Presentation on theme: "Joseph R. Padova, OTR/L Courtney Knobl, MS OTR/L"— Presentation transcript:
1Joseph R. Padova, OTR/L Courtney Knobl, MS OTR/L The Use of a Functional Digit Extension Splint to Promote The Integration of the Hemiparetic Hand during Activities of Daily Living.Joseph R. Padova, OTR/LCourtney Knobl, MS OTR/L
2Conflict of Interest Statement Joseph Padova, OTR/L made the Functional Low-profile Extension Assist Splint (RELEAS) being used as a splint of discussion.Joseph has a vested interest in the splint.However, the intention of this presentation is to review some of the problem solving used to design functional splinting for stroke patients and the potential for using functional splinting as an additional option for rehabilitation.
3Objectives:be able to identify at least three ways in which neuromuscular imbalances after a stroke can limit functional integration of the affected upper extremity.Analyze distal upper extremity movement patterns to help determine the potential for functional splinting as an option to improving hand function.Apply at least one current neuromuscular rehabilitative technique to maximize the integration of the splinted hand during activities of daily living.
4Promote your own ideas and see if they work. Research it and Write about Your Results to add to the Clinical base of Knowledge.Encourage to seek out ways to patent and promote what you come up with.
5Conflict of Interest Statement Courtney Knobl, MS OTR/L has No conflict of interest.
6DemographicsAccording to the American Heart Association there are approximately 780,000 new strokes in U.S.A each year (Heart Disease and Stroke Statistics, 2008).By best estimates as of 2005 approximately 5,800,000 stroke survivors (Heart Disease and Stroke Statistics, 2008).½ of stroke survivors are living with upper and lower limb disabilities ( Levey, Nichols, Schmailbrock and Clark, 2001; Ottawa, 2007).
7Rehabilitation has been more successful in restoring function in lower limb compared to the upper limb (Barreca, Wolf, Fasoli and Bohannon, 2003; Levey, Nichols, Schmailbrock and Clark, 2001; Page, 2007 Rosenstein, Ridgel Thota, Samameand Alberts, 2008).
8Even with Intensive Therapy Studies indicate that proximal arm active range of motion make larger gains compared to the hand (Barreca, Fasoli and Bohannon, 2003; Levey, Nichols, Schmailbrock and Clark, 2001).
9Inability to actively open the hand for pre-grasp and release is a severe functional deficit of many stroke patients (Levey, Nichols, Schmailbrock and Clark, 2001, Page, Sisto, Levine, McGrath, 2004; Fritz, Light, Patterson, Behrman and Davis, 2005).
10Medical Chemodenervations with Botoxin Shown to be effective to reduce motor over activity from spasticity in the wrist and finger flexors.But many patients still have poor ability to recruit finger extensors and volitional open the hand for grasp and release ( Brashear and Meyer, 2008).
11Is Dynamic Splinting an Option for Functional Hand Integration?
12Functional Splinting for Spasticity Literature review showed extremely limited information
13Interest in Functional Splinting New Interest in an old idea.Currently not many options for the hemiplegic upper limb.Most splints are static for positioning.
14Functional Splinting For the most part are large. Not designed for full day ADL and self care use
15Functional Splinting for the Spastic Upper Limb has Multiple Considerations
16Hyper response of the stretch receptor occurs when: The joint is moved too fast.The joint is moved too far.The movement is too forceful.
17Contractures and soft tissue tightness Will be a major component determining proximally the amount of distance a person can reach and place the hand.
18Contractures in the hand Will help determine how large the possible grip, or pinch will be based on how wide the hand can be opened.
19Quality of Motion will help Determine How well the patient can isolate movement patterns within the available AROM
20What Joints in the Hand Are Moving? The fingers only?The thumb only?Both the fingers and the thumb?
21How Is It Moving? Can the moving joints produce flexion and extension? If only flexion can it relax the grip?If only active flexion and it can relax the grip can the person produce a relaxed release?
