Good News about arthritis in my Good Hand

Eighteen years of overuse damaged the cartilage in the finger joints of my sound hand.  This produced bone-on-bone pain and swelling.  Fear about losing the use of my good hand motivated me to follow the joint protection principles I wrote about on February 11th, 18th, and 25th.    

After 2 months the pain and swelling in my good hand receded.  For example, a painful hand no longer wakes me up before my alarm clock goes off.  To see if the brief pain in my middle finger also disappears I decided to stop doing crossword puzzles.  Currently I am reading books I got from the library while I drink my morning coffee.  Thank God I have a book easel.  My post of          April 28, 2020 shows how I read hands-free.   

Now I have to figure what to do with my aching good shoulder.  Moving objects I use regularly to the bottom shelves in my kitchen cabinets has helped.  Now I have to tackle the ache I feel when I drive for 45 minutes.  When I visited Point Pleasant Beach recently, I was concerned about the ache I felt in my shoulder towards the end of the ride. This was a surprise because my good shoulder does not hurt when the steering wheel pulls to the left as I slow down to stop for a light.  However, keeping my car in its lane during long slow curves on the highway takes sustained effort.  My plan is to see if new tires and a front end alignment makes a difference. 

Bottom Line: Pain turned into a guide for what to do about arthritis.  homeafterstroke.blogspot.com

Freaked Out and Then Aggravated

I took Tylenol for three years because osteoarthritis had created bone-on-bone pain in my neck and low back.  I read on line that Tylenol can damage the liver so I freaked out when my feces turned yellow.  The liver secretes bile which turns feces brown.  My gastroenterologist said my feces would have been gray if my liver was not working at all.  I read the liver can repair itself, but I was not taking any chances.  On February 18th I stopped taking Tylenol.  Two weeks and 5 days later my feces turned brown. 

Now my arthritis pain kicks in every night which makes it difficult to fall asleep.  So I use hot packs that CVS calls Peas.  I put them in my microwave but am very careful to not overheat them.  When I touch them briefly they do not feel hot, but if I keep my hand on them I can feel the heat.  I am very conservative about the time I set the microwave for - 45 seconds for the big Peas and 30 seconds for the Peas I put on my neck.  The heat takes half an hour to be affective which is aggravating.  But it is better than rubbing my body and rocking while I watch TV at night because the dull ache makes me suffer.  homeafterstroke.blogspot.com 

A Painful Lesson About Need versus Want

After driving 51 miles every morning in rush hour traffic, I love relaxing while I sip coffee and do a puzzle from the Simon & Shuster Mega Crossword Puzzle Book.  When I do not know the name of a Greek God or other obscure facts, I look up the answer in the back of the book.  I have the satisfaction of doing a challenging puzzle while also finishing it.  Unfortunately, painful osteoporosis in my sound hand threatens my ability to drive a car one-handed.

Using paratransit to stay in my home would be difficult.  NJ paratransit can require riders to wait 40 minutes to be picked up and sometimes ride for an hour while other riders are delivered to their destinations.  It also has a two bag limit which requires multiple trips to the grocery store.  If I cannot find a way to make writing less painful, I will have to choose between something I love to do and driving which I need to do.  

Two adaptive devices that increase the diameter of a pen to discourage a tight grip did not work.  The hard plastic cylinder on the right has a tiny opening that does not accommodate my pens.  The soft tube on the left requires my painful hand to forcefully push the tube up onto the pen while I hold the pen in my mouth.  More pain is counter productive.  

My current strategy to make writing less painful has four parts.               1. Use double-sided tape to attach sticky Dycem to my pen.                         Increased friction means I do not have to grip as forcefully.              2.  Use a gel pen that allows ink to flow at a variety of angles.  

     Ball point pens are finicky about the angle you hold the pen.

3.  Put 2 or 3 fingers on top of the pen instead of the usual one.                     More fingers = less effort for each individual finger.                            4.  Keep all my fingers as straight as possible.  Bending my fingers               increases the pain. 

homeafterstroke.blogspot.com

Joint Protection Principles Part 2

Avoid a Prolonged Grasp.  A phone with a head set means my painful sound hand does not have to hold a phone for an hour when I talk to family and friends.  

I have an Accto book holder.  Movable arms (see arrow) accommodate different size books.  A lever in the back adjusts the tilt.  I recently read for half an hour while holding a magazine.  Pain in my hand woke me the next morning before my alarm clock went off.

