Download Management of the hemiplegic upper limb Trunk Control Alignment

8/27/2014
Management of the
hemiplegic upper limb
Christine Griffin, OTR/L MS,BCPR
Ohio State University Medical Center
[email protected]
Trunk Control
• Foundation of all head, neck, and limb
movement
• Functionally
– Reach beyond arm’s length
– Interaction with environment
• Anticipates
• Perceptual influence
(Gillen, 2011)
Alignment of the trunk
• Alignment/ Biomechanical Considerations
• Optimal alignment
– Anterior pelvic tilt
– Lumbar extension
– Thoracic extension
Lower trunk stability
• Pelvic position
• Co-Contraction of Muscles
– Ant abdominals & Lumbar Ext.→ thoracic ext
– Right & Left Lateral abdominals
(Bohman, 2003)
• Dynamic
– Changes in base of support
– Leading with upper vs. lower trunk
(Runyon, 2003)
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Dynamic Dissociation
• Normal control requires the ability to dissociate (separate) different parts of the body from each other
(Mohr, 1990)
– Eccentric/ Concentric muscle contraction
– Ex: Upper trunk rotation with lower trunk stability while reaching for clothing during dressing
• Difficulty with dissociation
– Soft tissue tightness
– Bony contracture
– Efforts by patient to decrease movement
Influence on Facial and Oral Motor
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Body Positioning
• Position of feet – EMG studies
– Knee Flexion Increased muscle activity in trunk
– Knee Extension Decreased muscle activity in trunk
(Anderson & Ortengren, 1974)
– When feet under knees, anterior pelvic tilt and trunk extension are enhanced
• Functional Influence
– Jebsen Taylor Hand Function Test
•Higher functional scores when patient sitting in neutral position vs. flexed or laterally flexed position
(Gillen et al., 2007)
Trunk Malalignment vs. Alignment
Vocalization
Swallowing
Manipulation of solid/ liquid food
Facial Expression
Respiration
(Runyon, 2003)
Photo from personal collection of Christine Griffin. Used with permission. 2
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Effect of pelvis on upper extremity
• Posterior pelvic tilt→ lumbar flexion→
thoracic flexion→ scapular abduction→
humerus internal rotation
• Anterior pelvic tilt→ lumbar extension→
thoracic extension→ scapular adduction→
humerus external rotation
Stretch for Thoracic/ Lumbar Ext
Wedge stretch
• Wedge Stretch
– Supine on large wedge
– Two towel rolls in inverted “T” position
• One in lumbar region
• One along spine in thoracic region
Photo from personal collection of Christine Griffin. Used with permission. 3
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Dynamic Trunk Control and Trunk Strengthening Activity
Taping
• Kinesio Tape
– Light flexible tape
– Supports muscle
– Removes congestion
(edema)
– Corrects joints
– Activates analgesic
system (pain relief)
(Gillen, 2004)
• McConnell Tape
/Leukotape
– Very rigid, needs 2
layers of tape to
protect skin
– Stabilizes
– Re-aligns
– Reduce Pain
(Gillen, 2004)
Photo from personal collection of Christine Griffin. Used with permission. Taping for Postural Training
Photo from personal collection of Christine Griffin. Used with permission.
Video of Taping for Postural Training
Video from personal collection of Christine Griffin. Used with permission.
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Frequency and Duration of Taping
• Varied evidence of frequency and duration
• Anecdotal report
– Duration of adhesive
– Skin tolerance of tape/ adhesive
Anatomy/ Biomechanics
• Joints/ articulation
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Glenohumeral
Scapulothoracic
Acromiclavicular
Sternoclavicalar – only bony attachment of upper
limb to the axial skeleton
• High mobility, Low articulation
– Joint relies on muscle strength for stability
– Post neurological event stability is lost with
muscle decreased function
• Reason why upper limb more effected than lower limb
Lab Time!!
• Anterior pelvic tilt
• Lumbar & Thoracic
Extension
• Lower trunk
facilitation
• Upper trunk
facilitation
Anatomy
• Key landmarks for the shoulder
– Scapula: Acromian, root of the spine, inferior
angle
– Humerus: Humeral head
• Scapula has a concave/ convex
relationship with the rib cage
• Scapula is a curved surface that easily tilts
and moves
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Alignment/ Approximation
• Scapula
– Acromian process is higher that the root of the
spine
– Inferior angle is against the rib cage
– Sits in neutral plane of elev./ dep., abd./ add.
