Management of the UE

Question 1

The fugl meyer assessment is

Answer 1

-Standardized way to test for motor recovery

-Impairment-based test organized by sequential recovery stages

-Utilizes a 3-point ordinal scale to measure impairments of volitional movement

-Grades: 0 (cannot be performed) to 2 (item can be fully performed)
-Cumulative scoring is 226 with additional subset scores

-Subtest exist for UE function
-Good validity and high reliability
-30-45 minutes to administer

Question 2

what is the 9 Hole Peg Test

Answer 2

-Measures finger dexterity

-One at a time pegs are moved from a container and placed as quickly as possible into 9 peg holes on a board. Pegs are then removed and returned to the container.

-Time is captured
-Normative values exist

Question 3

action research arm test

Answer 3

-Comprised of 19 UE functional tasks/movements

-4 subscales: grasping, gripping, pinching, and gross movement

-Ordinal scoring
*0= can perform no part of test
*3= performs test normally

-Total score of 57 indicating normal UE use
-Time to administer: 5-20 minutes
-Floor and ceiling effects are notable
-MCID: 12 points (dominant) and 17 points (non-dominant)

Question 4

the arm motor ability test

Answer 4

-The purpose is to evaluate disability in upper extremity function of ADL using a quantitative and qualitative measure

-Tests 13 ADLs involving one to three component tasks or movement segments

-28 items

-Required equipment: shoe, telephone, and shirt

-Not a free measure and reading an article/manual is required

Question 5

what is the Box and Block Test

Answer 5

-Assesses unilateral gross manual dexterity

-Performed in sitting

-Two square compartments, 150 colored and wooden cubes/blocks are placed in one

Instruction to move as many blocks as possible, one at a time, within a 60 sec timeline

The patient may observe test performance

Score is based on how many blocks are carried over the partition
Higher scores indicate better gross manual dexterity

Question 6

What is a dynamometry

Answer 6

Patients are asked to maintain an isometric contraction for 2-5 seconds for either a “make” or ”break” test

Scored using force production (kilograms, Newtons, or pounds of force)

Question 7

what are some consideration for upper limb intervention management

Answer 7

Musculoskeletal impairments
Sensory retraining
Strengthening
Improvement of selective capacity

Question 8

what are general goals of the upper limb intervention?

Answer 8

Early mobilization

ROM

Positioning strategies

Repetitive, task-specific practice with relevance and importance to the patient for those with some recovery of voluntary movement

Compensatory environmental adaptations may also need to be considered

Question 9

Safe model

Answer 9

An algorithm that can be used to guide upper limb rehabilitation

Functional outcomes are related to those individuals who have some voluntary finger extension and shoulder abduction acutely after experiencing a stroke

Best practice for arm recovery post stroke:

Question 10

ViaTherapy App

Answer 10

An app created for therapist to improve effectiveness and efficiency of caring for patients

Goal: to recall established therapies and to facilitate learning of new therapies for the upper limb

Questions asked regarding stroke acuity, shoulder pain risk, intervention considerations, etc.

Question 11

What are some interventions to improve ROM

Answer 11

Soft tissue/joint mobilization and ROM exercises early

PROM and AROM when possible
-Frequency will need to increase if contractures are present

Positioning strategies to promote optimal joint alignment
-Should be viewed as whole-body (the LEs and trunk affect the UEs)
-Address postural concerns

Requires coordination with team members, staff, family and caregivers

Question 12

What are consideration of mobilization

Answer 12

Attention should be paid to external rotation and humeral distraction especially in ranges of 90 degrees of flexion or more

Prioritize scapular mobilization to emphasize upward rotation to prevent impingement during overhead movements

Pulleys are contraindicated secondary to impairments in scapulohumeral movement

Prioritize elbow extension

Additional priority should be placed on maintaining the length of wrist and finger extensors

Consider Grades I and II mobilization of the carpal bones before stretching

Question 13

what are interventions to manage spasticity

Answer 13

Early mobilization and daily stretching

Once optimal/full range of motion is achieved, the limb should be placed in the lengthened position and maintained

Sustained stretching

Modalities can also be used: cold, massage, and electrical stimulation
-Cold: slows nerve conduction and decreases muscle spindle activity
-Functional Electrical Stimulation (FES): can be used to target the antagonist muscles for the goal of reciprocal inhibition

Botox injections may also be indicated

Question 14

what are interventions to improve sensory function

Answer 14

-Encourage utilization of the affected side to promote increased awareness and function

-Sensory retraining:
*Mirror therapy
*Repetitive sensory discrimination activities
*Bilateral simultaneous movements
*Repetitive task practice

-Sensory stimulation approaches:
*Compression techniques (weight-bearing, manual compression, inflatable pressure splints, intermittent pneumatic compression)
*Mobilizations
*Electrical stimulation
*Thermal stimulation or magnetic stimulation

Question 15

Supportive Devices for the Upper Extremity

Answer 15

-This is controversial topic

-Primary use is for shoulder joint protection when the limb is flaccid, during movement transitions and when the arm is in a dependent position

-Supportive slings also provide the therapist with additional places to utilize his or her hands (trunk, etc.)

