I am about 2 weeks post-stroke, and I have to say, I am in a strange period of dramatically improved overall feeling (relative to the previous weeks), but with frustrating aspects of my recovery dominating my overall field of vision. Impatient! Really, it has been a crazy week. In the last week I went from 15 minute bouts of concentration followed by a 45 minute nap, to 2 hours of concentration followed by a 45 minute nap. In other words, I feel more like myself in terms of capacity -- now I need to work on the endurance. (In case my boss is reading this 2 hours of concentration looks more like "surfing the interwebs" than it does "programming hydrologic models" - don't get any ideas) However, with greater abilities, has come a pretty intense muscular response known as "hyertrophia" or in laymans terms "spasticity", and perhaps even more distressing - boredom!!! Rachel came home Wednesday night, which is usually date-night, and tried to talk me into staying in. I almost cried. I definitely pouted, no kidding (not that poutings really all that rare), so she relented, we went out to a little neighborhood bistro "Tastebuds", had a burger, 1 beer, (Ommegang Belgian Pale Ale ) and then was in bed by 7:30 PM - almost back to normal!
That is the highlight of my day though, I am getting stir crazy, but in boredom comes epiphany or something, so at long last I have begun to master the art of drawing "paisley" (see drawings 2/12/2011 if you wantz a piece of my mad skillz).
Impatience aside, it has been a fascinating and gratifying recovery experience thus far. I am sure that I am on the "fat part" of the improvement curve, where rapid incrases in ability just happen spontaneously, and that soon they will begin to slow (if they haven't already, my drawing ability may have plateaued, more on that in the artsy-section of the blog post). Anyhow, over the last week I have documented 2 "threads" of my improvement, 1) fine motor skills, and 2) understanding. For the first, I have been trying to do at least one page of writing (lists, notes, anything requiring LETTERS), and some drawing to hone my fine motor skills. The second pursuit is simply to increase my own understanding so that I might guide myself better through this procss. If you like the human interest aspect of a stroke recovery (or you just want to make fun of my penmenship and "dream house" drawings), I have uploaded a gallery of scanned pages from the sketch-book that I began a week ago. I can't go so far as to say that I am proud of the drawings yet (and I have never been proud of my penmenship), but I feel like they show a real step forward. If you want to read about what I have learned about stroke recovery, how it pertains to my specific symptoms, and how I try to understand this based on my greatest body of physical knowledge (swimming), read on in the section "Hypertonia and Doing Less". To me, it's actually kind of fascinating, albeit dry. If you just want to know that I am doing better, wait no longer, I am improving RAPIDLY.
Drawing/Rehab-Activity Log
Part of my self-prescribed occupational therapy has been to draw. In all, this has been a really good thing for me, my notebook has provided me proof of just how rapidly my brain is adapting to its new configuration. The occupational therapist has also given me some drawing activities. One of the more difficult tasks is to maintain uniform sizes between multiple entities, and switching direction on curved continuous lines. The most interesting thing to me, as I have never had a particularly quick hand, is that slowing down does wonders. So, the potential is there, it is just not as rapid as it once was. As for the rest of the rehab, I have been a couple times to PT and Occupational Therapy. The majority of y day however, if not napping, is spent doing self-supervised activities that I figure must be good for me. Riding my bike trainer, yoga, guitar, and puttering about the house and neighborhood. The log below shows my daily activity summary, it is getting bigger!
2-9-2011- 4 sun salutations
- Bike 20:00 HR < 100
- Harvested Lettuce from cold frame
- Began drawing in book
| 2-9-2011
 | 2-10-2011
4 sun salutationsBike 20:00 @ HR < 115PT (walking test 6:00, bunch of other stuff) | 2-11-2011
50:00 yoga, 1 single sessionbike 25:00 @ HR < 115attempted 3-D perspective drawings | 2-11-2011
|
2-12-2011 - Woke up feeling good, thought about doing local RABA group ride, then remembered that I had a stroke
- Bike 25:00 HR < 120
- Could draw straight lines, did some better 3-D landscape drawings
- Over an hour of yoga in 3 sessions
- Walked around the block
| 2-12-2011 | 2-13-2011
50:00 of yoga in 2 sessionsshopped with mom for garden supplieslifted 2x50 lbs bag of lime, wheel-barrowed across the yard (mom and Rae yelled at me)Bike 25:00 @ HR < 120Wrote a couple of swim workouts | 2-14-2011- 2 sun salutations, some Feldenkrais cross-legged stuff, side twists and crawling - total 30:00 of yoga and a lot of sleeping
- 25:00 bike < 120 HR
- Valentines dinner with Rachel Rees (my wife!)