• Humerus
– Humeral head approximated into the glenoid
fossa
Alignment/ Approximation
• Therapist sitting lateral to
patient
– Front hand: Approximation
of humeral head into
glenoid fossa
– Back hand: Approximation
of scapula with inferior
angle in forward direction
– “Rotate the globe”
(Runyon, 2003)
(Runyon, 2003)
Scapular malalignment
• Occurs because of
– Inactivity around scapula
– Muscle imbalance around scapula
– Trunk malalignment
(Gillen, 2011)
Photo from personal collection of Christine Griffin. Used with permission. Scapular malalignment
• Presents as
– Subluxation
– Abnormal scapular humeral rhythm
– Pain and impingement
– Ineffective movement patterns
– Possible CRPS
– Decreased function
(Gillen, 2011)
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Shoulder subluxation
• Palpable gap between the acromion and humeral head
• Subluxations occur within the acute hypotonic phase of
hemiplegia
• Theory
– Occurs due to prolonged downward pull by gravity on the arm
against which hypotonic muscles offer little resistance (Chaco and
Wolf 1971). Results in overstretching of the glenohumeral capsule
(especially its superior aspect) and hypotonic supraspinatus and
deltoid muscles (Basmajian and Bazant 1959, Shahani et al. 1981)
– The combination of flaccid supportive musculature (in particular,
the supraspinatus muscle) and a downward rotated scapula was
presumed to predispose the head of the humerus to undergo
inferior subluxation relative to the glenoid fossa (Basmajian and
Bazant 1959 & Calliet 1980)
Shoulder subluxation
• Subluxation is a result of weak rotator cuff
muscles
– Rotator cuff seats the head of the humerus
into the glenoid fossa
• Remember Anatomy when considering tx
methods
– Rotator cuff (Internal muscle layer) and
Deltoid (external muscle layer)
– Focus on positioning and stability of scapula
first
Biomechanics of Subluxation
• Not a result of positioning of downward scapular
rotation
– Prevost et al., 1987
– Culham et al., 1995
– Price et al., 2001
• “Scapular position was not an important factor” and “unrelated” in the occurrence of inferior subluxation in hemiplegia (Prevost et al., 1987, & Price et
al., 2001)
• Scapula does have influence because of
alignment and biomechanical advantage in active
ROM
Subluxation Patterns
• Inferior
• Anterior
• Superior
(Ryerson & Levit, 1998)
• Assessment of subluxation clinically
– Palpation of subacromial space is most reliable form
– Finger widths for measurement
• (Hall et al, 1995 & Prevost et al., 1987)
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Prevention of Pain & Complications
• Scapulohumeral Rhythm
• In a normal shoulder has 2:1 ratio
Abnormal scapulohumeral rhythm
• Scapulohumeral rhythm with hemiplegia
– At most effected state neither portion actively
moves
– 2 parts humeral movement to 1 part scapular
movement
(Clarkson & Gilewich, 1989)
• With a non moving scapula & passively
moving humerus
– Subacromial trauma occurs at 90° shoulder
flexion
(Kumar, et al., 1990)
Photos from personal collection of Christine Griffin. Used with permission. Subacromial Trauma
• DO NOT perform
– over head arm raises
– PROM greater than 90°shoulder flexion or abduction
(Kumar et al., 1990)
• Will cause subacromial trauma
– Impingement of supraspinatus under coricoacromial
arch
– Increased pressure on subdeltoid bursa
– Impingement of brachial plexus
– Impingement arterial and venous supply
– Stretching of glenohumeral capsule
(Griffin, 1968; Peat, 1968)
Superimposed Orthopedic Injures
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Lesions of the rotator cuff
Lesions of the biceps tendon
Adhesive capsulitis
Brachial plexus traction injury
Impingement syndromes
(Gillen, 2011)
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Braus, Krauss, & Strobel, 1994
• Suggests that pain from SHS/ CRPS I is
initiated by a peripheral lesion (tissue or
nerve)
• Autopsy data
– Confirmed micro-bleeding of the
suprahumeral joint of the affected side
– Subacromial trauma
• If cause is peripheral, than prevention
program would be effective
Subacromial trauma is preventable!!
• Education is key
– Patient, therapist, staff, family
– https://patienteducation.osumc.edu/Documents/protect-shoulder.pdf
• Proper Handling
– During ADL’s and transfers
– Avoid inappropriate treatment choice
• Positioning
• Let Active ROM determine a patient’s
Passive ROM limitation
• Safe PROM
Braus, et al., 1994
• Implemented Prevention Protocol:
– Education to prevent peripheral injury
– No PROM before scapula mobilization
– No pain during exercise/ activity
– No infusions into affected hands
• Incidence of pain from SHS decreased
from 27% to 8%
Biomechanically safe PROM
• Completed by therapist or caregiver after
training
– Range scapula with approximation of scapular
humeral joint
(Runyon, 2003)
• Can be completed by patient
(Davies, 2000, Gillen, 2011)
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Range scapula with approximation of scapular humeral joint
• Elevation
– Approximate scapula and
humerus
– Perform scapular elevation
with inferior angle between
therapist’s thenar and
hypothenar eminence of
hand
– Have patient move into
posterior pelvic tilt
“Roll your belly back”
“Hide your belly button”
“Slouch and touch your chin
to your chest”
(Runyon, 2003)
Range scapula with approximation of scapular humeral joint
• Depression
– Approximate scapula and
humerus
– Therapist places finger tips
on patient’s spine of
scapula
– Have patient move head in
lateral direction away from
you. Ear on non-involved
side to shoulder on noninvolved side
(Runyon, 2003)
Photo from personal collection of Christine Griffin. Used with permission. Range scapula with approximation of scapular humeral joint
•
Adduction
– Approximate scapula and
humerus
– Therapist holds patient’s
axillary area in web space
– Perform adduction and
maintain hold
– Ask patient to slowly turn
head in opposite direction
– For additional stretch ask
patient to place opposite
hand on opposite hip with
thumb pointing down
(Runyon, 2003)
Photo from personal collection of Christine Griffin. Used with permission. Range scapula with approximation of scapular humeral joint
• Abduction
– Approximate scapula
and humerus
– Therapist places PIP’s
onto patient’s medial
border
– Perform abduction and
maintain
– Ask patient to slowly turn
head toward therapist
and reach for therapist’s
shoulder
(Runyon, 2003)
Photo from personal collection of Christine Griffin. Used with permission.
