Ling, Shawna S. DPT, CSCS1; Fisher, Beth E. PhD, PT2
Several published and ongoing studies are focusing on interventions to improve upper extremity (UE) function following stroke. Most of this research involves individuals during the acute phase poststroke with mild/moderate UE deficits. 1–3 The mild/moderate distinction is used to describe individuals with some volitional wrist and finger extension of the hemiparetic UE. 2–6 Correspondingly, individuals are frequently considered to have more severe UE deficits if they are unable to perform volitional wrist or finger movement. 7, 8 The acute classification refers to individuals who participate in intervention between the initial onset of stroke and 6 months poststroke. Patients classified as chronic are those whose stroke onset is greater than 6 months prior to intervention. While there are numerous studies on individuals with mild to moderate deficits, interventions for individuals with chronic and severe UE motor deficits are limited.
Goal-directed task practice with the hemiparetic UE largely characterizes the interventions studied in subjects with acute or chronic stroke and mild/moderate UE deficits. 1–6, 9–16 One form of this task specific training is Constraint Induced Therapy (CIT) in which tasks are practiced with the impaired UE while the unimpaired hand is constrained. 16 It has been demonstrated that subjects with acute or chronic stroke and mild/moderate UE deficits gain strength, range of motion (ROM), and overall functional use of the impaired UE after engaging in intense task practice whether intervention is offered early or later. 1, 3–5, 10, 13, 14, 16–18
Feys et al19 presented one of the few studies that examined the effect of UE intervention for individuals with acute onset of stroke and severe UE deficits. Individuals receiving UE sensorimotor stimulation (in addition to ‘usual rehabilitation procedures’) demonstrated increased UE Fugl-Meyer motor scores compared with control subjects that did not receive additional treatment. The difference between groups in motor impairment, however, did not generalize to any differences in functional use of the affected UE. 19
For the patient with severe UE deficits persisting past 6 months of stroke onset, even less is known about effective intervention. The few studies that have examined the effect of UE training for the patient with chronic stroke and severe UE deficits have shown limited improvement. There was no change in functional use of the impaired UE following CIT in an individual with a chronic stroke and severe UE limitations. 20 Whitall et al7 found enhanced motor performance in subjects with chronic stroke in response to bilateral UE training. However, while the subjects met the criteria of chronic stroke, all but one had mild UE impairment. The one subject categorized as having severe UE impairments showed no improvement.
In the following case report, we illustrate that analysis of movement that extended beyond a patient's volitional UE capability enabled us to develop an effective intervention for improved use of the UE despite the chronic and severe nature of the patient's deficits. We suggest that movement analysis, as a method to describe a patient's chosen strategy for task completion reveals the integration of multiple system impairments resulting from stroke, as well as the compensations made for those isolated impairments.
Using movement analysis, we hypothesized that in addition to isolated system impairments of his UE (ie, increased tone, decreased strength), our patient's alternative, compensatory strategy in and of itself, limited optimal use of the hemiparetic UE and interfered with successful task completion. 21 This hypothesis is similar to that proposed by Cristea et al, and others that have described compensation by patients with stroke as increased use of the redundancy of the motor system by recruiting excessive movements such as trunk and scapular movement. 21–23
Differences in movement strategies between the patient's performance and a nonstroke performance of the task, led to the development of a task specific intervention. 24 Working within the context of the task, our goal was to discourage a strategy for task performance in which our patient demonstrated, what Cirstea et al23 refers to as, ‘altered degrees of freedom to compensate for motor deficits.’ Instead, we attempted to promote a strategy that improved management of the degrees of freedom more characteristic of the nonstroke performance.
The focus of this case report is the use of movement analysis to guide both assessment of ineffective movement strategies and development of task specific intervention. The outcome of these 2 processes was to improve capability of the impaired UE despite chronic and severe deficits following stroke. This was achieved by using task specific training, which is a concept often used by physical therapists, but in the context of patients with chronic stroke and severe UE deficits, it often takes the form of teaching functional compensations (ie, use of the unimpaired UE) rather than improved use of the severely impaired limb.
RC is a 64-year-old male who sustained a right-sided ischemic stroke in the middle cerebral artery 4. 5 years ago, resulting in left sided weakness. He received standard inpatient and outpatient physical therapy, and continued to participate in adaptive physical education classes. At the time of this intervention, he was independent with ambulation in the community using a single point cane and left solid ankle-foot orthosis. Additionally, he was independent in all self-care activities. He accomplished all self-care and recreational activities without using his left UE. Tasks he deemed to have a higher demand for bilateral UE use such as cooking he deferred to his daughter.
