Astronauts & 1900's Women Get Surviving Stroke

Rebecca Dutton
Home After a Stroke

March 28, 2016

Before I had a stroke I would have found my post "9 Things I Have to Do to Drive Independently" obsessively tedious. I know of only two groups of able-bodied people who can understand what you have to do to thrive after a stroke.

Astronauts. Astronauts understand the conscious attention stroke survivors have to pay to familiar tasks that able-bodied people do without thinking. As I watched astronaut Scott Kelly demonstrate cooking and eating dinner on the International Space Station, I saw that he had a problem. He repeatedly dropped food because his hand forgot you have to attach an object to a surface or it will float away. To be fair, Scott was distracted by having to look towards the camera and explain what he was doing. I am sure he performs better when he does not divide his attention. I think he would understand why stroke survivors do not perform well when they try to multitask. I also think the months of practice Scott did on Earth would help him understand how hard it is for stroke survivors to relearn to do even simple tasks.

Urban Housewives in 1900. If women in 1900 could have read the nine things I do before I drive my car away from the curb, they would have said "welcome to my life." They knew about spending lots of time getting ready to do a task. For instance, before they could start doing laundry they had to do three chores. 1) They had to soak clothes the day before because cleaning agents were not very effective. 2) They had to hand carry 20 to 40 gallons of water from the sink to a large copper vat where the clothes were washed. 3) They had to wait for the coal fire under the copper vat to heat up the water. Only then could they start agitating the clothes by hand with a four foot long pole called a dolly stick.

Here is a re-enactment of doing laundry in 1900 from the PBS TV series, The 1900 House.

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Astronauts & 1900's Women Get Surviving Stroke

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Brain Plasticity Will Blow Your Mind

Rebecca Dutton
Home After a Stroke

February 6, 2013

SSTattler: Re-published January 30, 2016 Brain Plasticity Will Blow Your Mind.

New research on brain plasticity will blow your mind.  One amazing finding is that new stem cells are produced in the lateral ventricles of the adult brain (1).  What is even more amazing is how these stem cells migrate from the back of the brain to the olfactory bulb in the front of the brain (2).  Using time lapse imaging scientists have been able to watch stem cells latch onto a blood vessel highway and drag themselves to their destination.  First, brain chemicals push stem cells away from their birth place.  Additional chemicals stop the stem cells from getting off track along the way.  As the cells approach their destination more chemicals pull them in the right direction.

Equally amazing is the fact that new stem cells are produced in the hippocampus that controls memory (2).  Since learning is life-long, it is hard to believe that neuroscientists used to believe that remembering everything we learn can be crammed into the memory cells we were born with.  The adult brain grows thousands of new stem cells in the hippocampus every day (3).  Diffusion tensor imaging allowed scientists to see significant microstructure changes in the hippocampus after two hours of training (4).

9 Things I Must Do to Be Independent in Driving

Rebecca Dutton
Home After a Stroke

March 15, 2016

Regaining independence in driving took more than being trained to drive one-handed by a certified OT driving instructor. There were nine additional skills I had to master. I begin with two tasks that able-bodied people do before they pull away from the curb.

Safety. (1) The seatbelt was always twisted when I pulled it across my body. I learned I have to make sure the seat belt is completely straight when I pull it out.

Starting the Car. (2) My left arm is my sound arm so I have to lean over to see the slot for the key. I can pull the key out thru an opening in the steering wheel because this does not require the precise placement that inserting the key demands.

Pictures Can Explain What OTs Are Doing

Rebecca Dutton
Home After a Stroke

April 4, 2014

Aphasia is the inability to understand the spoken word and/or to express oneself verbally.  It is easy for PTs to communicate with aphasic clients because everything they do is aimed at walking.  PTs explain this without saying a word.  I went to PT and exercised, walked, and rested.  When I came down after lunch I exercised, walked, and rested.  This routine repeated every day so I did not need to ask why my PT had me slide a towel on the floor with my paralyzed foot.  OTs have a harder time telling clients what we are doing because we work on so many different ADL goals.

Fortunately aphasic clients may retain procedural knowledge.  This is the ability to execute the steps of a task that often requires visual information.  We do not talk ourselves through the steps of tying shoelaces.  We remember what the steps look like and what our hands are supposed to do.  Visual information is stored in a different location than language so procedural knowledge may be spared after a stroke.  Printing out clip art or photos found on the Internet may help OTs explain what they are doing to help their clients.  Here is an example.

