October 31, 2016

Brain Plasticity Will Blow Your Mind

New research on brain plasticity will blow your mind.  One amazing finding is that new stem cells are produced in the lateral ventricles of the adult brain (1).  What is even more amazing is how these stem cells migrate from the back of the brain to the olfactory bulb in the front of the brain (2).  Using time lapse imaging scientists have been able to watch stem cells latch onto a blood vessel highway and drag themselves to their destination.  First, brain chemicals push stem cells away from their birth place.  Additional chemicals stop the stem cells from getting off track along the way.  As the cells approach their destination more chemicals pull them in the right direction.  

Equally amazing is that new stem cells are produced in the hippocampus that is responsible for short-term memory (2).  Since learning is life-long, it is hard to believe that neuroscientists used to believe that remembering everything we learn can be crammed into the memory cells we were born with.  The adult brain grows thousands of new stem cells in the hippocampus every day (3).  Diffusion tensor imaging allowed scientists to see significant microstructure changes in the hippocampus after just two hours of training (4).

New technology confirms that nerve cells can sprout new branches.  For example, Marshall saw cortical regeneration for finger-thumb opposition (5).  A youtube video shows a neurite advancing towards other nerve cells and retreating.  New growth is called a neurite until it differentiates into an axon or a dentrite (6).  Researchers are still learning which chemicals support or hinder the neurogenesis seen in the video.  But they know that only repeated training makes new branches cluster together so they work efficiently as a group (7).  

I want to pull my hair out every time I hear someone say "The doctor told me there is a 6 month window for recovery after a stroke."

October 27, 2016

Researchers Dismiss Treatment If They Use the Wrong Outcome

I cannot die in peace until hand recovery is evaluated with tests that have a good basement.  Good basements detect changes before substantial recovery appears.  Researchers may find no significant improvement after treatment even though subjects report using their hemiplegic hand more at home.  When subjects report they use the hemiplegic hand to shower, it has been called subjective data.  Why is there a discrepancy between formal hand tests and subject report?  Do researchers find a lack of progress because they provided poor treatment or because they used tests loaded with difficult test items that were not a good match for the subjects they recruited?  The table below compares the Arm Motor Ability Test (AMAT) and the Test of Early Bilateral Hand Use (TEBHU).  The AMAT has many high level skills while the TEBHU (1) has five levels of hand use.  My hemiplegic hand cannot do any of the AMAT items listed below but it makes me independent during over 100 bimanual ADLs.  Not fair!
           AMAT                                      TEBHU
Finger mobility                                  Finger mobility                        
    Cut with knife                                    Cut with knife                        
    Button                                                Button                                    
    Draw line with pen & ruler                 Tie shoelaces                         
    Dial phone                                         
    Squeeze toothpaste on brush
    Wipe eyeglasses                                  
Wrist/forearm mobility                    Wrist/forearm mobility              
    Unscrew jar lid                                 Peel carrot
    Comb hair                                        Stir pot
    Scoop up beans                               Zip coat
    Turn door knob
    Take sandwich to mouth
    Take phone to ear

                                                         Reach for object and hold it still*
                                                              Reach for and hold carrot while sound hand peels   
                                                              Reach for and hold pot handle while sound hand stirs
                                                              Reach for/hold scraper while sound hand rakes up food

                                                         Hand-to-hand transfer and hold object still*
                                                              Put deodorant in hemi hand so sound hand can remove cap
                                                              Put t. paste tube in hemi hand so s. hand can remove cap
                                                              Put remote in hemi hand & carry so s. hand can use cane
                                                         Trap object on surface and hold it still*
                                                              Trap toilet paper on thigh so sound hand can tear paper    
                                                              Trap return stub for bill on table so s. hand can tear off stub
                                                              Trap envelope on table so s. hand can tear open envelop

*When I was able-bodied I did not know I used both hands for hundreds of tasks.  Many bimanual tasks are so brief or simple that they fall below the awareness of people who design hand evaluations.

1. Dutton R. My Last Degree: A Therapist Goes Home After a Stroke, 2nd ed. Bangor, Maine:
    Booklocker; 2013:55-65.

October 15, 2016

Why Should People Care What I Do?

People need to know why they should care about what I do.  So I do not start by talking about how to put on a bra with one hand.  First I write about clothes that do not fit because at my age my breasts are closer to my waist than I ever thought possible.  I write about how I would feel about saying "I'd love to come to dinner if you hook my bra when I get there."  I live alone so donning a bra enhances my social life.  Describing how a problem affects my life reveals what motivates me.

Having a stroke taught me why therapists and clients have a different point of view.  Therapists must write goals for Activities of Daily Living (ADLs) because this is how they get insurance companies to pay for our care.  They must also think about deficits because how they treat one deficit, like muscle weakness, is different from how they treat another deficit, like visual neglect.  As a stroke survivor, improving dressing skills and grip strength are methods not goals.  

Therapists need to link functional goals to personal anchors.  An anchor is anything people want so much that they are willing to work hard to get it and keep it.  For example, "don pants so you can sit on the patio and feel the sun on your face" links a mundane ADL to a valued activity for a client who has been kept inside for three months.  Clients should tell OTs what they really want and stop worrying it may sound trivial to an able-bodied person who can take things for granted.  For me OT's motto of Living Life to Its Fullest means turning "I should" into "I want to."

October 3, 2016

OT Reduces Hospital Re-admissions

The IMPACT Act was designed to improve healthcare by linking Medicare reimbursement to valuable outcomes.  Currently, value is crudely defined by outcomes that can be measured across multiple settings with many different medical conditions.  A basic outcome is the number of clients readmitted to the hospital within 30 days of discharge.  Medicare has begun to financially penalize hospitals with higher-than-average readmissions rates.  Hospital CEOs are very interested in finding out how to prevent these penalties.

Rogers and associates looked at what reduced hospital readmission in 7,174 people over 65 with pneumonia, heart failure, or a heart attack (1).  PT did not reduce readmissions for the three conditions.  An acute illness does not warrant a long hospital stay, but elderly people are often at greater risk because they more likely to have poor strength and endurance.  A short course of PT may not be enough to reverse physical deconditioning.  In addition, PTs are not trained to address the cognitive issues that some elderly clients have which makes it harder for them to follow medical instructions after they are discharged.

However, the study found that OT was associated with fewer readmissions in all three conditions.
OTs evaluate both physical and cognitive skills and can assess the match between a client's abilities, social resources, and physical environment at home.  OTs can recommend solutions when there is a mismatch between abilities and resources BEFORE the client goes home.  For example, there may be a need to train the caregiver or reduce fall hazards by installing grab rails.  The easiest way to quickly grasp an OT's ability to positively affect hospital readmission rates is to read a case study (2).

My Conclusions.
1.  These findings apply only to clients with pneumonia, heart failure, or a heart attack.
2.  Lowering costs is of value to hospitals but what about valued outcomes for the clients?
3.  This is a good start towards using value as a guideline for giving the healthcare system
     financial incentives to produce better results.

1. Rogers A, Bai G, Lavin R, Anderson G.  Higher hospital spending on occupational therapy is
    associated with lower readmission rates. Medical Care Research and Review. 2016;1-19. 
2. Renda M, Lee S, Keglovits M, Somerville E. The role of occupational therapy in reducing
    hospital admissions. OT Practice. 2016:August: CE5-CE6.