L16 A. Assessment of UL after stroke

Question 1

What are the 3 characteristics in the recovery of UL function?

Answer 1

1. Unacceptably poor - ~50% residual disability
2. >50% ‘do not have enough movement to work with’
3. Contribute to carer burden and loss of independence

Question 2

What is stroke rehab within the first 14 days?

Answer 2

95% without therapist

5% with therapist = minimal movements

17% of 5 mins that is using UL (training UL = small amount of time)

3mins of UL training (overall)

5mins if you could walk

1 min if you couldn’t walk

Question 3

What are 3 reasons why stroke rehab for the UL is important?

Answer 3

1. Animal models of BI – to show functional reorganisation of motor cortex – need 600-800 reps
   
   • BI = brain injuries
   • Get new connections going (neuroplasticity)
2. People with stroke can do 300 reps/hr
   
   • It is possible to do high intensity (while we dnt know how much is enough)
   • Large volume (not fitness) for skill improvement
3. Optimal dose for functional recovery in stroke pts unknown, but evidence – intensive, task oriented practice + early

*

Question 4

What are 5 reasons why people are not doing more UL stroke rehab?

Answer 4

1. Focus on discharge- Focus on balance and gait
   
   • Main reason for not being discharged = unsafe mobilisation
2. Safe gait primary determinant of d/c
3. Spend 1-2hrs max with pt – focus on gait
4. Often compensate with other limb
5. Gains are often slow (because little time spent on it?) – spend more time where most rapid gains are made

Question 5

What are 3 things we know about ‘normal’ upper limb function?

Answer 5

1. Arm places the hand in the appropriate position and orientation in space to interact with the environment – ***the hand drives movement
2. Arm and hand (and trunk) function as a single coordinated unit
3. In bimanual tasks, the two upper limbs may function as a single unit

Purpose and action/object guides the way the UL does the action.

Question 6

What happens after stroke?

Answer 6

Disuse = areas of brain do shrink in size (neuroplasticity)

Question 7

What is disuse?

Answer 7

Disuse = areas of brain do shrink in size (neuroplasticity)

Question 8

What are 3 things we know about “normal” reaching?

Answer 8

1. a smooth well timed movement, performed using a straight line trajectory with an initial ballistic phase that reaches a peak and is then followed by a second phase in which velocity decreases
2. When target is beyond arm’s length, trunk motion is integrated smoothly into transport phase of hand and is the last component to complete its motion
3. For bimanual tasks, two arms function as a coordinated unit, beginning and completing the movement simultaneously, even when requirements for each arm differ

Question 9

What are the 3 phases and essential components of reach to grasp?

Answer 9

1. Transport
2. Pre-shaping
3. Grasp

Question 10

How can no vision affect reach to grasp?

Answer 10

Question 11

What are 5 characteristics of “normal movement synergies being disrupted” after post?

Answer 11

1. loss of coordinated coupling between synergistic muscles of elbow & shoulder
2. hand path disrupted with marked deviations from straight line path
3. Increased variability in performance, decreased accuracy and decreased smoothness with some segmentation of movement
4. Delayed reaction time, movement time, peak velocity and time at which peak velocity occurs
5. With sensory loss - performance of reaching even slower, less fluent, less coordinated

Question 12

What are 4 characteristics of what happens after stroke?

Answer 12

1. Either cannot move (Completely flaccid), or will use compensations to achieve the goals
2. These become substitutes for efficient, flexible mvt
3. Become learned behaviours –> To do abnormal patterns
4. We need to assist them to re-learn more efficient, effective movements to achieve a task

Question 13

What are the 3 negative outcomes of abnormal patterns (post stroke)?

Answer 13

1. High energy
2. Pain
3. Disuse of some muscles and overuse/incorrect use of other muscles

Question 14

What are 6 common adaptive features in the UL (reach)?

Answer 14

1. Sh Abd, trunk LF and E to replace isolated sh F
2. Sh IR
3. Elbow F
4. Forearm pronation
5. Wr F and ulna dev
6. Finger F

Question 15

What do we know about ‘normal’ grasping?

