle sets in.
 Spatiotemporal effectiveness and
efficiency
It is highly difficult for the stroke subject to use paretic
limbs not only because of weakness, spasticity and
“learned non use” described by Edward Taub but….
largely also because of the following.
 Energetically uneconomic movement of paretic upper limb.
 Spatiotemporal inefficiency of paretic upper limb
 Poor esthetics and fear of repeated failure of paretic upper limb to
complete the task.
 Volitional movements like eating, drinking, picking up spectacle,
writing etc are largely done predominantly by one dominant
upper limb, making it easy for the left hemiplegics with right
sided dominance to carry on with right hand.
 Right hemiplegics with right sided dominance prefer use of left
hand over the paretic right hand for swiftness of movement and
for energy economy and less fatiguing experience.
 What is the solution?
 Re- reorganize the selforganied stroke CNS
before adaptation and habit sets in.
 Re- reorganize the stroke CNS before
permanent structural changes begin to
develop with consistent use of good limbs
to control, to restore and to regulate COM
[centre of mass] during all postural activities with

passage of time.
 What to do?
 Encourage the stroke subject to incorporate paretic limbs for postural
activities rather than voluntary activities which are largely unilateral
even before the stroke subject experienced stroke.
 Exploit the passive inertial trunk mass for passive mechanical stability.
 Exploit the bilateral innervation of trunk to trigger avalanche from
postural neuronal pool at various level of neuraxis to promote
anticipatory continuous postural activity in chain of flail weak paretic
spastic muscles of torso by guarded disequilibrium induced from
within the system and not externally induced.
 Take advantage of paretic torso being anatomically and mechanically
connected with non paretic torso at the central axis instead of focusing
on limbs.
 Encourage the entire torso with paretic and non paretic sides both
acting together as one whole integrated unit as, “ one whole is bigger
than sum total of its individual parts”.
 Turn disadvantage into advantage.

 “Take advantage out of a

disadvantage” - Use the passive inertial
mass of trunk for passive stability in
special postures rather than allowing
huge trunk mass to pose threat to the
stability and cause disequilibrium and
be constant trouble maker.
 Promote postural control from paretic
side
 Promote the upper limb to automatically act during
protective extension response to support the body mass
and to defend COM [centre of mass] with guarded
disequilibrium before it learns to control and regulate
the COM with paretic MSS [musculoskeletal system.]
 Promote the lower limb to support the head arm and
trunk mass [HAT mass] over the paretic hip without
trunk getting rotated away and without pelvis preferring
to stay on non paretic hip using mechanically safe
postures like Buddha posture, Namaz posture, side
sitting posture etc. specially designed for the individual
stroke subject.
 Byproducts Of automatic control on COM

 Selective control and use of hand in gesture and bilateral

activities becomes an automatic by product once paretic limbs
begin to contribute towards the postural change, postural
control and postural stability spontaneously, automatically,
spatiotemporally effectively without making efforts.
 Swing in the paretic arm during walking resurfaces with
automatic control on COM with paretic limbs.
 Speech has been studied to have close connectivity with basal
ganglia. Automatic control on posture also leads to automatic
return of speech as a byproduct in hemiplegics with sensory
motor aphasia.
 Paraesthesia and neglect and cognitive disorders disappear as
a byproduct with control on COM with paretic limbs.
 Remember
 Do not waste time on passive and assisted movement of limbs.
 Do not waste time on waiting for natural recovery and healing.
 Do not waste time on “spilled milk” I mean on the lesion in the brain.
 Do not waste time on constraining the good limbs, rather make use of entire body as one whole integrated
unit to prevent huge emotional, mental divide between two sides in the mind of the stroke subject that raises
all possibilities for physical divide during all motor acts when normally entire body works as one whole
integrated unit and not as divided two sides.
 “Normally abnormal, becomes Normal “ for stroke subject if, focus is laid on paretic side without
encouraging the entire whole integrated physical and mental being.
 Remember dead neural cell is not your problem as much as the living active neural cells that helps the brain
to selforganize depending on the ongoing interaction between brain, body, mind, and external environment;
the invariant constant gravity.
 Promote automatic use of paretic torso coupled with paretic limbs to control, regulate and restore COM sub-
cortically, spontaneously without thinking without external assistance by using patient’s own brain and his
entire body and mind as the best tool freely available at all point of time and re-reorganize the stroke brain in
presence of freely available gravity as the most powerful tool to cause guarded disequilibrium so as to trigger
avalanche of anticipatory postural neural pools to strengthen the weak paretic spastic muscles in a chain
reaction from within and not from outside with man made tools.
 Reintegrate two sides of the body so that there is automatic exchange of dominance between two sides
depending on the need of the moment.
 Remember your peripheral nerves are normal, loss of sensation is not a true loss and messages do reach up to
spinal cord which is also normal and above all if, you do not make a note of normal sensation under your
normal foot why do you think of sensation under the paretic foot? Normally you and me we do not think of
sensation under the foot while walking as it is highly sub cortical spinal affair and remember your nerves of
the periphery and your spinal cord is normal so please do not put your all attention on sensation under the
paretic foot, it will fix you in a major problem for lifetime if you do that.
 CONCLUSION[I]

 Forcing the use of paretic upper limb and

constraining the use of non paretic good limb
could disturb the stroke subject emotionally when
he needs to spend more time, more energy for an
esthetically not so beautiful and not so
spontaneous an act as against the use of non
paretic good limb especially when unilateral use of
the upper limb is normal for all of us for drinking,
eating, writing, etc and also for stroke subject even
before stroke happens to him.
 CONCLUSION[II]

 Forced use of paretic weak limb and constraining good limb for long hours
to practice eating drinking and writing etc may instill clear division
between the paretic and the non paretic side and kind of mental emotional divorce /
separation in the minds of the stroke subjects about functioning of two sides
and may lead to different psychosomatic consequences if, you learn to
focus on individual parts and not on the one whole.
 For the return of lost sensory motor control it is mandatory that stroke
subject’s entire MSS acts as one whole integrated unit without paying
highest attention to the act and to individual parts.
 Normally normal people take the balance for granted so did the stroke
subject before stroke happened to him and therefore true recovery is not in
treating muscle weakness and spasticity but is to channalize the
selforganized stroke brain to make paretic side capable once again to
control, restore and regulate COM as it did before stroke, so that muscle
strength returns without strengthening the muscle from exterior.
 There is no room for spasticity and contracture once two sides of body can
exchange the role to lead and to follow automatically depending on the
need of the moment.
 CONCLUSIN [III]

“Normally abnormal, becomes

Normal” for the stroke subject
with repeated forced use with
high focus on individual parts
and with compensatory actions
from muscle abundance at
several joints
Wishing smile for all, in this beautiful world.