GUIDE TO A QUICKER RECOVERY FOR PATIENTS WHO HAVE SUFFERED A STROKE

Occupational Therapy Summerlin Outpatient Therapy

[picture]

Introduction Because you have experienced a stroke, you are already aware that the way in which you have been able to perform many of your normal activities of daily life has been affected in some way. You may require assistance performing many activities associated with your daily routine such as getting out of bed, dressing, toileting, bathing, eating, and preparing meals. You may have become dependent on others to help you with many of these activities. The purpose of this pamphlet is to instruct those who have had a stroke and their caregivers in ways that will help you regain your independence. This pamphlet will be focused on the recovery of your non-use arm (the arm which has been affected by the stroke) which is an important part of performing your daily activities. We hope you understand that much of the independence you will regain is dependent upon you. Your part in the recovery process is to perform the home exercises you will learn throughout this pamphlet and the ones you will learn during therapy. We encourage you to safely perform as much of your daily routine as possible. The more you try to perform independently, the more functional you will become. This pamphlet will help to teach you ways to incorporate your non-use arm into your daily activities. Through this pamphlet you will learn about the brains ability to reorganize itself in order to regain function, something known as neuroplasticity. Then you will learn techniques that will help your brain in this process. We understand that dealing with the aftermath of a stroke is not easy, but we know that through hard work, you can regain some of your lost independence. You have started on a new journey and we hope that this pamphlet can be used as a guide along that journey to independence. Neuroplasticity As already mentioned, neuroplasticity is the brains ability to reorganize itself. By this, we mean that the brain has the ability to be shaped, molded, or changed throughout life regardless of age. Research has shown that the actual structure of the brain is changed when people learn a new skill (Draganski, Gaser, Busch, Schuierer, Bogdahn, & May, 2004). We know this is true for ourselves because we have learned new things throughout our lives. For example, we can learn how to use new technology when we put forth the work and effort to try and understand it. And research has shown that we can learn new things no matter how old we are (Kempermann, Gast, & Gage, 2002). This process of re-training the brain happens through two processes known as the Hebbian Affect and Axonal Sprouting. The Hebbian Affect refers to the ability of a brain cell (otherwise known as a neuron) to excite other nearby brain cells. Through repetitive firing of that brain cell, the ability to excite other nearby brain cells becomes easier. Through enough repetitive firing, a connection is created (known as axonal sprouting). A connection between muscle movement and brain cells is created in this

way. Step by step, from brain cell to brain cell until an entire connection is made between brain and muscle. With even more repetitive firing of those brain cells, the connection becomes stronger and stronger, making muscle movement easier to perform. To use another analogy, brain cells are similar to Wi-Fi. As we keep firing our brain cells, we keep this Wi-Fi connection on. Other nearby brain cells can then detect this signal until they create their own connection with the brain cell. This process continues until a continuous pathway is created from the brain to the muscles of the body. With continuous use that pathway becomes easier and more efficient. Think back to when you first learned to ride a bike. You were most likely awkward and clumsy the first time you got on. You probably fell time after time. Gradually, you started riding without falling for 5 feet then 10 feet then 15 feet, until you learned to ride without falling altogether. Over time, riding a bike became second nature to you and you didnt have to think about it. With neuroplasticity, the opposite of what we have discussed is also true. With disuse of the brain cells and muscles, potential connections start to wither away and die (known as axonal pruning). Weve all heard the old adage that your brain is like a muscle. Well, thats true! If you dont use it you lose it. And this is where therapy and home exercises comes in. We want to help you create these new connections and make sure you gain back previous abilities that have now become so difficult. So How Does This Apply to Stroke Now that we understand what neuroplasticity is and how it works, lets apply it to a stroke scenario. When a stroke happens, we know that parts of the brain die. This happens either because a blood clot got stuck in a blood vessel and prevented oxygen to getting to the brain or a blood vessel burst and bled into the brain, essentially causing parts of the brain to drown. As a result of the stroke, you have lost some or all of the function one side your body, which is called hemiparesis. The parts of your brain that died contained years of information and experiences related to how to move and work your non-use arm. Now all that information has now been erased. Even though parts of the brain have died, neuroplasticity teaches us that other parts of the brain have the ability to take over the lost functions of the parts of the brain that have died. However, this requires time and effort because your brain is starting from scratch. We have to retrain the brain and provide as much practice and experiences as we can so that those connection can be recreated. Those new connections are created through this process neuroplasticity that we discussed earlier. Neuroplasticity demands repetitive use of the non-use arm. Through repetitive use, connections and pathways can then be created. With even more repetition, these pathways become more efficient. And then with even more repetition, these pathways become a part of our motor memory (meaning that we no longer have to think so hard