RC's goal was to increase the use of his left UE in daily tasks, such as carrying a tray of food and using his left UE to stabilize a bottle while he opened it. The specific task described in this case report is that of carrying a load of laundry. RC's goal was to carry one load of laundry (approximately 8 pounds) in a two-handed laundry basket approximately 300 feet to an adjacent community laundromat. Entering the laundromat required that he negotiate one step. RC was seen as a participant in the University of Southern California's Physical Therapy program, therefore insurance restrictions were not a concern.
RC's disability was his inability to independently care for himself in the community, requiring assistance for bilateral UE tasks. At the time of initial examination, RC reported that he was not doing his own laundry at a community laundromat due to his inability to consistently manage the laundry basket the distance from his home to the laundromat and negotiate one step.
The functional limitations contributing to the above disability were his inability to reach forward and grasp a laundry basket and then ambulate without dropping its con-tents. 25 RC was unable to safely and consistently negotiate a curb while holding the basket. Functional limitations were measured by recording the time it took to complete 3 component parts of the total task. The 3 component parts were: (1) Basket Pick-Up and Walk Task, (2) Curb Task, and (3) Total time ambulating and maintaining grasp on the basket.
In addition, 2 types of examinations at the level of impairment were used to determine the physical therapy diagnosis to determine which impairments were underlying his functional limitations. 25–27 The 2 types of examinations were: (1) a standard neurological examination to evaluate isolated system deficits and (2) movement analysis to determine integrated multisystem deficits and compensation. 28 The neurological examination included the measurement of tone, synergy, range of motion, balance, strength, and sensation. The outcome of movement analysis was a qualitative description of RCs chosen movement strategy given the combined effect of his multiple isolated impairments, as well as his compensation for those impairments.
Objective Functional Measures
Timed measures were used to characterize the functional limitations. These times are presented in Table 1. The distance of 10 meters was chosen because the patient could consistently walk 10 meters over level terrain while maintaining grasp of the basket. All tasks were performed with one 8-pound load of laundry. The average of 3 timed trials was recorded.
1) Basket Pick-Up and Walk Task.
The laundry basket was set on a surface 18 inches high (approximately knee height). RC was instructed to pick up the basket and walk 10 meters over level terrain when signaled.
2) Curb Task.
While holding the laundry basket, RC walked 10 meters, stepped off a curb (6 inches), turned 180?, stepped back up the curb, and walked back to the starting point while maintaining grasp of the basket. Total distance 20 meters.
3) Total time ambulating and maintaining grasp on basket. This measure consisted of the total time that RC could maintain grasp of the basket while ambulating over level terrain. It did not include the time to pick up the basket.
Impairments Isolated system impairments
Only those measures hypothesized to contribute to the functional limitations are presented in Table 1. Total UE Fugl Meyer motor score was 18 out of possible 66. Upon raising his left arm, RC would elevate his scapula, abduct the humerus, and flex the elbow, thus achieving the full flexor synergy of the Fugl-Meyer. He was able to partially perform the extensor synergy of the Fugl Meyer, with limited elbow extension. He was unable to combine movement synergies or move out of synergy (part IV and V of the Fugl Meyer -not included). Every attempt to move the arm resulted in the flexor synergy pattern. Voluntary hand function was absent (part VIII). Grip strength, measured by hand-grasp dynamometer was 7 kg compared to 86–92 kg for age matched non-stroke male. 29 RC's score on the Fugl-Meyer Balance assessment was 10 out of 14. He was unable to stand solely on the affected or unaffected lower extremity for longer than 1 to 2 seconds. The significant ROM limitations were left active elbow extension of −20° and passive wrist extension of 10°.
Movement analysis involved a detailed, qualitative account of the patient's total body movement patterns (using biomechanical descriptors such as alignment of body segments and the sequencing of movement components) during task performance. 28 The patient's performance was then compared to nonstroke performance under conditions of no deficits from stroke. 28 Preintervention performance of the task was recorded on videotape and used to confirm observations. Observational assessment was qualitative without the aid of EMG or motion analysis. This method resembled the resources that would be available to an outpatient clinician.
Based on video movement analysis, the task of carrying a laundry basket was divided into 2 basic phases that incorporated the functional limitations identified above (1) reaching and grasping the basket, and (2) walking while holding the basket including going up and down a curb.