Answer 15

When reaching to grasp, the grasp component of the movement first involves preshaping of the hand, with hand aperture closely linked to the size and properties of the object to be manipulated

Question 17

What are 3 characteristics of “difficulty with pre-shaping hand prior to grasp” after post?

Answer 17

1. Hand may not open or may open excessively
2. Hand /thumb / fingers may not be oriented appropriately for object size, shape or weight
   
   • Can’t get arm in correction position
3. Lack of smooth, co-ordinated closure with appropriate force. Activation of additional sensorimotor areas assoc with jerky mvt

Question 18

What does grasp look like for a normal person vs post stroke?

Answer 18

Question 19

What are 2 characteristics of “difficulty grasp and lifting object” after post?

Answer 19

1. Difficulty building up force or sustaining force
2. Fluctuations in force and difficulties matching the force to the task may also occur

Question 20

What are 4 common adaptive features in the UL (grasp)?

Answer 20

1. Forearm pronation
2. Wr F and ulna dev
3. Thumb add – limited abd / F to open hand and lack of conjoint rotation to hold
4. Finger F all at once – IP – lack MCP and IP E and F

Question 21

What are 2 things we know about “normal” manipulation?

Answer 21

Many functional possibilities

1. due to the anatomical structure - allows multiple joint configurations
2. Due to abundance of neural connections - allows widespread neural interaction, a large number of muscles cooperate ‘as one’ to produce a required output

Question 22

What are 2 manipulation skills?

Answer 22

1. Functional tasks:
   
   • Writing, typing, clothing (zips, button, lace)
2. In-hand manipulation skills:
   
   • Translation – e.g. object to palm & back to fingers
   • Shift – move fingers up & down an object- Eg. going up and down a pen
   • Rotation – simple & complex

Question 23

What are examples of manipulation skills in functional tasks?

Answer 23

1. Writing, typing, clothing (zips, button, lace)
2. Holding and using a phone, hygiene (eg. brushing hair), eating (holding a spoon)

Question 24

What are 3 in-hand manipulation skills?

Answer 24

1. Translation – e.g. object to palm & back to fingers
2. Shift – move fingers up & down an object- Eg. going up and down a pen
3. Rotation – simple & complex

Question 25

What are 3 features of fingers after stroke?

Answer 25

1. greater ability to flex fingers than extend them à difficulty releasing objects (extension is often ‘missing’, increased F tone/spasticity – added)
2. clumsiness of fine finger control and an inability to move fingers independently
3. normal movement synergies disrupted – fingers and thumb do not act as one - lack of cooperation between muscles

Question 26

What do we know about the ‘normal’ role of the upper limb to stabilise?

Answer 26

Stabilise - use hand or digit to prevent objects moving

• e.g. Stabilise toast with one hand while butter with other
• e.g. Hold piece of paper with one hand while write with other

Question 27

What do we know about the ‘normal’ role of the upper limb to support?

Answer 27

Support – use hand or arm to balance

• e.g. Hold counter while putting on a shoe
• may even use hand or arm as additional base of support
• Three point kneel to weed garden, scrub floor
• Rarely

Question 28

What are 5 reasons for an inability to support on arm after a stroke?

Answer 28

1. Weakness (where?)
2. Loss of multijoint action (sh & elb)
3. Sufficient wrist E
4. Distal stabilization
5. Hand, finger positioning

Question 29

What are 3 main parts in assessment?

Question 30

What are 8 steps of the assessment?

Answer 30

1. Gathering information from client records
2. Initial observations
3. Patient interview
4. Functional task analysis
5. Impairment assessment
6. Objective outcome assessment
7. Gather info from other team members
8. Problem list

Question 31

What is a characteristic about “gathering information from client records” in the assessment for UL?

Answer 31

All info about functional tasks and UL impairments

Question 32

What 2 are characteristic about “initial observations” in the assessment for UL?

Answer 32

1. Any movement during interview
2. Positions, postures, behaviours, functional tasks
   
   • What would you expect in patient with
     
     • Flaccid paralysis?
     • Spasticity? – usual pattern of activity
     • Subluxation?
     • Pain?
     • ↓ sensation?
     • Neglect?