- PT and OT double header, crushed me
| 2-15-2011 - 30:00 biking, with 2:00 standing pedal
- 25:00 yoga, mostly laying on the mat
- This is the day that the hypertonia really nailed me
|
2-17-2011 - 10:00 cycling (too much hypertonia to do much of anything)
- 20:00 yoga
- massage at Skies of Indigo
- Went to Barrel Thief for lunch, total jello after massage - massage made me feel so much better...
- Baby sat Rowan Luscan solo for about 15 minutes! (we watched Ponyo - awesome animated film)
| | | | |
Hypertonia and Doing Less
Ever since my swimming mentorship wth Bob Mattson began, the notion of doing less: less effort with greater synchronization has been the central topic. The central notion has been that the great ones don't necessarily do "more right", but rather, "less wrong" -- at least as compared to those who are their peers or near-peers. With the developing swimmer, this has always seemed to me to be even more true. Those who create a ton of iterference in their swimming, perform at a lower level than those who don't -- view the conundrum of the skinny kid who whips the more muscular one. But beyond those easy examples, I seem to have seen this "do less wrong" strategy pervade all levels of performance. With the stroke recovery, I was shocked to experience what, to me, appears to be the same phenomenon - i.e., the struggle is to turn off unwanted muscles, as oposed to turning on wanted ones.
Hypertonia
My right side was initially paralyzed, but soon gained back the ability to perform rudimentary motions (probably 4-6 hours, certainly within a day). What has been shocking to me is that the right side of my body, as it has come back to life, has done so with a furious level of effort -- inappropriate muscular contraction is the rule. Rather than struggling to TURN ON the muscles that I need to perform a given task, I find that it is those muscles that are contracting inappropriately that limit my coordination. This is a condition known as "dystonia" and affects stroke patients, as well as some other folks who suffer from cerebral palsy or spinal cord injury.
Hypertonia is a condition marked by an abnormal increase in muscle tension and a reduced ability of a muscle to stretch. It is caused by injury to motor pathways in the central nervous system, which carry information from the central nervous system to the muscles and control posture, muscle tone, and reflexes. (1)
Apparently, this is one of the more common effects of stroke, and peaks somewhere between 1-3 months after the stroke. Jeez, I hope not! The level of interference that is produced by these spastic muscles is profound. When I try to do my Yoga, my right shoulder tries to force itself "out of joint" it seems (actually, it is just "subluxation" a common feeling for many swimmers, and is documented as a common symptom post-stroke [in good ole wikipedia - http://en.wikipedia.org/wiki/Stroke_recovery] ), just to reach above my head. This should be a transient phenomena, and ultimately, I might be limited more by an inability to trigger finely controlled motor units, but for now, it is these ones that resist being stilled that provide the greatest challenge. Ever since these symptoms have emerged, it has reminded me of the after-effects of the ice storm that hit the Mid-Atlantic in 1993 when I was an assistant swim coach at the University of Delaware. The destruction was massive during that storm, with limbs being sheared off of trees due to the weight of the snow and ice. The following spring however, I was struck by the ferocity with which the trees appeared to bounce back. With their normal growth patterns altered by this loss of limbs, the growth appeared somehow disorganized, but incredibly vigorous. I can only say that I looked out the window while driving down I-95 that following spring and thought, the trees along the road side looked like they were engulfed in green fire. A study of tree growth showed that radial (trunk) growth was reduced after the ice storm, so perhaps appearances can be deceiving. But, if that means that my limbs will come back swiftly, but my "trunk" will get skinnier, I am all for it.
Links on Hypertonia/Spasticity:
So how do you treat this stuff?
Good question. My afternoons google search seemed to yield little fruit, beyond things like "you will need physical or occupational therapy". There were some disagreements whether or not strength training was good or bad. Someone stepped up, and made some claims:
Spasticity must be prevented during the entire rehabilitation programme using the “anti-spasm or recovery pattern” at all times (Fig. b) Example: if a person is developing “spasticity in flexion” in the arm (arm turned in, elbow bent, fisted hand palm down), the anti-spasm pattern will be to position the arm turned out with the elbow and wrist straightened, hand palm up with the thumb and fingers opened. In other words, you must adopt the opposite patterns. From the day of onset of the paralysis the person must be placed in the “anti-spasm pattern” and all the exercises must lead into recovery patterns. Particular attention must be given to the position of the shoulder and the hip (see next sections).
