NEUROLOGIC UPPER EXTREMITY: Function and Management

TRUNK-LIMB CONNECTION

1. Anticipatory Postural Control

2. Interaction of UE’s with the Environment (Beyond Postural Support)

3. Dynamic trunk control for reach beyond arm’s length

4. Biomechanical Considerations

   1. Skeletal: Clavicle serves as a bridge between the trunk and UE complex (e.g., sternoclavicular joint)

   2. Origins and insertions of muscles that stabilize and move the UE are dependent on trunk stability and alignment

LOSS OF SCAPULAR ALIGNMENT AND CONTROL

1. Resting position of scapula (i.e., appropriate alignment)

2. Function of the scapula:

   1. stability,

   2. support overhead motions,

   3. glides to prevent impingement

3. Why does scapula fall out of alignment?

   1. Weakness in scapula

      1. of upper traps, of lower traps, etc.

   2. Muscle imbalance around the scapula

   3. Trunk mal-alignment (B in photo)

   4. Usually, downward rotation, “tipping”, and winging

      1. due to a problem with the serratus anterior

4. What to look for?

   1. scapula

   2. vertebrae

   3. pelvis 

observations

• curvature of the spine

• lateral flexion of the trunk 

• shortened left, elongated right side of the trunk

• (potentially) downward winging scapula (as seen by too much clarity)

• shoulder/arm/elbow is internally rotated 

• weight shifting more onto 1 side than the other 

normal alignment vs common malalignment of

• pelvis

• vertebral column

• rib cage

• shoulders

• head/neck

SCAPULA MAL-ALIGNMENT (results in)

1. Subluxation

   1. shoulder muscles are initially weak

   2. —> followed by gravity continuing to actively pull it down

2. Abnormal Scapulohumeral Rhythm

3. Pain and Impingement

   1. scapula can’t get out of the way when the shoulder goes into flexion

   2. —> followed by pain and impingement 

4. Ineffective & Inefficient Movement Patterns

5. Possible SHS (shoulder hand syndrome)/CRPS

6. Decreased Function

image

• A-B: neutral

• C-B: lateral flexion

SUBLUXATION PATTERNS + ***how you would treat a sublux

• patterns

  • Inferior

  • Anterior

  • Superior

• treating

  • Positioning & Support

    • goal: prevent the humeral head from pulling downward due to gravity

    • supportive positioning:

      • when sitting: keep the arm supported on a pillow or lap tray

      • when in bed: position the arm slightly abducted and externally rotated, with a pillow under the shoulder/arm

    • Avoid pulling on the arm

    • Supportive devices

      • e.g., humeral cuff sling, lap trays ← preferred over standard slings to reduce traction while allowing some movement

  • Facilitation & Strengthening

    • goal: re-activate and strengthen shoulder stabilizers

    • Facilitate scapular alignment (retraction + upward rotation) through guided movement or neuromuscular re-education

    • Strengthen key muscles:

      • Supraspinatus

      • Deltoid

      • Rotator cuff and scapular stabilizers

    • Therapeutic activities/exercises:

      • Weight-bearing through the affected arm on a stable surface

      • Gentle, supported reaching in different planes

      • Mirror therapy or bilateral task training for awareness and symmetry

  • Neuromuscular Electrical Stimulation (NMES)

    • goal: activate weak shoulder muscles and realign the humeral head

    • Commonly applied to supraspinatus and posterior deltoid

    • Shown to reduce inferior subluxation and improve shoulder control when used early post-stroke

  • Taping or Strapping

    • goal: provide proprioceptive input and mechanical support

    • Kinesio taping or therapeutic taping can help reposition the humeral head and cue muscle activation

    • Often used along with NMES or exercise—not as a standalone intervention

  • Tone Management (for spastic stages)

    • goal: reduce abnormal muscle pull contributing to anterior/superior subluxation

    • Stretch tight muscles

    • Use weight-bearing and slow, rhythmic movements to inhibit spasticity

    • Botulinum toxin injections may be prescribed by physicians for severe tone

  • Education

    • goal: prevent injury and promote independence

    • train patient and caregivers in safe handling, proper positioning, and use of support devices during mobility or transfers

INFERIOR SUBLUXATION

• evaluate by letting the arm hang (to see whether the arm is out of its socket)

• downward humeral head displacement

ANTERIOR SUBLUXATION

• forward and downward humeral head displacement

• humerus in extension

• elbow is flexed

• biceps tendon is getting overstretched by shoulder overextension 

SUPERIOR SUBLUXATION

• upward humeral head displacement

• occurs w/ movement 

• humerus goes up while in flexion, instead of dropping (what it’s supposed to do), resulting in impingement 

FACTORS ASSOCIATED WITH HEMIPLEGIC SHOULDER PAIN (HSP):

what might be correlated to HSP?

