Motor Relearning Program Notes

Upper Limb Functions

Arm

  • Common Problems Associated with Stroke:

    • Habitual posturing of the limbs.
    • Ignoring the affected arm.
    • Compensation with the intact arm.
    • Using the normal arm to move the affected arm.
    • Lack of sensation due to lack of mobility.
    • Development of soft tissue tightness and contracture.

  • UL Function - Arm (Carr et al., 1985)

    • Analysis in supine position, then progress to sitting if the patient can control the shoulder in sitting without excessive compensatory movement.
    • The ability to make postural adjustments that occur with arm movement.
    • Steps:
      1. Analyze common problems and compensatory strategies by observing the arm or hand.
      2. Practice UL function.
      3. Transference of training into daily life.

  • Essential Components:

    • Shoulder abduction.
    • Shoulder forward flexion.
    • Shoulder extension.
    • Elbow flexion and extension.
    • The major function of the arm is to enable the hand to be positioned in space for manipulation.

  • Common Problems and Compensatory Strategies:

    • Poor scapular movement: particularly lateral rotation and protraction, and persistent depression of the shoulder girdle.
    • Poor muscular control of the glenohumeral joint: leading to a lack of shoulder abduction and forward flexion.
    • Excessive shoulder girdle elevation and lateral flexion of the trunk.
    • Excessive and unnecessary: elbow flexion, internal rotation of the shoulder, and pronation of the forearm.

  • Train Motor Control for Reaching and Pointing - Arm (Carr et al., 1985)

    1. Patient is in supine lying.
    2. The therapist lifts the patient’s arm and supports it in forward flexion.
    3. Instruct the patient to reach up towards the ceiling.
      • Instructions:
        • 'Reach up towards the ceiling!'
        • 'Think about using your shoulder!'
        • 'Now let your shoulder go back onto the bed!'
      • Check:
        • Ensure scapula moves as it may have to be moved passively into position during the first few attempts.
        • Do not allow forearm to pronate or glenohumeral joint to internally rotate.
        • Do not allow the patient to retract the shoulder actively as the movement should involve eccentric muscle activity.
    4. Instructions:
      • 'See if you can take your hand down to your forehead - gently - don't let your hand drop. Now lift it up a little!'
      • Check:
        • Do not allow the patient to pronate forearm.
        • The palm should go to the forehead.
    5. Instructions:
      • ‘See if you can take your hand above your head to the pillow. I'll help you’
      • ‘Now try to reach above your head'
      • Check:
        • Do not allow the patient to pronate the forearm.
        • Do not allow the shoulder to abduct.
        • Check that scapula movement takes place.
    • As soon as the patient has some control over muscles such as the deltoid, pectorals, and triceps, he should progress to the following activities:
      • Patient practices holding his arm in forward flexion and moving it within an ever-increasing range, in all directions, always maintaining control.
        • Instructions:
          • 'Stretch up with your hand - keep your elbow straight!'
          • 'See if you can follow my hand!'
        • Check:
          • Do not allow the forearm to pronate, the elbow to flex, or the shoulder to internally rotate excessively.
    • Followed by sitting at a table, the patient practices reaching forward and upward
      • Instructions:
        • "Reach out to touch this. Don't let your arm drop."
      • Check:
        • Do not allow elevation of the shoulder girdle as a substitute for abduction or flexion of the shoulder.
        • Do not allow the elbow to flex unless it is required by the position of the object.
        • Make sure the patient reaches forward with the shoulder externally rotating.

Hand

  • Essential Components:

    • Radial deviation combined with wrist extension.
    • Wrist extension and flexion while holding an object.
    • Palmar abduction and rotation (opposition) at the CMC joint of the thumb.
    • Flexion and conjunct rotation (opposition) of individual fingers toward the thumb.
    • Flexion and extension of the MCP joint of fingers with IP joints in some flexion.
    • Supination and pronation of forearm while holding an object.
    • The major function of the hand is to grasp, release, and manipulate objects for specific purposes.

