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Thirty-four years ago, I was a new therapist, struggling through my first fieldwork experience. I used Connect-4* with a stroke survivor, for much longer than I should have. Why? Because I had watched my supervisor use it with this patient and I had no clue what else I might do. Over the following weeks I began to better understand how the activity supported his improvement in motor control, sequencing, planning and problem solving.
Years later, as an associate professor teaching occupational therapy coursework, my students would frequently ask “What should I do for someone who has a diagnosis of X?” My reply became “The diagnosis is not all that important. Ask yourself what your patient cannot do and why. Then, to get started, pick an activity - ANY activity - that promotes the return of those missing components, be they cognitive or motor.”
Occupational therapists working in rehabilitation settings are challenged to assist clients in maximizing the return of motor control in the affected limb. We encourage our practitioners to use activities which are purposeful as well as meaningful to our patients. The importance of purposeful vs non-purposeful activities are supported by the AOTA (AOTA, 2020). However, I frequently find it challenging to come up with novel activities, which both serve my goal of improving upper extremity movement, as well as being appealing to my clients. Be honest with me here, how long can you continue to practice buttoning a shirt?
My Interest in Kendo/Iaido
Some fifty odd years ago, while on R&R in Vietnam, I encountered a Japanese martial art, Kendo (the 'way of the sword'), which I have maintained an interest in pursuing. Early Japanese swordsman developed it as a safer way to train students or maintain their own skills. Kendo practitioners use split bamboo swords, along with helmets and body armour to reduce the risk of injury (The All Japan Kendo Foundation). In January 2020, I was recovering from my own surgery and decided to enrol at a local Dojo that offered Kendo instruction as part of my recovery. I quickly came to understand why Japanese children commonly start to participate in Kendo around the age of 7. I might be a healthy 72 year old, but I am still 72 years old and it soon became apparent that I no longer had the stamina or respiratory reserves to compete!
As luck would have it, my Sensei ('teacher') also includes a martial art form, Iaido, in our Kendo instruction. Whereas Kendo requires quick movements and great stamina, Iaido stresses slower, precise motion. Kendo also involves sparring against a partner, while Iaido is generally practiced solo. I found the movement sequences of Iaido challenging but somehow calming.
Literature suggests as many as 700,000 Americans will experience a cerebrovascular accident (CVA) in a given year, with nearly 500,000 survivors experiencing some level of remaining disability. (Kwon et al, 2004). For many of these survivors, a loss of upper extremity control will persist (Kyung et al, 2014).
This loss leads to reduced participation and/or independence in activities of daily living (ADLs and IADLs), with a concurrent reduction in quality of life and loss of self-esteem (Misook et al, 2016; Hillis, 2014).
Iaido as a Therapeutic Technique
Iaido is a martial art that emphasizes the ability to smoothly draw a sword from its scabbard ('Saya'). Students of this martial art use a non-sharpened metal or wooden sword ('bokken'). As I practiced my lessons and observed other students, I began to realize that Iaido required many of the motion patterns that were difficult for my patients. My Dojo kindly provided me with a lightweight bokken, to use in our occupational therapy clinic.
To-date we have used this with three patients. The initial individual had good standing balance, as well as the ability to perform many upper extremity motions, both in isolation as well as in mass. She was near the end of her treatment cycle and agreed to try this activity in an effort to 'fine tune' her abilities to perform bilateral activities. With a therapist guarding her balance, she followed movements I demonstrated for her. A second patient demonstrated good isolated motion, but had much difficulty with mass patterns. He initially was unable to perform reciprocal pronation/supination while holding the bokken. He stated he enjoyed the activity and would practice this sequence at home using a dowel or ruler prior to his next treatment session. On his follow-up session he was able to perform full pronation, with approximately 80° supination multiple times. He no longer had to grasp and release the sword with his affected hand as he supinated. He has continued to use the bokken during therapy sessions and is now working on increasing shoulder flexion while in supine. He was, with assistance, successfully able to use his affected arm to 'draw' the sheath from the sword during his last session.
