November 29, 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."

November 24, 2016

ADLs Are Where the Repetitions Are

Brain plasticity is amazing, but rewiring the brain requires thousands of repetitions (reps).   Activities of Daily Living (ADLs) are a great way to get the reps needed to retrain the brain.
Four examples show why two sets of ten cannot compete with ADLs.

1) Twice a day I open my hemiplegic hand to grasp a tube of toothpaste so my sound hand can remove the cap.  In nine years I have opened my hand over 5000 times before brushing my teeth.

2)  I have to turn 14 times to prepare cereal with a sliced banana.  I have made this same breakfast for nine years so I have made over 45,000 turns.  Add making a sandwich for lunch and preparing a hot meal for dinner and the number of turns I have made in the kitchen are in the hundreds of thousands.

3)  Shopping is therapy for my hand.  I open my hemiplegic hand to let go of the cart and reach for items with my sound hand.  My hemiplegic hand opens a 2nd time when I grab the cart to move on.  I open my hemiplegic hand to let go of the cart so my sound hand can empty the cart in the check-out lane and again to load food into my car.  Buy 30 items + empty cart + load car = open hand 64 times.  64 x 2 visits a week x 9 years means I have opened my hemiplegic hand 59,904 times in the grocery store.

4)  The distance I have walked at the grocery store is huge.  I step away from the shopping cart and bend down or reach up to get items I want.   The S-shaped curves I make to detour around people and other carts require more steps than walking in a straight line.  According to my pedometer I walk 2,000+ steps each time I visit the grocery store.  2,000 x 2 visits a week x nine years = 1,872,000 steps!

November 18, 2016

Caregivers Readiness

Forty caregivers of stroke survivors reported they often felt abandoned and wished they had someone they could call with questions (1).  This may sound surprising unless you understand that staff at different agencies do not communicate with each other.  This means each round of therapists has to do initial evaluations of the client.  This does not leave much time for talking to the caregiver.  This lack of communication is a problem.  Lutz found that "during rehabilitation many
of these caregivers still hoped and expected that the stroke survivor would return to pre-stroke function (p. 8)."  When caregivers realize what they have to do, the primary focus on the client is already entrenched.  

Reading this article on caregiver readiness reminded me that I was clueless when I was an OT.
It took having a stroke to teach me that caregivers are pummeled by a quadruple whammy.  They have to: 1) do the chores they have always done, 2) take on their partner's role, 3) be a therapist, and 4) be a case manager. A wife may take out the garbage, take the car to have the oil changed, and change the batteries in the smoke detectors.  A husband may go grocery shopping, cook and do laundry.  When they are therapists, caregivers may help with self-care like bathing, set up and supervise home exercises, and deal with a stroke survivor's bad moods.  As a case manager, caregivers may have to schedule multiple doctor appointments, deal with insurance companies, and make multiple trips to the drug store to pick-up multiple drugs.  Many caregivers do this without professional psychological support or respite care.  Now I see caregivers as angels.  

(1).  Lutz B et al. Improving stroke caregiver readiness for transition from inpatient rehabilitation
        to home. The Gerontologist. 2016; Vol 00:No.00,1-10. doi10.1093/geront/gnw135.

November 8, 2016

I Cannot Use Salt to Make Food Tasty

I had a 2nd stroke two years after my 1st stroke so I got serious about lowering my blood pressure with a low salt diet.  Low salt food tastes terrible so I learned to jack up the flavor of food with aromatics like onions and garlic.  Peeling garlic is a challenge even for able-bodied people.  I use the smooth side of meat pounder to smash the garlic open so I can remove the peel with
my sound hand.  This means my days of creating beautiful, thinly sliced garlic are over.  

I chop garlic with a large kitchen knife.  Rocking the knife over the garlic creates a mix of small and medium size pieces.  I place a food scraper in my hemiplegic hand so my sound hand can scoop up chopped food and slide it into a mixing bowl or pot.  But sometimes I want small uniform pieces of garlic that are evenly distributed in a dish.  I spice up turkey burgers by stirring crushed garlic into an egg before adding it to the raw meat so I will not bite into a big hunk of garlic.  However, a garlic crusher takes lots of hand strength to squeeze the two arms of the crusher together.

I rest the bottom arm of the garlic crusher on my cart and put my sound hand on the top arm.  Leaning on the top arm lets me press down with the strength of my whole arm.  I catch pieces of falling garlic by putting a piece of saran wrap** under the garlic crusher.  To get garlic clinging to the crusher into a bowl or pan, I place the crusher in my hemiplegic hand so my sound hand can use a knife to scrape off the garlic. 

Cleaning a garlic crusher is easy if it has a plastic grid that pushes the remnants out of the holes. I hold one arm of the garlic crusher in my hemiplegic hand and stabilize the 2nd arm against my stomach. Then my sound hand can use the tip of the knife to dig out remnants so they fall on the saran wrap.  I fold the saran wrap and put it in the garbage.

** To see how I tear off a sheet of saran wrap with one hand
click on this post.

November 2, 2016

Mrs. Bobath was wrong - hand use comes from my gut

I was dismayed that my NDT certification course did not teach me hand function comes from my gut.  I learned this when a PT had me do abdominal exercises after my back spasms returned.
I was surprised to feel abdominal muscles on my paralyzed side burning from effort.  My ability to reach improved after my abdominals got stronger. 

When you reach for an object (shoulder flexion) the shoulder blade (scapula) helps the arm by sliding forward.  Scapular muscles are attached to the ribs so if weak abdominal muscles do not keep the ribs still, the scapular muscles have a wobbly home base. Having weak stomach muscles meant my shoulder and elbow muscles were overworked when scapular muscles could not do their job.  I repeatedly got tendonitis in the long head of the biceps because this elbow muscle assisted weak shoulder muscles.  My biceps tendon used to swell so badly that it made a popping sound when it slipped out of its groove.  Exercise sessions had to end with ice to reduce the swelling.

I wonder how much faster I would have progressed if my OTs had worked on abdominal strength.  I do not blame my OTs.  As an NDT certified OT I do not know of a motor theory that links hand function to core muscles.  However, athletes like weight lifters and javelin throwers who need superior arm strength know how important abdominal strength is to upper extremity performance.  Stroke survivors exert this same kind of extreme effort when they lift their arm with paralyzed muscles.  Don't believe me?  Therapists use two hands to lift a paralyzed arm.  Even they are challenged when lifting all that dead weight.