1. Lack of G-H Joint External Rotation

2. Correlation: HSP and decreased UE motor function

3. Correlation: HSP and shoulder weakness

4. Correlation: Orthopedic involvement

   1. HSP and tendinitis of the long head of the biceps and supraspinatus

   2. Shoulder hand syndrome (SHS) in hemiplegia is initiated by peripheral lesions

   3. HSP and adhesive capsulitis, rotator cuff tear, and SHS

5. But NOT subluxation

6. Correlation: poor handling of the UE and pain

7. Choosing Wisely: Don’t use pulleys for people with a hemiplegic shoulder

   1. you will yank the shoulder overhead without looking at the scapula and its scapulohumeral rhythm

   2. different situation for an orthopedic situation, but you should NOT do this for hemiplegic cases

SHS (shoulder hand syndrome)/CRPS

• ***how would you prevent it

• Suggests that SHS in Hemiplegia is initiated by a Peripheral Lesion (tissue or nerve injury)

  • Risk factors:

    • visual neglect (perceptual negligence when someone doesn’t attend to their arm and subsequently drags it along everywhere),

    • subluxation,

    • shoulder weakness,

    • moderate spasticity

• Implemented Prevention Protocol:

  • Education to Family, Patient, and Staff at Admission to Prevent Peripheral Injury

  • Modified Bed and W/C Positioning to prevent pain in the arm

  • No PROM Before Scapula Mobilization

  • No Pain During Exercise/Activity/Positioning

  • No Infusions into Affected Hands 

• Incidence of SHS decreased from 27% to 8%

• symptoms

  • shoulder gets tight and painful

  • arm starts to look shiny (mid stages of the syndrome)

  • edema

UPPER EXTREMITY EVALUATION

• Clinical evaluation

  • AROM (flexor synergy versus isolated movements),

    • flexor synergy= abnormal all encompassing movement pattern in which muscles that normally work independently begin to contract together in a fixed, stereotypical way; it’s a sign of spasticity and loss of motor control following damage to the corticospinal tract

      • instead of being able to reach out smoothly, the arm tends to bend and pull toward the body (e.g., elbow, wrist, finger flexion, forearm supination, etc.)

      • Flexor synergy usually appears in the recovery phase after flaccidity, often as muscle tone starts returning

      • we want to aim to isolate these movements, so that the UE can be functional; plan interventions to reduce abnormal tone and promote isolated movement, such as through task-oriented training, neuromuscular re-education, or constraint-induced movement therapy

  • PROM

  • MMT (?)

    • hard to do unless a patient is a little further along and can do isolated movements without compensation from other muscles

  • Sensation

  • Spasticity

  • Pain

  • Posture (pelvis, trunk, scapula, shoulder, etc.)

  • Hand function

    • Fine motor coordination, grasp and release, and strength

• ADL

  • use of arm with ADL

  • how are they using that arm, especially in tasks?

UE STANDARDIZED ASSESSMENTS

• ***objective vs subjective?

• Fugl-Meyer Assessment-Upper extremity (FMA-UE)

  • objective

• Stroke Upper Limb Capacity Scale (SULCS)

  • objective

• Wolf Motor Function Test (WMFT)

  • objective

• Action Research Arm Test (ARAT)

  • objective

• Motor Activity Log (MAL)

  • subjective (self-report by patient)

• ABILHAND

  • subjective (self-report by patient)

• Functional Upper Extremity Levels (FUEL)

  • objective

• Jebsen-Taylor Hand Function Test (JTHFT)

  • objective

FMA-UE (Fugl-Meyer Assessment-Upper Extremity)

objective measure

• FMA measures recovery in stroke survivors (UE and LE)

