Shirley Desmond

Shirley is one of the ARNI Trust instructors, currently based in County Cork, Ireland.She has written an article for readers of the website about an issue which interests her concerning therapy of the hand. Hope you get a lot out of this.

Issues Arising Amongst Professional Trainers in Stroke Rehabilitation: Delayed therapy of the hand.

For most stroke survivor’s, motor deficits is the most prominent impairment. For those suffering with a long term physical impairment, the importance of an ongoing management plan in their lives has become very apparent to the Professional Trainers assisting them with their recovery on an ongoing basis.However,what often happens, is the individual who has suffered from a stroke, is given the diagnosis, admitted to hospital for varying degrees of rehabilitation, then may often be literally cast into the community and left to get on with their own recovery.

Yet,even though there is so much ongoing rehabilitation that can help survivors reach their full potential, there still seems to remain a cut-off point when some health care professionals assume that nothing more that can be done. Professional trainers usually come on the scene several months or years down the line post stroke. Their aim is to take the stroke survivor from the stage where physiotherapy has become unavailable or the therapy being administered seems to become ineffective for their more functional requirements, to a point where training becomes part of their daily activities.
While recovery of arm function is poor in a significant number of cases, leg function has proven to be less of a problem. One of the most common issues arising amongst Professional trainers in the later stages of a rehabilitation program for stroke survivors is the minimal movement, if any of the hand. Most stroke survivors have residual gait and balance problems and can be the only priority of rehabilitation with healthcare professionals. Motor deficits can take various forms, but reductions in strength (maximum voluntary force or torque) are probably the most obvious.

Upper-limb impairments following stroke can include weakness, pain, sensory loss, impaired dexterity, and in coordination. Individuals who suffer a stroke often experience moderate hand and wrist impairment, including significant delays in how long it takes to grip and release objects. It is crucial to tackle upper body limitations (reach and grasp/release) as soon as possible in conjunction with lower body limitations.
Frequently a healthcare professionals goal of therapy is to regain shoulder joint control first before restoring activity of the fingers in initial therapy outcome goals The largest deficit remaining for stroke survivors is greatest in the finger joints and often least in the shoulder for upper body functional movements. Often clients will throw the paretic hand at the targeted object, activating the shoulder joint first, then the elbow, wrist and lastly opening and closing the fingers to finally accomplish the grasp.

Grasping and holding objects is one of the prime task activities involved in active daily living (ADL), which requires the recruitment and complex integration of muscle activity from shoulder to fingers. A negative factor that leads to a decrease in the probability of return of upper limb function is the lack of spontaneous stimulation during functional activities. Each transfer and each attempt to stand or walk will require bilateral activity in the legs. In performing upper limb activities, the stroke survivor may use the non affected side exclusively.

Stroke survivors with upper limb spasticity can develop abnormal limb posturing, such as the classic adducted internally rotated shoulder, flexed elbow, flexed wrist and clenched fist. Activities such as opening the hand for washing and putting an arm down a sleeve may need the assistance of a carer / family member or the unaffected limb if the client cannot carry out the task voluntarily with the affected limb. Upper limb spasticity is thought to lead to reduced ‘active’ function as overactive muscles around the shoulder and elbow limit reaching activities, and spastic finger flexors impair potential finger extension.Sustained finger flexor muscle activity (threefold longer than that for the non paretic hand) can impose serious difficulty in stroke survivors’ ability to let go of a grasped object.

Although the key role of therapy should be focused on the very basic techniques in the early stages of rehabilitation for everyday use such as getting down to the floor and back up again unaided then working towards more complex tasks to rewire the brain and enhance the development of motor control and further strength. It is paramount as Professional Trainers to give clients the confidence to believe that they can take charge of their own recovery, promoting autonomy. Goals of therapy should be taken from a stage where initial therapy has now become infective for the survivors more functional needs to a stage where they are now more educated and encouraged to take control of their own recovery making training part of daily living.

A growing body of evidence indicates that intensive and repetitive task-orientated practice promotes upper limb recovery (Van Peppen et al, 2004).Typically; however, stroke survivors with severe upper limb paresis are unable to participate in task- orientated training because they have insufficient underlying movement. It may be the case that Professional Trainers are challenged with the greatest barrier of not enough movement to work with it in the hand.

More recently novel interventions such as below have been found to reduce arm impairment in severe paresis.

  • Constraint Induced Movement Therapy (CIMT).
  • Neuromuscular Stimulation/Functional Electric Stimulation.
  • Transcutaneous Electrical Nerve Stimulation (TENS).
  • Electromyography (EMG) Biofeedback.
  • Interactive Robotic Therapy.
  • Virtual Reality Training.

