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Joseph R. Padova, OTR/L Courtney Knobl, MS OTR/L

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1 Joseph 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/L Courtney Knobl, MS OTR/L

2 Conflict 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.

3 Objectives: 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.

4 Promote 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.

5 Conflict of Interest Statement
Courtney Knobl, MS OTR/L has No conflict of interest.

6 Demographics According 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).

7 Rehabilitation 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).

8 Even 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).

9 Inability 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).

10 Medical 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).

11 Is Dynamic Splinting an Option for Functional Hand Integration?

12 Functional Splinting for Spasticity
Literature review showed extremely limited information

13 Interest in Functional Splinting
New Interest in an old idea. Currently not many options for the hemiplegic upper limb. Most splints are static for positioning.

14 Functional Splinting For the most part are large.
Not designed for full day ADL and self care use

15 Functional Splinting for the Spastic Upper Limb has Multiple Considerations

16 Hyper response of the stretch receptor occurs when:
The joint is moved too fast. The joint is moved too far. The movement is too forceful.

17 Contractures and soft tissue tightness
Will be a major component determining proximally the amount of distance a person can reach and place the hand.

18 Contractures in the hand
Will help determine how large the possible grip, or pinch will be based on how wide the hand can be opened.

19 Quality of Motion will help Determine
How well the patient can isolate movement patterns within the available AROM

20 What Joints in the Hand Are Moving?
The fingers only? The thumb only? Both the fingers and the thumb?

21 How 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?

22 If 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.

23

24 Inclusion 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).

25 AROM 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).

26 Hand ROM Looking 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.

27 AROM Requirements Forearm : 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.

28 Inclusion 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.

29 Sensation 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.

30 13 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 CVA All had extensive acute rehabilitation and out patient physical and occupational therapy through the years.

31 AROM Summary: Amount of ranges varied:
Between 20 and 80 degrees arm flexion Between 20 to 60 degrees external rotation Between 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.

32 Continued All 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 hand 0 could integrate the hand other than a gross stabilizer with the fist.

33 Following 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.

34 Out of 13 Fitted with RELEAS for assisted pre-grasp, active grasp and assisted release
Able to complete task with RELEAS Unable to complete task with RELEAS Able to complete task without RELEAS Hold paper while folding 9 4 Hold open and stuff envelope Hold coupon sheets while cutting Pinch and rip open salt/sugar packets Open and apply bandage Hold and pull up pants/underpants Stabilize bowl while mixing Hold and release clothing/linen when folding

35 Continued Able to complete task with RELEAS
Unable to complete task with RELEAS Able to complete task without RELEAS Stabilize various sized boxes, paper, tape dispenser while wrapping packages 9 4 Hold fork and stabilize thin meats when cutting 6 7 Stabilize handles of pots and pans when cooking at the stove Integrate the hand to help push a shopping cart Tie bows on sneakers 2 11

36 Training 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.

37 Case 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

38 The patient 33 year old female s/p L CVA (04/05) R hand dominant
Resulting R hemi paresis R hand dominant

39 R UE presentation Decreased isolated active movement, increased spasticity Good attention to R UE Sensation grossly intact to light touch

40 In the past, pt has… Been through extensive in/outpatient rehab
Trialed multiple interventions (Saebo, Neuromove) Reported improved arm motion, but not hand function Had botox injections in finger flexors Produced no volitional extension for pre grasp/release

41 Video of R UE ROM

42 Clinical 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 function Proprioceptive feedback received by the hand in a functional grasp position might contribute to improved proximal control.

43 Enable Functional Task Participation
Functional task participation more favorable than exercise program Positive changes in hemiparetic UE when incorporated into tasks Functional tasks typically require use of both hands Recovery maximized through bimanual task training Simultaneously address other impairments (Davis, 2006). associated with improved movement of the UE Patients learn by solving task-specific problems (Timmermans, et al., 2009).

44 Cortical reorganization
Use dependent cortical reorganization (Gillan, G., 2011) Results from increased use of body part Leads to enhanced representation in cerebral cortex and reverses disadvantageous cortical reorganization Structural cortical changes (Gauthier, et al. 2007) Amount of UE use can alter brain activity or activation pattern

45 Facilitate Repetition for Motor Learning
Repetitions of specific UE movements produce lasting neural changes and optimize motor learning (Lang, et al., 2009).