  • hint: Fugl-Meyer is a gold standard example of a recovered stroke survivor

• Used in both clinical and research setting

• The Gold Standard for assessing recovery post-stroke (but could be better, since it’s not very function-based)

• Length of test: 30 minutes, but quicker once you have more experience

• Age range: 13-65+

• FMA-UE

  • Motor: Upper extremity, wrist, hand, coordination

  • Sensation

  • PROM

  • Pain

• Likert scale 0-2, with a max score of 66, with higher scores indicating greater recovery

STROKE UPPER LIMB CAPACITY SCALE (SULCS)

objective measure

• 10 tasks: simple to complex

• Performed standing or sitting

  • hint: SulcS; Standing or Sitting

• All tasks unaided

• Examines performance of task, not the quality (very functions-based!)

  • e.g., reaching, opening lids, grasping a high ball, combing hair 

  • hint: CAPACITY scale ==> PERFORMANCE, NOT QUALITY of a skill

• Score:

  • 0= Patient unable to perform the task in the manner described

  • 1= Patient is able to perform the task in the manner described

  • hint: CAPACITY ==> COMPUTER; scoring is like binary coding (0- no, 1- yes)

WOLF MOTOR FUNCTION TEST (WMFT)

objective measure

• Standardized assessment to quantify upper extremity motor ability through timed and functional tasks for stroke patients

  • hint: WOLVES can (1) execute, and (2) be fast

• Brain injury and stroke

• measured in 

  • Functional ability (WMFT-FA): 17 items on a 6-point scale (0-5) with higher scores indicating higher functioning levels, and 

  • Performance time (WMFT-PT): 120 seconds max for each item

• Standardized template so items can be placed in specific areas

  • and then doing tasks in these specific set-ups

Action Research Arm Test (ARAT)

standardized objective assessment to measure arm and hand functional performance

• Mostly used in research 

• Brain injury, stroke, MS

• 19 items divided into 4 subsets; hint: ARM TEST ==> what can you do with your UEs?

  • grasp (mostly this!),

  • grip,

  • pinch and

  • gross movements

• typically asks the patient to move their arm to move certain items

  • hint: ACTION ==> asking patients to make their arm ACTIVE

• Max score of 57, with higher scores indicating better performance

Motor Activity Log (MAL)

subjective measure; hint: LOG ==> subjective LOGGING of results by the interviewee

• Structured interview to examine *how much and ***how well the stroke survivor uses their affected arm

• Standardized questions (questionnaire/interview-type assessment, so it’s more subjective):

  • *Amount of use of their affected arm (Amount Scale or AS)

  • ***Quality of their movement (How Well Scale or HW)

ABILHAND

subjective measure

• Valid and reliable interview-based tool that measures participants’ perceived difficulty with the ***use of their arm and hands in 23 ***bimanual tasks

  • hint: BIL, HAND ==> use of BILateral HAND tasks; ABIL ==> see participant's subjective perception of what they’re ABLE to do

  • e.g., wrapping a gift, tying a shoelace

• Arthritis, CP, MS, stroke, limb loss

• Score: Impossible=0, difficult=1, easy=2, N/A=missing data 

  • subjective information 

• Enter data into the website for results by diagnosis

***FUNCTIONAL UPPER EXTREMITY LEVELS (FUEL)

objective measure

• FUEL is a semi-structured performance-based upper extremity classification system post-stroke

• Mostly used in the clinic and can be used with any ADL, IADL, in any setting

• 7 levels: w/ more movement, a patient will move up these scales 

  • (1) ***Non-functional

    • No voluntary movement or only reflexive activity; not used in daily activities

    • Presentation: flaccid or severely spastic limb

  • (2) ***dependent stabilizer

    • Arm can assist passively as a stabilizer, but cannot actively move

      • does not have enough motion to move their own arm + put it down on a surface to actively maintain a certain position

    • Presentation: limb positioned by the unaffected hand to help stabilize objects (e.g., unaffected arm places affected arm to hold paper while writing)

      • weak arm is dependent on the strong arm to help it, as it cannot stabilize itself for a task

  • (3) ***independent stabilizer

    • Arm can maintain a position independently, but without active manipulation

    • Presentation: can hold an object in place without help from the other hand (i.e., don’t need the stronger arm to help with stabilization), though not move it purposefully

