December 27, 2017

Walking in Snow with a Cane

Bottom Line: I am not ready to go to an assisted living facility were the van will take me to Wal-Mart once a week.

Warning: I do NOT poke my cane through the snow.  I wait until a neighbor I pay shovels my walkway and digs out my car.  I must be able to see the ground to tell if there is an icy patch that could make the spikes slip.  Checking the ground for ice slows me down, but it gets me to my car safely so I can drive.

The photo on the left shows the Briggs Ice Cane/Crutch Attachment.  I bought it at a medical supply store near my home.  The advantage of buying it in a store instead of on-line is the saleswoman got out a screwdriver and fastened the device to my cane.  It stays out of my way in the up position.














To lower the prongs, I place the cane in my hemiplegic (paralyzed) hand which holds the cane while my sound hand pushes the device down until I hear it snap into position.

The device makes my cane slightly heavier which slows me down which is not as bad thing.

I use another cane during warm weather rather than take this device off and put it back in the same place each winter.  homeafterstroke.blogspot.com

December 18, 2017

What a Therapist is Really Doing

Writing step-by-step instructions for how to treat stroke survivors would be like writing step-by-step instructions for how to play basketball.  The basket stays in the same position, but a player has to respond to players on the opposing team and make changes second by second.  Therapists face the same dilemma.  Haarman studied what therapists do when they walk stroke survivors (1).  Sensors on a stroke survivor's body found PTs used their hands to provide a corrective shift of 
only 2% of a client's body weight.  These tiny corrections lasted an average of 1.1 seconds.  Experienced therapists know bad things can happen if they wait to correct abnormal movements until they get larger.

Therapists also react to client behaviors that hinder recovery.  
I had clients who thought they were helping by standing up quickly and  launching themselves towards the bed.  I had fearful clients who pulled back the minute they felt me pull them forwards to do a transfer.  Add in day-to-day variables like fatigue and changes in muscle tone - guidelines are the best that can be provided for this logistical challenge therapists solve every day.

Even though I was an OT, I was not aware of my therapists' subtle, brief corrections after I had a stroke.  Stroke survivors have to concentrate fiercely to tell every body part what to do when we are relearning a movement.  When my PT walked me, I did not have one brain cell left to pay attention to what she was doing.  This led me to complain to my PT that walking was not getting easier as the days passed.  She told me I was improving because she was gradually giving me less and less assistance.  I never thought to tell this to my clients either.   homeafterstroke.blogspot.com

1.  Haarman JA, et al.  Manual physical assistance of therapists during gait training of stroke
     survivors: characteristics and predicting the timing. Journal of NeuroEngineering and 
     Rehabilitation.  2017:14(125).

November 21, 2017

Still Disappointed

A recent study on robotics leaves me disappointed once again.  Years of research on new technology for stroke survivors has not gotten past facilitating ARM movements.  As a stroke survivor I want to use the HAND at the end of my arm.  The challege is the wrist and fingers can perform 29 different movements.  Even worse, which of the 29 movements are needed depends on what each object demands. 

Researchers do not study simple movements that make a hand functional.  The photo shows my hemiplegic opening to hold a deoderant bottle resting on my lap so my sound hand can remove the cap.  The black lines show that
all activities do not require large shoulder movements.  Simple bimanual tasks would make it easier to program a robot, teach research subjects the task, and analyze data. 

To move research and treatment forward click on my Hand Evaluation page. homeafterstroke.blogspot.com

November 12, 2017

Doctors Do Not Prescribe Therapy After a Stroke

As a stroke survivor I was shocked to learn that clients get home health and out-patient services ONLY IF THEY ASK FOR THEM.  In the hospital clients are given a list of home health agencies in their county.  It is the client's responsibility to contact an agency and request services.  The agency then contacts their doctor who faxes a prescription to the agency.  Getting out-patient services is even harder.  Clients have to go on-line and ask friends if they know a good therapist.  Again they have to contact the agency who asks the doctor to fax a prescription.