Phase 1: Reaching & Grasping: Inability to Reach Toward Target with Shoulder Flexion and Elbow Extension
When attempting to raise his left UE in reaching tasks, RC used scapular elevation. 1 This was followed by scapular abduction, 2 slight upward rotation, 3 humeral abduction, and internal rotation, as well as elbow flexion. RC brought his left hand closer to the basket handle through a combination of horizontal humeral adduction and forward trunk flexion initiated at the hip. He then used his right hand, to guide the left to the basket handle.
RC reached toward the left basket handle with left humeral abduction and scapula elevation resulting in a hand position that was perpendicular to the basket handle with fingers pointed inferiorly and his wrist in a flexed position. No voluntary increase grasp of the left basket handle was observed. Left fingers were passively wrapped around the basket handle by the right hand.
Phase 2: Walking with the Basket Limited isometric grasp endurance with ambulation
RC exhibited limited grasp endurance while trying to maintain hold of the basket handles and ambulate. While ambulating with the basket, his UE alignment was such that the left scapula was positioned in abduction and elevation, the humerus abducted and internally rotated, with the elbow away from his body. The left handle would gradually slip from his hand. For the brief time that he was able to hold the basket while ambulating, he carried it with handles at the level of his greater trochanter with the left handle inferior to the right. He was unable to hold the basket away from his body, contributing to his bilaterally shortened step length as his upper thighs hit the basket with each step. Single limb stance time was uneven with less time on the left leg. During left stance phase he exhibited left trunk lean with further left humeral abduction. The lateral trunk deviation was often accompanied by loss of the basket from the left hand.
Limited single limb stance time in transitions up and down one step
Holding the laundry basket with bilateral UEs, precluded RC from using his cane to negotiate curbs. He stepped off the curb with his left leg, using his right leg to lower himself. Immediately upon placing his left leg down, he stepped quickly down with his right leg resulting in a minor loss of balance. RC was able to independently recover and remain upright by utilizing a step strategy and widening his base of support. Grasp of the basket was compromised as it was observed to fall further inferior on the left.
Based on the examination the physical therapy diagnosis for RC was an inability to carry the laundry basket secondary to: (1) UE movement limited to flexor synergy, (2) decreased elbow and wrist extension, (3) decreased grip strength, (4) decreased single limb balance, and (5) compensatory trunk and scapula movements (specifically left lateral trunk lean and scapula abduction and elevation while reaching for and carrying the basket).
Based on the chronic nature of RC's deficits we hypothesized that intervention would not improve volitional movement capability as determined by the Fugl-Meyer or grip strength, but would impact his ROM deficits, decreased balance, and his compensatory movement strategies. Additionally, we hypothesized that by addressing the compensatory movement (excessive trunk and scapular movements), his ability to use his left UE to maintain hold of the basket would improve. While left UE and lower extremity strength were not specifically measured, the observed scapula elevation and abduction upon initiation of arm movement may have been an attempt to raise the arm against gravity to compensate for shoulder weakness. Further, the trunk lean may have been an attempt to limit weight support on the left leg.
RC was seen for 8, one-hour treatment sessions, one session per week. Intervention included task specific training with modifications made to progress RC to his goal and activities to minimize compensations of excessive trunk and scapula motion. For purposes of this case report, intervention is detailed within the 2 basic phases of the task. Specific impairments (see Table 1) were treated within the context of the modified task specific activities outlined below. The one exception was passive wrist extension ROM in which soft tissue and joint mobilization techniques were performed for 15 to 20 minutes for the first 6 sessions. Only those interventions thought to be most beneficial in progressing RC toward his specific goal are presented.
Phase 1: Reaching & Grasping: Inability to Flex Shoulder with Elbow Extension in Reaching Toward Target
We hypothesized that the initiation of arm movement with scapular elevation and abduction followed by humeral abduction contributed to RC's inability to reach forward toward the handle using shoulder flexion with elbow extension. Therefore, intervention focused on scapular stabilization in order to control the degree of scapular motion while reaching and discourage the patient's preferred pattern of excessive scapular elevation and abduction.
RC performed closed chain activities to encourage scapular stabilization. He was challenged to move his body in relation to his fixed left arm, such as having him transition from sitting to left side lying with the left UE being actively loaded as part of his base of support. This was progressed to a modified quadruped position on his forearms to promote loading and weight bearing through the shoulder.
The following sequence of treatments was used to provide feedback to RC regarding his scapular positioning in standing. A 3-foot rod was placed horizontally behind RC's back hooking both of his elbows (Figure 1). This caused both scapulas to be held in a more adducted position in order to stabilize the rod. In this alignment of scapular and humeral adduction, with the rod in place, RC held a series of objects (pillow to large ball to laundry basket) that were hypothesized to require progressively greater scapular stabilization. Eventually, these objects were held without the rod to gradually reduce external cueing.
