Orthopedic Rehab Run Amok

Rehabilitation may include regaining flexibility, strength, endurance, and coordination.  When PTs treat orthopedic cases (e.g. broken hip) they focus on flexibility and strength.  One hour treatment sessions provide some work on endurance, but therapists assume endurance will increase as clients move more at home.  Coordination can be ignored because people with orthopedic injuries have intact brains.  Applying an orthopedic approach to stroke survivors produced no progress.

To reduce pain and increase flexibility in the shoulder de Jong et. al. treated 46 stroke survivors (1). Subjects in the experimental group were placed in one of two positions (photo on left) and shoulder muscles were given electrical stimulation for 45 minutes twice a day every day for eight weeks.  Subjects in the control group were placed in a sham position (photo on right) and forearm muscles were given electrical stimulation for the same amount of time.  "In the experimental group some participants reported that they considered the intervention to be very arduous, pain and spasticity medication were prescribed more frequently, and protocol compliance was lower (p. 250)."  If you have a tight shoulder can you imagine being trapped in either of the positions on the left for 90 minutes a day while your muscles were forced to contract for 45 minutes without a rest?

Shoulder flexibility and pain did not improve and neither did function during ADLs.  Using electrical stimulation to force muscles to contract does nothing to retrain the brain.  Assuming muscles can work together in a coordinated fashion is OK for orthopedic cases, but stroke survivors must learn to recruit and coordinate numerous muscles that have been paralyzed.  PTs like de Jong typically address only simple coordination because they treat in barren, unchanging environments that require a few repetitive motions.  Walking clients on flat floors in wide open spaces does not prepare PTs to think about the wide range of coordinated movements the upper extremities must perform. Working on one isometric contraction had very little chance of improving ADLs in stroke survivors.

 1. de Jong LD, Dijkstra PU, Gerritsen J, Geurts A, Postema K. Combined arm stretch positioning and neuromuscular electrical stimulation during rehabilitation does not improve range of motion, shoulder pain or function in patients after stroke: a randomized trial.  Journal of Physiotherapy. 2013;59:245-254.

Dysarthria is More Than a Slip of the Tongue

I had a stroke in the brain stem which connects the brain to the spinal cord. My stroke attacked a part of the brain stem called the pons - the bridge to the cerebellum which controls coordination.  The inability to coordinate muscles of my lips, cheeks, and tongue made my speech severely slurred (dysarthria).  The good news is that I never lost the ability to understand what people were saying.  The bad news is that people could not understand me. 

Incoordination of my diaphragm, which controls breathing, also made speaking difficult.  To speak you have to let your breath out slowly.  At first I exhaled explosively in one big gasp.  I had to repeatedly take extra breaths to finish even one sentence.  I gradually regained the ability to say more before running out of breath.  It is still tiring to speak in a group because I have to take many deep breaths to be heard.  Thankfully people never have trouble understanding me on the telephone.  I speak into an ear bud so I never have to raise my voice which requires more air. 

In nine years my dysarthria has never fully disappeared.  When I am not fully awake or I am tired my speech is still somewhat slurred.  I know this because people start staring at my mouth so they can read my lips. Sometimes I have to think about taking a full breathe because I am speaking too softly.  I know this because people start saying "What?" after I speak. 
I asked for help in the grocery store last night.  The woman who helped me scowled and looked at me like I was retarded.  After she left I realized I was incomprehensible because I was speaking so softly.

A Better Home Rehab Program

Home Sweet Home is the title of an article about an innovative program in home-based rehab (1).  This program differs from traditional home rehab in three important ways.  First, traditional home rehab provides little or no coordination among different staff visiting the home.  The program in Baltimore ensures coordination of care among therapists, nurses, and handymen who repair homes.  For example, the nurse evaluates pain, suggests medication changes if needed, and reports the pain issue to the OT.  The OT determines if pain interferes with ADLs, if assistive devices would reduce pain, and if environmental factors while sitting or standing are making the pain worse.  If modifying the home would reduce pain, the OT reports this to a handyman who makes changes in the home.

