Adventures in Serial Casting, Part I

Image from BBC

I recently worked on serial casts for a patient with brain injury to improve PROM and tone of the ankle. Here is the case study which will be followed by an entry of some of my own research into the topic.

Pt. is a ~60 y.o. female s/p multiple CVAs who was referred to OT for splinting assessment while in the neuro ICU. Pt. was connected to typical ICU monitors plus arterial line, was breathing comfortably on room air. She presents at a Rancho 3-4 level, depending on the day. Her L foot demonstrates increased tone, plantarflexion, and inversion. I was not able to passively stretch her ankle into neutral position and she demonstrated no AROM. I did not splint her per normal protocols (pre-fabricated multi-podus boot or individualized foot boot constructed from splinting material and cushioning as necessary) because I worried that she would not fit well into even an individualized splint due to the inversion and would be at risk for skin breakdown. I asked the doctors to consult PM&R at rounds, and the PM&R doctor injected the patient with a phenol nerve block (I'm not going to go into the differences between phenol and botox because I really don't know anything about it and that decision lies outside the OT realm. There is research on it if you're interested) which he said would be effective for 2-3 months.

After the nerve block, I was able to range pt's foot out of extreme inversion but not quite to neutral and she still had deficits in dorsiflexion PROM. At this time we were able to begin serial casting of the ankle. I can't say that I had experience with the specific technique, my previous casting experiences involved the elbow (in retrospect, this is much easier to cast in my opinion). However, I did take an athletic training class back in high school which involved many sessions of ankle taping (and after spraining my own ankle I got several years of experience taping my own ankle daily) so I did feel that I had a good concept of the necessary design (stirrups, figure 8s, heel locks and a general circumferential wrap).

Our first cast was applied after 15 minutes of a heat pack. Pt. was positioned on her non-affected side with L knee in flexion and L great toe in extension to inhibit tone and allow for the PT to get best stretch from her ankle. Gel pads were applied to bony prominences, cast padding was applied to the whole lower leg, and 3 layers of plaster were applied. This first cast was applied on a Friday, (only because I was on day 2 of 8 working days and would be there over the weekend to monitor) and removed on Monday with gains in PROM noted. I had forgotten the confidence that you need to operate a cast saw, but it came back. Her inversion problem was gone after this first cast. A second cast was applied on Monday afternoon and removed the following Friday by another therapist who decided to try out a standard multipodus boot at this time as the pt. could be ranged to neutral. However, when I saw her on Sunday, she still had the PROM to get to neutral but her increased tone was still pushing her into plantarflexion and thus she was pushing herself out of the boot.

We decided to do 1 additional cast in attempt to reduce the spasticity, but something was not right about this attempt. When following up the next day, there was an indentation on the medial portion of the leg that was concerning for increased pressure, and it was unreachable by tools to attempt to correct, so it had to be cut off. It still seemed wet, and I don't know why, but that made it harder to cut. I bivalved it in the hope that I would be able to fix it from the inside and make a long term splint. This was my last day before vacation and afterward they tried kinesiotaping to reduce tone as well but I was not present for that part. Thus ends the chronicle of the serial casting.

(Please stay tuned for an entry focusing on the research behind serial casting)

My First WiiHab

So our hospital has a Wii (actually 2, one lives solely in the burn unit) which I have thought was interesting since I didn't know how well it could be used in acute care. I missed the inservice but figured I could go ahead with my session since I have a Wii at home and am somewhat familiar with the games.

The way I see it, for the Wii to be used in acute care, you have to have a client who is sticking around for a few days, has the required cognitive capabilities to understand the system, and has deficits that can be addressed using the system. We currently have 3 games- the basic sports game, Wii Play, and Wii Fit. The first client that I had who would have been appropriate (since the program starting) was a cute little lady who was extrememly active prior to her stroke- walking 3 miles a day. Her only deficits were upper-level balance issues, but I was off after her evaluation so I didn't get to implement that plan. But I was able to use the Wii with another lady on the stroke floor. Sorry the case study isn't more in-depth, but several weeks have passed now...

