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CVA Upper Extremity Management

Terms in this set (90)

normal UE: velocity
30-90% reduction

-depend age, complexity of task
velocity decrease due
changes in sensory and perceptual systems, motor system, and arousal/motivation
normal UE: reaction times
slow

---slowing of central processing - the time it takes to make decision about next part in the movement sequence slows down
nornaml hand steady
during reach task decrease w age

--performace speed may be slowed
what does not change w age UE
ACCURACY
Grasping Changes Related to Age:
Decrease:
-manual dexterity
-sensation
-longer adapt final grasp of force
Most individuals with CVA or other neuropathologies will experience some difficulty with reaching, grasping and manipulation due to
-visually locationg target

-impair coordination, timing, trajectory

-dealy mvt

-sensory impair
L dominant hemisphere governs
motor programming

---timing, seq, ballisitc comopnenet of reach

apraxia
R non-domiant hemisphere processes
visual feedback
unilateral lesions to either hemi may affect
reaching behaviors by both UEs
Eval of UE after CVA: focus on
impact of UE fxn loss on social role

pp 7
Examination of UE Dysfunction
- strategies & mvt elements

-ability adapt

-cog, visual perceptual, musculoskeleltal, sensory

PP 8
Objective Measures of Impact on Function
pp 9

--action research arm test

--wolf motor function test
other elements of UE exam
pp 10

Handwriting analysis
Eye-head-hand coordination
Reach and grasp
Manipulate and release objects
Fine motor/dexterity activities
In-hand manipulation Bilateral coordination
hand writign
pp 11
eye-head coordination: assess
-saccades & smooth pursuits in near/far & peripheral visual fields

**test in sit, stand, walk
reach grasp
pp 13-14
gras stabilization
-sollermans grip assessment

-pencil/crayon grip
maniupulation & release
pp 16
assess fine motor & dexterity skills
-perdue peg board

-minnesota rate maniupulation test

-box & block test

**PP16
Consideration of Impairments
Perception/Cognition ROM
Strength
Edema
Sensation/ Hypersensitivity
Pain
Perception/Cognition
pp 19
rom: total composite finger flex
Finger tips to proximal palmar crease and distal palmar crease

**pp20
strength
pp 21
Effects of Edema on UE Function in Neurological Conditions: often occurs
-post stroke

-CRPS

-any autonomic nervous system disorder
Effects of Edema on UE Function in Neurological Conditions: due
insuffieicent muscle pump

--->expansion wrist/ hand = impede motion & lead to disuse
Effects of Edema on UE Function in Neurological Conditions: measurements
hemiplegia ONLY compare to involved limb itself
sensation: affects
-regulation of forces in response to the slip of an object

-formation of internal representations... important for regulating forces in lifts (motor plan)
Recovery of UE function after stroke: traditional thought
no function after 1m = bad prog
Recovery of UE function after stroke: new research
not always true:

Constraint Induced Movement Therapy (CIMT)
Bilateral Movement Therapy (BIMT)
Mirror Therapy
Augmented Feedback (Biofeedback, Robot Aided Training, FES (with or without dynamic splints)
Virtual Reality
Task Specific Training
CIMT: is a form of
massed practice
CIMT: designed to
improve fxn in hemiplegic UE by counteracting learned non-use

*put intact arm in sling*
CIMT: recognizes
cerebral cortex on affected side
CIMT: researched in
-stroke/tbi adults

-hemiplegic CP in child
CIMT: protocol adults
good arm in mitt/sling ALL WAKING HOURS for up to 14 days
CIMT: protocol child
6-10 hrs/day for 10-21 days
CIMT: tx
-repetitive

-task oriented training
CIMT: improvements
appear sustained for several yrs after intervention
CIMT: shaping
Tasks are performed in small successive steps

Practiced in sets of 10 30-second trials with explicit immediate feedback

Task is made progressively more difficult
CIMT: task practice
Less structured than shaping

Perform a functional task continuously for 15-20 minutes

Global feedback - KR at the end
CIMT: cautions, not good for
-balance disorders

>5y s/p stroke (most effective 1-5 ypost stroke?)

-limit rom..MUST BE ABLE TO actively ext finger/wrist 10-20 deg for grasp & release
Bilateral Movement Therapy (BIMT)
Perform identical movements simultaneously: the affected limb performs similarly to the unaffected limb and persists afterwards
Bilateral Movement Therapy (BIMT): acitivites
lacing something on a shelf, pushing/pulling, two handed drinking
Bilateral Movement Therapy (BIMT): loading
Loading unaffected arm with weight helps to facilitate muscle action on affected side
Bilateral Movement Therapy (BIMT): studies suggest
bimanual task-specific training, especially in early stroke rehab, may be more effective than CIMT
BIMT: study
pp30
Mirror Therapy
Box with mirror down the middle. Intact arm looks superimposed on hemiplegic arm
Mirror Therapy: perform
Perform BIMT tasks but can only see intact arm
Mirror Therapy: improve
Improved coordination and functional use seen
Mirror Therapy: research
limited, but easy to try
Augmented Feedback
Use of verbal or vibrotactile cues during functional reach training have been shown to enhance movement
Augmented Feedback: for what patients
-stroke
-parkinsons
-tbi
Augmented Feedback: consider using
-verbal/visual/auditory and vibration