  • Common Problems and Compensatory Strategies:

    • Difficulty grasping with wrist in extension: In the absence of wrist extensor activity, the long finger flexors act to flex the wrist as well as the fingers.
    • Difficulty extending and flexing the MCP joints with the IP joints in some flexion: In order to position the fingers for grasping and releasing an object.
    • Difficulty with abduction and rotation of the thumb for grasp and release.
    • Inability to release an object without flexing the wrist: Excessive extension of fingers and thumb on release (usually with some wrist flexion).
    • Tendency to pronate the forearm excessively: while holding on to or picking up an object.
    • Inability to hold different objects while moving the arm.
    • Difficulty cupping the hand.
    • Normal posture of the hand for grasping a glass: Lack of wrist and MCP extension, lack of CMC abduction.
    • Compensatory strategies: Compensatory abduction and flexion at MCP of thumb.

  • Train Motor Control for Manipulation - Wrist Extension (Carr et al., 1985)

    1. Patient is in sitting with arm supported on the table, forearm in the mid position, fingers and thumb around a glass. He attempts to lift the object up.
    2. The therapist holds the forearm in the mid position and helps the patient hold the glass so he can concentrate on activating his wrist muscles.
      • Instructions:
        • 'Lift the glass up. ' Let it down slowly'
    • Once the patient has elicited some extensor activity, progress to:
      1. With forearm in the mid position, the patient practices lifting the object up, extending the wrist, putting it down again, flexing the wrist, and putting it down again. He should hold the object throughout the movements.
        • Instructions:
          • 'Move the jar to this point on the table.'
        • Check:
          • Practice lifting an object up from the table and putting it down again, in different ranges of flexion and extension, using radial deviation, not elbow flexion.
          • The patient can also practice moving his hand back so he touches an object.

  • Train Motor Control for Manipulation - Forearm Supination (Carr et al., 1985)

    1. Patient is in sitting with arm supported on the table, forearm in mid position.
    2. Instruct the patient to supinate the forearm until the end of the object touches the table.
      • Instructions:
        • 'Touch the top of the bottle to the table—if you can't hold it firmly enough, I'll help you.’
      • Check:
        • Do not allow the forearm to lift off the table unless required by the task.

  • Train Palmar Abduction and Rotation of Thumb (Opposition) (Carr et al., 1985)

    1. Patient is in sitting with arm supported on the table, forearm in the mid position and wrist in extension while the patient attempts to grasp and release a glass.
    2. Instruct the patient to open hand to take the object.
      • Instructions:
        • Open your hand to take this. I'll help you! "Now, let it go!'
      • Check:
        • Do not allow wrist to flex or forearm to pronate.
        • When the patient has some thumb movement, make sure he abducts the thumb during release and does not slide it up the object by extending the CMC joint.

Oro-Facial Functions

  • Stroke can result in drooling of saliva or water, aspiration, and difficulty ingesting food.

  • Impaired function in swallowing can lead to the provision of a nasogastric (ryles) tube.

    • Disadvantages of nasogastric tube:
      • Unpleasant.
      • Causes hypersensitivity of oral area, which can cause hyperactive gag reflex (vomit), retraction of the tongue, aversion to touch, and presence of food in the mouth.
      • Irritation of the mucous membrane, leading to a lack of stimulus to chew or move the tongue, predisposing to esophageal reflux.
      • Deprivation of the pleasure of eating & drinking.

  • Oro-Facial Function (Carr et al., 1985)

    • Step 1 – Analysis:
      • Observation of the alignment and movements of lips, jaw, and tongue.
      • Observation of eating & drooling.
      • Lack of control over oro-facial muscles.
    • Steps 2 and 3: Practice in sitting position.
    • Step 4: Feedback.

  • Essential Components:

    • Swallowing Task:
      • Jaw closure.
      • Lip closure.
      • Elevation of the posterior third of the tongue to close off the posterior oral cavity.
      • Elevation of the lateral border of the tongue.

  • Common Problems:

    • Difficulty with swallowing.
    • Lack of control over oro-facial musculature, such as:
      • Open jaw.
      • Poor lip seal.
      • Immobile tongue (tongue may look enlarged and be too forward).
    • Result:
      • Drooling.
      • Food collecting between cheek and gums.

