Reviewing Virtual Reality Rehab

Between September 2011 and May 2017 Dean published 173 posts about the use of virtual reality to provide rehab for stroke survivors.  The results for the hand are depressing.  For six years research focused on a subject's ability to touch an object on the screen so the computer can move the object or make it disappear.  Enjoying these quick reactions is not enough to justify the cost of this expensive equipment.  It was a good place to start 6 years ago, but stroke survivors want to manipulate objects with their hand.

There is a glimmer of hope.  Gauthier (1) used video games that make stroke survivors do more than use their shoulder and elbow to reach forward and side to side.  These games require forearm and wrist motions.  This may not sound exciting but these motions orient our hand to the many different positions objects rest in. The photo shows the forearm is halfway between palm up and palm down so the hand can pick up a glass.  Cocking the wrist means the rim of the glass is not pointed at the ceiling but at the person's mouth.

Unfortunately, Gauthier selected stroke survivors who already had a few degrees of active forearm and wrist movement.  How can subjects make the leap from just reaching to turning their hand palm up to catch a parachute on a video screen?  My OT gave me exercises that helped me regain forearm and wrist motions.  These small motions make me more independent.  For example, I can turn my hand halfway between palm up and palm down to grab my cane so my sound hand can catch the door before the person in front of me lets it slam shut.  I picture stroke survivors practicing forearm and wrist motions and then immediately trying to turn their hand palm up so they can turn over a card on the computer screen.
Fun + lots of repetition is good.

1. Gauthier L, et al. Video game rehabilitation for outpatient stroke (VIGoROUS): protocol for a multi-center comparative effectiveness trial of in-home gamified constraint-induced movement therapy for rehabilitation of chronic upper extremity hemiparesis. BMC Neurology. 2017;17-109. doi:10.1186/s12883-017-0888-0.

A Great Why Deserves a Great How

I love a TV commercial where a father stands outside a gym after a basketball game and says he missed his son's winning shot because he was outside smoking a cigarette.  He decides to wear a skin patch to stop smoking.  The slogan for this TV ad is "a great why deserves a great how."
This commercial reminded me that the how-tos I know as an OT are not enough to be successful.

My walking endurance declined as the fear of being home-bound faded over 13 years of living with a stroke.  However, I live alone and cannot fold a wheelchair or lift it into the trunk of my car.  So I tried to improve by setting a goal of a specific number of steps on my pedometer.  I was frustrated when my data showed I walked less after I set this goal.  When my iphone played an annoying sound I turned it off and thought "I will walk tomorrow."  Then I remembered the calf muscle pump.

The heart is not strong enough to pump the blood out of the legs.  Blood pooling in the legs can form a blood clot which can break off and go to the brain to cause a stroke.  This made me think about what is happening when I sit at the computer, etc.  However, when calf muscles contract they squeeze the veins which helps push the blood upwards (see diagram below).  Between heart beats when the heart rests blood drops down inside the veins, but valves snap shut and blood is trapped at higher and higher levels.  This repeats until all the blood in the legs goes back to the heart.

I have met or exceeded my walking target every day for three weeks.  Having a concrete image of what is happening in my legs right this minute is the great why I needed to change my behavior.

Review of Paratransit

Clients do not know if they can use paratransit without knowing the demands of a system.  Here is a comparison of two systems I used.  One service covers the state of New Jersey and the other covers my county.  I needed paratransit because trips must be made repeatedly to stay at home - bank, grocery store, drug store, doctor, dentist, out-patient therapy, post office, clothing store, etc.  Paratransit kept me out of long-term care until I regained the ability to drive.

Language.  To qualify for the county service I had to give my address and diagnosis during a phone conversation.  The state required a one hour in-person interview where I had to explain why I could not take public transportation.  For example, my balance is poor so I would fall if I was standing when the vehicle started moving.  When making a reservation, both systems required me to tell them what ambulatory device I used so they knew what type of vehicle to send.

Planning Ahead.  For the county a reservation had to be made 2 weeks in advance and they asked only for my name.  For the state a reservation had to be made 24 hours in advance and they asked for my paratransit identification number.  To remember the pick-up times for a trip I wrote them on a calendar that sat on the table where I ate breakfast.  The county required only the name of the store because the person making the reservation was local and knew the area.  The state required exact addresses and names of cross streets because the person making the reservation was miles away.  I got out a list of these destination details before making a reservation.  Both services had a two bag limit.  This meant I had to plan multiple trips when I needed bulky objects like toilet paper.

Money Management.  The county service was free.  The state service required exact change.  They told me the cost of a one-way fare when I made a reservation.  Cost was based on what it would cost me to make that trip on public transportation (e.g. bus fare of $2.25).  I kept a small supply of one dollar bills and coins.