A towel sliding exercise may strengthen the arm which makes it easier to put on a shirt so the client can join the family for dinner.

If clients want to go home to eat a home cooked meal I am pretty sure they are not picturing themselves eating in bed wearing sweaty pajamas while the family eats at the dinning room table.

To close the deal salesmen have to offer customers something they want.  Guessing what a person wants is risky.  Better to show a client a notebook with pictures of hugging a child, petting a cat, sitting on the patio, etc.  It would be ideal if the family could bring in photos of activities the client enjoys.  Good salesmen watch a customer's face to see what makes his or her face light up.

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Dysarthria is More Than a Slip of the Tongue

Rebecca Dutton
Home After a Stroke

November 25, 2013

I had a stroke in the brain stem which connects the brain to the spinal cord. My stroke attacked a part of the brain stem called the pons - the bridge to the cerebellum which controls coordination. The inability to coordinate muscles of my lips, cheeks, and tongue made my speech severely slurred (dysarthria). The good news is that I never lost the ability to understand what people were saying. The bad news is that people could not understand me.

Incoordination of my diaphragm, which controls breathing, also made speaking difficult. To speak you have to let your breath out slowly. At first I exhaled explosively in one big gasp. I had to repeatedly take extra breaths to finish even one sentence. I gradually regained the ability to say more before running out of breath. It is still tiring to speak in a group because I have to take many deep breaths to be heard. Thankfully people never have trouble understanding me on the telephone. I speak into an ear bud so I never have to raise my voice which requires more air.

In nine years my dysarthria has never fully disappeared. When I am not fully awake or I am tired my speech is still somewhat slurred. I know this because people start staring at my mouth so they can read my lips. Sometimes I have to think about taking a full breathe because I am speaking too softly. I know this because people start saying "What?" after I speak.

I asked for help in the grocery store last night. The woman who helped me scowled and looked at me like I was retarded. After she left I realized I was incomprehensible because I was speaking so softly.

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Dysarthria is More Than a Slip of the Tongue

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Conclusions from Multiple Studies Can Be Flawed

Rebecca Dutton
Home After a Stroke

March 3, 2016

The gold standard of medicine has been to find one treatment that makes everyone healthy.  To find this "holy grail" authors compare the results from a large number of studies (meta-analyses, systematic reviews, Cochran Reports).  Yet conclusions from multiple studies can be flawed when a disease varies widely as stroke does.  Here is two examples of what I am talking about.

Researchers are doing new clinical trials on drugs that did not help large numbers of people with cancer.  Now that researchers know how to identify different subtypes of cancer, they want to see if old studies had a poor match between the drug and the subtype of cancer in the sample.

Researchers in the Efficacy of Nitric Oxide Study (ENOS) studied the effects of nitric oxide (NO) on stroke outcomes (1).  ENOS looked at the records of over 4,000 stroke survivors in 23 countries. NO had no beneficial effect. The ENOS authors did a 2nd analysis with a subset of people with strokes that affected the front half of the brain (1).  Ninety days later the subjects who received NO had significantly better outcomes on the Mini-Mental State Exam (cognition), Barthel Index (ADLs), EuroQol Scale (quality of life), and Zung Depression Scale.

Handicapped Bathrooms Are Badly Designed

Rebecca Dutton
Home After a Stroke

August 3, 2015

Handicapped bathrooms in hotels I have used since my stroke are poorly designed.  The most common error I have seen is placing the towel rack on a wall ten feet away from the tub across the extra large bathroom.  It may be dangerous for a companion to turn his or her back on a disabled person and walk away to retrieve a towel.  I solved this problem by dragging the luggage rack into the bathroom.  I placed my towel and bathrobe on the rack where I could reach them while sitting on my folding shower stool.  An inexpensive solution is to place hooks near the bathtub at wheelchair height.

I ran into 2 unique problems in one hotel handicapped bathroom.

1)  The shower curtain was so short and hung so far away from the tub that I could look down and see a four inch wide strip of the bathroom floor.  A wet floor is a Fall Hazard.  Before I got in the tub I did my best to soak up the water by putting a bath towel on the floor.  An inexpensive solution is to purchase longer shower curtains that can be tucked inside the bathtub.

A New Hand Evaluation for Stroke Survivors

Rebecca Dutton
Home After a Stroke

February 25, 2016

Van Lew and associates (1) studied the reliability of a hand evaluation called Functional Upper Extremity Levels (FUEL).