    • e.g., holding paper while writing, supporting a bowl

  • (4) ***gross assist

    • some active movement; able to assist the unaffected arm in simple tasks

    • Presentation: can hold or stabilize items but has limited fine motor control, and no individuation (e.g., hold a cup while the other hand pours)

    • able to grasp things, but has no functional release (i.e., needs help of the stronger hand to release)

    • e.g., holding a cup while the other hand pours, stabilizing clothing

  • (5) ***proximal dependent semi-functional assist

    • Performs portions of tasks and begins fine motor movement

    • Presentation: reaches and grasps weakly, may manipulate light objects slowly and awkwardly (e.g., help fasten/button clothing, assist in washing face)

    • some fine motor, some gross grasp, some functional release

  • (6) semi-functional assist

    • Arm and hand perform more complex tasks, but are still slower or less coordinated than the unaffected side

    • Presentation: can use affected arm for most daily tasks (e.g., eating, grooming, folding laundry) though not fully efficient

  • (7) functional assist

    • Arm and hand function normally in daily life

    • Presentation: smooth, coordinated movement; strength and speed comparable to the unaffected side

    • e.g., writing, cooking, all ADLs/IADLs

• Can be used for goal writing, treatment planning, and to track UE motoric and functional improvement

JEBSEN-TAYLOR HAND FUNCTION TEST (JTHFT)

objective measure

• The Jebsen Taylor Hand Function Test (JTHFT) is a standardized and objective measure of fine and gross motor ***hand functions that uses simulated activities of daily living (ADLs)

  • hint: “HAND FUNCTION TEST” ==> HAND FUNCTIONS TESTED through ADL execution

• Stroke, arthritis, Brain injury, SCI

• 7 subtests performed with both UE; hint: JEBSON-T has 7 letters ==> 7 subtests

  • writing,

  • tuning cards,

  • picking up small objects,

  • stacking checkers,

  • simulated feeding,

  • moving light and

  • heavy cans

• Score: time to complete each task, with lower scores indicating greater function

INTERVENTIONS…

FUNCTION!

use arm as much as they can!

1. Push

2. Pull

3. Prop (up)

4. Reach

5. Slide (sliding objects)

6. Engage Hand via Placement

7. Grasp/manipulate

8. Carry….Etc….Etc

9. SUPPORT DAILY LIVING TASKS

PREPARATION: SOFT TISSUE ELONGATION (PROM)

• Soft tissue elongation & mobilization

  • To maintain joint play/lubrication

  • Prevent secondary orthopedic complications

  • Deformity control

• Deliberate/Frequent/Full Movement of Limbs with Terminal Stretch (Active vs. Passive)

• LLPS (PROM) vs. HLBS (splinting)

• 24 Hour Positioning Protocol (while in bed, wheelchair)

• Areas of concern

  • Mobility of the Scapula on the Thoracic Wall: retraction/downward rotation

  • Shoulder internal rotation

  • Elbow and wrist flexion

  • Composite flexion

  • Interossei and lumbrical tightness

PREPERATION: TREATMENT TO DECREASE EXCESSIVE SPASTICITY

1. Guide Appropriate Use of Available Motor Control (AAROM)

   1. guide the movement that they do have to keep the arm moving

2. Maintain Soft Tissue Length (PROM)

3. Encourage Slow/Controlled Movement

   1. Avoid Excessive Effort during movement 

4. Relaxation and modalities

   1. something warm could help

5. Weight Bearing 

   1. weight-bearing positions can help decrease tone

      1. e.g., quadriped positions

6. Refer when appropriate for pharmacological interventions

   1. e.g., botox could help- especially for getting rid of spasticity

      1. Unfortunately, it does paralyze the muscle (keeps it from firing), so this may also affect people’s abilities to complete tasks

SHOULDER SUPPORT GOALS

• Protect Joint Capsule

• Prevent Overstretch of Supraspinatus

• Support Weight of Arm

• Prevent Distraction

  • i.e., prevent subluxation

SLING USE

• MINIMIZED!!!!!!; it’s not bad, but we don’t want to be excessive with it (left picture is discouraged; middle and right pictures encouraged)

  • Initial Upright Function Training

  • Specific Activities

  • Immediate Removal

  • Avoid slings that position the shoulder in…

    • internal rotation and

    • elbow flexion

  • Investigate Alternate Means of Support

TAPING THE SHOULDER

KinesioTape- more flexible (left photo), providing more facilitation to strengthen muscles 

