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.

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

On My Nerves

As a stroke survivor I have heard that to regain muscle control, I have to forge neural pathways between an undamaged part of my brain and the nerves that network through my muscles.

One tool I've used to facilitate innervation (nerve growth) is Neuromuscular Electrical Stimulation. In addition to receiving electrical stimulation as a regular part of physical therapy three times per week, I purchased a small NMES unit to use at home while doing hand exercises. Initially my arm and fingers moved only when triggered by the unit, which works by sticking electrodes to the skin and sending electrical pulses through the muscles. Basically, the stimulator does the job of nerves until they can do it for themselves — sort of like jumpstarting a car.

Additional methods of stimulation include massage, heat and exercise.  I use them all.

Stimulation triggers blood flow into the targeted area, causing oxygenation of the nerves. Nerves require oxygen in order to transmit impulses. Nerves transmitting impulses is how we move our muscles. Moving our muscles causes more blood to flood into them, starting the cycle again.

STIMULATION + OXYGENATION = INNERVATION

When we don't use our muscles, blood passes by on the circulation super highway without being detoured to nerves in nooks and crannies. No oxygen = no impulses = no movement; unused muscle tissue can atrophy and develop adhesions (tissue fibers that stick together because they're not lubricated).

When I follow the formula and innervation begins, I feel tingling, pain and/or twitching. Once I perceive these feelings, I know I have a connection to my brain, that my nerves are awake and ready for instruction. Then comes the hard work of strengthening and coordinating my muscles.

Thanks to Dr. Arbi Derian for explaining this to me and helping me to achieve it.

Get a Grip

One thing that continues to blow my mind is how the stroke affected every part of my left-hand side — my toes, my intestines, my ear canal, even my eyeball.

My left eyeball now gets irritated easily. When I first tried to soothe it with eye drops, the drop plopped in one side of my eye and rolled out the other. I had no blink reflex because I couldn't feel the drop hitting my eye. It kept happening, so I started calling my Visine, "Eye Drop Outs." I had to learn to blink right away to "catch" the drop in my eye. Once I could feel dampness on my lids, I knew the drop had reached its target.

I remembered this lesson during my first efforts to pick up exercise balls with my fingers. The balls kept popping out of my hand. I was applying more pressure than necessary because I couldn't feel the ball against my fingertips. I had to learn to moderate my grip pressure.

I was explaining this to a friend who suffers from neuropathy. She said, "I know exactly what you mean! I was trying to pick up a bobby pin and I couldn't do it, because I couldn't feel it!" 

Wow. That was awesome not only to have my realization affirmed — that a sense of touch is important to grip — but to be reminded that if this stroke hadn't gotten me, some other thing probably would have. There is just a whole smorgasbord of difficulties out there to suffer from.

Over time, as I've practiced moving the exercise balls, I've begun to feel them. I had the clear sensation last week of the rough texture of the balls brushing my fingertips as I released them.

Next post: a formula for reawakening nerves.

Body Awareness

Practicing yoga pre-stroke gave me a familiarity with the mechanics of my body. I learned how to roll and tuck my shoulder blades to open my chest. I learned how to stretch my feet both wider and longer. I learned to balance my weight not only side-to-side but back-to-front. I learned to be aware of the subtleties of my body.

In recovery I am aware of my body changing. Some of the exercises given to me in the weeks immediately following the stroke were premature. I stopped doing them in favor of exercises that seemed more helpful. Now I'm realizing my body is ready to go back to some of those abandoned exercises; I need the skills they were designed to teach. 

As I do each exercise, I try to be aware of the muscles being targeted. I often ask my therapist to touch the muscle I'm working. This helps me focus my mind on it, making my efforts more effective. And by being aware of the sensations and behavior of my body, I can communicate better with my therapists. This helps them help me.

For more than two years now, I have been almost constantly and uncomfortably aware of the pains and deficits of my affected side: It burns, buzzes, tingles, cramps. Sweet sleep or an hour of television provides brief escape. But the long-term escape — recovery — comes from paying close attention. My body wants to heal itself … is trying to heal itself. If I pay attention, I can help it.

Three Steps Back

In my recovery each advance has been hard-fought and has brought new freedoms. Walking without a cane meant being able to carry items from point A to point B. Stronger muscles meant more stamina — to run an errand or do a chore. These abilities gave me a sense of usefulness, which helped my mood.

In the last months of 2012, I surrendered these luxuries by agreeing to an experimental treatment designed to improve my lopsided gait. Arbi had the unusual idea of injecting Botox into my peroneous longus and peroneous brevis muscles, essentially immobilizing them. Without them my foot inverts (rotates inward). To walk I was therefore forced to engage my weak extensor muscles, which assist with foot "eversion." This was the objective: to strengthen the minor muscles around my ankle.

By the end of each day, my ankle was so tired and painful, I couldn't stand up even to microwave dinner. I became more dependent on my husband again. I started using a cane again. Friends who had celebrated my progress watched me regress.
It was really hard.

But three months later my ankle is stronger, my foot straighter and my gait more even. I now sometimes take a half-dozen steps that feel almost normal. I can envision a time when I will walk without a limp and what that might feel like.

But it won't be within the next few months. Arbi just told me that the experiment has been such a success, he wants to repeat it —
to force those tiny ankle muscles to work even harder.
Sigh. Six steps forward, three steps back.