to perform an action). The end product is that your lost function is at least partially restored and you have become more independent as a result. How to promote neuroplasticity Repetition Did you notice the common theme of neuroplasticity? The theme is repetition. In order to create new connections, make connections more efficient, and create motor memory, you need to repeatedly be using your non-use arm. Research was performed in which participants performed intensive repetitive exercises, multiple times a week. Participants showed better recovery of the non-use arm than others who did not perform the exercises (Kawahira et al., 2010). Repetition means much more than coming to therapy 2-3 times a week. Therapy does NOT give your brain and non-use arm enough repetitive use. Your brain will need multiple repetitions EACH DAY, MULTIPLE times a day in order to have a better, quicker recovery. One of the best ways to apply the principle of repetition is to incorporate exercises or other aspects of therapy into your daily routine. One way this can be done is to perform exercises before or after mealtimes. In this way, you can be sure that you will perform exercises at least 3 times a day. Another idea is to incorporate exercises during our sleep schedule, meaning after waking up and before going to bed. Later we will discuss the ways to incorporate the non-use arm during daily tasks. Ultimately, these are just suggestions and you must find a way to incorporate your own home exercise program into your daily routine in such a way that works for you. Motor Imagery Motor imagery refers to the act of thinking about a movement even if this movement does not occur. Research studies have shown that even thinking about moving the non-use arm even though it does not move when you try to move it, will help recreate connections between the brain and the muscles (Page, Levine, Sisto, & Johnston, 2001). This happens because the act of consciously thinking about moving helps to activate those parts of your brain that create the movement. This in turn will send signals to the muscles in the arm for the certain movement that you are imagining you are performing. For example, I want you to think about moving your non-use arm straight up in front of you and then reaching all the way above your head. Really imagine that you are actually performing this movement. Now because you have done this, you have started to recreate the connection between brain and muscle. So how can we apply this principle to everyday tasks? This is a good question because if we can make a habit or routine of this principle than we can also start to apply the principle of repetition which we just learned about. We know that others probably help you with your daily tasks to some extent. This may include such things as getting dressed in the morning, taking a shower, putting on make-up, brushing teeth, eating, brushing hair, shaving, or getting in and out of bed. When others are helping

you with these tasks, start to imagine that you are the one that is actually moving your non-use arm. For example, if your spouse or caregiver helps you get dressed in the morning by lifting your non-use arm into the shirt sleeve, imagine that you are the one that is actually moving the arm into the shirt sleeve. Seek for similar opportunities to apply this principle to other daily tasks throughout the day. Weight Bearing Just because your non-use arm is weaker than it used to be and you have less movement, does not mean that you should neglect it or leave it out when performing daily tasks. One way to incorporate the non-use arm into daily tasks is through weight bearing into the non-use arm. Weight bearing, as one would think, is the process of putting your body weight into your arm. One study was performed that showed that weight bearing into the non-use arm helps to increase the connection between the brain and the muscles of the arm (Brouwer, B. J. & Ambury, P., 1994). We urge you to incorporate your non-use arm in your daily tasks in this way because it helps recreated lost connections, decrease hypertonicity (tightness of the arm), and strengthen the arm. Taking care of your non-use arm does NOT mean tucking it in against your body all day. Taking care of non-use arm DOES mean to help it regain lost function. The following explanations and pictures will help show you how you can perform weight bearing into the non-use arm as well as incorporate it into daily tasks: To perform weight bearing into the non-use arm, flex the wrist down, grab the fingers and make them straight, and place your hand flat on the desired surface. Then spread out the fingers and make your elbow straight. Shift your weight into your non-use arm such that it is helping to support the body. Perform as much as you can tolerate and get help from a family member or caregiver if needed.

You can use weight bearing while reaching for items on the table, on the countertop, or into cabinets. This could be during a meal to reach for food, in the kitchen reaching for utensils, or in the bathroom while reaching for toiletries.

You can also perform weight bearing during your morning routine. Some good ways to do this are when brushing your teeth or combing your hair.

Exercises Home exercises are a great way to get your non-use arm moving. There are many benefits to moving your non-use arm. Just like weight bearing, exercises help decrease hypertonicity, recreate lost connections, and strengthen the arm. Another benefit is that as the non-use arm keeps moving you will have less secondary complications such as subluxation. Subluxation is when the humerus (upper bone in the arm that connects to the shoulder) starts to fall out of its socket. This can be a painful experience that is often preventable. The exercises that are shown below are called self-range of motion exercises. Range of motion refers to the movement of joints. These exercises are to be performed if you have little to no movement of the non-use arm. These exercises involve interlocking the fingers of both hands and then moving the affected arm in different

planes of motion. Once you have more movement of your non-use arm, you will want to perform these exercises without the help of your other arm. If you are unable to perform these movements, have a family member or caregiver perform the movements for you. The following pictures were taken while sitting at a table, but these exercises can also be adapted to other positions like sitting in a wheelchair or lying in bed. As was discussed previously, these exercises should be performed multiple times each day in order to re-train the brain with repetition. One word of caution: these exercises should cause little to no pain. If you cannot achieve full range as shown in the pictures, that is OK. Shoulder Flexion Interlock your finger and place your arms in front of you. Lift them up as high as you are able in pain-free range while keeping your elbows straight. Try to repeat at least 10 times, 3 times a day.

