Putting It All Together

Last summer I “tried my hand” at rowing a boat. My husband Ian and I were staying with family at the Hood Canal in Washington State. I picked my way carefully over the pebbled beach and climbed into the rowboat while Ian held it steady. He rowed away from shore and handed me the oars – one at a time, of course, because I had to position my affected hand on the left oar.

I tried to row the boat. The left oar flailed.

First uncoordinated attempt: note different oar positions.

I needed to help my affected side through a few strokes so it could get the feel of the circular motion. I gave the right oar to Ian and placed my right hand over my left, guiding myself through the motions -- dipping and pulling, pushing and leaning.

When that felt comfortable, I traded oars with Ian. Now I observed my right side doing the same motions. I felt how the oar pushed on my thumb as I reached forward, and pulled on my index joint as I leaned backward. When I had that sensation locked in my mind, I took both oars.

My healthy side made longer, stronger strokes, my husband pointed out. I eased up on the strong side, allowing my affected side to set the pace, consciously synchronizing my movements.

Row, row, rowing the boat!

Next thing I knew, I was rowing the boat gently down the lake – for about 10 strokes, then my affected hand tired and wouldn’t hold the oar anymore.

I repeated the exercise a couple times over the next few days. By day three I had muscle memory and was able to start off with coordinated strokes. It felt so good to exercise my body this way!

Dear Santa: a rowing machine might be a great therapy tool for me to build strength and re-coordinate muscles.

Reflections

"Pay no attention to that man behind the curtain." -Wizard of Oz

I concealed my affected hand behind a mirror while I watched the reflections of my healthy hand open and close. This tricked my brain: As I watched the reflection of my healthy hand, I had the sensation that my affected hand mimicked the movement! But I couldn’t resist peaking behind the mirror, where I saw the reality of my curled limp hand. For me, that shattered any benefit of mirror therapy.   

What I find more useful is to study my healthy side for clues on how to use my challenged side. When working with SaeboFlex to grasp balls, I sometimes notice my movement feels unnatural. I am approaching the ball in a way that makes it easier to grasp given my disability. I stop and study how my healthy side would do it.  I observe the angle I reach from, the position of my hand, then try to mimic that with my affected side – because my objective isn’t to pick up a therapy ball – but to move my affected side as normally as possible. 

I learned from Eric that symmetry is important. He sees a heavy crease in the skin on my affected side, while the healthy side has a fine line. He sees the ridge of a curving tendon on my affected shin, while its mate runs straight. He shows me a mound and hollow in my affected calf compared with the smooth curve of the healthy muscle on the other side. He tells me to imagine my skin like a sausage casing and to spread the meat evenly inside it.

My body is a roadmap showing me where it needs work: level the shoulders, flatten the torso, balance the hips. Today my mirror therapy encourages me to look at both sides.   

Mind Over Muscle

Pre-stroke I worked out listening to my iPod, thoughts meandering over yesterday, today and tomorrow.  Post-stroke my mind needs to engage as much as my muscles.  First, I relax the spastic muscles in the area I want to exercise; second, I link my brain to the muscles I want to work (harder with some than others); third, I put my core muscles in proper position. Now I exercise, holding all of the above in mind as I repeat the motions.

I liken it to golf and all I had to keep in mind simultaneously to hit the ball on the sweet spot: Keep that elbow straight, rotate those hips, keep that head down – oh yeah, and try to relax! I sucked at golf.

I’m working harder at rehabilitation than I ever did at golf.  The most mentally challenging aspect for me is correcting bad habits – not just those acquired through adaptive functioning – but those that pre-exist the stroke.

Instead of keeping my feet parallel and engaging my core muscles, I turn out one foot for stability. Eric calls it my kickstand and says a lot of people do this, which contributes to the prevalence of lower back pain. I do it when I’m standing at the kitchen counter, in line at the post office, lifting weights. 

The other bad habit many of us have is to use our joints for stability instead of our muscles. It’s easier to lock our knees than to use our leg and core muscles. I use my hip like a linchpin, taking all the weight on it and cocking it as needed to move me. No wonder it hurts. 

For healthy recovery, I need to stop relying on my joints and make better use of my muscles.