Recall that RC attempted to grasp the left basket handle using a movement pattern of scapula elevation and abduction along with humeral abduction and internal rotation that placed his flexed wrist and fingers perpendicular to the basket handle. By having RC maintain his scapula in a position of adduction and his elbow against his trunk, his palm/hand emerged parallel to the handle enabling him to use his palm as a contact surface for grasping.
Phase 2: Walking with the Basket
1) Limited isometric grasp endurance with ambulation. While RC had several difficulties in maneuvering the laundry basket, a key limitation was his tendency to drop the basket while walking. It was hypothesized that RC's initial left arm position (scapula abduction and elevation, humeral abduction and internal rotation, with the elbow away from the body) in combination with excess trunk motion during gait (left lateral trunk lean during left stance) limited his ability to maintain hold of the basket. Specifically, when RC's trunk leaned left during the left stance phase of gait, the left arm (elbow) came further away from his trunk. This arm position essentially ‘pulled’ his left hand away from the handle and he was unable to maintain the basket.
To resolve these arm and trunk deviations, RC was asked to maintain his scapula adduction described earlier while walking and holding a large ball. Then a flat tray was balanced on top of the ball (Figure 2). Later, cups were added atop the tray. Success in this task required that RC ambulate with a stable trunk alignment (ie, decreased coronal plane deviations). These tasks were performed under variable practice conditions (ie, tile, low carpet, through doorways).
The task of holding a tray atop a ball was later progressed and made more task specific with a laundry basket. Once this was mastered the task was intensified by having RC hold the laundry basket with 3 cups of water placed on the bottom of the basket. He was instructed not to spill the water, requiring that he maintain scapula adduction and a level trunk and pelvic position.
2) Limited single limb stance time in transitions up and down one step.
The above manipulations with the basket were practiced during lower extremity balance activities and progressed to the specific task of carrying the basket up and down one curb. For example, while maintaining the basket with the left arm positioned against the trunk (ie, scapular and humeral adduction and humeral external rotation to neutral), RC was asked to assume and maintain a stride stance on level ground. The right foot was then placed on progressively elevated surfaces (2–8 inches) biasing greater support through the left lower extremity. RC then practiced shifting his weight in all directions over the left lower extremity. Single limb balance activities were progressed to stepping up and down from a curb while maintaining grasp of the laundry basket.
At the conclusion of the 8 treatment sessions, RC improved functional use of his left UE for his specific goal of carrying a laundry basket. As such, he was now able to do his own laundry at the community laundromat. He was able to reach forward towards the laundry basket, maintain grasp of the laundry basket handle on the left side while ambulating 300 feet (to community laundromat), and negotiate one curb while maintaining bilateral grasp of laundry basket.
Objective Functional Measures
RC improved in all preintervention functional measures (Table 1). His time for the ‘Basket Pick-Up and Walk Task’ improved from 26. 3 seconds to 18. 0 seconds, a 31. 5% change. The ‘Curb Task’ improved from 57. 0 seconds to 51. 0 seconds, a 10. 5% improvement. His total time ambulating while holding the basket with one load of laundry improved from 57. 0 seconds to 5 minutes, representing a 426% change. Additionally, RC was also able to ambulate over a variety of surfaces (low-carpet, tile, doorways, ramps, 1 step) without losing grip of the basket or losing his balance.
Isolated system impairments
RC showed minimal changes in isolated impairment measures after 8 weeks of therapy (Table 1). His Fugl-Meyer UE motor and balance scores were unchanged at 18/66 and 10/14, respectively. RC improved left active elbow extension and increased passive left wrist extension.
RC was videotaped at the conclusion of 8 weeks of therapy. Postintervention videotaped performance of the task was compared to the preintervention assessment.
Phase 1: Reaching & Grasping: Inability to Flex Shoulder with Elbow Extension in Reaching Toward Target
When reaching toward the basket handles, RC initiated the motion with left UE shoulder flexion. Scapular elevation and abduction, as well as humeral abduction and internal rotation were decreased compared to preintervention video performance. He continued to require right hand assistance for left hand grasp of the handle. Therefore, while actual voluntary grasp of the handles with finger flexion did not change his initial approach toward the basket did.
His postintervention position of scapular adduction paired with humeral external rotation to neutral enabled a hand position with the palm more parallel to the basket handle. This change of proximal positioning allowed the left palm to be used as a contact surface.
