Retur til forsiden   Retur til index

WFOT Stockholm

26 June 2002

Birgitte Christensen - Denmark

Se lysbillederne, der hører til foredraget. (Billederne vil komme i et nyt vindue, som du kan lukke for at komme tilbage hertil).

See the pictures following the speach. (Copyright)

Jeg skal venligst gøre opmærksom på at der er copyright på alt billedmateriale. Hvis du vil se billederne i fuld størrelse, kan du klikke på ikonet diasshow, og trykke på din venstre musetast for at se næste billede.

 

Occupational therapists are responsible for rehabilitation of hand function. The hand is extremely important for use in any kind of activities. This presentation will focus on clinical tools and interventions for forced use for the low level stroke patient.

 

I work at a rehabilitation centre in Vordingborg Denmark and my special interest is stroke patients.

After suffering a stroke the patient is left with only one hand, and without stimulation of hand function the brain will suffer from missing input. The patient will end up as one handed, which has been described as learned disuse.

Even if the function will recover months later, the brain has "forgotten" the hand and the neural capacity will be used for other purposes. It is important to start early and to continue giving the patient possibility to work alone, since our time for intervention has a limit.

 

Key words in Occupational therapy are activity and we want to educate movements in the daily life. Using the explanation of the theoretical model, movement is seen as a product of interaction of multiple processes, including:

a Perceptual, Cognitive, Emotional and Motor processes within the individual person. This is described by Mulder and Gentile

and the Interaction between the individual, the task and the environment described by Horak, Majsak, Winstein

Patients without supervision, or modification of task or environment would automatically accomplish skills using movement strategies of least resistance – The Princip "As easy as possible" which leads to learned disuse of the impaired limb (Taub)

For the low-level patient, biomechanical problems will occur within a few weeks. Helping our Low-level stroke patients in everyday life, means re-training of tasks and goal specific activities. We have integrated an educational model into the treatment of impairments and focuses on the re- education of Patients in motor task. We can’t change the patient immediately, but we can change the task and the environment.

 

The low-level stroke patient is defined using the motor recovery stages as stated in the Chedoke–McMaster Stroke Assessment. We concentrate on stages 1 to 4:

stage 1: Flaccid paralysis. Absence of any form of movements

stage 2: Spasticity is present. No voluntary movement, but a stimulus will
elicit the flexor and extensor synergies.

stage 3: Spasticity is marked. The synergistic movements can be elicited

voluntarily. In most cases, the flexion synergy dominates the arm, the extension synergy the leg.

stage 4: Spasticity decreases. Movements combining antagonistic synergies can
be performed when the prime movers are the strong components of the synergy.

We practice a holistic and rational approach, derived from Margaret Johnstone

The aims of the sessions remain the same: Active participation of the patient to accomplish a task specific activity using the impaired limb (Johnstone). Johnstone have always focused on rehabilitation of hand function and has developed a lot of tools. The basics are kept simple, easy to understand and can be used by others than trained therapists such as nurses and carers.

The difference to the original approach is the explanation of movement disorders and their rational transformation into skilful handling. The brain plasticity makes it possible for the patient to get improvement for months and years but treatment time often stops after a few months. We have to make it possible that the patient can work alone.

Occupational therapists focus on the activity level in the ICF. From my point of view I see it as a staircase where we have to walk down to IMPAIRMENT level focused on primary symptoms. To create a learning situation we work on the activity level and to make the patient work alone at the PARTICIPATION LEVEL we need to structure environment. Without this jumping up and down, the ACTIVITY level will most often lead to compensation.

 

Activity problems for the low level patient are caused by impairment problems as:

Thinking of the possibility to perform activities we can also use guiding, but it needs 1 therapist for every patient and therefore guiding has a limit in time for the therapist.

Patients with low level strokes would not qualify to participate in therapy interventions of the paralyzed side as Taub has described in Constraint Induced Movement Therapy. Entry into such a program requires minimal voluntary motor action and no serious cognitive deficits. The patient has a limit in function.

 

Combining empirical handling techniques and clinical tools for intensive training, we practice task- specific or goal-orientated activities.

The low level patient are often unable to perform the whole task without associated reactions, and "part practice" with relevance to the whole task is a necessity. A very important "part practice" is to keep using the paralysed arm in an outward rotated position.

Margaret Johnstone has developed various tools to be integrated in a dynamic rehabilitation program and to be used by the interdisciplinary team and not only therapists. In particular inflatable air splints and rocking devices.