What They Got Right

To prove the efficacy of treatment approaches, researchers need tests that are sensitive enough to detect both emerging movement and small improvements.  Hand tests traditionally begin by asking clients to reach out, pick up an object sitting on a table, and release the object by placing it back on the table.  Many stroke survivors cannot do this.  The FUEL provides sensitivity by describing 3 levels of skill below the starting level of traditional tests.

      Level 1 = Dependent Stabilizer.  The sound hand places the affected hand on an object.  The weight of the hand stabilizes the object so the sound can manipulate the object.  Level 2 = Independent Stabilizer.  The affected hand places itself on the object (e.g. hand holding down wad of toilet paper so other hand can tear paper).  Level 3 = Gross Assist.  Affected hand holds an object with a gross grasp.  No functional release is present.

What They Missed

Nails Do Not Stop Growing After a Stroke

Rebecca Dutton
Home After a Stroke

February 14, 2016

CAUTION: 

CLIPPING NAILS REQUIRES GOOD SENSATION

AND COORDINATION

I live alone so I have to cut my nails. I cut the nails on my sound hand by operating an adapted nail clipper with my affected hand. I returned the small nail clipper shown on the bottom. The pointed end (see V-shape) dug into my palm when I pushed down. The short handle also meant I had to press hard to get enough force to cut my nail. I use the larger nail clipper shown on top. The end of the handle is square which is more comfortable. The longer handle gives me better leverage when I push down.

Are Resting Hand Splints a Waste of Money?

Rebecca Dutton
Home After a Stroke

May 1, 2014

Studies of resting hand splints make me cringe when researchers ask the wrong questions. Studies done by Lannin (1) and Burge (2) asked if resting hand splints improve functional hand use. A resting splint that places the hand in one static position does not retrain the brain.

So it is not surprising that Lannin and Burge found resting hand splints produced no significant improvement on hand function tests, like the Motor Assessment Scale.
           
Lannin (1) also concluded "splinting has little or no effect on the loss of range of motion" (p. 113) because both subjects who did and did not wear a resting splint lost some wrist range of motion (ROM). Unfortunately, Lannin told therapists treating subjects who were wearing a resting splint to stop all passive stretching and restrict active hand exercises to 10 minutes a day.

I asked a different question. What would happen if I continue to do passive stretching and active hand exercises, but stop wearing my SaeboFlex resting splint at night? After a month of not wearing this splint it felt like my thumb was getting tighter. I resumed wearing this splint and the next morning I woke up with a ferocious ache in my thumb. Every night that I wear my splint I wake up with no resistance to thumb ROM although my thumb is tight by the evening. I don't think my resting splint has eliminated my spasticity, but I believe it has prevented a contracture.

Big Ballet

Rebecca Dutton
Home After a Stroke

June 15, 2014

I love dance so I watched a mini-series called Big Ballet on the Ovation channel. The show is about overweight women and men learning to perform the ballet Swan Lake. My intuition told me watching them struggle would help me with a dilemma in my stroke recovery.

Who made this project possible? Wayne Sleep choreographed the ballet. He is a 5 foot 2 inch man who refused to leave professional ballet because he was too small. Monica Loughman who trained the dancers is a retired ballerina. The cast had to gain strength, flexibility, and endurance, learn the steps in the ballet, and express the emotions of characters in a classic story of love and betrayal. Watching a brave group of people triumph over fear of failure and rejection was thrilling because everyone has struggled with these emotions.

How does Big Ballet relate to my dilemma? Occasionally I see people staring at me with a look of horror on their faces. They are imaging something that has nothing to do with me, but it is hard not to take their negative reaction personally. I have thought of several nasty things to say but never followed through because this would intensify the negative feelings I have at that moment. What I learned from watching large men and women dance is they can be graceful. The next time people stare at me I will try to remember the satisfaction I felt when I learned to push a garbage can to the curb. This is not a small thing. You cannot live alone in your home if garbage piles up.

Brain Plasticity Will Blow Your Mind

Rebecca Dutton
Home After a Stroke

February 6, 2013

New research on brain plasticity will blow your mind.  One amazing finding is that new stem cells are produced in the lateral ventricles of the adult brain (1).  What is even more amazing is how these stem cells migrate from the back of the brain to the olfactory bulb in the front of the brain (2).  Using time lapse imaging scientists have been able to watch stem cells latch onto a blood vessel highway and drag themselves to their destination.  First, brain chemicals push stem cells away from their birth place.  Additional chemicals stop the stem cells from getting off track along the way.  As the cells approach their destination more chemicals pull them in the right direction.

