Reaching task/open chain activity

The reaching task described requires the patient to reach for a book on a shelf that is at forehead level. First, initiation of any movement pattern requires a motivational drive to perform; therefore, the activity must have an inherent purpose. The motivation behind and purpose of this activity may be to further knowledge, enhance leisure time, or pass a midterm examination. To complete this activity successfully, the patient must process appropriately the visual/perceptual information collected during the scanning process before initiating the reach pattern. Because the item is above eye level, neck extension with concurrent right and left lateral head and neck rotation and sufficient ocular range of motion (ROM) are required. A person collects a variety of visual information during visual scanning that helps identify particular characteristics of the book (e.g., call number, title, color, and size). This information is interpreted by several visual/perceptual processes (e.g., figure ground, color discrimination, and depth perception). See Chapters 16 and 18.

Before initiation of the reach pattern the lower extremities and trunk undergo several postural adjustments to provide stabilization (anticipatory reactions). The antigravity shoulder muscles prepare to bring the arm to shelf level, and the hand is prepositioned and oriented to prepare for grasping. While the reach pattern is being performed, the scapula protracts and rotates upward by the combination actions of the serratus anterior and upper and lower trapezius muscles. The rotator cuff keeps the humerus in a position biased toward external rotation and seats the head of the humerus in the glenoid fossa. The lower extremities and trunk stay active and stable during the performance of the pattern and may assist with a weight shift toward the shelves depending on the body position.

When the hand makes contact with the book, it is molded to the spine of the book, and the pattern of function is reversed (eccentrically) to return the book to the side of the body. After the person removes the book from the shelf, the grasp and pattern of skeletal muscle recruitment may be adjusted depending on the weight of the book. Although this activity pattern is preplanned based on prior experience, the book may be lighter or heavier than anticipated, so adjustments must be made in response to the feedback. (For example, attempting to pick up a supposedly full suitcase that is actually empty results in an exaggerated lifting motion that may cause a loss of balance.) While the book is being returned to the side, a variety of adjustments may have to be made to allow visualization of the cover of the book or call number (Fig. 10-1).

Figure 10-1 Reaching task.

Weight-bearing task/closed chain activity

The weight-bearing task described requires the patient to use one arm as a postural support (i.e., extended-arm weight-bearing to support function) on a kitchen table while the other arm and hand wipe the table. As mentioned previously, motivation and purpose are required. The motivation may be hunger (so the table must be cleaned in preparation for a meal), extrinsic (e.g., visitors), or work-related (e.g., table space needed to balance the checkbook or prepare a lecture). Because the weight-bearing arm is being used as a postural support, a variety of postural adjustments occur in the arm. The weight-bearing arm is active during the task; the active skeletal muscles include (but are not limited to) the scapula muscles biased toward protraction and stabilizing, the elbow extensors, the lower extremities, and the trunk muscles. The amount of skeletal muscle activity in the arm may decrease because of fatigue, resulting in a “locked” elbow, an inactive scapula biased toward an elevated position and retraction, and the trunk inactive and “hanging” on the arm.

The arm wiping the table must stay active (closed chain with superimposed movement) and endure the entire activity if the task is going to be successful. The shoulder complex of this arm glides the hand and sponge along the table surface, so the upper extremity is supported by the environment and is moving simultaneously. The amount of force and pressure exerted on the hand depends on the demands of the task (e.g., wiping crumbs or cleaning off dried syrup). A variety of weight shifts occur during this activity, and they are affected by the size of the table and amount of pressure needed by the wiping hand to accomplish the task. The degree and variety of motor output is specific to the demands of the task.

As with all upper extremity tasks, multiple visual/perceptual processes are required for successful completion of this task. These processes are used to locate the crumbs on the table, clean both sides of the table, and determine when the task is complete (i.e., when the table is clean) (Fig. 10-2).

Figure 10-2 A, Using the right upper extremity as a postural support while the left upper extremity is supported by the table but moving. Intervention for the involved upper extremities should include engaging the patient in activities that use the upper extremities to support task performance. B, An alignment that fosters minimal upper extremity activity. Compare with A.

Motor activity log (self-report)

The Motor Activity Log is a self-report questionnaire (report by patient or family) related to actual use of the involved upper extremity outside of structured therapy time. It uses a semistructured interview format. Quality of movement (“How well” scale) and amount of use (“How much” scale) are graded on a 6-point scale. At present, there are 14, 28, and 30 item versions of the tool. Sample items include hold book, use a towel, pick up a glass, write/type, and steady myself, etc.^179-181

Manual ability measure (mam-36) (self-report)

The 36-item Manual Ability Measure (MAM-36) is a new Rasch-developed, self-report disability outcome measure. It contains 36 gender neutral, common performed everyday hand tasks. The patient is asked to report the ease or difficulty of performing such items. It used a 4-point rating scale, with 1 indicating “Unable” (I am unable to do the task all by myself), 2 indicating “Very hard” (It is very hard for me to do the task and I usually ask others to do it for me unless no one is around), 3 indicating “A little hard” (I usually do the task myself, although it takes longer or more effort now than before), and 4 indicating “Easy” (I can do the task without any problem). The MAM-36 can be accessed.⁴⁹ A look-up table from raw scores to converted 0-100 Rasch measures is available.⁴⁸

Abilhand questionnaire (self-report)

The ABILHAND questionnaire asks clients to use a 3-point scale (0 = impossible, 2 = easy) to rate how difficult it would be to complete 23 bimanual tasks (e.g., hammering a nail, wrapping a gift, thread a needle, file nails, cut meat, peel onions, open jar, etc.). Grip strength, motricity, dexterity, and depression are significantly correlated with the ABILHAND measures.¹⁴⁴

Assessment of motor and process skills

The therapists evaluate motor and process skills^68,69 within the context of basic ADL and instrumental activities of daily living (IADL). The quality of the person’s ADL performance is assessed by rating the effort, efficiency, safety, and independence of 16 ADL motor and 20 ADL process skill items, while the person is doing chosen, familiar, and life-relevant ADL tasks. There are more than 100 tasks to choose from, thus promoting a client-centered approach to assessment. Examples of evaluated motor skills include posture, mobility, coordination, strength, reach, manipulation, grip, lifting, effort, and energy expenditure. See Chapter 21.