All of the above interventions show very promising results, but it has been shown that these devices are most effective with task-related training to aid in plasticity. Although promising, these interventions are not accessible to the majority of stroke survivors due to cost. Clearly, there is a pressing need to develop economical nonrobotic devices to aid the stroke survivor with severe paresis. With a view to achieving this objective, a low-cost, nonrobotic training device such as the neurogripper can be beneficial to rehabilitation of the hand.

The Neurogripper is a hand training device relying on the use of elasicity to combat the effects of spascity.An effective piece of equipment used to iniate and increase extension of the fingers. Upper body rehabilitation gears towards reaching and grasping objects. The prime issues first arises with weakness in the fingers, elbow and shoulder. Conversly not all rehab programmes place emphasis on recovery of finger movement as many therapists practicing in this field are misguided into regaining movement at the shoulder joint first. It is important for professional trainers to be targeting all joints from the outset. A successful upper body rehabilitation program is one in which focus is placed on grasp and release (finger joints) as much as possible whilst placing the same focus on the reaching component (elbow & shoulder joint). Sustained finger flexor muscle activity can impose serious difficulty in stroke survivors’ ability to let go of a grasped object and the neurogripper has proven to be a successful tool in combating this deficit.

A recent clinical trial by Seo et al (2009) has shown individuals who have suffered a severe stroke can release an object more quickly (37%) when the paretic arm is supported on a platform but the support did not make it easier to grasp the object The assistive device used in the study compensates for gravitational forces, thereby supporting the weight of the arm and permitting relaxation of the muscles of the arm and shoulder. This allows the stroke survivor to more easily control the muscles of the fingers, wrist and hand. It was also noted that a special device may not be necessary. Supporting the paretic arm with the non-paretic arm, or using a table to support the arm, may do just as well. Based on the clinical findings, it may be appropriate to allow part of rehabilitation of the hand to be carried out on a surface to assist the release of an object whilst training.

Research by Bohannon et al (1991) has previously shown weakness to be correlated with poor performance in hand-to-mouth action and ADL performance (Boissy et al, 1999, Mercier & Bourbonnais, 2004) whereas tone (measured with the Modified Ashworth Scale) did not correlate with functional movement. It has now also been demonstrated that even a small change in strength can promote substantial improvements in function and disability (Weiss et al, 2000, Ouellette et al, 2004).Numerous trials conducted into the investigation of strength training in relation to quality of physical function, limb strength, balance and motor performance have continually proven positive effects of such an important intervention. It has now been reported in the literature that muscle weakness is an essential target of therapeutic intervention to increase performance at functional activities (Bohannon, 2007) and therefore it is highly recommended that strength training be part of the rehabilitation process.

One of the latest clinical trials conducted to date, Lee et al (2010) confirms a high intensity resistance training program such as the ARNI Techniques often used in stroke rehabilitation to be a successful and productive method to perform with stroke survivors. Although the study assessed lower limb muscle performance in chronic stroke patients, it can be postulated the same results identified in the study (improved muscle strength, peak performance & muscle endurance) can be translated into improved upper body performance outcomes. As research and practice shows upper body functional gains to be far more difficult to accomplish than the lower extremity, a more aggressive form of training such as the Arni Techniques should be adopted.

In addition the research is now beginning to suggest that actually it may be muscle weakness that presents a more serious consequence to functional movement in relation to hemiplegia rather than spascity.A programme recommended is one based on strengthening in function rather than strengthening in isolation. Evidence now showing maximal grip strength correlating with multiple indicators of upper-limb potential for function ,can be measured by squeezing a hand dynamometer regularly .Monitoring changes in grip strength and recording progress into a training diary is such an incentive to encourage further training.As Harris & Eng (2007) have demonstrated post-stroke upper –limb weakness corresponding to the severity of the stroke, and it is crucial not only for the paretic arm to be strengthened but both extremities need to be targeted by resistance training.

In the healthy brain, the hemispheres work together to respond to stimuli and coordinate movement. When one hemisphere of the brain suffers injury from a stroke, it upsets the balance between the two hemispheres. Active-passive bilateral therapy aims to restore that balance, so that the two sides can work together. Therapy involves having stroke survivors perform a task using the non-paretic and the paretic hand together to retrain balance between the hemispheres. When added to the conventional therapy that forces the use of the paretic limb repeatedly, this active-passive bilateral therapy may improve hand function.