I think neurologists, orthopedic surgeons, and general practitioners do not order therapy for stroke survivors for two reasons.  1. They have not kept up with advances in rehab for strokes.  You would think at least a neurologist would stay current, but they diagnose dozens of neurological conditions and cannot keep up with advances in dozens of fields.  Not staying current may mean a doctor thinks recovery after a stroke is possible only for a short while so there is no point in ordering therapy months or years after onset.

2.  The next time doctors they see me I am not cured.  They do not see the value of small gains.  The photo on left shows how gaining the ability to raise and straighten my hemiplegic arm allowed me to lean my hemiplegic hand on the counter when working at a sink.  This was a valuable way to prevent falls when I had poor balance.  The photo on the right shows that weak hip muscles allowed my knee to swerve left or right instead of staying in the middle when I bent my knee (red arrow).  After a round of PT I did strengthening exercises correctly at home (green arrow) to avoid knee replacement surgery.

               -- 

October 11, 2017

More Mini Exercises

Steinberg says adding another chore "stands little chance of lasting over time."  He thinks habit training is a good way to make exercising a reliable routine (1).  I agree with one condition.  It is easy to find an excuse to skip doing a long set of exercises (e.g. I am tired, I have a busy day).  However, in the 14 years since my stroke I learned I will do 5 repetitions every day IF I use an object as a memory aid.  I call doing a few reps every day until I die "mini-exercise."  It is hard to find an excuse to not do a mini-exercise.  Here is another example to add to my 1st post on
mini-exercise.

As an OT I had to pry open the hands of clients who had a lot of spasticity in their hand.  I do not want this to happen to me.  So before I open my hand to hold a deodorant bottle I practice opening my hand by placing it on the bed where I am sitting.




I repeat this exercise two times before I take the cap off the bottle and two times before I put the cap back on.  Four reps per day for years = lots of exercise.





1.  Steinberg O. Carryover Empowerment. OT Practice. 2017;July 10:14-18.

October 3, 2017

How I Get the Therapy I Need

Depressing statistics about getting therapy after in-patient rehab match my personal experience.
Researchers who analyzed data for 1,695 stroke survivors found that only 35.6% were referred to therapy after in-patient rehab ended (1).  Before the rehab hospital discharged me, a social worker gave me a list of home-health services in my county.  No one checked to make sure I contacted any of these home health agencies.  Getting out-patient therapy is even harder.  You have to do your own research (e.g. ask friends, Google) to find an out-patient therapist.

No internist, neurologist, or orthopedic surgeon has ever recommended PT or OT.  I get the therapy I need by asking for it.  I have never had a doctor refuse to give me a prescription for therapy, but none of these doctors has asked how my treatment is going.  I have to be in charge of my rehab.  I do not ask for therapy to go fishing for whatever therapists can think of to make me do.  I get what I need by creating a list of concerns that I bring to the initial therapy session.  I also check to determine when each concern is met during therapy.

I have had numerous rounds of out-patient OT and PT for stroke and orthopedic issues  However, none of the therapists told me it is time to end treatment until administrative staff tell them I have reached the therapy cap set by Medicare.  They looked surprised when I want to end therapy early because they have addressed my concerns.  I want to save the therapy time I have left for that year in case a new problem comes up.

1.  https://wakespace.lib.wfu.edu/handle/10339/86352

September 9, 2017

Happiness is Biochemical

"Your brain is like Velcro for negative experiences and like Teflon for positive ones" (1, p. 41).
We briefly notice positive experiences but they slip away the way a fried egg slides out of a Teflon-coated pan.  Our stone age brain is wired to immediately store negative experiences that may be threats (1).  A brain scan study found a part of the brain (amygdala) was activated faster when people saw fearful faces than when they saw neutral or happy faces (2).  24 hours later, they remembered more fearful faces than neutral or happy faces when shown the photos again. 

Surprisingly being happy does not require a positive attitude.  It requires concrete action.  Meditation has a positive affect on mood (3), but requires disciple and time.  Here is a simple action that can change the brain.

Take 5 seconds to enjoy a happy moment (1).  I try to notice happy events I did not plan, like the parking spot I got that was close to the entrance of a crowded grocery store the day before Christmas.  Lately I have been enjoying a shower.  I have been standing still for 5 seconds after I get out of the shower to enjoy this luxurious feeling.  When you are happy the brain releases dopamine which builds a more richly detailed positive memory.  For me, noticing multiple brief episodes of happiness has a cumulative effect that affects how I feel at the end of the day.