Arm motor ability test

The Arm Motor Ability Test (AMAT) has been used to determine the effectiveness of constraint-induced movement therapy (CIMT) and includes 13 unilateral and bilateral tasks. Sample items include tying a shoe, opening a jar, wiping up spilled water, using a light switch, using utensils, and drinking. The therapist times task performance and rates movement quality on a 6-point scale. The test is appropriate for evaluating motor skills in high-level clients with active wrist and finger extension. However, most of the AMAT activities are too difficult and frustrating for persons with little motor recovery.^102,146

Wolf motor function test

The Wolf Motor Function Test has been used to document the outcomes related to CIMT and includes a variety of tasks such basic reaching tasks (e.g., lifting arm from lap to table, extending elbow with and without a weight attached) and more functional activities that involve fine motor control (e.g., picking up a pencil, turning a key in a lock). All tasks but one are unilateral and appropriate for both the dominant and nondominant arm. As many tasks do not require distal control, it is appropriate for people with a more involved upper extremity. The therapist times task performance and qualitatively grades movement.¹⁹¹

Chedoke arm and hand activity inventory

Chedoke Arm and Hand Activity Inventory is a functional measure with 13 items that are assessed using a 7-point quantitative scale, similar to that of the FIM instrument (e.g., 1 = total assist and 7 = independent). It yields a total raw sum of 91 (minimum score = 13) that can be converted to a percentage. Sample items include opening a jar of coffee, dialing 911, zipping a zipper, carrying a bag up the stairs, and drying back with towel.^12,13

Jebsen test of hand function

The Jebsen Test of Hand Function⁹⁷ includes the performance of seven test activities: writing a short sentence, turning over index cards, picking up small objects and placing them in a container, stacking checkers, simulating eating, moving empty large cans, and moving weighted large cans during timed trials. The original paper is based on data collected from 360 normal subjects and patients, including patients with hemiparesis resulting from a stroke. The mean times and standard deviations for normal subjects (with their dominant and nondominant hand) are published in the paper. The test is standardized and reliable and does not have a practice effect. Therapists must be aware that some of the tasks are simulated activities, and some tasks cannot be considered ADL tasks.

Action research arm test

The Action Research Arm Test consists of 19 items in four categories: pinch, grasp, grip, and gross movement. The test is short (approximately 10 minutes). Items are graded on a 4-point scale. Scores for each subtest range from 0 (unable to perform any task) to 6 (able to perform all six tasks). Performance is rated on a 4-point scale ranging from 0 (unable to perform) to 3 (performs normally). The test is most useful for patients with some distal function. The tasks included are contrived.¹¹⁷

Motor assessment scale

Developed by Carr and Shepherd, the Motor Assessment Scale⁴⁴ has been found to be highly reliable, with an average interrater correlation of 0.95 and a 0.98 average test/retest correlation. This evaluation includes sections on upper arm function, hand movements, and advanced hand activities. The upper arm function section includes movement patterns without tasks; the hand sections incorporate the use of objects. Each item is scored on a 7-point scale.

Box and block test

The number of wooden blocks (2.5×2.5×2.5 cm) that can be transported from compartment of box to another in one minute is counted.^120,145

Nine-hole peg test

A measure of dexterity, the Nine Hole Peg Test consists of a plastic console with a shallow round dish to contain the pegs on one end of the console and the nine-hole peg-board on the opposite end. Time taken to complete the test is measured as the patient grasps nine pegs and places them in and removes them from the holes on the console.¹³⁶

Functional test for the hemiplegic/paretic upper extremity

Although this evaluation¹⁸⁸ is based on Brunnstrom’s view that motor recovery takes place in a specific sequence, it does involve functional tasks associated with daily living. This test has been found to be highly correlated with scores on the Fugl-Meyer Assessment and requires approximately 30 minutes to administer. It consists of 17 test items arranged in seven levels according to difficulty. Examples of tasks evaluated include folding a sheet, stabilizing a jar, hooking and zipping a zipper, screwing in a light bulb, and placing a box on a shelf.

Upper extremity performance test for the elderly/test d’evaluation des membres supérieurs de personnes agées (tempa)

This test consists of four unilateral (pick up and move a jar, pick up a pitcher and pour water into a glass, handle coins, and move small objects) and five bilateral (open a jar and take a spoonful of coffee, unlock a lock and open a pill container, write on an envelope and place a stamp on it, tie a scarf around your neck, and shuffle and deal playing cards) functional tasks. It includes speed of execution and functional ratings. The functional rating is related to level of independence and uses a 4-point scale.⁶⁰

Frenchay arm test

This quick test includes five items, such as hair combing with the weak arm and drinking water. Items are graded as successful or unsuccessful.⁸⁷

Motricity index

This test includes a brief impairment measure of upper extremity function after stroke. Items include pinch strength, elbow flexion, and abduction.⁵¹

Rivermead motor assessment (arm section)