  • Train Motor Control for Swallowing - Jaw Closure (Carr et al., 1985)

    1. Patient is in sitting.
    2. Patient’s tongue must be inside the mouth.
    3. The therapist closes the patient’s jaw and holds it closed with the atlanto-occipital joint in the mid position or asks the patient to close the mouth and jaw with teeth gently together. Open the mouth and jaw repetitively.
      • Instructions:
        • 'Close your mouth and jaw! ‘Keep your teeth gently together!' ‘Now open your mouth and close it again.' 'Relax this (intact) side of your mouth’
      • Check:
        • When assisting, make sure the head is not pushed back.
        • Make sure teeth are occluded.
        • Make sure the mouth opens symmetrically.

  • Train Motor Control for Swallowing - Lip Closure (Carr et al., 1985)

    1. Patient is in sitting.
    2. Patient’s tongue must be inside the mouth.
    3. The therapist holds the jaw closed, using her finger to indicate to the patient the lip area which is not functioning.
      • Instructions:
        • 'Keep your lips gently together!' 'Relax this (intact) side of your face!
      • Check:
        • Do not allow the patient to suck on the lower lip as this interferes with tongue movement for swallowing.
        • Do not encourage the patient to pout.
        • The jaw must be closed.
        • Make sure the nose is clear.

  • Train Motor Control for Swallowing - Tongue Movement

    1. Patient is in sitting.
    2. The therapist uses an index finger to give a horizontal digital vibration to the anterior third of the tongue with firm pressure downward. (horizontal digital vibration = small amplitude).
    3. Precaution: The therapist’s finger should not be in the patient’s mouth for > 5 seconds.
    4. Then, the therapist assists jaw closure.
      • Check:
        • Tell the patient when he has swallowed as he may not know.
        • When assisting jaw closure, make sure the head is not pushed back.
        • Make sure you push downwards on the tongue.
        • Do not repeatedly ask the patient to swallow because swallowing in the absence of saliva requires effort.

  • Train Motor Control for Swallowing - Elevate Posterior Third of Tongue (Carr et al., 1985)

    1. Patient is in sitting.
    2. The therapist uses an index finger to give firm pressure to the anterior third of the tongue in a downward direction to close off the posterior oral cavity.
    3. Follow immediately with the therapist assisting lips and jaw closure.
      • Check:
        • Tell the patient when he has swallowed as he may not know.
        • When assisting jaw closure, make sure the head is not pushed back.
        • Do not put fingers too far back on the tongue.
        • Make sure you push downwards on the tongue.
        • Do not repeatedly ask the patient to swallow because swallowing in the absence of saliva requires effort.

  • Common Problems

    • Imbalance of facial movements and expression.
    • Lack of control over the lower part of the face on the affected side (Carr et al., 1985).

  • Train Motor Control for Facial Movements and Expression - Through Opening and Closing the Mouth (Carr et al., 1985)

    1. Patient is in sitting.
    2. The therapist uses his/her finger to indicate where to relax and where to move.
    3. The therapist instructs patient to open the mouth, relax the intact side of the face (overactivity), and close the mouth.
    • Do not give bilateral facial exercises, as there will be an increase in the tendency towards reactivity on the intact side.
    • Many patients are able to activate muscles on the affected side once they have decreased overactivity of the intact side.

Sitting Up Over Side of Bed

  • How is it done?

    • Supine → sitting up?
    • Elderly?
    • Adulthood?
    • Turn to one side → use hand to push to sitting up → swing the leg.
    • Stroke patients?
    • Turn to the intact side → use hand and elbow to push to sitting up while lowering the leg.

  • Essential Components (Carr et al., 1985)

    • Turning onto the side:
      • Rotation and flexion of the neck.
      • Hip and knee flexion.
      • Flexion of the shoulder and protraction of the shoulder girdle.
      • Rotation within the trunk.

  • Turning on to the Intact Side - Common Problems and Compensatory Strategies (Carr et al., 1985)

    • Common problems:
      • Difficulty in hip and knee flexion on the affected side.
      • Difficulty in flexion of the shoulder and protraction of the shoulder girdle.
    • Compensatory strategies:
      • Inappropriate compensatory movement of the intact side (e.g., pull himself over using the intact side).

  • Essential Components - Sitting Up Over Side of Bed (Carr et al., 1985)

    • Lateral flexion of the neck.
    • Lateral flexion of the trunk.
    • Legs are lifted & lowered over the side of the bed.

