Physical Therapy for Pamela Space

Physical Therapy for Pamela Space
As of March 21, 2012

I was eager to get Mom into my care to get her some physical therapy as soon as possible. I heard that the professionals were making poor or little progress and I was sure that she would better cooperate with my guidance; the longer she waited, the harder it would be to help her. Although she found the routines quite painful, she was a good trooper and dutifully put in the effort and time and we achieved progress, although slowly. I'm sure that after four months of being in this routine that it could be continued by others. Keep in mind that she is physically unable to perform these exercises on her own; she needs setup, guidance, and physical maneuvering in great amounts. Also, she would not have the will power to do these even if she were physically able; she does not like the pain and a common reaction to avoid it is to fall asleep. So someone or a combination of family and professionals will need to continue these daily rigors. Please do not skip even one day, as she will quickly revert and lose progress and thus make it that much more difficult to achieve final success. Once she reaches the goals, she can be normal in her use of the leg and arm, and without pain, but it must be a steady process to achieve that.

Leg exercises:
After Mom's knee replacement in the fall of 2011, she needed physical therapy for range of motion. This needs to be performed daily as a minimum, more often if possible. We have been working on this every day for the last 4 months and she has made progress, although slowly. The harder aspect is to achieve a straight leg (I suffered a knee injury in 1994, so I'm aware of the process first hand; it took me 2 years to get close to normal). This is used for walking, as a proper gait will be disrupted with a falling motion if the knee can not straighten enough to allow the heel to contact the ground at the proper time when swinging the leg forward.

It is easiest to have her sit in a comfortable chair and hold her leg out on an Ottoman that is nearly the same height as the chair seat. Rather than hold her down with my hands, I apply weights to the upper part of the shim. My device is simply a pillow case with cans of food in them, separated into the two corners and then the excess material looped around the middle to keep everything in place. We had gotten up to 7.5 pounds total in weights and she was just ready to have that increased. It is also necessary to have the center of the knee remain at the top position, which results in the foot being canted slightly outwards. Since she is unable to sustain this position herself, I placed an object on the outside of her foot to rest against such that her foot would be out about 15 degrees.

I would allow this weight to bear for 5 minutes, then SLOWLY let it bend back to about 90 degrees. Then I give it a few back and forth movements to loosen it up and then usually hold the heel and give the leg some gentle bounces to loosen up the joint and the quadriceps that want to try to keep the knee from being forced into this uncomfortable position.

Then we work on the other side of the range, bending the knee back (this is needed to allow getting her weight over her feet for standing from a seated position). At first she should be able to get it about 10 degrees past 90 without any problem. Then slowly inch it further back until she experiences pain. The pain should be directly on the scar, where we are trying to stretch the skin. If the pain is elsewhere, then gentle rubbing of those areas (keeping the skin in contact the entire time and rotating the base of the palms; i.e. pressure without friction) alleviates that pain. Then let the knee out slightly past 90 and bring it back in. Eventually the pain should reside just on the surface of the knee where the scar is; then keep moving it back very slowly to as far as she can tolerate. I then strap it into position and let it sit for 2 minutes.

I then slowly let it out, give it some back and forth movements between 90 and near full extension to loosen it up, possibly bouncing it again while holding the knee. Then it's back to the full extension position again for 5 minutes and then back to the bending the knee back position.

This time you should be able to get it even further back. Hold it in this position for at least 2 minutes and then slowly let it back out when done. We usually do just these two sets, but a third could be done if you have the time.

Strengthening the legs:
Dad had purchased a pedaling machine and we had her do 30 minutes almost every day immediately after breakfast. We could only have no friction on the tensioner or just the slightest amount. There can be no distractions around, such as a TV, otherwise that will catch her attention and she will stop pedaling. She also needs to be watched as she occasionally will just get bored and stop or fall asleep.

Be sure that the equipment is aligned well. It should be situated directly between her legs and parallel to the legs. She will often want to slouch sideways, so I had to use pillows on the side to keep her situated vertically. Make sure that the knees do not reach full extension on the forward stroke, but also that the unit is not too close such as to bend the right knee too far (the first stroke is always painful); I used a strap around the equipment and around the front legs of the chair to keep it from running away. Be sure she is situated towards the edge of the seat so that her thighs do not press against an edge and cause pain on each stroke (I stuffed a bunch of pillows and blankets behind her to move her forward). Occasionally her feet may slide back or twist in the pedals, requiring readjustment so that the shoes do not hit part of the equipment.

The pedaling is good for quick movement of the legs, but strength should also be worked on. Have her sit in the chair, put her feet at shoulder width apart, bring the feet in towards her butt as far as possible without pain. Then hold both her hands and have her lean forward as far as possible, trying to put her eyes over the balls of her feet so that the majority of her weight is forward. Then with just a gentle pull forward, instruct her to press with her legs to raise herself up. She is actually pretty strong and can do this well, but don't pull her up and only give as much pull forward as needed to allow her to balance her weight over her feet and give her steadiness of balance. Then reverse the process by having her very SLOWLY bend her knees so that her butt approaches the seat of the chair. Don't allow her to bend her knees part way and then plop the rest of the way. She can bend all the way down and this is a good strengthening exercise. It may take several tries for her to do it properly, but don't let her plop. Mastering this will allow her to more easily get herself up from chairs and more safely sit down. Do this for 10 repetitions. As she improves, give her a minutes rest and repeat.

