August 31, 2016

Cooking is Therapy for My Hand

Cooking is good therapy for the hand because many tasks have to done with both hands.
Here are a few examples of kitchen tasks that force me to use my hemiplegic hand.

The photo shows me holding a Cuisinart container with one hand while the other hand scrapes out the food that always sticks to the side of the container. 

Two more examples - One hand holds a pot still while the other hand stirs the food.  One hand opens the refrigerator door and the other hand takes food off a shelf.  


The photo gives you an idea of how many times I had to sit down to squeeze jars and bottles between my thighs to remove the cap when my hemiplegic hand was flaccid.  Now I reach out and hold the container still with my hemiplegic hand while my sound hand turns the lid.   
A stroke taught me many ADLs use a palmar grasp which is holding an object with the sides of the fingers rather than holding an object with the fingertips.  In the photo my fingertips are not in contact with the object or with each other.  Why wait to use your hand until tip pinch emerges when a palmar grasp allows able-bodied adults to do many ADLs that need to be done thousands of times?

I am not the only one who thinks cooking is good therapy for the hemiplegic hand.  OTs at Samuel Merritt University developed a treatment program for stroke survivors that includes preparing lunch and cleaning up the kitchen (1).  The group that used both hands during cooking activities in OT used their hemiplegic hand more often at home than the group who received constraint-induced therapy.  Cognitive research shows that transferring skills to a new setting is more likely to happen when the pratice task closely resembles the target task.

1.  Hayner, K., Gibson, G., & Giles, G. (2010).  Comparison of constraint-induced movement
     therapy and bilateral treatment of equal intensity in people with chronic upper-extremity
     dysfunction after cerebrovascular accident.  American Journal of Occupational Therapy, 64(4),
     528-539.

August 25, 2016

How I Learned to Turn My Head While Walking

I was able to look straight forward while I was in rehab because my PT had me walk in wide uncluttered spaces.  When I went home I learned that if I turned my head while walking outdoors, I stumbled or drifted in the direction my head was turned.  But I want to turn my head to look at a store window or talk to the person walking next to me.

Being afraid to look around while walking made me hold my head still.  This made my neck stiff.
I conquered each problem with its own strategy.  1) Every morning I slowly and gently move my head in circles while sitting.  This loosens my neck muscles while eliminating the possibility that I will fall.  2) I forced myself to look in store windows when I walk.  I began by turning my head for one second.  As I repeatedly turned my head to look at window displays my brain began to process this movement without losing the ability to monitor if I was drifting to the side.  These two strategies have eliminated the icky feeling I used to get when I turned my head while walking.  I will use them until I die because they allow me to participate in fun activities - window shopping and socializing while walking without slamming into friends and family.

Mirelman and associates confirmed the relationship between mobility and cognition (1).  Older adults with a history of falls had significantly fewer falls six months after walking with virtual reality feedback that added a cognitive component.  While walking on a treadmill, experimental subjects could see their foot movements projected on a screen as they responded to simulated obstacles, distractors, and multiple pathways.  Control subjects who just walked on a treadmill for an equal amount of time did not experience a decrease in falls.  The awareness of and ability to respond to environmental challenges is an important part of being able to walk safely.

1.  Mirelman A, Rochester L, Maidan I, et al. Addition of a non-invasive virtual reality component to
     treadmill training to reduce fall risk in older adults (V-TIME): a randomized controlled trial.
     www.thelancet,com/journals/lancet/article/PIIS140-6736(16)31325-3/abstract.

August 16, 2016

A Practical Way to Improve Hand Recovery

Problem.  PTs often make stroke survivors make 8 trips around the gym each day while OTs may
             treat the upper extremity for only 4 to 11 minutes out of a 47 minute treatment session (1).
             It is not surprising that repeated practice in PT produces quick leg recovery after a stroke. 
Problem.  Constraint therapy forced doctors to accept that recovery is possible years after a stroke
            BUT it is only for stroke survivors who already have some hand movement and who agree
            to an intense schedule of 2 to 6 hours of supervised therapy per day.