Second, traditional home rehab has handymen install medical durable equipment, like putting grab bars in the bath tub.  The program in Baltimore also has handymen do home repairs that make the home dangerous.  For a client named Mrs. V., the handyman repaired the floor in her bathroom that was collapsing and repaired basement flooring that was loose and torn.  As Bridges says,
few programs address both housing and health issues (1).

Third, traditional home rehab is client-centered.  The program in Baltimore is client-directed.  At the 1st visit the OT evaluates the client and the client shares his or her concerns.  At the 2nd visit the OT evaluates the home environment and helps the client pick three goals the client identifies as important.  For example, Mrs. V. wanted to increase her walking endurance, attend church to receive social support, and safely reach for items on the floor and over head.  At the 3rd visit the OT helps the client find two things the client will implement to solve problem #1.  Two more visits are devoted to solving problems # 2 and 3.

This innovative program in Baltimore is continuing thanks to a grant that is part of Obamacare (Affordable Care Act).  A pilot program conducted in 2010 found that 94% of the clients reported their quality of life had improved.

1.  Bridges, A, Szanton,, S, Evelyn-Gustave, A, Smith, F, Gitlin, L. Home sweet home. OT Practice.
     2013;18(16):9-13.

ADLs Are Where the Repetitions Are

Barb's last post expressed how I feel about exercise.  Barb said exercises "console survivors that they are working as hard as they can when they are not."  The reality is that rewiring the brain requires thousands of repetitions (reps).  Barb wonders if therapists do not tell clients that a few exercises are not enough because they do not want to discourage us or themselves.

Activities of Daily Living (ADLs) are one way to get thousands of reps. For example, twice a day I open my hand to grasp a tube of toothpaste so my sound hand can remove the cap.  In nine years I have opened my hand over 5000 times before brushing my teeth.  It takes 14 turns to prepare cereal with a sliced banana.  I've made this same breakfast for nine years so I have had to make over 45,000 turns.  Add making a sandwich for lunch and preparing a hot meal for dinner and the number of turns I've made in the kitchen are in the hundreds of thousands.

The distance I've walked at the grocery store is huge.  I step away from the shopping cart and bend down or reach up to get items I want. How far I walk away from my cart varies based on where I find a space to park my cart.  Detouring around people and other carts requires S-shaped curves that add more steps than walking in a straight line.  According to my pedometer I walk 2,000+ steps each time I visit the grocery store.  2,000 x 2 visits a week x nine years = 1,872,000 steps!

Shopping is also therapy for my hand.  I open my hemiplegic hand to let go of the cart and reach for items with my sound left hand.  My hemiplegic hand opens a 2nd time when I grab the cart to move on.  Finally, I open my hemiplegic hand to take it off the cart so my sound hand can empty the cart in the check-out lane and again to load food into my car.  Buy 30 items + empty cart + load car x open 2 times = 64.  64 x 2 visits a week x 9 years = I've opened my hand 59,904 times.

Long-handled Bath Sponges Are My Pet Peeve

Not being allowed to shower and wash my hair for two weeks after my stroke was misery I will never forget.  As an American I have always had quick access to copious amounts of clean water.  I took the pleasure of warm water streaming down my body for granted.  Showering is a simple pleasure I don't want ruined by aggravation.  Anti-depressants don't always come in the shape of a pill.  Feeling clean always lifts my spirits.

I'm sorry I ordered long-handled bath sponges for stroke survivors when I was an OT.  Long-handled sponges help clients with hip replacements wash their feet.  Having a stroke taught me this device has three flaws.  1)  Stroke survivors need a bath sponge to wash their back, but choking up on the long handle was cumbersome.  I had to be careful not to stab myself in the head with the end of the handle as my hand moved up and down.  2)  The sponge is silky soft so feet won't be tickled, but I want a textured surface for the itchy places on my back.  3)  The long straight handle makes it difficult to store the bath sponge which stays wet for 24 hours.  I lost track of how many times it slid off my hospital nightstand and bathroom sink.  When I got home I ordered the Buff-Puff sponge and replacable sponge heads.  It has a short curved handle that makes it easy to hang up to dry on a suction hook.

