Hemiparetic UE Flashcards
Normal Upper extremity movement and control
- Trunk Postural Stability
- Shoulder stability and mobility
- Elbow stability and mobility
- Wrist stability and mobility
- Grasp and Prehension patterns
- Thumb and Finger manipulation
- Bilateral UE movements
Gross grasp
object is in contact with palm and palmar surface of digits
palmar prehension
tripod grasp
thumb poses one or more fingers
lateral prehension
thumb opposes radial side of index and middle finger (key grip)
Key components of upper extremity control
- Locating an item/target- coordinated movement of the eyes, head, and trunk
- Reaching for an item/target- includes transportation of the arm and hand in space as well as maintaining postural control during task
- Grasp- Includes grip formation, grasp, and release
- In hand manipulation
prior to unilateral arm raise, what do you see?
increased muscle activity in the hamstrings, gastrocnemius, and erector spine muscles are evident
to counteract the destabilizing effects of the arm raise
Assessments for UE clinical deficits
- spasticity: modified ashworth scale (elbow and knee!)
- fractionation: Fugl- Meyer Scale
- upper extremity function: action research arm test and Chedocke McMaster Impairment Scale
Action Research Arm Test
- Assesses UE function and dexterity
- 19 items designed to assess four areas of function- grasp, grip, pinch, and gross movement
- Each item scored 0 (no movement) to 3 (normal
performance)
Prognosis of UE recovery
- proximal shoulder and elbow control on admission is good
- finger AROM is key component
- Finger ext AROM within 72 hrs regain full recovery at 6 mo
- 98% that some degree of dexterity is achieved at 6 mo for CVA survivors who have finger ext and shoulder abduction on day 2
- greater the non-motor impairments that accompany the motor deficits, the less likely they will be independent
- earlier improvements in motor function increase likelihood of reaching
What level should a hemiplegic UE be before full rehabilitation efforts designed to restore function in the arm are attempted?
Stage 4
Will you be successful with attempts trying to rehabilitate an upper extremity of a person with a score less than level 4?
nope
a more palliative compensatory approach is recommended
CMS Stage 1
- Flaccid paralysis is present
- Phasic stretch reflexes are absent or hypoactive
- Active movement cannot be elicited reflexively with a facilitatory stimulus or volitionally
CMS Stage 2
- Spasticity is present and is felt as a resistance to passive movement
- No voluntary movement is present but a facilitatory stimulus will elicit the limb synergies reflexively
- These limb synergies consist of stereotypical flexor and extensor movements
CMS Stage 3
- Spasticity is marked
- The synergistic movements can be elicited voluntarily but are not obligatory
CMS Stage 4
- Spasticity decreases
- Synergy patterns can be reversed if movement takes place in the weaker synergy first
- Movement combining antagonistic synergies can be performed when the prime movers are the strong components of the synergy
CMS Stage 5
- Spasticity wanes, but is evident with rapid movement and at the extremes of range
- Synergy patterns can be revised even if the movement takes place in the strongest synergy first
- Movements that utilize the weak components of both synergies acting as prime movers can be performed
CMS Stage 6
Coordination and patterns of movement can be near normal
- Spasticity as demonstrated as resistance to passive movement is no longer present
- Abnormal patterns of movement with faulty timing emerge when rapid or complex actions are requested
CMS Stage 7
- Normal
- A “normal” variety of rapid, age appropriate complex movement patterns are possible with normal timing, coordination, strength and endurance
- There is no evidence of functional impairment compared to the normal side
- There is “normal” sensory perceptual motor system
2 Focuses of rehabilitation
- enhancing or facilitating recovery
- encouraging transfer from unaffected limb
Enhancing or facilitating recovery
- Repetitive practice
- Strength Training
- CIMT
- FES
- Robot Assisted
- Sensory stimulation
Encouraging Transfer from unaffected limb
- CIMT
- Bilateral activity training
- mirror therapy
What is the goal of training
recovery of movement components composing functional tasks and recovery of performance of the whole complex task
What principles is treatment based on?