Photos from personal collection of Christine Griffin. Used with permission.
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Scapulothoracic Mobilization: Upward Rotation
• Patient lying on
unaffected side
Clinical Use of Scapular Mobilization
• Assess current position of both scapulas
• Use only scapular stretches necessary to
achieve approximation and symmetry of
Hemiplegic side scapula with NonHemiplegic side scapula
– Approximate scapula
and humerus and
support upper limb
– Therapist places
fingertips on medial
border by inferior
angle
– Perform upward
rotation and maintain
(Dale, 2005)
Photo from personal collection of Christine Griffin. Used with permission.
Lab Time!!
• Anterior pelvic tilt
• Lumbar & Thoracic
Extension
• Approximation
• Scapular mobilization
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Elevation
Depression
Adduction
Abduction
Upward rotation
Photos from personal collection of Christine Griffin. Used with permission.
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Biomechanically safe PROM completed by
patient
Active Scapular Stability
• “Rock the baby” Cradle arm with trunk
rotation to 60° shoulder abduction
(Gillen, 2011)
Images from Ohio State University Medical Center. Used with permission
Photos from personal collection of Christine Griffin. Used with permission.
Biomechanically safe PROM completed by patient
• Lack of Glenohumeral
joint external rotation is
associated with pain
Gravity Eliminated AAROM
• Stability of scapula on
thoracic wall with
emphasis on upward
rotation
– (Bohannon et al 1986, and
Zorowitz et al, 1995)
• Stretch for external
rotation
(Gillen, 2011)
• Improves shoulder
function and
subluxation
– Lay supine with
45°shoulder abduction
– Gently rotate to external
rotation
– Lay forearm on pillow for
prolonged stretch
Photos from personal collection of Christine Griffin. Used with permission.
(Gillen, 2011)
Photo from personal collection of Christine Griffin. Used with permission.
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Edema and Hemiplegia
• Increased venous congestion
• Decreased muscle activity – lack of muscle pump for venous return – Limited stimulation to superficial lymphatics
• Limbs in dependent position
• Poor positioning – obstruction of subclavical and pelvic area: lymphatic and venous flow
(Konosky, 2008, and Leibovitz et al., 2007)
Treatment for Edema Management
• Limited evidence
• Combination of mobilization and garments
– Manual edema mobilization techniques
• Manual lymph drainage, massage
– Garments
• Jobst ®, Isotoner ® gloves, Coban ®, Lymphadema wrapping
• Elevation alone can lead to guarding and disuse (Harden et al., 2006; Swan, 2004)
• Active motion in conjunction with elevation is more effective (Barreca, 2003)
Edema Measurement
• Measuring tape around joints
– Inter‐rater reliability
– Very specific locations
• Volumetric Measurement
– A change of 12mL or more is considered clinically significant
(Post et al, 2003)
Positional Elevation
• Gravity to assist hemodynamic flow in the limb backward and down toward heart
– Assist to clear venous/ lmphatic congestion
• Contraindications
– Heart failure – overstress the heart
– DVT – transport clot to heart, lungs, brain
– Arterial dysfunction – Raynaud’s phenomenon: decreased viability of distal end of limb (fingers and toes)
(Burkhardt, 2004)
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Positional Elevation
• Helps to mobilize fluid
• Edema returns when limb returns to dependent position
• Elevation of lower limb with 90° hip flexion not effective
– Compression of vessels in pelvic region
• Iliac artery/ vein
• Grouping of lymph nodes in pelvic region
– Not above level of heart
(Konosky, 2008)
• Manual Lymphatic Massage
– Superficial lymph nodes at neck, groin, and armpit are stimulated first
– Light pressure: Superficial delicate structures
– Massaged lightly with scooping technique
– Proximal extremity first, the middle portion second, and distal portion last
(Burkhardt, 2004)
Elevation and Manual Massage Combined
Manual Massage
Manual Massage
AAROM with elevation
Compression Garments
• Prevent backflow and limb refilling
– Have to clear fluid first
• Temporary compression garments
– Tubular support bandages
– Isotoner Gloves
– Self Adherent Wraps (ex. Coban)
• Compression Wrapping bandages
– Requires training
– Not Ace Bandage
– Comprilan
(Burkhardt, 2004)
Photos from personal collection of Christine Griffin. Used with permission.