Question 33

What are 6 “positions, postures, behaviours, functional tasks” would you expect in a stroke patient? What would symptoms show?

Answer 33

1. Flaccid paralysis?
   
   • Still, not moving (no hypertonia)
2. Spasticity? – usual pattern of activity
3. Subluxation?
4. Pain?
   
   • Guarding
5. ↓ sensation?
   
   • Poor proprioception(arm gets left behind) JPS
6. Neglect?

Question 34

What are 4 things to observe in the “functional task analysis” in the assessment for UL?

Answer 34

1. Support / stabilise
2. Reach
3. Grasp and release
4. Manipulation

Start at the level appropriate to patient’s ability and goals

Severely affected = start at support and stabilise

Mildly affected = reach and grasp

Question 35

What are 7 things to ask in the “patient interview in the assessment for UL?

Answer 35

1. Functional tasks with UL – egs?
   
   • Tell me what you can do with this arm? Just show me, pat your mirror arm or their arm
   • Start proximal (more likely to feel)
   • Don’t say “can you squeeze my arm?”
2. Do you have any mvt? – show me
3. Pain – usual qns – irritability, aggravating / relieving factors
   
   • More likely to get pain in UL compared to LL
   • Shoulder or hand
4. Positive UMN features
   
   • Does your arm feel tight anywhere?
5. Sensation
   
   • Does your arm feel tight anywhere?
6. Patient goals
   
   • What can’t you do right now and what do you want to do?
7. Previous / current sh problems
   
   • Possible rotator cuff
   • Hand dominance

Question 36

What is the higher and lower level of grasp and release of the UL?

Answer 36

1. Higher level: sitting – grasp cup placed on table, pick up smaller items
2. Lower level: sitting – arm supported bytable, grasp slightly smaller diameter object

Question 37

What is the higher and lower level of support/stabilise of the UL?

Answer 37

1. Higher level: sitting – support weight on hand with sh Abd & elbow E
2. Lower level: sitting –support weight on elb / forearm

Question 38

What is the higher and lower level of reach of the UL?

Answer 38

• Higher level: sitting – reach for cup placed on table
• Lower level: sitting – protraction with arm supported by table, supine - protraction

Question 39

What is the higher level of manipulation of the UL?

Answer 39

Higher level: sitting – pick up & manipulate smaller items – depends on what they want to do & analysis of mvt– e.g. pick up small blocks, everyday items spoon, washer, finger E – tap phone

Question 40

What are the 3 purposes of the functional task analysis in assessment?

Answer 40

1. Aim to measure performance – eg ensure do tasks in objective measures (eg MAS 6, 7, 8), number of reps, range, time hold
2. Investigate components of movement – what is contributing to deficits in functional task performance
3. E.g. lack of selective muscle activation in sh ER
4. Test your hypothesis by modifying the task / support / assistance then by evaluating impairments to confirm

Question 41

What are 2 features of O for OBSERVE in ORDER?

Answer 41

1. Prepare the environment
   
   • Consider their safety – what are they about to do and what to you think is the appropriate environment
   • E.g. Reach for object
2. Position yourself
   
   • So you can see, for client safety, for your own ergonomic health

Question 42

What are 2 features of R for REQUEST in ORDER?

Answer 42

1. Engage
   
   • Choose a task that relates to their goal, that they may to be able to do – e.g. don’t choose a task that you know they will not be able to perform
   • May need to get their attention – e.g. neglect
2. Ask – verbal command
   
   • Voice clear, loud, short commands with emphasis. Don’t ramblE
   • Tell them in lay terms what task they will do: “Can you touch my hand?”
   • May need to count in – 1, 2, 3 and go…
   • Can you reach for the cup –> less explanations

Question 43

What are 2 features of D for DIRECT in ORDER?

Answer 43

1. Visual
   
   1. Demonstration - you could demonstrate the task. They could watch their other limb do the task.
   2. Reach for an object – have a known endpoint of the movement
   3. Mirror to see what they are doing- Get them to do it with the other side (unaffected side)
2. Auditory
   
   1. Explain in more detail – “Your shoulder hitches up. Try to keep it down as you reach.”
   2. You could emphasize your voice to direct the movement. e.g. reach Up, UP, UP…

Question 44

What are 2 features of E for ENHANCE in ORDER?