Coming From the Core

One of the first observations Eric made when analyzing my walk was that my stomach muscles were not engaging. I've heard  "Let your fingers do the walking," but "Let your belly do the walking?"

Many muscles, not just leg muscles, play a role in walking. I was engaging only the powerful quadriceps on top of my thigh to swing my leg forward from the hip. Eric wanted me instead to tighten my abdominal muscles and use them to help lift my leg forward.

At first the abdominals on my affected side would not engage. To "turn them on," Eric sat me in a chair and told me to exhale as if I were blowing up a balloon. Once I could force no more air out, I froze my belly muscles in that tight position and held it as long as I could. No sit-ups, no crunches, but I broke a sweat.

My abdominals now remembered what it felt like to work and had been given permission to do so. I practiced walking, using my abs to help lift my leg, which no longer felt as heavy as when I had been swinging it. Over time, my abdominal muscles began to flatten instead of bulging uselessly on the affected side.

Now we're working on my back muscles, which need to help stabilize me when walking.  This has proven especially challenging because of a lower back problem that preexists my stroke. Apparently, I have been misusing my abs and back muscles for years.  Now that I'm addressing the core issues, my back pain has changed; it's no longer a spike in the hip joint, but a soreness in the hip muscle – like after a good work-out.

I think I'm learning to walk properly for the first time in my life.

Incremental Improvement

I don’t want my recent posts to give the impression that once Eric releases the trapped energy in a particular area of my body that it’s cured. It isn’t. The tension can build again and the adaptive habits of the past five years can reassert themselves. 

When Eric works on me, I’m able to move correctly for a limited number of repetitions, but my muscles fatigue quickly because they are unaccustomed to exercise and don’t store much energy yet.  Consistent with everything else you’ve read on neuroplasticity, I have to use the muscles repeatedly in the correct way for my body to reestablish healthy muscle memory.

The benefit of my sessions with Eric is that he gives my muscles space to move. An ankle locked like a block of cement must be swung and plunked on the ground. An ankle that flexes, however, lands heel-to-toe and ready to push off for the next step, which encourages the calf muscles to work. 

When my tension rebuilds, Eric releases it again and, over time, there has been sustained improvement. It’s a slow process that requires my constant mindfulness. Sometimes I think about babies learning to walk and marvel at how relatively unconscious they are. I am conscious of every step and must focus my attention on so many muscles. No wonder I fatigue so easily!

To maximize neuroplasticity, I’ve added another therapy day to my schedule so that I see Eric three times per week. We are greatly supported in our efforts by his boss, Dr. Arbi Derian, who still weight-trains me once per week and treats me three times per week with electrical stimulation, adjustments and passive stretching.

I always feel better after my treatments and believe they will help me continue to improve incrementally.

As Above, So Below

I marvel at the connectedness of my arm and leg – how working on my arm causes a reaction in my leg and vice versa. I’m told the body is wired for efficiency – that the nervous system’s control mechanism for the arm and leg, which perform essentially similar motions, is the same. Brain damage makes you wish nature had built in system redundancy, but alas.

What this means is that I can’t work on one area in isolation. More than any other function, I would like to recover my leg – so I can walk quickly and distances, ride a bicycle, kick in the water. But sometimes my foot hits a wall in its progress and the solution has been to work on my arm.  When the tension in my wrist releases, my ankle relaxes and the foot straightens out.

Eric tells me “as above, so below,” meaning that you can roughly approximate the shoulder to the hip, the elbow to the knee, the wrist to the ankle and the fingers to the toes. It’s no coincidence that the finger and toe I have trouble extending are the same – the second. 

Recently, as Eric and I practiced walking, I was having trouble straightening my foot and my ankle threatened to roll outward.  I pointed to tightness under my upper arm. As he worked through it, the triceps engaged to roll my arm and shoulder back. Simultaneously and without thought, the peroneus muscle on my outer calf adjusted to pull my heel straight beneath my leg.  Eric worked the kink through my hand and there was a snap as the tendon in my second finger released.

I set off across the gym floor on a straight ankle and a flat foot with a gloriously elongated second toe.  