Snow Shoes for a Stroke Survivor

Since my stroke I'm careful about venturing outside when it snows, but I'm not trapped inside until spring comes either.  I never walk on snow covered concrete, gravel, or grass. because uneven slippery surfaces are a fall hazard for stroke survivors.  However, once streets, sidewalks, and access to my car are clear I wear boots over my shoes to protect them from the slush.  Boots I tried on at a shoe store would not fit over my leg brace.  My leg brace won't let me point my toes which is a pre-requisite for donning boots.  On-line I found the Neos overshoe with a Velvro opening that goes all the way down to my toes.  The Villager model is lightweight and designed for occasional use which is perfect for me.

A video at www.overshoesonline.com shows how to don this boot.  Warning #1: I do not put the boots on while standing as the video shows because I do not have good standing balance.  My boots go on safely while I am sitting.  A trick the video doesn't show is to make the ankle straps as long as I can before I put on the boots.  After I snap the straps closed I pull on the ends of the straps to make them tight.  Warning #2: The first set of boots I ordered was too big so they flopped around when I walked.  Bottom Line: I get good traction from the treads and don't arrive with soggy shoes.  I walk more slowly with boots on, but that beats not being able to keep important appointments like a visit to the doctor.

Why I Can't Be My Own Therapist

My post on finger exercises is a perfect example of why I can't be my own therapist.  When I'm struggling with an object I don't have one brain cell left free to analyze what my body is doing.  One advantage of being an OT is that I instantly understand what my OT is telling me.  I thought the muscle that bends the joint closest to my thumbnail was the bad boy.  My OT helped me understand that my real problem was weak muscles at the base of my thumb (see arrow).  As an OT I know that a muscle imbalance gets worse when I use it so Cathy had my attention.
 

A 2nd advantage of being an OT is that I see the connection between exercise and function.

I've done the exercise in the photo on the left all year round for SIX YEARS.  WHY?  I do this because the tip pinch I use to take bills out of envelopes and fold laundry isn't forceful enough to manage a zipper.  I'm not independent in driving if I can't zip my coat when the weather turns cold.  Brrrr!

Being an OT makes me a picky consumer.  If my therapists say I should do an exercise I have to see a visible pay off.  Olympic athletes are going to talk to their coaches when the exercises they are given don't make them jump higher or run faster.  When I was in the rehab hospital I was too emotionally devastated and physically exhausted to think about why I was doing an exercise. 

As an out-patient I exercise and then verify.  Ta-da! 

 

 

P.S.  Photos above show me wearing rubber fingertips used to count money that I bought at an office supply store (e.g. Staples).  I use them for two reasons.  First, my OT has two good hands when she uses a vibrator.  While my sound hand holds the vibrator, the rubber fingertips act like a 2nd hand that keeps my hemiplegic hand in a functional position.  Second, I wear them to zip my coat at the beginning of winter because my weak tip pinch makes me slow.  As the winter progresses I can zip my coat faster so I don't take the rubber fingertips out of my coat pocket.  Speed isn't an issue in therapy, but how long I stand at the exit of a store zipping my coat while people walk past matters to me.

What I Learned About Caregivers

I live alone so I am both a stroke survivor and a caregiver.  Things have been going smoothly so I had forgotten how much caregivers do.  In my last post I talked about a water main break.  I had to find and contact a plumber to come see why my water was a scalding 155 degrees. I had to be home when the plumber replaced the thermostat and the heater coils.  Instead of thinking about my exercises I was making arrangements to get my hot water heater fixed.  If I were still married my husband would have taken care of this.

