PT and the UE Flashcards
what are some fxnal activity and performance limitations with the UE following stroke?
carrying, moving, lifting and handling objects
fine hand use (grasp, manipulate, release)
hand and arm use (pull, push, reach, throw, catch, etc)
self care (washing, dressing, drinking, toileting, eating, looking after oneself)
what is the typical position of the scap following stroke?
abd and downward rotation
t/f: with the downward pull of the scap, there is nothing stopping the downward pull of the humerus except the muscles which stretch out very quickly
true
what are the UE changes w/hemiparesis?
losses of motor and sensory fxn
varying degrees of muscle tone
mal-alignment of the pelvis and trunk
PPT and upper trunk flexion
trunk shortening and lat flexion
inf displaced humerus
ant positioned humerus
downwardly rotated scap
laterally shifted/rotated scap
change in scapulohumeral rhythm
what are the primary risks and complications limiting recovery following stroke?
ROM losses
edema
shoulder subluxation
pain
where in the shoulder can there be ROM losses?
scapulothoracic
scapulohumeral
GH
hand/finger/wrist
what should we ALWAYS inspect for post stroke at the shoulder?
for pain and subluxation
t/f: biomechanical alignment is key in interventions post stroke
true
how do we provide biomechanical alignment?
start at the base
90 deg hip and knee flex
ant tilt/neutral pelvis
symmetrical WB
may use stool on ground and arm support
what are the SAFE requirements?
visible shoulder abduction and voluntary finger extension
what happens to the prognosis when a pt meets the SAFE requirements?
the prognosis is significantly better
if the pt meets the SAFE requirements within 2 days, what is the prognosis?
98% probability of return of UE fxn
if the pt meets the SAFE requirements in >12 days, what is the prognosis?
the prognosis goes way down if it takes this long
what complications in the shoulder can dramatically change recovery?
presence of shoulder pain and/or subluxation
what are the 4 categories of recovery for the UE?
(I) no muscles activity
(II) demonstrates active shoulder abduction
(III) demonstrates shoulder and finger extension
(IV) shoulder pain and subluxation
what interventions should we focus on for pts with no muscle activity?
ESTIM for motor recovery
motor imagery/mental practice
sensory training/sensory discrimination training
what are the interventions for pts with no muscle activity?
active assisted or PROM for hand edema
assess hand edema
instruct pt in compensation techniques for fxn
ESTIM for motor recovery
motor imagery/mental practice
sensory training/sensory discrimination training
avoiding hand splinting
pt and fam ed on passive protection and care of the UE
what are the key factors to consider about the UE in supine?
need to reduce the effects of gravity on the UE by supporting the arm in light WB
make sure the humerus and scap are in good position
avoid hand edema by elevating the extremity
what are the key factors to consider about the UE in SL on the affected side?
watch the scap and humerus
make sure the shoulder is protracted and the hand is supported in WB to promote recovery
what are the key factors to consider about the UE in SL on the unaffected side?
the shoulder has a tendency to retract, so get good protraction and support the UE
want as much ER as feasible
what are the key factors to consider for the UE in sitting?
use what you have available to support the UE
WB through the elbow and forearm
check the scap
for the preservation of fxning of the hand, we have to ensure maintanance of what two things?
1) the fxnal arch of the hand
2) ROM of the hand and fingers
t/f: sometimes, if spasticity is too high, the only way to manage it is w/really strong material/surface to keep them in a fxnal hand position
true
protective handling involves what 2 things?
protective, proper transfer technique
protection and maintenance of jt integrity
we want at least ___ degrees of wrist extension to be maintained
25
what do we mean by proper transfer techniques for protective handling post stroke?
avoid pulling or lifting on the affected limb during mobility or transfers (educate fam, staff, nursing)
how can we protect and maintain jt integrity?
ensuring good GH jt alignment and scap mobility on the thorax
avoiding passive or active shoulder flexion beyond 90 degrees
avoiding overhead pulleys
why should we avoid passive or active shoulder flexion beyond 90 degrees post stroke?
it can cause impingement and CRPS
when is the only time it may be acceptable to flex the shoulder beyond 90 degrees post stroke?
if the scap is gliding towards upward rotation and has sufficient ER available
how can we mobilize and protect the UE with transfers?
tuck the involved extremity into a pocket, gait belt, or under your arm
if higher level of fxn-can use uninvolved extremity to support the involved extremity (b/l clasp)
WB
how can we mobilize and protect the UE in gait?
