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03/20/2010 my email to my physical medicine doctor (10 months post-stroke, after being discharged from OT because I plateaued in my left-arm range of motion/strength; “we don’t do maintenance therapy”):
“I read this recently and it expresses my feelings very succinctly:
‘To everyone else, I look okay, everyone keeps telling me I look “better.” I’m not okay. It’s like one of those android movies. I’m not me anymore. I’m still in the box I came in, but someone’s fucking with the wiring inside.’” Jonathan Kellerman, Therapy, 2004
3/30/10 7:46 PM from my Physical Medicine doctor (10 months post-stroke):
“I'm not surprised to see you express this. And I think I understand a little how you feel. I don't think anyone here thinks you are O.K. Or have returned to how you were after sustaining significant (sic) damage from the cerebral bleed, but we think you have improved substantially and achieved most of what it is now possible to achieve in terms of recovery.”
7/30/10 9:46 PM my response to my Physical Medicine doctor (13 months post-stroke):
“…as already proven by my continuing work on my left shoulder which now has a much greater range of motion since you discharged me from Occupational Therapy a few months ago (March, 2010), and by using several therapies to improve my mind's wiring (cognition, conceptual processing and memory retention, vision processing) none of which you felt valuable nor beneficial for me.”
Learning About Stroke Effects – and Medical Professionals’ Attitudes:
“The 90-day Recovery Myth,” or the “Six month Recovery Myth”
The way this goes is: the medical "'expert's" tell patients that the functionality they recover in the first 90-days or 6-months is "all they can expect." In many cases, like the comments above, the medical "experts" can't think beyond this myth and consequently aren't responsive/amenable to a particular patient's push to continue to recover greater control and functionality [other than the few ADL's of eating, toileting, limited dressing, and limited human interactions].
With this type of attitude as their guidance from their physical medicine doctor, many patients have a significant struggle to overcome this myopic view to get minimal support for physical/occupational/vision/or other beneficial therapies to regain greater control of their lives.
Many of us don't have the benefit of the U.S Congressional Health Plan, so we have to struggle against the myth, and high medical rehabilitation costs, to get a comprehensive rehabilitation therapy program.
[12 to 16, then 26 months post-stroke] I want to contrast the above attitude with that of my Neurologist, Dr. Sonu, who went back and rechecked my CT scans in response to my questions about my vision processing issues - despite the "standard response" of my HMO Ophthamologist who insisted that nothing was wrong. Dr. Sonu found that a blood clot had occurred directly above my visual cortex AND MIGHT HAVE CONTRIBUTED to the vision issues, and then discussed alternative treatments with other physicians she knew at UCLA, and provided reasonable alternatives for me to try. One year later, using my home computer and several vision therapy programs, my depth perception improved 100 percent.]
[12 to 16, then 26 months post-stroke] I want to contrast the above attitude with that of my Neurologist, Dr. Sonu, who went back and rechecked my CT scans in response to my questions about my vision processing issues - despite the "standard response" of my HMO Ophthamologist who insisted that nothing was wrong. Dr. Sonu found that a blood clot had occurred directly above my visual cortex AND MIGHT HAVE CONTRIBUTED to the vision issues, and then discussed alternative treatments with other physicians she knew at UCLA, and provided reasonable alternatives for me to try. One year later, using my home computer and several vision therapy programs, my depth perception improved 100 percent.]
[18 to 30 months post-stroke] I am very lucky that we have been able to afford aquatic therapy, private outpatient Occupational Therapy, some robotic therapy, and limited Vision Processing Therapy during the last 30 months post-stroke. As a result, I am getting stronger, with better balance, better eyesight/visual perception and able to drive my car myself, and volunteer helping patients and therapists using a therapy robot at Rancho Los Amigos National Rehabilitation Center and, also doing administrative support as a volunteer for Northridge Hospital Rehabilitation Center. My volunteer work is also a form of cognitive therapy, helping to get my brain functioning again.
A Brief Thought About THERAPISTS I've been very lucky to have had some great Physical, Occupational, Speech Therapists, and others who've given me guidance , support and friendship. [Eleni, Mimi K, Mimi Z, Mia, Molly, Roger, Gayle, Ken, Justin, Amy, Kathleen, Sandra, Mai, Peggy, Elise, Carolee] The characteristics of these most important people who have encouraged and guided me in my recovery are Positive guidance, encouraging, pushing the limits, honesty, creativity, interest, ingenuity, caring, levity, realistic expectations, friendship - these are just a few of the adjectives when I think of them.
