Don’t give up on your arm

As a PT, and now the daughter of a stroke survivor, I’ve seen my father’s left leg recover some function while his left arm hasn’t changed much in 8 months. Working in the rehab field and based on the current literature, it’s extremely common to see a stroke survivor walk somewhat efficiently with a limp while their affected arm dangles lifeless at their side – even years after their stroke. Clinical notes and textbooks argue that in most stroke survivors, the function in the leg comes back far ahead of, and often more completely, than the arm. 

It seemed like a consistent enough problem that the physical therapist in me has spent the past 8 months desperately searching for the “Why?” and what I’ve found is this:

There is no physiological or anatomical reason for this.

I repeat – there is no reason (based on the anatomy or neuro anatomy) for this discrepancy.  So what does this mean and why is the arm so slow to return? Why do so many stroke survivors never recover meaningful use of their affected upper extremity?

The best theory I can compile (based on my reading and experience) is that this is only because of functional needs. Simply put – it’s because you can’t walk on one leg but you can function with one arm. From day one post stroke the focus of recovery is to get you up and moving so you have to use the leg each time you step. It gets all the attention while the arm just hangs there!

The current “compensatory” direction of the rehabilitation system perpetuates this “learned disuse” of the affected arm by teaching you to function without it. The arm simply isn’t treated in the acute and subacute rehab setting because insurance and time don’t allow it.  Both give stroke victims such a limited window in which to recover that safety in the home environment becomes the goal – not rehabilitation of meaningful function. You’re taught to dress yourself with the good arm, eat with the good arm, use the cane in the good arm, reach back for the chair with the good arm and etc, etc, etc. I can’t even begin to express the despair I felt when Dad was told to “just use the good arm” all the time to do things like dress, eat and bathe during his time at rehab. He already knew how to use that arm. Why weren’t the rehab professionals working on the affected side!?!

Even more frustrating is this false notion that exists in the inpatient setting that PT deals with the leg and OT deals with the arm. I can tell you that this is lazy rehab. PTs are trained to rehab the entire body – not just the leg).  Even worse, OT didn’t work on the affected arm! It almost came to blows when I found out that Dad spent an entire hour in OT “practicing” ordering Easter dinner online.  They kept telling me that his “cognitive function” needed rehab too and when I said “isn’t that what speech does?”, his OT said “Ocupational therapy does cognitive rehab too.” Well then who the heck works the arm!?!? If the rehab world won’t help you what do you do? 

You work the arm.

You have to crawl before you can walk…

Start small. Begin with exercises that you can do daily that do not require the help of another person. Start with exercises that can be done safely while sitting. I’d recommend that you sit in front of a mirror so you can see your progress – work to make the movement even on both sides and move slowly and deliberately (no spastic or jumpy movements).

  1. Shoulder shrugs: Shrug your shoulders up to your ears and relax back down. Be sure to move the affected arm and do not let your neck bend sideways. Think of “good posture” throughout. Do 20-30 attempts multiple times a day.
  2. Scap retracts: While siting with good posture, squeeze the shoulder blades back and down. Focus on keeping the torso and head still and get that affected arm to move back with the unaffected arm. Do 15-30 attempts multiple times a day.
  3. Rock the baby: Hook the affected arm and the unaffected arm on your lap in front of you. Do this by resting the forearm of your affected arm on the forearm of the unaffected arm. Hold the elbow of the affected arm with your good hand for support.  Then slowly rock both arms side to side. Use  the muscles in the affected arm as much as possible and try to make the motion big – moving evenly to the left and right side. Do 15-30 attempts multiple times a day.

These are just a small start. Each of the above exercises work to help you regain control of the shoulder blade and the muscles that lift and support the arm for movement. Most PTs believe in regaining proximal to distal (muscles closer to the torso and then muscles farther down the arm). While it’s not the only theory out there – it’s got great support in the literature and I’ve seen it work wonders on Dad. Motion and strength are starting to return now that he’s no longer in the “inpatient” system and spending several hours a day working just the arm.

One thing to remember: If the affected arm is still weak and partially (or completely) paralyzed, be sure that you are protecting the shoulder by supporting it so that it does not sublux (hang down and out of socket at the shoulder). When sitting, place a pillow under it, use a sling when walking (but never leave it on while siting) and considering taping or bracing until the shoulder muscles start to support the shoulder on their own.  I’ll have a blog post about that in the coming weeks too (so much information, so little time).

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One thought on “Don’t give up on your arm

  1. Sara G

    Angie –
    We are very well aware as IP PT’s to rehab the “whole body”. While my goals are based on function because that is mandatory for insurance repayment, your father and I spent plenty of time beginning UE return by facilitating UE weight bearing activities (seated, tall kneeling, quad, and prone, just to name a few) which start the proximal return of muscle activation and sensation which is critical for regaining shoulder and trunk stability. While we are limited in our treatment time, I can assure you that my approach was not lazy and I do not concentrate exclusively on the LE. Also, due to the acuteness of injury, neuro return may not be functionally seen while a patient is in their IP stay, but that doesn’t mean we haven’t started laying the groundwork for neuro plasticity and UE recovery which is almost always emerging in more functional ways once patients reach OP solely based on time from onset of injury. While I can’t speak for other therapists interventions, PT is not neglectful of the UE during our plan of care.

    I hope your father is doing very well. He is missed!

    Liked by 1 person

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