This text is part of a comprehensive battery and contains 15 items related to motor recovery of the arm. Sample items include protracting a shoulder girdle while supine, picking up a piece of paper from the table in front and releasing five times, cutting putty on a plate with a knife and fork, and placing string around the head and tying a bow in the back. The scores are dichotomous: success (1) or failure (0).¹¹⁵

Fugl-meyer assessment (upper extremity motor function)

Familiarity with this impairment-based test is helpful because the test is used in many research papers to document improvement in function. The assessment is based on the motor recovery model developed by Twitchell and on Brunnstrom’s idea that motor recovery occurs in a specific sequence of steps. Improved motor function is considered a deviation from stereotypical synergies defined by Brunnstrom in this test. The test does not involve the use of functional tasks. Sections include ROM, sensation, balance, upper extremity, and lower extremity. Items are graded on a 3-point scale.⁷²

Task-oriented reaching and manipulation

The events leading up to a simple voluntary movement such as reaching for a glass of water involve multiple complex processes. Ghez⁷⁴ classifies these processes as follows. First, the person needs to identify the glass and its position in space. This first step encompasses a variety of visual and perceptual processes. Second, the person needs to select a plan of action to bring the glass to the mouth. Ghez points out that this step involves specifying which body parts are needed and in which direction they should move. To do this, the person must evaluate the location of the glass in relation to the position of the hand and body. The information collected allows the motor system to determine the appropriate trajectory of the hand. The last step is the execution of the response. Multiple commands are sent to the motor neurons specifying the temporal sequence of muscle activation, the forces to be developed, the changes in joint angles, the orientation of the hand to fit the glass, and the coordination of the shoulder with the distal arm to ensure that the glass will be grasped on contact and immediately. Multiple problems can interfere with these three steps, including the issues discussed in the previous section, visual dysfunction, and praxis deficits.

Two components of upper extremity function have been described by Jeannerod^95,96: the transportation component, which includes the trajectory of the arm between the starting position and the object, and the manipulation component, which is the formation of grip by combined movements of the thumb and the index finger during arm movement.

In her study of reaching deficits in subjects with left hemiparesis, Trombly¹⁷⁷ used kinematic analysis and electromyography to document impairments in voluntary arm movements. Her analysis demonstrated that the ability to reach smoothly and with coordination was significantly less in the impaired arms than in the unimpaired arms. The continuous movement strategy used during reaching activities was lost, movement time was longer, peak velocity occurred earlier, and indications of weakness were present.

In a follow-up study, Trombly¹⁷⁶ documented the observed improvements in her subjects’ reaching abilities. Her findings indicated that the amplitude of peak velocity improved over time. The level of muscular activity did not improve, but the discontinuity of movements decreased. From her findings, Trombly hypothesized that therapy that allows relearning of sensorimotor relationships is warranted for some patients. She stated that the “level and pattern of muscle activity of these subjects depended on the biomechanical demands of the task rather than any stereotypical neurological linkages between muscles.”

From a treatment perspective, research by Trombly and Wu¹⁷⁸ concluded that “Goal-directed reach enabled persons with stroke to display characteristics typical of reach to a target by persons who have not had a stroke better than reaching out in space. These findings support the occupational therapy practice of using objects in a functional context to improve coordinated movement. However, the nature of the objects to be used requires further study.”

Van Vliet and colleagues¹⁸⁵ studied subjects in the early months after a stroke. The subjects were able to improve their reaching kinematics during a three- to four-week period; they progressed toward normal performance. Providing the subjects with a meaningful task (e.g., drinking from a cup) helped them perform the reach-to-grasp movement.

Jeannerod⁹⁶ stated that “Formation of the finger grip during the action of grasping a visual object involves two main functional requirements, the fulfillment of which will determine the quality of the grasp. First, the grip must be adapted to the size, shape, and use of the object to be grasped. Second, the relative timing of the finger movements must be coordinated with that of the other component of prehension by which the hand is transported to the spatial location of the object.” Jeannerod observed that finger posturing anticipates the real grasp and occurs during transportation of the hand. This shaping of the hand is a mechanism independent of the manipulation itself. If treatment programs focused on improved function of the upper extremity are to be designed, then they must include a variety of common objects with different shapes, sizes, and textures to affect this reaching component.

Exner,⁶⁶ who defined in-hand manipulation as the process of adjusting objects being grasped in the hand, developed a classification system to assist the therapist in activity choice, despite the system not being standardized on stroke survivors (Box 10-1 outlines Exner classification system).

Wu, Trombly, and Lin¹⁹⁸ demonstrated that using material-based occupation (e.g., picking up a pen and preparing to write one’s name) enhanced quality of movement performance more than imagery-based occupation (e.g., pretending to pick up a pen and preparing to sign one’s name) and exercise (e.g., moving the arm forward). Their data suggested that material-based occupation resulted in decreased reaction time, movement time, and movement units. Although this study was performed on normal subjects, they inferred that material-based occupation may be used to elicit efficient and economical preprogrammed movement for performing tasks.

In a study of fine motor coordination training, Neistadt¹³³ examined the effects of constructing puzzles and performing kitchen activities on fine motor coordination in a group of brain-injured men. Her results demonstrated that the subjects in the functional meal preparation group showed significantly greater improvements in dominant hand dexterity, which is used for picking up small objects, than the subjects in the tabletop puzzle activity group. Her findings suggested that functional activities are more effective (not to mention more meaningful) than tabletop activities for fine motor coordination training in the brain-injured population.

