Were you worried something had happened? :-) No, just decided not to push things by trying to get the day's happenings down on the blog in a timely manner while on Day Program. So, will be catching up in the next few days.

December 18, 2006

Today was a very full day, and it went very well, with the exception of interaction with the nurse. The first thing she told us what that Gary’s urine sample from last week had been thrown out instead of cultured. She said she would cut into his therapy time before lunch to take another sample. We won’t get the results of it back for forty-eight hours, and it will be too late to schedule him for a urodynamics study here, if that is what the results indicate should be his next step. So he will have to do that at home. He is scheduled to talk with the doctor tomorrow anyway, about possible future steps, but it would have been nice to have the results in hand on which to base our questions.

First on the schedule was the group fitness training. We made it better by proceeding at our own pace, and for some of the exercises I got Gary a theraband I saw lying around for him to do them with. It didn’t make sense to do exercises for traps with dumbbells like they were doing (holding the dumbbells, bringing the elbows back, and squeezing the traps) because that mostly worked the muscles holding up the dumbbells, not the traps. But by holding an exercise band with both hands and doing the same motion the lower traps were targeted.

The next hour was a PT session of practice bumping up into the wheelchair. First she put the “bump-up” chair-like device in front of his wheelchair. It had a sling seat about twelve inches off the floor that he was supposed to bump up onto. He sat with his back to it and put his hands on the handles at his sides (which were about at the seat level), and then on three he threw his head forward and depressed so his butt went up and back. He made it to the sling chair. Next a belt was wrapped around his knees to keep his legs stable underneath him rather than having his knees splay out. This, they said, was key – his weight was partially supported by his legs during the next bump-up, and they could act sort of like a fulcrum. From this position, he put his hands on the next (upper) set of handles on the device, and repeated his movements so that he bumped up to his wheelchair (the seat cushion had been taken off, as that would give him three less inches that he would have to overcome). He did it, and the therapist said, “That was completely too easy.” :-) To get back down, the thing he had to keep in mind was to start with his hands below him to gently lower himself, rather than keep his hands at his current height and end up plunking down to the lower level. After he did that a few times, I took the place of the therapist in spotting Gary. I was really amazed – all I was doing was providing him guidance (making sure he ended up far enough back on the chair), not lift. I wouldn’t have believed he was lifting his booty up that far and getting on the chair basically all by himself if I hadn’t experienced how little help I was giving him – I thought surely the therapist had to be helping him more than that!

I will have to remember to take a picture of this bump-up device. They no longer manufacture it, but maybe we could find someone to make Gary something like it, although maybe he will decide just to use a portable step, which is what he practiced on next. To do that, first he strapped himself into the J-pad, which is what he would do if he was going to spend some time on floor-level. The step they had was a little low, but we figured out that one about nine inches high, twenty-two inches wide, and fourteen inches deep would work quite well – we would also put a nonskid surface on the bottom of it and several layers of carpeting on the top of it to protect his butt. He practiced bumping up to the stair and then from the stair to the chair (without its cushion) a few times, the last time with me as his spotter, and again I thought him astoundingly successful. To get back down from the chair, he would lower his hands to the step, and then ease down. After the last time of going to and from the chair, he stuck out his tongue, indicating he was beat :-) Fortunately ;-) the session was over. So he transferred over to the mat and put his cushion back on his wheelchair, like he would have to do if he ever “really” bumped up to his chair at home, then transferred back into his chair.

So, if he ever wants to go upstairs in our house, he now has a way to do it, as the technique is similar. He’d strap on the J-pad to protect his booty and then bump up each stair. (Added a few days later when he and I actually practiced bumping up the stairway at Shepherd under a therapists guidance: it is not quite as easy as his bump-up practice to the chair. It is scarier for him because he is throwing his head downward in the direction of a flight of stairs when he is bumping up them! But he would do this with a companion, if at all possible (unless he is alone in an emergency situation), who would spot him (holding him at his waist, etc., as I'll describe on a later day's entry)to make sure he didn't lose his balance.)