Ms Z was getting an extensive neuro workup for several symptoms, including visual dysfunctions, L-sided paralysis, mental status changes, seizures. Original possible diagnoses were PRES vs an unlikely conversion disorder. Her visual problems were very odd, starting out where she could only see shadows, then she could identify broad swaths of color and light/dark, to where her acuity was markedly improved at which time the optometrist diagnosed a L hemianopsia. She also had a L hemiparesis. As our sessions progressed, she regained hand movement progressing to intermittant elbow and shoulder control. She also progressed to verbal cues only for supine to sit, and was then able to transfer to a chair with min assist of 2, needing her L knee blocked. Once we could transfer her to an appropriate chair, she could come down to our gym to use the Wii.

I thought she would be a good Wii candidate since her controlled ROM of the LUE was intermittant. I hoped that given a distracting BUE task that the control might become more consistent. This was my plan on Friday... when I came in on Monday we had to cut the session short due to LP, and then on Tuesday Ms Z had full ROM of her LUE! Not from anything I did, but just part of the strange waxing and waning of symptoms. She then had some RUE control deficits. I decided that since her coordination was still off that the Wii session could continue. We worked on Wii boxing to address standing balance, endurance, and UE ROM control. Our first day, Ms Z was unable to tolerate a full "round" vs the computer opponent (3 minutes) while standing. However, she persevered while seated and did complete 2 bouts. Our second day, she was able to complete a full bout while standing (10 minutes in parallel bars with contact guard support from PT). We then added in additional challenges, using different punches (inspired by TurboJam), and trying to better facilitate weight shifting both front-back and right-left.

I was happy with how the boxing activity worked out... my next session was going to be more visually-spatial based and require more refined isometric control of the shoulder, but Ms Z was discharged that night to rehab. Even though her initial reaction to the wii was "this doesn't apply to me because I do not play sports," she did get very active and involved in the activity, progressing on performance components she needed for independence. The novelty of the activity was also good since she was getting frustrated with an extended hospital stay. It was a worthwhile therapy experience for both of us.

I feel that I learned a lot from these sessions, and I went home and reevaluated my wii games (sports and play... don't have a wii fit). That brought me to a gigantic list of things that could be better about the games from a therapy perspective. It is a LONG list, I will share it hopefully this week and would love to hear others' thoughts on using the Wii in rehab. For more thoughts on the subject, you can check out a blog dedicated to WiiHab here.

Trying for a better week

Goals this week are a little morbid.
So I had multiple pt deaths last week, 2 expected, but 1 not. None due to receiving OT services or lack thereof but still not a pleasant thing. I did get one lady up to the chair about 5 hours before she coded, didn't do much else since her O2 sats were not stellar. So I've been a little depressed and I would just like for people to stay alive this week.

Saw a cute-as-a-button 89 y.o. lady on Friday who had a pontine CVA (blessedly mild) but told me "I've never been sick all my life, so if I die it's ok" and I am just thinking NOOOOOOOOOO!!!!!!!!! The COTA saw her yesterday and she met all her OT goals, but after that she transfered into intermediate care for continually BAD blood pressures (222/101 etc) which is not good. Went in and talked to her today...hopefully they will get her heart under control. She is totally asymptomatic and does great from a functional standpoint, however she keeps having these skyrocketing BPs. Everything would probably be under better control if she had come to the ER right away but she arrived 4 days s/p onset of symptoms and only came in when her MD called and noticed her slurred speech. Worse- she lives with an adult child... how can you not notice that your mom has major weakness on one side, slurring speech, and struggling to walk? Seriously, better to come in sooner than later.

Saw a bunch of pts with multi-trauma today... one guy I saw OOB for the first time in 3-4 weeks, an older lady with dementia who we presume fell down the stairs and refused to put on her TLSO, and a man who was involved in a head-on car crash- now in the ICU only seen for splinting. He has BUE intrinsic plus/resting hand splints and BLE foot boots now. Probably has a TBI as well that can't be evaluated yet so he will have a long recovery road ahead. Been learning (and relearning) a lot of stuff about splinting lately.