1. Hanson R, Mendius R. Buddha's Brain. Oakland, CA: New Harbinger Publications; 2009.
2. Yang E, Zald D, Blake R. Fearful expressions gain preferential access to awareness during
    continuous flash suppression. Emotion. 2007;5:227-250
3. Holzel B, Lazar S, Gars T, Schuman-Olivier Z, Vago, D, Ott U. How does mindfulness
     meditation work?  Proposing mechanisms of action from a conceptual and neural perspective.
     Perspectives on Psychological Science.2011;6:537-539.

August 28, 2017

A Great Camera for Stroke Surviors

Giving Power Point presentations to stroke support groups forced me to learn how to use a digital camera.  Using my camera for a year showed me I have a new hobby I can enjoy.       I e-mail photos to my family, put photos on my blog, and can save beautiful memories like this visit to Sayen Gardens.  However, here were five problems I had to solve along the way.
(1) I cannot hold the camera still with one hand so I would get blurry photos with many cameras. Cannon has cameras with Image Stabilization which corrects for movement that occurs when I press on the shutter button. (2)  Instead of buying on-line, I went to a store so I could play with several different cameras.  Going through sub-menus to choose different focus options was difficult with one hand.  My Cannon Power Shot A1100 model has a round dial on top of the camera I can turn to different settings.  I turn the dial so the arrow is pointing to the icon I want and I am done.
  
(3)  I am one-handed so I had to learn to use 3 fingers of my sound hand to hold the camera while the index finger of my sound hand pushes the shutter button.  (4) My sound left hand created another problem.  Shutter buttons are always on the right so sometimes I get a photo with a finger partially covering the lens (bottom right corner of photo).     I am saved by viewing the photo and reshooting if needed.  (5)  Impaired standing balance forces me to look at my surroundings to stay vertical.  I hold the camera at arm's length and look at the LCD monitor so objects in my peripheral vision can show me if I am vertical.  This is much safer than obscuring my vision by holding the camera to my face to look through the viewfinder.                                                                                                                Bottom-Line: Anti-depressants do not just come in a pill

August 21, 2017

When I Cannot Finish What I Started

If I were still married, asking my husband to fix me breakfast would have been a disaster.  Harley got up at 6 a.m. every day we were married.  His routine was to go to a convenience store like 7-11 to get a cup of coffee and sweet roll and come home to putter in the garage while I got ready for work. Then he drove me to the train station where I bought coffee and a bagel.  On Sunday I slept in and he went to a flea market.  I am a night person who can count the number of times I have seen the sunrise on one hand.  If he made breakfast for me after my stroke, one of us would have had to change a life-long habit.  Repeated frustration can turn into resentment.

If I want to wake up when I prefer, it does not matter if I can get out a box of cereal, a bowl, and a spoon.  My hemiplegic hand has to reach out to grab the handle of the milk container to stop it from moving when my sound hand pulls off the cap.  Even if my husband opened the container the 1st time, prying the cap off one-handed could make the container tip over.

 If I cannot open the milk container I cannot finish what I started


July 13, 2017

Good and Bad News About Hand Recovery

I do not have a high level of hand recovery so I look for studies that do not cherry-pick high functioning stroke survivors to test the efficacy of hand rehab.  Many studies with positive results start with stroke survivors who already have beginning finger and thumb movement.  To decide how excited to get I look at the outcome measures to see if the results apply to someone like me.

Franck studied stroke survivors with no spontaneous hand recovery (1).  Group 1 was taught to keep the affected arm/hand in an "optimal condition" and told what to do when discomfort occurred. Before rehab, the highest score on the Fugl-Meyer test was a 9 out of 66.  After 6 weeks of rehab for 4.5 hours per week, the highest Fugl-Meyer score was a 20 which can be achieved with
NO hand or wrist movement.  After rehab, object manipulation on the Action Research Arm Test (ARAT) improved from 0 to 1 out of 57 for one subject.  This is bad news.