Answer 44

1. Tactile
   
   • Hands on the patient to guide their movement
   • where to move, or to hold a limb in place
   • (e.g. can’t hold elbow straight on their own)
   • Can use your body to assist.
2. Proprioception
   
   1. E.g. Approximation along arm to facilitate extensor muscles

Question 45

What are 2 features of R for REPLACE in ORDER?

Answer 45

1. Stabilisation
   
   • Of posture for orientation or movement
   • E.g. trunk strap to restrict trunk F when protraction, airsplint for elbow E
2. Facilitation
   
   • Type of touch depends on what you are trying to do – facilitatory – sweep tapping triceps
   • Could include FES of wrist E while grasping

Question 46

What are 3 characteristic about “impairments” (active, isolated, mvt) in the assessment for UL?

Answer 46

1. If higher functioning – able to lift arm to 60deg / distal UL function
2. Do starting in sitting- If they can get arm up to 60˚ –> start in sitting if not, start in supine
3. Sitting – start with active mvts
   
   • Sh F, Abd, Hor F / E, IR / ER
   • Elb F / E,
   • Forearm pro / sup (at table)
   • Wr F /E, Rad & ulna dev (at table)
   • Fingers/thumb – F/E, Abd/Add, lumbricals, opposition (attable)

Question 47

What are 3 characteristic about “objective examination” in the assessment for UL?

Answer 47

1. Passive ROM – particularly EROM (See how much AROM –> overpressure)
2. Assess any structural changes – eg subluxation
3. UMN positive features (eg spasticity)

Question 48

What are3 investigations for impairments “if unable to do any functional task analysis” in the assessment for UL? (eg. total flaccid paralysis)

Answer 48

1. Active movement - search for activity & facilitate to optimise attempt
2. Passive range of motion – all joints & mvts
3. Monitor influence of UMN positive features (eg spasticity in finger F)

Unable to do 60˚

Question 49

What are 6 characteristic about “searching and exliciting muscle activities” in the assessment for UL?

Answer 49

1. Search for the most likely activity first – least affected by negative adaptations - proximal
2. Assist pt to move limb into position – note handling (eg distraction + ER during sh F)
3. Stabilise proximally or distally to the joint
4. Ask if they can perform the mvt
5. If not, mid range, eccentric activity – eg. elbow extension, then isometric
6. Provide targets, use manual facilitation

Question 50

What are 3characteristics “in spine for assessin in the assessment g shoulder ROM” for UL?

Answer 50

1. Determining if any activity
   
   • protraction, sh F/E, Hor F/E, elb F/E (MAS score)
   • Can do forearm / hand / fingers / thumb here or in sit – sit is often better – can see & more functional
2. Passive ROM – sh F, Abd/ER, Abd, Elb E
3. Resistance to passive mvt at diff jts?
   
   • Joint stiffness
   • Tone
   • Muscle shortening or lengthening
   • Pain

Question 51

What are 3 UL impairments to assess?

Answer 51

1. Muscle activation / strength
2. Sensation UL
3. Spasticity, increased reflexes

Question 52

What are 5 UL secondary adaptations?

Answer 52

1. Subluxation sh – finger breadths- Generally 2-3 fingers = severe, 1 finger= mild
2. Joint range
3. Muscle length changes
4. Learned non use – note during activity (eg rolling)
5. Adaptive motor behaviour – note during activity (eg rolling)

Question 53

What are 4 participation restrictions when review arm function in context of everyday tasks?

Answer 53

1. Roll over, sit up on the side of the bed
2. Wash, dry, dress and groom
3. Drink, eat, write, read etc
4. Activities important to the indiv

Question 54

What are 2 participation restrictions?

Answer 54

1. Review arm function in context of everyday tasks
2. Individual patients goals
   
   • Community participation

Question 55

What are 4 key causes of poor performance?

Answer 55

1. What are the participation restrictions that matter ?
2. What is the key limitation? What’s missing?
3. Which impairments are the key underlying problem?

Question 56

What are 4 objective measures for the UL?

Answer 56