May 26, 2015

Smart Phones and Stroke, Part 1

Part 1 is about how a stroke limits what I can do with a smart phone and how I feel about it. 

I do not have to worry about falling while staring at my smart phone as I walk.  My one good hand is busy controlling the cane I walk with due to my poor balance.






My sitting balance is not as good this guy on the boat.  I do not have to worry about missing a whale because I cannot stop staring at my smart phone. 






I use my one good hand to hold the spinner knob that controls the steering wheel.  Letting go of the spinner knob to use my phone would be a new definition of hands-free driving.

I can use my smart phone to ignore people.  However, after my stroke visiting with others is such a treat that I have never done it.  Years ago I read a science fiction book about a time when people interacted only as 3-D holograms.  Anyone who craved face-to-face human contact was considered mentally ill.    I remember thinking I would be dead before technology made this future happen.  Then I saw eight twenty-somethings playing with their smart phones after they finished eating in a restaurant.  The zone of silence was eerie. 

I am still learning how to take photos with my smart phone.  The touch screen is so sensitive that the phone takes seven copies of the same picture before I can take my thumb off the button.  My four other fingers struggle to cradle the phone.  I am learning to put less pressure on the screen and remove my thumb more quickly, but I still love my camera that is perfect for a stroke survivor.

May 17, 2015

PoNS Inspired Therapy Update

This is an update to my post PoNS Inspired Therapy.  I am thrilled to feel changes since I started in March to gently brush my tongue with a soft toothbrush.  Instead of feeling numb, the hemiplegic (paralyzed) side of my tongue feels slightly irritable and brushing now produces a small amount of saliva.  The sound side of my tongue feels less hypersensitive.  I am blown away by the fact that neuroplasticity is still present eleven years after my stroke. 

Brief tongue brushing does not replicate the several minutes of electrical tongue stimulation the PoNS device provides so I started singing before I take my pills to wake up my tongue even more.  I enjoy accompanying myself on an electric piano.  I use my sound hand to play the high notes in the treble clef.  My voice sounds terrible, but I enjoy using the musical phrasing I learned as a child - singing softer or louder, slower or faster - to convey the emotional message of a song.  My beloved Actto bookrest holds my music.

Last week I spontaneously started putting food on the sound side of my mouth, biting off a tiny fragment, and using my tongue to push the food to the hemiplegic side to chew.  This exquisitely delicate tongue control reminded me of the early days after my stroke when food got caught on the hemiplegic side of my mouth.  To know if a lump of food was stuck between my teeth and cheek, my sound hand had to touch my cheek.  I had no control over the right side of my tongue so I had to use my finger to pull the food back to my sound side.  Yuk! 

Chewing on my hemiplegic side addresses a long-term hope.  After chewing, the hemiplegic side of my tongue gets lots of practice pushing food to the back of my throat which initiates the swallowing reflex.  I hope this will improve my ability to swallow pills.  

May 5, 2015

Resting Splints Revisited

When I joined the staff of a nursing home as their first OT I opened a stroke survivor's hand after her fingernails grew into her palm because the nursing staff did not know how to inhibit her high muscle tone.  I remember that visual image when I read that stroke survivors get no benefit from wearing resting splints.  This conclusion is based on studies that looked only at hard plastic splints which are static (does not move).  After my spasticity broke two hard plastic splints, I bought a dynamic (moves) resting splint called SaeboStretch.  It bends when my muscle tone increases and goes back to its original shape when my muscles relax. 

Andringa studied a dynamic resting hand splint made by Ultraflex in Pottstown, Pennsylvania (1).  Six stroke survivors wore the dynamic Ultraflex splint for six hours during the day for six months.  Subjects reported significantly less pain at 3 and 6 months (p< 0.05).  Passive wrist extension
did not increase significantly at 3 months but was significantly greater at 6 months (p< 0.05). Subjects wore the Ultraflex splint during the day so forced disuse may have slowed recovery.  

One of Andringa's subjects illustrated the ultimate challenge of hand splinting.  He stopped wearing the splint after 4 months because it did not meet his expectations of what he thought the splint would do (1).  When clients are not told what they can expect when they wear a hand splint they are free to imagine the outcome.  Read the rationales for splinting in Are Resting Splints a Waste of Money?

 1. Andringa A, Ingrid G, Van de Port, Meijer J. Tolerance and effectiveness of a new dynamic
    hand-wrist orthosis in chronic stroke patients. NeuroRehabilitation. 2013;33(2):225-231.

April 26, 2015

A Physiatrist Has My Back

When I was an OT I did not realize stroke survivors deal with challenges for years after treatment ends.  Eleven years after my stroke I am grateful I still have access to a physiatrist (doctor who specializes in rehabilitation medicine).  (1) Dr. Terry, a physiatrist, has a deep understanding of my situation.  He listened attentively when I expressed concern about the increasing tightness in my hemiplegic (paralyzed) hand.  Instead of ignoring my concern he talked about when muscle tightness helps or interferes with function.  I did not have to explain why I wanted to go back to OT.  A physiatrist is one of the reasons I do not go downhill when a new challenge appears.

Here are four more reasons to see a physiatrist.  (2)  Regular in-patient meetings mean the staff have to think clearly about my case in order to present it to the physiatrist and to each other.
(3)  Physiatrists know how hard clients work to become independent.  Dr. Terry is one of the few doctors who does not try to undress me like I am a child.  After he asked to see my hemiplegic foot he hesitated for a moment.  This gave me a chance to take off my leg brace.  (4)  He asks about my personal life because he sees me as more than a paralyzed arm and leg.  (5) He knows the buzz words insurance company adjustors are looking for.  He has never given my insurance company an excuse to deny coverage for services he has ordered. 

Kinoshita compared outcomes for stroke survivors whose care was coordinated by a physiatrist versus other types of physicians (1).  The study found that stroke survivors whose care was coordinated by a physiatrist had significantly more frequent regular conferencing (see #2 above), had significantly higher scores on the Functional Independence Measure (p< .005), and were more likely to be discharged to their home (p< .005).  This is a huge advantage.

1. Kinoshita S, Kakuda W, Momosaki R, Yamada N, Sugawara H, Watanabe S, Abo M. Clinical
    management provided by board-certified physiatrists in early rehabilitation is a significant
    determinant of functional improvement in acute stroke patients.  Journal of Stroke &
    Cerebrovascular Diseases. 2015;24(5):1019-1024.

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?