22If Fingers and Thumb Flexion, Without Extension Functional Low-profile Extension Assist Splint ( RELEAS ) may be appropriate.Uses a neoprene thumb spica splint,Dorsal mounted flex rod, or spring-loaded outrigger.Buddy splints to support the index and long fingers.The dynamic forces are use to open the thumb, index and long fingers following a crude pinch.Works best with Modified Ashworth of 2 or less.
24Inclusion Criteria Be oriented. Able to follow at least 3 step verbal, written, or demonstrated instructions.Have no more than a mild left inattention to the affected body parts (this does not include learned nonuse).
25AROM Requirements At least 20 degrees arm flexion and abduction. Move the hand from midline to neutral external rotation.Move the elbow from at least 50 degrees flexion to -20 of extension (extension can be eccentric or concentric).
26Hand ROMLooking for the ability of the hand to produce either a lateral pinch, or a 3 jaw pinch once the index, long finger and thumb are passively ranged into supported low resistance extension.
27AROM RequirementsForearm : Although desirable, not an inclusion, or exclusion criteria as it can be positioned by functional strapping if needed.Wrist : Although desirable, not an inclusion, or exclusion criteria as it can be positioned by adding a wrist support to the FLEAS if needed.
28Inclusion Criteria Unable to volitionally open the hand. Be able to squeeze the evaluators hand.Be able to stop squeezing when gripping the evaluators hand.Hand should not elicit spasticity resistance greater than a 2 on the Modified Ashworth when the digits and fingers are passively opened.
29Sensation Not as clear cut yet. Of the 13 patients fit so far 1 could only identify deep pressure and pain. Another only had pain perception.Both were able to visually compensate and complete all the tasks except tying bows and holding a fork.All tasks took increased time and physical effort.
3013 patients fitted with the RELEAS 4 < five years post CVA.5 were five to seven years.3 between eight to 10 years.1 was 20 years post CVAAll had extensive acute rehabilitation and out patient physical and occupational therapy through the years.
31AROM Summary: Amount of ranges varied: Between 20 and 80 degrees arm flexionBetween 20 to 60 degrees external rotationBetween 20 to 125 degrees elbow flexion.Supination from full pronation varied from -15 degrees from neutral to 69 degrees.Varied from – 30 of a neutral wrist to 45 degrees wrist extension.10 had a Modified Ashworth in the finger flexors of two; 2 had one plus; 1 had a one.
32ContinuedAll could demonstrate the ability to control the movement patterns to touch the intact hand with the opposite hand at midline.0 could open the hand.All could recruit and relax the flexors of the hand0 could integrate the hand other than a gross stabilizer with the fist.
33Following RELEAS fabrication and average of 15 training sessions AROM of the proximal U.E. and the Modified Ashworth measurement remained approximately unchanged.However with the RELEAS all could integrate the affected hand for grasp, pinch, placement and release.
34Out of 13 Fitted with RELEAS for assisted pre-grasp, active grasp and assisted release Able to complete task with RELEASUnable to complete task with RELEASAble to complete task without RELEASHold paper while folding94Hold open and stuff envelopeHold coupon sheets while cuttingPinch and rip open salt/sugar packetsOpen and apply bandageHold and pull up pants/underpantsStabilize bowl while mixingHold and release clothing/linen when folding
35Continued Able to complete task with RELEAS Unable to complete task with RELEASAble to complete task without RELEASStabilize various sized boxes, paper, tape dispenser while wrapping packages94Hold fork and stabilize thin meats when cutting67Stabilize handles of pots and pans when cooking at the stoveIntegrate the hand to help push a shopping cartTie bows on sneakers211
36Training Time Variable due to patients personal goals. Ranged from 12 to 26 sessions depending on the complexity of the case to achieve independent integration level for appropriate tasks.Relatively short time span considering not being able integrate a volitional hand component for years since the initial stroke.
