November 26, 2015

Answering Machine Challenge

Opening voice mail requires a code.  I use an answering machine because all I have to do is push the blinking button on the machine to hear a message.  I also use an ear bud to listen and speak into the phone.  My wireless phone and ear bud allow me to go to the table to take notes and go to the couch to talk for an hour to friends and family hands free.  

Dilemma.  I thought I was being clever when I hung the ear bud on the antenna for the phone.  Hanging the wire in front of the phone makes the ear piece cover the blinking button (under red arrow).  I have made this mistake many times.  Then I missed a message from a dear friend who called me after her surgery.  Having my friend think I did not care enough to return her call made me change my behavior.  Maintaining relationships has been a valuable part of my recovery.

Solution.  Now I place the wire for the ear bud behind the phone and make sure the ear piece is not covering the blinking button (see red arrow).  Even this change was not enough.  I have to turn the phone so it points towards the corner of the counter (3rd photo) instead of being lined up with the edge of the counter (2nd photo).  Now when I walk in the front door I can see the blinking light as soon as I pass the TV.  

November 15, 2015

Tying Shoes One-handed

I shuddered when my OT put brown shoelaces on my beige shoes.  I had forgotten elastic shoelaces only come in black, brown, and white.  I want to wear the color-coordinated laces I paid for.  I refuse to wear shoes with Velcro straps that a 10 year old would be embarrassed to wear to school.  I was horrified when my PT suggested I wear jogging shoes.  It would upset me to give a professional presentation or go to a wedding with shoes that an able-bodied adult would not wear.

I pull the free end of the lace shown in photo #1 across the shoe and slip my index finger under the top horizontal lace (photo #2).  My index finger is pointing towards my body.  I use the tip of my index finger to drag the lace under the horizontal lace to make a loop.

Photo #3 shows I used my thumb to push the lace through the 1st loop to create a 2nd loop.  You cannot see the 1st loop because my thumb is in it.  I take my thumb out of the 1st loop and yank the 2nd loop side to side to tighten the half slipknot.

With time the shoe lace stretches so I tuck in the free end of the lace so I will not trip over it.

Dutton, R. (2013)  My Last Degree: A Therapist Goes Home After a Stroke, 2nd ed., pp. 90-95.  Bangor, Maine: Booklocker.

November 4, 2015

The Zipping Challenge is Not What You Think

Now that it is cold I need to zip my coat.  Velcro closures on my raincoat do not keep me warm.  When I sit, gaps form between the Velcro tabs which lets body heat escape.  I was surprised to learn the hardest part of zipping a coat is not grabbing the zipper tab.  The step that requires the most precise finger control is holding the bottom of the coat.  The 2nd photo below shows I am holding the bottom of the coat with three fingers in a 3-jaw chuck grasp.

Holding the bottom of a coat has to accomplish two things.  First, my bottom finger is keeping the joined tab and the zipper perfectly aligned.  ONLY IF you accomplish the 1st step do you get to proceed to the 2nd step which is holding the bottom of the coat still as the other hand pulls up the zipper tab.  Having a stroke does not stop zippers from being cantankerous.

Before zipping I use one remedial strategy.
To remember what I learned while doing finger exercises, I rehearse pinching my thumb and index finger together to wake up the muscles I need to zip.  I use 3 compensatory strategies.  (1) I don a rubber finger cot designed to sort money to get better traction.  (2)  My hemiplegic (paralyzed) thumb and finger grab a small piece of fabric that is attached to the zipper tab (see white rectangle above).  The fabric is less slippery than the metal tab.  (3) My hemiplegic hand can pull the zipper tab up only two inches.  Going higher requires wrist flexion which forces my hand to open.  After two inches I switch my hemiplegic hand to holding the bottom of the coat still while my sound hand finishes the zipping.  The 3rd photo shows you why I am not sad that I use a combination of remediating deficits and compensation.  I also hate being stared at when I stand next to a wall near a store exit so I will not get bumped by people as I zip my coat - another reason to speed things up with compensation + remediation.

October 27, 2015

The Garden Hose Won This Time

As the oldest daughter, I learned to pretend to be calm when bad things happened to my younger siblings, like my sister falling off her bike and shoving her two front teeth into her gums.  So I was surprised to hear myself crying hysterically while I talked to a 911 operator.  I had to crawl to the phone because my back muscles were spasming so badly I could not stand up.  Two days earlier I had fallen on my patio while wrestling with a garden hose.  I did not stand up straight after I connected the hose.  I think I tripped over the hose as I took a big step to regain my balance.  The black rectangle shows the small space I had to maneuver in.  When I am inside I prevent falls by clearing the space I have to work in.  Now I will transfer that strategy to outside.  A friend put that stiff garden hose on the curb for garbage collection.  I will buy a more flexible hose in the spring.

