April 14, 2015

Chedoke Arm and Hand Activity Inventory

The Chedoke is a bimanual hand test that captures lots of baseline data because it lets clients use the affected hand hold the jar or turn the lid (1).  Yet OTs who used the Chedoke wondered why they needed another ADL test (2).  One OT said "So am I really that worried about exactly how much effort the other one [hand] is putting in [to completing the task]?"  Ignoring whether the affected hand does any work during a task defeats the purpose of working on recovery (see photo).  When clients get to a step that requires two hands we deserve a test that gives us credit for the ability to transfer what we gained with exercise.

Unfortunately, OTs who gave the Chedoke to stroke survivors concluded it has too many high level tasks for clients with severe motor impairments (2, 3). Chedoke tasks are draw line with a ruler, pour glass of water, button, zip, cut with knife and fork, put toothpaste on toothbrush, dial 911, clean eyeglasses, open jar, dry back with towel, wring out cloth, carry bag up stairs, and place container on table. This conclusion is disappointing because many advances in stroke rehab target clients who do not regain hand function with traditional treatment.  How can researchers test the efficacy of new treatment approaches if they use tests with poor basements that cannot show what clients can do when hand movement first emerges?

After a stroke I discovered easier bimanual ADL tasks (4).  Level 3 is being able to reach out and hold an object still as the other hand manipulates the object.  Able-bodied adults do this dozens of time a day but take this skill for granted which is why it never appears on hand evaluations.
Levels 1 & 2 employ simple strategies able-bodied adults never use.  For example, have the sound hand place a deodorant bottle in the affected hand which places the bottle on the thigh and holds it still as the sound hand removes the cap.  Hand-to-hand transfers done close to the body are easier than opening the hand as you struggle to lift a heavy arm to table top height.  See nine easier bimanual tasks in Hand Evaluations at the top of my blog. 

April 3, 2015

Garbage Can Send You to a Nursing Home

I live alone so I cannot stay in my home if stinky garbage piles up on my patio.  People would call the health department.  After my stroke a neighbor took my garbage to the curb for a few months.  However, I do not want neighbors to think if they help me for a short while they have volunteered for life.  Paying a nursing home $8,000 a month is a really expensive way to get rid of garbage (Genworth Survey of Long-Term Care).  Here are adaptive devices that make me independent.

Garbage. I use Hefty Ultimate garbage bags.  They have an elastic drawstring built into the top of the bag which grips the top of the garbage can in my kitchen.  I place the full garbage bag on the seat of a kitchen chair so I do not have to lean down very far to tie a knot in the drawstring with my teeth and sound hand.  Once the bag is tightly sealed I kick it down my front steps without any spills.  I put the bag in a rolling garbage can to take the garbage to the curb.  I learned not to push the garbage can by tilting the can and rolling it on the wheels.  The first time I did this I almost fell when the garbage can got away from me.  By putting the wheels in front (see arrow) I can push it like a rolling walker.  CAUTION: I used to drag a cane in my hemiplegic hand so I could walk back to the house.  Now my balance is good enough to walk back without a cane.

Recycling. My town recycles glass, metal, and plastic containers.  The short yellow container I was given is too heavy and awkward for me to carry to the curb.  The photo shows the Devault Plant Dolly.  Six casters under the dolly make it roll smoothly.  To pull the dolly back to the house, I threaded a long strap through the central hole that is designed to let plants drain.

March 26, 2015

Arthritis + Stroke = Modified Joint Protection

Five years ago an x-ray showed early signs of arthritis in my sound thumb.  I did not worry about it until this thumb started to ache.  I have overused my sound hand for 11 years and need it to last for another 20 years.  Below are examples of joint protection principles for the thumbs of stroke survivors.  I had to modify these principles which were written for two-handed people with arthritis.

