March 28, 2016

Astronauts & 1900's Women Get Surviving Stroke

Before I had a stroke I would have found my post "9 Things I Have to Do to Drive Independently" obsessively tedious.  I know of only two groups of able-bodied people who can understand what you have to do to thrive after a stroke.

Astronauts.  Astronauts understand the conscious attention stroke survivors have to pay to familiar tasks that able-bodied people do without thinking.  As I watched astronaut Scott Kelly demonstrate cooking and eating dinner on the International Space Station, I saw that he had a problem.  He repeatedly dropped food because his hand forgot you have to attach an object to a surface or it will float away.  To be fair, Scott was distracted by having to look towards the camera and explain what he was doing.  I am sure he performs better when he does not divide his attention.  I think he would understand why stroke survivors do not perform well when they try to multitask.  I also think the months of practice Scott did on Earth would help him understand how hard it is for stroke survivors to relearn to do even simple tasks.

Urban Housewives in 1900.  If women in 1900 could have read the nine things I do before I drive my car away from the curb, they would have said "welcome to my life."  They knew about spending lots of time getting ready to do a task.  For instance, before they could start doing laundry they had to do three chores.  1) They had to soak clothes the day before because cleaning agents were not very effective.  2) They had to hand carry 20 to 40 gallons of water from the sink to a large copper vat where the clothes were washed.  3)  They had to wait for the coal fire under the copper vat to heat up the water.  Only then could they start agitating the clothes by hand with a four foot long pole called a dolly stick. 

Here is a re-enactment of doing laundry in 1900 from the PBS TV series, The 1900 House.

March 16, 2016

My Car Key

When I started driving after my stroke I learned a painful lesson.  When I went to throw out the junk that had accumulated on the passenger's seat, my hemiplegic (paralyzed) hand cannot hold thin objects like a car key.  To free my sound hand I put the key on the dashboard.  When I was finished cleaning I locked and shut the door. To my horror I saw my car key on the dashboard.  My purse with the extra key was on the driver's seat.  As I waited for the American Automobile Association (AAA) to rescue me I vowed never to do this again.

Of course I did it again, but this time I was 40 miles from home.  I went to get a newspaper off the back seat.  My big city streetsmarts made me lock and close the front door.  After I retrieved the paper I locked and shut the back door.  Once again I was looking at my purse on the driver's seat.  For 45 years I put my car key in one hand for two seconds so I could grab something with my other hand.  While I waited for AAA a second time I finally admitted that I cannot be trusted to remember where my car key is when it is not in my non-dominant hand. 

I went to Home Depot and bought a flexible wrist coil I can attach keys to.  Now when I get out my car key it goes: (1) in my coat or pants pocket or (2) on my wrist.  I prefer to slip the coil on my wrist because the pressure on my wrist says it is safe to close the car door.  I'm happy to report that I have not locked my key in the car since I spent $1.97 for this cheap adaptive device.
P.S.  The coil makes it easy to find the key is my purse. 

March 3, 2016

Conclusions from Multiple Studies Can Be Flawed

The gold standard of medicine has been to find one treatment that makes everyone healthy.  To find this "holy grail" authors compare the results from a large number of studies (meta-analyses, systematic reviews, Cochran Reports).  Yet conclusions from multiple studies can be flawed when a disease varies widely as stroke does.  Here is two examples of what I am talking about.

Researchers are doing new clinical trials on drugs that did not help large numbers of people with cancer.  Now that researchers know how to identify different subtypes of cancer, they want to see if old studies had a poor match between the drug and the subtype of cancer in the sample.

Researchers in the Efficacy of Nitric Oxide Study (ENOS) studied the effects of nitric oxide (NO) on stroke outcomes (1).  ENOS looked at the records of over 4,000 stroke survivors in 23 countries. NO had no beneficial effect. The ENOS authors did a 2nd analysis with a subset of people with strokes that affected the front half of the brain (1).  Ninety days later the subjects who received NO had significantly better outcomes on the Mini-Mental State Exam (cognition), Barthel Index (ADLs), EuroQol Scale (quality of life), and Zung Depression Scale.

Bottom Line. Authors of meta-analyses, systematic reviews, and Cochran Reports need to take a more nuanced approach.  When deciding what helps people with a disease that varies widely, conclusions that ignore how samples differ across studies can dismiss beneficial treatment effects.

Example of a Nuanced Approach. The CAREX exoskeleton helped stroke survivors draw circles by providing two kinds of assistance (2).  High functioning stroke survivors who had strength but lacked control improved when they were given path assistance.  Low functioning stroke survivors who lacked strength improved when CAREX supported the arm so they had less weight to move.  

1. Woodhouse L, Scutt P, Krishnan K, Berge E, Gommans J, Ntaios G, Wardlaw J, Sprigg N, Bath
     P. Effects of hyperacute administration (within 6 hours) of transdermal glyceryl trinitrate, a nitric
     oxide donor, on outcome after stroke. Stroke. 2015;46:3194-3201.

March 1, 2016

Rehearsal Is Better Than Practice

I used to get upset every time I tried a new task.  A stroke makes me slow and clumsy when I try something new.  My performance goes downhill as I get more and more frustrated.  I finally learned to think of my first attempt as a rehearsal rather than practice.  Coaches will tell you to work out with the team, but that does not mean they will let you play in the game.  Music teachers want their students to practice, but they do not expect most of us to do anything with the instrument we are learning to play.  In therapy, practice takes the form of exercises and Activities of Daily Living (ADLs) without knowing how these activities will change my life. 

Rehearsal, on the other hand, implies a later performance in the real world.  For example, if I have trouble zipping my coat I stop and rehearse pinching my hemiplegic thumb and index finger together before I grasp the zipper pull.  If I know an item will be difficult to find in a store, I rehearse saying the item's name before I go in the store and ask an employee where the item is located. 

Thinking of my first attempt as a rehearsal changes how I feel.  I try to remind myself that even professional musicians don't expect to be perfect the first time they play a new piece of music.  If my frustration escalates to anger during my first rehearsal I stop the task.  When I try the new task the next day I am quicker and more coordinated.  Sometimes the mistakes I made the day before give me an idea for how to make the task easier.  Able-bodied people are amazed by how well I do things.  I do not tell them I rehearse.