By Dietrich W. Miesler, MA, CMT
Originally published in Massage & Bodywork magazine, August/September 2000.
When working with stroke victims it is important to realize that in the case of a spastic stroke, the muscles are not out of commission, but they are out of control. The balance between flexors and extenders is gone; so is the wonderful phenomenon of muscle groups that, in a fantastic choreography, can bring the most incredible variation of strength and direction of movement to bear on the most mundane moves.
All this is taken for granted until something goes wrong. The terrifying event of a stroke is impossible to experience vicariously. You lose consciousness and when you wake up, life has changed. You can’t move like you used to, you can’t walk, and the most terrible thing, you can’t talk anymore. You want to communicate, but you can’t. I still believe that health care personnel do not appreciate enough the utter terror the stroke survivor must feel, especially in the first few days.
But let’s not rehash the material of the first two installments already published. We want to know how we can use our hands to help the patients reorient themselves to the new situation. Remember that every stroke patient is different and observation is the key to determining protocol.
First of all, let’s learn the difference between a left-sided stroke and a right-sided stroke. A stroke on the left side can often lead to temporary speech impediments, because the speech center — Broca’s area — is in the left temple region. Still, the paralysis that goes hand in hand with the speech problem is on the right side, because nerves cross over. By the same token, right-sided strokes lead to left-sided paralysis.
Now what actually happens with the nerves and why? Most strokes happen either because of broken aneurysms or clogged arteries. A bursting aneurysm deprives the affected area of circulating blood. That means the oxygen supply is interrupted and the longer this state is continued, the more nerve cells die. The more cells that die, the more muscle motor units are out of control. Since the flexors are stronger than the extenders, you have people in nursing homes whose arms are so severely contracted that they can not be straightened out. That phenomenon goes from the shoulder to the elbow, and on to the wrist and fingers which are rolled into a tight fist with the thumb lying across like a seal.
This state is due to many years of neglect by caretakers. I personally believe it is the fact that stroke patients are habitually put in this “you will never do anything again” bag from day one, so they never get over the initial shock when waking after a stroke. Then, in many cases, they hear the discouraging words: “You never will walk again, you never will drive a car again, you will never use your arm again, and you never will speak again.” What is most disappointing to me is that even physical therapists take part in this cruel game. So for us as massage therapists, rule No. 1 is never discourage any stroke patient with this type of prognostication, because no one really knows how far a determined patient can go in his efforts to rehabilitate. I always have to think of Trudy from Part 2 (June/July 2000). The doctors were fighting to put her in a nursing home and her husband took her home anyway. After four years, she displays practically no trace of any handicap, and I venture to say that with massage added to all the ingenious, common-sense things she did, she might have succeeded in half the time.
Getting to Work
To demonstrate the protocol for working with stroke clients, we look to 80-year-old Mader, a man who suffered a stroke six weeks earlier. His daughter, Rosie, a licensed massage therapist, called me after reading our first installment on this topic, hoping I could help her work on her father.
In working with Mader’s “fresh” stroke, we weren’t faced with the typical contorted shoulder and elbow you usually find with those patients whose stroke is a year old or more. This is something you are usually confronted with when working in a nursing home. Mader still had passive movement in both the shoulder and the elbow, and we did not have to disengage his curled fingers. Instead, Mader’s fingers were so incredibly thick and strong that a glove was sufficient to keep them from curling up.
Start by turning the hand palm up to get it in the proper attitude for your thumb to massage the finger flexors. It never ceases to amaze me how many therapists turn the hand over to massage the extender tendons on the back of the fingers. This is strictly an unthinking habit, because you can’t accomplish anything by fiddling around on the tendons.
Start the arm sequence with opening up the fist and following up with the thumb on the palmar surface of the fingers, starting with the little finger and ending up at the thumb. Form a little groove with the other fingers of your hand and let the thumb do its thing.
Then you immediately have to grasp the tips of your client’s fingers, because if he was a stroke survivor of a year or more, the fingers would immediately close again into a fist, albeit not as tight as it would have been originally. With Mader, the muscles had not settled in their spastic mode yet. If you hook your fingers under the first digit, you can close your hand around your client’s fingers and play with them by straightening them out and helping them to curl again, but always as a unit. Do so as if to remind digits of what they once could do by themselves. The idea of starting at the hand when you want to fluff1 a whole arm is based on the logic that the arm is a functional unit and starting at the most distal end will indicate the damaged areas of the more proximal muscles in a logical sequence. It seems to be the fastest way to find out where the problem areas are. For instance, notice that the wrist is prevented from dorsiflexing, for which the pronator muscles and the extenders of the arm are responsible.