Strength.  The county provided door-to-door service which meant the driver provided physical assistance to go up and down stairs or a ramp and carry packages.  The state provided curb-to-curb service,  This meant the driver stood by the vehicle while I got myself in and out of the house and transported packages.  Both services had vehicles with a wheelchair lift to get a client in and out of the vehicle. 

Time Management.  The county service picked me up close to the time of my reservation.  The state picked me up within 40 minutes of the time I requested.  I had to plan an extra 80 minutes into every trip in case I had to wait the maximum time at both ends of my trip.

Endurance.  The county sent a vehicle to my neighborhood to take people over 65 to the senior center.  That meant I had a short 2 mile ride with the seniors before I was dropped off at the grocery store.  The state runs long trips with multiple destinations.  When I had to wait for other people to be picked up and dropped off, I might ride for an hour before reaching my destination.  Even more tiring was the 40 minutes I might have to stand before I was picked up at the store. 
I had to be at the door so I could see the vehicle which waited only 5 minutes.  I bought a folding three-legged stool with a shoulder strap that hunters use so I could sit down if I got too tired.

Balance.  Both services did not allow the drivers to start driving until I was seated and had my seat belt fastened.  Vehicles that carried wheelchairs had tie-downs which the drivers handled.

Bottom-Line.  Different paratransit services require different physical and cognitive skills. 
A generic test like the Transportation Skills Assessment Tool is not enough to assess a good person-environment fit.

Some People Feel Compelled to Help

I snapped at a dear friend when she offered to retie my loose shoelace.  Even though I said I could do it, she insisted on helping.  This made me angry because every doctor I have seen since my stroke reaches down to untie my shoes during a physical exam.  They do this quickly because they know it is inappropriate for a male doctor to undress a female patient.  I do not know how old I was when I decided my clothing is a part of my personal space, but it was a long time ago.

I have yet to convince people they cannot tie my shoelaces. Telling my friend I could do it as fast with one hand as she could do it with two hands was not a deterrent.  She said "I could tie your shoe at least once so you won't have to."  My strategy to handle this more gracefully next time will be to point and say "Can you tie a shoelace that has only one free end?"  

P.S.  The strategy above works.  Able-bodied people no longer get upset when I will not let them help me tie my shoe.

Surgery is Dangerous for Me

Since knee surgery my standing balance is worse.  I have repeatedly stumbled backwards because I cannot feel when I am leaning too far behind vertical.  Losing my balance was the first symptom of my two brainstem strokes.
My strokes were caused by narrowing of the vertebral artery that supplies blood to the pons.  The pons in the brainstem is the bridge to the cerebellum which controls balance.

There is a chance that bending my neck back to put a breathing tube down my throat during surgery put a kink in the vertebral artery in my neck.  If a 15 minute meniscal repair surgery impaired my balance, I do not want to see what happens after a longer knee replacement surgery.   

Bottom-Line: I am serious about the exercises I got from my latest PT.

Rolling Discharge While I am Still in Therapy

When I am in therapy I do a rolling discharge.  I never wait until I am discharged to start doing exercises at home because there are often problems transferring exercises to a new environment.

The 1st challenge is modifying how I exercise at home because I do not have the right equipment.  For example, my PT had me lie on my stomach on an 8 foot wide mat table and bend my knee.    I need strong knee flexors to stop the joint-damaging SNAP my knee makes when I straighten it to swing my leg forward to take a step.  However, my single bed at home is narrow.  I tried lying on my back close to one edge, rolling onto my stomach which moves me to the other edge, and carefully inching my way back to the center by pushing with my elbows.  This was scary and stressful for my hemiplegic arm.

My soft bed also does not provide a firm surface to push off of.  I tried folding a yoga mat to create a firmer surface under my belly, but it was a nightmare to position with one hand.

The 2nd challenge is establishing a consistent routine that saves me from muscle atrophy after I  worked so hard in therapy.  A reliable memory aid helps me follow through on my good intentions.  I reach under the bed covers to remove the ball that keeps the covers off my hyper-sensitive big toe.  Instead of rolling the ball into its corner, now I roll it towards my leg brace.  After I don my brace the ball reminds me to go to the bathroom, stand while I hold onto the grab bar next to my bathtub, and bend my knee.  I can do 8 repetitions before my weak hamstrings poop out.

Bottom-Line:  Figuring out how to do exercises at home can take creativity and persistence.  Starting this process before therapy ends means I can ask my therapist for suggestions.

Mini Exercise

Pain did not end after knee surgery so I asked for PT.  My PT discovered my knee problem was caused by weak muscles that do not keep my joints in good alignment.  However, I cannot be trusted to do boring, time-consuming exercises that never end because my weakness will never fully go away.  In the 13 years since my stroke I learned I will do 3 to 5 repetitions every day  IF I use an object as a memory aid.  The stranger the memory aid the better it is at catching my attention.  I call doing a few reps every day forever a mini-exercise.