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Compression Gloves
• Contraindications
– IV’s, fistulas, acute blood clot, severally impaired circulation, open wound
• Evaluation
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Color of finger and nail bed 3‐5 min. post donning
Compression at wrist
Does entire arm have swelling
Position during day
Skin integrity
Movement
(Konosky, 2008)
Compression Gloves
• Off the shelf vs custom
– Determined by shape and size of limb
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•
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Provides 15‐32 mmHg of pressure
Seams on the outside
Cost
Long term vs short term
(Konosky, 2008)
Taping & Hemiplegic Shoulder
• Conflicting evidence that taping reduces pain
Intervention
– Ancliffe, 1992
– Hanger et al, 2000
– Griffin & Bernhardt, 2006
• Inner layer vs. outer layer
• “Moderate evidence that Strapping (taping)
does not improve upper limb function or ROM”
with a subluxation
– Ebrsr.com, 2010
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Taping and Hemiplegic Shoulder
Postural Training
• Postural retraining
• Approximation during AROM
– Need to have muscle activity around joint you
are taping to be affective
• Once taping is applied, complete scapular
stability exercises and gravity eliminated
AAROM exercises
– Home Exercise Program & Therapy Sessions
Photo from personal collection of Christine Griffin. Used with permission.
Anterior Hyperlaxity & Inferior Hyperlaxity
Pictures from personal collection of Christine Griffin. Used with permission.
Video of Taping for
Anterior Hyperlaxity & Inferior Hyperlaxity
Video from personal collection of Christine Griffin. Used with permission.
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Active Motion ‐ Closed Chain AAROM with PVC pole
Slings
• Debated in literature for at least 30 years
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Variety of available slings
Controversy regarding effectiveness
When and how slings should be used
Possibly add to complications resulting from an extremity affected by stroke
• (Gillen, 2011)
• Common goals by surveyed therapists
– Decrease and prevent subluxation and pain
• (Boyd & Gaylord, 1986)
Photos from personal collection of Christine Griffin. Used with permission.
Slings
• Hurd, 1974, Full arm sling:
– No difference found in shoulder ROM, pain, or subluxation for pt’s with or without slings
• Zorowitz, 1995, Single‐strap hemisling, Bobath roll, Cavalier support, Roylan humeral cuff sling:
– “No absolute evidence that supports prevent or reduce long term shoulder subluxation” “or that a support will prevent complications of the shoulder subluxation”
• Dieruf, 2005, GivMohr Sling:
– Reduces a subluxation when worn. No comment on long term effects, functional outcomes, ROM, or pain
Slings
• Ada et al, Cochrane Database Systematic Review, 2005
– “There is insufficient evidence that to conclude whether slings and wheelchair attachments prevent subluxation, decrease pain, increase function or adversely increase contracture in the shoulder after stroke”
• Ebrsr.com, 2012
– “There is limited evidence that shoulder slings influence clinical outcomes”
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Slings
Slings and Subluxation – Cailliet, 1980
Pros
• If goal of sling is to provide glenohumeral joint stability, then the device must support the scapula on the rib cage in approximation to compensate for lack of support of the rotator cuff. • Currently no slings on the market assist with realigning the scapula on the rib cage
• Therefore, slings cannot be prescribed to “reduce a subluxation”
Slings
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Minimize use!!
Immediate removal
Pt. becomes dependent
Avoid slings that position G‐H joint in Internal Rotation
• Investigate alternate means of support
– Lap trays, positioning in bed
(Gillen, 2011)
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•
•
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Protects from injury during transfers
Allows therapist to control trunk and lower limbs during initial functional mobility
May relieve pressure on brachial plexis and artery
Supports weight of arm
(Gillen, 2011)
Cons
• May contribute to neglect
• May contribute to learned nonuse
• May hold upper limb in a shortened position
• May initiate CRPS (Immobility, edema, pain)
• May predispose to pain due to shortened internal rotation
• Does not reduce subluxation
• Does not approximate scapula
• Prevents reciprocal arm swing
• Blocks sensory input
• Prevents balance reaction of upper limb
• May block spontaneous use
Prevention of Secondary Impairment of Immobility: Resting hand splint
• Splinting has not been shown to effectively reduce spasticity, prevent contracture formation, or be effective to help improve active function following stroke.
– Lannin et al. (2003)
– Harvey et al. (2006)
– Lannin et al. (2007)
– Basaran et al. (2012)
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Prevention of Secondary Impairment of Immobility: Resting hand splint
• “Despite numerous studies, two Level I systematic reviews reported that there is insufficient evidence to support the use of resting hand splints as a routine intervention in stroke rehabilitation”
(Lannin & Hebert, 2003; Ma & Trombly, 2002)
• EBRSR 2013
– There is strong (Level 1a) evidence that hand splinting does not improve impairment or reduce disability.