Sietsema and colleagues¹⁶³ studied brain-injured patients engaged in rote exercise tasks and occupationally embedded tasks (e.g., reaching out to control a computer game). Their subjects had “mild to moderate spasticity” on evaluation. Their results indicated that the game elicited significantly more ROM during the reach pattern performance than the rote exercise. Their study supported the hypothesis that occupationally embedded interventions promote increased performance. The authors hypothesized that the game provided motivating feedback that enhanced performance.

At this point, research has confirmed that the demands and goals of the task influence motor output.¹⁹⁸ For example, the characteristics of an item being carried across a kitchen influence factors such as how fast a person moves, whether one or two hands are used to grip the object, how close to the body the item is carried, and how stable the arms are held. In daily life, there are many examples of the ways in which movement in daily activities is influenced by the environment (e.g., carrying empty ice trays or full trays, a half-glass of wine or a full cup of coffee, one paper plate or a stack of china plates).

Rosenbaum and Jorgensen¹⁵³ have demonstrated that the goal of the task influences motor output. Their subjects were asked to reach for a cylinder and stand it on one end or the other. Depending on the goal of the task (e.g., which side they were to stand the cylinder on), subjects reached with a pronated or supinated grasp pattern. Box 10-2 provides sample activities used to retrain reach patterns. See Chapters 4 and 5.

Weight-bearing to support function

The use of weight-bearing tasks has long been advocated in patients after stroke. Upper extremity weight-bearing has been suggested anecdotally for achieving a variety of therapeutic goals, including inhibiting hypertonus by moving the body proximally against the distal upper extremity⁵⁵ and stimulating upper extremity extension during protective responses.¹⁹ Brouwer and Ambury³⁷ concluded that upper extremity weight-bearing normalizes corticospinal facilitation of motor units in stroke patients. They hypothesized that the mechanism responsible for their results was a sustained increase in motor cortical excitability through augmented afferent input.

McIllroy and Maki¹²² and Marsden, Merton, and Morton¹¹⁸ documented that if the upper extremity is used as a postural support (e.g., during weight-bearing), postural responses to the movements of the opposite arm occur throughout the weight-bearing upper extremity and to other perturbations of posture. Their paper also demonstrated that postural responses from the triceps only occurred when the hand was in contact with a firm object.

Although from a neurophysiological perspective, the effect of weight bearing on upper extremity control (e.g. the “normalization of tone” and “inhibition of spasticity”) remains controversial and unproven, the use of weight-bearing patterns is still necessary for treating the upper extremity after a stroke if the goal of treatment is to improve functional performance. Examples include using the more affected upper extremity in a weight-bearing pattern and as a postural support while manipulating clothing during toileting activities or to enhance participation in IADL (e.g., using the more affected extremity as a postural support during activities requiring standing such as doing the laundry or preparing a meal).

Therapists also can use weight-bearing activities to address impairments that interfere with function. The problem of soft-tissue shortening in the long flexors can be prevented or reversed by bearing weight on extended wrists with extended digits to maintain or increase tissue length. If evaluation reveals that weakness in the extremity is having a limiting effect on function, the therapist can use extended-arm weight-bearing activities to strengthen the triceps and scapula musculature if the weight-bearing activities are performed in appropriate alignment and the weight-bearing pattern remains active during the activity.

To ensure appropriate alignment, the therapists should avoid severe internal rotation, forced elbow extension, and an inactive trunk in patients.¹⁵⁶ During weight-bearing activities, maintenance of palmar hand arches is important for maintaining biomechanical alignment and enhancing active patterns. The points of contact between the weight-bearing surface and the hand include the thenar eminence, hypothenar eminence, metacarpal heads, and palmar surfaces of the phalanges.¹⁰⁰ The arch should be maintained so that therapists can insert a finger between the web space and the first metacarpal head and slide it under the hand until they make contact with the hypothenar eminence.

Although the more affected arm is in a weight-bearing position, the less involved extremity should be engaged in activities that promote weight shifting in all directions (Fig. 10-4). Weight-bearing activities can be performed by the forearm or an extended arm, depending on the demands of the task and the level of available motor control. See Table 10-1 for a review of evidence related to task related training.

Figure 10-4 A to C, Weight-bearing during daily occupations.

Constraint-induced movement therapy (traditional and modified protocols)

The term learned nonuse was coined by Taub.¹⁷¹ The learned nonuse phenomenon originally was identified in primate studies and later was applied to chronic stroke patients. With deafferentation of a single forelimb of a monkey, the animal would not use that limb in an unrestricted (free) environment. The monkey’s initial attempts to use the limb resulted in failures (e.g., dropping food, losing balance, and falling). The monkeys in this study soon found that they could function in their environment with three limbs instead of four. Continued attempts to use the affected limb led to repeated failures at attempted tasks; the effect was suppression of any desire to use that limb. The monkeys learned not to use the limb to avoid failure, which masked any future recovery of limb function. Taub and colleagues¹⁷¹ pointed out that in a free situation, the monkeys did not learn that they could regain use of the forelimb as they recovered function. When the intact forelimb was restrained, the monkeys were forced to use the affected side. This technique converted a useless limb into one capable of function.

Taub¹⁷¹ hypothesized that the nonuse or limited use of an affected upper extremity in human beings after stroke could in some cases result from a similar phenomenon of learned suppression. To test this hypothesis, Taub¹⁷¹ studied nine patients with chronic (i.e., greater than one year after stroke) hemiplegia. To be included in this study, patients had to demonstrate the ability to extend the metacarpophalangeal and interphalangeal joints at least 10 degrees, extend the wrist 20 degrees, and walk without an assistive device. They had to have grossly intact cognitive function, no excess spasticity, be right-arm dominant, and be less than 75-years-old.