Equally amazing is the fact that new stem cells are produced in the hippocampus that controls memory (2).  Since learning is life-long, it is hard to believe that neuroscientists used to believe that remembering everything we learn can be crammed into the memory cells we were born with.  The adult brain grows thousands of new stem cells in the hippocampus every day (3).  Diffusion tensor imaging allowed scientists to see significant microstructure changes in the hippocampus after two hours of training (4).

Will I Be Homebound This Winter?

Rebecca Dutton
Home After a Stroke

November 4, 2014

Trenton, New Jersey used to have such mild winters that officials closed the schools when there was only 2 inches of snow on the ground. The dip in the jet stream that brings cold Artic air south shows why Trenton was lucky (black dot = Trenton). Last winter Trenton had six major snow storms in six weeks that were measured in feet instead of inches. Strong storms in the Artic now blow the jet stream farther south to include me. So much pack ice has melted due to global warming that the air is saturated with water vapor which turns into snow on my street. I want people who have recently found my blog to see this post about one of my winter strategies. Also see my next post on using a cane in the snow.

Why Mice Are Not Men

Rebecca Dutton
Home After a Stroke

January 13, 2016

The Dilemma. Innovative treatments have helped mice who have been given strokes, but the results often cannot be duplicated in humans. A researcher on TV helped me remember a fact I learned in college that partially explains these disappointing results. Since the early 1900's researchers have bought specific strains of mice (e.g. B6). These strains have been inbred for generations so there is very little variability in the sample. Follow-up studies may use the same strain of mouse to eliminate sample differences as an explanation for why new findings confirm or refute the original study. Researchers eliminate other alternative explanations for their results by keeping the cages, food, and activities the same for all animals in the study. On the other hand, humans are a diverse group that has interbred for thousands of years. Humans also have the freedom to vary their life experience which modifies their brains and bodies.

Bottom Line #1. Apple can send updates to improve their smart phones because the codes are identical in every iphone on the planet. Using genetically engineered mice makes it easier to get consistent results in animal studies. The freedom humans expect is a double-edged sword.

Bottom Line #2. No treatment is 100% effective. Even when a clinical trial is successful, some subjects do not respond positively to the treatment. It is impossible to predict if you will be like the subjects who responded positively or the subjects who were not helped by the treatment. A trial period is needed to see if a treatment protocol will help you.

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Why Mice Are Not Men

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The Flexion Synergy Can Be Good

Rebecca Dutton
Home After a Stroke

January 3, 2012

At first a hemiplegic arm is limp (Brunnstrom Stage 1). Stage 2 is exciting because stroke survivors see small limb movements. In Stage 2 my shoulder could fling my hand onto my thigh, but my hand slid off because my elbow muscles were weak. Small movements turn into a synergy (Stage 3). Synergy means muscles work together, but a stroke creates abnormal synergies that produce one movement pattern. The photo shows a version of the flexion synergy that affects the arm. There are many versions of this synergy so your movement may look different from other stroke survivors. A trait everyone shares is that to move one joint you have to move the whole limb whether you want to or not. This is exhausting. When the flexion synergy is full blown it keeps the hand fisted and the arm close to the body.

I made Stage 3 functional by doing home exercises with a spring-loaded splint called SaeboFlex. Being able to open my hand a few inches so it can receive an object from my sound hand is very useful. Hand-to-hand transfers let my hand hold objects while my sound hand manipulates them. Hand-to-hand transfers are useful because many basic ADLs take place close to the body. 

Snow Shoes for a Stroke Survivor

Rebecca Dutton
Home After a Stroke

January 4, 2016

Since my stroke I'm careful about venturing outside when it snows, but I'm not trapped inside until spring comes either.  I never walk on snow covered concrete, gravel, or grass. because uneven slippery surfaces are a fall hazard.  Oonce streets, sidewalks, and access to my car are clear I wear boots over my shoes to protect them from the slush.  Boots I tried on at a shoe store would not fit over my leg brace.  My leg brace won't let me point my toes which is a pre-requisite for donning boots.  On-line I found the Neos overshoe with a Velvro opening that goes all the way down to my toes.  The Villager model is lightweight and designed for occasional use which is perfect for me.

A video at www.overshoesonline.com shows how to don this boot.  Warning #1: I do not put the boots on while standing as the video shows because I do not have good standing balance.  My boots go on safely while I am sitting.  A trick the video doesn't show is to make the ankle straps as long as I can before I put on the boots.  After I snap the straps closed I pull on the ends of the straps to make them tight.  Warning #2: The first set of boots I ordered was too big so they flopped around when I walked.  Bottom Line: I get good traction from the treads and don't arrive with soggy shoes.  I walk more slowly with boots on, but that beats not being able to keep important appointments like a visit to the doctor.