Phase 2: Walking with the Basket Limited isometric grasp endurance with ambulation
The most notable improvement RC made was maintaining grasp of the basket while walking. The change in left UE position (towards scapula adduction and depression as well as humeral adduction and external rotation) enabled RC to maintain hold of the basket while walking. During left single limb stance, left lateral trunk lean was reduced as evidenced by shoulders maintaining a level position throughout the gait cycle. It appeared that the decrease in both trunk lean and scapula elevation contributed to RC maintaining left scapula adduction. The improved scapula adduction, in turn assisted in minimizing humeral abduction and internal rotation. This resulting UE position appeared to enable RC more control with holding the basket, with his left palm parallel rather than perpendicular to the basket handle. Additionally, RC was able to actively flex both left and right shoulders to bring the basket away from his body while walking, such that the basket itself no longer posed an obstacle to swing limb advancement. This combined with the ability to hold the basket above his greater trochanter enabled him to advance the swing limb without hitting the basket with his thighs. Finally, left single limb stance time as well as step length now appeared to be equivalent to the right side potentially contributing to RC's improved times on the chosen functional measures with increased velocity when ambulating and holding the basket.
Limited single limb stance time in transitions up and down one step
RC was able to make use of improved trunk and shoulder alignment while progressing up and down one step with the laundry basket. He was now able step down with his right lower extremity (while supporting on the left lower extremity) without loss of balance. Additionally, his scapular position appeared to contribute to his ability to use forward shoulder flexion to move the basket away from his legs and assess his foot placement and depth of the step, a maneuver he was not able to do preintervention (Figure 3). Previously, any such motion with the basket would cause him to lose his left grip. The improvement in basket handling as well as lower extremity stance stability enabled RC to improve his time on the ‘Basket Pick-Up & Walk Task’ and the ‘Curb Task.’ The movement of his legs no longer disturbed his grasp while walking or transitioning up and down the curb resulting in faster task performance.
At the 20-week follow-up with no therapy from week 8 to week 20, RC reported continued ability to do his own laundry. Concomitantly, he demonstrated continued improvement in the objective functional measures. For ‘Basket Pick-Up and Walk Task,’ his time continued to improve from 26. 3 seconds at initial evaluation, to 18. 0 seconds at postintervention assessment, and then to 9. 3 seconds at follow-up, an overall change of 65%. For the ‘Curb Task,’ his time also continued to improve from 57. 0 seconds at initial evaluation, to 51. 0 seconds at postintervention assessment, and then to 41. 7 seconds at follow-up, an overall change of 27%. Fugl Meyer UE motor scores and balance scores did not change, 18/66 and 10/14 respectively.
At the 20-week follow-up, RC reported independence with the task of picking up a laundry basket, carrying it, and progressing up and down one step. He reported feeling more confident that he would not suddenly drop the basket. RC recognized that he had improved capabilities with his left UE when he stabilized his scapula and trunk position.
This case report describes the effective use of movement analysis to increase functional use of the UE in an individual with chronic, severe UE deficits following a stroke. Analysis of movement during performance of the patient's chosen task revealed a strategy in which our patient demonstrated ‘altered degrees of freedom to compensate for motor deficits.’22, 23 We hypothesized that these movement alterations further limited the potential for use of his severely impaired left UE. Intervention was then directed at resolving or minimizing those movement alterations, thus affording RC greater use of his left UE despite persistent deficits in volitional movement capability.
Functional Measure vs. Impairment Measures
Based on measures of impairment and chronicity of stroke, one would not predict any increased use of RC's left UE. 31 The postintervention measures, however, illustrate a substantial improvement in functional capability specific to RC's goal despite no improvements on standardized measures of UE impairment such as the Fugl-Meyer UE motor score, Fugl-Meyer balance score, and grip strength. For example, his grip measures did not change, yet he was able to progress from a short duration of sustained grasp of the laundry basket (57. 0 seconds) to maintained grasp of the basket handles while walking for extended length of time (5 minutes) (Table 1). The improved sustained grasp of the basket without changes of handgrip measures may be explained by RC's position of scapular adduction and depression and decreased lateral trunk lean enabling greater use of shoulder horizontal adduction to maintain the basket between his UE.