----high quality sensory input stimulates recovery & reorganization of cortical maps after injury
Virtual Reality: research protocol
3x w for 1 hr

x16 sessions

pp33
Robot-Aided Training
pp 34
Functional Electrical Stimulation in UE Impairment: research
pp 35
Functional Electrical Stimulation in UE Impairment: better outcomes if
use FES w dynamic splint or CIMT

**limit by high level of time, train, education
Functional Electrical Stimulation in UE Impairment: protocol
-30 minutes FES

-15-20 minutes NMES over 6-18 weeks
For Patients with No Active Movement: try
biofeedback combo w NMES

--> inititate early motor recruitment prior to strength
For Patients with No Active Movement: combine w/ what motions
repeated resistive isometric movements graded to patient's ability to generate torque
For Patients with No Active Movement: may be more beneficial than
more beneficial than less intensive activities (like PNF) if no active movement
Strengthening Protocol in Stroke: old thought
resistance training would increase spasticity and hamper movement

----- NOT supported by current research
Strengthening Protocol in Stroke: several studies now say
pp 36
Strengthening Protocol in Stroke: use
graded forces based on pt availale ability
Task Specific Training: research
pp 38
Task Specific Training: the group showed
greater improvements in:

-trunk control,

-straighter hand paths,

-improved interjoint coordination on the involved UE

-less compensatory movements
Task-Specific Training: enviroement
Enriched environments & challenging tasks enhance neural plasticity during recovery of fxn
Task-Specific Training: body part to work on
proximal control:

-particularly of trunk & scapular muscles

--->simultaneously w distal hand activities
Task-Specific Training: MUST recognize
recognize value of hand-dominance if it is involved side

Must retrain both limbs eventually to new roles
Task-Specific Training: ask pt questions while perfoming to
enhance perceptual deficits

--
Is the object heavy or light - slippery or not

Can you open you hand wide enough to grasp the object
Task-Specific Training: integrate what kind of tasks
age-appropriate familiar or enjoyable tasks

Folding laundry facilitates bimanual activity

Playing with blocks works on coordination, eye-hand control
Treatment of the Hemiplegic Shoulder:
-most mobile jt in body

---least stable after CVA
Treatment of the Hemiplegic Shoulder: primary stability comes from
RC muscles

--contract to hold humeral head against glenoid fossa

-->prevent head from gliding off & impinge against acromion
Treatment of the Hemiplegic Shoulder: shoulder capsule
primary stabilizing ligament

- limits displacement of humeral head away from glenoid fossa.
Hemiplegic Shoulder: sublux
common see 3-4 cm gap between acromion & humeral head
Hemiplegic Shoulder: sublux causes
old: weakness/ hypotonicity of RC blamed

New theory: passive stability of shoulder occurs when scapula is normal resting position of slight upward rotation- sup capsule is taut, glenoid fossa acts as shelf

Hemiplegic shoulder=slight downward rotation. Sup capsule is slackened, head is allowed to slip
Treatment strategy: for sublux
-strengthen RC

-strength scap stabilizers that upwardly rotate scap

-NMES

-taping

-combo of strength, NMES, fxn train (longest lasting effect)
NMES
electrodes on supraspinatus and post deltoid

----increase from 30 min to 8 hrs/day
taping
lateral shoulder to reduce sublux, extra to stabilize scap and humeral head
Adverse effects of subluxation
Undue stress on neurovascular structures around shoulder joint may lead to chronic pain, RSD, impingement

To minimize stress, the weight of the shoulder should be supported.
Ways to support hemiplegic UE
-sling

-forearm trough

-lap trays/half trays
sling
widely used, but restrain arm in ways that promote contracture and synergy patterns and prevent functional use of limb
forearm trough
attaches to w/c.

-Gives max support.

--->Arms often falls out of trough or patient changes position
lap tray
not as effective as trough

-- arm can slip (bumper helps), get in way


**half tray that swing away= better*
Hemiplegic Shoulder Pain: common c/o
-sublux can be cause
Hemiplegic Shoulder Pain: MOST COMMON cause
adhesivie capsulitits
adhesive capsulitis/frozen shoulder
trauma or immobility

Marked by loss of ROM, especially ER, then AB & flex , followed by pain
adhesive capsulitis: work to maintain
ROM from beginning: joint mobs (post and inf glides), heat/cold, stretching

If already tight may need to be aggressive
adhesive capsulitis: precaution
Precautions= spasticity, limited sensation
adhesive capsulitis: KEY
Key= maintain ROM, strength, movement
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