  • Sitting Up Over Side of Bed - Common Problems and Compensatory Strategies (Carr et al., 1985)

    • Common problems:
      • The patient rotates the neck and flexes it forward instead of flexing it laterally, usually occurring because of poor neck and lateral trunk movement.
      • Poor lifting and lowering of the leg over the side of the bed.
    • Compensatory strategies:
      • Pulls the body to sitting up over the side of the bed using the intact hand.
      • Hooks the intact leg under the affected leg to sit up over the side of the bed. This will shift his weight back as he attempts to sit up.

  • To Train Lateral Flexion of Neck (Carr et al., 1985)

    1. Patient is in side lying.
    2. The therapist assists the patient to lift his head off the pillow, and the patient attempts to lower his head to the pillow → eccentric contraction of lateral flexor.
    3. The patient practices lifting his head sideways unaided.
      • Instructions:
        • 'Lower your head to the pillow.' ‘Lift your head from the pillow!' 'This is what you will do when I help you sit up over the side of the bed.'
      • Check:
        • Don’t allow rotation and forward flexion of the neck.

  • To Assist Patient to Sit Over Side of Bed (Carr et al., 1985)

    1. The patient lifts his head laterally, while the therapist, with one hand under the shoulder and the other pushing downwards on his pelvis, helps him to move up into the sitting position. The therapist may need to assist his legs over the side of the bed.
      • Instructions:
        • 'Lift your head sideways!' ‘Now, sit up and I'll help you!'
      • Check:
        • Do not pull on the patient's arm.
        • Remind him to keep his head moving sideways.
        • It may be necessary to move his legs over the side of the bed before commencing the movement.
        • Do not let his weight go backwards.
        • The patient will use his intact arm for leverage without prompting.

  • To Assist Patient to Lie Down (Carr et al., 1985)

    1. From the sitting position, the patient shifts his weight down sideways onto his intact forearm. The therapist reminds him to move his head laterally in the opposite direction as she lifts his legs up onto the bed. The patient lowers himself down onto his side.
      • Instructions:
        • 'Lower yourself onto your arm!' "Don't let your head flop down!
      • Check:
        • Do not pull on the patient's arm.
        • Remind him to control his head position.
        • Do not let his weight go backwards.

Balance Sitting

  • Definition: The ability to sit without using undue muscle activity.

  • Step 1: Analysis of task.

    • Observation of the patient’s alignment in quiet sitting.
    • Observation of the patient’s alignment in sitting while doing a variety of motor tasks (reaching, grasping an object, etc.).

  • Steps 2 and 3: Practice of missing component and task.

  • Step 4: Transference of learning.

  • Essential Components:

    • Feet and knees close together.
    • Weights evenly distributed.
    • Hip flexion with trunk extension.
    • Head balanced on shoulder’s level.

  • Common Problems and Compensatory Strategies (Carr et al., 1985)

    • Common problems:
      • Imbalance sitting.
      • Inappropriate adjustment of body segments.
      • Poor lateral flexion of the trunk.
    • Compensatory strategies:
      • Wide BOS (e.g., feet & knee apart).
      • Uses of hand for a wider base and increase his/her stability.
      • Shuffles feet.
      • Leans forward and backward when doing the task that requires body weight to shift sideways:
        *Note: that even though he can achieve his goal, he would not be able to if the glass were placed further sideways or backwards.

  • To Train Postural Adjustments to Shift in COG (Carr et al., 1985)

    1. Patient is in sitting with hands on the lap.
    2. Instruct the patient to turn the head and trunk to look over his shoulder (turn around and look behind you), return to the mid-position, and repeat to the other side.
      • Instructions:
        • 'Turn around and look behind you!' 'Turn your body as well as your head.' 'Don't lean back.'
      • Check:
        • Do not allow him to move his legs to one side unnecessarily. Make sure he keeps his hands in his lap and his intact shoulder relaxed.

  • To Train Postural Adjustments to Shift in COG (Carr et al., 1985)

    1. Patient is in sitting with hands on the lap.
    2. The therapist assists the patient sideways to support himself on the forearm of his affected side on one or two pillows. The patient practices sitting up from this position.
      • Instructions:
        • 'Lower yourself onto the pillow!' 'Now, sit up.'
      • Check:
        • Do not allow him to lean back.
        • Make sure his shoulder is over his elbow, and his head flexes laterally.

