Week 7- Stroke: UL function

Question 1

Principles of training can be grouped into “skill training” or “compensatory strategies”. Briefly explain what is in each.

Answer 1

Skill training:
a) Part- task training
- Target impairments, incr ability to perform missing essential components
b) Whole- task training

Compensatory strategies:
- Use of intact arm and leg, use of equipment

Question 2

In skill training, how do you make it more difficult?

Answer 2

TASK FACTORS:
- Incr reps, frequency, duration
- Incr resistance
- Part task –> whole task
- Add cognitive task
- Decr manual guidance/ assistance

ENVIRONMENTAL FACTORS:
- Decr base of support
- Increase attentional demands

Question 3

Training reaching and manipulation requires which 4 steps?

Answer 3

1. Observation of movement / missing components
2. Identification of impairment driving missing components
3. Development and application of training strategies
4. Evaluation

Question 4

How can you test the following potential impairments:
a) Strength
b) ROM
c) Spasticity
d) Coordination/ Dexterity

Answer 4

a) MMT
b) Goniometer
c) Tardieu Scale
d) Coordination tests

Question 5

What are the 2 phases of reaching and manipulation?

Answer 5

1. Transportation phase- hand moves quickly to target
2. Manipulation phase- final adjustment to the grasp aperture is made prior to grasping (under visual guidance)

Question 6

Goal directed movement depends on what?

Answer 6

Starting position of shoulder/ arm/ hand:
1. Object position in space
2. Object characteristics
3. What you do with the object

Question 7

Briefly explain the following 3 stages:
a) Reaching
b) Grasp
c) Manipulation

Answer 7

a) Reaching
Transportation phase:
- Shoulder/ arm moves towards target
Pre-shaping:
- Hand and forearm
- Anticipating shape of the object

b) Grasp
- Thumb and fingers make contact with the object (usually under visual guidance)

c) Manipulation
- Any adjustments to force control or position

Question 8

What movements are involved in reaching?

Answer 8

• Protraction and elevation of shoulder (Scap/Th jnt)
• External rotation, flexion, horizontal flexion, abduction, extension of shoulder (GH joint)
• Extension/flexion of elbow
• Pronation/supination of forearm
• Extension and radial deviation of wrist
• Extension of fingers and abduction of thumb (opening of hand aperture between thumb and fingers)

Question 9

What movements are involved in manipulation?

Answer 9

• Flexion/extension of wrist and fingers
• Flexion and abduction (conjoint rotation) of thumb and fingers
• Closure of thumb and fingers (MCP joint flex+ IP in some ext)
• Cupping of hand
• Independent finger movements (fl/ext)

Note: Movements will vary according to the characteristics of the object, position in space and task.

Question 10

What are some patterns that can occur in patients that impact their ability for reaching and manipulation?

Answer 10

• Inactivity of shoulder ABDuctors + flaccid RC
• Co-activation of muscles and poor control of synergistic muscles (esp SH flexors + elbow ext)

Question 11

Appropriate treatment strategies for impaired reaching and manipulation

Answer 11

• Electrical stimulation
• (Modified) CIMT (constraint- induced movement therapy)
• Mirror therapy (if completely flaccid hand- as adjunct)
• Mental practice
• Robotics
• Task- specific practice

Question 12

What is the importance of repetitive task specific training?

Answer 12

• Increase strength of neural connections, amount- and quality- of movement
• Best practice for stroke rehab in Aus

Question 13

What is involved in CIMT? What degree of movements do you need to be eligible for this treatment?

Answer 13

Constraint- induced movement therapy:
- Intensive graded task specific use of only affected limb.
To be eligible:
- 10 deg of active wrist ext
- 10 deg of thumb abduction
- 10 deg of finger ext (all fingers)
- Minimal cognitive/ perceptual deficits

Question 14

Dosage and timing of CIMT protocols

Answer 14

• 30 mins to 6hrs per day
• From 2-7 sessions per week
• 2-12 weeks

Question 15

What is mirror therapy and what does it involve?

Answer 15

• Patient imagines that the hand in the mirror is the paretic hand.
• Ask patient to perform tasks with non- paretic hand AND attempt to try and replicate the movement with their paretic hand (which is covered).
• Provides feedback that the hand is actually functioning.
• Start with simple movements (flex + ext) and gradually incr complexity

Question 16

What 4 requirements for mirror therapy?