Living alone showed me that caregivers are pummeled by a triple whammy. They have to (1) do the chores they have always done, (2) take on their partner's role, and (3) be a therapist.  For example, a wife may have to take out the garbage, take the car to have the oil changed, and change the batteries in the smoke detectors.  A husband may have to cook, do laundry, and deal with insurance companies.  When caregivers become therapists they may have to help with self-care, set up home exercises, transport a spouse to appointments, and deal with a stroke survivor's bad moods. Yikes!

When I was a therapist I visualized caregivers helping with self-care and exercises.  I never pictured them doing additional chores.  I never thought about them needing time to recharge their batteries with rest, fun, and social support.  Now I cringe when I realize I used to think "oh the spouse or adult child will take care of that."

Bathing When I Travel

My life was recently disrupted by a water main break.  Here is a photo of the dirty water that came through my pipes after the broken valve was replaced and the water was turned back on.  Thank God I was able to drive to the store to buy bottled water. Thank God for my friend Barbara who has a bathroom on the first floor.  In addition to the glorious feeling of being clean after a shower I enjoyed washing my hands by simply turning the faucet handle.


Caution: This folding stool may not be safe if you are heavy or need physical assistance to stand up and sit down.  Thank God I found a folding shower stool I can bring when I visit people who do not have a handicapped bathroom.  Thank God a luggage saleswoman suggested I transport the stool in a nylon garment bag because the stool is too wide for anything but the widest suitcase.  I bought this stool at a local medical supply house instead of buying it on-line.  I wanted to (a) see if I could open it myself and (b) feel how sturdy it felt when I sat on it.  After I'm done showering I drape a bath towel over the closed toilet lid, place the folded stool on the towel, and use the ends of the towel to wipe off the water.  I drape the towel over the folded stool and find a place in the bathroom to keep it out of people's way. 

Is a shower stool compensation for my bad balance?  Yes.  Does this make me sad?  No. 
This adaptive device has allowed me to travel to see family and friends, present at conferences,
go on vacation, and find shelter when the power goes out (e.g. hurricane Sandy).  

Cancer versus Stroke

When Medicare was enacted in 1965 breast cancer was a death sentence.  It was such a devastating diagnosis that no one talked about it.  President Ford's wife was the first woman I heard admit she had breast cancer.  Today if you ask doctors what they recommend for treating breast cancer the answer depends on several factors.  Is the cancer stimulated by estrogen? 
Do you have the genetic form of breast cancer?  Has the cancer spread to the lymph nodes?  Does a combination of surgery, chemo and radiation therapy increase your odds of recovery?  

In 1965 a stroke meant families expected to do everything for you because they thought people with strokes were invalids.  Even people with heart attacks were called invalids.  With little or no activity some victims deteriorated and died two or three years after their stroke.  Neuroscientists said only very young children had brains that could recover from a stroke.  Recovery seen in adults was explained away by saying it was swelling in the traumatized brain that was going away.  When I was a young therapist a doctor told me all I could do was keep stroke victims physically active until this spontaneous recovery occurred.

Neuroscience and stroke rehabilitation have come a long way since 1965, but more advances are needed.  Doctors don't have a variety of options to reverse the effects of a stroke (e.g. tPA, BDNF, stem cells).  They do not know why some people with strokes rewire their brains while others don't. Therapists often do not have research done with large groups to show who responds well to new treatments (e.g. robotic arms, smart electric stimulation devices).  Clients have to try each new treatment to see if it has a positive effect.  

I'm glad I no longer live in a world where scientists refuse to do research on stroke because they think it is hopeless.  Now I get to read Dean's blog that keeps me up-to-date on the latest stroke research.  However, I would ask hard questions before I volunteered for a clinical trial.  Children were born without arms and legs after the Food and Drug Administration approved thalidomide.  I'm glad human subjects committees force researchers to jump through more hoops than they used to.  At 66 I may not live long enough to see the next big leap in stroke care, but I know it is coming.