Patients were assigned to a control or an experimental group. The experimental group underwent forced-use/CIMT in which the intact limb was placed in a sling and resting-hand splint. The restraint was worn at all times during waking hours except when toileting, when napping, and at times when balance might be compromised. The restraint was worn for 14 days. Each weekday, patients received therapy and were given a variety of tasks—such as eating with utensils, playing ball, playing Chinese checkers and dominoes, writing, and sweeping—to perform with the paretic limb for six hours throughout the day.

The treatment of the control group focused on increasing attention to the paretic limb. This group was told that they had more potential in their extremities than they were using. Therapists performed passive ROM activities, and patients performed ROM activities daily for 15 minutes. The affected limb was not given any training for active movement.

Each group was evaluated before and after intervention with a variety of arm function evaluations and a self-reported Motor Activity Log. The experimental group had significantly faster mean performance speeds from the evaluations, increased quality of movement, and an increased ability to use the extremity in ADL. These improvements were reevaluated two years later; they were at least maintained if not increased. Although the comparison group made subtle gains after intervention, the gains were not retained for the follow-up evaluation. Taub and colleagues¹⁷¹ concluded that the motor ability of stroke patients who met their inclusion criteria could be increased significantly by the interventions effective for overcoming learned nonuse.

Wolf and colleagues¹⁹² researched forced-use treatment in 25 chronic hemiplegic and stroke patients with minimal to moderate extensor muscle function. The CIMT program lasted for two weeks, with the intact limb being restrained during waking hours. The authors noted significant changes in performance of 19 of the 21 tasks that were evaluated, with most changes persisting for one year after the study. The authors concluded that learned nonuse does occur in select patients with neurological deficits and that this behavior can be reversed through application of a CIMT paradigm.

Van der Lee and colleagues¹⁸² completed an observer-blinded randomized clinical trial with 66 chronic stroke patients who were randomized to two weeks of CIMT or a comparison of equally intensive bimanual training based on two weeks of neurodevelopmental therapy. One week after the last treatment session, the authors found a significant difference in effectiveness in favor of CIMT group compared with the neurodevelopmental therapy group, after correction for baseline differences, on the Action Research Arm Test and the Motor Activity Log amount of use score. One-year follow-up effects were observed only for the Action Research Arm Test. The authors also found that the differences in treatment effect for the Action Research Arm Test and the Motor Activity Log amount of use scores were clinically relevant for patients with sensory disorders and hemineglect, respectively.

The EXCITE trial¹⁹³ was a prospective, single-blind, randomized, multisite study and included 222 patients with stroke. Subjects were randomized to either customary care or constraint-induced therapy. Constraint-induced therapy consisted of two components applied over a two-week period; subjects performed intense practice of functional tasks using the affected hand for six hours per day plus subjects reduced use of the unaffected hand by covering it with a mitt for at least 90% of waking hours. The trial found significantly positive results that were maintained in the long term. Outcome measures included:

Dromerick, Edwards, and Hahn⁶³ questioned whether a CIMT program could be implemented in the acute stroke population (two weeks after stroke) and whether this intervention was more effective than traditional upper extremity interventions (control group) during the acute period. The research team enrolled 23 subjects in a pilot randomized, controlled trial that compared CIMT with traditional therapies. Treatment plans were designed to make sure that patients in both groups received equivalent time and intensity of treatment directly, and an occupational therapist supervised the program. The subjects received routine interdisciplinary stroke rehabilitation, except for the CIMT that occurred during the regularly scheduled occupational therapy sessions. Individualized and circuit-training techniques were used in both groups. All subjects received study treatment for two hours per day, five days per week, for two consecutive weeks. Twenty subjects completed the trial. The CIMT group had significantly higher scores on the Action Research Arm Test and pinch subscale scores. Differences in the mean grip, grasp, and gross movement subscale scores of the Action Research Arm Test did not reach statistical significance. ADL performance was not significantly different between groups. No subject withdrew because of pain or frustration. The authors concluded that CIMT during acute rehabilitation is feasible. Furthermore, CIMT was associated with less arm impairment at the end of the trial.

Page and colleagues¹⁴⁰ examined the feasibility and efficacy of a modified CIMT protocol administered on an outpatient basis. Their protocol was developed to be more consistent with therapy scheduling and reimbursement patterns, in other words, more user friendly and feasible from the therapist’s perspective. They examined six patients who were in a subacute stage of stroke recovery and who exhibited learned nonuse. The patients were assigned to one of three groups; two patients received half-hour physical and occupational therapy sessions three times a week for 10 weeks while they simultaneously had their unaffected arms and hands restrained five days per week during five hours identified as times of frequent use; two patients received regular therapy, and two control patients received no therapy. Outcomes were measured by the Fugl-Meyer Assessment of motor recovery, the Action Research Arm Test, the Wolf Motor Function Test, and the Motor Activity Log. Patients receiving modified CIMT exhibited substantial improvements on the Fugl-Meyer Assessment, Action Research Arm Test, the Wolf Motor Function Test and reported increases in amount and quality of use of the limb based on the Motor Activity Log. Patients receiving traditional or no therapy exhibited no improvements. The author concluded that modified CIMT may be an efficacious method of improving function and use of the affected arms of patients exhibiting learned nonuse. See Table 10-3 for CIMT protocols.