WB on a moving cart or table (make sure the humeral head doesn’t move up)
can use urself as the AD and use your fingers for directional cues
b/l engagement
what is the problem with slings?
they promote non-use and assymetry of the trunk and extremity
they prevent normal mov’t from occuring
put the arm in a synergistic patterns
no sling does anything to realign the scap
t/f: slings are a tool to be used while gaining proximal stability and should not be used long term
true
what three types of slings support the GH jt?
Bobath sling
Give-Mohr sling
hook hemi harness
what is the Give-Mohr sling?
elastic fabric sling that has a hand device for the pt to hold onto
every mov’t gives input to the shoulder
leaves the arm free for normal mov’t in gait
what is the hook hemi harness?
intends to keep the humerus from downward subluxation
what is the problem with the Bobath, Give-Mohr, and hook hemi harness slings?
the pt can’t put them on independently
if a pt demonstrates active shoulder abduction WITHOUT finger extension, what interventions are appropriate?
motor imagery/mental practice
strength training
task specific training
ESTIM-NMES
mirror therapy
robot assisted training
video gaming
sensory retraining
if a pt demonstrates active shoulder abduction WITH finger extension, what interventions are appropriate?
modified CIMT
motor imagery/mental practice
sensory retraining
video gaming
when is there strong evidence for mental practice/imagery?
when used in conjunction with PT
t/f: there is good evidence for mental practice/imagery as an individual intervention
false
what are the 3 techniques for active recruitment and facilitation/strengthening of motor responses in the UE?
1) critical to maintain a proper scap and GH positioning
2) UT relaxation
3) facilitation of active response
what muscles are critical to keep the scap against the trunk?
rhomboids
MT
LT
why is UT relaxation important?
bc 90% of pts post stroke have their UT getting in the way of normal recruitment bc it becomes overused
in the closed chain, we facilitate what activity?
tonic activity
in the open chain, we facilitate what activity?
phasic activity
how do we facilitate tonic activity?
with weight bearing (WB)
how do we facilitate phasic activity?
with PNF and other techniques
why do we do UE weight bearing?
bc it temporarily moves the head of the humerus back up into the glenoid fossa and assists in realignment of the jt
it fires/facilitates supportive musculature through stimulation of jt receptors for normal activation of shoulder muscles
t/f: WB only provides temporary realignment of the jt and must be combined with other facilitation and protection strategies
true
what are the indications for air splints?
increased ROM
reduction of hypertonicity (rest, mov’t)
stabilization
allow WB
what are the mechanisms for how air splinting works?
neutral warmth
prolonged stretch
deep pressure
t/f: air splints are a great option for when gait training and needing to control UE hypertonicity
true
t/f: kinesiotaping should be used in conjunction with other techniques to be effective
true
when used in conjunction with other techniques, what are the benefits of kinesiotaping?
facilitate/inhibit muscle fxn
support jt structure
reduce pain
provide proprioceptive feedback
achieve and maintain alignment
t/f: mirror therapy is a promising treatment option for early after stroke
true
what is mirror therapy?
stimulating the involved UE by using the uninvolved UE
what are the benefits of MT (mirror therapy) early post stroke?
improves sensory awareness and recovery
improves attentional deficits
improves motor recovery in distal hemiplegic limb
MT works well if ____ is available
abduction
t/f: MT needs to be combined with conventional stroke rehab
true
t/f: MT is a good option for someone early in recovery who is beginning to have shoulder pain
true
what is the dosage for MT?
1/5 hours/day, 5 days/weeks for 4 weeks for improved motor performance and temp sense
t/f: MT translates into ADLs like task specific interventions do
false
what is involved in fxnal retraining?
motorized and ergonomic robotic arm
software which combines personalized, pt-specific exercises and games to engage and motivate
what are the interventions for pts that demonstrate shoulder and finger extension?
modified CIMT
motor imagery/mental practice
sensory retraining
video gaming
virtual reality training
what is a technique for encouraging the use of the affected arm?
CIMT
what is involved in CIMT?
restricting use of the unaffected hand for several hours a day and performing tasks over and over w/the affected arm
what technique involves “forced use” of the hand and fingers that causes the brain to reorganize to help move the hand?
CIMT
what are the 3 procedures of CIMT?