Before rehab, Group 2 had a small amount of hand use during object manipulation as seen by ARAT scores that ranged from 1 to 9 out of 57 (1). Group 2 was given "high-intensity" therapy for
6 hours per week for 6 weeks to use their hand during functional tasks.  After rehab the highest ARAT score improved from 9 to 42 out of 57.  This level of improvement can be achieved ONLY by gaining the ability to pick up objects like a ball.  After rehab, the highest Fugl-Meyer score improved from 25 to 54 out of 66.  This dramatic improvement can ONLY be achieved with hand and wrist movements.  Turning a little bit of spontaneous recovery into the ability to pick up objects is good news.

1. Franck J, Johannes R, Smeets E, Seelen H. Changes in arm-hand function and arm-hand skill
    performance in patients after stroke during and after rehabilitation. PLOS One. 6/21/2017.
    doi.org/10.11371/journal.pone.0179453

June 20, 2017

Reviewing Virtual Reality Rehab

Between September 2011 and May 2017 Dean published 173 posts about the use of virtual reality to provide rehab for stroke survivors.  The results for the hand are depressing.  For six years research focused on a subject's ability to touch an object on the screen so the computer can move the object or make it disappear.  Enjoying these quick reactions is not enough to justify the cost of this expensive equipment.  It was a good place to start 6 years ago, but stroke survivors want to manipulate objects with their hand.

There is a glimmer of hope.  Gauthier (1) used video games that make stroke survivors do more than use their shoulder and elbow to reach forward and side to side.  These games require forearm and wrist motions.  This may not sound exciting but these motions orient our hand to the many different positions objects rest in. The photo shows the forearm is halfway between palm up and palm down so the hand can pick up a glass.  Cocking the wrist means the rim of the glass is not pointed at the ceiling but at the person's mouth.

Unfortunately, Gauthier selected stroke survivors who already had a few degrees of active forearm and wrist movement.  How can subjects make the leap from just reaching to turning their hand palm up to catch a parachute on a video screen?  My OT gave me exercises that helped me regain forearm and wrist motions.  These small motions make me more independent.  For example, I can turn my hand halfway between palm up and palm down to grab my cane so my sound hand can catch the door before the person in front of me lets it slam shut.  I picture stroke survivors practicing forearm and wrist motions and then immediately trying to turn their hand palm up so they can turn over a card on the computer screen.
Fun + lots of repetition is good.
1. Gauthier L, et al. Video game rehabilitation for outpatient stroke (VIGoROUS): protocol for a multi-center comparative effectiveness trial of in-home gamified constraint-induced movement therapy for rehabilitation of chronic upper extremity hemiparesis. BMC Neurology. 2017;17-109. doi:10.1186/s12883-017-0888-0.

May 29, 2017

Some People Feel Compelled to Help

I snapped at a dear friend when she offered to retie my loose shoelace.  Even though I said I could do it, she insisted on helping.  This made me angry because every doctor I have seen since my stroke reaches down to untie my shoes during a physical exam.  They do this quickly because they know it is inappropriate for a male doctor to undress a female patient.  I do not know how old I was when I decided my clothing is a part of my personal space, but it was a long time ago.

I have yet to convince people they cannot tie my shoelaces. Telling my friend I could do it as fast with one hand as she could do it with two hands was not a deterrent.  She said "I could tie your shoe at least once so you won't have to."  My strategy to handle this more gracefully next time will be to point and say "Can you tie a shoelace that has only one free end?"                                                                                                                        The strategy above works.  Able-bodied people no longer get upset when I will not let them help me tie my shoe.

May 22, 2017

Surgery is Dangerous for Me

Since knee surgery my standing balance is worse.  I have repeatedly stumbled backwards because I cannot feel when I am leaning too far behind vertical.  Losing my balance was the first symptom of my two brainstem strokes.
My strokes were caused by narrowing of the vertebral artery that supplies blood to the pons.  The pons in the brainstem is the bridge to the cerebellum which controls balance.

There is a chance that bending my neck back to put a breathing tube down my throat during surgery put a kink in the vertebral artery in my neck.  If a 15 minute meniscal repair surgery impaired my balance, I do not want to see what happens after a longer knee replacement surgery.   