Next was an PT session. Since Gary was having some trouble leaning while on the commode chair, she suggested he use his chain loops to wrap around the grab bar that will be to his right and behind him (it is in the shower, actually) when he is at home, and then loop his arm through it and lean. She also said that if the commode chair placement over the toilet seems awkward when we are home, that he could always set the chair over a bucket lined with a trash bag. In fact, she pointed out, this is what he may have to resort to when he is traveling, if the bathroom setup isn’t perfect. It might be easier to do the bowel program in bed, he thinks, rather than lug a commode chair around with him.

Gary’s next task was learning how to do skin checks of his own butt and back. The PT taught him a double mirror technique, lying on his side on the bed and looking into his small flexible-handled mirror to see the reflection from a large mirror. This worked quite well, and she suggested we get a large wardrobe mirror and have it mounted horizontally to the side of his bed.

Next he again practiced coming to sit from a supine position in the bed. As long as he has room enough to roll over practically into a prone and then sit, he is fine, but that coming straight up by grabbing onto his pants or under the back of his legs and then wiggling from side to side trying to get his elbows underneath him is something he can’t do by himself. We can’t see him running into the absolute necessity to do it this way, though.

She taught his some towel roll stretches, because his shoulders and chest are very tight, and also, his posture in the chair isn’t the greatest – he always curves to one side, and the PT thinks it might be because his left chest wall needs stretching out. Both the PT and seating clinic commented on his posture, so I think that is something he needs to make a more conscious effort of being aware of ;-). It would just not be good for him to get permanently deformed in that curved position.

The first stretch she showed him was simply to roll up a towel or two and put the roll lengthwise along his spine as he lies on his back. He then puts his arms out at shoulder level in “crucifix” position, palms up. She said he could do some weight training exercises in that position, like a bench press (or “bear hug,” as she called it), which would, on account of the weights, give him even more stretch. The second exercise was lay on his right side and put the roll of towels under his side. (She said we could use a bolster, but in the catalogue she had, they cost around eighty plus dollars – maybe there’d be just a firm foam roll we could buy cheaper.) For more of a stretch, I could put one hand on his hip and the other under his armpit and stretch him out by pushing on both hands. She said he should do these stretches for fifteen minutes in each position, so while watching TV on the futon would be a good time for this. Fortunately she said it wasn’t necessary for me to be constantly stretching him when he is in the side position, because that would be quite tiring!

Next was an OT session. Since Gary had been having trouble keeping his balance doing his weight shifts while on the commode chair, she had him get on it (fully clothed) and practice the weight shifts. She helped him learn where he needed to put his hands on the chair to maintain his balance to do the depression weight shift. He may not be able to hold it as long as he is supposed to, so she also went over another kind of weight shift which he is now allowed to do but couldn’t before on account of his flap – the weight shift where he bends straight forward over his knees, the goal being to bend far enough forward so that he lifts his butt from whatever chair he is in. She thought that if he did a series of depression shifts for short intervals and then this lean-over shift for awhile, for a total time of about a minute, then he should be fine. In general they don’t encourage the lean-over shift because it doesn’t develop/maintain arm and shoulder strength at the same time as relieving pressure on one’s bottom – a sort of “kill two birds with one stone” method.

She then had him wrap chain loops (the ends of a piece of cloth are sewn together to make a circle and then these “loops” are “chained together” to a length good for the individual to use for stretching, etc.) around a support in a position behind and to the side of him – the position they would be in if he wrapped them around the grab bar in the shower while he was on the commode seat over the toilet – and she had him use them to lean over while simulating doing the bowel program. Gary thought that technique will work out well.

He will need to put a support under his feet while on the commode chair so that they don’t dangle, for one thing. More importantly, that would keep his knees slightly above thigh level, and that would put a little pressure on his abdominal cavity, she said, aiding with the bowel movement. We figured out he needs a step about four inches high.

