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

Fact or Fiction: Understanding recovery of movement after stroke

Last week, I presented a talk for stroke survivors affiliated with The Pacific Stroke Association.  Several attendees asked me to post my slides.  I am doing so, but some of the slides may not be entirely self explanatory.

Feel free to contact me with questions.

PSA 3-17

Cross-Brain Exercises

I was giving a talk over the weekend to a group of stroke survivors when a woman in the audience reminded me to talk about “cross-brain exercises.”  She had used these types of exercises to help her own post-stroke recovery.

There are lots of websites, You Tube videos, and books about exercises that encourage the two halves of your brain to communicate with each other. This is especially important when one half has been injured!   Historically, these exercises have been used for children to aid in neuromuscular development, but they are great for any brain ~ young, old, or injured.

Just a few ideas:

1. Reach for bean bags, balls, stuffed animals, or other objects across midline, then throw them at a target. You can use your sound or affected hand to do this exercise.  You can also use your feet to kick rather than throw across midline.

2. Draw large Figure Eights (the infinity sign or an 8 turned on its side) on paper or in the air with a finger. While drawing the Figure Eight follow the path closely with your eyes, but do not allow your head to move.  Then try it again, keeping your eyes quiet while allowing your head to move as you follow the Figure Eight.

3. Strength and coordination training of the sound hand or leg has been shown to be beneficial for affected / weak side. Practice lifting a weight with one hand and then placing it on the opposite side of the body without switching hands. Or lift a weight on your ankle and cross your leg over to the other side.

4. Touch the opposite elbow and to knee. You can begin by touching your elbow the the strong side to the knee of your weak side, and then vice versa.

5. Cross one foot over while sitting, then alternate.  To make this more difficult, cross one foot over the other while standing against the wall, or if you are doing really well over the other while walking sideways.

6. Windmills-Stand with feet spread apart and arms extended out to the sides. Bend over at waist and tap right hand to left foot or knee. Stand back up and then bend and tap left hand to right foot or knee.

Those are a few ideas.  You can also do cognitive exercises such as:

  1. Working puzzles.  Start with a 32 piece puzzle and work your way up to a 500 piece puzzle as you get better at it.
  2. Work on “hidden word puzzles”
  3. Play card games

The basic idea is to use your brain daily. If movement is limited, do the best you can to cross body, cross brain. Be creative!!