Week 10 Flashcards
Characteristics of UL function after stroke
Arm movements are:
• Slower
• More jerky
• Exhibit less direct movement paths
• Are less well timed
• Are more likely to include trunk movement
• Are more likely to have wider hand aperture than required
Common UL kinematic deviations after stroke
Common kinematic deviations in shoulder, forearm/elbow, wrist • ↓ Shoulder flexion • ↓ Shoulder external rotation • ↓ Elbow extension • ↓ Supination • ↓ Wrist extension/radial deviation
Common kinematic deviations in MCP, PIP, DIP
• ↓ MCP and IP flex/ext
• ↓ Thumb abd/rotation
• ↓ Cupping of hand / opposition of 4th and 5th fingers
• ↓ Force through 2nd finger with IP joints in extension
• ↓ Force modulation
• ↓ Individuation of fingers
Outcome measures for UL
Nine-hole peg test (9HPT)
• Time taken to place all pegs into holes on the board and then remove them and place them back into container
Box and block test
• Number of blocks transferred from one compartment to the other compartment in 60 seconds
Options for UL intervention
- Repetitive task training
- Strengthening exercise
- CIMT
- Mechanically assisted arm training (robotics)
- Virtual reality and interactive games
- Electrical stimulation
- Mirror therapy
- Mental practice
Improving UL function after stroke (for very weak/paralysed and weak)
Paralysed or very weak UL
• Grade 0-2
• Strengthening is essential
• Task specific practice will have to be highly modified
Weak and uncoordinated UL
• Grade 3-4
• Task specific training needed to improve dexterity
UL strengthening exercise strategies for Grades 0-1 and 2
Grade 0-1
- Mid range
- Decrease gravity
- Decrease friction
- Shorten lever arm
- Decrease degrees of freedom
- Provide feedback
Grade 2:
- Full range
- Shortened range
- Sustained contraction
- Increase speed
- Decrease degrees of freedom
- Provide feedback
Recommendation on mechanically assisted training in UL
Weak recommendation for stroke survivors with mild to severe arm weakness: mechanically assisted training (e.g. robotics) may be used to form UL function
Smart arm, dynamic splint, robotics
Mental practice for UL
Weak recommendation for stroke survivors with mild to moderate arm weakness: mental practice + active motor training may be used to improve UL function
Visualise the image of doing the task, the setting, the associated sensations
Mirror therapy for UL
Weak recommendation for stroke survivors with mild to moderate arm weakness: mirror therapy + routine therapy may be used to improve UL function
Move non-paretic arm while looking in a mirror that gives the impression that the paretic limb is moving
Electrical stimulation for UL
Weak recommendation for stroke survivors with mild to severe arm weakness: electrical stimulation + motor training may be used to improve UL function
Interventions for weak UL with decreased coordination/dexterity
Options for intervention • Repetitive task specific training • Constraint Induced Movement Therapy (CIMT) • Virtual reality and interactive games • Mirror therapy • Mental practice
Recommendations about repetitive task specific training
Weak recommendation for stroke survivors with at least some voluntary movement of the arm and hand: repetitive task-specific training may be used to improve UL function
- Need to analyse essential components of the client’s goal
- target patients specific problems such as their KD’s, any slowness/jerkiness
- Include KP and KR that is relevant to the KD or dexterity problem
- High repetitions
Amount of rehabilitation
Strong recommendation for stroke survivors, rehabilitation should be structured to provide as much scheduled therapy (occupational therapy and physiotherapy) as possible.
Group circuit class therapy should be used to increase scheduled therapy time.
Weak recommendation for minimum of three hours a day of scheduled therapy (OT and physio) is recommended, ensuring at least two hours of active task practice occur during this time.
Consensus-based recommendation for stroke survivors should be encouraged to continue with active task practice
outside of scheduled therapy sessions. This could include strategies such as:
• self-directed, independent practice
• semi-supervised and assisted practice involving family/friends, as appropriate
Constraint induced movement therapy
CIMT effective at improving: • Arm function • Hand function (dexterity) • Arm motor impairment • Use of the arm in everyday life • No significant effect on disability (i.e. ability to perform ADLs
Includes:
- At least 2 weeks of intensive, supervised task practice with the affected hand for 2 to 5 hours per day, 5 days per week
- Homework tasks
- Restraint of the unaffected hand in a mitt or sling for at least 6 hours a day
- Trunk restraint
- Shaping, repetitive exercises, and instructions for behavioural change
Shaping (in CIMT)
= Adjusting the feature of task training
Adjusting the load
• Weight or size of the object to challenge strength
• Influence of gravity to challenge strength
Timing - challenge speed by
• Increasing the number of reps completed in the same time
• Decreasing the time it takes to complete the same activity
• Increasing amount of time the task is carried out for to challenge endurance
• Change object position: further away to challenge ROM, raising the height to challenge strength