Really hope week 2 on neuro floor is better than week 1. Not making a lot of progress on the stroke textbook but I have gone through several AJOTs and other research articles, hope to have a summary post soon. Also still working on a Malcolm Gladwell related post. In other work news, am now on the documentation committee following our strategic planning meeting so I hope to make that both comprehensive and quicker, if possible. Added a bunch of new 'tweepz' on twitter, hopefully that won't cause any brain overload but may be helpful resources, so if you do the tweet thing, go ahead and check it out. :)

drawings from a client w/ impaired vision post CVA

These pictures were drawn by a client with an interesting and complex history of CVA.
Mr. R presented to our general medicine floor a few months ago after a fall, and had been unable to stay home unattended during the day without problems. He had experienced a stroke 1 month prior to admission, outside the US, and as far as we learned had received nothing but the most basic treatment to stabilize him, no rehabilitation whatsoever. While this gentleman had virtually no motor involvement, he had MAJOR deficits in short term memory, to the point where he had what I would call "5 questions a day," which varied slightly day-to-day, but would be repeated for the duration of that day no matter how they were answered. He retained very little of the answers that were provided, though this ability waxed and waned. This would have been a great enough barrier to home discharge, however, he also had severe visual involvement. I appealed for a neuro-ophthalmology consult but they declined to participate since this was not an acute event. So I did what I could to evaluate this issue.

Clock Drawing: I found this interesting since the numbers are running counterclockwise, and he did draw them in descending order. I couldn't find any information on other cases with the numbers running backwards.
These pictures are his attempts to reproduce the above drawings. He was able to describe the shapes in the drawings somewhat, but unable to figure out what the whole picture was.

We had a similar issue when he was trying to '"cross out the m's" or reproduce written letters. He could write letters accurately but couldn't read them effectively unless directly cued to trace the example and trace the letter in question.

Mr R's decreased vision was really a secondary problem to the decreased short term memory. He would occasionally report new, altered visual symptoms which made evaluation difficult, and functionally, his vision was less limiting than other deficits. For instance, he needed help to find his way to the bathroom, but needed only verbal cues for perseveration to shave his face. I believe the family had to pursue nursing placement since they couldn't provide 24 hour supervision, which is sad, but between his memory and visual deficits he did need that level of care.

What I'm Reading Now

Current reading pile

• Mansfield Park, Jane Austen- trying to finish this so I can get on with everything else. The first 200 pages were not particularly exciting, but now it's picking up
• The Tipping Point, Malcolm Gladwell- borrowed this from my dad and my husband now picked up the audio book. I'm a little competitive, so I'll have to keep up while he's reading.
• Stroke Rehabilitation: A function-based approach- I bought this quite a while ago, but now need to get around to reading it since I will be on the neuro side of the floor quite soon.
  
• OT Practice 7/13- did take a break from the novel to go through that. Have to browse the OT Connections Forum to see what the conversations are about that... the main article was interesting, I just need to process it in relation to my own life.
• Rehabilitation of Traumatic Brain Injury in Active Duty Military Personnel and Veterans: Defense and Veterans Brain Injury Center Randomized Controlled Trial of Two Rehabilitation Approaches (Archives of Physical Medicine and Rehabilitation Vol 89, Dec 2008)- Saw this referenced in the previous OT Practice and it referred to 2 different treatment approaches that I wanted more information on. Haven't set out to tackle it yet.
• Self-care, productivity, and leisure, or dimensions of occupational experience? Rethinking occupational "categories" (Canadian Journal of Occupational Therapy April 2009 Vol 6 Num 2)- Saw the abstract on Karen's blog and had my library buds pull it for me. Should be an interesting challenge to daily practice.
• Validation of a New Coma Scale: The FOUR Score (Annals of Neurology 2005; 58:585-593)- I saw this in our new employee handbook in the 'preparing for neuro' section. I can't remember if I learned about this before or not. I know that we did the Glasgow Coma Scale and the Rancho Los Amigos Scale for Brain Injury, but I thought I would look into this. Not sure if it is used on our floor or not, but it's worth learning about.
• 17 files from my neuro professor/coworker- piles of powerpoints, buckets of documents, all in preparation for the scary neuro floor. eeep!
  

So that's what I'm up to. I love reading, but sometimes there is too much... this doesn't even take into account my Google Reader list or daily newspaper browsing. Anyone know an electronic reader that will transport the information into my mind?

May is Stroke Awareness Month

Read the CDC feature on stroke

Make sure your friends and family know the signs of stroke so that they can be prepared to act in an emergency.

Check out these sites for more info:
American Stroke Association (a division of the American Heart Association)
Internet Stroke Center

OT WebGems- Manipulate the Brain Edition

I love brain stuff. Here's a few pieces on how that great organ works and changes, also a couple of behavioral modification pieces thrown in.