movement practice as close to normative as progression of training was based on the recovery of volitional capability and motor task difficulty, according to the motor task difficulty hierarchy
Role of errors
patients should work around 80-90% of accuracy with reaching tasks
6 strategies for reducing or preventing pain in the hemiplegic UE
- careful handling
- electrical stimulation to prevent shoulder subluxation
- splinting and sling use
- spasticity and contracture management
- movement with elevation (remember scapular rhythm)
- AVOID OVERHEAD PULLEYS
should you distally fix a flaccid limb?
- no
- be careful with lifting machines
Definition of priming techniques
Interventions that may prepare the sensorimotor system for subsequent motor practice, thereby enhancing its effects
sensory stimulation for priming
- These methods provide sensory input that engages the patient’s attention and orients the individual to the paretic limb
- Passive movement has similar effects while also providing sensory feedback to the motor system
4 principles of sensory stimulation
- treatment/augment
- treatment/recalibrate
- treatment/substitute
- treatment/predictive strategies
sensory stimulation - treatment/ augment
increase sensory perception by repetitive stimulation
* only rehabilitative one
sensory stimulation - treatment/recalibrate
teach to equate new sensations with reality
sensory stimulation - treatment/substitute
teach use of another form of sensory information
sensory stimulation - treatment/predictive strategies
- teach person to move by anticipating what must be done vs being dependent on sensory feedback during the task
- kind of like a memorization
how to improve sensory discrimination
- Play games with eyes closed
- Place coarse and unusual surfaces on objects
frequently handled to help with feedback (fine sandpaper on pens, toothbrushes, eating utensils) - Place hand in box filled with rice, beans, and
retrieve objects
How to improve graphesthesia
replicate drawing of letters and numbers on skin of hand/digits
how to improve localization
touch subject on the digit and hand and have subject put finger on spot where touched
stereognosia
interpret information about object through touch
kinesthesia
- Using the index or middle finger for pointing, move the patient’s UE to a location in space and have the patient replicate the movement
Bilateral priming
- Active Passive Bilateral Priming
prior to UE task specific training: Same activities performed by both limbs simultaneously - Unaffected active wrist flexion/extension drives passive ROM of affected wrist
bilateral priming exclusion criteria
Complete sensory loss, Neglect, Cerebellar stroke
action observation
Performance of a motor task while watching a mirror image of another individual perform the same task
* Thought to increase cortical excitability
mirror therapy
- Use visual input for priming
- The patient observes specific movements or
tasks performed by the therapist or by their nonparetic limb reflected in a mirror placed at the body’s midline
evidence behind mirror therapy
- Frontoparietal circuitries respond not only during one’s own movement but also during the observation of others’ movements
- Observation may promote activation of these circuitries
mental imagery
- Used to internally generate somatosensory and visual input to the motor system.
Some neuroimaging studies show that mental practice and imagery can activate regions in the motor system.
Conceptualized as motor plans without execution.
Repetitive generation of motor plans may promote
physiological patterns of activation in motor cortical circuitries that are either directly damaged or functionally impaired
what does aerobic exercise promote?
