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PHTY3140 > L18C-19D. Management of UL function after stroke > Flashcards

L18C-19D. Management of UL function after stroke Flashcards

1
Q

What are 3 features of training for the uper limb?

A

Train concurrently. Train top down & bottom up.

  1. Train everyday tasks that matter
    • Generic
    • Specific to the individual tasks
  2. Train activities critical to those task
    • Support, reach, grasp and release, manipulation
  3. Address underlying impairments
    • Anticipate and prevent secondary adaptations
    • Motor, sensory, perceptual, motor planning
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2
Q

What are 6 managements of secondary impairments of the upper limb?

A
  1. Get arm & hand active!
  2. Provide support where necessary: Strapping, shoulder or wrist supports, wheelchair gutters
    • Wheelchair gutter provides active support, prevents secondary shoulder subluxation
  3. Anticipate and prevent muscle length issues: Contractures or lengthening
    1. Get muscle activity however you can
    2. Use arm in vulnerable ranges: e.g. EOR ER, elbow E
    3. Adapt flexibility habits
  4. Prevent learned non-use
  5. Force use
  6. Pain management
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3
Q

What are 2 flexibility habits of upper limb retraining?

A
  1. Be in positions that do not promote spasticity or contractures.
  2. Have a few different positions to alternate through the day, so the arms do not stay in F pattern.
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4
Q

What are 3 management of shoulder subluxation for upper limb retraining?

A
  1. 7-80% of post-stroke patients have shoulder subluxation. This is linked with paralysis.
  2. Cannot reduce subluxation once occurred, thus prevention is paramount.
  3. Start prevention ASAP
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5
Q

What are 2 evidence for management of shoulder subluxation for upper limb retraining?

A
  1. Electrical stimulation of supraspinatus & posterior deltoid
    • 1-6 hours/day, 5-7 days/week, motor contraction
  2. External support recommended: e.g. Gutter armrest, firm supportive sling
    • Shoulder support sling relocates HOH in GHJ (weak evidence)
    • FES stimulates muscles to stabilise HOH in GHJ
    • Depends on where you work, they might use sling or FES
    • Collar & cup?
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6
Q

What is an electrical stimulation as evidence for management of shoulder subluxation for upper limb retraining?

A

Electrical stimulation of supraspinatus & posterior deltoid

  • 1-6 hours/day, 5-7 days/week, motor contraction
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7
Q

What is an electrical support as evidence for management of shoulder subluxation for upper limb retraining?

A

recommended: e.g. Gutter armrest, firm supportive sling

  • Shoulder support sling relocates HOH in GHJ (weak evidence)
  • FES stimulates muscles to stabilise HOH in GHJ
  • Depends on where you work, they might use sling or FES
  • Collar & cup?
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8
Q

What are the 5 managements for shoulder pain for upper limb retraining?

A
  1. Lacking strong evidence for management
  2. Taping: Skin integrity issue? Use fixomoll. Probably try other things first.
  3. Electrical stimulation
  4. Prevent trauma (handling, slings, education)
  5. Pain reducing techniques: Acute pain management
    • Manual therapy (e.g. Mobilisation in neutral HOH up & down, up to grade 3)
    • Heat is better than ice
    • Pain medications
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9
Q

What are 3 essential components missing in a task when training in the management of UL muscles?

A
  1. Elicit muscle activity
  2. Strength training
  3. Dexterity: Speed, accuracy
  • Driven by goals
  • Functional context
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10
Q

What are 7 methods of elicitig muscle activity when retraining the upper limb?

A
  1. Demo with unaffected side, guide movement
  2. Manual facilitation
    • Approximation to activate extensors
    • Sweep-tapping
    • Depending on muscle groups
  3. Stabilise non-moving joints proximal/distal (e.g. air splint) and demand activity in key muscles
    • Serratus, external rotators, anterior deltoid, triceps, supinator, wrist extensors, finger flexors
    • IR is always active (pecs) - do not want more IR
  4. Make the task easy: Gravity-minimised positions, friction-free surfaces.
  5. Make the task specific: Targets, guides, feedback
  6. High repetition, record reps especially early stage.
  7. Use FES, mental imagery if flaccid paralysis.
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11
Q

How can you elicite protraction when in sidelying when retraining the upper limb?

A

Sidelying: Bedex

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12
Q

How can you elicite protraction when in supine when retraining the upper limb?