37Case study 1: R.H.Intro: this is a bit of a more complex case and was not included in the sample of patients that joe had previously described. This patient case study will just illustrate how learning course might be complicated if/when opting to do functional splinting for a patient with multiple performance deficits
38The patient 33 year old female s/p L CVA (04/05) R hand dominant Resulting R hemi paresisR hand dominant
39R UE presentationDecreased isolated active movement, increased spasticityGood attention to R UESensation grossly intact to light touch
40In the past, pt has… Been through extensive in/outpatient rehab Trialed multiple interventions (Saebo, Neuromove)Reported improved arm motion, but not hand functionHad botox injections in finger flexorsProduced no volitional extension for pre grasp/release
42Clinical Reasoning for Initiating RELEAS Training: “It is the hand that guides the arm rather than the other way around” (Gordon, 1987).Want to provide patients with enhanced opportunities for goal directed upper limb tasks, and thus improve limb movement and functionProprioceptive feedback received by the hand in a functional grasp position might contribute to improved proximal control.
43Enable Functional Task Participation Functional task participation more favorable than exercise programPositive changes in hemiparetic UE when incorporated into tasksFunctional tasks typically require use of both handsRecovery maximized through bimanual task trainingSimultaneously address other impairments (Davis, 2006).associated with improved movement of the UEPatients learn by solving task-specific problems (Timmermans, et al., 2009).
44Cortical reorganization Use dependent cortical reorganization (Gillan, G., 2011)Results from increased use of body partLeads to enhanced representation in cerebral cortex and reverses disadvantageous cortical reorganizationStructural cortical changes (Gauthier, et al. 2007)Amount of UE use can alter brain activity or activation pattern
45Facilitate Repetition for Motor Learning Repetitions of specific UE movements produce lasting neural changes and optimize motor learning (Lang, et al., 2009).
46Outpatient OT Goals Pt will: And… Demonstrate increased right shoulder flexion AROM by ≥20°Be I with updated HEPAnd…
47With RELEAS, pt will integrate R UE to bimanually: Open small ziploc bags and water bottlesOpen and apply bandagesOpen sealed envelopeFold paper and stuff into envelopeApply toothpaste to toothbrush
48Within 10 sessions, pt able to: Rip sugar packetsCut coupons with scissorsRip and apply bandageOpen toothpaste container and apply to toothbrushFold paper and stuff into envelopeOpen sealed envelopeStabilize pot on stove and stirManipulate zipper and zip/unzip jacket
51Within 15 sessions Pt was able to: Hang shirt on hanger and remove Use R hand to stabilize bowl while stirringFold towel and shirtSweep floor holding broom with both handsALSO DEMONSTRATED ↑ SHOULDER FLEXION BY 21°
53Pt’s subjective view… “This splint is so functional” Reported previously unable to incorporate right upper extremity into functional tasks“And now I don’t have to think about it - I just incorporate my right hand into tasks”
56The patient…49 year old right handed female s/p R CVA (10/08) with resulting left hemiparesisMod I ambulation with quad cane, transfersMod I ADLs (one handed techniques)Intermittent A with IADLs56
57Performance deficits L hemi: no integration of L UE into any tasks Gaze preference to right sideDeficits with attention, problem solving, memory, organizationDeficits with visual organization, visual memoryLearned nonuse of L from october to april/may = ~7 months* Mild gaze preference to right side, cognitive deficits, and psychosocial issues All of these factors have resulted in a prolonged training time as compared with others (may have affected compliance/carryover)-v/p deficits
58Initial L UE status – 3/09 Decreased active movement Available active movement was not functionalPoor isolationIncreased toneAble to grasp flat object when placed into handUnable to release objectSensation to light touch grossly intact~Mod synergy shoulder, max in elbow, severe synergy in hand and wrist – unable to isolate movementsAbout 2/5 modified ashworth throughout extremity -2/5 finger flexorsGrasp on domino (5 cm x 1cm), playing card***See videos in upcoming slide
59Goals Pt’s goal: “To use this left arm” Goals agreed upon with pt: Increase L UE PROM/AROMI with home programUtilize L UE as gross A with basic functional bimanual tasks (ie: opening containers)
60By discharge, with RELEAS, pt was able to: Bring left upper extremity to midlineGrasp/release objects with left handMaintain grasp on container with left hand while placing object in container with right handOpen containers bimanually at midlineContainers were standard spice containers = circumference about cmDischarge was after about 9 training sessions with FLEAS – I’ll talk about why she was discharged in a couple slides
61Functional Task Completion without RELEAS Towards end of first course of care; this is after about 4 or 5 training sessions with the FLEAS – patient, at this point, had started to learn how to relax L UEAble to complete some of these tasks, but not functionally.