46 Outpatient OT Goals Pt will: And…
Demonstrate increased right shoulder flexion AROM by ≥20° Be I with updated HEP And…

47 With RELEAS, pt will integrate R UE to bimanually:
Open small ziploc bags and water bottles Open and apply bandages Open sealed envelope Fold paper and stuff into envelope Apply toothpaste to toothbrush

48 Within 10 sessions, pt able to:
Rip sugar packets Cut coupons with scissors Rip and apply bandage Open toothpaste container and apply to toothbrush Fold paper and stuff into envelope Open sealed envelope Stabilize pot on stove and stir Manipulate zipper and zip/unzip jacket

49 Cutting with Scissors

50 Opening bandage

51 Within 15 sessions Pt was able to: Hang shirt on hanger and remove
Use R hand to stabilize bowl while stirring Fold towel and shirt Sweep floor holding broom with both hands ALSO DEMONSTRATED ↑ SHOULDER FLEXION BY 21°

52 Sweeping

53 Pt’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”

54 Case 2 H.

55 Case Study 3: M.N.

56 The patient… 49 year old right handed female s/p R CVA (10/08) with resulting left hemiparesis Mod I ambulation with quad cane, transfers Mod I ADLs (one handed techniques) Intermittent A with IADLs 56

57 Performance deficits L hemi: no integration of L UE into any tasks
Gaze preference to right side Deficits with attention, problem solving, memory, organization Deficits with visual organization, visual memory Learned 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

58 Initial L UE status – 3/09 Decreased active movement
Available active movement was not functional Poor isolation Increased tone Able to grasp flat object when placed into hand Unable to release object Sensation to light touch grossly intact ~Mod synergy shoulder, max in elbow, severe synergy in hand and wrist – unable to isolate movements About 2/5 modified ashworth throughout extremity -2/5 finger flexors Grasp on domino (5 cm x 1cm), playing card ***See videos in upcoming slide

59 Goals Pt’s goal: “To use this left arm” Goals agreed upon with pt:
Increase L UE PROM/AROM I with home program Utilize L UE as gross A with basic functional bimanual tasks (ie: opening containers)

60 By discharge, with RELEAS, pt was able to:
Bring left upper extremity to midline Grasp/release objects with left hand Maintain grasp on container with left hand while placing object in container with right hand Open containers bimanually at midline Containers were standard spice containers = circumference about cm Discharge was after about 9 training sessions with FLEAS – I’ll talk about why she was discharged in a couple slides

61 Functional 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 UE Able to complete some of these tasks, but not functionally.

62 Functional 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

63 Plan of care following discharge
Instructed to continue with use of RELEAS program at home Patient to return to outpatient OT several months later to further progress her L UE Referred to OT again in 10/09 functional use

64 Goals 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 feet Utilize B UEs to manipulate zipper Utilize B UEs to consistently cut coupons Utilize B UEs to complete ironing task Utilize L UE to A with cooking task minimal active digit extension in index finger; no active extension in remaining digits Minimal active thumb extension (relaxation?) *Difficulty with following tasks: Maintaining grasp on bag while walking Cutting with scissors Placing objects into bag with right, while holding with left Manipulation of zipper 64

65 Functional task completion

66 Patient’s active range of motion
10/30/09 4/12/10 Shoulder flexion 30° 89° Shoulder external rotation 38° Elbow flexion 111° 124° Elbow extension -16° Digit extension ¼ range second digit; 0° remaining digits ½ range second digit; ¼ range remaining digits Thumb extension ¼ range ¾ range 4/12 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 limb Elbow extension: concentric – relaxing arm at side

67 Effective bimanual completion of functional tasks
10/30/09 RELEAS 4/12/10 RELEAS 4/12/10 no RELEAS Open containers Rip sugar packets Cut paper with scissors Iron Stir a pot on the stove Stabilize zipper Open and carry bag Fold paper Hang 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 task 34 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 = able 67

68 Patient’s subjective view…
Patient “loved coming to OT.” Frustration with slow recovery of L UE function However, 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

69 Final Findings Increased initiation and use of L UE with functional tasks Improved L UE active range of motion Able to learn all tasks Increased time required, but pt improved on all tasks with repetition and practice Ue is disabled without use of hand. Slower progress due to decreased isolated proximal movement, neglect, cog deficits I 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

70 Implications Improved digit extension as a result of consistent use of L UE? Improved attention to left, although no objective testing done pre and post Active movement as a means to improve unilateral neglect (Gillan, G., 2009) Pt learned how to relax muscles following contraction Pt 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:

71 Conclusion Functional 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.

72 Conclusion Functional 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.

73 References 1. 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.

74 References Davis, 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


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