Harris and associates designed a self-administered hand therapy program for a larger range of stroke survivors with a less intensive approach (2).  One-hundred and three subjects with mild, moderate, and severe impairment on the upper extremity Fugl-Meyer test (UEFM) were recruited soon after they were admitted to a rehab hospital.  Subjects in the experimental group were given booklets and equipment graded to their level and asked to do exercises and functional tasks for
1 hour a day 6 days a week during breaks in the therapy schedule.  Subjects actually did an average of 3 hours spread over 4.8 days per week.  Subjects in the control group read and did homework about stroke and their health during breaks in the therapy schedule.  A site coordinator taught the program and then monitored each subject once a week. 

Experimental subjects did an average of 12 hours of self-administered hand therapy spread over 4 weeks while in a rehab hospital.  They were significantly better than control subjects at reaching for and grasping objects on the ARAT (P=0.031) and using their hand during functional tasks on the Chedoke (P<0.001).  A limitation for self-administered therapy is cognitive and language deficits.  Stroke survivors in this study were excluded if they had receptive aphasia or a score lower than 20 on the Mini Mental Status Examination (MMSE).  A score of 18 to 23 on the MMSE indicates a mild cognitive impairment.

Bottom-line: Numerous studies have shown that therapy which exceeds a typical rehab schedule improves outcomes.  A self-administered hand therapy program that required minimal therapist time and moderate client time to supplement in-patient OT produced significant gains in hand recovery for stroke survivors with minimal cognitive impairments.

1.  Berhardt J, Chan J, Nicola I, Collier J. Little therapy, little physical activity: rehabilitation within
     the first 14 days of organized stroke unit care. J Rehabil Med. 2007;39:43-48.

2. Harris JE, Eng JJ, Miller WC, Dawson AS. A self-administered graded repetitive arm
    supplementary program (GRASP) improves arm function during inpatient stroke rehabilitation.
    Stroke. 2009;40:2123-2128.

August 4, 2016

Solutions for My Extreme Sleep Deprivation

I have had insomnia off and on all my life, but my stroke brought this problem to a new level.  I had a stroke in the brainstem which contains the reticular formation that puts us to sleep and wakes us up. Since my stroke I have repeatedly had nights where I get only two hours of sleep per night.  In February I did not sleep for two days.  What FREAKED ME OUT was that I did not feel sleepy for
2 days so I got aggressive about addressing this problem.  If you want to read about what sleep deprivation does to your brain read Dean's posts.

Daytime routine.  I avoid caffeine after 10 in the morning and exercising and eating late at night.

Bedroom environment.  I sleep in a dark bedroom with no TV.  The alarm clock is placed where I cannot see it.  Sometimes I wake up and find I am sweating.  After my February freak out I lowered the room temperature because a lower body temperature tells the brain to sleep. 

Preparing for bed.  If I am sleepy at 10 p.m. I go to bed.  If I wake up in the middle of the night at least I have slept for 4 or 5 hours because I went to bed early.  If I am still wide awake at 10 p.m. I go to war. (1) I turn off the TV, wash my face and brush my teeth, and come back to the living room to listen to a calming CD (e.g. sounds of the ocean) for as long as it takes for me to feel sleepy.
(2) While I listen to the CD I assess my body.  If my knee hurts I take Tylenol.  If the constant burning in my foot bothers me I provide a competing sensation by taking a warm gel pack to bed. 

Back up plans.  (1) If I lay in bed and cannot fall asleep, I get up and eat a banana.  Bananas have tryptophan that helps the body make the melatonin that makes us sleepy.  This strategy works only when I realize how long I have been lying awake AND I have the fortitude to get out of bed. 
(2) If I wake up at 3 a.m. to go to the bathroom I do not wait to see if I will fall asleep again.
Before I get back into bed I start a calming CD at a low volume or turn on a fan for a low
background noise. This often helps me fall asleep again.