cerebral blood flow
- increase in BDNF which improves neuroplasticity
things we know about individuals following a stroke
- Reduced Speed / Amplitude due to decreased motor control
- Decreased descending input onto motor neurons Abnormal and excessive cocontraction
decreased presynaptic inhibition of antagonist prior to movement
impaired reciprocal inhibition of antagonist muscles during voluntary movements. - Changes in visco-elastic properties of spastic muscles restrains movement
neural factors affecting force generation
- decrease in overall number of motor units available
- decrease in fast motor units
- decrease in motor unit firing rate
*** overall, decreased descending input
how to treat the neural factors affecting force generation
- NMES; EMG-BF
- Type and speed of contraction for strengthening
- isokinetic exercise and facilitation of agonist
biomechanical factors affecting force generation
- altered length tension relationship
- altered moment arm
- altered force velocity relationship
How to treat the biomechanical factors affecting force generation
- optimize muscle length
- optimize moment arm
- practice fast movements
neural factors causing decreased speed/amplitude
- decreased presynaptic inhibition of antagonist –> treat with inhibition techniques as needed
- impaired reciprocal inhibition –> treat with EMG-BF
biomechanical factors causing decreased speed/amplitude
- altered passive properties of spastic muscle
- treat with slow stretch/serial casting
abnormal synergy patterns
– Decreased access to dorsolateral descending systems (which innervate more distal musculature). Recall medial motor systems tend to be involved in more axial (proximal) (gross movements) control. (neural)
– abnormal sensory information. (neural)
– biomechanical advantage: moment arm; L-T
– practice/habit/learned disuse (behavioral)
How to treat synergy
- activate muscles in functional patterns
– limb activities which are slightly more isolated than
present capabilities
– facilitation to desired muscle groups
– bilateral symmetrical activities
– position limb
– closed chain activities
– restrain unaffected limb (forced use)
– Electrotherapeutic modalities: EMG-BF / NMES
task specific training
o Place limb and the trunk in postures where tone in the hand and arm are decreased; practice using normal movements to manipulate objects in this position
o Place the limb and trunk in positions that positively
influence / exploit the biomechanical factors and/or
constraints on movement.
o Supine for early shoulder, elbow control
o Sidelying for early reaching
o Write / trace pictures
o Hold, deal, organize cards
o Type on a keyboard – let gravity help with fingers o Stack objects o Use affected hand as much as possible o Grasp objects of different shapes, sizes
how constraint induced movement therapy works
- Includes forced use
Wearing a mitt on the unaffected UE during most waking hours which forces use of the hemiparetic UE
Home activity
2 weeks Includes one-on-one training for as much as 6 hrs/day over several weeks
select group of patients to use CIMT with
- 20 degrees of wrist extension
- 10 degrees of finger extension
- No sensory or cognitive deficits
what does CIMT include
repetitive task and adaptive task practice
repetitive tasks in CIMT
continuous efforts to execute movements that usually are repeated – eating, grooming, brushing teeth
adaptive tasks in CIMT
– “shaping” / operant conditioning
– repetitions of a defined movement such as picking up blocks and moving them toward a bucket in a series of trials.
o Coaching and encouragement is done by the therapist.
o Performance records are kept as a means of motivation.
o Make the task more challenging as success occurs through – distance, direction,
load, speed
modified CIMT
- “Distributed” practice
- Mitt is worn for several hours each day over a 10-week period.
- Home based practice is supplemented with outpatient therapy several times / week
– still need inclusion criteria
3 types of task practice
- performance
- repetitive
- adaptive
performance practice
looking at ultimate end of movement for ideal performance
repetitive practice
no alteration/manipulation of variables
adaptive practice
Modification of task or environment to progressively challenge patient with use of encouragement and log for performance
manipulating output variables and task parameters
- speed, direction, distance moved
- end goal
- position of performance
- properties of the object/surface
severe impairment
o Maintain a comfortable, pain-free, mobile arm and hand
o Positioning, support at rest, careful handling.
o Self-ROM training via a qualified professional
o Avoid overhead pulley systems
o Use some external support for UE in stage 1 or 2 during transfers, mobility, and in wheelchair
o Use compensatory techniques and environmental adaptations
when should you ditch slings?
when they have enough motor recruitment to shrug the shoulder up
moderate impairment
Engage in repetitive and intense use of novel tasks that challenge the stroke survivor to acquire necessary motor skills to use the involved upper limb during functional tasks and activities
minimal impairment
focused fine motor tasks that apply to the individuals return to life roles