Inflatable air splints are used for:

1. Biomechanical advantages to

-Influence length-associated tissue changes and muscle tone

- for Stabilisation and Mobilisation

- for Preventions and treatment of muscle contractions, especially in delayed treatment cases

And they are used for

2. Dynamic boost to sensory input by

-Weight bearing and

-Intermittent pressure

Rocking devices are used for:

-Rhythmical movements to influence muscle tone and for relaxation

-Vestibular stimulation

-Dynamic weight transference and

-Stimulation of automatic movements

Following pictures gives an idea of how to make forced use for the low level patient. We give the patient possibility to work alone. The problem here is abnormal tone.

The inflatable pressure splints make it possible to let the paralysed arms stay in outward rotation, and to get constant input through the shoulder. The patient in the rockingchair gets the input through the shoulder while rocking. This activity can be used in all four stages of low level strokes. We have created the environment in a way that they can work without therapist hands on, and have a joyful time talking together.

When the problem is lack of motivation we need to find some automatic activity that the patient likes.

In this case we use the rocking chair while the patient is listening to good music. The paralysed arm is placed on the table in abduction, in order to keep soft tissues from shortening. The arm is in a position where the shoulder gets repetition of input through the rhythmic stimulation.

When we se a lack of motivation it is important to make the task goal oriented and easy to understand. In this case we use the rocking table and a pump. For every pump the patient can se the ball getting bigger and there is an immediately result to the action.

When sensory problems is present we need to give the Central Nervous System extra input

This can be done through repetition in weight bearing and weight shift. In this case we are playing 3 in a row, and pauses can be hold prone lying to minimise extensor tone

Or it can be done with intermittent pressure as here combining the rocking chair and the flow pulse.

The arm is well positioned in abduction to prevent muscle shortening in the arm.

 

Patients with perceptual impairments have problems doing training activities alone and statistical they will improve less.

A patient with neglect will often, if they are left alone be found in a position like this at the ward. The nurses are well trained to establish the environment in a way that the patient will get input through the paralysed side f. ex. when the afternoon coffee is served while the paralysed arm is positioned on the table next to the patient, and the flow pack can be used at the same time.

Activity problems can also be caused by biomechanical impairments like oedema or loss of range of motion. Soft tissues have to be mobilised for a longer period than the time with the therapist.

Especially the flexion of the MCP joint and slight extension of the wrist is necessary for rebuilding a functional hand. We use a ball in the hand and tape it like a fist before bandaging the hand with an elastic bandage. After that it is positioned in the half arm splint and the patient is helped to make weight shift through the paralysed arm.

This patient came to our rehabilitation centre four months after unset of stroke, and because of an untreated oedema, she had a stiff hand. She was able to mobilise her hand herself through the small finger splint and function in the hand appeared after half a year. She worked hard for hours alone with forced use through weight shift and weight bearing.

The postural muscles are much stronger than the antagonists. For the paralysed arm, patterns of flexion and inward rotation are strong and leave the patient with activity problems.

This patient Peter worked for 8 months to establish outward rotation and extension. Now he controls the outward rotation and extension when working with the balance stick developed by the Swiss occupational therapist Franziska Waelder. The environment is structured in a way that he gets feedback when reaching. He gets the full outward rotation reaching the wall and is able to extend reaching the plinth. The corner behind gives him feedback on position in space.

Peters activity goal is to go skiing and he wants to be able to control weight shift through the leg. In the beginning he had no idea of the movement but memorizing how to go down the hill skiing he suddenly got the movement from feed foreword. The structured environment by the wall and the closet gives him the feedback of the movement. To be able to work on controlling the arm movements he use a special adaptation also created by Franziska Waelder. The hand is positioned in the hand splint and the elbow is kept in extension and outward rotation by the strips adapted to the splint.

Peter has started work again and most of the time he is working at the computer using left hand, but the right hand is kept free from muscle shortening and gets constantly input through weight bearing.

He has always made the ironing of shirts himself and with the pressure splint and the Waelder strip he can walk around and constantly keep the paralyzed hand is in outward rotation through all activities.

Change between weight shift and moving around is possible for Peter to do alone. He is able to control associated movements and overflow will build up function instead of spasticity.

From unset of stroke he was extremely flaccid in his right side. After 3 months he had a server hyper tone and was not able to find any movements on his own caused motor and proprioceptive problems. Now 8 months after he has regained muscles control to lift his arm into outward rotation and extension. He’s new goal is to eat with knife and fork within a year.