In order to remove the blockage in the wrist, fluff the forearm. Do this by forming two C-clamps with your hands and work up the forearm with the thumbs on the extenders and the other eight fingers on the flexors. As you continue doing this for a few minutes, check once in a while if the range of motion in the wrist has improved. In a relatively fresh arm like Mader’s, you could get a positive response fairly quickly. In an old, set arm, you can not expect instant success. However, I worked with one lady who was able to extend the arm for a greeting, after maybe four sessions. And if you observe a noticeable improvement, of course you have to share your observation with your clients. Then watch them beam. Your words certainly beat the tired phrase: “You’ll never be able to use your arm again.”
Let’s move to the upper arm. You already have the advantage with Mader’s arm not being caught yet in two unyielding joint muscle groups, such as the shoulder musculature which is still pliable and strong enough to allow almost full range of motion, and the elbow muscles which also allow nearly full straightening and range of motion. Both facts are prerequisites for possibly revitalizing the whole arm. This is a simple fluffing move which chiefly addresses the triceps musculature.
Once we get into the shoulder musculature, we’re dealing with a much more complex muscle system. This system is not only important for facilitating the circular movement of the arm, but it is also involved in the postural problems of the whole upper body — from the distortion of a sagging face to the loss of square shoulder appearance. The position of the whole arm plays a decisive role in which muscles of the shoulder group receive the benefits of the manipulation of the left hand.
The key to keeping the shoulder in its right place is this exercise: grasping hands, the client pulls up over the head and holds until he has to let go. It is even more beneficial if it is in a recumbent position, when lying in bed, because it does not require that much physical strength by the patient. The needed light support under the right elbow is not needed because of the weight of the arm that has to be lifted, but instead to overcome the force with which the muscles in the elbow work against the move. That indicates the muscles around the elbow were not fluffed enough.
Finally, let’s look at a simple trick with which you can get the upper trapezius to totally relax. If you stand behind the client, you can easily push the shoulder toward the neck which foreshortens the distance from the upper traps‚ origins to the insertion points at the shoulder blade and the clavicle, and you can really do a good, painless job of working the upper traps from the spine to the tip of the shoulder.
Now let’s move to the leg, which is also affected by stroke. For instance, something as simple as getting from the sitting to the standing position requires mental and physical preparation. The problem is the fact that the thigh muscles of the quadriceps no longer can do their thing, namely lifting the body. The problem usually is the knee, more so than the hip, and of course the ankle is important, too. So, going back to the principle we established in the upper extremity, we begin our work at the most distal area— the foot.
First, let’s look briefly at what the patient has to go through when he begins to walk again. The knee is bending just a fraction of the range it normally would have to in order to walk. Even if it could bend that well, the quads would not be able to hold the body weight. What complicates the whole process even more is the fact that a cane can’t be held in the right hand, because it is usually even worse off than the right leg. Hence, the whole body is leaning toward the left side.
Rosie continued to show me what she had been doing to her father during the past few months. She showed a good manual dexterity in all the standard techniques and I am convinced it was her activity with her dad that helped with his physical recovery.
While she worked his leg, Mader did his arm stretching routine without being asked to do it. It is much easier to do in the recumbent position than being upright, either sitting or standing. It is gratifying to work with a client who is so wide awake to his needs. This stretch is extremely important.
When I took over from Rosie, I showed her the Day-Break leg routine which starts at the sole then goes to ankle articulation, which probably is the most important move on the whole leg. It is a sequence that drains stagnant blood from the foot by stimulating the endothelium derived relaxation factor (EDRF) reflex. EDRF is a strong vasodilator that comes to bear again in fluffing the calf. With the calf relaxed, move up the muscle, squeezing every inch or so. Make sure this is a flowing move.
Rosie was a good student and picked up the important features of ankle articulation. She also realized the eminent importance of a knee bolster. It puts the knee into a relaxed attitude that makes fluffing of the calf much more effective.
The important thing about fluffing is that it must be done on a muscle in a relaxed position. If this is the situation, then your moves practically tease the individual muscle fibers apart and allow the whole muscle to be flooded with blood. Again the EDRF phenomenon plays an important role, especially in portions of the muscles where there are atherosclerotic conditions that can be reduced by recurrent fluffing.
The last move is the ROM move of the whole leg. You have to lift the lower leg up with one hand underneath the heel and the other hand under the popliteal area. You have to make sure the leg is always parallel to the surface on which the patient is lying. You then begin irregular moves which we accomplish by moving the two hands against each other. The irregularity is necessary to prevent the patient from picking up the rhythm and helping you along, which is exactly the opposite of what you want to achieve.
There was a surprising moment at the end of our session when Mader suddenly lifted his paralyzed leg and moved it up and down as if nothing ever was wrong with it. And then he laughed — loudly. When Rosie visited him the following day, Mader was in a bad mood because he could not repeat his previous day’s feat. Rosie repeated the process and her father was again able to raise his legs and do his little air bicycle routine. I believe that having the knee elevated and having the muscles fluffed is the key to this spontaneous event. A satisfied grin says it all.