A

Supine: Reach up

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13
Q

How can you elicite protraction when in sitting when retraining the upper limb?

A

At desk

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14
Q

How can you elicite protraction in the earlier stages when retraining the upper limb?

A

Need to make protraction easier and limit compensatory movements (shoulder add + IR + elbow F + wrist F + fingers F)

Need target as feedback

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15
Q

How do you elicit shoulder flexion when retraining the upper limb?

A
  • Shoulder F: Stand beside a wall, move arm back and forth on paper
  • Pen records distance
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16
Q

How do you elicit shoulder horizontal abduction/adduction when retraining the upper limb?

A
  • Shoulder horizontal F/E: Stand facing a wall, move arm left and right on paper
  • Pen records distance
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17
Q

How do you elicit shoulder external rotation when retraining the upper limb?

A
  • Hand slides on paper in shoulder ER
  • Cup is target
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18
Q

How do you elicit wrist extension when retraining the upper limb?

A
  • Usually sitting - see movement
  • Eccentric > holding > concentric
  • Gravity-minimised to use gravity
  • Paper to bring home to get set up and instructions correct
  • Bendy straws taped to wrist as feedback

Paper has instruction Keep forearm still, wrist E to reach target

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19
Q

How do you elicit thumb abduction when retraining the upper limb?

A
  • Bendy straws taped to wrist as feedback to prevent compensatory movement
  • Compensatory movements: Pronation + thumb abd
  • Very small movements
  • Need to be precise
  • Set up for home practice
  • Keep arm still, move thumb to touch green cup
  • Bendy straw taped on wrist prevents wrist E
  • Shampoo bottle prevents pronation
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20
Q

What are 8 features of muscle strength training when retraining the upper limb?

A
  1. Eccentric > isometric > concentric
  2. Mid-range > all range
  3. May need to start with a very small range
  4. CKC > OKC
  5. Work in appropriate positions
  6. Increase repetitions, frequency, load
  7. Power: Vary reaction time, speed and timing
  8. Sustain force

Introduce task specific strengthening

  • Part practice
  • Whole task
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21
Q

What are 8 features of independent exercises when retraining the upper limb?

A
  1. Start small. Set achievable tasks to ensure success.
  2. Patient to count number of reps
  3. Work individual muscles - stabilize distal & proximal joints
  4. Ensure exercises can be done on ward safely
    • e.g. Sitting in chair/wheelchair, lying in bed
  5. Provide equipment for exercises
    • Suitable table for closed chain reaching
    • Theraband or weights
    • Mirror box
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22
Q

What are examples of strengthening triceps when retraining the upper limb?

A
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23
Q

What are examples of strengthening shoulder ER when retraining the upper limb?

A
24
Q

What are examples of FES reach forward when retraining the upper limb?

A
  • Hold object, reach forward, push bean bag off the table
  • Bottle allows neutral pronation/supination, wrist E, prevent fingers F.
25
Q

What are examples of strengthening elbow E + index finger E when retraining the upper limb?

A
26
Q

What are examples of strengthening wrist extension when retraining the upper limb?

A
  • Object prevents fingers E
  • Block allows more wrist E range
    • Pillow is too soft - arm will sink in
  • Other arm to stabilise, or to feel the muscles working
27
Q

What are 6 features of muscle dexterity training (provide experience with tasks that demand) when retraining the upper limb?

A
  1. Coordination
  2. Smooth movement
  3. Fast movement
  4. Rapid reversal of movement
  5. Bimanual
  6. Appropriate response to task: Force, timing, fractionation.
28
Q

What are 5 features of sensation retraining when retraining the upper limb?

A
  1. Demand cognitive involvement
  2. Is your arm bent or straight? Can you feel it bending?
  3. Close your eyes - bend your arm, straighten your arm
  4. Which cup is heaviest? Feel the weight of the cup with your good hand
  5. Really think about how it feels. Now try to copy that feeling with your affected hand

Less evidence for sensation retraining

  • Force use
  • Sensory stimulation, sensory discrimination training: Exposure to different stimuli such as texture, shape, temperature, position
    • Improve sensory discrimination for some people
    • Combine this with other things
29
Q

What are 3 managements of Visuo-Spatial Impairments when retraining the upper limb?

