Goal Oriented Rehab

A study found people in rehab improved more when they worked on goals that were meaningful (1).  There are three kinds of OT goals, but you often see only two of them during an OT session.

1. The Preparation

OTs see many clients who need 100's of repetitions to rewire the brain and rebuild the body.  Examples include opening the hand with help from of a spring-loaded splint and scanning to the left for visual neglect.   

2. The I Shoulds
Many people have the same shoulds.  We all should get dressed so we can visit with others, do laundry so we have clean clothes, write legibly so we can sign credit card slips, and have good memory strategies so we get to appointments on time.  The photo shows my affected hand opening to hold the lint trap.

3. The I Want Tos

"I want to" is something personal that makes a client's face light up - like cuddling with a beloved cat without getting your bare thighs scratched.  Many valued activities do not take place during therapy because they require special equipment or environments.  OTs must link "I should" to        "I want to" so clients can understand what OT is trying to accomplish.  A linking statement might be "don a bra so you will not be embarrassed when you eat lunch with friends."  I live alone so donning my bra enhances my social life.  Or if a homebound client wants to feel the sun on his or her face, an OT can point to pictures or say "leg brace - patio."  homeafterstroke.blogspot.com

1. Lenze ER, et al.  Effect of enhanced medical rehabilitation on functional recovery in older adults
    receiving skilled nursing post-acute rehabilitation.  JAMA Network Open (in press).

Organizing My Purse is a Vital Shopping Strategy

Trying to find something in my purse by digging around with one hand is awful.  Organizing my purse reduces frustration when I go shopping.  Every woman organizes her purse differently so my examples are intended to help stroke survivors realize a purse does not have to be a buzz kill.

I put my car key on a green wrist coil to make it easy to retrieve.  I grab the wrist coil instead of searching for the key.  I made the mistake of setting the key down to pick up an object on my car seat and then locking and shutting the door.  Seeing my car key on the dashboard was awful.  The AAA car service unlocked my car after I waited for an hour.  When I made this mistake a 2nd time I knew I needed the sensory cue of the coil around my wrist to tell me I have my car key before I get out of my car.                                                                                                My house key is on a straight flexible coil that is hooked on my purse.  All I have to do is pull on the coil to make my house key slip out my purse.   

I can handle credit cards quickly because I keep them in a zippered compartment that holds only a driver's license, one credit card, an ATM card, and a library card.  While sitting in the parking lot I place the card I need vertically so it stands out from the other cards which are horizontal.  Cards go back in this zippered compartment in a flash.  Less frequently used cards like my health insurance card are in another compartment.    homeafterstroke.blogspot.com

Walking in a Barren Environment

Walking in wide, empty spaces did not prepare me for tasks that force me to stop concentrating fiercely on my hemiplegic leg while I am walking.  In-patient PTs walked me in gyms with equipment and people sitting around the periphery.  When two clients who are walking approach each other the PTs look at each other and decide who will stand still while the other person moves first.  Home health PTs walked me around the block in the middle of the day when nobody was outside.  PTs work in a barren environment that does not make them aware of cognitive demands.

Stroke survivors need to walk sideways between tables at a restaurant and go down stairs that have a railing only on their affected side.  At a store - walk in circles around racks of clothing and stop for people who are not watching where they are going.  At a hair salon - sit down in the chair without tripping over the big metal footrest.  Using a public toilet - turn around to sit on the toilet regardless of which side the grab bar is on.   Clients and family members need to understand that walking requires problem solving as well as physical mobility.  

Football coaches do more than have players throw and catch footballs and do foot agility drills.  Football players eventually have to stop concentrating on their body and start thinking about their opponents' strategy as they move.  Athletes and musicians have rehearsals to make the transition from practice to function.  Why are stroke survivors not getting the same kind of help?  homeafterstroke.blogspot.com

Home Programs Are Like Dieting

Home exercise programs are like dieting.  Both are "shoulds" that make me feel guilty when I do not do them.  As an OT I know exercise is important, but home exercises get boring after a few months.  I am still doing home exercises because each one is anchored to something I want.
For example, avoiding pain is a powerful anchor.

After I felt my OT massage a painful knot out of my shoulder I was determined to stop it from coming back.  The painful knot formed because I was repeatedly using my shoulder (see photo) to lift my hand. 






I start with my arms down at my sides and raise both hands to the middle of my chest using only my elbows.  This put less stress on my shoulder muscles when I lift my hand.  I do this movement 3 times before I take my pills with yogurt each day.

I set out the yogurt, spoon, and pills before I start exercising.  I am afraid I will lose the sensation of what normal movement feels like if I stop to gather supplies.  An anchor turns "I should" into "I want to."
homeafterstroke.blogspot.com

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 in the future (1).  A brain scan study found the brain was activated faster when people saw fearful faces than when they saw neutral or happy faces (2).  24 hours later, they also remembered more fearful faces than neutral or happy faces when they saw the photos again. 

Surprisingly, being happy does not require a positive attitude.  It requires action.  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 when I got the parking spot close to the entrance of a crowded grocery store the day before Christmas.  I sat still for 5 seconds, enjoying this treat before I got out of my car.  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 pay attention to brief moments of happiness, the brain releases dopamine which builds a richly detailed positive memory.  For me, noticing brief episodes of happiness has a cumulative effect that affects how I feel at the end of the day.  homeafterstroke.blogspot.com

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

Adaptive Garderning After a Stroke

Anti-depressants do not just come in a pill.  I am glad I found a way to garden after my stroke because it makes me happy.  I get to enjoy beautiful flowers every time I come home.  However, each year I forget the tricks I discovered so I took photos and described the steps.

At first I pulled plants out of their containers one-handed.  The moist dirt balls broke apart.  I learned to let the plants dry out a little.  The photo shows a child size spade I slide down the sides of each container to loosen the roots.  


I use a big plastic pot that is lighter than clay.  After I partially fill the pot, I put a ring on top of the dirt.  I made this ring out of a disposable plastic cutting board.  The ring keeps plants away from the rim and gives me something to lean the 1st row of plants against.  A small cup helps me fill the narrow space between the ring and the edge of the pot.  I make sure the plants are touching each other so they grow into a thick ball that prevents water evaporation.  I drop fistfuls of dirt in the small spaces between the plants.  Then I pull out the ring.

I use my hemiplegic (paralyzed) hand to hold the watering can still so it will not tip over as I fill it with the hose.  I use the garden hose to wash off the dirt I have spilled on my concrete patio. 

I lower the pot onto a bench and carefully slide it next to the chair I sit in to watch the sunset and drink a cup of coffee.                                                                                                                        P.S. Rebecca you only need four 4-packs.  homeafterstroke.blogspot.com