April 27, 2017

Two Sets of Ten Do Not Undo 12 Hours of Disuse

I had back spasms after my stroke.  It was terrifying to be frozen in standing hoping I would not drop my cane or fall down.  I was highly motivated when a PT gave me exercises to strengthen the weak abdominals that let my back arch every time I lift my hemiplegic leg.  I do these exercises before I get out of bed in the morning.  However, a few repetitions do not undo the effects of
12 hours of disuse.  

If exercise was enough, coaches would stop after they make football players run laps around the field and throw and catch footballs.  Exercise conditions the body, but the mind has to learn to use new skills when we are distracted.  Exercise strengthens muscles, but it does not retrain the brain to use muscles when we have a cognitive challenge.  

Transferring gains from exercise to my daily routine has had mixed results.  Success: I consistently lift my hemiplegic leg higher than is necessary to walk up the steps to my front door.  I am pleased I do not see scuff marks on the top on my new shoe.  I am no longer dragging the toe of my shoe over the edge of the step. 
 
Failure: I want to stop arching my back when I lean my stomach against a counter for support. I am failing two-thirds of the time.  To remind myself to reach forward and lean on my right hemiplegic hand, I put a beige piece of non-slip shelf liner on the front edge of the kitchen sink.  I kept forgetting to do this so I added a 2nd memory aid.  A blue piece of non-slip shelf liner reminds me to 1st rest my sound hand on the counter when my hemiplegic hand reaches for the counter.  I am improving so I know I can stop this bad habit.

April 18, 2017

Two Ways Therapists Earn Their Pay

Therapists help clients in many ways but here are two ways therapists earn their pay.

1.  Contraindications.  When I taught OT students I used case studies to make them to think about the needs of each client.  I had students work in small groups to treatment plan for one case and then had them individually treatment plan for a different  case on an exam.  This allowed me to identify students who knew which solutions from the 1st case could be used with the 2nd case.
For example, the 1st stroke survivor had a tight arm that did not want to straighten to allow him to don a shirt.  This client should be taught to use gravity to relax the arm by hanging it between his legs before dressing. On the exam I gave them a stroke survivor who had flaccid shoulder muscles that could not hold the arm in its socket.  Hanging the arm between the legs was contraindicated because it can damage nerves by stretching them.  A client should not have a brachial plexus injury added to the paralysis created by a stroke.  Students lost double points when they blindly used protocols that endangered a client.  The phrase "all strokes are different" can irritate stroke survivors, but a therapist who thinks all strokes are the same is dangerous.

2.  Nothing Works 100% of the Time.  When science finds a new cure it never saves 100% of the people.  A treatment protocol is considered successful when it cures a majority of the people.  It is a therapist's job to figure out what to do when a client does not respond to a protocol that has succeeded with other clients.  For example, the PT who is treating me after my knee surgery taped my knee.  I never dreamed the tape would aggravate the constant burning I feel in my foot.  When the burning sensation crept up my calf to my knee I took the tape off.  She will have to find another way to increase my knee stability.  Apple would lose business if updates they send to iphones work on only 80% of phones.  Humans have to live with the fact that we are not identical clones that respond identically to protocols.

April 10, 2017

Saved by Dumb Luck AGAIN

Pain is a great motivator.  A painful crack (black line in photo) that starts in the quick of my sound thumb returned this winter.  Every time I picked up an object the pressure opened this crack which was very painful.  So I was happy that dumb luck saved me again.  I bought a garden glove to wear when washing dishes because this glove is bigger and looser than a regular kitchen glove.  The roomier fit makes it easier to slip on my hand. 

The dumb luck came when I stapled the top of the glove
(see circle in 3rd photo) to shorten it.  As soon as I saw the cuff I created my hemiplegic (affected) hand reached out and pulled the glove on without my thinking about it. 





After I am done using the glove I remove it by resting the glove on a towel.  My slightly fisted hemiplegic hand traps the end of the glove while I pull my sound hand out.





Luck struck again when I realized the cuff could be used to hang the glove on a hook on the inside of the sink cabinet door.

I love avoiding medical catalogues that sell expensive equipment.

April 4, 2017

Time to Spend $32,500 on Stem Cell Therapy?

TeleHealth Medical Group is offering stem cell therapy to stroke survivors for $32,500.  So it is time to ask myself if I would do it.  A recent clinical study (1) raises four common sense concerns.

1.  Six of the 18 subjects experienced "serious treatment emergent adverse events."  While all events were resolved, it is disturbing that one-third of the people had problems after the surgery. Adverse treatment effects are real to me because I took hormone replacement therapy when it
was an exciting new way to handle menopause.  Unfortunately, hormone replacement therapy raises triclyceride levels which are fats in the blood that clog blood vessels.  My triclyceride levels went sky high which probably contributed to my stroke.  I have made my contribution to science so I will let others take the risk associated with stem cell therapy.

2.  The thrill of lifting an arm or leg one day after surgery is evident on the face of two subjects, but do isolated movements translate into functional gains?  The woman who beamed while lifting her arm over her head was pregnant at the time of the video above, but can she safely carry her child in her affected arm?  I have lost track of how many objects I have dropped while holding them next to my body as I walk, like dirty clothes, a book, and a pillow.  The problem with tests that evaluate movement outside of a meaningful context is that stroke survivors do not know what they can do when they have a cognitive challenge.  Manipulating an object while holding a squirmy, fussy baby is not the same as holding your arm in the air.  As an OT I was happy when clients made gains on motor tests.  A stroke showed me that passing items on a non-functional test is not good enough.

3.  After surgery there were significant gains in movement on the Fugl-Meyer Motor total score, but the majority of those gains happened in the first two months (mean increase for the group = 11.4 points).  Very small gains were made over the next ten months (mean additional increase = 1.4 points).  Are researchers telling subjects that stem cell therapy creates a small window where they have to do intensive rehab to retrain the brain?  Is Dr. Steinberg telling his clients that surgery is only the first step in recovery?

4.  $32,500 is a lot of money that I need to stay in my home.  I am willing to bet that TeleHealth Medical Group does not offer a guarantee that stroke survivors will see meaningful results.

1.  Steinberg G, Kondziolka D, Weschler L, et al.  Clinical outcomes of transplanted modified  
     bone marrow-derived mesenchymal stem cells in stroke: A phase 1/2a study. Stroke. 2016;47
     (7):1817-1824.