Horizontal Abduction/Adduction Interlock you fingers and place your arms in front of you. Swing your arms from side to side with your elbows straight. Try to repeat at least 10 times, 3 times a day.

Elbow Flexion/Extension Interlock your fingers and place your arms in front of you. Bend your elbows so that your hands move toward your chin. Try to repeat at least 10 times, 3 times a day.

Supination Interlock you fingers and turn your non-use hand between palm-up and palm-down. Try to repeat at least 10 times, 3 times a day.

Wrist Flexion/Extension With your other hand, bend your non-use wrist back and forth. This exercise may be easier to perform at a table with a towel as shown. Try to repeat at least 10 times, 3 times a day.

Finger Flexion/Extension Using your other hand, spread out the fingers of your non-use hand as if to make a flat hand and then pull them into your hand as if making a fist. Try to repeat at least 10 times, 3 times a day.

Thumb Flexion/Extension Move your thumb out away from your hand and back into the palm of your hand. Try to repeat at least 10 times, 3 times a day.

Bed Positioning Appropriate bed positioning is extremely important because the non-use arm will be placed in that position for multiple hours each night. When positioned correctly, bed positioning can be very beneficial for the non-use arm and lead to increased neuroplasticity. Good positioning can help keep the non-use arm stretched out or be involved in weight bearing. And weve already discussed the importance and benefits of weight bearing. On the other hand, incorrect positioning can lead to increased tightness or increased subluxation of the non-use arm, both of which mean increased pain when moving the non-use arm (just a reminder that subluxation is when the arm or leg falls out of its socket). The following pictures and descriptions will provide 3 different ways of performing bed positioning for the non-use arm and leg. Contrary to what many believe, the most beneficial of all these positions is lying on the non-use

side because you are performing weight bearing. However, it is important that the nonuse arm be positioned appropriately while lying on the non-use side or you may cause damage or increase pain. Lying on the Non-Use Side When lying on the non-use side, keep the non-use arm out away from the body and the non-use leg straight as shown in the picture. Make sure that you are NOT lying on the non-use shoulder, but that the shoulder is pulled out so that you are lying on the shoulder blade (known as the scapula). Lying on the non-use shoulder could cause harm to it and could also be painful. Ideally, the non-use arm should be turned so that the palm is facing up..

Similar to lying on the non-use side, keep the non-use arm out away from the body. Placing the non-use arm on pillows as shown helps to keep the arm fully supported. Support helps keep the arm positioned appropriately and prevent subluxation. The non-use leg should be bent and fully supported by pillows as well to prevent subluxation of the leg.

When lying on the back, keep pillows underneath the non-use arm and shoulder. This helps prevent subluxation and provides comfort of the non-use arm. Keeping a pillow underneath the non-use knee helps to prevent subluxation of the leg.

Other Resources Websites The following are a few websites that can help provide additional information about stroke: stroke.org stroke-rehab.com strokecenter.org strokeassociate.org

Stroke Support Group Summerlin Hospital holds a monthly stroke support group on the 4th Thursday of every month 3:00-4:00 PM in Conference Room 3 at Summerlin Hospital. Please RSVP by calling (702) 233-7061. It provides an opportunity for you to hear from others who are currently or have experienced similar challenges to yours. It also provides an opportunity to hear how others have recovered from their stroke and the hard work it took them to get there. It offers a positive forum for stroke survivors and their caregivers to handle common, yet sometimes difficult life issues after stroke.

References Brouwer, B. J. & Ambury, P. (1994). Upper extremity weight-bearing effect on corticospinal excitability following stroke. Archives of Physical Medicine and Rehabilitation, 75(8), 861-866. doi: 10.1016/0003-9993(94)90110-4 Draganski, B., Gaser, C., Busch, V., Schuierer, G., Bogdahn U., & May, A. (2004). Neurplasticity: Changes in grey matter induced by training. Nature, 427, 311-312. doi:10.1038/427311a Kawahira, K., Shimodozono, M., Etoh, S., Kamada, K., Nomoa, T., & Tanaka, N. (2010). Effects of intensive repetition of a new facilitation technique on motor functional recovery of the hemiplegic upper limb and hand. Brain Injury, 24(10), 12021213. doi: 10.3109/02699052.2010.506855 Kempermann, G., Gast, D., & Gage, F. H. (2002). Neuroplasticity in old age: Sustained fivefold induction of hippocampal neurogenesis by long-term environmental enrichment. Annals of Neurology, 52(2), 135-143. doi: 10.1002/ana.10262 Page, S. J., Levine, P., Sisto, S., & Johnston, M. V. (2001). A randomized efficacy and feasibility study of imagery in acute stroke. Clinical Rehabilitation 15(3), 233240. doi: 10.1191/026921501672063235