62Functional Task Completion with RELEAS So, as you can see – ROM doesn’t really change with use of splint, but you can see how she now has a functional hand to work with
63Plan of care following discharge Instructed to continue with use of RELEAS program at homePatient to return to outpatient OT several months later to further progress her L UEReferred to OT again in 10/09functional use
64Goals established on OT eval, 10/09 “To get my left hand and arm better…”Goals agreed upon with patient on eval:Utilize L UE to carry bag (≤ 5#) for ≥ twenty feetUtilize B UEs to manipulate zipperUtilize B UEs to consistently cut couponsUtilize B UEs to complete ironing taskUtilize L UE to A with cooking taskminimal active digit extension in index finger; no active extension in remaining digitsMinimal active thumb extension (relaxation?)*Difficulty with following tasks:Maintaining grasp on bag while walkingCutting with scissorsPlacing objects into bag with right, while holding with leftManipulation of zipper64
66Patient’s active range of motion 10/30/094/12/10Shoulder flexion30°89°Shoulder external rotation7°38°Elbow flexion111°124°Elbow extension-16°Digit extension¼ range second digit; 0° remaining digits½ range second digit; ¼ range remaining digitsThumb extension¼ range¾ range4/12 was her 34th visit. I was able to continue seeing her this time because she continued to make progress with functional L UE use and L UE ROM, and was able to justify to insurance, who continued to agree to more visits after I requested. I chose this date because she was due for a re-eval for insurance, and I wanted to give most current info.Hard to say if this was all directly related to FLEAS program, but FLEAS program I think certainly contributed to these gains.Although digit extension did improve in ideal conditions (forearms resting on table, wrist passively flexed, digits passively extended), it was still overpowered by digit flexion and patient was unable to carryover this active extension to actual tasks due to motor overactivity throughout limbElbow extension: concentric – relaxing arm at side
67Effective bimanual completion of functional tasks 10/30/09 RELEAS4/12/10 RELEAS4/12/10 no RELEASOpen containersRip sugar packetsCut paper with scissorsIronStir a pot on the stoveStabilize zipperOpen and carry bagFold paperHang shirt on hanger*Unable = unable to complete task functionally, bimanually and consistently. patient may have been able to complete task for short time period, or with ineffective finger position (increased PIP flexion); or patient would initiate one handed completion of task34 visits. This is more than other stroke patients I’ve worked with, due to previously stated performance deficits. Also, our sessions incorporated a lot of other NMRE interventions= unable = able67
68Patient’s subjective view… Patient “loved coming to OT.”Frustration with slow recovery of L UE functionHowever, reported working with RELEAS gave her “hope for this hand…”Patient increasingly able to problem solve with OT on ways to incorporate L UE into tasks
69Final FindingsIncreased initiation and use of L UE with functional tasksImproved L UE active range of motionAble to learn all tasksIncreased time required, but pt improved on all tasks with repetition and practiceUe is disabled without use of hand.Slower progress due to decreased isolated proximal movement, neglect, cog deficitsI was doing a lot of traditional NMRE with her, so hard to tease out if the FLEAS was the reason for the AROM improvements – but it certainly contributed.69
70ImplicationsImproved digit extension as a result of consistent use of L UE?Improved attention to left, although no objective testing done pre and postActive movement as a means to improve unilateral neglect (Gillan, G., 2009)Pt learned how to relax muscles following contractionPt with improved attention to left UE – 0% initial attention to L UE without use of splint to ~40% by end of first course of care to ~90% currently. This an estimate based on the decreased frequency and need for VCs.“Limb activation has been shown across a series of studies that unilateral neglect can be improved by encouraging patients to make even small movements with the left side…active movement is more effective than passive” (Gillan, G., 2009).Article: Motor Neglect:
71ConclusionFunctional splinting is a relatively new concept in stroke and brain injury rehabilitation.Due to the diverse symptoms of hemiplegia, including weakness, orthopedic considerations, spasticity variations and cognitive/perceptual and sensory deficits it is unlikely that one type of splint will be appropriate for all.Appropriate splint choice and functional outcome is enhanced by a team approach to manage complex cases.The type of splint that once was appropriate may change as the patient changes over time.