A third patient is working on increasing grip strength. He works with exercise putty at home, but had some knowledge of this martial art and was enthusiastic about increasing the amount of time he can hold the sword. His ultimate goal is to develop grip strength to decrease the incidence of 'drops' at home. One additional benefit of using Iaido is that the motion sequences can easily be done in sitting; neither the 2nd or 3rd patients are able to safely stand without contact guard at this time.
We do not teach Iaido
I should make it clear at this point that I am NOT attempting to teach my patients how to become Iaido practitioners. I am but a student myself, still struggling greatly with the required motions, balance and coordination. In introducing the activity, I mention the term Iaido briefly, but I do not attempt to teach full sequences, nor do I teach the purpose of any of the sequences (attack, defend, etc). No treatment session is devoted completely to Iaido and it is used only when an ADL/IADL deficit can be addressed by one or more of the motions required by Iaido practice.
A variety of activities
I firmly believe that we need to use a wide range of activities when working with clients...
Often, the more novel and interesting the activity, the better chance that patients will be compliant and increase the time spent in self practice.
I might work with a patient whose grip is weak, but who wants to work towards being able to hold a cup in their affected hand. We might start with an empty plastic cup, moving towards a styrofoam cup (carrying without crushing), to cups with increasing dry weight, to cups with increasing amounts of liquid - and finally a walk to the cafeteria and return to the clinic with that cup full of liquid (which they can then drink). I can increase the challenge level, by asking a client to talk to me as we walk, as this multi-tasking will engage other parts of the brain.
Patients working on fine motor control are sometimes challenged to keep time to music they enjoy. We start with unilateral and bilateral wrist motions. If they are able, we progress to individual digits. If they do well with this and are interested, I might move on to teach them rudiments, drawn from my days as a drummer in a dance band. For fun, I often attempt to teach them some of the names of the patterns, such as flamadiddle, paradiddle** and ratamaque. The terms can be as challenging to pronounce as the motions are to perform; we frequently end up having a good laugh together!
Other patients learn how to play Solitaire, without a computer. This is a common activity for those needing to address deficits in lateral pinch, upper extremity motions (particularly of the forearm), as well as the ability to plan, problem solve and recognize errors.
Each activity is introduced by 'attaching' it to an important ADL or IADL task, that the patient finds challenging or impossible. After treatment sessions using these novel activities, we engage in discussions about whether a client feels the novel activity is helping them achieve greater independence in the targeted ADL task. Patients will, on occasion, ask that we return to task-specific behaviors and that wish will always be granted. I want my patients, however, to understand that 'living' provides an infinite number of ways they can enhance their own recovery, if they will challenge themselves to use the affected limb at home, as well as in the clinic.
Unique terms
** Paradiddles are one of 26 sequences of drumbeats (called rudiments) drummers are often required to learn. The paradiddle is made up of alternating beats R L RR or L R LL.
* Connect 4 is a strategy game, played by two players, with each attempting to get 4 of their tokens in a row: vertically, horizontally or diagonally.
With appreciation to Karate International of Raleigh, North Carolina for the use of their logo.
Sources cited
American Occupational Therapy Association (in press). Occupational therapy practice framework: Domain and process (4th ed.). American Journal of Occupational Therapy, 74 (Supplement 2). Advance online publication.
Hillis, A and Tippett, D (2014, November 11). Stroke Recovery: Surprising Influences and Residual Consequences. Retrieved September 30 2020 from: https://doi.org/10.1155/2014/378263.
Kyung et al (2014). Correlation between the activities of daily living of stroke patients in a community setting and their quality of life. Retrieved September 30 2020 from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3976015/
Misook et al (2016). Effects of Self-Esteem, Optimism and Perceived Control on Depressive Symptoms in Stroke Survivor-Spouse Dyads. Retrieved September 30 2020 from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4526460/pdf/nihms-640858.pdf
Kwon et al (2004). Disability Measures in Stroke: Relationship Among the Barthel Index, the Functional Independence Measure, and the Modified Rankin Scale. Retrieved September 30 2020 from: https://www.ahajournals.org/doi/pdf/10.1161/01.STR.0000119385.56094.32
The All Japan Kendo Foundation (n.d.). Retrieved from: https://www.kendo.or.jp/en/knowledge/kendo-origin/