1. Use Stronger Joints.  Pouring from a full milk container forces me to squeeze the sides of the container tightly so it will not slip out of my hand.  Squeezing tightly makes my thumb ache.  So I pour milk two-handed.  The arrow is pointing at my hemiplegic (paralyzed) hand.  The muscles of my hemiplegic shoulder, elbow, and wrist are doing the heavy lifting while my sound hand makes sure the spout is aimed correctly.  I appreciate not feeling pain every morning when I prepare cereal for breakfast.

2.  Minimize Force.  I cannot swallow pills with liquids so every day I open a container of yogurt.  Manufacturers put strong glue on the lid to maintain a tight seal.  Opening the lid makes my thumb ache because I have to grip the tab so tightly.  My hemiplegic thumb cannot help my sound thumb on this task.  I reduce the force I exert by wearing a rubber finger cot
used for counting money.  Greater traction means my thumb can pinch less forcefully.
I cannot avoid using my sound thumb to open the top of a sock to get it on my foot. The photo on the left shows my thumb and index finger stretched far apart.  This makes my thumb ache.  Now I open the sock barely enough to get the sock over my toes.  Other fingers do the hard work of pulling the sock up the rest of the way.

3.  Avoid Static Positions.  Holding a book for a long time with my sound hand makes my thumb ache. So I place my Actto bookrest on a laptop desk covered with non-slip shelf liner.  An arrow in the photo points at a clear colored tab that adjusts the angle (i.e. more vertical or more horizontal).  With the bookrest sitting on my laptop desk I can reach behind and easily release and reclamp this tab with one hand.

The photo on the right has an arrow pointing at a clear colored plastic arm that holds the book open.  There is enough friction to fight the weight of the open book but I can easily reposition the plastic arms (e.g. far out for a big book and close in for a thin book).  I have loved to read all my life so I am glad an assistive device lets me enjoy this activity without pain.

March 15, 2015

PoNS Inspired Therapy

I read about a device called PoNS that delivers mild electric stimulation to the tongue (1).  Thousands of sensory receptors on the tongue send information to the brainstem.  This got my attention because I had a brainstem stroke.  Brain scans and EEG studies found that milliseconds after using PoNS all parts of the brain start to fire.  Brain damaged subjects who used PoNS during therapy got better (e.g. while walking on a treadmill).

I have been aspirating pills into my lungs lately so I decided to gently stroke my tongue with an extra soft toothbrush.  The hemiplegic side of my tongue was numb while the sound side was hypersensitive.  Tongue stimulation produced saliva only when I brushed the sound side. I turned the toothbrush over to the smooth side and pressed down on my tongue.  The sound side arched up into a hump, but the hemiplegic side stayed flat unless I concentrated fiercely.    I have been blaming my epiglottis (see arrow) for not covering the trachea  - the flap that covers the opening to my lungs when I swallow.  Moving food to the back of my throat with a tongue that is numb and floppy on one side cannot be good.

Before I take my morning pills I do tongue stimulation and then sing or read out loud to warm up my tongue and throat muscles.  The 1st time I did tongue stroking I felt a weird sensation on the affected side of my tongue for several hours.  For several days I have safely swallowed numerous pills in the morning.  However, this positive outcome fades by lunch time.  I will continue brushing and pressing down on my tongue to see where this leads.  Gently using an extra soft toothbrush is cheaper than driving 900 miles to Wisconsin where Dr. Yuri Danolov has a PoNS clinic.  My past recovery has confirmed the research on neuroplasticity, so it is worth a try.

1. Doidge N. The Brain's Way of Healing Itself. New York, NY: Penguin Books; 2015.

March 6, 2015

Rehearsal 2/2015

I rehearsed finding my Congressman's office before I visited him.  I did not want to bring anxiety to the meeting.  Thank God It's a Rehearsal (TGIR) because I do not handle a rapid series of obstacles well since my stroke.  My nerves of steel under pressure have disappeared.

1.  Three map services (Google maps, Garmin, Map Quest) sent me down a two lane county road because it is the shortest route.  I did not get stuck behind a slow moving truck, but 15 cars coming from the other direction did.  I went home via a four lane state highway so I know how to arrive
on-time for the meeting.  TGIR.