Neurofacilitation Techniques
• Proprioceptive Neuromuscular Facilitation
– Kraft et al, 1992
• NMES vs. PNF
• NMES over PNF
• Rood
– No Evidence
Neurofacilitation Techniques
• Brunnstrom’s Movement Theory
• Limited Evidence
– Wagennar et al. (1990) (n=7): “Time series analysis indicated that for one patient only, walking speed progressed more during the Brunnstrom phases than the NDT phases”
– Last update 1992 by Sawner & LaVigne: Studies (25) cited to support the approach were published between 1898‐1960
Neurofacilitation Techniques
• NDT/Bobath
– Paci (2003): Systematic review of 15 papers concluding “Results show no evidence providing the effectiveness of neurodevelopmental treatment or supporting neurodevelopmental treatment as the optimal type of treatment, but neither do methodological limitations allow for conclusions of non‐efficacy”
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Neurofacilitation Techniques
• NDT/Bobath
• Luke et al. (2004): Systematic review of 8 trials to determine the effectiveness of the Bobath concept at reducing upper limb impairments, activity limitations and participation restrictions after stroke
• “Comparisons of the Bobath concept with other approaches do not demonstrate superiority of one approach over the other at improving upper limb impairment, activity or participation”
Neurofacilitation Techniques
• NDT/Bobath
• Rao (2011) or Rensink (2009) Systematic review of 9 trials concluding – “The evidence overwhelmingly points to the lack of effectiveness of the Bobath approach when compared with a task‐oriented approach”
Neurofacilitation Techniques
• NDT/Bobath
• Kollen et al. (2009)
– Based on predetermined criteria 16 studies invovling
813 patients with stroke were included for further analysis
– There was no evidence of superiority of Bobath on sensorimotor control of upper and lower limb, dexterity, mobility, activites of daily living, health‐
related quality of life, and cost‐effectiveness
– This systematic review confirms that overall the Bobath Concept is not superior to other approaches
Neurofacilitation Techniques
• NDT/Bobath
– The Dutch NDT Study Group/ Haffsteinsdottir, et al. 2005.
– N=324: propspective multi‐center (12) non‐
randomized parallel study
– NDT vs. conventional treatment
• Monitored via intervention checks including nursing
• NDT group received more OT/PT
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Neurofacilitation Techniques
• Conclusion
– “The NDT approach was not effective in the care of stroke patients in the hospital setting. Health care professionals need to reconsider the use of the approach”
– “Previous studies have already focused on several other outcomes measures such as walking ability, motor performance, muscle strength, upper extremity function, and depression but these were also unaffected but the NDT approach”
– “Recovery after stroke may best be stimulated by the patient practicing motor tasks under similar conditions of strength, speed, and accuracy as in real life, and with similar cognition demands”
Shift in Rehabilitation Approach
• Self Examination
• Intervention supported by Evidence and Research
• Paradigm shift from traditional theories to Neuroplasticity
Neurofacilitation Techniques
• Proprioceptive Neuromuscular Facilitation,
Rood, and Brunnstrom Approach
– Evidence “sparse and inconclusive”
(Sabari, 2010)
– Based on outdated views of motor recovery and motor control
(Ma & Trombly, 2002; Pollock, Baer, Pomeroy, & Langhorne,
2007; Steultjens et al., 2003)
• Neurodevelopment Treatment
– No evidence of significantly better outcomes for NDT when
compared with other treatments to improve upper limb motor
function
(Luke, Dodd, & Brock, 2004; Paci, 2003)
Neuroplasticity – What is it?
• Neuroplasticity  Changing the brain
• Capability of CNS to alter function and structure in response to use and motor learning
• Reorganization of undamaged systems in the brain
• The brain responds to functional/ environmental demands
• Occurs after Repetitive Practice
(Lundy‐ Ekman, 2007, Kass, 1991, Donoghue et al, 1991)
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Neuroplasticity
• Borders of neuro mapping are not defined
– Brain is moldable according to the will and
actions of the individual
• Nudo (2001)
– Adaptive plasticity in motor cortex
– Functional and structural dynamic nature of
the cerebral cortex
Repetitive Practice
• High Intensity/ High Repetition → Cortical
Changes
• Motivational Strategies for Patient
– Self control vs. External Control
• Patient education
– Importance of intensity of repetition
– Intensive HEP
Neuroplasticity
• Possible Explanations
– Areas of the brain assume functions that were
once the responsibility of a damaged area of the
brain
– Areas of the brain lay dormant until needed to
assume functioning for damaged regions
– Creating new pathways for the connections between
neurons
(Gutman, 2008)
Learned Non- Use
• Decrease is muscle/ motor activity →
decrease in function → frustration →
avoidance of activity
• What happens cortically?