Lift with the Strongest Joint: I use my elbow to lift heavy objects like

cereal and milk containers.  My painful sound hand acts as a pivot to aim the container opening while my affected arm controls how far I lift the containers. homeafterstroke.blogspot.com

Joint Protection Principles Part 1

I am trying not to freak out because I have osteoarthritis from overusing my sound hand for 18 years.  Xrays confirm I have bone-on-bone contact which causes pain.  I cannot count on another disease killing me before my sound hand becomes useless.  So I am using the pain in my index and middle finger to tell me which joint protection strategies are helpful.  For example, when I put away a stack of clean cereal bowls, it hurts to lift a stack of 3 bowls but not 2.  My hope is that reducing pain means I am putting less stress on my joints which will make my hand useful longer.

Slide Rather Than Lift.  I used to fill up my kettle and then carry it to the stove.  Now I put in water for only 1-2 coffee cups and slide it on a dishrag from the sink to the stove.  No pain.

I use my kitchen cart to roll clean dishes from my dishwasher to the cabinets.  This means I do not have to make multiple trips to carry all these heavy objects to put them away.  I lift dishes from waist height to only the 1st cabinet shelf.  No pain.   

Avoid Repeated Gripping.  I cannot stand to watch the same commercials 4 times every hour for months so I constantly change the TV channels with my remote control.  My remote is not heavy, but my painful thumb and middle finger have to hold it tightly because it wobbles as my painful index finger pushes a button. 
 

Now I place the remote on my palm while my sound hand rests on my couch. When my thumb reaches over to press a button, my palm presses the remote against my thigh which holds it still. No pain.  homeafterstroke.blogspot.com

Reducing Spasticity Without Needles

Many stroke survivors suffer with painful muscle spasticity.  

For example, the photo shows that spasticity can force stroke survivors to point their toes every time they straighten their knee to take a step.  Spasticity has been treated with Botox shots and repeatedly sticking needles into the painful area (needling).  

Researchers found a less painful way to treat spasticity (1).          Both the experimental group (n=25) and control group (n=25) got 30 minutes of exercise followed by 30 minutes of wearing a TENS unit that provided relaxing muscle stimulation.  The experimental group then had their ankles taped in the bent position to stop them from pointing their foot.  The tape was replaced every day.  Treatment was given 5 days a week for 6 weeks.

After treatment both groups showed reduced ankle spasticity and faster gait.  However, the group that also had their ankle taped improved significantly more (p < 0.05).  Creating a less painful way to treat a painful condition would be my preference.  homeafterstroke.blogspot.com

1. Tae-Sung In, Jin-Wae Jung, Kyoung-Sim Jung, Hwi-Young Cho. Effectiveness of transcutaneous electrical nerve stimulation with taping for stroke rehabilitation.  Biomed Research International. 2021; Article ID 9912094. doi:10.1155/2021/99112094.

Tricks for Stretching a Tight Hemiplegic Hand

I am haunted by a client who had her fingernails grow into her palm because the nurses could not open her tight hemiplegic (paralyzed) hand.  Here are tricks that make opening a tight hand easier. Trick # 1.  Using force makes spastic muscles fight harder. The instant you feel resistance slow down so movement is barely visible.  Patience pays off. 
Trick # 2.  Try not to touch the client's palm.  This may stimulate the hand to close.
 
Trick # 3.  To open the hand, start by bending the wrist slightly 1st.  This is how police get people to open their hand to drop a weapon.  Bending the wrist relaxes tendons that cross over the wrist before they go to the ends of your fingers.
Caution: Aim for a small amount of wrist flexion (see angle in photo).  As the tendons relax, the fingers will open slightly so you do not have to pull on fingers curled in a tight fist. 

Trick # 4.   A fist will relax even further if you straighten the thumb.  The thumb has half the muscles in the hand so it is a bully.  The trick is to wrap several fingers around the base of the client's thumb rather than pulling with the bony ends of your fingers.

 

Caution:  Overstretching the fingers can damage muscles  needed for active movement later on (lumbricals and interossei).  Always keep the fingers in a straight line with the palm.              DO NOT straighten the fingers like in the photo on the left.  

When stretching the wrist, it is better to aim for partial finger extension so muscles will relax instead of fight you.  I can get my wrist all the way back now, but I always keep my fingers in line with my palm (see green arrows).  homeafterstroke.blogspot.com

More Good and Bad News

The good news is exercise can help stroke survivors regain control of their body.  I have done exercises for 17 years after my stroke.  Pain motivates me to exercise.  When I fell I broke a forearm bone (ulna) near my hemiplegic elbow which caused arthritis.  This produces a sharp pain if I do not stretch.  Before I get out of bed, I repeatedly bend and straighten this elbow and rotate this forearm.  I also have a bad back that creates agony if I do not stretch every day.  I get up in the morning to go to the bathroom and go back to bed to stretch my back while my muscles are still warm.  Skipping 2 days makes me stiff and skipping 3 days produces pain.  

