Knee Surgery Drama

Two problems I worried about before total knee replacement surgery were resolved easily.  I was afraid the epidural anesthesia shot in my back would be painful.  It was nothing to worry about.
A nurse stood in front of me as I sat on the edge of the table.  She cradled my body in such a reassuring way that I immedately relaxed.  The needle they used to deliver a local numbing agent was tiny - I have had mosquito bites that hurt worse.  The 2nd problem I worried about was needing bread to take pills.  Pills have gone into my lung when I tried to swallow them wih water.  One way for me to take pills safely is to cut bread into small squares to wrap around each pill.
I squeeze the bread into a ball which drags the pill down my throat.  I did not know what I would do without a pizza cutter, but a plastic spoon worked almost as well.  The curved shape of the spoon made it easy to rock as I pressed down to cut.

There were two problems I did not anticipate.  One was throwing up every pill the nurse gave me when I woke up after surgery until bedtime.  Without blood pressure medicine my blood pressure soared to 207/90.  A nurse gave me milk which coated my stomach and finally allowed me to keep down pills.  I lost two days waiting for my blood pressure to come back down.  This waiting created a 2nd problem - several times I felt like I was going to scream because doing nothing for hours drove me crazy.  Thank God my friend Janet urged me to bring music to the hospital.  When I turned on my ipod I instantly relaxed and thought "music is worth staying alive for."

Goal Oriented Rehab

A recent study found people in rehab improved more when they worked on goals that were meaningful (1).  However, the way OTs help clients achieve goals can be confusing.  There are three components of OT treatment, but you often see only two of them during an OT session.

1. The Preparation

Preparation works on a client's deficits.  Preparation may be placing pegs in holes for hand opening and closing, scanning to the left for visual neglect, and learning what the different parts of a memory notebook are for.  

2. The I Shoulds
Many people have the same shoulds.  We all should get dressed so we can visit with others, 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.

Exercise and functional "I shoulds" are not incentives for maintaining rehab gains.  Clients need meaningful goals that turn
"I should" into "I want to."

3. The I Want Tos

"I want to" is something personal that makes a client's face light up - like wanting to cuddle with a beloved cat without getting your bare thighs scratched.  Many valued activities do not take place during therapy because they require special equipment.  OTs can make linking statements so clients understand what their OT is trying to accomplish.  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, an OT can point to pictures and say "leg brace - patio."

1. Lenze ER, et al.  Effect of enhanced medical rehabilitation on functional recovery in older adults
    receiving skilled nursing post-acute rehabilitation.  JAMA Network Open (in press).

Tricks for Stretching a Tight Hemiplegic Hand

I am haunted by a client who had her fingernails grow into her palm because the nurses could not open her tight hemiplegic (paralyzed) hand.  Here are tricks that make opening a tight hand easier. Trick # 1.  Using force makes spastic muscles fight harder. The instant you feel resistance slow down so movement is barely visible.  Patience pays off. 
Trick # 2.  Try not to touch the client's palm.  This may stimulate the hand to close.
 
Trick # 3.  To open the hand, start by bending the wrist slightly 1st.  This is how police get people to open their hand to drop a weapon.  Bending the wrist relaxes tendons that cross over the wrist before they go to the ends of your fingers.
Caution: Aim for a small amount of wrist flexion (see angle in photo).  As the tendons relax, the fingers will open slightly so you do not have to pull on fingers curled in a tight fist. 

Trick # 4.   A fist will relax even further if you straighten the thumb.  The thumb has half the muscles in the hand so it is a bully.  The trick is to wrap several fingers around the base of the client's thumb rather than pulling with the bony ends of your fingers.

 

Caution:  Overstretching the fingers can damage muscles  needed for active movement later on (lumbricals and interossei).  Always keep the fingers in a straight line with the palm.              DO NOT straighten the fingers like in the photo on the left.  

When stretching the wrist, it is better to aim for partial finger extension so muscles will relax instead of fight you.  I can get my wrist all the way back now, but I always keep my fingers in line with my palm (see green arrows).  

What I Learned About Splints as a Stroke Survivor

When spasticity from a stroke holds muscles in one position, muscle fibers become short which restricts motion.  Lannin (1) concluded "splinting has little or no effect on the loss of range of motion" (p. 113).  Unfortunately, Lannin told therapists to stop all passive stretching and restrict active hand exercises to 10 minutes a day.  So the data does not tell us if a resting night splint is a useful addition to standard therapy.