1. Facilitates (weak) muscles or inhibits (tight) muscles

2. Removes swelling

3. Activates Analgesic System

4. Commonly used with little evidence

Athletic Tape/Strapping- more rigid (right photo), providing more structural support to put muscles back in place 

1. Stabilizes

2. Re-aligns

3. Some evidence to decrease pain

WHEELCHAIR ADAPTATIONS

to support the arm and shoulder when sitting in a wheelchair

• to prevent subluxation 

e.g., 

• full-trays (left photo)

• half-trays (right photo) 

ELECTRICAL STIMULATION (ES)

ES reduces the severity of glenohumeral subluxation, but there was no significant effect on upper limb motor recovery or upper limb spasticity

• potentially good for prepping before a session 

TASK CHOICE TO REGAIN UPPER EXTREMITY CONTROL

function!

1. Fixed Distal Point Weight-Bearing (Forearm or Hand)

   1. weight bearing through the extended arm

   2. weight bearing through/on the forearm

2. Supported Reach (Closed chain activity)

   1. for clients w/ less hand functions (b/c they can only work on proximal movements)

   2. e.g., sliding a hand across a table, sliding a hand up a wall

3. Reach into Space (Opened chain activity)

   1. just reaching up above

4. Grade Level of Antigravity/Gravity Motion and Amount of Support

• Not a Developmental Process; you don’t need to go sequentially through these steps

• e.g., can do reaching into space for 90% of the exercise, and then do the last 10% of reaching in a supported position

---

1. Muscle contractions are task-specific

2. Different Contractions (isometrics, concentric, eccentric)

3. But can train at different arm positions

   1. e.g., Open chain to reach for lower-level items, then closed chain for high-level

WEIGHTBEARING ACTIVITIES

Impairment Level

• Elongate Shortened Muscles

• Postural Stability

• Strengthening Proximal Groups 

• Sensory Input

Activity Level

• Upright function

• Improve the reach span of the opposite arm

• Fall prevention

• Assist transitional movements 

• Improve activity tolerance

PROVIDE OPPORTUNITY TO USE AND MOVE ALL DAY

give activities the patient can do outside of their therapy sessions; educate them on how to incorporate their arm into everyday tasks (repetition promotes neural learning)

1. Overhead suspension slings or mobile arm supports

2. Activity-based bedside and home program

   1. Self PROM or Self AAROM

   2. Set the patient up to perform self-care during off times (e.g., lunch, dinner, doffing clothing, before bed, grooming, etc.)

   3. Mirror therapy, action observation, mental practice

3. Provide choices of activities for any and all available movement

EFFECTIVENESS OF VARIOUS TRADITIONAL APPROACHES (ADULT NEUROLOGY)

gist: do your prep work before your session —> and then get into task-related interventions (best way to go about sessions)

1. Rood: no research support

2. PNF: no research support

3. Movement Therapy (Brunnstrom): no research support

EFFECTIVENESS OF TASK ORIENTED INTERVENTIONS

gist: do your prep work before your session —> and then get into task-related interventions (best way to go about sessions)

• Task-related training of UE and LE vs. control (immobilization): favored task-oriented

• Task-specific reaching and balance vs. sham: favored task-oriented

• Usual care vs. task practice vs. strengthening: favored task practice

• Occupationally embedded exercise vs. rote exercise: favored occupationally embedded tx

• NDT vs. Task-Oriented/MRP: favored task-oriented

• NDT vs. Task-Oriented: favored task-oriented on functional measures

ADJUNCTIVE INTERVENTIONS (IN ADDITION TO USUAL OT CARE)

1. Mirror Therapy (MT)

2. Mental Practice (MP)

3. Action Observation (AO)

4. Robotics

5. NMES & Bioness

6. Virtual Reality

7. Saeboflex

8. Constraint Induced Movement Therapy (CIMT) and Modified Constraint Induced Movement Therapy (mCIMT)

MIRROR THERAPY (MT): WHAT IS IT?

• Mirror therapy is designed to improve limb and ADL function poststroke through visual feedback

• The visual feedback "tricks our brains" into thinking that the involved arm is moving (by looking at the mirror image of the unaffected hand)

• Why does it work?

