Hemi UE Flashcards
four primary impairments with hemiplegia
paresis/plegia
loss of fractionated movement
tone
sensation impairments
four secondary impairments with hemiplegia
muscle/soft tissue length
alignment
edema
pain
how does UE control change depending on the task
pointing requires the arm to move as a unit vs grasping requires segmental control
what are the four key elements of UE function moving in space
locate target, reach, grasp, and hand manipulation
what drives UE FUNCTION
vision and perception
what drives UE ADJUSTMENTS
somatosensory information
three motor pre-requisites for functional UE use
trunk and proximal stability
UE joint control/strength
hand control/strength/dexterity
what percentage of patients cannot incorporate use of involved UE functionally into daily activities post stroke (6 m)
65%
what is the most common long term effect of neuro pathology?
loss of arm function
what predicts functional UE recovery?
admission level of UE function (in other words, patients with no proximal arm control on admission have poor prognosis for recovery of hand function)
two simple bedside tests within 72 hours of stroke can predict functional recovery of hemiplegic arm at 6 months
shoulder abduction (SA) and finger extension (FE) - SAFE score is a summative MMT (max score 10)
how does SAFE score on day 2 post stroke predict dexterity at 6 months?
some SAFE has 98% probabilty of some dexterity
no SAFE has 25% probability of some dexterity
Describe the PREP 2 algorithm
what is the prognosis and treatment focus for those who score “excellent” on the Prep 2 algorithm
return to normal/almost normal dexterity; promote normal use
what is the prognosis and treatment focus for those who score “good” on the Prep 2 algorithm
useful helper hand with ADLs but not dexterity; promote function
what is the prognosis and treatment focus for those who score “limited” on the Prep 2 algorithm
limited helper hand; promote function
what is the prognosis and treatment focus for those who score “poor” on the Prep 2 algorithm
no useful/may use other hand to move and place limb; promote compensation
T/F: pain does not immediately begin in the shoulder following stroke
false: it is possible for pain to begin in the shoulder particularly with overhead movements rather quickly
differentiate between synergy and spasticity
synergy occurs during volitional movement and spasticity is an involuntary response to passive movement
T/F: patient can mediate synergy responses
false: patients cannot mediate response
are synergies predictable? discuss
yes, but there may be variations in quality due to variable spasticity with each patient
UE flexor (dominant) synergy pattern
scap: elevation and retraction
shoulder: ABER (spasticity will be ADIR)
elbow: flexion
forearm: supination (spasticity will be pronation)
wrist: flexion
fingers and thumb: flexion and adduction
UE extensor synergy
scap: protraction and depression
shoulder: ADIR
elbow: extension
forearm: pronation
wrist: “relative extension”
fingers and thumb: flexion and adduction
how does sensory impact UE motor function after a stroke
patient sensory experience becomes their new normal, so PT guidance of afflicted UE can give a more normal experience
how does sensory experience impact tone?
patient may increase muscle tension for increased sensory experience and stability
T/F: UE treatment selectively/only impact UE impairment recovery
false: ambulatory levels changed due to UE focused training due to UE training increasing trunk and LE control demands
what is the grasp reflex
sensory stimuli in the palm elicit hand closing
how should PT address the grasp reflex?
if a patient has some flexion/grasp, PT focus should be on OPENING the hand in a FUNCTIONAL CONTEXT
what is the key to hand opening (i.e. how can you open the hand clinically)?
thumb extension/abduction
what is the most common contracture post stroke
wrist flexion
in what patient population should we consider lap trays and arm troughs?
for any patient with shoulder subluxation
why choose a lap tray over an arm trough?
when we have movement that we want to integrate into function
what is a benefit and a drawback to self-assisted UE activities?
benefit: bilateral and sensory experience
drawback: compensatory
what are three strategies to facilitate UE function?
PNF
functional training in various positions
integrate effected UE in mobility/transfers
what is CIMT
constraint induced movement therapy: (1) forced use (2) shaping the task to be appropriate, challenging, and rewarding (3) repetitive massed practice
prerequisites for CIMT
10 deg active wrist extension, thumb abd/ext, and ext of at least 2 digits
evidence to support CIMT?
meh at best
Despite the weak evidence for bimanual arm training, how does it work?
- do just the weak arm
- do the task bimanually
- do the function
what is the best part of CIMT?
facilitates awareness and force the use of the UE
what is the best part of bimanual arm training?
easier to perform for the patient and more functional
evidence supports the use of mirror tx as useful adjuvant therapy for the hemiplegic UE… what are the three most important components?
large mirror
no manipulation tasks
unilateral v bilateral effort
in comparison with conventional therapy, Robot Assisted Rehab (RAR) is …. more/less…. effective in improving UE motor recovery
more!
T/F: RAR shows significant improvements in ADLs
false
T/F: change in outcome measure of UE function represents change in daily function
false
Shoulder subluxation occurs in 60-73% of hemiplegic patients, in which direction is subluxation most common? least common?
most - inferior; least - superior
how would you quantify shoulder subluxation?
finger width of separation between the acromion and humerus
what are three clinical management strategies for shoulder subluxation?
- prevent - restore alignment to trunk and scapulae
- fix - manually reset the humerus
- maintain - hold alignment during tx
how do you manually reset a humerus?
ER and approximation
T/F: every shoulder subluxation in the stroke population is painless
false - may be painful or pain free
pain and loss of ROM in the shoulder may begin as early as ____
1-2 weeks post-stroke
which muscle is implicated in the flaccid phase of stroke with regards to shoulder stability
supraspinatus
which muscles are implicated in the spastic phase with regards to shoulder subluxation
subscapularis and pectoralis major
Painful hemiplegic shoulder is associated with __(3)___
subluxation, spasticity, and poor functional outcome
what does the evidence say for treatment of shoulder subluxation? (Arya 2018)
- FES for reducing subluxation
- slings/orthotics for temporary effect
- nothing impacts/facilitates UE functional recovery
How do you use FES for hemiplegic shoulders? (Vafadar 2015)?
- 1 and only goal: reduce subluxation
- target supraspinatus and deltoid
- dont expect carryover, pain relief, or functional improvement
so if FES only reduces chances of subluxation and doesn’t impact any other aspect of care… why do you even want to use it?
it can help free up the provider’s hands to allow treatment to be more effective
What are the benefits to slings/orthotics (2)
- supports UE/frees up the PT
2. good for standing/transitions in a nonfunctional UE
what are the drawbacks to slings/orthotics? (4)
- non functional
- discourages use
- contractures
- no lasting effect
what about taping for shoulder sublux prevention?
new, but promising - no good evidence
what are three outcome measures associated with UE hemiplegics?
Action Research Arm Test (ARAT) - recommend for exposure
Fugl-Meyer Motor Assessment - recommended for students
what are three outcome measures associated with UE hemiplegics?
Action Research Arm Test (ARAT) - recommend for exposure
Fugl-Meyer Motor Assessment - recommended for students
Wolf Motor Function Test