2.  The office was not on the left side of the shopping center as all the map services indicated.  After driving through the entire shopping center I found the correct building.  However, the office is on the 2nd floor.  I had to walk into a liquor store to learn the stairwell to the 2nd floor was outside in an obscure corner.  Grrr!  Really TGIR.

3.  On my trip home on another road I came to a wacky entrance for the NJ Turnpike.  Two lanes suddenly widened into five lanes a few hundred feet from the on-ramps.  The south bound on-ramp is easily a mile long before you reach the toll booth which is unnerving.  I navigated this connection with confidence because I learned to use it three months ago when I located a meditation group in the area.  I went to a meeting once and told myself I would never have to use that whacky on-ramp again.  I needed that information today.  TGIR.

4.  I am still learning the quirks of Google maps on my iPhone.  Today I learned she does not say "recalculating" like my Garmin GPS device does when I deviate from the planned route.  I had to look down at the map to see if her verbal instructions matched my new route.  They did.  When I go on my next trip I will not have to take my eyes off the road to see what Google maps is doing when I think I am in charge.  TGIR.

Click here to see how rehearsal helps me enjoy community outings.

February 24, 2015

More About Cheap Equipment

Having a stroke often means losing income.  In addition, there are expenses that are not covered by health insurance.  So this post is not about cutting up a banana.  It is about saving money.
The last place I look for equipment is medical catalogues where things are always expensive.
I begin by looking for helpful objects in my home and in local stores like Bed Bath and Beyond.
To see previous examples of truly cheap equipment click here and click here.  In this post I talk about two pieces of cheap equipment I use to slice bananas for my cereal. 

#1 is a one dollar non-slip placemat I found at my grocery store that keeps the plate still as I slice.  It is far cheaper than Dycem.
#2 is the cheapest, thinnest paper plate I could find.  Since bananas are curved, I turn the plate so my knife is always perpendicular to the section of the banana I am slicing.  Because slices of banana roll around I turn the plate so my knife is always perpendicular to each slice as I cut it in half.

The thin paper plate bends easily so I can pour the sliced banana into my bowl.

Do you have a cheap solution you would like to share?

February 13, 2015

Does Reaching a Plateau Really Happen?

Regaining a skill 11 years after my stroke made me wonder why I believed in plateaus when
I was an OT.  Here are four factors that changed my belief about recovery after a stroke.

What Has Changed.  1)  Brain plasticity will blow your mind.  Click here to learn how an adult's brain grows new stem cells every night and makes them migrate to where they are needed.
2)  There is lots of new technology like electric muscle stimulation with biofeedback (click here).
3)  Blogging lets stroke survivors share their triumphs.  My continued progress is not unique.  4)  People who have a stroke as young or middle-aged adults have higher expectations placed on them that people who have strokes in their 70s and 80s.  Family members cannot maintain their own health if they do everything for a disabled adult for decades.  Reducing the time a family can care for a stroke survivor is expensive.  Assisted living where assistance costs extra is a long-term solution many families cannot afford. 

What Perpetuates the Myth.  Therapists see clients for days or weeks.  This small window is suited to orthopedic cases like hip replacements because bones and muscles repair themselves fairly quickly.  Brain recovery takes longer because the brain is so complex.  Therapists do not see the progress stroke survivors make in the next stage of rehab (e.g. out-patient) or after therapy ends.

The Alternative.  Using the word plateau shuts down the conversation.  "Will I get better?" is an opportunity to ask if there is something a client wants to do.  Here is something I wanted.  I have baby-fine short hair so I need a good haircut.  Before I sit down in a beauty salon chair I have to back up and then straddle the wide footrest.  The chair was initially an obstacle to having a good hair day so I never get tired of defeating it.  Challenges that pushed my continued recovery were walking backwards, twisting my trunk so I can reach far behind me to grab the armrest, and sitting down with my feet 18 inches apart.

The Bottom Line.  Skill acquisition can stop because of our beliefs as well as our abilities.  My progress has slowed over the years, but I have repeatedly seen
new goals spur new gains.  This evidence has changed what I think will happen to me.   

