December 4, 2014

Constraint Therapy is Good and Bad

When a student told a blogger that the time for stroke recovery is brief I decided to write about constraint therapy.  It was designed by Edward Taub who believes recovery can happen for years after a stroke.  Constraint therapy involves 1 or more hours of therapy that focuses exclusively on the hemiplegic hand plus leaving a mitt on the sound hand for 3+ hours at home each day to force the hemiplegic hand to work.

Constraint therapy is good because it challenged long held beliefs about neuroplasticity.
Constraint therapy is bad because it is appropriate for a limited pool of clients.  1) Stroke survivors must already be able to extend (straighten) their fingers 10 degrees and their wrist 20 degrees.
2) It is good for men who have women to take care of them.  It would be nice if every husband helped with all the chores at home while wives constrain their sound hand every day.

Current research offers an alternative.  Hayner found guiding both hands to work while making lunch, eating, and cleaning up helped stroke survivors improve as much as subjects whose hand was constrained during the same activity (1).  Sterr found that stroke survivors who were helped to use their hemiplegic hand for 90 or 180 minutes improved as much as subjects who received constraint therapy for the same amount of time (2).  These and other studies have shown that practice which is less intense and comes in several forms can produce recovery.  

A spring-loaded SaeboFlex splint helps me open my hand 100 times.  I live alone so I am glad these exercises help my hemiplegic hand open to hold 100+ objects while my sound hand manipulates those objects.  In 11 years my hemiplegic hand has opened to hold a tube of toothpaste 16,060 times so my sound hand can take the cap off and open again when I put the cap back on.

Bottom Line: Taub showed therapists and stroke survivors they need to let go of old myths.

1. Hayner K, Gibson G, Giles G. Comparison of constraint-induced therapy and bilateral treatment
    of equal intensity in people with chronic upper-extremity dysfunction after cardiovascular    
    accident.  American Journal of Occupational Therapy. 2010;64(4):528-539.
2.  Sterr A, Oneill D, Dean P, Herron K.  CI therapy is beneficial to patients with chronic low-
     functioning hemiparesis after stroke. Front. Neurol. 2014;5:

November 30, 2014

Finger Exercises

When I grasped thin objects like a zipper tab my thumb and index finger used to bend ferociously.  Trapping the zipper tab against my thumbnail made the zipper tab slide out of my hand.  After analyzing the muscle imbalance in my hand, my OT gave me exercises.  Caution: Bad practice can strengthen muscles that are already too strong. The photos below illustrate the kind of individualized exercise program an OT can create for you.  



The 1st exercise is touching my thumb to my index finger.  The vibrator stimulates the weak muscles at the base of my thumb that were not working (see black arrow).   





The 2nd exercise is straightening my fingers against a rubber band.  Initially my middle finger straightened more than my index finger (see arrow on left). 

 


To correct this muscle imbalance my OT added a 3rd exercise. Tendon stroking is pressing firmly along the tendon from my wrist to the 1st knuckle.  For me this sensory input stimulates both index finger and thumb extension.  

November 6, 2014

Walking in Snow with a Cane

Bottom Line: I am not ready to go to an assisted living facility were the center's van will take me to Wal-Mart once a week.

The photo on the left shows the Briggs Ice Cane/Crutch Attachment.  I bought it at a medical supply store near my home.  The advantage of buying it in a store instead of on-line is the saleswoman got out a screwdriver and fastened the device to my cane.  It stays out of my way in the up position until I put it down.(photo below). 
I place the cane in my hemiplegic (paralyzed) hand which holds the cane still while my sound hand pushes the device down until I hear it snap into position.

The device makes my cane slightly heavier which slows me down.  I use another cane during warm weather rather than take this device off and try to get it back in the same place each winter.





Warning #1: I do NOT poke my cane through the snow.  I wait until after a neighbor I pay shovels my walkway and digs out my car.  I must be able to see the ground to tell if there is an icy patch that could make the spikes slip.  Checking the ground for ice slows me down, but it gets me to my car safely so I can drive. 

Warning # 2: People who plow store parking lots do not always do a good job of removing ice from handicapped parking spots.  Before I get out of my car I open the door and look at the ground to see if I want to leave the device down or push it up out of my way.

October 31, 2014

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 that is 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.

My dysarthria has never fully disappeared.  When I am tired my speech is still somewhat slurred.
I know this because people start staring at my mouth start saying "What?" after I speak.  Then I have to remind myself to take a full breathe because I am speaking too softly.  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.

September 25, 2014

OTs are Brainwashed and It's Not Their Fault

As an OT I did not know I was brainwashed by Jebsen to think that only the dominant hand is important.  Jebsen made either hand do what the dominant hand does, like use a spoon to scoop beans out of a bowl.  Jebsen-inspired test items have been adopted by other people who designed hand tests for 35 years.  For example, the Fugl-Meyer Test asks clients to use either hand to pick up small objects.  This is something the dominant hand does.  Asking the non-dominant hand to do tasks it never does is not a valid way to assess recovery.  