  • Not sure 100% but 3 theories

    • Increase attention to the affected side

    • Motor Neuron System

    • Motor system

TWO APPROACHES (of mirror therapy) USED IN ADDITION TO USUAL OT

• WHAT IS IT?

• HOW IS IT DONE?

• WHO IS A CANDIDATE?

• Bimanual Mirror Therapy

  • trying to move (the hand inside the box) as much as possible; trying to duplicate the strong arm 

• Unimanual Mirror Therapy

  • hand (inside of the box) sits in there and does nothing; the patient solely observes the strong arm without attempting to duplicate it

  • research actually shows better improvements w/ this version, as the different feedback/conflict in bimanual mirror therapy (when the impaired side is unable to replicate the same movements as the strong arm) makes results worse 

• Who is a candidate?

  • Acute, subacute, chronic stroke

  • Cognitively able to follow directions and attend to tasks

  • No severe visual or perceptual deficits

  • No motor requirements (However, for research, they may need some movement)

MENTAL PRACTICE (MP)

• WHAT IS IT?

• HOW IS IT DONE?

• WHO IS A CANDIDATE?

• Mental Practice: a training method of mental rehearsal with the goal of improved performance in the absence of physical practice

• MP can be conducted before or after traditional OT

• Usually administered through a CD recording of the therapist’s voice; they are approximately 10-15 minutes in length:

  • 10 minutes in length (utilized 2x daily)

  • Starts with a focusing exercise

  • Mental Imagery for specific tasks (ADL, reaching, etc.)

  • Repetition is built into the scripts

  • Ends with refocusing

• Candidate:

  • cognitively intact (must be able to attend/have general cognitive functioning)

  • no motor requirements

==> can be used for upper limb recovery (e.g., for someone who is more flaccid)

ACTION OBSERVATION (AO)

• WHAT IS IT?

• HOW IS IT DONE?

• WHO IS A CANDIDATE?

• Action observation is an intervention in which a person observes a ”typical” person perform a functional task either by video or though live performance in the stroke population

• Usually, the person is asked to practice the task after AO

• Candidate:

  • cognitively intact,

  • no motor requirements,

  • however, some movement to perform task after AO

image e.g., 

• patient watches a video and tries to replicate it 

ROBOTICS

• WHAT IS IT?

• HOW IS IT DONE?

• WHO IS A CANDIDATE?

• Robots are defined as programmable, multifunctional manipulators that can move limbs to accomplish tasks

• Place the arm in the robot, and the robot assists the hand in movement

  • Increase dosage, consistent practice, and reduce the burden on OT

• Candidate:

  • No severe tone (will not fit into the robot if tone is too strong),

  • minimal hand and arm requirements

DO ROBOTICS WORK?

Many studies have been shown to improve motor function (i.e., proximal arm function); however, they do not appear to improve hand function, ADL, or muscle tone

NEUROMUSCULAR ELECTRICAL STIMULATION (NMES) & BIONESS

• WHAT IS IT?

• HOW IS IT DONE?

• WHO IS A CANDIDATE?

• NMES is a method to facilitate limb movements by using electrical current to paretic limbs; good to use during session functional tasks, and exercises (as long as it’s timed correctly)

  • usually for elbow and wrist extension

• Functional electrical stimulation (FES) is a subcategory of NMES and is defined as the use of e-stimulation during voluntary movement

• Candidate:

  • No contraindication (e.g., pacemaker),

  • Requires MMT 1/5,

  • Able to tolerate

Bioness: H200, L300

• WHAT IS IT?

• HOW IS IT DONE?

helps with tasks such as grasp (UE), release (UE), extending (UE or for someone w/ foot drop (right photo))

VIRTUAL REALITY

• WHAT IS IT?

• HOW IS IT DONE?

• WHO IS A CANDIDATE?

• Virtual reality (VR): use of interactive simulations for patients to engage in environments that feel similar to the real environment and increase practice through games

• In VR, patients can interact with virtual environments and objects either through head-mounted devices or flat screens

• Candidate:

  • Require some movement,

  • Can cause virtual sickness,

  • No severe tone

SAEBOFLEX & SAEBO REACH

• WHAT IS IT?

• HOW IS IT DONE?

• WHO IS A CANDIDATE?

