The Arm – No Movement Yet

In Stage One, the arm is flaccid. It is lifeless. This is the stage of cortical shock during which most cortical and brainstem neurons are in electrical silence.

The shoulder is generally subluxed and the arm has fallen out of the joint.  I have an earlier blog post about some Dos and Don’ts.  Most important is Do Not over stretch the shoulder joint!  Motion of the shoulder and arm at this time should only be done with the stroke survivor is laying on their back AND the arm should never be brought past about 90* shoulder flexion (the arm is vertical to the body when someone is laying on their back).  Over-stretching will damage the tendons and joint of the shoulder!

  Often the hand is swollen and puffy looking. It can sometimes look plastic and can sometimes hurt. The most important thing here is routinely touching and massaging the hand. Someone else may need to help the stroke survivor with this.

SITTING OR LAYING ON YOUR BACK

Hand massage– massage the web between the thumb and index for 30 seconds, then gently straighten each finger individually by working down the length of the finger from the first knuckle to the tip of the finger. Continue the massage for a minimum of 2 minutes.

Rotation of the forearm– after massaging the hand, hold it open at the wrist and fingers then rotate between palm down (pronation) and palm up (supination) for a minimum of 2 minutes. End by bringing the wrist into a full extension stretch.

Elbow Flexion/Extension with Pronation Supination– holding the hand at wrist and thumb to maintain an open position, move the elbow into flexion with supination, then into extension with pronation. Continue for a minimum of 2 minutes.

LAYING ON YOUR BACK

It is very important that the stroke survivor is laying on their back for the following exercises.  We want Gravity to assist in bringing the shoulder into the socket and stimulating the sensory receptors for the muscles of postural stability. The shoulder blade is stabilized by being in laid upon so shoulder flexion should not exceed 90* at this time.

Ceiling Reach with small circles– An assistant or therapist brings the paretic arm to a 90* flexion angle to the body. Hand-holds should be behind the elbow keeping it straight and at the wrist or fingertips bringing the hand into extension. Maintain this position for a minimum of 2 minutes while doing VERY small circles with the shoulder joint. Carefully lower the arm to the mat, rest and repeat.

Ceiling Reach with elbow flexion/extension– An assistant or therapist brings the paretic arm to a 90* flexion angle to the body. Hand-holds should be behind the elbow keeping it straight and at the wrist or fingertips bringing the hand into extension. Bend the elbow 15* asking the stroke survivor to assist you. Then Straighten the elbow asking the stroke survivor to assist you. Repeat this motion with the arm at 90* shoulder flexion for a minimum of two minutes. Carefully lower the arm to the mat, rest and repeat.

AFTER TIME and PRACTICE WITH THESE EXERCISES, THE ARM WILL BEGIN TO HAVE SOME RESISTANCE TO MOVEMENT (tone) AND EVEN SLIGHT MOVEMENT AT THE ELBOW AND SHOULDER.  THAT IS EXCITING!  THEN IS IS TIME TO MOVE TO STAGE 2 EXERCISES. 

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Eye Exercises for Visual Field Loss

Often a stroke survivor, or survivor of traumatic brain injury, has a loss of visual field perception, often termed Hemianopsia.  They may be unable to see to one side, or they may have blind spaces in their visual field.  Many eye doctors still believe that this visual field neglect never improves after a stroke. However, in my experience, exercises that promote eye, neck and inner ear coordination do in fact help reduce the visual deficit.

Below are some exercises that I frequently use with patients in the clinic.

EXERCISES FOR VESTIBULAR-OCULAR-COLIC COORDINATION

Exercises should be completed at least 3x/day for a minimum of 10 days. It is important to have adequate water/hydration before and after each exercise set.

The GOAL OF THESE Exercises is to maintain your visual focus on the target, despite either the target or the head moving. Exercises should first be done SITTING. After all exercises are easy to complete in sitting – be sure to do the full 10 days – then you can progress to doing them in STANDING.

 Briefly close the eyes and rest between each Exercise Set. If they cause extreme dizziness (greater than 5/10 intensity) then a reassessment should be done. All exercises are initially done for 10 days with only horizontal or vertical movements. Diagonal patterns should not be added until the other directions are easy and cause no dizziness.

* IF the stroke survivor cannot hold the card(s), then another person can hold the card(s)*

EXERCISE ONE – STATIONARY HEAD / MOVING TARGET

Hold a playing card or small object arms length from your eyes, nose height. Keeping your head completely stationary, move the card/object slowly from Right -> Midline -> Left -> Midline -> Right (repeat 3x) .

While the card/object is moving keep your eyes focused on it , but your head still.

After a brief rest, keep your head completely stationary, move the card/object slowly

Up -> Midline -> Down – Midline (repeat 3 x)

 

EXERCISE TWO – STATIONARY TARGET / MOVING HEAD

Hold a playing card or small object arms length from your eyes, nose height. Keeping the card/object completely stationary, move your head slowly from Right -> Midline -> Left -> Midline -> Right (repeat 3x) .

While your head is moving keep your eyes focused on the card/object.

After a brief rest, Keep the target completely stationary, move your head slowly Up -> Midline -> Down – Midline (repeat 3 x)

 

EXERCISE THREE – TWO STATIONARY TARGETS / STATIONARY HEAD

Hold a playing card or small object in each hand, arms length, nose height with approx. 3 feet spread between hands. Keeping your head still, rapidly look from left to right focusing on the card/object on one side then the other (10x each side)

 

ReLearning to Walk After A Stroke

I recently presented at a Stroke Symposium for the Pacific Stroke Association and several members of the audience asked me to post my slides.  They are posted here for educational purposes only. Not all of the slides are self-explanatory, so if you have questions please feel free to contact me.