A
  1. Use concrete goals
    1. Active movement - massage unaffected with affected
    2. Search for object, work into neglected space
  2. When severe
    • Start at midline and work around if necessary
    • Follow a continuous line into the neglected space (e.g. Keep watching the hand as it moves)
    • Use blinkered glasses
  3. Progress
    • Reduce distractions initially and reintroduce when ready
      • Small room
      • Schedule session at quiet time
    • Reduce strategies to cue
    • Reduce feedback, and demand patient provides feedback
    • Mimic real world - introduce variations in equipment, environment for training, person coaching, tasks attempted.
30
Q

What are 4 managements of Motor Planning Impairments when retraining the upper limb?

A
  1. Tailor training to needs & goals
  2. Tie training to the daily routines
  3. Ideational dyspraxia: Lead them through sequence, copy how the other hand does it
  4. Ideomotor dyspraxia: Encourage spontaneous movement, use real life events, purposeful requests
31
Q

What are 4 managements of retraining of activities when retraining the upper limb? What are 4 ways to progress task training?

A
  1. Strengthen muscles in range/action appropriate to task
  2. Retrain sensation: Joint angles, actions, sensations appropriate to task
  3. Commence task training: Ensure success > normal pattern must be achieved

Progress:

  1. Progress task complexity
  2. Challenge all underlying impairments
  3. Real world environment
  4. Include practice as part of everyday routine
32
Q

What are 4 features of training support and stabilising when retraining the upper limb?

A
  1. Strengthen muscles at lengths appropriate for stabilising & support
    • Scapula stabilisers: Lower & upper trapexius, serratus anterior
    • External & internal rotators
    • Elbow extensors (triceps)
  2. Retrain sensation at joint angles appropriate for stabilising & support
    • Scapula, shoulder, elbow, wrist
  3. Support on elbow or outstretched hand to achieve task
    • In sitting, hand in front, out to the side, behind, above them
    • In standing, hand in front, out to the side, behind, above them
    • In side lying, prone lying, on all fours
    • Reach with the other hand, crawling on elbows or outstretched hands
  4. Progress task to challenge all impairments
    • Support on arm out of visual field
    • Do repetitions to increase strength
    • Demand response that involves speed and timing
33
Q

What are 3 features of training support and stabilising (strengthen muscles at lengths appropriate for stabilising & support) when retraining the upper limb?

A
  1. Scapula stabilisers: Lower & upper trapexius, serratus anterior
  2. External & internal rotators
  3. Elbow extensors (triceps)
34
Q

What is a 1 feature of training support and stabilising (retrain sensation at joint angles appropriate for stabilising & support) when retraining the upper limb?

A

Scapula, shoulder, elbow, wrist…

35
Q

What are 4 features of training support and stabilising (support on elbow or outstretched hand to achieve task) when retraining the upper limb?

A
  1. In sitting, hand in front, out to the side, behind, above them
  2. In standing, hand in front, out to the side, behind, above them
  3. In side lying, prone lying, on all fours
  4. Reach with the other hand, crawling on elbows or outstretched hands
36
Q

What are 3 features of training support and stabilising (progress task to challenge all impairments) when retraining the upper limb?

A
  1. Support on arm out of visual field
  2. Do repetitions to increase strength
  3. Demand response that involves speed and timing
37
Q

What are 4 features of training reaching when retraining the upper limb?

A
  1. Strengthen muscles at lengths appropriate for reaching
    • Lower traps, serratus anterior, external rotation, anterior deltoid, triceps etc.
  2. Retrain sensation at joint angles appropriate for reaching
    • Shoulder neutral rotation + F, elbow F 90°/full E
  3. Commence reaching - to achieve a task
    • Using CKC tasks - push weights off table
    • Gravity-minimised e.g. in lying
  4. Progress tasks to challenge all impairments
    • OKC reaching ○ Increased load and differing objects
    • Outside visual field
    • In a busy environment
38
Q

What is a feature of training reaching (strengthen muscles at lengths appropriate for reaching) when retraining the upper limb?

A

Lower traps, serratus anterior, external rotation, anterior deltoid, triceps etc.

39
Q

What is a feature of training reaching (retrain sensation at joint angles appropriate for reaching) when retraining the upper limb?

A

Shoulder neutral rotation + F, elbow F 90°/full E

40
Q

What are 2 features of training reaching (commence reaching - to achieve a task) when retraining the upper limb?

A
  1. Using CKC tasks - push weights off table
  2. Gravity-minimised e.g. in lying
41
Q

What are 4 features of training reaching (progress tasks to challenge all impairments) when retraining the upper limb?