Table 10-3 Tested Constraint-Induced Movement Therapy Protocols

In addition to the apparent functional improvements in the select group of patients who are appropriate for a trial of CIMT, researchers have demonstrated that CIMT produces long-term alteration in brain function. This is the first documented cortical-level change associated with a therapy-induced improvement in the rehabilitation of movement after neurological injury. Liepert and colleagues¹¹⁰ investigated whether CIMT could produce treatment-induced plastic changes/reorganization of the motor cortex in the human brain. Using focal transcranial magnetic stimulation, the authors mapped cortical motor output area of a hand muscle on both sides in 13 stroke patients in the chronic stage of their illness before and after a 12-day-period of CIMT. The authors found the following:

Taub and colleagues¹⁷¹ summarized by stating that if the “neural substrate for a movement is destroyed by CNS injury, no amount of intervention designed to overcome learned nonuse can be successful in helping recover lost function. However, many stroke patients . . . have considerably more motor ability available than they utilize. The suppression of this additional motor capacity is set up by unsuccessful attempts at movement in the acute poststroke phase . . . increased motor activity should then become increasingly possible, but the suppression of movement remains unabated and inhibits use of the limb. However, if individuals are correctly motivated to use this unexpressed ability, they will be able to do so.” See Table 10-1 for a review of evidence related to constraint induced movement therapy (Box 10-4). See Chapter 6.

Managing inefficient and ineffective movement patterns

Being unable to move effectively and therefore unable to interact with the environment is one of the most devastating sequelae of stroke. The loss of the ability to move effectively is a negative stroke symptom.

The movement patterns of stroke survivors have long been discussed in the literature. Controversy continues over the nature of these patterns. These movement patterns have been described as reflex based, a release of abnormal synergies, the result of reversed inhibition or the release of lower patterns of activity from higher inhibitory control, and as learned patterns of movement. Mathiowetz and Bass-Haugen¹²¹ point out that more contemporary models of motor control describe patterns developing after central nervous system damage as results of attempts to use remaining resources to achieve occupational performance. They give the example of a typical flexor pattern (scapula retraction, internal rotation, elbow/wrist/digit flexion) in the upper extremity; the pattern can stem from factors other than spasticity, such as the inability to recruit appropriate muscles, weakness, soft-tissue tightness, and perceptual deficits.

Carr and Shepherd⁴² state that “muscles that are held persistently in a shortened position not only develop contracture but also appear ‘easier’ for the patients to activate. . . . In the stroke patient such activity appears to become habitual, certain muscle groups, apparently those whose mechanical advantages are greatest (because of their shortened length), contracting persistently to the disadvantage of others.” The therapist can observe this phenomenon if a patient is reaching out to a target. Many patients have difficulty with the protraction, elbow extension, and wrist and digit extension patterns of this task. If the therapist observes the patients who have been in a resting posture (e.g., seated in a wheelchair) for a prolonged time, the shortened muscles include the retractors, elbow flexors, and wrist and digit flexors.

Ada and colleagues¹ hypothesize that muscle weakness or paralysis effectively immobilize the upper limb, which results in soft-tissue contracture. The immobility causes length-associated changes in muscles, and persistent positioning results in contracture. These changes in the upper limb result in compensatory movements that generate strong neural connections after frequent repetition, ensuring that the compensatory or adaptive movement patterns become learned rather than more effective and efficient.

A Russian neurologist, Nicoli Bernstein, emphasized a early task-oriented view of motor performance and introduced the concept that purposeful movement is organized to solve motor problems and the concept of degrees of freedom.¹⁵⁸ He hypothesized that the principal problem faced by the central nervous system was the large number of joints and muscles in the human body and the infinite combinations of muscle action. For example, the upper extremity has multiple degrees of freedom if the number of planes through which each joint moves are combined. When contemplating the combinations of degrees of freedom in the trunk, scapula, and shoulder to the hand, it becomes evident that task of controlling them is phenomenal. Bernstein states that “The coordination of a movement is the process of mastering redundant degrees of freedom of the moving organ, that is, its conversion to a controllable system.”¹⁵⁸ Bernstein views motor control as a person’s ability to coordinate kinematic linkages that limit degrees of freedom. See Chapter 5.

Flinn⁷⁰ uses the example of gymnasts learning a new maneuver to apply the concept of degrees of freedom to a task. Gymnasts limit the degrees of freedom in the task by holding some joints rigid while focusing on one specific body part (e.g., foot placement). Although the gymnasts initially may appear stiff, as they become able to control more degrees of freedom, the stiffness disappears and movement relaxes. This example can be applied to learning how to roller-blade, ice-skate, or perform a new swimming stroke. Sabari¹⁵⁸ discusses a patient with hemiplegia who does not dissociate the pelvis from the lumbar spine or scapula from the thorax, which may be an effort to decrease the degrees of freedom.

With this concept in mind, many of the ineffective movement patterns observed in patients can be attributed to attempts to control the degrees of freedom. Therapists need to consider this during treatment planning when choosing activities. The degrees of freedom must be controlled carefully by stabilizing or eliminating use of some of the joints and therefore decreasing the number of joints involved (e.g., supporting the distal extremity on a table or substituting flat-hand stabilization for a hand grasp).⁷⁰ Gillen^76,77 has demonstrated a variety of methods to improve task performance in clients with central nervous system dysfunction by manipulating the degrees of freedom via positioning, splinting, movement retraining, and equipment. Further research is required with the stroke population.