When I was an OT I did not know how mind-numbing exercise is when it must be done every day until a client with a chronic condition dies.  Here is one of the mini-exercises I added to my daily routine because I do not want knee replacement surgery.

My PT had me do lunges to strengthen my knee.  My knee wobbled left or right (red arrow) as it bent because my hip muscles are weak.  After 1 or 2 reps my knee stays lined up with my foot (green arrow) because hip muscles work together to keep my knee in the midline.  I chose the toilet to prompt me to do a few lunges.  On his TV show Dr. Oz showed how much water sprays out of a toilet when it is flushed so I got in the habit of lowering the lid before I flush.  I have to wait for 10 seconds so I thought I may as well do lunges.

Two Sets of Ten Do Not Undo 12 Hours of Disuse

I had back spasms after my stroke.  It was terrifying to be frozen in standing hoping I would not drop my cane or fall down.  I was highly motivated when a PT gave me exercises to strengthen the weak abdominals that let my back arch every time I lift my hemiplegic leg.  I do these exercises before I get out of bed in the morning.  However, a few repetitions do not undo the effects of
12 hours of disuse.  

If exercise was enough, coaches would stop after they make football players run laps around the field and throw and catch footballs.  Exercise conditions the body, but the mind has to learn to use new skills when we are distracted.  Exercise strengthens muscles, but it does not retrain the brain to use muscles when we have a cognitive challenge.  

Transferring gains from exercise to my daily routine has had mixed results.  Success: I consistently lift my hemiplegic leg higher than is necessary to walk up the steps to my front door.  I am pleased I do not see scuff marks on the top on my new shoe.  I am no longer dragging the toe of my shoe over the edge of the step. 

 

Failure: I want to stop arching my back when I lean my stomach against a counter for support. I am failing two-thirds of the time.  To remind myself to reach forward and lean on my right hemiplegic hand, I put a beige piece of non-slip shelf liner on the front edge of the kitchen sink.  I kept forgetting to do this so I added a 2nd memory aid.  A blue piece of non-slip shelf liner reminds me to 1st rest my sound hand on the counter when my hemiplegic hand reaches for the counter.  I am improving so I know I can stop this bad habit.

Two Ways Therapists Earn Their Pay

Therapists help clients in many ways but here are two ways therapists earn their pay.

1.  Contraindications.  When I taught OT students I used case studies to help them to think about the needs of each client.  I had students work in small groups to treatment plan for one case and then had them individually treatment plan for another case on an exam.  This allowed me to identify students who knew which solutions from the 1st case could be used with the 2nd case.  For example, the 1st stroke survivor had a tight arm that did not want to straighten to allow him to don a shirt.  This client should be taught to use gravity to relax the arm by hanging it between his legs before dressing.  However, on the exam I gave them a stroke survivor who had flaccid shoulder muscles that could not hold the arm in its socket.  Hanging the arm between the legs was contraindicated because it can damage nerves by stretching them.  A client should not have a brachial plexus injury added to the paralysis created by a stroke.  Students lost double points when they blindly used protocols that endangered a client.  The phrase "all strokes are different" can irritate stroke survivors, but a therapist who thinks all strokes are the same is dangerous.

2.  Nothing Works 100% of the Time.  When science finds a new cure it never saves 100% of the people.  A treatment protocol is considered successful when it cures a majority of the people.  It is a therapist's job to figure out what to do when a client does not respond to a protocol that has succeeded with many other clients.  For example, the PT who is treating me after my knee surgery taped my knee.  I never dreamed the tape would aggravate the constant burning I feel in my foot.  When the burning sensation crept up my calf to my knee I took the tape off.  She will have to find another way to increase my knee stability.  Apple would lose business if updates they send to iphones work on only 80% of phones.  Humans have to live with the fact that we are not identical clones that respond identically to protocols.

Saved by Dumb Luck AGAIN

Pain is a great motivator.  A painful crack (black line in photo) that starts in the quick of my sound thumb returned this winter.  Every time I picked up an object the pressure opened this crack which was very painful.  So I was happy that dumb luck saved me again.  I bought a garden glove to wear when washing dishes because this glove is bigger and looser than a regular kitchen glove.  The roomier fit makes it easier to slip on my hand. 

The dumb luck came when I stapled the top of the glove
(see circle in 3rd photo) to shorten it.  As soon as I saw the cuff I created my hemiplegic (affected) hand reached out and pulled the glove on without my thinking about it. 





After I am done using the glove I remove it by resting the glove on a towel.  My slightly fisted hemiplegic hand traps the end of the glove while I pull my sound hand out.

Luck struck again when I realized the cuff could be used to hang the glove on a hook on the inside of the sink cabinet door.

I love avoiding medical catalogues that sell expensive equipment.