Cirstea and colleagues work may be used as an explanation for improved functional use of the UE without concomitant change in standardized measures of impairment. 23 Excessive trunk and scapular movements with attempts to use the affected arm following stroke, are described as an exploitation of the redundancy of the motor system. 22, 23 In light of shoulder weakness poststroke, scapular elevation may be the most parsimonious solution for managing the weight of the limb against gravity in order to raise the arm. However, some underlying capability an individual may have to recruit shoulder flexors may then be masked. By restricting excessive trunk and scapular movements, RC attained greater functional use of the UE and demonstrated some increased ability to flex his shoulder. This suggests that his compensatory strategy in and of itself, limited optimal use of the hemiparetic UE. 21, 23
The UE Fugl-Meyer motor assessment is used to determine the volitional movement capability of the hemiparetic arm 32–34 and also is used as a predictor of UE functional recovery. 34 The Fugl-Meyer is not intended to identify nor implicate compensatory motions (ie, scapular position and trunk lean) that may be further compromising already impaired UE capabilities. In RC's case, modification of his preferred strategy for arm elevation (scapular elevation and abduction to move the arm and to stabilize an object) appeared to be essential for increasing functional use of his UE in his chosen task. Despite these changes in functional performance of his goal task, there was no change in UE Fugl-Meyer motor score. It is possible that the UE Fugl-Meyer motor assessment was not sensitive enough to capture the subtle changes in movement capability that contributed to his modified movement pattern for arm reach. This illustrates the beneficial use of movement analysis in determining how overall altered movement strategies proximal to the arm may be limiting functional potential of the arm.
We expected that RC's improved capability for negotiating curbs might be reflected in the Fugl-Meyer balance score. Again, there was no change in single limb balance. Higher scores on the Fugl-Meyer balance assessment are obtained as time on single limb is increased. RC demonstrated improved capability to support body weight on the left lower extremity, but only under the condition of partial double limb support (ie, contact of the right lower extremity on an elevated surface). This improved capability may have afforded him greater control for the short period of time that his right lower extremity ascended or descended the curb. Greater challenges to and more practice of left lower extremity support might eventually enable RC to support his body weight on a single limb for enable RC to support body weight for the 10 seconds required by the Fugl-Meyer.
The outcome of this case report differs from a study conducted by Feys et al in which UE sensorimotor stimulation was provided for patients with severe UE deficits acutely post-stroke. Significant changes in UE Fugl Meyer motor scores but not in overall UE function were found. 19 The difference in outcome between Feys et al and the present report may be related to the different hypotheses driving the interventions. The intervention of Feys and colleagues was an attempt to improve motor recovery of the affected UE through repeated stimulation of muscle activity. The intervention detailed in this report was motivated by the idea that the patient had organized his degrees of freedom for use of his UE in a less than optimal way. We speculate that the intervention benefited the patient by introducing an alternative solution for accomplishing the task that did not rely on motor recovery of the UE.
Bonifer & Anderson used CIT with a patient with chronic, severe UE deficits and found only slight improvement in impairment level measures with no change in functional use of the UE. 20 The authors suggested that an alternate treatment approach for patients with severe UE deficits be the use of closed chain activities to promote shoulder girdle stability. The successful application of closed chain proximal training in the present case lends some support for the idea of developing proximal shoulder motor control to enable more distal function of the UE.
Similar to the findings in this case report, the contribution of trunk deviations to UE limitations, also was demonstrated in a study by Michaelsen and colleagues. 35 They found functional changes in reaching tasks in patients with stroke by addressing excessive trunk motion that occurred simultaneously with the arm reach. When the trunk motion of these patients was restrained during reaching tasks, improvement in distal function of the elbow and shoulder motion was observed. 35 Therefore, by determining movement compensations that contribute to abnormal extremity patterns and illustrating to patients the cost of those compensations, functional improvements of the extremity may be made.
Hypothesized Reason for Functional Changes
Investigations of intervention techniques for patients with chronic strokes and mild to moderate UE deficits, have focused on specific tasks to be completed with the hand, without analysis of movement patterns used by the subject as the task is performed. 2–7, 10, 12, 20, 36, 37 Presumably, for patients with greater spontaneous recovery post stroke, movement deviations in other body segments have less impact on UE capability. However, for patients with less volitional UE capability, analysis of the total body movement during task performance may reveal that some underlying capability of the limb is hindered by compensatory motions in linked segments.
Learning to manage a laundry basket poststroke is a task that might well be addressed by focusing on use of the hand for holding an object. However, if that had been the approach taken with RC, he may not have achieved his goal. By focusing on those aspects of his movement (ie, initiation of arm movement with scapular elevation; lateral trunk lean in gait) presumed to compound his already significant problems with using his left hand, his overall functional capacity to use his left UE and hand in holding an object improved. Additionally, the treatment sessions enabled RC to recognize that there was a relationship between changes he made in his proximal shoulder and trunk movements and improvement in the use of his left UE.