On the Table: Re-coordination

Sometimes Eric and I spend our sessions in the massage room. I lie on my back and he circles the table, moving each of my body parts into its correct position.  He does this over and over again – jostling, rotating and pressing me into proper alignment.

The sessions are relaxing, but I don’t just lie there: I’m an active participant, paying close attention to where he shifts my body. He’s constantly correcting the rise of my shoulder, the tuck of my chin, the tilt of my hips. My job is to learn to assume these positions myself.

I focus on the position he leaves me in as he moves onto another part of my body. When he reaches my spastic arm or leg, my torso often contorts: on the healthy side, my ribs bulge, my back arches. This compensation for my affected limbs is particularly noticeable on the table where I feel the absence of the supportive pressure beneath my back.

These same types of contortions occur when I’m upright and trying to use my affected leg. But they are more controllable on the table where maintaining balance is not a factor. If I can gently reassert the proper spine position while Eric works, my spastic muscles respond favorably, elongating as he pulls and shifts them to release the trapped energy that makes them stiff.

This illuminates two of the important principles that Eric has taught me:

1) The connectedness of the body – how the parts affect each other.

2) The necessity of re-coordination in stroke survivors to remind all of the muscles how they are supposed to work together.

More on these as we continue to examine Eric’s techniques.

Eric the Closer

Two years ago I started working with a therapist I call Eric the Closer because he fine-tunes me. When I asked him to label his brand of therapy, he paused. How do you encapsulate his techniques?

Not really massage – energy redistribution.

Not really strength-training – recoordination.

Not really reeducation – a new level of consciousness. 

“I guess polarity therapy,” he says.

The dictionary definition sounds airy-fairy – “restoring the flow and balance of energy in the body.” I’d be a skeptic if I hadn’t experienced results: My foot has straightened out, my shoulders and hips sit even, my gait and balance have improved, and my fingers have relaxed.

Example of a typical session: Eric gives me a simple exercise. I do maybe three repetitions and my ankle seizes up and my toes curl. Eric takes hold of my foot and commences battle – untwisting the calf muscles, shifting the ankle, coaxing the toes to elongate.

“Feel that,” he exclaims.  “Feel the cold coming out?!” Now I’m aware of it: my ankle is freezing from the inside. He holds my ankle and stamps his foot, dispelling the trapped energy. A flush of warmth. The skin on my foot and lower leg glows pink as blood pours into the nutrient-starved tissues. We are both sweating.

It’s painful, exhausting, exacting work. As Eric manipulates me into shape, my groans and exclamations sound like childbirth. I keep expecting the gym manager to tell us “Get a room.”

To benefit from the therapy, I’ve had to let go of self-consciousness in a way that harkens back to the rehab hospital – nothing is private or sacred. I cry out, push back, tell Eric where I need his healing hands; in them, I have the strong sense that I will go as far as I can in my rehabilitation. 

Recovery Beyond Two Years

I am five years post-stroke. Two-and-a-half years ago I started working with a new therapist. I hinted about the work we’re doing in Rehab From Rehab, but I’ve avoided specifics for two reasons:

1. I could not imagine how to write about his techniques.

2. I didn’t want to report on techniques that did not deliver results.

I’m heartened to state now that I have improved and there is good reason to believe I will continue to improve. How much? Will I ever be able to use my hand? No one knows.

I have recently been in touch with a stroke survivor and new reader to my blog who seemed to want assurance that a second round of Botox injections on a spastic forearm would yield a worthwhile result. While I wrote back with encouraging details of my Botox experience, I think my most important point was this: I would have lost heart and gone insane years ago if I’d been focusing on the result.

The information we stroke survivors want to hear is that we’re going to get better and how long it’s going to take. The past few years have taught me to shift my attention to the process and to focus on enjoying my life today.

I understand that it can be demoralizing to invest the time, money, and emotional energy in therapy when there is no immediate evidence of a result. In Stolen Identity, I wrote about the types of motivation that keep us going in an exercise regimen – the most helpful being the “identity motivator.”

Yes, I’ve continued therapy past the two-year mark and it has yielded incremental results. But I’m going to keep doing therapy because I’ve made the decision that’s who I am.

Next post: About my new therapist