A
  1. OKC reaching
  2. Increased load and differing objects
  3. Outside visual field
  4. In a busy environment
42
Q
A
43
Q

What are 4 features of training grasp and release when retraining the upper limb?

A
  1. Strengthen muscles at lengths appropriate for grasping
    • Wrist extensors, supinators, finger & thumb extensors & flexors
  2. Retrain sensation at joint angles, textures appropriate for grasping
    • Forearm, wrist, fingers, thumb
  3. Commence grasp & release - to achieve a task
    • Bimanual tasks: Unscrew lids on jars, pull cones apart
    • Reach to grasp, reach to release •
  4. Progress tasks to challenge all impairments
    • Different shaped & weight & orientation of objects
    • Grasp, release, maintain through range, out of vision
    • Speed - catch and throw a ball
    • Hold cup while pouring water into it
44
Q

What is a features of training grasp and release (strengthen muscles at lengths appropriate for grasping) when retraining the upper limb?

A

Wrist extensors, supinators, finger & thumb extensors & flexors

45
Q

What is a feature of training grasp and release (retrain sensation at joint angles, textures appropriate for grasping) when retraining the upper limb?

A

Forearm, wrist, fingers, thumb

46
Q

What are 2 features of training grasp and release (commence grasp & release - to achieve a task) when retraining the upper limb?

A
  1. Bimanual tasks: Unscrew lids on jars, pull cones apart ○
  2. Reach to grasp, reach to release
47
Q

What are 4 features of training grasp and release (progress tasks to challenge all impairments) when retraining the upper limb?

A
  1. Different shaped & weight & orientation of objects
  2. Grasp, release, maintain through range, out of vision
  3. Speed - catch and throw a ball
  4. Hold cup while pouring water into it
48
Q

What are 4 features of training manipulation when retraining the upper limb?

A
  1. Strengthen muscles appropriate to the task
    • Wrist, finger, thumb F/E, abd/add, supinators, pronators, intrinsics, lumbricals
  2. Retrain sensation at different joint angles, textures, objects
    • Forearm, wrist, fingers, thumb
  3. Commence manipulation to achieve a task
    • Bimanual tasks: Undo jars
    • Between hand and surface - writing
    • Within hand - undo tape
  4. Progress to challenge all impairments
    • Gross to fine motor skills
    • Different shapes, textures, orientation of objects,
    • Different strength, speed, timing endurance
    • Different points of range of arm, within & outside visual field
49
Q

What is a feature of training manipulation (Strengthen muscles appropriate to the task) when retraining the upper limb?

A

Wrist, finger, thumb F/E, abd/add, supinators, pronators, intrinsics, lumbricals

50
Q

What is a feature of training manipulation (retrain sensation at different joint angles, textures, objects) when retraining the upper limb?

A

Forearm, wrist, fingers, thumb

51
Q

What are 3 features of training manipulation (commence manipulation to achieve a task) when retraining the upper limb?

A
  1. Bimanual tasks: Undo jars
  2. Between hand and surface - writing
  3. Within hand - undo tape
52
Q

What are 4 features of training manipulation (progress to challenge all impairments) when retraining the upper limb?

A
  1. Gross to fine motor skills
  2. Different shapes, textures, orientation of objects,
  3. Different strength, speed, timing endurance
  4. Different points of range of arm, within & outside visual field
53
Q

What are 4 features of retraining ADLs when retraining the upper limb?

A
  1. Work on goals
  2. Train critical ADLs
  3. Immediately relevant to individual and lifestyles
  4. Pre-empt repetition of maladaptive motor patterns
  5. Pre-empt learned non-use.
54
Q

What are 6 features of post-acute rehabilitation when retraining the upper limb?

A

Assist stroke survivors to achieve their goals

Equip stroke survivors with skills & knowledge to progress recovery

  1. You are the coach
  2. Promote independent practice from day 1
  3. Create environment for independent practice
  4. Teach use of simple measurement tools
  5. Goal directed, problem solving approach
  6. Teach break down and progression of activities
55
Q

What are 6 features promoting independent practice for post-acute rehabilitation when retraining the upper limb?

A
  1. Simple exercises from day 1
  2. Create environment for independent practice
    • On ward, in gym, workstations, groups, classes
    • Workstations - independent/semi-supervised
  3. FES
  4. Encourage, measure, acknowledge and reward it
    • Keep record of patient exercise

PHTY3140 (28 decks)

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