Midline Orientation

This week a patient's son asked me if there was a way to strap, bolster, or otherwise "manhandle" (his word, not mine) his mother into an upright position. She'd had a pretty severe stroke, the most functionally limiting effect of which was a severely impaired midline orientation, with pusher's syndrome.

Just to review, your brain is getting signals from your whole body about it's relationship to the environment: muscles and joints send signals about where each piece is in space and in relation to each other, pressure receptors in your skin send signals about weight distribution, your semi-circular canals (in your ears) and your optic nerves send signals about the orientation of your head to the environment and to the rest of your body. A stroke interferes with one or more of these feedback systems, impacting your ability to sit upright.


If hemiparesis or hemi-weakness (paralysis or weakness on one side) is the only issue, then it's usually a simple matter of training you to check your orientation with each position change until you relearn what middle "feels" like. Unfortunately, it's rare that a stroke will effect only the muscles on one side without also interfering with the brain's perception of that side as well. A person with pusher's syndrome has an impaired midline, and the sensation that they are off balance causes them to try and hold themselves upright with every ounce of strength available to them. However, because there are perceptual deficits in addition to the hemiparesis, what ends up happening is that every muscle on their unaffected side works overtime to push them over to their weak side.


This is where we were at with my patient when her son asked about positioning. He was having a hard time watching his mother struggle to be comfortable and upright.

So, with his mother seated at the edge of the bed, I explained it all to him (all while working with her of course). How your body perceives its middle. How the more you try to prop up the weak side, the harder the strong side pushes against you (I learned this the hard way, after many sessions that ended with my back or arm sore and me sweating like an olympic distance runner). I asked my patient to explain what it feels like when I tried to push her upright (she said, they all do, that it feels like I'm trying to push her over). I pointed out how, if I blocked her arm from pushing, you could see her strong leg inch out to the side and start to push her also. I explained the strategy of not resisting her and letting her push herself over until she could feel that she wasn't straight, then helping her correct. I had her lean onto her strong elbow, in hopes of reducing the fear of falling to that strong side (after all, she's seated on a bed, there's no real danger). I brought out the long mirror so that she could use visual cues to help orient herself. I showed him what I call the "more flies with honey than vinegar" technique of sitting on the strong side and asking the patient to lean against my shoulder. Then I had him sit next to her and play along, so he could feel it for himself. If a picture's worth a thousand words, then an experience must be worth its weight in gold.

His mom and I have been doing this balance training stuff for the for first 20-30 minutes of every session since she got here- she has the worst post-stroke balance I have ever seen since I started this job. But she's really sharp, so she understands what's going on and she works hard, cognitively, to fight against the reflexes that aren't working for her. I could tell that she enjoyed being a part of this educational moment for her son, that she enjoyed being able to explain to him exactly what was going on for her. After 15 minutes or so, she found her midline, and she maintained it with only verbal cues for the rest of the session. Her son was able to take over cueing and prompting instead of me. It was totally fun and successful. Yay.

Throughout this treatment there was an observing part of me that was suddenly stunned that I knew all this. Because the thing is that I didn't learn ANY of that in OT school. I didn't even learn about impaired midlines at all. (Though this is how I spend so much of my time with any stroke patient.) I learned all of it on the job. Through observation, through asking questions of doctors, through asking for some mentoring assistance from more experienced therapists. The weird thing is that there wasn't one moment when I put it all together and came up with a theory or a framework. I just kept putting it together. Trial and error, an answer from a senior therapist here, an observation there, stuff I learned about neuro-plasticity, casual lunchtime conversations with co-workers; wait two years and voila- knowledge! Practical knowledge that I can use, and even share with others. Freaky. Just imagine what I'll be surprised by in two more years. Or twenty.