  • To Train Postural Adjustments to Shift in COG (Carr et al., 1985)

    1. Patient is in sitting with hands on the lap.
    2. The patient reaches forward to touch an object, downwards towards the floor, and to both sides, each time returning to the upright position. The therapist supports the affected arm while necessary.
      • Instructions:
        • 'Reach out and touch.’ 'Look at the object!' 'Now, sit up again.’ 'Let's do it again — come on — see if you can reach a little further! 'Stay there a little longer —now, go back slowly!
      • Check:
        • Make sure to correct head and trunk movements.
        • Direct patient's eyes towards a target.
        • Keep drawing the patient's attention towards his affected side, making sure he has his weight on this side when appropriate.

Standing Up and Sitting Down

  • Standing Up - Essential Components

    • Foot placement.
    • Inclination of the trunk forward by flexion at the hips with neck and spine extended.
    • Movement of the knees forward.
    • Extension of hips and knees for final standing alignment.

  • Sitting Down - Essential Components

    • Inclination of the trunk forward by flexion at the hips with neck and spine extended.
    • Movement of knees forward.
    • Knee flexion.

  • Common Problems and Compensatory Strategies (Carr et al., 1985)

    • Common problems:
      • Inability to shift the center of gravity sufficiently forward, i.e., failure to move shoulders forward over feet and move knees forward (Failure on Inclination of trunk forward and movement of knees forward).
      • Failure on affected foot placement.
    • Compensatory strategies:
      • Puts much body weight on the intact side.
      • Shifts body forward by flexing the head and trunk instead of the hip.
      • Body weight on the intact foot only.

  • To Train Trunk Inclination Forward At Hips with Movement of Knees Forward (Carr et al., 1985)

    1. Patient is in sitting, feet flat on the floor.
    2. The patient practices inclining his trunk forward by flexing at the hips with the neck and trunk extended, with enough momentum to move the knees forward. He should aim to push down and back through his feet.
      • Instructions:
        • 'Move your shoulders in front of your feet and push down and back through your feet.' 'Push down more through this (affected) foot.' 'Look straight ahead!'
      • Check:
        • Avoid phrases such as 'Lean forward', 'Take your head to your toes', as these will encourage the patient to move incorrectly.
        • Do not stand too close to the patient as this will interfere with the shoulder and knee trajectories and the shift of the center of gravity forward.
        • Do not stand in a position that prevents the patient from bearing weight through the affected side.

  • Practice of Standing Up (Carr et al., 1985)

    1. If the patient is very weak, overweight, or unable to generate sufficient force to stand up, he may need two people to assist him to stand up.
    2. Practice of standing up may be facilitated by the use of a higher chair (which eliminates some of the difficulty involved in generating force) which will enable them to improve control over the more difficult action of standing up.

  • Practice of Standing Up (Carr et al., 1985)

    1. With his shoulders and knees forward, the patient practices standing up.
    2. The therapist can give him the idea of pushing down through his affected foot by pushing down through his knee along the line of the shank while moving it forward.
      • Instructions:
        • ‘Press down through your (affected) foot and stand up.’ when he is standing: 'Bring your hips forward/towards me!
      • Check:
        • Make sure some weight is taken through the affected foot.
        • Do not wedge your knee against the patient's knee while he is standing up as this interferes with the forward movement of the knee.
        • Do not let the patient move to the edge of the chair to compensate for the lack of forward inclination of the trunk when the chair is of the correct height and there is room for the feet to move back.
        • Do not extend the knee passively backwards when it should be shifting forward.
        • Make sure the patient does as much of the task as he can.
        • Make sure the shoulders move far enough forward.

  • Practice of Sitting Down (Carr et al., 1985)

    1. The therapist may need to help the patient with the forward movement of the shoulders and knees at the beginning of the movement. The therapist keeps the weight on the affected leg as the patient sits down by pushing down through his knee.
      • Instructions:
        • ‘Move your bottom down and back and sit down! 'Move your knees forward.'
      • Check:
        • Do not stand too close to the patient or hold his arms in such a way as to interfere with the forward movement of shoulders and knees.
        • Make sure some weight is borne through the affected foot.