ADLs Are Where the Repetitions Are

Brain plasticity is amazing, but rewiring the brain requires thousands of repetitions.   Activities of Daily Living (ADLs) are a great way to get those reps. The examples below show why three sets of ten each day cannot compete with ADLs.

1) Twice a day I open my affected hand to grasp a tube of toothpaste so my sound hand can remove the cap.  My affected hand opens again to hold the tube while my sound hand puts the cap back on.  In nine years I have opened my hand over 5000 times before brushing my teeth.

2)  Shopping is therapy for my hand.  I open my affected hand to let go of the cart to reach for items with my sound hand.  My affected  hand opens a 2nd time when I grab the cart to move on. My affected hand opens a 3rd time so I can empty the cart in the check-out lane and again to load food into my car.  Pick uping 30 items + empty cart + load car means I open my hand 60 + 2 + 2 = 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.

3)  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 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!
homeafterstroke.blogspot.com

Are You Disabled?

A physical deficit may be permanent but feeling disabled can change depending on the expectations and resources of a specific environment (1).  Let me give you an example.  I heard people in the hospital say they cannot wait to eat a home-cooked meal.  But there is a catch.  At home people may be dismayed if "pop-pop" shows up for a meal when he needs a shower and a shave, is dressed in his pajamas, and has bed head.  I do not think dietary staff who deliver our meals expect patients to look good.  Resources can also be different in different situations.      In the hospital, aides help people with A.M. care and the dietary department cooks.  At home, the person who cooks and assists someone with an impairment may be the same person.  You may feel more disabled at home because your family has different expectations and resources than the hospital.  

Whether you are disabled also depends an whether you think independence should always be the goal.  Phalen says no one is truly independent (1).  Many people do not cut their hair, change the oil in their car, or prepare their tax returns.  However, able-bodied people help each other by dividing up a list of tasks.  Stroke survivors who have only one good hand may not be able to finish what they started unless they get help for specific steps during a task.  Repeatedly waiting for help during a task can get on your nerves.  My thumb leans on the independence side of the scale.  homeafterstroke.blogspot.com

1. Phalen SK. Constructions of disability: A call for critical reflexivity in occupational therapy. Canadian Journal of Occupational Therapy. 2011;78, 164-172. doi:10.2182/cjot.2011.1.78.3.4.

Practical Guide to Giving Assistance

Activities of daily living (ADLs) evaluations divide assistance into mimimal, moderate, and maximal.  The Functional Independence Measure defines these levels by the percentage of a task a client can do independently like 25 - 49%.  OTs can guesstimate these percentages because they see hundreds of clients which helps them judge a client's performance.  Caregivers need a more practical way to know how much to help.

Minimal assistance = you can multitask because your loved one can do a lot, but stay near by.      Moderate assistance = sit or stand in front of loved one because they will need repeated help.  Maximum assistance = look for ways for your loved one to help you ( e.g. have them put their arm around you to help you scoot them to the front edge of the wheelchair before you stand them up).

OTs have an incentive to keep their hands in their lap - every time they help it lowers a client's ADL score.  Caregivers have different incentives for waiting to see how much their loved one can do.  Caregivers need energy to do chores their loved one usually does, like cleaning toilets and mowing the lawn.  Caregivers also need energy to make doctor and therapy appointments, arrange transportation, deal with health insurance bills, pick up medications, set up home exercises, and deal with a loved one's difficult emotions. 

When therapists say a client needs assistance, caregivers need to think about asking for help before they get into trouble.  Nurses gave caregivers a preparedness questionnaire before discharge from rehab and asked them what they were thinking as they answered each question (1).  A dialogue is much better than a handout.  homeafterstroke.blogspot.com

1. Carmicia M, Lutz B, Harvath T, Joseph J.  Using the Preparedness Assessment for the Transition Home After Stroke Instrument to identify stroke caregiver concerns predischarge: Uncertainty, anticipation, and cues to action.  Rehabilil Nurs.  2021;Jan-Feb 46(1);33-42.  

I Take My Brace Out of My Shoe Twice a Year

Putting my foot in my brace and then putting my brace in my shoe with one hand is insanely difficult.  Instead I leave my brace in my shoe except twice a year when I transfer it between my black shoes for winter and my tan shoes for summer.

My sound hand grasps the tongue of the shoe and I let the weight of the brace swing the shoe up in the air.  I hook my hemiplegic elbow behind my knee to help lift my hemiplegic leg so I can put my toes partway in the brace.  Finally I put the shoe down on the floor and press downwards to slide my foot in the rest of the way.  No swearing required.  homeafterstroke.blogspot.com