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

Human Standing

I see so many clients post-stroke who have poor standing balance yet have already begun to “walk”. They don’t actually walk, they “hobble”. Thing is that I have also noticed a lot of people who have never had a stroke also “hobble”, due to back pain.

I think that we have been ignoring the amazing features of the human brain and physiology that allow us to walk upright on two very small bases of support.  It is really kind of crazy that two little feet can keep us upright!  Well, we have more going for us than our feet…

Balance and upright posture is controlled by sensory interactions within our brains.  We do not “think” about balance, we simply balance. This requires that our brain be able to continuously compare input from our EYES, our INNER EAR, and SENSORY RECEPTORS in our MUSCLES.  After a stroke…or even an injury to the back… this sensory comparison is all out of whack! It is imperative to recalibrate the brain and the sensory signals it is utilizing.

A simple daily exercise will make a huge difference:

Stand against a wall with your heels touching the baseboard, hips touching the wall, shoulders touching the wall, head touching the wall.  Close your eyes.  Hold this position for 2 minutes with your eyes closed!  It will feel strange. Perhaps difficult and occasionally it may not seem possible. Stick with it.  After 2 minutes, open your eyes and then slowly turn your head to the left and then to the right, three times. Returning the head to midline each time.

Do this exercise 3 times per day every day for 2 weeks.

Once this is easy, the do the same exercise while standing in the corner of the kitchen. You will no longer be touching the wall, but instead free-standing as if you were against a wall.

*Always have supervision when doing any kind of balance training* Never try the exercise alone the first time*

Highs, Lows and Plateaus upcoming VIDEOS

I have heard from a lot of people now that they would love to see some videos to accompany the Stages of Recovery that I talk about in my book.  These stages were defined by a Swedish Physical Therapist, Signe Brunnstrom (1966, 1970), who described the process of recovery following stroke-induced hemiplegia. The Brunnstrom Approach, emphasizes the importance of encouraging movement within the synergistic pattern of movement that evolves post-stroke. As the stroke survivor improves, the exercises change.

I have spent quite a bit of time working out a series of exercises to help progress clients through the Stages of Recovery.  Keep a look out for upcoming videos and feel free to share them!

In the past, I have been stymied at Stage 5 and not sure how to help promote individual movement of the fingers.  Recently, I have had the opportunity to demo the Music Glove by Flint Rehabilitation and am very excited about the potential to rediscover finger movement: https://www.flintrehabilitation.com

Look forward to more to come.  DOWNLOAD SLIDES 03-15

Stroke Camp – La Jolla

I had the pleasure of attending Stroke Camp last week in La Jolla California.

@http://www.strokecamp.org/

I went as a volunteer and also to promote my new book, “Highs, Lows, and Plateaus: a path to recovery from stroke.”

@http://www.amazon.com/Highs-Lows-Plateaus-Recovery-Stroke/dp/1491862319

I can honestly say that I gained so much more than I gave!  It was a weekend of laughter and camaraderie ~ a weekend of sharing and supporting ~ a weekend of gaining strength from each other.  I met some amazing people and have so much respect for the stroke survivors and their loved ones who live each day with the struggles of stroke, and yet they turn those struggles into moments of inspiration and strength.

As anyone there can attest, I cry very easily.  Sometimes I tell people that I have “dry eye” and that the lubricating tears are just a side effect of the disorder.  Not true.  I just cry easily.  My daughter says it is because my heart sometimes brims over as tears.  At stroke camp, I did not cry tears of sadness.  Instead they were tears of release, of celebration for the strength of the human spirit.

Every day we hear about the pain and suffering and cruelty of our world.  What I experienced was only love and respect. That is what we need to be shouting from the mountain tops.  Not our differences, but our similarities ~ as people. From that we gain strength. Cheers to the Entire Team from “Stroke Camp”.  You are everyday heroes !