Answer 16

1. Cognition (attention, memory and concentration)
2. Vision (to see image in mirror)
3. Trunk control to sit unsupervised
4. Non- paretic limb must have normal pain free ROM

Question 17

What are 2 negative side effects of mirror therapy?

Answer 17

• Emotional distress
• Dizziness/ nausea

Question 18

What is happening at the shoulder joint when you reach for an object?

Answer 18

• Slight elevation of shoulder
• Protraction of shoulder (Scap/Th joint)
• Shoulder flexion
• Elbow extension

Question 19

What is happening at the elbow and wrist joint when you reach for an object?

Answer 19

Elbow: slight supination
Wrist: extension and radial deviation to position hand to grasp cup

Question 20

What is happening at the finger and thumb joint when you reach for an object?

Answer 20

Finger:
- Extension at MCP joints (2-5)
- Perhaps further extension at interphalangeal joints 2-5- depending on size of cup

Thumb:
- Extension + abduction at MC joint 1

Question 21

What is happening at the finger joints when you grasp an object (cup)?

Answer 21

• Flexion of the MCP joints (2-5) + interphalangeal joints
• Flexion + abduction at MC joint 1

Question 22

When a patient struggles with shoulder elevation, what are some possible underlying impairments?

Answer 22

• Weak RC muscles- unable to stabilise humeral head in glenoid fossa.
• Lack of scapula/ humeral rhythm- inability to stabilise scapula

Question 23

Impaired manipulation of objects: Aperture

Answer 23

• When unimpaired people pick up a cup the aperture is always slightly larger than the cup
• Mechanical coupling is difficult
• Easier to flex than extend – Need to extend AND flex

Question 24

When a patient struggles with thumb conjoint rotation, what are some possible underlying impairments?

Answer 24

• Dystonia
• Contracture
• Spasticity
• Reduce dexterity/ problematic movement pattern

Question 25

What are some UL function tests for general coordination?

Answer 25

- Box and blocks - 9 HPT - Action researcher arm test (grasp, grip, pinch, gross movement)

Question 26

How many people who have had a stroke have trouble with UL function? Why is it more likely for leg function to improve but less likely for arm/ hand and shoulder function?

Answer 26

* About 70% of people. * Demand always being put on legs --> more likely for legs to get better and withstand load. Arms not so much.

Question 27

True or False: CIMT is only recommended for patients who have absent hand functioning on the affected side. This generates greater improvements in that affected limb in the long- term.

Answer 27

FALSE. CIMT only recommended if patient has some hand function.

Question 28

What is CIMT?

Answer 28

Constraint- Induced Movement Therapy (CIMT) * Set of rehab techniques designed to reduced functional problems in the most affected upper extremity of stroke clients. * Involves constraining movements of the less- affected arm, usually with sling or mitt for 90% waking hours, while intensively inducing the use of the more- affected arm. * Concentrated, repetitive training is done for 6 hours a day for a 2–3-week period.

Question 29

What is "Modified CIMT" (mCIMT)?

Answer 29

* Less intense treatment that involves the same principles as CIMT (i.e. restraint of the less-affected upper extremity and practice of functional activities of the more-affected extremity), but with less intensity than traditional CIMT (i.e. less time). * The common therapeutic factor in all CIMT techniques includes concentrated, repetitive tasks with the more-affected arm.

Question 30

What is "Mirror Therapy"?

Answer 30

* Mirror is used to create reflective illusion of affected limb in order to trick brain into thinking movement has occurred w/o pain, or to create positive visual feedback of limb movement. * Involves placing the affected limb behind a mirror. The mirror is positioned so the reflection of the opposing limb appears in place of the hidden limb. * Exploits brain’s preference to prioritise visual feedback over somatosensory/ proprioceptive feedback concerning limb position.

Question 31

True or False: Interventions involving repetitive practice improve strength after stroke, and these improvements are accompanied by improvements in activity.

Answer 31

TRUE.

Question 32

What are the 3 most common interventions involving repetitive practice that can be implemented to improve strength after a stroke?

Answer 32

- Most common= task- specific training - Largest effects on strength= CIMT - 2nd largest effect on strength= assistive technology

Question 33

What is meant by "repetitive practice"?

Answer 33

- Examples of “repetitive practice tasks” (from google search) --> involves patient repeatedly performing functional movements, such as walking, reaching, or manipulating objects, to promote motor learning and restore neural pathways. - This task- specific training helps patients improve mobility and function by reinforcing the motor skills needed for daily activities through high repetition.