Bottom-Line: I am serious about the exercises I got from my latest PT.

May 13, 2017

Rolling Discharge While I am Still in Therapy

When I am in therapy I do a rolling discharge.  I never wait until I am discharged to start doing exercises at home because there are often problems transferring exercises to a new environment.

The 1st challenge is modifying how I exercise at home because I do not have the right equipment.  For example, my PT had me lie on my stomach on an 8 foot wide mat table and bend my knee.    I need strong knee flexors to stop the joint-damaging SNAP my knee makes when I straighten it to swing my leg forward to take a step.  However, my single bed at home is narrow.  I tried lying on my back close to one edge, rolling onto my stomach which moves me to the other edge, and carefully inching my way back to the center by pushing with my elbows.  This was scary and stressful for my hemiplegic arm.
My soft bed also does not provide a firm surface to push off of.  I tried folding a yoga mat to create a firmer surface under my belly, but it was a nightmare to position with one hand.

The 2nd challenge is establishing a consistent routine that saves me from muscle atrophy after I  worked so hard in therapy.  A reliable memory aid helps me follow through on my good intentions.  I reach under the bed covers to remove the ball that keeps the covers off my hyper-sensitive big toe.  Instead of rolling the ball into its corner, now I roll it towards my leg brace.  After I don my brace the ball reminds me to go to the bathroom, stand while I hold onto the grab bar next to my bathtub, and bend my knee.  I can do 8 repetitions before my weak hamstrings poop out.

Bottom-Line:  Figuring out how to do exercises at home can take creativity and persistence.  Starting this process before therapy ends means I can ask my therapist for suggestions.

May 5, 2017

Mini Exercise

Knee surgery did not end my pain so I asked for PT.  My PT said my knee problem was caused by weak muscles that do not keep my joints in good alignment.  Yet I cannot be trusted to do boring, time-consuming exercises that never end.  When I was an OT I did not know how mind-numbing exercise is when it must be done every day until a client with a chronic condition dies.

I find it easier to incorporate an exercise into a daily activity than to add another exercise to my to-do list.  In the 13 years since my stroke I learned I will do 3 to 5 repetitions every day IF I use a familiar object as a memory aid.  I call doing a few reps every day forever a mini-exercise.  Here is one of the mini-exercises I do daily because I do not want knee replacement surgery.

My PT had me do lunges to strengthen my knee.  My knee wobbled left or right (red arrow) as it bent because my hip muscles are weak.  After a few reps hip muscles keep my knee lined up with my foot (green arrow).  I chose the toilet to prompt me to do lunges.  On his TV show Dr. Oz showed how much water sprays out when a toilet is flushed so I got in the habit of lowering the lid before I flush.  I have to wait for 10 seconds so I may as well do 10 lunges.
I do this at least twice during my morning routine.

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 allow my back to arch every time I lift my hemiplegic leg.  I do these exercises every morning before I get out of bed.  However, a few repetitions do not undo the effects of 12 hours of disuse.  

If exercise was enough, coaches would stop after they have football players run laps around the field and throw and catch footballs.  Exercise strengthens muscles but does not retrain the brain to use muscles when we are distracted.  Here is an example of what I mean.

I want to stop arching my back when I lean my stomach against a counter for support. I am failing 2/3rds 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 before my hemiplegic hand reaches for the counter.  I am improving so I know I can learn this new habit.  homeafterstroke.blogspot.com

March 29, 2017

Constraint Therapy is Good and Bad

Constraint therapy involves 1 or more hours of therapy that focuses exclusively on the hemiplegic hand plus wearing a mitt on the sound hand for 3+ hours at home each day to force the hemiplegic hand to work.  Constraint therapy is good because it challenged long held beliefs that clients cannot recover function for years after a stroke.

Constraint therapy is bad because it is appropriate for a limited pool of clients.  1) Stroke survivors must already be able to extend (straighten) their fingers 10 degrees and their wrist 20 degrees.
2) It is good for men who have women to take care of them.  Husbands may not be willing to help with chores at home while wives constrain their sound hand all day.