I wondered what would happen if I continued to do passive stretching and active hand exercises, but stopped wearing my resting splint at night.  After a month of not wearing this splint I could feel my thumb getting tighter.  I resumed wearing my splint and the next morning I woke up with a wicked ache in my thumb.  My thumb is tight by bedtime so my splint has not eliminated spasticity.  Placing the hand in one static position does not retrain the brain to produce active range of motion (AROM).  Yet I believe my splint has prevented a painful permanent contracture.

I love my new SaeboStretch resting splint I wear at night.  The new soft straps do not cut into my skin the way the old plastic straps did.  This version also uses a new kind of "Velcro" that does not have spiky hooks that scratch my bare thigh.  Notice that there are now two finger straps and two thumb straps.  The cover zips off so it can be washed.



1.  Lannin N, Cusick A, McCluskey A, Herbert R. Effects of splinting on wrist contracture after
     stroke. Stroke. 2009;38:111-116.

The Gift That Keeps on Giving

In the hospital my PT had me reach down with my sound hand to pick up cones sitting on a stool and stand up to place the cones on a shelf at head height.  When I started to wobble less as I reached down to pull up my pants at the toilet, I saw the value of this exercise. I could not go home if I needed 24 hour assistance for toileting.  When Michelle did not have me squat in the morning,
I asked to do it in the afternoon.  After I went home activity analysis helped me identify how squatting keeps me safe during dozens of tasks.  Activity analysis is the gift that keeps on giving because it tells me WHY I WORKED SO HARD.

   I bend my knees and hips when I reach down to:
* Pull up my underwear and pants after toileting
* Pick up my cane after it has fallen on the floor for the thousandth time
* Get clothing out of the bottom drawer of the dresser
* Get shoes from the floor of the closet
* Get a milk carton sitting on the bottom shelf of the refrigerator
* Get a box of cereal from the bottom shelf of a kitchen cabinet
* Get a heavy pot from the bottom shelf of a kitchen cabinet
* Get a box of dishwasher detergent from under the sink
* Take a heavy book from bottom shelf of book case
* Plug a cord into a low electrical outlet 
* Pull clothes out of the dryer
* Use a garden hose to fill a watering can that is sitting on the ground
* Empty a waste basket
* Pickup a bag of garbage to take it to the outdoor garbage can
* Pick up purchases sitting on the floor of my car

P.S. Reaching down by bending at the waist with straight legs is hard on my arthritic low back.

First Painless Car Inspection Ever

When I bought a new car I did not have to worry about a car inspection for four years.
I dreaded having to explain that I have a car with a devise that blocks the accelerator pedal on the right.  When I step on the 2nd accelerator pedal on the left, a metal arm pushes down on the real accelorator pedal.  Unfortunately, this puts the accelerator pedal to the left of the brake.  A lifetime of stepping on the left pedal to brake is a difficult habit to suppress.  The 1st man who insisted he could drive my modified car drove it into another car.

I was thrilled that the state inspection station now has a special line that allowed me to drive the car myself.  I did not hold up the line while dozens of people watched me lean down to pull on the ring that removes the entire device.  The brake test that required an abrupt stop on a pressure plate has been eliminated.  My trip through the inspection line ended peacefully with watching a technician put a new sticker on my windshield.

The Canary Died

When the canary died, miners knew there was poisonous gas that they could not smell.  Every morning I use a deodrant bottle to test if the muscles that make a fist are getting too strong.  For a long time my index finger was curved instead of straight when I opened my hand.  The day I had to pry my hand open so it could grasp the bottle was a red flag.  I worked too hard for 2 years to make this hand functional.  I do not want to go back to holding an object by putting it in my mouth or squeezing it between my thighs so my sound hand can manipulate the object.  I live alone so there is no "honey do" at my house.

My OT designed these exercises to remediate my specific weaknesses.  My first session was long, but I finally felt finger movement.  I was relieved that I got a positive result after years of neglect.

The arrow on the left points to a muscle that has forgotten how to straighten my thumb.
I need a vibrator to wake this muscle up.  Stroking the tendons of muscles that straighten my fingers wakes those muscles up as well.

I kept forgetting to do these exercises so I put an empty deodorant bottle in front of the TV screen.  It was amazing how quickly I learned to ignore that shape blocking a part of the TV screen.  An example of how good intentions are not enough.
So I put the vibrator next to the sink when I finish breakfast.
I tucked the cord under the sink to prevent a fall when I came back to prepare lunch.  This memory aid is so absurd that it worked.  I quickly got better at doing these exercises and they
do not take much time.