72ConclusionFunctional splinting is a relatively new concept in stroke and brain injury rehabilitation.Due to the diverse symptoms of hemiplegia, including weakness, orthopedic considerations, spasticity variations and cognitive/perceptual and sensory deficits it is unlikely that one type of splint will be appropriate for all.Appropriate splint choice and functional outcome is enhanced by a team approach to manage complex cases.The type of splint that once was appropriate may change as the patient changes over time.
73References1. Heart Disease and Stroke Statistics — 2008 Update, American Heart Association, Dallas, Texas, 2008.2. Levey CE, Nichols DS, Schmalbrock PM, Chaker DW. Functional MRI Evidence of Cortical Reorganization in Upper Limb Stroke Hemiplegia Treated with Constraint-Induced Movement Therapy. American Journal of Physical Medicine and Rehabilitation. 2001;80:4-12.3. Ottawa Panel Evidence-Based Clinical Practice Guide Post Stroke Rehabilitation. Available at Accessed May 22,2007.4. Page S, Levine D. Modified Constraint-Induced Movement Therapy in Patients With Chronic Stroke Exhibiting Minimal Movement Ability in the Affected Arm. Physical Therapy. 2007;87:5. Functional Tone Management Arm Training Program featuring the Saeboflex TM Orthosis, A Novel Approach for Treating the Neurologically Impaired Upper Extremity. Workshop at MossRehab Hospital Elkins Park, 2006.6. Saebo No Plateau in Sight. Available at Accessed January 6,2008.8. Ness H200TM. Available at Accessed January 6,2008.9. Phelan C. The Journey of a New Product Designed and Invented by an O.T. Exploring Hand Therapy. Available at Accessed January 8,2007.9. Bohannon RW, Smith MB: Interrater reliability of a modified Ashworth Scale of muscle spasticity. Phys Ther 1987; 67(2);10. Kraft GH, Fitts SS, Hammond MC: Techniques to improve function of the arm and hand in chronic hemiplegia. Archives of Physical Medicine and Rehabilitation 73: , 1992.
74ReferencesDavis, J.Z. (2006). Task selection and enriched environments: a functional upper extremity training program for stroke survivors. Topics in Stroke Rehabilitation, 13(3), 1-11.Gauthier, L.V., et al. (2007). Remodeling the Brain: Plastic Structural Brain Changes Produced by Different Motor Therapies After Stroke. Stroke, 39(5):Gillan, G. (2009). Adult Onset Apraxia and Unilateral Neglect Syndromes: An Overview. Presented on Sept 19, 2009 at Moss Rehab Hospital, Philadelphia PA.Nudo, R.J, Plautz, E.J., Frost, S.B. (2001). Role of Adaptive Plasticity in Recovery of Function After Damage to Motor Cortex. Muscle Nerve, 24(8),Schweghofer, N., et al., (2009). A Functional Threshold for Long-Term Use of Hand and Arm Function Can be Determined: Predictions From A Computational Model and Supporting Data From the Extremity Constraint-Induced Therapy Evaluation (EXCITE)Trial. Physical Therapy.Woldag, H and Hummelsheim, H. (2002). Evidence-based physiotherapeutic concepts for improving arm and hand function in stroke patients. Journal of Neurology, 249:5, pp