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Evolving Approaches to Rehabilitation
Dr. Mindy Aisen, MD Chief Medical Officer
Rancho Los Amigos National Rehabilitation Center
Rehabilitation and Brain Recovery “Plasticity and Robotics,” ‘”Meaningful practice makes perfect”
Dr. Mindy Aisen, MD Chief Medical Officer
Rancho Los Amigos National Rehabilitation Center
American Physical Therapy Association (APTA)
Results for Patients with Neurological Conditions
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1) “Functional Learning Processes”
When should upper limb function be trained after stroke? Evidence for and against early intervention
Valerie M. Pomeroy, PhD
St George's University of London (now University of East Anglia),v.pomeroy@uea.ac.uk
Abstract
Very little time is available for arm and hand training while patients are in hospital after stroke. Therapeutic strategies that use intensive practice in the early days and weeks after stroke may improve the recovery of upper limb function. This paper considers the physiology of the brain in acute stroke and evaluates the evidence for and against early intensive activity of the upper limb as an essential precursor to any decision to invest in increased activity.
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2) Motor Imagery to Enhance Recovery After Subcortical Stroke: Who Might Benefit, Daily Dose, and Potential Effects
1. Lucy Simmons, BSc
University of Cambridge
2. Nikhil Sharma, MB, ChB, MRCP (UK)
University of Cambridge
3. Jean-Claude Baron, MD, FRCP, FMedSci
University of Cambridge
4. Valerie M. Pomeroy, PhD
St George's University of London (now University of East Anglia),v.pomeroy@uea.ac.uk
Abstract
Background. Motor imagery may enhance motor recovery after stroke. Objectives. To estimate the proportion of patients able to perform motor imagery, the feasibility of delivery of motor imagery training (MIT), and the effects of MIT on motor recovery in an exploratory study. Methods. An immediate pretreatment and posttreatment single-group design was used to study 10 patients after subcortical stroke with neuromuscular weakness in the upper limb. MIT that included upper limb activities reflecting everyday tasks was provided for 10 consecutive working days. Measures included assessment of chaotic motor imagery, patient report of tolerability of MIT, Motricity Index (MI), Nine Hole Peg Test (9HPT), and quality of movement (MAL-QOM). MIT dose was changed in response to patient feedback. Graphed motor function scores were inspected visually for clinically important changes. Results. Four of the 10 patients were unable to perform motor imagery. Patient opinion was positive about the content and shaped daily dose of MIT given in two 20-minute periods separated by a 10-minute rest. Clinically important changes in motor scores were found. Four patients increased MI score (range 8-16), 3 patients increased 9HPT score (range 0.02-0.04 pegs/second), and 4 patients increased MAL-QOM score (range 0.63-1.29). Conclusions. MIT was received positively by patients, but 40% were unable to perform imagery and interindividual variations were found on motor function.
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3. Development Of Treatment Schedules For Research: A Structured Review To Identify Methodologies Used And A Worked Example Of ‘Mobilisation And Tactile Stimulation’ For Stroke Patients
Abstract
Purpose
To identify methodologies used to describe the content of current physical therapy and to formulate a treatment schedule for ‘mobilisation and tactile stimulation’ (MTS) for the paretic upper limb after stroke as a precursor to evaluative research.
Method
This study was conducted in two major parts. Part 1 was a systematic review of studies developing descriptions of current physical therapies. Studies were identified by an electronic search of MEDLINE, EMBASE and CINHAL and by searching the reference lists of studies fulfilling the review's inclusion criteria. Three reviewers extracted data independently on methodologies used. In Part 2, seven experienced neurophysiotherapists completed individual semi-structured interviews. Verbatim transcripts were condensed independently by two researchers into draft lists of interventions, which were subsequently compared for agreement. Disagreement was resolved through discussion. A preliminary list of interventions was produced, then discussed and refined at a focus group meeting to produce a final list. This was transformed into a draft treatment schedule, piloted in clinical practice and refined further to produce the final treatment schedule.
Results
Part 1. Several methodologies to describe therapy were identified from the 15 studies reviewed. These commonly involve five stages: (1) generation of treatment lists using expert opinion, clinical experiences and/or the literature; (2) refinement of the list into a treatment schedule by consulting expert clinicians (discussion groups, focus groups, workshops); (3) piloting the treatment schedule in clinical practice; (4) establishment of external validity (generalisability); and (5) testing reliability of the schedule. Part 2. Detailed descriptions of treatment were listed under subheadings including: passive and accessory movements; massage; sensory input; selective movement; and functional patterns. Identified treatment aims included reduction of hypersensitivity, increased sensory awareness and improved alignment of structures.
Conclusion
Appropriate methods for describing current therapy have been identified and an MTS treatment schedule has been produced that can now be evaluated in pilot studies.
Keywords: Sensory input; Physical therapy techniques; Clinical observation; Classification; Stroke; Rehabilitation
Article Outline
o Methods
§ Findings
o Purpose
o Methods
o Results
§ Content
§ Dose
o Phase 1
o Phase 2
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· The
difference between Neuro and Orthopedic Rehabilitation
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