 

 

Well Peter reached his goals after 8 months intensive training. He used hours of breaks with repetitive input to the shoulder joint during the rocking machine.

In Belgium and Switzerland there has been made a study on the effect of repetition of input to the paralysed shoulder. In a single-blind, randomized, controlled trial, 100 patients were allocated to either an experimental group that received an additional treatment, or to a control group. The intervention was carried out for 30 minutes on a daily basis 5 days a week during a period of 6 weeks.

 

THE MAIN CONCLUSIONS OF THE STUDY WERE:

Summary

We want the low-level patient, even with severe sensory, motor, cognitive and perceptual problems, to be able to practice some activity on his own (Feys).

We want patients to spend more time in training than waiting for therapy (DeWeerdt ).

We want to encourage an active positive attitude to support patients and carers (Mant) on their journey of recovery to overcome the problems, frustrations and limitations involved through having a stroke (Fellowship 1990 awarded to M. Johnstone for emphasis on home-care team).

Master clinicians like Margaret Johnstone and many others have contributed to our professional growth and shown through keen observations, that people have the potential to change and learn, irrespective of damage or alteration in CNS function.

 

 

 

 

 

 

 

References:

-Ada et al (1999) Stroke Rehabilitation: Does the Therapy area provide a physical challenge?
Australian Journal of Physiotherapy Vol.45 33-38

-Carr J,Shepherd R,(1999) Neurological Rehabilitation Butterworth-Heinemann

-Carr J.,Shepherd R (1987) Movement Science Aspen Publishers, USA

-Chedoke-McMaster University (1995) Chedoke-McMaster Stroke Assessment Chedoke McMaster Hospitals and University
-DeWeerdt W.,Selz B. et al (2000) Time use of stroke patients in an intensive rehabilitation
unit:a comparison between a Belgian and a Swiss setting Disability and Rehabilitation vol 22 no.4,181-186

-Feys et al (1998) Effect of a Therapeutic Intervention for the Hemiplegic Upper Limb in the Acute
Phase After Stroke A Single – Blind,Randomized,Controlled Multicenter Trial Stroke. 29:785-792

-Hochstenbach J. Mulder T.(1999) Neuropsychology and the relearning of motor skills following stroke International Journal of Rehabilitation Research 22 11-19

-Horak F.(1991) Assumptions Underlying Motor control for Neurological Rehabilitation
Contemporary Management of Motor Control Problems Proceedings of the 11 Step Conference
Foundation for Physical Therapy

-Johnstone M (1996) Home Care for the Stroke Patient Churchill Livingstone

-Johnstone M (1995) Restoration of Normal Movement after Stroke Churchill Livingston
-Kunkel A.(1999)Constraint-Induced Movement Therapy for Motor Recovery in Chronic Stroke Patients Arch Phys Med Rehabil Vol80

-Kwakkel G (1998) Dynamics in Functional Recovery after Stroke Ponsen and Looijen Netherlands
-Kwakkel G et al (1999) Therapy Impact on Functional Recovery in Stroke Rehabilitation
Physiotherapy vol 85 377-391

-Langhammer B. Stanghelle J (2000) Bobath or Motor Relearning Programme?A comparison of
two differnt approaches of physiotherapy in stroke rehabilitation:a randomised controlled study
Clinical Rehabilitation 14 361-369

-Majsak M. (1996) Application of Motor Learning Principles to the Stroke Population Aspen Publishers

Mant J et al(2000) Family and Support for Stroke:a randomised controlled trial.Lancet Vol 356

-Nudo et al (1996) Neural Substrates for the Effects of Rehabilitative Training on Motor
Recovery after Ischemic Infarkt Science Vol 272 1791-1794

-Shumway-Cook A,Woollacott(1995) Motor Control Williams and Wilkins, USA-;808-813.
-Taub E. et al (1993)Technique to Improve Chronic Motor Deficit after Stroke Arch. Phys Med Rehabil vol.74,April

-Winstein,CJ(1987)Motor Learning considerations in Stroke Rehabilitation.In Duncan,P.W. &M.B.
Badke(Eds.),Stroke Rehabilitation:The recovery of motor control;109-134Chicago.IL:Year Book Medical Pub.
-Wolf S.et al (1989) Forced Use of Hemiplegic Upper Extremities to reverse the Effect of Learned
Nonuse among Chronic Stroke and Head-Injured Patients Experimental Neurology 104,125-132

 

Retur til forsiden    Retur til index    Til top