Negative features:
-Little assist with reducing subluxation
-Prolonged use could lead to contractures
-Limits spontaneous use
-Block balance reactions

Question 16

Shoulder Subluxation

Answer 16

-Occurs secondary to muscular and biomechanical factors of glenohumeral joint stability

*Inferior subluxation is the most common
*Often secondary to shoulder abduction, forward flexion of the humerus, or scapular depression and downward rotation

-Evaluation and monitoring can occur with measurement
*Place the UE in a non-supported position and use a tape measure to measure the gap in the glenohumeral joint

Question 17

shoulder pain post stroke

Answer 17

-Flaccid: reduction of support and action of the rotator cuff
-Proprioceptive loss
-Lack of muscle tone
-Muscle paralysis

Spastic:
-Abnormal muscle tone could contribute to poor scapular position
-Subluxation and restricted movement could occur
-Ex: adhesive capsulitis

Question 18

Management of Shoulder Pain

Answer 18

-Optimize posture
-Assist with proper positioning and handling
-Utilization of supportive devices
-Scapular mobilization
-Encourage active movement
-Manage edema if present

Question 19

Other Subluxation Considerations

Answer 19

Humeral taping
Neuromuscular electrical stimulation
Hand in pocket or hand on purse

Question 20

what is motor imagery

Answer 20

-The application of imagery techniques for improving motor performance and learning

-Practice can be visual or kinesthetic
—Instruct: “see” or “feel” the movement as you image executing it

-Cognitive engagement is necessary for practice

Best combined with physical practice

Assess a patient’s ability to imagine: quick mental chronometry screen

Question 21

what is mirror therapy

Answer 21

-May be an effective adjunct to improve motor function by way of visual feedback

-A type of therapeutic intervention that focuses on moving the less impaired limb while watching its mirror reflection

-Mirror is placed in the midsagittal plane with the image presenting as if it is the hemiparetic limb

-Belief that a mirror helps create the illusion that the affected hand is moving

-May improve UE recovery, distal motor function and reduce hemi-neglect

-Can be combined with task-specific training, MI as well as NMES

Question 22

what is electrical stimulation

Answer 22

-Stimulation of the peripheral nerves and muscles with external electrodes to apply to selected and task-based movements

-NMS or EMG-triggered NMS

-Goals to improve sensory awareness, prevent or reduce shoulder subluxation and facilitate volitional movements

-To promote alignment: application of electrodes on deltoid and supraspinatus

Once selective capacity of the upper limb is achieved, e-stim is not used

Question 23

Simultaneous Bilateral Training

Answer 23

Involves using both arms simultaneously or alone or in combination with augmented sensory feedback

Ex: bilateral arm training with rhythmic auditory cueing

Theory exists that similar movement in the less affected extremity facilitate movement in the more affected extremity

Question 24

Robotic-Assisted Training

Answer 24

Utilized with individuals who have moderate-severe motor impairments

Used in conjunction with task-oriented training and motor learning principles

May include:
-Pneumatic actuators
-Reach and grasp/release movements are often targeted
-Unilateral or bilateral
-Enables high levels of intensive practice
-Can target proximal, distal and proximal plus distal UL muscles

Question 25

Strengthening

Answer 25

-Upper limb strength has an importance to postural control and function, gait and locomotion

-Progressive strength training is recommended

-May be limitations in carryover to function

-Lack of specificity or intensity could be the reason for this

-Modalities: free weights, elastic bands or tubing, or machines

-Can utilize gravity-eliminated positions

-Should occur 2-3 X per week, 8-12 repetitions, for 3 sets

-Enhanced with task-oriented functional activities

Circuit training is also helpful

Question 26

Strengthening Exercise Precautions

Answer 26

*Adaptive equipment (e.g., gloves) can maintain contact with exercise equipment

*Impaired sensation can pose risk to injury

*Impaired postural control could result in falls

*Consider the incidence of HTN and cardiac disease, so ensure BP is stable
Consider beginning with submaximal protocols

Question 27

Upper Limb Task-Specific Training

Answer 27

Active control is required

UE can be utilized as a stabilizer, an assist and a manipulator

Reaching tasks should be done with meaningful objects

Can be done to help with reducing the obligatory synergy postures

Weight bearing in modified plantigrade position

Utilize the stronger extremity to perform a functional task

Consider combination with other activities such as a balance tasks

Multiple progressions can be added

Question 28

Virtual Reality and Video Games

Answer 28

Patients need some active isolated movement to participate

Gains have been noted earlier in recovery

High frequency participation has been shown to improve outcomes

Clear understanding of the game and its application may enhance efficacy

Question 29

Constraint-Induced Movement Therapy (CIMT)

Answer 29

Designed to promote increased use of the more affected UE

Intense task-oriented practice for up to 6 hours per say

Performed on consecutive weekdays for 10-15 days

The less affected UE is restrained for up to 90% of waking hours with use of a mitt

The therapist can use shaping techniques to modify and progress performance

Feedback, coaching, modeling and encouragement are provided

Modified CMIT may be used