When I was able-bodied I did not know what my non-dominant hand was doing except when both hands worked continuously, like typing.  I regret brainwashing hundreds of OT students by showing them a drawing of a palmar grasp that emerges at 6 months.  A palmar grasp involves holding an object with the palm and sides of the fingers instead of the fingertips.  This drawing gives the impression that a palmar grasp is a primitive stage infants pass through on the way to something better.  It does not create an image of adults holding age-appropriate objects.  I wish I could have shown my students the four photos below. 
A palmar grasp lets my non-dominant hand hold the watering can still while my other hand controls the garden hose.

 
A palmar grasp has allowed me to take the cap off the toothpaste tube 6,570 times in nine years.
A palmar grasp lets me hold the hair dryer while my sound hand fluffs my hair.

Notice the ends of my fingers are not in contact with the food scraper, the food, or each other.

Able-bodied adults use the palm and sides of their fingers thousands of times in a life time.  Helping an adult client regain a palmar grasp is a huge gift.  

July 31, 2014

Back Pain + Stroke = Disaster

I herniated a disc in my back and had sciatica 20 years ago so I've been stretching my back for years.  After my stroke I was worried my back pain would come back.  It did.  A recent bout of back spasms taught me stretching my back every morning is not enough.  Freezing in place when a back spasm hits and hoping I can walk slowly to sit down without dropping my cane is scary. 

My PT showed me I arch my back because my abdominal muscles on my paralyzed side are weak (bottom half of red line on left).  To stop myself from falling forwards while standing I lean back (top half of red line).  I also arch my back every time I lift my leg to walk.  Leg muscles (small arrow pointing upwards) need a stable base to pull on.  Abdominal muscles (arrows pointing downwards) are suppose to hold the pelvis and spine still when my leg moves.  

It gets worse.  I discovered I arch my back when I lean down to pick up an object, like when I reach down to get a pot from a bottom cabinet, get milk from the bottom shelf of the refrigerator, or pick up something from the floor.  I arch my back when I wash a dish because I am leaning my stomach on the edge of the counter for support.  

My PT taught me to do leg lifts with bent rather than straight knees.  I decided to intensify the workout.  I clasp my hands together, lift both arms over head, and lift my head while twisting to the left until my right shoulder blade lifts off the bed.  Before I start doing a leg lift I press my low back against the mattress and take a deep breath.  When I move I slowly let my breath out through pursed lips.  Holding my breath would increase my blood pressure.  I was dismayed that my NDT certification course did not teach that hand function comes from my gut.

Bottom Line: It takes both stretching my tight back and strengthening my weak abdominals to keep back spasms away.

June 30, 2014

Hand Use Able-bodied Adults Take for Granted


When my hand was flaccid I had to put objects in my mouth or squeeze them between my thighs to hold objects still.  This made me aware of the dozens of times each day I used to reach out to hold an object still so the other hand could manipulate it.  Here is an example of what I mean.  It is aggravating to get out cereal, a bowl, and a spoon, but not be able to open the milk.  My hand can now hold the milk container still so it does not spin around when I remove the cap, but first I have to reach for the handle. 

Using my hemiplegic right arm to reach for and hold a lint trap so my sound left hand can clean the lint trap sounds like a deceptively easy skill.  If shoulder muscles struggle to lift the arm, high muscle tone can cascade down the arm and make hand muscles tighten.  It is difficult to open a tight hand.  I am grateful that my OTs, NeuroMove, and Saeboflex helped me regain  this simple skill.  Being able to reach out and open my hemiplegic hand to hold objects helps me do 26 ADL tasks

June 26, 2014

The World's Tiniest Hand Splints


Problem #1.  When I drive for 30 or more minutes my paralyzed hand gets tight from the constant vibration.    Solution #1: To keep my hand open I use foam tubing designed to slip over the handle of eating utensils.  It has a 5/8 inch opening that runs down the center of the tube.  The fit is not tight enough to keep my fingers absolutely straight, but the foam traps body heat which relaxes my muscles.  My hand starts out stiff as the photo shows and ends flat on my thigh by the time I arrive at my destination.  The foam also provides traction so my hand does not slip off my thigh. 

Problem #2.  Pushing a heavy shopping cart makes my thumb bend severely.    Solution #2.    I slip a piece of foam over my thumb.  The foam keeps my thumbnail from digging into the side of my index finger.

Problem #3.  I have to grip a peanut butter jar tightly which makes my index finger and thumb bend sharply (see black line). 
A severely bent thumb means I am strengthening a bully who is already too strong!  I eat a peanut butter sandwich every day because Smart Balance peanut butter has omega-3 oil which lowers my high triglycerides (a bad fat in the blood).


Solution #3: I keep my thumb and index finger straight by donning rubber finger cots used to count money.  The finger cots give me traction that keeps my fingers straight as my sound hand uses a knife to dig peanut butter out of the jar.  I keep the finger cots in a shot glass for measuring liquor.  The shot glass sits on the windowsill in my kitchen.