Drama is for young people who have more energy than they know what to do with

Stroke survivors and caregivers cannot afford to let repeated frustration drain their energy.
I learned how frustrating and tiring a.m. care can be when I did one task after the other after my stroke.  Here is why bathing leaves me feeling refreshed instead of exhausted and frustrated.

Washing.  I do not struggle to soap up a washcloth one-handed or chase a bar of soap after I drop it.  I pour shower gel on a nylon poof and knead it a few times to get it soapy.  To wash my sound arm, I use a gross grasp in my affected hand to hold the nylon poof.  I do not struggle to wring out a washcloth one-handed.  I hang the nylon poof on a suction-cup hook, hose it down, and let it air dry.  I use shampoo suds to wash my face.

Before I could hold the shower hose with my affected hand (see photo) I used my forearm to press the head of the shower hose against my stomach.  Water runs downhill.  This frees my sound hand to deal with the nooks and crannies.  If my husband was alive I would still want to bathe this private part of my body.

Drying.  My towel rack is next to the shower so I can reach it while sitting on my shower chair.  I drape the towel over one shoulder to dry my arms and trunk.  After I get out of the shower
I stand to dry my crotch with the towel draped over my shoulder.  My shoulder carries the weight of the towel so it is easy for my sound hand to manipulate the free end.  I do not huff and puff while holding up my affected leg to dry it.  I don a terrycloth bathrobe which dries my buttocks and thighs.  I let my calves air dry while I brush my teeth and comb my hair.

Dressing.  For the 1st year after my stroke, dressing was easier if I rested after bathing.  I laid on the bed in my bathrobe with a towel under my wet hair and listened to music on the radio.

Pain Scales

Getting clearance for knee surgery has been repeatedly delayed.  I used some of my time to document my pain levels.  Pain is rated on a 10 point scale.  Dividing pain into mild, moderate,
and severe is not enough to identify 10 different levels.  Noting whether pain was intermittent or constant helped.  It also helped to document when pain disrupted my ability to do Activities of Daily Living (ADLs) and how much pain reliever I took.  At the upper range of pain, documenting emotional distress added further refinement.  Here are the 10 levels of pain I have experienced over a lifetime.

1.  I have to think to recall if I had mild / intermittent pain during the day
2 . I am spontaneously aware of mild / intermittent pain throughout the day
3.  Mild / Constant pain.  1000 mg Tylenol at bedtime.  Must do some ADL tasks differently
     (e.g. walk down stairs backwards)
4.  Severe but brief pain made me afraid I could not finish an ADL task (e.g. thought about leaving
     filled cart in grocery store and going home).
5.  Moderate / Intermittent pain.  Added 500 mg Tylenol in a.m. because I ache before I get up
6.  Moderate / Constant pain makes me achy and exhausted by the end of the day.
     Worried about what 9 months of Tylenol is doing to my liver.
7.  I cannot tolerate constant moderate pain much longer.  Irritable!! 
     Need 2 attempts to do some ADL tasks (e.g. stand up).
8.  Severe pain makes me say "Ow that hurts" but I am able to remain still.
9.  Severe pain makes me Yell "OW" and I move or collapse involuntarily.
10. Excruciating pain: Not able to make any sound because I cannot exhale or inhale.

Handicapped Parking

My handicapped parking tag was missing when I got my car back from the auto repair shop.
It was not in the pocket on the driver's side door or under the seats or on the floor.  I know where handicapped parking is for every store I visit so I am really IRRITATED because I keep forgetting to look for an empty spot in regular parking.  I am irritated I have to go to the Department of Motor Vehicles (DMV)  and sign a letter in front of a DMV employee to get a replacement hang tag.

Handicapped parking is more than being close to the door of a store.  The wider handicapped space is very helpful.  It is difficult to load purchases in the car because a regular parking space leaves very little room to open the car door.  Able-bodied people solve this problem by leaving their shopping cart at the back of their vehicle and walking the bags to the open car door.  I have poor balance so walking with a bag in my sound hand instead of a cane is a fall hazard for me.  The wider space lets me pull the cart up to my open car door to unload my bags.

A regular size parking space is difficult for another reason.  It is hard to get in and out of a car when I can open my car door only two feet.  This small opening makes it hard for me to maneuver a heavy leg brace that will not let me point my toes.  A wide handicapped parking space is especially important for someone in a wheelchair.  They need the car door to open widely so they can slide from their wheelchair onto the car seat.