Just a reminder:  IF you are holding onto anything with your hands, or if a therapist is holding onto you during your “balance exercises”  you are NOT working on balance.  One must not have contact with anything when learning to balance on their own, therefore it is very important that you practice only in safe confine with another person guarding for safety. I recommend standing with your back very near but not touching a corner, then placing a walker or chair or person in front of you for safety. 

ReLearning to Walk 09.17

The Subluxed Shoulder – stage one

The subluxed shoulder is a common problem post stroke and often treated only with a sling, that really does not offer much support.  I think we need to change the way we treat the subluxed shoulder.  Historically, weight bearing through the paretic arm has mostly resulted in a painful shoulder.  Often the paretic hand is bound / tied to the handle bar of machine that does reciprocal pedaling/rowing/etc.  This is really not good for the subluxed shoulder. Every revolution of the handle bar is essentially pulling the arm out of the shoulder joint again.

In my book “Highs, Lows, and Plateaus: a path to recovery from stroke” I talk about the stages of recovery following a stroke.  Not everyone goes through these precise stages but it provides a framework.  Early on the arm is often flaccid and the shoulder joint becomes subluxed, i.e. the upper arm bone literally slips out of the shoulder socket.  A few DO and DO NOT lessons that I have learned:

DO

  • Use a sling to keep the arm safe when walking
  • Electrical stimulation to the muscles of the shoulder joint is helpful when used daily on a set protocol.
  • All exercises for the arm should be done while lying on your back.  This provides stability to the shoulder blade and also allows the upper arm to gently glide back into the joint.
  • The first exercise is to bring the weak arm gently over head (with help from your strong arm) so that with your hands together, both arms are vertical to the body (90 flexion) and the elbows are straight.  Then  make TINY little circles with the hands allowing a gentle motion of the shoulder joint. This allows the joint to gently settle into the socket and stimulate the sensory receptors that then excite the muscles around the joint.

DO NOT

  • DO NOT Use any type of reciprocal exercise machine for the weak arm!
  • DO NOT Put weight through the weak arm – not until the shoulder joint is no longer subluxed out of the socket
  • DO NOT Overstretch the arm by having any motion that brings the arm overhead or out to the side.  If an overhead motion is made, then the shoulder blade MUST also be rotated to prevent the arm bone from pinching into the front of the shoulder socket

As you do the first exercise the muscles around the shoulder joint will begin to activate again. As the subluxation resolves, the exercises are advanced.

 

 

 

Progress in 2014

2014 was a good year… now cheers to 2015!

I wanted to highlight a few successes that some of my clients had in 2014:

K. received a new dynamic ankle brace and is now walking more than ever.  He reports that he can feel the muscles in his weak leg getting stronger, and he can walk over uneven ground, up /down stairs easily and finally can say that he enjoys walking again.

C. is using her fingers again!  Not quite two years post stroke and she is able to use her hand to help her with all kinds of daily activities.  She has returned to work full-time and has also gotten back in the routine of being “mom” in her family now. It was hard having her daughter and husband take care of the baby, but she is back. This year, is dedicated to fine motor control in those fingers!

E. became independent in transferring into the shower, is driving his own van, and is learning to walk again.  Not bad for someone who is not even three years post injury to his cervical spinal cord.  No need for an electric chair because he can push himself in his new lightweight chair and feels he is getting stronger (below the level of lesion) every day.

S. returned to work full time, is using her right hand for typing and is talking up a storm!  She and her family have fought hard.  Still a ways to go until this young woman feels satisfied with her recovery, but I have no doubt she will get there.

M. barely survived his stroke, but he is getting better every day.  He can stand independently, transfer for showers and walk short distances.  Mostly delayed now by distorted vision that makes it hard to move, but he is having a surgical procedure this week that hopes to improve his vision.

Just a few successes.  Would love to hear from others about the Highs, Lows, and Plateaus of recovery.

Cheers to 2015!

Options for ankle bracing

Why is the ankle so difficult to recover function after a stroke?  There are a lot of reasons that circle around the neurological control of the ankle, the complexity of the ankle joint, and problems with sensory awareness after stroke.  If you think about it, it is pretty cool that a foot and skinny little ankle can support our entire body all day long!

So, I really do not like the plastic molded ankle joints that so many people are sent home with!  They make NO sense to me.  They are rigid, have no energy storage, block sensory signals from the foot, block the natural motion of the foot bones and they are just plain ugly.  I think it is time we all start demanding that stroke survivors be fit with dynamic, energy storing ankle braces.

There are a lot available, but here are the four I have worked with just this week and have been very pleased with how well they work in not only providing support to the ankle, but providing for a dynamic, energy-storing system that actually helps one learn to walk again.

 

 
 

 

Please note that this information is provided for educational purposes and does NOT provide endorsement of any particular device.

Get rid of the rigid AFO

The rigid AFO serves a purpose early in rehabilitation following stroke.  It provides stability to the weak leg, allowing people to safely stand and transfer.  This rigid AFO, however, is NOT the ankle brace that should be used when one is learning how to walk again.  It is time to start demanding that ankle orthosis be made so that a hinged ankle and some form of dorsiflexion assistance can be added once the survivor is ready to learn to walk.  Using a rigid ankle brace almost demands that the person learn to walk with a stiff leg, that is thrown forward with hip hike and circumduction.  One cannot bend the knee for walking if the ankle is fixed!  Simple biomechanics.   So, how do we change the way Therapists, Physicians, and Orthotists approach the ankle??