Current research offers an alternative.  Hayner found guiding both hands to work while making lunch, eating, and cleaning up helped stroke survivors improve as much as subjects whose hand was constrained during the same activity (1).  Sterr also found that stroke survivors who were helped to use their hemiplegic hand for 90 or 180 minutes improved as much as subjects who received constraint therapy for the same amount of time (2).  These and other studies have shown that any practice which is intense can produce recovery.  

1. Hayner K, Gibson G, Giles G. Comparison of constraint-induced therapy and bilateral treatment
    of equal intensity in people with chronic upper-extremity dysfunction after cardiovascular    
    accident.  American Journal of Occupational Therapy. 2010;64(4):528-539.
2.  Sterr A, Oneill D, Dean P, Herron K.  CI therapy is beneficial to patients with chronic low-
     functioning hemiparesis after stroke. Front. Neurol. 2014;5:

March 4, 2017

Hand Use Able-bodied Adults Take for Granted


When my hand was flaccid I had to put objects in my mouth or squeeze them between my thighs to hold objects still.  This made me aware of the dozens of times each day I used to reach out to hold an object still so the other hand could manipulate it.  Here is an example of what I mean.  It is aggravating to get out cereal, a bowl, and a spoon, but not be able to open the milk.  My hand can now hold the milk container still so it does not spin around when I remove the cap, but first I have to reach for the handle. 

Using my hemiplegic right arm to reach for and hold a lint trap so my sound left hand can clean the lint trap sounds like a deceptively easy skill.  If shoulder muscles struggle to lift the arm, high muscle tone can cascade down the arm and make hand muscles tighten.  It is difficult to open a tight hand.  I am grateful that my OTs, NeuroMove, and Saeboflex helped me regain  this simple skill.  Being able to reach out and open my hemiplegic hand to hold objects helps me do 26 ADL tasks

February 7, 2017

Opening Cans With One Hand

I do not use lots of canned food because most are heavily salted.  However, I love to make homemade spaghetti sauce and chili which require some canned food.  I make a big batch and freeze it in individual food containers that can be heated in the microwave.  Since I cannot make food taste better with butter or cream sauces I add lots of veggies to these one pot recipes.

I use an electric can opener made by Krups that uncrimps the metal rather than cutting it.  This leaves a smooth edge so the top can be put back on if you want to use the contents later.  The photo on the right shows how a right-handed person holds it while the photo below shows how my left hand holds it so I can see what I am doing.

Short cans do not have the clearance I need so I put them on a food storage container.  Since I do not open cans that often I have trouble finding the exact angle the opener requires.  I have to try two to three times before my wrist remembers the correct angle.          I know when I get it right because the noise changes from a high pitched whine to a low pitched growl.  The only time this can opener has let me down is when a hurricane has cut my electricity.

February 2, 2017

Research on Therapy Can Be Misleading

Researchers found stroke survivors regained hand function after Wii therapy (1).  They used stroke survivors who already had some finger movement before treatment began.  First, subjects must have small finger movements to be eligible for the modified constraint therapy given to the control group.  Second, the outcome measure was loaded with high level test items like picking up a paper clip (Wolf Motor Function Test). 

A study of the Smart Glove also used high-functioning subjects who were able to pass items on the Purdue Pegboard Test, the Jebsen-Taylor Test (e.g. write, scoop up beans with a spoon), and the Fugle-Meyer Test: distal items (e.g. pick up piece of paper) (2). 

Treatment may be appropriate only for a sub-set of clients so you should always read the description of the sample and outcome measures used in the study.  When researchers use high functioning subjects it makes the treatment look good, but can create false hope.

1) Trinh T, Scheuer S, Thompson-Butel A, Shiner C, McNulty P. Cardiovascular fitness is     
    improved post-stroke with upper-limb Wii-based movement therapy but not dose-matched  
    constraint therapy. Top Stroke Rehabil. 2016; June 23(3):206-16.
2) Shin J, Kim M, Lee J, et al. Effects of virtual reality-based rehabilitation on distal upper    
    extremity function and health-related quality of life: a single-blinded, randomized controlled     
    trial. jrneuroengrehab.biomedcentral.com/articles/10.1186/s12984-016-0125-x. Accessed   
    January 31, 2017.