• Kleim (1998)
– Motor cortex representation diminishes with
immobilization beyond nine days
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Neuroplasticity is Skill/ Activity
Dependent
• Nudo, 2001
– Plasticity is limited to behavioral experiences
• Nudo, 2003
– Plasticity of the motor cortex are skilldependent rather than simply use dependent.
• Cauragh, 2005
– Upper extremity gains evolve from motor
experiences and activity-dependent
interventions
Thickbroom (Clin Neurophysiol 2004)
– Results: After treatment, motor maps of the
hand showed displacement in 17 pt’s. Ten
pt’s showed normalization of corticospinal
conduction and a positive correlation between
the magnitude of the map shift and grip
strength in the affected hand.
– Conclusion: The present findings provide
evidence that cortical plasticity and
reorganization occurring after a stroke is
functionally significant.
Chronic Recovery
• Thickbroom, 2004
– Purpose: Investigate the relationship between
changes in motor cortex organization and degree of
motor function after stroke
– Subjects: 27 pt’s with upper limb motor deficits up to
23 yrs after onset
– Intervention: The hand’s corticomotor area was
mapped with transcranial magnetic stimulation. Motor
Assessment Scale and grip strength measurement
were used as functional assessments. Task oriented
treatment was provided
Neuroplasticity
• Active repetitive task oriented motion
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Methods of Neuroplasticity
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•
•
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Task Based Practice
Mental Practice
NMES
Constraint Induced Movement Therapy
Task Oriented Approach
• Based on systems model of motor control and theories of motor learning
• Therapist is a teacher of motor skills
– Select contextually appropriate functional tasks
– Vary tasks to increase transfer of learning
– Structure the environment the conditions of the task are present
– Provide feedback
(Carr and Shepherd, 2003, and Gentile, 2000)
Positive Effects of Task Oriented Approach on Impairment level and Function
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Barker et al., 2008
Blennerhasset et al., 2004
Caraugh et al., 2006
Michaelson et al., 2006
Nelles et al.,2001
Stinear et al., 2008
Theilman et al., 2004
Winstein et al, 2004
Task Oriented Approach
• Hubbard et al, 2009, Systematic Review
– “We recommend that task‐specific training be routinely applied by occupational therapists as a component of their neuromotor interventions, particularly in management related to post‐stroke upper limb recovery”
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Task Based Practice Opportunities
• Improved function of hemiplegic upper limb
when using functional objects and activities
vs. performing similar movement sequences
in the absence of task performance
– (Wu, Trombly, Lin, and Tickle-Degnen, 1998; Trombly and
Wu, 1999; Wu, Trombly, Lin, and Tickle-Degnen, 2000;
Fasoli, Trombly, Tickle-Degnen, and Verfaellie, 2002;
Smedley et al., 1986; Winstein et al., 2004)
• Client’s are not making connection between
non-functional activities and functional
outcomes
Occupational Therapist Determines
• Each client’s current potential to relearn motor and cognitive skills
• How to match task‐based challenges to each person's current potential
• How to modify each person’s environment to provide the appropriate balance between challenge and compensation
– (Sabari, 2011)
Real Life Challenges
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•
Busy caseload
Productivity standards
Limited time
Challenging patients and family members
Non‐productive time: Documentation, meetings, in‐services, etc.
Occupation Kits
• Treatment kits made prior to treatment session
• Lower Level – Gross Grasp
–
–
–
–
–
–
–
–
–
Placing eating utensils in organizer
Placing magazines in organizer
Table setting for 8
Removing dishes from drying rack
Placing tools in tool box
Placing CD’s in rack
Placing cooking utensils in tall container
Placing folded socks in bin/ drawer
Placing cans/jars on shelving
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Occupation Kits Higher Level – Bilateral coordination and fine motor coordination
– Folding clothes in laundry basket
– Hanging clothes on retractable clothes line
– Packing a suitcase with clothes
– Putting batteries in remote control
– Putting toilet paper on holder and pull off a sheet
– Installing toilet paper holder on base
– Sanding plywood
– Installing a door knob
– Installing a smoke alarm
– Sorting and assembling assorted sized nuts and bolts
– Separating and placing play money in wallet
– Coins in coin bank or change purse
– Medication into pill organizer
– Wrapping a gift/ package
– Stuffing envelopes
– Sorting paper clips
– Cutting and stapling paper
– Sorting coupons
– Scrap booking
Mental Practice - Imagery
• Rehearsing task or series of tasks
mentally – Cognitive Rehearsal
• No physical activity
• Athletes – Sports psychology
• Supplement conventional therapy
• Used at any stage in recovery
(Braun et al., 2006, & Jackson et al., 2001)
Mental Practice
• Activates the musculature in the same
pattern that correlates with imagined
movements – measurable on EMG
• Activates the cortical representation in the
same pattern that correlates with imagined
movements – measurable on fMRI
• Improves learning & performance
• Reorganizes motor cortex - Neuroplasticity
Mental Practice
• Most plausible mechanism to explain
– “Stored motor plans for executing movements
can be accessed and reinforced during
mental practice”
(Page, 2001)
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Mental Practice – How is it done?