Preventing fatigue also motivates me to exercise.  A stroke can create crushing fatigue that I cannot push through.  After 2 days of walking indoors I feel tired when I walk in the community.      So at the end of each day I write that day's aerobic activity on a monthly calendar I keep on my kitchen table.  At breakfast I can see if I sat at home the day before and plan the current day's aerobic activity.  Examples include Fitbit data when I walk in my neighborhood and shopping that requires me to push a cart and repeatedly lift objects.

The bad news is I can no longer be trusted to do exercises that maintain strength.  1st, gradually losing strength does not raise red flags that compel me to act.  2nd, I have a life so I no longer want to organize my day around home exercises.  However, I repeatedly do a few reps that do not disrupt the activity I am doing.  It is hard to find an excuse for not doing these brief exercises. 

For example, I get up from the computer every 20 minutes to turn off an alarm on my iphone in the kitchen.  This alarm prompts me to do 3 brief exercises.  Before I stand up, I lean down so my hand almost touches the foor and straighten my fingers ONE time.  When I sit back up, I reach back to touch the back of my chair with both forearms ONE time.  This stretches the muscle that pulls my arm across the front of my chest (pec major).  After I go to the kitchen to turn off the iphone alarm, I sit and open my hand THREE times.  

I also open my hand when I sit on my bed to use deoderant.        I open my hand ONCE before I take the cap off the bottle and ONCE after I put the cap back on.

homeafterstroke.blogspot.com

Painful Lesson About Falls

Linda wrote a post in Leading a Healthy Life about dislocating her hip when she bent at the waist instead of bending her knees while reaching down to pick up something.  She screamed when her hip slipped out of its socket, when family members helped her sit on a chair, when the EMTs moved her to a transport chair, when they carried her up the basement stairs, when they put her in the ambulance, etc.  I also take chances when I reach down to pick up an object.  Even though I know better, it is frustrating to not be able to move the way I used to as an able-bodied person. 

I am grateful that Linda shared her painful experience.  Her description was so vivid it has changed my behavior.  For example, I put heavy bags on the top step (red circle) so I can I load them first into a rolling cart inside my front door.  I do not want them to crush fragile products like bread.  When I leaned way down to grab lighter bags on a lower step I thought "don't do this."  Now I use a safer strategy.  I expend the energy to walk down to a lower step (green circle) before I lift the lighter bags up to the top step.    

A few days later I felt my heels come off the floor while I was struggling to maintain my balance as I squatted to pick up an object under a chair.  Again I thought "don't do this."  I moved the chair.  In the coming weeks I will look for instances when I put my body in a precarious position.  Linda, thank you for reminding me to be careful.  homeafterstroke.blogspot.com

My Pain Got worse

My central pain became intolerable at night.  Central pain is constant pain created by brain damage.  Symptoms include pain caused by normally non-painful stimuli, constant burning, 

electric shock-like pain, and a stinging, tingling, or pins-and-needles sensation.  These abnormal sensations are usually localized to one body part, especially the hands or feet.  I have a constant burning sensation in my hemiplegic foot.  Three strategies give me relief.

Initially (1) taking Tylenol and (2) raising the sheet off of my foot helped me fall asleep.  In the photo I placed a ball outside the covers to show you what the ball under the covers looks like.  The ball keeps the covers off the end of my big toe all night long.  When these two strategies were not enough to help me fall sleep I added a 3rd strategy.

(3) Gel packs heated in a microwave oven.  WARNING: Gel packs heat up very quickly and are deceivingly cool at 1st touch.  I heat the gel pack for only 25 seconds on High because a stroke took away my ability to tell the difference between hot and cold in my leg. To safely remove the gel pack from the microwave and transport it to my bedroom, I put it on a stiff paper plate.  I place the gel pack NEXT to my foot. The gentle heat gradually extinguishes the burning sensation in my foot so I can fall asleep.

 Two sensations can cancel each other out.  This is why you rub a painful body part that has bumped into an object.  Ben Gay cream works because it has Capsaicin that produces a mild burning sensation that cancels the awareness of muscle pain.  homeafterstroke.blogspot.com

Kinesio Taping Reviewed

A subluxed shoulder is painful because the upper arm (humerus) has slipped out of the shoulder socket.  It felt like someone had punched my shoulder very hard.  Subluxation is rated by how many fingers you can fit in the space created by this abnormal shoulder separation.  I had a one finger subluxation so the hospital staff put a small lap tray that slid over one armrest of my wheelchair.  I made sure the staff put the tray on every day because I knew nerve damage can occur if nerves in the shoulder are stretched too much. 