February 3, 2015

Snow Strategies, Part 3

I was lucky.  Trenton, NJ got only 4 inches of snow from Blizzard Juno instead of the 18 inches they predicted.  I cleared my sidewalk by pushing the light fluffy snow with a small light shovel while wearing snow boots (click here).  However, clearing snow off my car is always a balance challenge.  Before I lean my chest and stomach against the car for support I don an apron I do not tie.  An arrow is pointing at a smudge mark that ended up on the apron instead of my coat.  My sound hand and forearm cannot handle the weight of a long device for pushing snow off a car so I use a shorter, lighter device designed to clean windshields.  By 2 p.m. my car was free of snow. 

As I was driving to my breakfast club the next morning I thought about the people in Maine who got clobbered with 35 inches of snow and 50 mile per winds that created tall snow drifts.  That image triggered memories from my summer vacation in Maine two years ago.  I remembered the people who smiled at me as I walked around.  Instead of pretending they did not see me, many people initiated eye contact and smiled before I did.  Perhaps people who live in a harsh climate feel a connection with people who know how to defeat adversity.

January 26, 2015

Muscle Memory Finally Kicked In

I am stunned.  Eleven years after a stroke my muscle memory still works.  For months I have been doing abdominal exercises to prevent back spasms (click here).  However, arching my back while leaning against the kitchen counter persisted so I used a memory aid to stop this bad habit.  I leaned on my arm after placing my hand on a piece of Dycem.  This created a space between my stomach and the sink.  A few weeks ago I became aware of my body telling me the twisted way I was standing at the sink did not feel good. I immediately stood up tall and straight.  I do not know how long I have been doing this because I no longer have to tell my back and stomach muscles what to do. 

Athletes call the ability to quickly execute a practiced movement muscle memory.  Muscles do not remember - the brain remembers.  A part of the brain called the cerebellum stores motor memories so it can automatically tell muscles what to do.  Motor memory kicked in during the first few years after my stroke, but I did not know this could still happen to me.  Relearning movement is mentally exhausting because stroke survivors have to tell their body to do EVERY LITTLE movement.
Moving without thinking about it is a blessing.

Bottom Line: My back and my brain are happy about this unexpected development.

January 17, 2015

Part of OT is Hidden

Some people think OTs are the dressing or handwriting guys.  Yet OT's official slogan is Living Life to Its Fullest (R).  The disparity between what people think OT is and how OTs see themselves occurs because OT is like an iceberg.  An important part of what OTs are trying to accomplish is hidden.  There are three components of OT treatment, but you see only two in an OT session.

1. The Preparation.
Preparation addresses each client's individual deficits.  Examples include exercises to open the hand while reaching, scanning strategies for visual neglect, learning what the parts of a memory notebook are for, and learning how to stop negative self-talk.  

2. The I Shoulds
Many people have the same shoulds.  We all should get dressed so we can leave the house, do laundry so we have clean clothes, write legibly so we can sign credit card slips, and have good memory strategies so we get to appointments on time.  OTs call "I shoulds" functional outcomes.  Insurance companies will not pay for therapy if clients do not show some functional gains.

3. The I Want Tos.
"I want to" is personal, like petting a beloved cat.  Valued activities occur outside of therapy so clients may not see how they are connected to OT.  OTs need to make linking statements so clients understand the full value of OT.  A linking statement might be "don a bra so I will not be embarrassed when I eat lunch with friends."  I live alone so donning my bra enhances my social life.  If a client wants to feel the sun on his or her face, pointing while saying "leg brace - patio" can make a client's face light up. 

Preparation and functional training are essential but they do not sustain our commitment to action when we recover slowly.  Practicing a tip pinch so I can zip my coat needs to be followed by "because I want to..........."  Valued activities help us maintain the physical, cognitive, language, and social skills we work so hard to regain.  Living life to the fullest does not mean going to Paris.  It means satisfying deep human needs like feeling needed and having fun.  It means turning
"I should" into "I want to."