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)

 

May is “Stroke Awareness Month”

When I was actively lecturing on the warning signs of stroke and the need for immediate medical attention, I would get letters from people.  Lots of letters.  Letters that said thank you for teaching the warning signs of stroke.  It is so important to know when to call 911 – because everyday heroes are the ones that can change the outcome for a person having a stroke.

An excerpt from my book “Highs, Lows, and Plateaus: a path to recovery from stroke”

“It is very important for everyone to recognize the signs of stroke, because stroke strikes anywhere, anytime, across age, ethnicity, and socio-economic groups. I have never known anyone who planned on having a stroke. But, I know a lot of people who survived with minimal deficit because someone else recognized the signs and sought help. Unfortunately, in my field of work, I also know a lot of people whose symptoms of stroke went unrecognized. Remember, according to our national statistics, fewer that 7 percent of stroke victims get to the hospital in time for emergency intervention.

The odd thing about a stroke is that the person having a stroke often does not fully realize that anything is wrong. When asked if they are o.k. the person having the stroke quite often says they are fine or makes up a reason to explain their behavior. Remember, it is the brain that is under attack – and this is the same brain that is supposed to be identifying that something is wrong! A brain under attack is going to have to rely on someone else to identify the problem and seek help.”

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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!

Focus should be on “partially complete” versus “incomplete”

Rehab gyms across the country, such as SciFit and ProjectWalk are changing the scope of recovery following spinal cord injury and stroke. Rather than focusing on the deficits and problems left by the injury, their focus is on the potential for neuroplasticity and learning within the human central nervous system. Movement recovery depends on a demand for use. Rehab professionals should embrace a change from speaking of the negative “incomplete” and focusing on the positive “partially complete”. This is the only way we can change the dialogue around recovery.

I would love to hear from survivors who have continued to improve and reach their goals despite a negative prediction set by many health care providers.

The Highs and the Lows

It seems that each week, I hear from someone who has been told by their doctor “not to expect any further recovery.” Most recently, I heard this from a young man who had an incomplete Spinal Cord Injury only a few months ago! Such a statement by a doctor is utter non-sense, so I ask myself “Why would someone say that?”. What I have decided is that health care professionals play it safe by not promoting any form of expectation from their patients. If someone is told they will never do anything again, and then they accomplish something they are pleasantly pleased… in fact, they feel that they have beat the odds.

I think we need to let people expect more. We need to instill hope through information and education and resources. No false promises, but rather the opportunity to believe in the power of neurorecovery and the strength and resilience of the human spirit.

Well two months after meeting that young man, he has already made tremendous gains and yet the words of his doctor still haunt him. It will take a long time to diffuse the negativity of comments that are destructive to the potential of hope, handwork and neuroplasticity.

WORLD STROKE DAY

Today is World Stroke Day. It is a day dedicated to increasing awareness about stroke and the warning signs of stroke. Stroke strikes anywhere, anytime, across age, ethnicity, and socio-economic groups. I have never known anyone who planned on having a stroke.

Stroke is the result of disrupted blood flow to the brain. The more technical term is Cerebral Vascular Accident (CVA): cerebral = brain, vascular = blood flow, accident = unexpected. The more attention-catching media term is Brain Attack – much like a Heart Attack. A heart attack occurs when blood flow to the heart is interrupted and the cells that are electrical in nature stop functioning. Likewise, a brain attack occurs when the blood flow to the brain is interrupted causing the cells that are electrical in nature to stop communicating. The symptoms of the brain attack (stroke) will depend on which pathway for blood flow is interrupted and thus the corresponding region of cells whose communication is compromised.

I graduated with my bachelors’ degree in Physical Therapy in 1985. At that time, there was not a lot that could be done in regards to the emergency treatment of stroke. By the time I earned my doctoral degree in Neuroscience and Physiology in 1995 progress was in the making. In February 1996, a clot-busting medication was approved, by the Federal Drug Administration, for the emergency treatment of stroke.

Advances in imaging and drug delivery have helped to lengthen the treatment window for using tPA. Clot-retrieval devices that mechanically reach into a blood vessel to remove the clot have recently come onto the treatment scene and have lengthened the treatment time window. Surgical advances have also been made in the treatment of hemorrhagic stroke.

In 2003, the Joint Commission, a nonprofit organization that accredits and certifies healthcare organizations, joined forces with the American Heart Association and American Stroke Association (AHA/ASA) to begin certification of Primary Stroke Centers (http://www.strokeassociation.org). These centers are certified to provide for emergency treatment of stroke. More than 900 hospitals nationwide have been certified. It may be worth knowing which hospitals in your area are certified.

In 2012 this accreditation process was expanded and the Joint Commission together with AHA/ASA began certification of comprehensive stroke centers. These centers are even more specialized having advanced treatment and surgical tools for the emergency management of stroke.

With more awareness, better treatment and improved follow-up rehabilitation, we can reduce the devastation caused by stroke.