Many of the inefficient movement patterns in stroke survivors may result from attempting tasks beyond their level of motor control (Fig. 10-5). Many therapists have watched patients with newly developed motor control proudly show how they can “lift their arm.” Of course, the resulting movement is a stereotypical pattern used by stroke survivors. Mathiowetz and Bass-Haugen¹²¹ suggest that the use of these movement patterns is evidence of attempts to use remaining systems to complete tasks. They give the example of a patient with weak shoulder flexors trying to lift an arm. The patient flexes the elbow when trying to raise the arm because this movement strategy shortens the lever arm and makes shoulder flexion easier. This phenomenon can be observed in those with other diagnoses that result in proximal weakness (Fig. 10-6).

Figure 10-5 A, When asked to reach, this patient uses a stereotypical flexor pattern. Note trunk lateral flexion, scapula adduction, humeral abduction, and distal flexion. B, When the position of the activity is changed to correspond with the available motor control, and the patient is given a goal (e.g., “Pick up the bottle”), movement pattern is more effective and efficient. C, Another position change of same activity results in forward reach with less impact of compensations seen in A. The patient reaches with wrist extension, and his hand is prepositioned for successful task completion. The purpose of the activity drives motor output.

Figure 10-6 Compensatory movements from proximal weakness. A, This person’s is status post left brain damage resulting in right sided weakness including right scapula instability. Compensatory strategies used to lift her arm include lateral trunk flexion, trunk rotation, scapula adduction and elevation, and elbow flexion. These compensatory movement strategies act to decrease the degrees of freedom, provide proximal stability, and shorten the lever arm of the upper extremity. This person has relatively preserved elbow extension strength, which she cannot use during this movement as it will create a longer lever arm and a loss of control. In the recent past, this movement pattern was attributed to abnormal flexor tone placing the treatment focus on decreasing tone in the antagonistic muscle groups (i.e., elbow flexors). A more current treatment approach includes interventions related to proximal strengthening and practice of graded reach patterns ( i.e., a focus on the weak agonists). B, This man is using very similar compensatory movements as the woman in A, although his diagnosis is a right rotator cuff tear. The inefficient and ineffective movement patterns and the compensatory movements are secondary to proximal weakness.

Based on these concepts, the roles of the occupational therapist in treating inefficient and ineffective upper extremity patterns are the following:

Figure 10-7 Suspension arm sling. Unweighting the upper extremity may promote increased use during the day. The therapist must consider ways in which the patient can move and use the upper extremity outside of therapy. Caution: When evaluating patients using this device, the therapist must make sure that the movement is being generated by the upper extremity as opposed to swinging the arm by moving the trunk.

Figure 10-8 Daily planner to promote upper extremity function throughout the day.

In terms of treatment, Mathiowetz and Bass-Haugen¹²¹ suggest that therapists help the patients “find the optimal strategy for achieving functional goals.” Goals can be achieved by altering the task requirements, altering the environmental context, and by guiding remediation of the component deficits that interfere with functional performance. The most powerful tools occupational therapists have for intervention are functional activities. Although functional activities have formed the basis of treatment since the profession was developed, only recently has the true impact of functional tasks been evaluated in this area of intervention (Fig. 10-9). See Chapter 4.

Figure 10-9 Reaching activities used to challenge available motor control appropriately. A, When attempting to lift both arms, this man uses an ineffective and inefficient movement pattern. He recruits his available scapula elevators, elbow flexors, trunk extensors, and head/neck extensors. Although it may appear that he lacks elbow extension or that his elbow flexors are “spastic” or “overactive,” muscle testing in supine yields a grade of 4 out of 5 for all elbow musculature. His lack of ability to use elbow extension in this movement may indicate an attempt to shorten the lever arm and control the degrees of freedom. B and C, Using leisure and work tasks that are more appropriate to this man’s level of motor control. Both activities are considered supported reach because the hand is in contact with the work surface. Note that the upper extremity patterns are more effective and efficient. D, The therapist provides graded physical assist to complete the task as increased biomechanical demands are made using the incline of the car. E and F, Grading the reaching in space activity using gravity to make the task progressively more difficult.

Mental practice/imagery

The use of imagery in treatment has received an increasing amount of support in the literature. Using imagery and mental practice has been shown to do the following:

Yue and Cole²⁰² proposed a method for increasing skeletal muscle strength. Healthy subjects were separated into three groups: those receiving imagining training (i.e., training in which the person imagines a muscle is contracting but is not activating the muscle), those receiving contraction training, and a control group. Training resulted in a maximum voluntary contraction force increase of 22% in the imagining group, 30% in the contraction group, and 3.7% in the control group. This study demonstrated that strength increases can be achieved without muscle activation. Early strength increases appear to result from practice efforts on central motor programming. This study adds to the increasing evidence that the neural origin of strength increases before muscle hypertrophy.

In an early study focused on improving upper extremity function after stroke, Page¹³⁹ hypothesized that imagery use combined with traditional occupational therapy could enhance motor recovery in patients with upper extremity hemiparesis. He provided eight chronic stroke patients with a four-week course of occupational therapy and imagery (a 20-minute audio tape that consisted of relaxation followed by cognitive visual images related to the upper extremity being used in weight-bearing tasks and functional tasks that were practiced in occupational therapy). This group was compared with eight controls that received only occupational therapy. He concluded that the patients who received occupational therapy and imagery had significantly more improved function as measured by the upper extremity section of the Fugl-Meyer Assessment. Since then, multiple studies have documented the effectiveness of this adjunctive intervention. See Table 10-1 for a review of evidence related to mental practice (Box 10-5).

Electromyographic biofeedback

Electromyographic (EMG) biofeedback shows promise and should be studied further for its potential use in treating upper extremity dysfunction after stroke. Biofeedback is provided by electronic instruments that measure and give information about neuromuscular or autonomic activity in the form of auditory or visual feedback signals.