She then went over some arm exercises with dumbbells and back exercises with an exercise band (theraband) that she would like him to incorporate into his routine, three sets of twenty of each exercise. She said if he did them every day, that would be great, but he should do them at least three times a week (I’m betting he goes for the latter ;-) – I could see him resisting the idea of adding in more exercises to the routine he has been doing; but he really hasn’t been doing the triceps work they would like, for one thing; hopefully he will talk to a trainer at the university and figure which exercises he has been doing target the muscles this PT wants him to, and hopefully he will then add in any additional exercises he really should). The first two are done while seated in the chair. The first exercise is a front extension to ninety degrees – in other words, lift arm straight out in front of you to shoulder height – and do so nice and slow. Next, biceps curls, two sets with palms up, last set “hammer curls” where the thumb is up – those are only done to ninety degrees, though. The next exercises are done on the mat. Lay with the towel roll under the spine for them. The first is the triceps extension, elbow pointing up to the ceiling and the other arm supporting the working arm. The arm is lifted straight up. Next were serratus punches – both arms are extended simultaneously straight up, and one “punches” them toward the ceiling simultaneously. Next was the bend press, circling the arms around as in a bear hug and squeezing the pecs. Finally for the arms was external rotation. You lie on your side, keep your top elbow tucked to your side, and lift the weight from bed (or mat or whatever your lying on) in a semicircular motion as high as possible (still with elbow pressed to the side).

Then came two back exercises, done in the chair with the theraband. The first you loop the band around a post and pull straight back and squeeze your traps for five seconds. The second you hold both ends of the band in your hands, keep your elbows up and out to the sides, and squeeze straight back.

Next with the PT came car transfers to an SUV. She taught him a slightly different way to do it, so we will have to go over that with Michel Smith (don’t worry, Michel, it’ll be easy ;-)). Gary is to angle the chair more straight in at the car seat, giving less slope to the transfer board, and he also is to put his feet into the car first so their weight doesn’t dangle. He pulls his legs forward as far as possible, scoots to the left corner of the transfer board, and then transfers up. The key to getting out of the SUV is to go slow down the board. The helper (me or Michel, for instance) only needs to stay behind him and keep a knee aimed under his butt in case he needs the support or help with his balance.

Next with the PT he practiced transfers to and from a low sofa seat. He needed a little help, but was so much better than when he did these last summer.

The next hour was with the nurse, during which she was supposed to be going over skin checks with him. She was of no help, in fact, didn’t seem to have a clue. Most people here are helpful, many extraordinarily so, but occasionally there is the person that is not very good. One thing that Gary didn’t like was when we brought up the problem of how he would do skin checks of his back if he was traveling alone, and she told him he wouldn’t be traveling alone. He told her that NOW he couldn’t travel alone, but that he would in the future. He commented to me afterward that he didn’t appreciate her saying to him that he wouldn’t be traveling alone.

That was the last of the day, so we went home and carried on our usual routine. I had checked my email, and on the RSFic list someone was “complaining,” at least partly in jest, that she was blocked in writing a “fic” (fiction story based on the characters of a TV show, etc., in this case “Remington Steele”) because she wanted L.A. to be cold, wet, and rainy. I wrote her back and said she should get over it, because L.A. was unlikely to experience a dramatic climactic change soon. She wrote back something on the order of, “Bugger! How am I supposed to recreate a Yorkshire moor if the weather won’t wuther?” Her “weather won’t wuther” made me laugh, and while I was on my walk (and more later, while I was meditating) a poem for her came to mind. In case it you can get some enjoyment from it, here it is (I suppose I should say that this person is Australian, and her name is Robyn. I hope she won’t mind me identifying her that much):

Why, weather, won't you wuther?
Robyn rants and raves.
Frost and sleet and frozen feet,
Is what the Aussie craves.
But no, L.A., you do not provide
That which Robyn seeks.
You give her sun, you give her tide –
If she is lucky, rain for weeks.
This, she cries, just will not do –
What story can be made from these?
And so, dear weather, we beg of you:
For Fic's sake, her appease.