• Audio recording
1.
2.
Period of deep relaxation (3-5 min.)
Mental Practice Portion
•
•
3.
Involve every aspect of the experience including size of room,
and full description of the movement including the feel of the
movement.
“Imaging you are sitting in your favorite chair. The room is
quiet. There is a table in front of the chair” “imagine there is a
cup on that table with fresh apple juice in it. Feel yourself
reaching for the cup. Feel the weight of your arm as you reach
out. Feel your elbow straightening and your wrist extending.
Your hand opens, and your fingertips touch the cool china
cup” etc.
Practice in the real world. Three listening sessions to one
practice session
(Levine, 2009)
Liu et al, 2005
Page et al 2000, 2001, 2005, 2007
• Method
– Tape recorded guided imagery + traditional
therapy vs. traditional therapy
– Mentally perform series of tasks
• Ex: reach for cup
– 10 min – 1 hr/ day, 3-5 sessions/ week, 3-6
weeks
• Results
– Significant improvement in Fugl-Meyer and
Action Research Arm Test Scores
Visual Mental Practice
Ertelt et al, 2007
• Mental imagery of specific task +
traditional therapy vs. Functional training
of specific task + traditional therapy
• Method
• Method
– Over 3 weeks, trained to perform 3 sets of
daily tasks for 1 hr./ day
• Results
• Results
– Mental imagery group had higher ADL
function than mental imagery + functional
training
– Watch video of upper limb movement &
perform movement VS. watch video of
geometric shapes & perform movement
– Significant improvement in video group of
upper limb movement that sustained for at
least 8 weeks
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Systematic Reviews
Mental Practice Evidence
• Nilsen, et al., 2010
• Teasel, 2009 ebrsr.com
– “Consistent and positive outcomes have been documented, including decreased upper extremity impairment, increased upper extremity function, and increase in everyday use of the limb outside of structured therapy”
• Jackson, 2001
– “Data from psychophysical, neurophysiological, and brain imaging studies support the existence of a similarity between executed and imagined actions”
Motor Recovery and Electrical Stimulation after Stroke
Client centered
Low
High
Task Specific
Low
High
Cyclic
E-stim
EMGTriggered
E-stim
Functional
E-stim
Stimulation for Shoulder Subluxation
– “There is strong evidence that mental practice
may improve upper-extremity motor and ADL
performance following stroke”
• Nilsen, et al., 2010
– “When added to physical practice, mental
practice is an effective intervention. Further
research is warranted to determine who will
benefit, dosing, and most effective protocols”
Cyclic Neuro Muscular Electrical Stimulation (NMES)
• Does not require active participation
• Goals
– Decrease spasticity
– Muscle strength
– Reduce edema
– Improves motor impairment in mild to
moderate stroke
Slide property of Stephen Page, Used with permission 28
8/27/2014
Electro Myograph Generated (EMG) ‐
Triggered
• Must actively move to reach established
threshold to “trigger” NMES to activate
• Outcome
– Increased function
– Decreased motor impairment
– Increase ability to concentrate (specifically on
using the affected side of the body)
– Enhance behavioral training (active pt
participation)
– Marked increase in reaction time
– Increase AROM
EMG – Triggered NMES
EMG‐Triggered ES
• How does it work?
– Set stimulation intensity and EMG threshold
– Electrodes sense trace contraction/muscular attempt
– Device rewards patient with stimulation
– Begin sequence again…
(Hill‐Herman, 2010)
EMG – Triggered NMES
• Effective for flaccid upper limb as well
(Page & Levine, 2006)
• EMG triggered NMES for wrist extension and
qualify for CIMT program
• Bilateral movements
(Cauraugh et al., 2005)
• Bilateral motion vs. unilateral vs. no protocol
• Significant improvements in bilateral motion group
Photos from personal collection of Christine Griffin. Used with permission.
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EMG – Triggered NMES Video
Exercise & Functional Use
Functional Electrical Stimulation (FES)
• Cyclic NMES during functional movements
and functional activity
• Goals:
– Improve hand function and voluntary movement
– Facilitate neuromuscular reeducation
– Regulate muscle tone (decrease spasticity)
– Prevent atrophy- muscle strengthening
– Initiate and regain voluntary motor functions (muscle
reeducation)
– Enhance behavioral training
Videos from personal collection of Christine Griffin. Used with permission.
FES purpose
• Adaptive
• Similar to an adaptive device to be used in order to
engage in functional activity
• Therapeutic
• Used during therapy in order to retrain brain and
muscles how to work and how to work together
• Supplemental
• Can be used above and beyond what is done in
treatment during home exercise program and can be
combined with other interventions
(Hill-Herman, 2010)
Traditional FES
• E-Stim applied to muscles to elicit limb
movement in specific sequence during
functional tasks
• NMES units, splints, and other supports
may be used
• Patient actively moves limb to engage in
activity (task specific and client centered)
(Hill-Herman, 2010)
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Neuro-prosthesis for FES
Neuro-prosthesis for FES
• Orthoses with embedded electrodes
• Custom fit to individual
– Extensor panel
– Flexor panel
– Inserts
– Straps
Photos from personal collection of Christine Griffin. Used with permission.
