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.  

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