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Snow Shoes for a Stroke Survivor

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My Heart Does Not Get to Choose

Rebecca Dutton
Home After a Stroke

February 24, 2013

I used to think emotions like joy and love are good while emotions like sadness and anger are bad.  Now I believe that how I react to my emotions is what is good or bad.  It is bad when I am so pre-occupied by mental chatter that I let moments of joy fly past me unnoticed.  It is good when I stop what I am doing and take a few seconds to appreciate when I am happy.  It is bad when I rerun upsetting episodes in my head.  It is good when I use anger to propel me towards a solution.

IF I could go back and tell my younger self  to stop rerunning memories that upset me, I doubt it would make any difference.  First, when I was young I had the tremendous energy it takes to sustain emotional drama.  Second, being snubbed recently reminded me of how intense emotions can be.  Emotions can feel so real that they seem unstoppable.

Pain is a Great Motivator

Rebecca Dutton
Home After a Stroke

December 16, 2015

My PT made me realize the gluteus maximus (GM) muscle on my hemiplegic (paralyzed) side was as soft as unkneaded bread dough.  This buttock muscle is called a hip extensor because it extends the leg behind the body.  Only ballerinas and runners use the GM in this way.

I am worried about this weak muscle because the GM helps other hip muscles keep the pelvis from wobbling as we swing our leg forward to take a step (1).  If the GM does not help stabilize the pelvis, low back muscles have to do it.  With my history of back pain, my GM has to get stronger.

Precision PT = Progress 11 Years After My Stroke

Rebecca Dutton
Home After a Stroke

December 2, 2015

I started PT after injuring my back when I fell on my patio in October.  This is my first experience with precision PT.  Instead of having me do generic exercises like walk on the treadmill, Tony evaluated the individual muscles of my back and hemiplegic (paralyzed) leg.  Here are two of the many things I learned 11 years post stroke.

#1.  Back spasms are a future risk for me because abdominal muscles on my hemiplegic side are still very weak.  The stomach crunches I have been doing (photo) let me use many muscles to assist my stomach muscles.  Tony, my PT, had me repeatedly lift only my bent hemiplegic leg slowly while lying on my back and then lower my leg without touching my foot to the mat.  OMG.
I felt increased muscle tone in my abdominals for hours.  Guess what I am doing every morning before I get out of bed.

#2.  Tony discovered I developed the bad habit of locking my hemiplegic knee so my leg muscles do not have to work.  Now I stand with both knees slightly bent during 4 activities of daily living (ADLs) - brushing my teeth, putting curlers in my hair, putting on make-up, and standing in line at the store.  Standing in line with both knees slightly bent was the hardest to do consistently.  Putting both hands on the handle of the shopping cart is a cue that makes me compliant.  Retraining the brain requires lots of repetition.  This new habit is not automatic yet, but I have become aware of when I lock this knee so I can tell it to stop.

Bottom Line:  I anchor each new exercise to a specific ADL which acts as a visual trigger.  It is wonderful not to have to think "I forgot/did not have time for X exercise" at the end of the day.

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Precision PT = Progress 11 Years After My Stroke

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Answering Machine Challenge

Rebecca Dutton
Home After a Stroke

November 26, 2015

Opening voice mail requires a code.  I use an answering machine because all I have to do is push the blinking button on the machine to hear a message.  I also use an ear bud to listen and speak into the phone.  My wireless phone and ear bud allow me to go to the table to take notes and go to the couch to talk for an hour to friends and family hands free.

Dilemma.  I thought I was being clever when I hung the ear bud on the antenna for the phone.  Hanging the wire in front of the phone makes the ear piece cover the blinking button (under red arrow).  I have made this mistake many times.  Then I missed a message from a dear friend who called me after her surgery.  Having my friend think I did not care enough to return her call made me change my behavior.  Maintaining relationships has been a valuable part of my recovery.

Solution.  Now I place the wire for the ear bud behind the phone and make sure the ear piece is not covering the blinking button (see red arrow).  Even this change was not enough.  I have to turn the phone so it points towards the corner of the counter (3rd photo) instead of being lined up with the edge of the counter (2nd photo).  Now when I walk in the front door I can see the blinking light as soon as I pass the TV.

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Answering Machine Challenge

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