The lap tray could not support my shoulder when I walked and did exercises while sitting on a mat table.  My shoulder ached constantly during these times until my OT bound it up with Kinesio tape. This wide tape provides support but is stretchy enough to allow movement.  I wore the tape 24 hours a day - even in the shower.  It eventually came loose and had to be replaced every third day.

Hanger and associates found stroke survivors who had their shoulder Kinesio taped had less shoulder pain (1).  The improvement got very close to statistical significance (p = 0.11) because some people were helped while others were not.  Kinesio tape was the only thing that made that my constant shoulder pain go away.  homeafterstroke.blogspot.com

1.  Hanger H, Whitewood P, Brown G, Ball M, Harper J, Cox R, Sainsbury R. A randomized controlled trial of strapping to prevent post-stroke shoulder pain. Clinical Rehabilitation. 2000;14(4):370-380.

Pain Scales

My knee surgery has been delayed.  I used some of my time to document pain levels.  Dividing pain into mild, moderate, and severe is not enough to identify 10 different levels.  Noting whether pain was intermittent or constant was helpful.  It helped to document when pain disrupted my Activities of Daily Living (ADLs) and how much pain reliever I took.  At 6-10, emotional distress added further refinement.  Here are the 10 levels of pain I have experienced over a lifetime.

1.  Have to think to recall if I had Mild  Intermittent pain during the day.
2 . Spontaneously aware of Mild  Intermittent pain throughout the day.
3.  Mild  Constant pain.  650 mg Tylenol at bedtime.  Must do some ADL tasks differently
     (e.g. walk down stairs backwards).
4.  Moderate  Intermittent pain.  Added 650 mg Tylenol in a.m. because I ache before I get up.
5.  Moderate  Constant pain makes me achy and exhausted by the end of the day.
     Worried about what 9 months of Tylenol is doing to my liver.
6.  I cannot tolerate Constant  Moderate pain much longer.  Irritable!! 
     Need 2 attempts to do some ADL tasks (e.g. stand up).
7.  Severe pain makes me afraid I cannot finish a task (e.g. thought about leaving loaded cart in

     the grocery store and going home).

8.  Severe pain makes me say "Ow that hurts" but I am able to remain still.
9.  Severe pain makes me Yell "OW" and I jerk involuntarily.
10. Excruciating pain: Not able to make any sound because I cannot exhale or inhale.
        homeafterstroke.blogspot.com

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.  So I was 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, I learned the hard way that a few repetitions do not undo the effects of 12 hours of disuse.  Exercise strengthens muscles but does not retrain the brain to use muscles when we are distracted.  Here is an example.

About 2/3rds of the time I arch my back when I lean my stomach against a counter for support as I reach.  To remind myself to lean on my right hemiplegic hand when reaching, 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 beige shelf liner.  I am improving so I know I can learn this new habit.  homeafterstroke.blogspot.com

What I Learned About Splints as a Stroke Survivor

When spasticity from a stroke holds muscles in one position, muscle become short which restricts motion.  Lannin (1) concluded "splinting has little or no effect on the loss of range of motion"

(p. 113).  However, Lannin told therapists to stop passive stretching and restrict active hand exercises to 10 minutes a day.  So the data does not tell us if a resting night splint is a useful addition to standard therapy.

I wondered what would happen if I did passive stretching and active hand exercises, but stopped wearing my resting splint at night.  After a month of not wearing a splint I could feel my thumb getting tighter.  I resumed wearing my splint and the next morning I woke up with a wicked ache in my thumb.  Closing my hand all day makes my thumb tight by bedtime so my splint has not eliminated spasticity.  Yet I believe my splint has prevented a painful permanent contracture.

I love my new SaeboStretch resting splint that I wear at night.  The new soft straps do not cut into my skin the way the old plastic straps did.  This version also uses a new kind of "Velcro" that does not have spiky hooks that scratch my bare thigh.  There are two thumb straps and three finger straps. The third strap that is hard to see holds down the little finger.  The cover zips off so it can be washed.  homeafterstroke.blogspot.com

1.  Lannin N, Cusick A, McCluskey A, Herbert R. Effects of splinting on wrist contracture after
     stroke. Stroke. 2009;38:111-116.