• Dynamic orthosis developed for stroke survivors who have difficulty with hand function

  • springs open your hands for you (for someone who needs to practice grasp and release exercises) 

• Used during repetitive task practice to improve UE motor function

• candidate

  • Recovering from stroke, TBI, SCI, radial nerve palsy

  • Hand and arm weakness, wrist drop, or unable to open the hand

  • Minimum 15 degrees of shoulder AROM in any direction

  • Minimum 15 degrees of elbow flexion AROM

  • Passively position the wrist in 15 degrees of extension with the finger straight

  • Some ability to pick up items

  • Minimal to moderate spasticity in hand/wrist (possibly severe)

CONSTRAINT INDUCED MOVEMENT THERAPY (CIMT) & MODIFIED CONSTRAINT INDUCED MOVEMENT THERAPY (MCIMT)

• WHAT IS IT?

• MOTOR CRITERIA

• COMPONENTS OF THE INTERVENTION

• Constraint Induced Movement Therapy (CIMT) is an intervention developed to reverse the effects of learned non-use

  • Hypothesized causes of learned non-use:

    • Negative reinforcement experienced by the patients as they unsuccessfully attempt to use the affected limb

    • Positive reinforcement experienced by using the less involved hand and/or use of successful adaptations

• Motor Criteria

  • 20 degrees of extension of the wrist and 10 degrees of extension of each finger or

  • 10 degrees extension of the wrist, 10 degrees abduction of the thumb, and 10 degrees extension of any two other digits or

  • Able to lift a wash rag off a table using any type of prehension and then release it

• Components of the Intervention

  • Repetitive, ***mass practice!, task-oriented training (this is the key to the intervention)

    • ***Shaping/Grading

      • Shaping= have them do little bits at a time and reward small progress towards a more complex skill

      • Grading= making the activity easier or harder to meet them where they are

    • Task Practice 

  • Adherence-enhancing behavioral strategies — ***Transfer Package

    • Behavioral contract (i.e., contract to sign saying you will do everything you need to do, even at home (e.g., at-home exercises))

    • Home diary

    • Home skill assignment

    • Home practice

    • Motor Activity Log

  • ***Constraining the use of the non-affected UE

    • Mitt restraint or cast for kids

    • Any method to continually remind the participant to use the more affected UE

! = involves performing a skill or task with very few or no breaks, aiming to maximize repetitions in a short period (different from rote exercise, which is a type of learning that uses repetition without deep engagement, for memorizing procedures)

• mass practice is better for physical skills and motivated learners

• remote exercise focuses more on memorization and lacks deeper understanding or critical thinking

PROTOCOLS: TRADITIONAL CIMT

• Wear a protective safety mitt on the unaffected hand for 90% of their waking hours over a 2-week period, including 2 weekends, for a total of 14 days

• On each weekday, participants received ***shaping (adaptive task practice) and standard task training of the paretic limb for up to 6 hours per day

***= process of training the affected arm through a series of tasks that are progressively more difficult, with rewards given for improvements

PROTOCOLS: MODIFIED CIMT

• Over a 10-week period, subjects' less affected arms were restrained every weekday for 5 hours

• Half-hour, one-on-one sessions of more affected arm therapy occur 3 days per week during the 10-week period; this component included ***shaping (adaptive task practice)

***= process of training the affected arm through a series of tasks that are progressively more difficult, with rewards given for improvements

functional vs nonfunctional arm

Functional Arm

• An arm that can be actively and purposefully used during daily activities (ADLs/IADLs)

• Key Features:

  • Has voluntary movement, strength, and coordination

  • Can reach, grasp, release, and manipulate objects effectively

  • Contributes meaningfully to bilateral or independent tasks

• Examples of use:

  • Brushing teeth or feeding self oneself

  • Reaching for and lifting a cup

  • Typing, writing, or buttoning clothing

Nonfunctional Arm

• An arm that cannot be used actively or effectively for functional tasks.

• Key Features:

  • Little to no voluntary movement

  • May show flaccidity, spasticity, or poor motor control

  • Cannot assist or only provides passive support/stabilization

  • Often dependent on positioning or the unaffected hand for placement

• Examples of use (if any):

  • Used passively for support (e.g., resting on a table)

  • May be positioned to prevent injury or assist with balance