post stroke upper extremity rehabilitation - a clinical perspective

Post-Stroke Upper Extremity

Rehabilitation –

A Clinical Perspective

Phinoj K. Abraham, MOTh., (Neuro-Occupational Therapist)

NewRo, Bengaluru

Learning Objectives

To share some views and experience of

What to do?

How to do?

in post stroke upper extremity Rehabilitation from

an Occupational Therapy Perspective

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What to do first?

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What to do?

‘Diagnosis specific’&

‘Prognosis Oriented’

Evidence basedtreatment planning

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A) Diagnosis Specificity

• Therapy planning SHOULD be based on the precise diagnosis of Stroke

– Ex:

A 28 year old male civil engineer with left hemiparesis

C/c : Difficulty in eating in ‘buffet’ systemBrunnstrom's recovery Stage for Hand : Stage 6/7

Power : ~ 4+/5

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Diagnosis Specificity Contd…

• ‘Activity Analysis’ showed– Inability to maintain the plate steadily (horizontally) in his

left hand especially while serving dishes / while talking to others. At the same time he can describe what is the ‘correct’ way of holding

• Why?– Right MCA territory Infarct– Involvement of Rt. Parietal Lobe

‘Perceptual – Motor’ aspect is usually a neglected domain in early post stroke U/E rehab

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Need of Diagnosis specificity in treatment planning…

• An infarct at ganglio-capsular region usually produce ‘Plastic Rigidity’. (Paul Kaplan,1940) This will be helpful to train the U/E to be a ‘supportive hand’.

• The probability of recovery of isolated UE movement decreases progressively with lesion location as follows: cortex, corona radiata, and Post. Limb of Internal Capsule (Shelton and Reding- 2001)

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B) Prognosis Oriented

• Why?

“You must always be able to predict what's next

and then have the ‘flexibility to evolve’.”

Marc Benioff

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B) Prognosis Oriented Contd…

• How? based on • Area and/or type of brain damage 1

» Patients with anterior circulation infarcts, right hemispheric strokes, visual gaze deficits etc… were associated with poor arm function.

• Initial degree of motor Impairment2

» Severe paresis vs. mild paresis» Active finger extension & shoulder abduction

• Other factors» Time of initial ‘Medical Intervention’» Presence / absence of cognitive impairment 1) EBRSR, 2013

2) EBRSR,, 2014,

1) EBRSR, 4,Rehab of hemiplegic U/E, 20142) EBRSR, 10, Upper extremity Interventions, 2013

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Group 1 Group 2 Group 3Functional

Hand Supportive Hand Non functional Hand

Complete to 'functionally adequate' Recovery

Partial Recovery, predominantly in the proximal upper extremity. Functionally, weight bearing & gross grasp/lift can be possible

Poor recovery

14% - 38%1,2 30%1,2 - 50% --

RemediatingIntervention

Remediating and Compensatory Intervention

Compensatory Interventions and interventions to prevent 20

Complication.

How to do it?

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Overview

• Interventions for Group 1



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Intervention for Group 1

• It’s a continuous process with considerable

overlap between each step

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1111 2222 3333 4444 5555 66aa66aa 66bb66bb 66cc66ccStep

Intervention For Group 1

–

• Deficits like,

– Diplopia, Photosensitivity, hemianopia etc…

– Neglect, Visual Inattention etc…

– Emotional Lability, attention deficits etc…

Step – 1 : Understand / Management of 'Key' Visual, Perceptual and cognitive Deficits to make the patient 'Ready' for rehabilitation

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Intervention For Group 1 Contd…

Step 2 : Eye- Head - Trunk Coordination Training : to locate a target in space (Visual Regard)

Conventional Method• Training the different control

system separately

Contemporary Methods• Virtual Reality

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Two key challenges at this phase are

– Effect of Gravity– Weight of the upper extremity on relatively

unstable shoulder joint

Step-3 : Training for Reach

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Upper Extremity Un-weighing System (UEUS)

• Highlights– Offer partial to complete

Un-weighing of U/E– Simple & Affordable– Virtual Reality Compatible

• Limitations– Allows only 2D Movements.– Graded Un-weighing is not

present

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Coscia et al. Journal of Neuro Engineering and Rehabilitation 2014, 11:22

UEUS - Components

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UEUS & Virtual Reality - Video

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Step 3 Contd…

Reach against gravity

Key Challenge here is the smooth, graded transition

of reach movement from eliminated gravity to

against gravity

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‘Hydraulic’ cut-out table with ‘Flip-Up’ top

Highlights

• Flip-up table top with graded adjustment(0-700)

• Hydraulic height adjustment mechanism

• Cut-out top

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How does it work?

