Tag Archives: arm rehab

Break it down

Recovering from a stroke is a daunting task.  Where do you start?  What do you do first? What movements need to be trained first? Second? Third? And if that wasn’t enough – what about the very low level stroke survivors?  The ones with lots and lots of impairments.  They have so much to overcome and the day is only so long…What do you prioritize?

Start with one task. Any task.  It almost doesn’t matter what it is – it just has to be important to you, to the survivor.  Walking, getting up from a chair, reaching to grab an object on the table, opening a door, holding a cell phone.  Any task that is meaningful is recoverable. I’ll say it again –

Any task that is meaningful to the survivor is recoverable.

Wait – what? I know some of you are thinking, “but that goes against what the doctors have told me” or “I’ve seen survivors with permanent disability so you must be wrong.”  I’m not wrong and I’m not an unrealistic optimist. Here’s why:

Those doctors aren’t thinking long-term.  They can’t possibly fathom the amount of time recovery takes or the amount of hours that go into it.  They’re taught that the brain, once damaged, stays damaged.  They’re taught to think negatively because in our litigious society, hope can lead to liability. They aren’t dreamers – they can’t be.  Let them handle your blood pressure and cholesterol but don’t let them dictate your prognosis.

And yes, there are stroke survivors who years later have disability. That doesn’t mean that they’re done recovering – it just means that they have “plateaued.” Their efforts and their training are no longer sufficient to challenge the system and promote rewiring.  They are living in the “status quo” because they’ve got a routine that they’re doing and they aren’t changing it.  Maybe they are comfortable with their day-to-day.  It’s safe and they’re not afraid all the time.  That’s absolutely okay – if they’re happy and they have a meaningful life that they enjoy!

But if they’re not happy or fulfilled (or you are the survivor and in that situation) – read on!

What to do:

To change the system you must challenge it to rewire and perform meaningful tasks – and you must do so REPEATEDLY. When I say repeatedly, I mean A LOT of repetitions and quite OFTEN. How many repetitions? While there is no “magic number” studies show that 1200 repetitions begins to activate new areas of the brain.  So there’s a starting point – more than 1200 repetitions before anything even begins to improve….

Well crap (excuse my language) – that’s a lot of repetitions just to get started. (sad face).  And when most of those repetitions are UNSUCCESSFUL there is another issue to deal with – frustration. Frustration is a rehab killer.  The hardest part of rehabbing Dad has been finding a way to eliminate or “push through” the frustration that comes with a lot of unsuccessful efforts.  In order for him to regain movement he has to try to move, but when he makes an attempt and nothing happens, his world comes crashing down again and again.  I’ve tried lots of things to help him through, but ultimately the ONLY WAY that has worked is to break the task down into small and achievable parts.

This is where my background as a physical therapist and a gymnastics coach have come in handy.  If you think of a task as a sequence of parts or a series of movements you can rehab your way back to doing anything. Remember – the brain is plastic (meaning it wants to rewire and learn new things), you just have to stimulate it.

Here’s an example:

The Task: Reaching and grabbing an object on the table with your affected side while sitting.

The steps of that task:

  1. Sitting in a chair with good posture
  2. Bending the elbow and lifting the hand off your lap
  3. Lifting the arm up off your lap
  4. Lifting the arm up onto the front edge of the table
  5. Extending (straightening) the elbow
  6. Sliding/reaching across the table with the arm
  7. Moving your hand close to the object – so that you can grab it (positioning it)
  8. Opening your fingers to place the object in your hand
  9. Closing your fingers around the object
  10. Squeezing the object with enough force to hold it

Now I’m guessing some of those parts you can do right now with success and some you can’t.  That’s okay – you have to start somewhere!  Take any of those parts (in any order you want) and try to do 30-50 attempts of one part several times a day. If you can’t physically move the arm or hand, that’s fine – you’re still trying to connect the brain and the arm so it counts.  If you’re tired of watching nothing happen, take a break from the physical and VISUALIZE IT (see the post titled “Day dreaming can be beneficial”).  That also counts toward those 1200 repetitions. After several days (maybe weeks depending on how many you do per day) and lots and  lots of repetitions – you’ll be able to do that part of the task!  You’ll see success and as Dad reminds me constantly:

“One small improvement leads to more improvements.  It just takes a little success each day to make you want to try again tomorrow.”

With one part down, it’s time to move on to another part and repeat the process.  Keep practicing the first part, but also add in repetitions of the second part.  Ta-da! You have an exercise routine that YOU created and YOU progress! And it’s got the big 3 “must-haves” for rehab and progress – It’s challenging in that it’s different daily and forces remodeling, it’s meaningful to you and it’s repetitive.

The best part of this method is that the possible tasks are endless and you pick what you want to regain most.  If you’re struggling to break something down and can’t think of the component parts – message me or leaving a request in the comments.  I’ll give you a break down of the task you’re working toward and help you learn the process so that you can do the next one.

And remember –

“Through perseverance, many people won successes out of what seemed destined to be certain failures.” 

 

 

 

 

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Day dreaming can be beneficial…

In athletics, mental imagery has been proven to improve performance and to allow athletes better focus (whether it be during practice or during competition).  It allows athletes to review the motor program and the sequence of their movements prior to participation.  It makes them better. Period.

Stroke survivors ARE athletes, so why not visualize the goals that you’ve set for yourself? Mental imagery can relax you, it can focus your attention and it allows you to see success immediately (something stroke doesn’t allow in the “real world”). Just thinking about a task or imagining that you are using the affected arm has been shown to activate areas of the brain and increase overall brain activity.  It helps relax you and can improve your mood.  It is effective as practice for movement even though you are not moving!  It can be done by any stroke survivor, no matter your level of current disability. And most importantly, it is SAFE!  Since you are not moving, you can use visualization anywhere and at any time without worrying about what could happen.

Oh yeah.  One more thing….IT WORKS! Visualization can improve motor function after a stroke!

So how and what do you visualize? How much and how often?

Well, the “how” is easy. Set yourself up in a comfortable chair and minimize all distractions (radio, TV, family, pets, etc).  Close your eyes and force yourself to relax.  Maybe take a few deep breaths to calm yourself before your start.

Now, the “what” is completely up to you.  It needs to be meaningful to you – so be creative and think about things that you are passionate about. (I have Dad imagine walking around Citizen’s Bank Park at a Phillies game – see above).  It needs to be challenging – so imagine yourself rehabbed and recovered, doing things that are beyond your reach now.  And finally, it has to be repetitive – so visualize the same task often during the day/week.  Try to start with 3-5 minutes at a time and work up to 10 minutes as you are able.

Make the images in your brain detailed.  Think about smell, sight, taste.  Focus on sensation (through your affected hand/foot) and allow yourself to imagine everything from temperature, to texture, to pressure.  Recall memories to fill in the gaps – what is the weather like? What does your shoulder feel like?  How heavy is your foot as you lift it?  BE SPECIFIC and don’t let any detail go unappreciated. Most importantly – be dedicated to the idea that this IS going to help you and that you ARE going to recover.  This visualization is a predictor of future events – not just a day dream.

 

 

 

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).