Tries’ review¹⁷⁵ of the literature included a variety of rationales for integrating this noninvasive modality, including training voluntary inhibition of spastic muscles and restoring muscle balance, into an upper extremity program. Tries¹⁷⁵ outlined specific techniques for scapula mobility and stability, humeral rotation, integrating scapular and humeral rotation with a forward reach pattern, and reinforcement of functional patterns in the elbow, forearm, and hand.

Tries¹⁷⁵ presented a case study outlining the applications of biofeedback for a left-sided hemiplegic patient. Her case study illustrated that despite sensory, cognitive, and perceptual impairments, this patient had significant clinical upper limb functional improvements when combining EMG biofeedback and traditional occupational therapy.

Greenberg and Fowler⁸⁰ compared kinesthetic biofeedback (feedback information pertaining to actual movement of a body part rather than the activity of muscle fibers) to conventional occupational therapy. Their results indicated that kinesthetic biofeedback was equally as therapeutic as but no more effective than conventional occupational therapy for increasing elbow extension in hemiplegic subjects.

Crow and colleagues⁵³ studied two groups (a group receiving biofeedback and a control group) of 20 patients. The patients were studied before and after six weeks of treatment and during a follow-up visit six weeks later. Although the groups did not differ significantly before treatment, the biofeedback group improved significantly on arm-function evaluations. At the six-week follow-up, the beneficial effects were discovered not to have persisted in the experimental group.

Schleenbaker and Mainous¹⁶¹ concluded from their meta-analysis that biofeedback is an effective tool in neuromuscular reeducation for executing ADL. The use of EMG biofeedback warrants further investigation into its use as an adjunct tool to enhance upper extremity function in select patients with hemiparesis. See Table 10-1 for a review of evidence related to EMG biofeedback.

Electrical stimulation

Electrical stimulation has been used in poststroke upper extremity rehabilitation for many years. Potential uses have included reduction of shoulder subluxation, reduction of pain, improved motor control, and increasing use of the involved extremity. In general, the effects of electrical stimulation have been the most consistent at improving limb impairments such as ROM and reducing pain. The effects on function and ADL have received less attention and have been inconsistent. See Table 10-1 and Table 10-4 for an evidenced-based review of electrical stimulation.

Table 10-4 Effectiveness of Electrical Stimulation to Decrease Arm Impairment and Improve Function after Stroke

Electromyographic-triggered electrical stimulation

Electrical stimulation can be triggered by voluntary movement or nontriggered. EMG-triggered stimulation detects underlying muscle activity when it reaches a threshold level prior to providing the stimulation. The stroke survivor must voluntarily activate the correct muscles prior to the stimulation facilitating the motor response. This type of stimulation assures that the intervention is not passive in nature. Triggered electrical stimulation may be more effective than nontriggered electrical stimulation in facilitating upper extremity motor recovery following stroke.⁵⁹ This intervention has been shown to be effective at improving wrist extension, a key movement to be considered a candidate for some task oriented approaches such as CIMT. See Table 10-1 for an evidence-based review of EMG-triggered electrical stimulation.

Bilateral training

Recently, bilateral training (i.e., patients practice identical activities with both upper limbs simultaneously) has been proposed as a strategy to improve upper limb control and function post stroke.^130a The theory and rationale as to why the intervention may be effective has been described as follows: “Control of bilaterally identical synchronous movement appears to occur centrally through bilaterally distributed neural networks linked via the corpus callosum and involving cortical and subcortical areas. These networks indicate a common facilitatory drive to both motor cortices thought to lead to tight temporal and spatial coupling of limb movement observed during bilaterally identical synchronous voluntary movement. Beneficial effects of bilateral training in stroke are assumed to arise from this coupling effect in which the nonparetic limb provides a template for the paretic limb in terms of movement characteristics, facilitating restoration of movement.”¹²⁹ Stoykov and Corcos¹⁶⁹ further reviewed neural mechanisms mediating bilateral training including recruitment of the ipsilateral corticospinal track, increased control from the contralesional hemisphere, and a normalization of inhibitory mechanism.

Although some findings have been inconsistent, a recent meta-analysis and randomized controlled trials have demonstrated improvement. Protocols vary but typically use either functional tasks or repetitive arm movements. This technique has been combined with auditory rhythmic cuing and neuromuscular stimulation. Some research has concluded that the technique may be more beneficial for those with proximal limb involvement. See Tables 10-1 and 10-5 for an evidence-based review of bilateral training. See Box 10-6 for a sample protocol.

Table 10-5 Characteristics of Each Study Used in the Meta-Analysis by Stewart and Colleagues¹⁶⁸

Mirror therapy

A relatively new intervention, this intervention appears to be cost-efficient and is able to be done independently. Yavuzer and colleagues¹⁹⁹ describe the intervention as “During the mirror practices, patients were seated close to a table on which a mirror (35×35 cm) was placed vertically. The involved hand was placed behind the mirror and the noninvolved hand in front of the mirror. The practice consisted of nonparetic-side wrist and finger flexion and extension movements while patients looked into the mirror, watching the image of their noninvolved hand, thus seeing the reflection of the hand movement projected over the involved hand. Patients could see only the noninvolved hand in the mirror; otherwise, the noninvolved hand was hidden from sight. During the session patients were asked to try to do the same movements with the paretic hand while they were moving the nonparetic hand” (Fig. 10-11). See Table 10-1 for an evidence-based review of mirror training.

Figure 10-11 Mirror training. Set-up for mirror therapy: The patient’s affected arm is hidden behind the mirror. While he is moving his unaffected arm, he is watching its mirror image as if it were the affected one.