Starting off, research shows that even mild concussions can have effects years into the future, which has got to be troublesome news to anyone involved in contact sports. Go go helmet developers!

An fMRI study looked at how older and younger individuals processed negative images, and the researchers concluded that the older women were able to cope with these problems better. So hopefully one can become less stressed over time, that's what I'm hoping for anyway.

This piece has been floating around my bookmarks page for a long time (note that the subtitle discusses the election season) but it's an interesting look at irrational behavior and why humans take offense.

Researchers at Johns Hopkins found that controlled doses of carbon monoxide can prevent damage after a stroke, which makes sense after hearing about it, but who is smart enough to think this up ahead of time? Still seems to have a short window to operate, but I love seeing the new advances.

On another stroke note, here are some of the gender differences in care before and after CVA.

This was an interesting study involving deep brain stimulation in patients w/ Parkinsons, which I found fascinating.

Behavior modification is always useful, not least when used on ourselves. This article discusses how the fear of being labeled a hypocrite will lead people to make lifestyle changes. This ADVANCE piece discusses the benefit of actually accomplishing things even when they're hard. And this is a more detailed piece, also from ADVANCE about learning emotional awareness and control.

That's it for today, as my brain is currently hoping for no micro-trauma from roller-coaster riding!

OT WebGems- Brain Edition

OT WebGems charges on like a hybrid car rolling downhill! Ok, "brain" is a pretty broad term for an edition. The following links are mostly CVA related, with some NON-controversial information on stem cell research, and a couple of other thinly related articles. Who doesn't like neuro-know-how? Onward!


TIA Diagnosis- Neurologists have found 3 indicators to help avoid misdiagnose TIA. Briefly, if the person has had a slow onset of symptoms, vague symptoms (w/ or w/o neurological symptoms) and/or if a TIA had previously been ruled out at another time, then it is not likely a TIA. We do get therapy orders for pts w/ TIA, though they sometimes turn into a 'walky-talky' (as the speech therapist calls it) before we get there. I did get eval orders on a person who I had discharged on eval the previous day as she continued to have neuro events while in the hospital.

Stroke Centers- This study found that pts who received care at a specialized stroke center recovered better and stayed better than those who had care at a non-specialized hospital. They recommend telecommunication for rural hospitals, but I wonder if they explored the SES factors of their participants, as there can be some major overall health differences between city-dwellers & others who can get to a specialized center and those who are in a more rural environment.

Brain Implants- Scientists have found that there is some same-sided brain control over body movements, and are using brain-computer interfaces to help overcome hemiparesis. They can't leave the implants in long-term though... yet. Also, if you have not yet looked at BrainGate, you should definitely check into it. One of my classmates found this in late 2006, and they have continued to improve their research and tests.

Reprogramming Adults' Cells- Scientists have now taken a fully developed adult cell and transformed it into a different type of cell. This isn't super-new, especially because one of my former fieldwork CIs had a pt who had an experimental procedure where stem cells were used from his nose to help him overcome a paralysis. But, very cool.

Google- This was an interesting article about brain scans done in older adults during web surfing, but I think they missed a discussion point. It was the web-savvy users who showed the greatest brain activity during surfing, which I would think means that people need to develop their 'brain-gain' activities early in life and continue them, or that you would get less benefit from starting one of those activities later in life and being less skilled at it. I'm not sure if that really fits with what we already know about brain development though.

Amnesia- I throw this in here as a short, less-scientific but good intro to neuro article addressing amnesia and whether one knows they have it or not. Just happened to come across it while writing this.

Body Snatchers!- Scientists were able to create an illusion of body swapping between a person and a mannequin, tricking the brain's sensory perceptions. A cool jumping off point for robotics, VR, and possibly sensory reeducation?

OT Web Gems- Research Edition

Ok, update first. I have not been intending to neglect the blog of late, especially when Karen was nice enough to include me in her OT Practice article. However, I have had a few complications this week. One, I am procrastinating preparing for my inservice (11/21) and have been trying to do that before doing fun things. Two, I am having a lot of shoulder impingement problems and while I don't know what is causing them, I know the computer isn't making it better, so I've been online less. Anyway, I have several entries half-started and other ideas brewing, so there will be updates once I get my life in line.

On to the web gems!