RC's continued improvement at 20 weeks, in the ‘Basket Pick-Up and Walk Task,’ and the ‘Curb Task’ demonstrated that he was able to build upon the skills he attained during treatment. This may be attributed to his continued practice once the treatments ended. Even with the continued improvement, RC required focused attention on task performance as evidenced by decreased verbalization. Given the chronicity and severity of his deficits, he may need more extensive practice to make this task more automatic.
Further investigation of effective interventions for patients with chronic strokes and severe UE impairments is needed. Given the chronic and severe nature of RC's UE deficits, he would most likely not have qualified for intensive physical therapy services under current health insurance guidelines. Future studies with a larger patient sample should be undertaken to determine the benefit of movement analysis (for identification of ineffective compensations) paired with task specific training (to minimize compensations) for individuals that do not qualify for focused UE intervention. Demonstrating the effectiveness of this approach in a larger sample of subjects could lead to changes in the current insurance guidelines for services that are considered reimbursable.
Reliability of movement analysis should be established through multiple evaluators. However, the contribution of excess motion at other joints to UE motor deficits might be identified more readily and would be quantifiable with the use of motion analysis.
This case report describes how increased functional use of the hemiparetic UE is possible in a patient with chronic stroke and severe loss of UE motor function. Upper extremity goals are traditionally addressed by focusing on the ability to move the hand, however, the contribution of excess motion at other joints and their impact on UE function needs to be considered. The observed movement pattern RC used to perform his chosen task limited goal achievement: carry a laundry basket with both upper extremities 300 feet while negotiating one curb. Using information gained from both the neurologic examination as well as movement analysis, we hypothesized that the observed movement pattern is the result of both impairments directly related to the stroke as well as compensations for those impairments through altered movement strategies. Thus, movement analysis can be used to determine how compensatory movement strategies may be limiting functional potential as well as guide task specific training towards one's goals. Overall, this case report illustrates the potential for functional recovery despite the chronic nature and severity of a stroke and reveals an effective intervention strategy (task specific training in the context of movement analysis) for retraining functional use of the hemiparetic UE in individuals that lack the volitional movement capability to benefit from intensive practice of the affected UE.
1 Winstein CJ, Rose DK, Tan SM, Lewthwaite R, Chui HC, Azen SP. A randomized controlled comparison of upper extremity rehabilitation strategies in acute stroke: Immediate and longer-term outcomes. Arch Phys Med Rehabil. 2004;85(4):620–628.
2 Page SJ, Sisto S, Johnston MV, Levine P, Hughes M. Modified constraint-induced therapy in subacute stroke: a case report. Arch Phys Med Rehabil. 2002;83:286–290.
3 Blanton S, Wolf S. An application of upper-extremity constraint-induced movement therapy in a patient with subacute stroke. Phys Ther. 1999;79:847–853.
4 Kunkel A, Kopp B, Muller G, et al. Constraint-induced movement therapy for motor recovery in chronic stroke patients. Arch Phys Med Rehabil. 1999;80:624–628.
5 Miltner WH, Bauder H, Sommer M, Dettmers C, Taub E. Effects of constraint-induced movement therapy on patients with chronic motor deficits after stroke: a replication. Stroke. 1999;30:586–592.
6 Van der Lee JH, Wagenaar RC, Lankhorst GJ, Vogelaar TW, Deville WL, Bouter LM. Forced use of the upper extremity in chronic stroke patients: results from a single-blind randomized clinical trial. Stroke. 1999;30:2369–2375.
7 Whitall J, McCombe WS, Silver KH, Macko RF. Repetitive bilateral arm training with rhythmic auditory cueing improves motor function in chronic hemiparetic stroke. Stroke. 2000;31:2390–2395.
8 Nakayama H, Jorgensen HS, Raaschou HO, Olsen TS. Compensation in recovery of upper extremity function after stroke: the Copenhagen Stroke Study. Arch Phys Med Rehabil. 1994;75:852–857.
9 Butefisch C, Hummelsheim H, Denzler P, Mauritz KH. Repetitive training of isolated movements improves the outcome of motor rehabilitation of the centrally paretic hand. J Neurol Sci. 1995;130:59–68.
10 Dromerick AW, Edwards DF, Hahn M. Does the application of constraint-induced movement therapy during acute rehabilitation reduce arm impairment after ischemic stroke? Stroke. 2000;31:2984–2988.
