Arm and hand mobility

[mushtaq]

Hello everyone,

I am hoping to get some advice and insight to help one of my students here in Tanzania.

My student severely broke his left arm in several places as a child and other than having it set, received no other medical attention or physical therapy. (Medical care in most of Africa is marginal at best). Consequently, he has gone through most of his life with one arm and hand that is almost non-functional. (He is thirty nine now).

When he came into my class, he had no mobility in the last two fingers of his left hand; the entire hand was atrophied, as well as the arm, being about an inch and a half shorter than the right and about two thirds the diameter.

What I have done so far is have him concentrate on the Warrior Wellness finger, wrist, elbow and shoulder exercises daily, and I built him a special club of 1.5 kg to use for his left arm.

In the last month the results have been extremely positive. He has regained a significant amount of use in his left hand. He can now move his small and ring fingers with difficulty (as opposed to not at all) he has increased the muscle mass of that hand and improved his grip strength. He has, this week begun to use a five kg club for many exercises on his left side.

I am looking for any suggestions for anything else that can help him recover as much use of his arm as is possible.

Any Ideas?

Mushtaq Ali
Arusha, Tanzania

[Scott Sonnon]

Mushtaq, my friend,

Congratulations on your student's progress! You're obviously doing everything right. Something additionally which may accelerate his mobility will be to mobilize the opposite leg, especially the toes, foot and ankle. Immobility in his arm tends to lead to fixations in the swing phase of gait... which in turn reinforces / binds issues in the arm.

[mushtaq]

Coach Sonnon,

Thank you very much for your advice, I will begin implementing it tomorrow.

As an aside, the student in question, whose name is Rijwan, dropped by today for a short visit. He mentioned how amazed he is with his progress as he had never hoped to be able to use his hand in any real way again. I told him that I had put his problem to the forum looking for more help. He asked me to pass his Salaams to you (the traditional greeting of “Peace be with you”) and to tell you that he remembers you to God with gratitude for what your work has given back to him.

Mushtaq Ali

[Scott Sonnon]

It's a privilege to be of service.

[bob_stra]

One thing I remember from kinesiology is that the body prefers bilateral learning, to the extent that if one learns something one handed there is some transfer of learning to the other hand. (Realistically of course, this implies the learning isn't in the hands at all, but in the nervous system, no?). There is also some evidence to suggest that using the "weak hand" gives rise to greater learning. Perhaps this is because the "weak side" doesn't have a habitual pattern of use. (Note: there is also an argument for using the strong side first)

Also, visual feedback is important. There was one study conducted on Parkinson patients (Frosberg 1984) in which the therapist drew a white line on the floor for the patient to walk along / follow with eyes. They found that troublesome gait improved as much as when patients are given L-dopa medication!

Speed and parasitic action can often prevent one from carrying out a desired action. For example, there was an experiment done with a bunch of undergrad students. They gave them a button to press as they watched a second hand sweep around a clock. The task was to press the button as the second hand got to 8. Every now and again, they would stop the clock before it got to 8. It his instance, the students were told do nothing. Guess what - depending on how close to 8 they stopped the clock determined whether or not the students were able to inhibit the "pre learnt" parasitic movement (lifting finger). IIRC, they discovered that it takes a minimum of 200mseconds to inhibit such a parasitic movement. In the real world, this might be modified by emotion, drugs, skill level (elite vs beginners), injury (esp eye injury for this kind of thing) etc so that the time needed to inhibit might blow out to 300-500mseconds or be as low as 50mseconds. Practically, this doesn't seem like much, but if this pattern of inhibition didn't happen, even basic motor task would be impossible. IF you search for "degrees of freedom problem" you should be able to find out more.

There is also a lot that can be said about massed (all in one go) vs distributed (over time) practice schedules, mental only practice, movement cues attendants, feedback etc. See if you can get a copy of "Motor Learning: Concepts and applications" by Magill. It gives the theory and then the application to various settings (rehab, kids, older adults etc). Older versions can be found for $10 on amazon.

