Thursday, June 23, 2016

Stroke rehab: Where do I start?

I do a ton of talks to OTs and PTs (mostly-- some other clinicians mixed in there from time to time). Sometimes I get a specific question. Its a simple question, but perplexing.

"When treating a stroke survivor where do I start? What should I look for first?"

Here's the way I answer this question...

When I meet a survivor, the first thing I check out is the hemi-side hand. The hand tells you a ton:
  • Is spasticity an issue? If it is it will show up in spades in the hand. All those little joints, and those little muscles pulling those little appendages. And the massive strength
    difference between the muscles that close the hand against the muscles that open the hand. Let's put it this way, you can hang from one hand. Your entire body weight through those little appendages. The muscles that open the hand have the strength to do one thing: open the hand. There is a huge difference in strength between the two groups of muscle groups. So if the question is, Is spasticity a problem  the hand will usually be the first to reveal it.
  • Is the survivor paying attention to that hand? Many survivors will play with the affected hand constantly grabbing it and opening it. This is a good sign; unilateral neglect is probs not an issue.
  • Are they able to squeeze the hand shut from and opened position? A lot of people, even clinicians, think that closing the hand is a bad thing. Opening is a good thing, but closing is a bad thing. I think closing is a good thing and opening is even a better thing! You need both. It kind of like the joke: "How you feeling?" "I'm alive!" "Well that beats the alternative!" (OK, its a dad joke. But I'm a dad- so its OK!) So, being able to close the hand beats the alternative. The alternative is nothing. The dreaded flaccidity.
  • Are they able to open the hand? Can they "relax-open" the hand. That is, can the survivor relax the flexors so much that, while there is not activation of the muscles that open the hand, there is at least a deactivation of the muscles that close the hand. That deactivation is important. Why? Because of the point made above- those muscles are incredibly strong vs the opposing muscles. So the first thing needed to open the hand is the ability to shut of the muscles that close the hand.
  • How does the hand look? Is it swollen? Is it the same color as the unaffected side? Does it have the same
    amount of hair. Is it painful. All those can tell you something (esp. in someone who has a post-stroke shoulder dislocation).
  • What's going on globally? The hand takes up huge swaths of the brain. In some ways the most visible reflection of the brain is the hand, so the hand gives you global perspective on the brain.
So as a clinical or survivor or caregiver, the first thing to ask is, how is the hand doing?


oc1dean said...

My first question would be: What do you want to recover? That will lead directly to the passion, drive and resilience to do the work necessary to get there. I would expect there is not a therapist in the world that could successfully get me there under current knowledge but it is a start.

Peter G Levine said...

Dean! I'd agree, but this entry is more about diagnosis than the direction recovery should take.

oc1dean said...

Ok Peter then I would have them look at the CT, MRI and PET scans to see what areas are dead vs. what is in the penumbra to see what can be saved. This would have to be one week later after the cascade of death has played out. That is assuming that the therapists have been taught what to do for penumbra vs. dead brain. Of course I realize this probably is impossible, my therapists never saw my scans and if all the therapists are getting is ET - evaluate and treat - then the doctor has not helped them at all.

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