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May 2022 No. 73

Using Your Orthopedic Skills to Treat a Stroke Patient

Karol S. Young OTD, OTR/L, CHT

 

For a hand therapist specially trained in orthopedic injuries, treating a stroke patient can be daunting. Our rural outpatient clinic receives referrals for patients along the continuum of post stroke recovery with symptoms including muscle weakness, spasticity, decreased coordination, and motor planning difficulty. Here are a few ideas to help hand therapists treat the post-stroke upper extremity.

Address Spasticity

It is difficult to know where to begin when a patient presents with the typical spasticity posture of shoulder adduction, forearm pronation, and flexion of the elbow, wrist, and fingers. Orthopedic based assessments such as range of motion (ROM) and manual muscle testing usually do not provide the needed information and other assessments may be necessary to track progress. The Modified Ashworth Scale is a quick rating scale used to score spasticity severity (1). Performance-based measures such as timing a functional task (putting on a shirt or opening a container) gathers objective information while the patient performs a combination of functional upper extremity movements.

Treatment to address spasticity is based on severity and requires a multi-modal approach which may include a self-stretching program and/or an orthosis to reduce joint contractures. Individuals with spasticity often adapt, and can use the affected extremity as a gross motor assist to hold and stabilize objects.

Begin Proximally

Just as with orthopedic conditions, proximal control is important to support the affected limb following stroke. Start with scapular motions in side lying with the affected arm on a pillow. Ask the patient to protract, retract, elevate, depress, upwardly rotate, and downward rotate the shoulder. During these motions, provide verbal and tactile cues to assist the patient. See Figure 1-3. When the patient is able complete these motions side lying, progress the patient to a sitting position while supporting the affected upper extremity on a table (Figure 2).

Figure 1. Patient in side lying performing scapular ROM

Figure 2. Therapist assisting the patient with scapular ROM

Figure 3. Patient performing scapular motion with arm supported on a table

Focus on Extension

Both spasticity and weakness limit the ability to move the arm away from the body as the stronger flexor tone usually overpowers the weaker extension. Therefore, active extension at the elbow, wrist, and fingers is typically the priority in regaining motor control.

Motor relearning can be accomplished by combining extension with repetitive, task-specific activities (2). Examples are wiping a table (Figures 4a&b) or using tenodesis for grasp/release of objects (Figures 5a&b). Incorporating functional activities into the desired movement patterns promotes neural changes, improving voluntary motor control (3).

Figure 4a & 4b. Patient wiping a table

Figure 5a & 5b. Using tenodesis to aid in grasp/release

Include Graded Motor Imagery

Commonly used to treat pain associated with hand injuries, graded motor imagery provides feedback to the sensorimotor cortex of the brain and can also improve hand function after stroke (5,6). We follow the phases of graded motor imagery as described by Prignac and Stralka (7).

Once the patient completes laterality training, the home exercise program includes twenty minutes daily of graded motor imagery using a mirror (Figure 6). The patient looks at the reflection of active movement patterns of the uninvolved extremity while imagining the reflection is the motor function of the involved extremity. The patient then performs active motion with the uninvolved extremity while attempting to actively copy the motion with the affected side.

Figure 6. Using graded motor imagery to provide feedback to the sensorimotor cortex of the brain

Although it is ideal for therapists specializing in neurological conditions to treat stroke patients, orthopedic based outpatient hand therapists may be required to treat stroke patients. While the deficits from a stroke result from a central nervous system insult, some techniques we use with orthopedic patients can help this patient population. When we realize we can apply the skills we already have, we may actually find we enjoy the challenge!

 

1. Bohannon RW, Smith MB. Interrater reliability of a Modified Ashworth Scale of muscle spasticity. Phys Ther. 1987;67(2):206-207.

2. French B, Thomas LH, Coupe J, et al. Repetitive task training for improving functional ability after stroke. Cochrane Database Syst Rev. 2016;11(11):CD006073. Published 2016 Nov 14. doi:10.1002/14651858.CD006073.pub3

3. Muratori LM, Lamberg EM, Quinn L, Duff S. Applying principles of motor learning and control to upper extremity rehabilitation. J Hand Ther. 2013;26 (2):94-103 DOI:https://doi.org/10.1016/j.jht.2012.12.007

4. Ji EK, Wang HH, Jung SJ, et al. Graded motor imagery training as a home exercise program for upper limb motor function in patients with chronic stroke: A randomized controlled trial. Medicine (Baltimore). 2021;100(3):e24351. doi:10.1097/MD.0000000000024351

5. Madhoun HY, Tan B, Feng Y, et al. Task-based mirror therapy enhances the upper limb motor function in subacute stroke patients: a randomized control trial. Eur J Phys Rehabil Med. 2020;56(3):265-271. doi:10.23736/S1973-9087.20.06070-0

6. Priganc V, Stralka S. Graded motor imagery. J Hand Ther. 2011.24:164-169.

 

Download Clinical Pearl No. 73, Using Your Orthopedic Skills to Treat a Stroke Patient, May 2022

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Disclaimer: BraceLab Clinical Pearls are intended to be an informal sharing of practical clinical ideas; not formal evidence-based conclusions of fact.

 
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