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• Synergy patterns can be reversed if movement

takes place in the weaker synergy first

Ref: Chedoke McMaster Stroke Impairment Inventory : Stage 4

Step 4 : Training for Grasp Release (Extension of fingers and thumb)

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• Initially starts with Gross grasp

• Incorporated with ‘Meaningful activities’

• In a meaningful ‘Context’ (i.e.,Task Oriented)

– Eg: holding a glass of water

Step 5 : Training for Grasp (Flexion of fingers and thumb)

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Key Consideration:

Occupational Performance

Step – 6a : Training for Hand Manipulation Skills

ADLADL

LeisureLeisureWorkWork

Environment

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(One’s ability to carry out ROLESand ROUTINES efficiently)

Therapy through ‘Occupation’

Job specific training (Work) Task specific training (ADL)

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Therapy through ‘Occupation’

Leisure Diagnosis Specific

Prevocational Training

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• Most of the ADL (Activities of Daily Living)

• Eye-Hand Coordination is a ‘key’ here

Step – 6b : Bilateral hand coordination training

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The fruitfulness of rehabilitation lies when the learning at ‘ideal’ environment transforms to the ‘real’ environment

Transfer of Learning– To ADL– To Work– To Lesiure

Step – 6c : Transfer of learning

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Prevocational Training Unit

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Kitchen & Homemaking skills Simulation Unit

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6c. Transfer of learning

Hand Function with Different Types / levels of Reach

Homemaking Skills

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Overview




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Interventions for Group 2• For the Affected Hand

– Step 1-3 are same– Training for sustained gross grasp (at least ½

range of digit flexion)– Independent weight bearing on affected hand– Technology /equipments like SaeboFlex™

• For the Un-affected Hand– Compensatory strategy training like ‘one handed

techniques for dressing’

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Overview




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Interventions for Group 3Flaccid Hand

For the affected Hand: • To prevent secondary

complication like T/C/D’s• ‘Shoulder subluxation’

management• Teaching Proper handling

techniques of affected U/E• Prescription of sling, if

required

Hypertonic hand

For the affected Hand• To prevent secondary

complication like T/C/Ds, • To ease ADL activities &

maintain hygiene• Teach routine passive range

of motion exercises• Some PROM exercises

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Compensatory techniques to un-affected hand

Take Home Message

• Post-stroke U/E rehabilitation should be based on

diagnosis specific and prognostic oriented treatment

planning

• The focus of the therapy SHOULD be on functional

Independence NOT confined to reach, grasp release

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Key References• Stroke Rehabilitation Clinician Handbook 2014; Chapter 4. Motor

Rehabilitation; Section 4b. Rehab of Hemiplegic Upper Extremity Post Stroke by Robert Teasell and Norhayati Hussein | www.ebrsr.com

• EBRSR (Evidence-Based Review of Stroke Rehabilitation) 2013, Module10, Upper Extremity Interventions by Norine Foley et al | www.ebrsr.com

• ‘Rehabilitation of stroke’ by Paul E Kaplan and Rene Cailliet- Butterworth Heinemann publication

• Effect of Lesion Location on Upper Limb Motor Recovery After Stroke by Fátima de N.A.P. Shelton, MD; Michael J. Reding, MD (Stroke. 2001;32:107-112.) http://stroke.ahajo1u0r7nals.org

• The effect of arm weight support on upper limb muscle synergies during reaching movements by Coscia et al. Journal of NeuroEngineering and Rehabilitation 2014, 11:22 http://www.jneuroengrehab.com/content/11/1/22

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Acknowledgement

My sincere gratitude to the directors of NewRo,®

my colleagues and friends for their support

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The Art & Science of Empowering Lives…

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About the Speaker• Mr. Phinoj K. Abraham has done his Bachelor of occupational

therapy from KMCH college of Occupational Therapy, Coimbatore and his Master of Occupational Therapy (MOTh) in Neurosciences from ‘All India Institute of Physical Medicine and Rehabilitation’ (AIIPMR), Mumbai

• He is currently working as Chief Neuro Occupational Therapist at atNewRo, Bengaluru, India.

• He was working as Asst. Professor in Occupational Therapy at SRMCollege of Occupational Therapy, Chennai.

• He has designed several therapy gadgets and devices like Upper Extremity Un-weighing System (UEUS), Hemiplegic Upper Extremity Orthosis (HUEO), Hydraulic cut-out table with flip up top, prevocational evaluation and workstation etc..

• Contact Email: [email protected]

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post stroke upper extremity rehabilitation - a clinical perspective

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