In the field of stroke rehabilitation, there does not exist one superior form of therapy over the next. What is currently evident is no two brains are the same nor are different stroke experiences the same. The goal outcome for any programme is one in which the stroke survivor does the very task they most want to do, which is shown to be the most effective way for neural learning to occur (Patton et al,2008).

As the research has shown strength training to be very promising in functional gains, it is not necessary to use weights as the stroke survivor can use their own body weight at first.

It is important for the stroke survivor to establish personal goals to work towards.

An example of goals for the client could be:

  • Short term goal: to achieve isolation movement in the wrist.
  • Midterm goal: full target range of movement when raising arm to front.
  • Long term goal: moving fingers independently & better handwriting.
  • The program should focus on:

Task specific practice (eg.wanting to comb the hair, you would practice lifting the comb & combing the hair).
Task-related practice (eg.breaking down the task into its component parts; arranging the fingers around the comb with the opposite hand ,then grasping & lifting, then putting it down, as one exercise, leading to the ability to grasp & have less work with the other hand over time. In addition to lifting the comb to the hair can be broken down into its component parts & so on).

Task- inter related practice (eg.carrying out other movements such as grasping a stick & moving it up & down which is not related to the actual task-focus but will have a positive knock on effect for task specific movements).

A successful exercise programme is one in which is personalized on the needs of the client. Professionals’ trainers content of therapy should be based around task-specific/task related and task-inter related functional movements, physical coping strategies and body –weight resistance training with a progression to weight training in the later stages.

References

Bohannon,RW,(2007),Muscle Strength & Muscle Training after Stroke: Journal of Rehabilitation Science,Vol 39 (1),pp.14-20
Bohannon,RW,Warren,ME,Cogman,KA,(1991), Motor variables correlated with the hand-to-mouth manoeuvre in stroke patients: Archives of Physical Medicine & Rehabiliation,Vol 72 (9),pp.682-684
Boissy,P,Bourbonnais,D,Carlotti,MM,Gravel,D,Arsenault,BA,(1999),Maximal Grip Force in Chronic Stroke Subjects & its Relationship to Global Upper Extremity Function: Clinical Rehabiliation,Vol 13 (4),pp.354-362
Harris,JE,Eng,JJ(2007),Paretic Upper-Limb Strength Best Explains Arm Activity in People With Stroke: Journal of the American Physical Therapy Association,Vol 87 (1),pp.88-97
Lee,MG,Kilbreath,SL,Singh,MF,Zeman,B,Davis,GM,(2010),Effect of Progressive Resistance Training on Muscle Performance after Chronic Stroke: Medicine & Science in Sports & Exercise,Vol 42(1),pp.23-34
Mercier,C,Bourbonnais,D,(2004),Relative Shoulder Flexor & Handgrip Strength is Related to Upper Limb Function after Stroke:Clinincal Rehabiliation,Vol 18 (2),pp.215-221
Oullette,MM,LeBrasseur,NK,Bean,JF,Phillips,E,Stein,J,Frontera,WR,Fielding,RA (2004),High- Intensity Resistance Training Improves Muscle Strength ,Self-Reported Function, and Disability in Long-Term Stroke Survivors: Journal of The American Heart Association.35;1404-1409
Patton,J,Small,SL,Rymer,WZ,(2008),Functional Restoration for the Stroke Survivior:Informing the Efforts of Engineers: Topics in Stroke Rehabiliation,Vol 15 (6),pp.521-5417
Santos,M,Zahner,LH,McKieran,BJ,Mahnken,JD,Quaney,B,(2006),Neuromuscular Electrical Stimulation Improves Severe Hand Dysfunction: Journal of Neurologic Physical Therapy,Vol 30 (4),pp.175-183
Seo,NJ,Rymer,WZ,Kamper,DG(2009,Delays in Grip Initiation & Termination in Persons With Stroke: Effects of Arm Support & Active Muscle Stretch Exercises: Journal of Neurophysiology,101 ,pp.3108-3115
Van Peppen,RPS,Kwakkel,G,Wood-Dauphinee,S,Hendricks,HJM,Van der Wees,PJ,Dekker,J,(2004),The Impact of Physical Therapy on Functional Outcomes after Stroke: What’s the Evidence. Clinical Rehabilitation,Vol 18 (8),pp.833-862
Weiss,A,Suzuki,T,Bean,J,Fielding,R (2000),High Intensity Strength Training Improves Strength & Functional Performance After Stroke: American Journal of Physical Medicine & Rehabilitation,Vol 74 (4),pp.369-376