Five years ago a bone scan found osteoporosis in my lumber spine so I am glad the CT scan the ER doctor ordered did not find any fractures.  However, intense back spasms made it impossible for me to walk.  Fortunately, 36 hours of taking a muscle relaxant while in the hospital made it possible for me to return home with home health services.  Once I got home and wanted to do more than sit up in bed I noticed that the muscle relaxant made me really tired.  When I stopped taking the medication my back got much stiffer.

My back is really stiff in the morning.  I have to lie on a heating pad for 10 minutes, do gentle leg lifts under the covers, and take an extra strength Tylenol so I can do more than hobble around the house.  If I sit for more than 30 minutes my back gets stiff.  When I stand up I have to go lie down to relax my back muscles and do gentle stretches my home health PT gave me.  My PT finally had me walk outdoors.  After walking about 6 car lengths, the hip muscles that I fell on started to burn.  The only thing that relieved this burning was taking the small steps I use when I walk on grass.  What a bummer.  Thank goodness I start out-patient PT soon.

October 17, 2015

Snow Strategies Are Here

It is October and I cannot believe I already have to use my first snow strategy.  I am paying for the frostbite I endured when I was growing up because girls were not allowed to wear pants to high school.  Imagine walking a mile in below freezing weather with bare knees because you are wearing a skirt and knee high socks.  I arrived at school with hard, white blotches of frostbite every cold winter day.  I think the repeated frostbite killed the oil glands in my skin.  The skin on my legs is extremely dry so I have to apply skin cream after every shower even though it is still 20 degrees above freezing.  

After I put on my underwear and top I use my teeth to pull a disposable glove on my sound hand so I will not get skin cream in my hair and make-up.  I sit on the closed seat of my toilet and pump a line of skin cream on one thigh.  With my sound index finger I pick up skin cream and spread it on my calves and the front of both thighs.  I wish I could tell you how good this feels.  I let the skin cream soak in while I fix my hair and put on make-up.  No scratching dry skin through my pants.  The skin cream has the same subtle scent as my shower gel so there are no
                                                     competing odors.  Happy.  Happy.  Happy.

October 5, 2015

It is Hurricane Season Again

September was beautiful but my thoughts go to 2011 and 2012 when New Jersey was hit by Hurricanes Irene and Sandy.  Here is my consolidated list of bolded To-Do items just in case.

Shop.  Put gas in my car and get cash because gas pumps and ATM machines do not work without electricity.  I have three flashlights and a lantern, but never remember how old the batteries are.  Buy seven D batteries before they all gone.  I cannot walk in the dark so if my flashlight batteries die I have to crawl.  Aiming a flashlight at a task is difficult so I need a lantern. 
Buy ice.  I can put food in a cooler when the electricity goes out.  Buy bottled water, peanut butter, bread, cereal, and milk.  Buy canned food.  I can use an Oxo Goodgrips can opener when the electricity goes out.  My sound hand squeezes the two handles to lock them shut on the can, turns the crank, and pushes the grey button to release the can opener.  My hemiplegic hand lightly holds the closed handles to keep the can from sliding around.  The magnet in the can opener lifts the lid.  

Prep Home.  Charge my cell phone.  Charge my iPod so I will have a radio to get the news.  Put new batteries in flashlights and lantern.  Fill empty containers with water and place them in my bathtub so I can flush my toilet in case the water is cut off.  Run the dishwasher and do laundry while I still have electricity.  Put garbage cans in the shed so the wind will not blow them away.

If I Need to Evacuate.  Pack a rolling suitcase with medicine, soap, a small towel, clothes, toothpaste, and toothbrush.  Put my flash drive, checkbook, safety deposit box key, and contact information for my home owners insurance in my purse.  Pack stamps, return labels, envelopes, and business addresses so I can pay bills by mail (no Internet)Bring a blanket to the shelter.  A blanket takes up half my suitcase so pack carefully.  I can carry a pillow under my hemiplegic arm, but a blanket that keeps sliding is too much for this arm to handle. 

Put adapted equipment that will be hard to replace in trunk of my car.  My friends do not have a handicapped bathroom so put my folding shower stool in a garment bag.  Pack the camera I use for this blog which I can operate one-handed, my Saebo splints, an Asus notebook that is small enough for me to handle during Power Point presentations, and rain and winter coats I can zip.    Find a better way to transport software CDs (e.g. Word) that I cannot afford to replace if I lose my computer. 

September 27, 2015

Frustration is a Promise Breaker and Unsafe

Frustration is emotionally draining.  Stroke survivors cannot afford 15 seconds of frustration as they struggle to pull up their pants one-handed every time they go to the bathroom or 15+ minutes of frustration while cutting up food.  Fatigue is common after a stroke so the energy frustration uses is not good.  If frustration exhausts stroke survivors, the promise they made is going to be broken.  

Frustration can also be unsafe.  Safety awareness goes out the window as frustration mounts.  Grunting and concentrating fiercely for ten minutes while struggling to open my hand during an OT session is one thing.  Cutting off a piece of my finger is another.  Dropping a therapy ball is not the same thing as dropping a knife.  In my opinion, activities that require knives or high heat should be done by working smarter instead of harder. See one solution below.