- Shoulder forward with the arm turned outward
- Elbow straightened, hand palm up with the fingers open, thumb away from the index finger
- Pelvis drawn forward with the leg turned to the inside
- Hip, knee and ankle slightly bent
- Elongation of the trunk
(4)
This was from an organization that works in developing nations, providing medical relief. As for sites whose audience in someone who is working in the litigous environment that prevails in the first world, they might be a bit more reluctant to say anything of substance about a potentially controversial subject. My neurologist Robert Cohen (Richmond Magazine Top Neurologist 2009), who is awesome (his early care of me was seen as crucial by my family, I wasn't really awake for it of course), was kind of non-committal, encouraging me to be active, do what I am doing, but don't overdo it. This is consistent with my physical therapists, who have assuredd me that I would outgrow their services shortly if I have not already done so (they didn't just want to send me packin without throwing me a little bone). However, I did find at least one case where someone had explored the differences in spasticity in both stroke and non-stroke patients with a series of "passive movements" of the knee - worth a try, at least I like the name of their approach (5). One further study, while only comparing 2 different approaches (electro stim versus not), showed riding on a stationary bike to be quite effective in reducing hypertonia, and I might note that I have been cycling every day, and have only a fraction of the trouble on my legs that I do in my arms. This is also interesting to note because at least one of the sources that I saw said that the incidence of hypertonia was greater in the weight bearing extremities -- maybe I cursed myself through all those years of swimming! Better yet, maybe I need to get back to the pool. Anyway, what is REALLY interesting is that while I have been acting non-plussed by all of the "keep doing what you're doing but don't overdo it" talk, my biking has been super-low intensity (max sustained HR of 115 recorded this week), whereas, the hypertonia really kicked in with a vengeance in my upper body after a day with PT followed by OT, followed by 20 minutes of guitar, and capped off by unloading 2 x 50 lb bag of lime from the car (I just moved it from the trunk to the wheel barrow, I know, I know, and my mom watched and was hollering at me the whole time - I think I'm dumb). Hmmm, maybe there is something to all of this "keep doing what you're doing but don't overdo it".
Moving Forward
Experiencing my body now, I feel something akin to the freestyler whose arms are robotically moving through a "perfect" high-elbow recovery, an extension, and an entry into the water that is premeditated, stiff, mechanical, and essentially over-wrought. This has been a surprise, even thought my experience with coaching swimming has prepared me to in some ways expect this. I know too that some of the developmental pieces are found in teaching the body foreign motions - it is a key to our Finding Freestyle approach and canon of drill progressions. But, perhaps these crucial drills that we use are helping folks to turn off the wrong muscles as they are teaching the new "physical vocabulary".
So, the questions this ultimately leaves me with: In terms of stroke recovery, what is the most effective way of dealing with this (or, for that mater, should I?), as a swimming coach, does turning off unneccessary motor units benefit us as much as turning on necessary ones?? Is it in fact easier to turn them on than turn them off?
Next step: get back in the water and start swimming. Next week I will hit the pool with my buddy Dave Luscan, and I can't wait.
End Notes
1) National Institute of Neurological Disorders and Stroke - Hypertonia Information Page - http://www.ninds.nih.gov/disorders/hypertonia/hypertonia.htm
2) Spasticity After Stroke: Its Occurrence and Association With Motor Impairments and Activity Limitations. Disa K. Sommerfeld, PT, MSc; Elsy U.-B. Eek, PT, MSc; Anna-Karin Svensson, PT, MSc; Lotta Widén Holmqvist, PT, PhD; Magnus H. von Arbin, MD, PhD. http://stroke.ahajournals.org/cgi/content/full/35/1/134
3) http://www.livestrong.com/article/194417-how-to-reduce-the-muscle-tone-stroke/
4) Stroke Recovery. http://www.aifo.it/english/resources/online/books/cbr/stroke-carraro/2stroke%26recovery.pdf
5) "Reduction of Spastic Hypertonia During Repeated Passive Knee Movements in Stroke Patients" http://www4.fct.unesp.br/docentes/fisio/augusto/artigos%20cient%EDficos/2002%20-%20Reduction%20of%20spastic%20hypertonia%20during%20repeated%20passive%20knee%20movements%20in%20stroke%20patients.pdf
6) Effect of a bout of leg cycling with electrical stimulation on reduction of hypertonia in patients with stroke. Yeh CY, Tsai KH, Su FC, Lo HC. School of Physical Therapy, Chung Shan Medical University, and Physical Therapy Room, Chung Shan Medical University Hospital, Taichung City, Taiwan. http://www.calstatela.edu/faculty/rdeleon/563/Skold.pdf