January 31, 2017

Community Ambulation Falls Thru the Cracks

Stroke survivors have to figure out how to walk safely in the community.  Walking in PT gyms and on deserted sidewalks did not prepare me for walking in community settings.  I had to teach myself how to maneuver around carts and people in a grocery store, squeeze past closely placed chairs and tables in a restaurant, and deal with children in a shopping mall who do not look where they are going.  PTs do not know that walking requires divided attention because they walk clients in wide empty spaces that provide no cognitive challenges.  Equally unfortunate, OTs who are trained to assess and treat cognitive issues do not assess community ambulation because walking is PTs domain.  So community ambulation falls through the cracks. 

A recent study simulated the unpredictability of walking in the community.  Inness learned what stroke survivors did when they experienced an unexpected balance challenge (1).  Subjects were asked to stand with their feet on two force plates.  At an unexpected time the force plates were tipped forward and subjects had to recover their balance by stepping forward onto a third force plate. Clinical tests like the Berg Balance Test did not have a significant correlation with the unexpected stepping test.  The Berg Test does not measure real world balance because it allows clients to concentrate fiercely on their own body and decide when they want to initiate movement.

Bottom Line: Being afraid to walk in crowded environments is a major barrier to participating in valued community activities.  Limiting gait training to walking in the home contributes to social isolation and depression. 

1.  Inness E, Mansfield A, Lakhani B, Bayley M, McIlroy W. Impaired reactive stepping among
     patients ready for discharge from inpatient stroke rehabilitation.
     http://ptjournal.apta.org/content/early/2014/08/06/ptj.20130603.abstract.

January 14, 2017

Snow At My Door

Sometimes I can wait 1 or 2 days for the snow to melt when my area gets a warm spell after it snows.  This snow storm was followed by a 5 day cold spell.  Adding 2 more days for the snow to melt means I could have been home bound for a week.  Fortunately, this snow storm dropped only 3 inches of light, fluffy snow.



I handle this much snow with a broom and child-sized shovel (red handle) that I keep outside my front door.  With my sound hand and armpit, I sweep snow off my steps, push the snow off my walkway, and make a path to the door of my car.  I get rid of the accumulating pile of snow by using the shovel to flick the snow onto my lawn or make a pile in the street.  My neighbor does not drive so I do not feel guilty about making a low pile of snow in her empty parking space.

To clean snow off my car, I wear an apron so I can lean against the car without getting my coat dirty.  I hang the apron around my neck but do not tie the strings behind me.  I shove the snow off my car with the tool designed to clean wind shields.  It is easy for me to control because it is light and the handle is short.  It has a soft side that will not scratch the paint on my car and a blade side to clean the windshield.  Pushing snow off my car dumps snow on my feet so I wear snow boots (see previous post) that I can don one-handed.  When I get snow on my hand I am grateful for the super warm mittens I used when I was skiing.

I keep a container of ice melting crystals next to my front door.  This large container has a spout designed for sprinkling, but the container is too heavy for me to control.  I use a funnel to pour a manageable amount in a small container.  I place the small container and funnel in my bathroom sink to make the transfer.  Compensation does not make me sad - it keeps me in my home.  

January 3, 2017

STILL Being Undressed Like a Baby

Babies are not asked if they want to be undressed - they are expected to submit when people start pulling off their clothing.  I cannot believe doctors have been undressing me like a baby since I had a stroke 12 years ago.  I recently saw a doctor who reached down and undid the top strap of my leg brace so he could look at my lower leg.  To hide my anger, I told him I have taken off my brace and shoe 10,000 times and can do it faster than he can.  Yelling at a surgeon who is going to cut me open to repair a torn meniscus in my knee is not wise.  

Here is the script I will try the next time a doctor starts undressing me.  "If you were a gynecologist you would not undress a female patient.  But I understand your dilemma.  I specialized in stroke rehab and cannot tell what stroke survivors can do while they are sitting.  I would ask "Do you need help with.........."  (Dean, Mark -  have doctors tried to undress since you had a stroke?)

If the doctor asks me if I need help I will say "I can do it but thank you for offering."