OT Student Survey on working with adults with developmental disabilities. I can't remember if I posted this already or not, but I'm guessing that since it's in my inbox that I have not. Oops.

Kessler Rehab Research- this site will make it to my sidebar when I next update that. Research on SCI, CVA, TBI

NIH Clinical Trials- can't really remember why I bookmarked this, as I don't deal in pharmaceuticals, but it may be relevant to those in research

StrokEngine- love it! lots of good categorized info on the latest CVA research. Another to be added to the toolbar

MOHO Clearinghouse- an alert reader on one of the AOTA listservs (holiday time is a great time to renew your membership- new practitioners get 2 years reduced rates!) pointed this site out. Has some good free MOHO based stuff, as well as some research links and products you can buy. I intend to use the play inventories with some of my older kids when I have time to print them out.

Some interesting cases

The hospital has actually been slow for a little while, but I couldn't catch a break during that time since my pediatric caseload was simultaneously growing. The peds caseload will require a separate entry, as it has exploded a bit. Anyway, the circle of hospital life always comes back around from slow with only a few pts to overfull with referrals coming out of our collective ears. We've managed to fill up again just in time for us to be shorthanded as a colleague takes a weeklong trip. But, before I get totally overwhelmed again, here's some stories on a few of the interesting people I've seen recently.


I have been working with Mr. H for the past 2 weeks. A great elderly gentleman who is mentally extremely sharp. I believe that he remembers absolutely everything I have ever told him (so hopefully he will remember to get those grab bars installed at home!). Really nice guy, good sense of humor, and absolutely tries his hardest to work with us. He came in with a hip fracture and a previous dx of Parkinson's Disease. Thank goodness that he had an ORIF, as he has a special method of mobility that would not work at all if he had hip precautions. He's become one of my favorites, which is good, because since he moves slower it takes considerably more time to do a treatment. He has progressed from being MAX Ax2 to stand, also for LE dressing, to being CG-SBA. Terrific progress.

Mr. R has also had a strange journey that I've gotten to share. He had a history of problems with his shoulders and had 1 rotator cuff surgery a long time back. It had taken him a long time to recover, but he did get a lot of UE motion back. Then, over the course of a couple months, he gets run down, stops exercises, has some cardiac issues and pneumonia and winds up in the hospital. When he first arrived on our skilled unit, he had such minimal ROM in his arms that he could not use them to help stand up, and was MAX A 1-2 for all ADL tasks. We had really made some progress, and he was able to dress upper and lower body w/CG-MIN Ax1 and was looking ready to discharge soon. Unfortunately, he had a bowel obstruction, wound up back in acute care for a week. He's been readmitted to the skilled unit now and hopefully hasn't deteriorated too much in the interim.

Most complicated evaluation of the week goes to Mrs. MA, who had a very intense CVA. She had multiple infarcts in the L MCA distribution in the frontal, parietal, and temporal lobes. This also resulted in mass effects, which usually happens in hemorrhagic CVAs, not ischemic. First thought: Holy cow!!!! This lady has expressive aphasia, and is limited mostly to the word "okay." On the day that I saw her for the eval, she was doing a little better, using a few more words appropriately and trying to construct sentences that would start out intelligble. Us "Thurapee Girls" descended en masse- OT, Speech, PT. We got her OOB and into a chair, at which point the telemetry nurses descended upon us freaking out- Mrs MA's heartrate was 190. So, back to bed, PT exited stage left, and I did my first cotreat with our new speech therapist. It's terrible to say that I've had fieldworks and been practicing over a year and never cotreated with speech, but it's a situation of coincidental circumstances and not out of some crazy "no teamwork" philosophy. I do cotreats w/ PT all the time, but really had to switch my brain channels for working with speech. Challenging, but fun! We worked on communication briefly, and worked feeding and groming into the bedside swallowing eval. Also, I learned a new fun fact- no cranberry juice for people on Coumadin. Good to know. I hope that this interesting lady makes a good recovery while she's with us... she'll likely discharge to community SNF or maybe acute rehab if she starts doing better.

Also have another TKR pt. who is going to recover function much faster than knee flexion or mobility. She's mobidly obese, but has excellent flexibility (way better than me) and can do lower body dressing in bed. That's not usually something I do with people who do not have a spinal cord injury, but it works. However, she's still struggling a lot with basic mobility and knee ROM. We will likely see her on the skilled floor.