I also took her on 15 minutes walks every day (sometimes more than once and sometimes longer). She can easily lose her balance, so I would walk by her side with my hand under her arm pit so that I could support her weight if she started to topple. She can easily trip on very small things and when she feels that the fall is inevitable, she simply relaxes and it would take immense strength to prevent her going down. Thus the best I could do was to hold her to gently guide her to the ground to avoid injury. The first time she did this, I was holding her left hand and I nearly broke her arm trying to pull it to stop her fall; she was in pain for several days and it curtailed our arm exercises. Holding her closer to her torso worked much better, but it still takes a lot of strength to ease the fall.

Arm exercises:
Although she had a stroke about a year ago, I was surprised that it was allowed for her left arm to just become useless. With a lot of work and pain over the last several months, we have been able to get her to get close to full extension, hold a glass of water and drink from it, and unwrap a foil covered chocolate. She still has great difficulty with control; the arm and hand sometimes will not obey her. Also she had developed a habit of gripping with the hand, so those muscles are very strong and make it difficult to learn to relax it and also use the opposite muscles that are used to open the hand. The goal was to give her flexibility of the elbow, range of motion of the digits, motor control of the hand and wrist, and overall re-wiring of the brain to make it perform as she desired.

We did our arm and hand exercises at the dining table. For the arm, we would start by trying to stretch that tendon on the inside of the elbow. Place something supportive and soft under the elbow and slowly open up the arm, trying to get to nearly straight, usually with the palm of the hand laying on the table, eventually. I usually used my hand for support, but this can become very tiring, but gives better control on the height of the elbow to ensure a full stretch of that inside tendon. She will most likely not be successful on the first attempt and you'll need to alleviate the pain by bringing the arm back up. While doing this, we might as well work on the other side of the flexibility and have her bend her elbow towards her shoulder. She can not currently do this on her own and her muscles will often resist the intention, requiring a slow, patient process to find how far back she can go. Occasionally she can touch her shoulder either with her thumb or fingers and I encourage her to try to do so.

Then go back to the full extension and slowly work towards getting the palm to lay flat on the table. Be sure to have enough padding underneath the elbow such that the arm becomes nearly straight when reaching this goal. The inside of the elbow should be nearly intolerably painful, so do it very slowly and gently. Sometimes the bicep muscles will want to kick in to save the arm from the expected suffering, so she needs to be coaxed into relaxing the arm and you gently and slowly straighten out the arm. If she's smiling too much, you're probably not making any progress. Watch her eyes; they will start to grimace as you reach the pain threshold.

Hand exercises:
Ultimately, the arm improvements are useless without a functioning hand at the end. Control and flexibility are the goals. We start off by having her lay her hand on the table (no elbow support to torture the elbow stretch) and try to get it to relax to get the fingers as straight as possible. At this point she still can not completely achieve this with the control and muscles of the left hand alone and although she gets 80% of the way there, I usually will push the hand down for the final bit so that the hand can become accustomed to that position (she can also do this herself and often will).

Then we have her make a fist as fast and as smoothly as she can. I have her repeat these steps several times before moving onto the next movement. Then I have her rotate the wrist, starting with a fist that is knuckles to the table and then rotating such that the thumb should be on top. Try to get the first knuckles to be vertical. Repeat this movement several times. It's often harder to get the thumb up than it is to lay the knuckles back down.

Repeat this several times. Then start alternating it with the first hand exercise where the fingers straighten out from a fist position. She is still very slow at accomplishing these tasks and sometimes can't make the hand do as she wishes at all; but usually continued encouragement will yield results. If she has not succeeded in 30 seconds, use your own hands to position her hands into the desired position to help train the brain that this position is OK.

Then comes the trickier movement. If she wants to grab a glass from a table, she will need to open her fingers while the wrist is positioned with the thumb on top. We would practice two different ways: one is to start with the palm on the table with the fingers outstretched and then rotating the wrist, the other to start with a fist position with the thumb on top and then opening the fingers.

These are currently extremely tough for her to do and almost always require assistance to get to the final position.

Of course, to achieve the final result of grabbing a glass, the thumb must also have flexibility and control. This is still very far from success at this time, but we work on it, mostly with external assistance.

Start with the palm down and the thumb in. Then bring the thumb out at much as possible. Repeat this many times and try to do it faster each time. Then put the hand up on edge with the fingers straight and thumb on top, then move the thumb away from the palm as far as possible, as if to grab a glass. Repeat this many times and try to do it faster each time.

Then have her grab a short glass half filled with water and have her raise it up from the table about 10 inches (keeping the water level), then bring it to her mouth to drink; repeat several times. Then give her a foil covered chocolate and tell her that she can hold it with her right hand, but all the unwrapping and putting the candy to her mouth must be done with the left hand.

Routine:
Pedaling immediately after breakfast.
Knee exercises immediately after Pedaling.
Strength exercises immediately after Knee exercises.
Walking in the afternoon.
Arm exercises immediately after dinner.
Hand exercises immediately after Arm exercises.

As you can tell, these exercises take several hours each day. And this is just the minimum she needs. It would be good if the stretching exercises on the knee, elbow, and hand could be done more than once a day.