1) massed practice of repetitive, structured, practice-intensive therapy in the use of the more affected arm
2) constraint (restraint) of the less affected arm 90% of waking hours
3) transfer program, which includes monitoring arm use in life situations and problem solving to overcome perceived barriers to using the extremity
what is the 10x10x10 rule in CIMT?
to be considered a candidate for CIMT, they must have at least:
10 degrees active wrist extension
10 degrees active thumb abduction
10 degrees active extension of any other 2 digits on the affected hand
other than the 10x10x10 rule, what other inclusion criteria must be met for CIMT?
pt must be able to walk relatively short distances w/o an AD
pt must have a high level of motivation and commitment
pt must have sufficient endurance
what is the exclusion criteria for CIMT?
presence of chronic pain or co-morbidities that would limit participation
what is involved in experience dependent cortical reorganization?
synapses that have potential for activation are recruited after the usually dominant system has failed
these neurons get set into constant use through repetition and practice
what are the disadvantages of CIMT?
it requires a lot of labor from pts and medical staff
pts endure many hours of frustration
pts can suffer from muscle soreness resulting in stiffness and discomfort in the involved UE
acute CIMT can be harmful by increasing the size of the lesion
it is not beneficial to all pts with stroke/BI (typically for pts with higher level of fxn)
longer treatment=high cost (not reimbursed through insurance)
what are the results of modified CIMT?
the results are consistent with more intense CIMT protocols
what is the protocol for modified CIMT?
30 minutes of 1 on 1 therapy 3 days/week
5 hours/day in restraint (weekdays)
10 weeks
what does neuromuscular electric stimulation do?
boosts arm and hand recovery through sensory electrical stimulation (SES)
specifically for hand closing/opening
it improves fxn, weakness, and spasticity
t/f: virtual reality is task-specific training
true
t/f: virtual reality is a beneficial intervention when used as an adjunct to usual care and when compared w/the same dose of conventional therapy
true
virtual reality may be beneficial in improving what?
UE fxn and ADL fxn
t/f: there is sufficient evidience of VR and interactive video gaming on grip strength, gait speed, or global motor fxn
false
what are the interventions for a patient with shoulder pain and subluxation?
ed and training for the pt and family regarding UE care
gentle mobs for those w/decreased ROM or pain
ESTIM for subluxation
analgesic meds
avoid strapping
botox
when a pt with shoulder pain and subluxation has ROM losses, what should we include?
gentle mobs
education and training for the pt and family
when a pt with shoulder pain and subluxation has ROM losses, what should we avoid?
PROM/AROM of shoulder flexion greater than 90 degrees
overhead pulleys
what is the incidence of pain in individuals with hemiplegia?
5-84%
what are some causes of shoulder pain post stroke?
subluxation
impingement
when the shoulder subluxes, what things can happen?
brachial plexus injury
structural tears (35%)
tendinopathies (53%)
what results from impingement at the shoulder?
sub-acromial fluid collection
what is the cause of hand pain post stroke?
pain syndrome-CRPS
shoulder subluxation is the result of not only the effect of gravity but also the effect of ____ of the depressor muscles
spasticity
how do we clinically rate subluxation at the shoulder?
measure the separation in terms of horizontal finger widths
how do we manage shoulder subluxation?
active recruitment of the supraspinatus and deltoids
passive protection
what 2 muscles are essential to maintain GH alignment?
the supraspinatus and deltoids
t/f: the supraspinatus prevents the downward pull and subluxation of the humerus
true
what is fxnal electrical stimulation (FES) effective and not effective for?
effective for prevention/reduction of subluxation but not for pain or motor recovery post-stroke
several researchers have reported success w/management of shoulder subluxation with FES with what protocol?
gradually increasing stimulation times that ultimately reached 6-7 hours/day
on-off ratio typically 1:3
who is Bioness implantable ESTIM for?
pts who respond well to ESTIM when it’s on, but gone when taken off
what muscle does the Bioness implantable ESTIM target?
deltoids
WC attachments result in a __mm reduction of subluxation
15
slings with elbow flexion result in a __mm reduction in subluxation
10
slings with elbow extension result in a __mm reduction in subluxation
4
what is the best intervention for reduction of subluxation?
WB and ESTIM
t/f: traditional passive tapping and strapping has strong evidence that it reduces subluxation
false, strapping should be avoided
what is CRPS?
hyperactivity of somatosensory, autonomic, and motor systems resulting in regional pain, vascular, and trophic changes and atrophy
the onset of CRPS is influenced by what things post stroke?
type of stroke
severity of motor loss, sensory loss, and spasticity
GH jt subluxation
what is the EBP treatment consensus for CRPS?
medical and rehab combo is the best intervention
what is involved in medical intervention for CRPS?
low doses of oral corticosteroids
nerve blocks
Botox
what is involved in rehab of CRPS?
PROM to pain tolerance (with careful attention to the scap)
proper positioning in WB
neuromotor re-education to facilitate normal task specific use of the UE
mirror therapy
AVOID MODALITIES
why should we avoid modalities in CRPS treatment?
bc they have abborant sensory processing and their pain is at the matrix level and is not a muscular pain