Here's hoping we don't get TOO busy... since that takes away the time that we can spend on each person and simultaneously takes away my sanity. :)

Play Ball!

Had a really fun treatment today. Props to Mr A for withstanding over 2 hours of therapy today and to my pseudo-boss for being willing to listen to my ideas. Mr H is in his upper 80's and had a basilar artery stroke. When I first saw him in the hospital last week, he had poor sitting balance, very poor standing balance, and couldn't hold onto a walker w/ his R hand. Since then, he has made some great progress. (sidenote- spontaneous recovery is a frustrating concept to me. I wish that you could predict why some people get great recovery from cerebral events quickly, and others never do. me=control freak)

I had spent 45 minutes before lunch working with him sitting EOB while doing resistive clothespins and reaching in all planes, also did the extreme fine motor kit. No sitting balance issues. Sitting balance is the precursor to standing balance, so yes, this is relevant to his continued independence. Teaming up w/ my experienced PT friend and a rehab aide, we later found Mr A game to try our sitting balance game. We got to sit him on a ball, where he did great with dynamic sitting balance, even after incorporating throwing and catching another ball. Great BUE coordination. The only thing he didn't do well was the cognitive portion of this that we eventually worked up to- naming a different major city with every throw. We did try some dynamic standing at the end of this exercise, but that is still in the future.

This is the 2nd time in a year of employment that I have seen/heard of the ball being used. The first time, I was sitting on it to eat lunch. It makes me miss the rehab center, makes me find a commonality with a non-particularly-liked employee of said center who told me during my fieldwork that she could never NOT work on the stroke team, as the other diagnoses were boring. It certainly is interesting and sparks my curiosity over my future again... I have strong interests in CVA and SCI but they are generally separated and very specialized.

Here's to you, Mrs. K

My Mrs. B is off to acute rehab. Despite the PTA's view that "it won't make any difference," I think that she is capable of great recovery. This week, she was able to don her bra independently using a clothespin to hold it to her pants, participate in the modified pilates for neuromuscular reeducation, and complete a shower with more ease. We did the resistive clothespins on her second to last day, and she was able to independently seek and manipulate all but the hardest pins, a drastic improvement from Day 1 (which I did get to see). I got to say goodbye and give her a hug, and she was so appreciative of me... it was so sad because I formed a strong bond with this strong lady. In retrospect, she reminds me very much of a patient I worked very closely with at the end of my rehab fieldwork- Mrs. S. They are different in diagnosis (Mrs. S had a FOOSH which resulted in a R wrist ORIF and R hip replacement) but both have a great drive to get better. Even though the healing takes longer, since they were both in their 80s, I believe that they both did quite well with rehab, and do miss their special personalities. Thinking about it also makes me wish I was back in the intensive rehab world again, and makes me worry about whether I have the chops for that anyway.

Sadly enough, as my dad would say there's always an object lesson. Mrs B was the patient who alerted me to how my changed pediatric schedule and personal focus has affected the inpatient environment. I was able to work with her less often than I wanted due to my peds schedule and the responsibilities that come when working on a small staff. I was only in inpatient all day 2 out of my 4 workdays, and one of those was often spent entrenched in acute care evaluations. Not only was I working less w/ Mrs B, I was also working less with the patients down "my" hallway. The division of hallways was setup about a year ago, and obviously is still in play, though my peds schedule has had a strange effect on it. Since I was not around to constantly direct care for "my" patients, they got fewer ADLs and less personalized care from the rest of the staff. I found weekly updates hard to complete, and little attention was paid to the altered treatment plans.

I feel terrible about the decreased level of care that I feel these people have gotten, but it's hard to understand how others' complacency let it get to this point. I will have to spend the next month (until school starts) advocating louder for their needs and paying greater attention to their treatments and developments, even if I never get to see them. Who knows what effect the school year schedule will have... I've been adding kids left and right since June and will have to make spots available somewhere, while still carrying a full hospital caseload.

I hope I can get all this worked out... I am trying to worry about it less so that I have more mental peace. But good luck Mrs B- may those at the county rehab recognize your special light and help you achieve all that is possible.

I used too many abbreviations today, here are some explanations if you're unfamiliar with any of them: PTA- physical therapy assistant; FOOSH- fall on outstretched hand; ORIF- open reduction internal fixation operation.