Video for FES
Functional Use & Gravity Eliminated AAROM
NMES – Neuro Muscular Electrical
Stimulation Evidence
• Systematic Review: EBRSR, 2013
– There is strong (Level 1a) evidence that FES
treatment improves upper extremity function in acute
and chronic stroke.
– There is moderate (Level 1b) evidence that EMGtriggered FES is not superior to cyclic FES.
– Functional Electrical Stimulation therapy improves
hemiparetic upper extremity function.
Videos from personal collection of Christine Griffin. Used with permission.
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Shoulder Subluxation & NMES
• Surface NMES
– Muscles stimulated
• Posterior deltoid
• Supraspinatus
• Prevents and reduces subluxation
(Faghri et al., 1994; Chantraine et al., 1999)
• Recommended Protocol
– 6 hours daily, five days a week for 6 weeks (Paci et al. 2005)
Percutaneous Stimulation
• Physiatrists inserts electrodes into rotator
cuff muscles
– Outpatient surgery with general anesthesia
– Port remains in shoulder, pads removable
– Neurocontrol – Medtronic
(Yu, et al., 2001)
Shoulder Subluxation ‐ Surface NMES
• Rationale
– Re-education of glenohumeral joint muscles
– Repositioning of humeral head
– Improved joint alignment can provide stable base for
improved functional use of upper limb
• Evidence: NMES for shoulder subluxation
– There is strong (Level 1a) evidence that that electrical
stimulation helps to prevent the development of shoulder
subluxation, does reduce shoulder subluxation,
– There is strong (Level 1a) evidence that electrical
stimulation does not reduce hemiplegic shoulder pain
following stroke. (Teasell, 2012)
Shoulder Subluxation Stimulation
• Percutaneous
stimulation
– Decreases shoulder
pain:
• Immediately following
treatment
• 3 months after treatment
• 6 months after treatment
(Yu, et al., 2004; Chae, Yu, & Walker, 2001)
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Constraint Induced Movement Therapy (CIMT)
• Forced use to counteract learned nonuse
– Patient unsuccessful with use of affected limb, so would stop initiating use of limb during tasks
Constraint Induced Movement Therapy (CIMT)
• Main factor – Massed practice during repetitive functional activities
• Restriction of less effected arm 90% of day during a 2 week period
• Participation in upper limb therapy program 6hrs/day during the 2 week period – Restraint of unaffected hand/ arm
• Motor inclusion criteria
• Shaping is very important (picking appropriate activities)
– Select tasks that address the motor impairment and patient is able to carry out parts of the motor sequence
– Has direct relationship to success of treatment
(Taub et al., 1999)
– 10 MCP extension and 20° wrist extension
– Distal function is a critical factor
(Gillen, 2011)
EXCITE: Trial, Wolf et al, 2006
• EXCITE: Extremity Constraint – Induced
Therapy Evaluation
– Multi-Center, 222 subjects, over 3 yrs
– 6 hrs/ day, 5 days/ week, 2 weeks
– Significant improvement in Wolf Motor
Function Test and Motor Activity Log
– Lasted 24 months later
CIMT
• Neuroplasticty
•
•
•
•
•
•
– Induces cortical representation of the affected upper limb
Effects sustained for at least 2 years after intervention
Beneficial treatment for patients with some active wrist and hand motion
Taub et al, 2006
Boake et al, 2007
Dahl et al, 2008
Myint et al, 2008
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Modified CIMT
CIMT ‐Timing
• Teasel, ebrsr.com
• Acute
• Dosing
– Restriction of less effected arm 5 hrs/day, 5 days/wk
– Participation in upper limb therapy program 1 hr/ day, 3 days/ week, 10 weeks
– “There is conflicting evidence of benefit of CIMT in comparison to traditional therapies in the acute stage of stroke”
• Chronic
• mCIMT performed better on Fugl‐Meyer and Action Research Arm test than “usual care” following treatment and at 12 month follow up
– “There is strong evidence of benefit of CIMT and mCIMT in comparison to traditional therapies in the chronic stage of stroke. Benefits appear to be confined to stroke patients with some active wrist and hand movements, particularly those with sensory loss and neglect”
(Page et al, 2002, 2004, 2005)
Useful references
• www.ebrsr.com
• Stronger after stroke, Your roadmap to
recovery by Peter G. Levine
• My Stroke of Insight, A brain scientist’s
personal journey by Jill Bolte Taylor
• Occupational Therapy Practice Guidelines for
Adults with Stroke, The AOTA Practice
Guidelines Series
• Stroke Rehabilitation, A function-based
Approach by Glenn Gillen
Questions?
•
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