[Jarlo Ilano]

The "new" thing in training those people who have suffered strokes resulting in hemiparesis (weakness/dyscoordination) of one side is Constrained Induced therapy. It used to be called "forced use". The gist of it is that the "good arm" is binded, so the person is obliged to do all activities with the "bad arm". The typical protocol is six hours a day.

http://66.102.7.104/search?q=cache:X3-s6kYtD8AJ:weblink.pt/efns2002/press_releases/Wagenaar%2520pr%2520rls.doc+constrained+stroke&hl=en&ie=UTF-8

Less drastic is Mushtaq's progression of encouraging use of his friend's arm is progressive ways that it has not experienced previously.
I guess you can think of strokes, and situations such as Rijwan's, as the extreme of Sensory Motor Amnesia.

In line with this, and what Bob posted, you might want to try ABC type, two handed movements with the clubs. This coordinated body movement will not just take the weaker arm along for the ride, but will help progression by "priming" the arm with, as Bob mentioned, the body's preference for bilateral activities. Two hand training also will allow heavier weight, so the "irradiation" or "overflow" principle of PNF, will help wake that arm up from its amnesia.

Congratulations Mushtaq, your success with your student, makes you as much a therapist as myself or any of my colleagues. Wonderful! I hope you continue on.

Jarlo

[bob_stra]

The "new" thing in training those people who have suffered strokes resulting in hemiparesis (weakness/dyscoordination) of one side is Constrained Induced therapy. It used to be called "forced use". The gist of it is that the "good arm" is binded, so the person is obliged to do all activities with the "bad arm". The typical protocol is six hours a day.



They use to do that to left handed kids in the 1920's so as to make them right handed.

I think it bizarre myself, especially the 6hrs / day protocol.

To each is own. I might put this topic on my "list of things to submit for CST mag", as it's of interest to me. (no, I've still not done the others. For shame)

[Scott Sonnon]

They use to do that to left handed kids in the 1920's so as to make them right handed. Try the 1970's in the US. I was forced to write right handed until 2nd grade. Because of the addition of dyslexia to inappropriately 'forced' handedness everything I produced could only be read in a mirror.

My baffled grade school teachers intended to place me in 'special education' because of my "disability" - that is... until one teacher indignant to their problematic lunacy, placed the pencil in my other hand.... and instantly solved the issue.

That landed me on television for the first time for a documentary called, "I'm in my right mind."

What concerns me is how much we are still ignorant... where are we still forcing children to do unnatural deeds in the name of what we believe to be 'right'?

[mushtaq]

Greetings all,

First, please let me express my gratitude for all of the truly intelligent and thoughtful ideas and feedback. I gotta tell you guys, as far a internet forums go, this one delivers as being both the most information rich and genteel (in the old sense of the word) I have personally experienced.

Bob’s post jogged my memory about a learning pattern for bilateral movement from Erickson model hypnosis.

The pattern goes like this;

Do the movement sequence you want to learn on your “strong” side three to five times. Then stop and go through the same motions on the same side, in memory, paying careful attention to kinesthetic memory of the movements, the same number of times. Then go through the movements in imagination on the “weak” side again paying careful attention to replicating the kinesthetic sensations of the movements. Then do the movement the same number of times on the “weak” side while “remembering” the feel of the movements from the “imaginary” work.

As I remember (though it has been a while since I have practiced this kind of thing) this seems to accelerate the learning for the “weak” side.

I’ll let y’all know hoe this works.

Coach Sonnon’s suggestion for working with the opposite foot and leg was spot on. Rijwan does have an interesting catch in the swing of his right leg.

I have encouraged him to also concentrate on the ankle and foot work from Warrior Wellness in his daily routine.

I think I will not suggest that he force himself to use his left hand and arm exclusively for the moment. Though I will encourage him do as many tasks with that side as he can and switch back to his right if he begins experiencing any emotional stress with using his left hand. I am hoping to build up a “bank” of pleasurable and comfortable experiences with using his left side. At the moment he carries a good deal of feelings of shame, frustration and embarrassment associated with his left hand and arm, I don’t want to inadvertently add to them.

Thanks again,

Mushtaq Ali

[Jarlo Ilano]

Wonderful Mushtaq!

Very much like the somatic approaches which acknowledge that there is no mind-body duality. Our postures and movements are very much inseparable from our emotions and mindset. We need to tailor our treatments to the patient's temperament, personality, and past history.

"Forced Use" methodology may be better for those with the temperament for it, and not with the strong emotional components.

You seem spot on! Brilliant!

Thank you for sharing.

Jarlo