Pilates power!

Admittedly, I have been very terrible about keeping up with Pilates since starting the videos w/ my OT buddies during first year. I have done perhaps 2 10 minute sessions since last year, which is pretty pathetic. But I finally got to use some techniques w/ one of my stroke pts- Mrs. K. I had her doing an adapted mermaid while seated EOB. Really trying to bring back some normative movement in her RUE, as the natural flow is gone. It was hard for her, but she is such a trooper, really willing to work. Hopefully I can continue to incorporate these exercises for relevant treatments. :)

Stroke Season

One of my OT coworkers always says that as the heat goes up, the stroke rate goes up too. I evaluated 4 stroke patients yesterday. One was my friend from acute care who transferred to the SNF floor. Hopefully, I will get to continue to work with her and continue our partnership. I have a lot of cool treatment ideas for her right now and am working on a list to share w/ the COTA to get her more comfortable working with CVA pts.

Another lady came in and only speech therapy had been ordered on admission, but I got a referral the next day. She was a little defensive about me showing up to see her, but we took a nice walk and discovered that though she'd been having trouble reading (a major barrier to her preferred leisure activities) she could still recognize symbols and was about 70% on reading basic words. I picked her up solely to educate her on low vision techniques that would make it easier for her to read (fonts, more space between words, high contrast).

Had a very unfortunate gentleman in his early 60's who had a bilateral cerebellar infarct with a 1-sided thalamus infarct as well. This man had just started a new job, so it can be assumed that he was a reasonably active individual PTA. Unfortunately, his current assests are moderate head control, moderate ability to hold sitting balance, and movement in his L elbow and hand. No current speech production, questionable ability to understand others, and a mix of flaccidity and extensor tone in different extremities.

Last guy came in with minimal involvement- some slurred speech, decreased endurance, and slight proprioceptive and sensory deficits. He will go home soon, but there is some question to the future. The PT tried to allude to this with him by saying, "This might be considered a wake-up call" but there is little hope of him changing the behaviors that caused the stroke to start with- obesity, HTN, no exercise, no checkups with doctors, etc. People can change after such events, my dad did after his heart attack and now starts the day with 30-45 minutes of cardio exercise and a cup of oatmeal. But in order to change, you've got to answer the phone on that wake-up call. Here's hoping that this guy does so that I don't see him in 2 months in worse condition.

Title LGT the American Heart Association.

Being the therapist that inspires

I have pride today. Couple of days where I've been able to delve into projects and treatments and feeling quite good about it all. I've had some successes and am happy about it, so here's some notes on the whole business.

I've been working with a L MCA stroke patient and got to spend an hour with her today even though she is on acute care. Our acute care patients get short sessions too often, especially when we are overloaded elsewhere. But this little lady was willing to work and has good potential (I wish that the MDs would take our advice and send her to rehab instead of SNF, but that's a different story). We took steps, we did FMC exercises, we did self-ROM, and we opened 4 of the easy level clothespins 2x each. Those closepins were difficult for both of us, but she felt the taste of success and showed decreased depressive behaviors, so that was good. When I came back for her afternoon session, she said to her visitors, "That's my therapist! She's going to get me better!" BIG SMILE. She'll get herself better, but I will take the compliment. :)

My 5 year old from the post on Failures was back yesterday with his mom. We worked on some activities to challenge his balance, which wasn't difficult since his center of gravity is in his head. We worked on the swing (he does have independent reciprocal swinging motion!) and eventually progressed to catching and throwing a ball while swinging. I made big goofy faces about how strong his throws were and he giggled and kept going instead of saying "I can't" which is his favorite word set.

And I've been doing some good work on projects the past 2 days. Raided the speech therapy room (we are currently -2.5 STs) and borrowed a stack of books to explore. Among my finds was the Adolescent Test Of Problem Solving, which will be used on my 13 y.o. coming in on Monday, and a book on communication problems w/ pediatric TBI. The big ticket item though was the manual and installation disks (floppys!) for communication board software. I made the IT guy come install it ASAP as we get calls fairly frequently for communication boards for people in the hospital. It will take some getting used to, as it was designed for Windows 3.1, but I hope to persevere soon! Apparently, you can download a free trial of their new software here.