I avoid frustration and increase safety when cutting up food.  For example, I cut up an orange using a Swedish Deluxe cutting board that has a vise.

Graham Drummand has arthritis.  He designed a cutting board that gives him control even though he is unable to fully close his hand around the knife handle or the food.  I am sure frustration and safety issues motivated him to design this cutting board.


September 16, 2015

Walking in the Dark, Part 2

I went to a great concert with a friend.  The old auditorium was beautiful.  However, we had to walk four blocks to the car in the dark.  The street lighting was so poor in certain sections that I could barely see the sidewalk.  The darkness was intensified by the low light of a new moon.  Decreased light is a fall hazard for me because my stroke damaged the bridge to the cerebellum (pons) that controls balance.  I learned I stay vertical by using my vision when I toured a huge Christmas light display with my brother three years ago.  This experience gave me the foresight to prevent a fall by asking my friend if I could put my sound hand on her shoulder as we walked.  When I maintain physical contact with an object that is vertical I know I am vertical.

The four block walk to the car was a wake-up call.  I have let my walking endurance decline so my hemiplegic (paralyzed) leg tired quickly.  I started scuffing my toe because I did not lift my leg high enough.  My walking improved when I handed my cane to my friend.  My hemiplegic hand can usually hold onto my cane while I drag the rubber tip on the ground - but not tonight.

Bottom Line: Once again I learned that mobility in the community = motor control + problem solving.

September 4, 2015

OT Fails with Stroke Survivors in Care-Homes

Professor Sackley who teaches PT at the University of East Anglia in England conducted a study that provided 2500 hours of OT to 1042 stroke survivors in nursing homes (1).  The treatment
did not produce a significant change.  This study is disappointing for the following reasons.

1.  The study used a 50 year old outcome measure called the Barthel Index of ADLs.  The Barthel has 3 levels: zero = dependent, one = needs help, and two = independent.  People who are frail enough to be in a nursing home are unlikely to become totally independent.  Other researchers have used ADL tests that are sensitive to small changes, like the Functional Independence Measure which has seven levels of assistance.  

2.  Another outcome measure was the Rivermead Mobility Index.  Having worked in a nursing home I know that the nursing staff do not have a stake in encouraging residents to get out of bed independently or walk unassisted.  Decreased mobility makes it easier to keep residents safe with fewer staff.  No increase in mobility in a nursing home is not surprising.

3.  The average treatment was only 5.1 sessions and only 15% of the time was spend on ADL and mobility training which the outcome measures evaluated.  The majority of time was spent on evaluation and "communication."  

Bottom Line: Professor Sackley said "we need to rethink what is needed for these patients."
I agree.  Dressing and walking 10 meters are "shoulds" that people do to get the life they want.   People with chronic conditions need the incentive of participating in activities they enjoy to sustain their commitment to action.  Asking nursing home residents "What activity makes you happy or lifts your spirits?" has to come before teaching them the skills they need to participate in an activity.

(1) OT Fails in Care-Home Stroke Patients presented at the XXIII European Stroke Conference on
      May 6-9, 2014, Nice, France.

August 25, 2015

My Conclusion About Swallowing Training

Impaired swallowing has lingered for 11 years after my stroke.  So I am thrilled that 3 strategies improved my ability to swallow - neck elongation, increased sensory awareness, and strengthening hip adductor muscles (see 8/15/15 post about these muscles).

#1.  Many ST websites recommend making swallowing safer by lowering the chin towards the chest.  However, many people sit or stand with their head jutting in front of their trunk (see arrow).  Lowering the chin when the head is in this forward position may collapse throat structures.  This "chin tucked" strategy never stopped pills from going into the opening for my lungs (trachea).

Instead I make my neck as long as possible by making sure my head is in a straight line with my trunk before I drop my chin slightly.  This maneuver helps send pills down my esophagus to my stomach.

#2.  Stroking my tongue with a soft toothbrush after I read about PONs therapy taught me the hemiplegic (paralyzed) side of my tongue was numb.  I decided to start chewing food on the hemiplegic side of my mouth.  This makes me swallow symmetrically which makes me more aware of when food touches the hemiplegic side of my throat.  Increased sensory awareness tells me when I am about to swallow food while taking a breath.

#3.  When squeezing a ball between my knees I felt increased muscle tone in my throat muscles. 
I know muscle tone cascades down a limb from the shoulder to the hand.  It seems reasonable that muscle tone would cascade up from the pelvic floor.  Now I can quickly tighten my throat to stop food that slips to the back of my throat when I am about to take a breath.  This pause gives my tongue time to shove the food back to the front of my mouth.  Authors in my post on urinary incontinence said midline stability requires coordination among three "diaphragms" - the pelvic floor, the diaphragm we breath with, and throat muscles. 

Bottom Line:  Swallowing training may require an interdisciplinary approach.