11 Levy CE, Nichols DS, Schmalbrock PM, Keller P, Chakeres DW. Functional MRI evidence of cortical reorganization in upper-limb stroke hemiplegia treated with constraint-induced movement therapy. Am J Phys Med Rehabil. 2001;80:4–12.
12 Liepert J, Bauder H, Wolfgang HR, Miltner WH, Taub E, Weiller C. Treatment-induced cortical reorganization after stroke in humans. Stroke. 2000;31:1210–1216.
13 Page SJ, Sisto SA, Levine P. Modified constraint-induced therapy in chronic stroke. Am J Phys Med Rehabil. 2002;81:870–875.
14 Page SJ, Sisto SA, Levine P, Johnston MV, Hughes M. Modified constraint induced therapy: a randomized feasibility and efficacy study. J Rehabil Res Dev. 2001;38:583–590.
15 Taub E, Miller NE, Novack TA, et al. Technique to improve chronic motor deficit after stroke. Arch Phys Med Rehabil. 1993;74:347–354.
16 Wolf SL, Blanton S, Baer H, Breshears J, Butler AJ. Repetitive task practice: a critical review of constraint-induced movement therapy in stroke. Neurology. 2002;8:325–338.
17 Sunderland A, Fletcher D, Bradley L, Tinson D, Hewer RL, Wade DT. Enhanced physical therapy for arm function after stroke: a one year follow up study. J Neurol Neurosurg Psychiatry. 1994;57:856–858.
18 Taub E, Uswatte G, Morris DM. Improved motor recovery after stroke and massive cortical reorganization following Constraint-Induced Movement therapy. Phys Med Rehabil Clin N Am. 2003;14(1 Suppl):S77-91, ix.
19 Feys HM, De Weerdt WJ, Selz BE, et al. Effect of a therapeutic intervention for the hemiplegic upper limb in the acute phase after stroke:a single-blind, randomized, controlled multicenter trial. Stroke. 1998;29:785–792.
20 Bonifer N, Anderson K. Application of constraint-induced movement therapy for an individual with severe chronic upper-extremity hemiplegia. Phys Ther. 2003;83:384–398.
21 Roby-Brami A, Feydy A, Combeaud M, Biryukova E V, Bussel B, Levin MF. Motor compensation and recovery for reaching in stroke patients. Acta Neurol Scand. 2003;107:369–381.
22 Levin MF, Michaelsen SM, Cirstea CM, Roby-Brami A. Use of the trunk for reaching targets placed within and beyond the reach in adult hemiparesis. Exp Brain Res. 2002;143:171–180.
23 Cirstea MC, Levin MF. Compensatory strategies for reaching in stroke. Brain. 2000;123(Pt 5):940–953.
24 Morris ME. Movement disorders in people with Parkinson disease: a model for physical therapy. Phys Ther. 2000;80:578–597.
25 Quinn L, Gordon J. Functional Outcomes. Documentation for Rehabilitation. 1st ed. Saint Louis, Mo: Saunders; 2003.
26 Rose SJ. Physical therapy diagnosis: role and function. Phys Ther. 1989; 69:535–537.
27 Sahrmann SA. Diagnosis by the physical therapist–a prerequisite for treatment. A special communication. Phys Ther. 1988;68:1703–1706.
28 Fisher BE, Yakura J. Movement analysis:A different perspective. Orthop Phys Ther Clin N Am. 1993;2:1–14.
29 Magee D. Forearm, Wrist, and Hand. Orthopedic Physical Assessment. Philadelphia, Pa: WB Saunders; 1997:275–330.
30 The shoulder complex. In: Norkin CC, Levangie PK, ed. Joint Structure and Function: A Comprehensive Analysis
. Philadelphia, Pa: FA Davis Company; 1992:207–261.
31 Duncan PW, Goldstein LB, Horner RD, Landsman PB, Samsa GP, Matchar DB. Similar motor recovery of upper and lower extremities after stroke. Stroke. 1994;25:1181–1188.
32 Duncan PW, Propst M, Nelson SG. Reliability of the Fugl-Meyer assessment of sensorimotor recovery following cerebrovascular accident. Phys Ther. 1983;63:1606–1610.
33 Gladstone DJ, Danells CJ, Black SE. The Fugl-meyer assessment of motor recovery after stroke: a critical review of its measurement properties. Neurorehabil Neural Repair. 2002;16:232–240.
34 Shelton FD, Volpe BT, Reding M. Motor impairment as a predictor of functional recovery and guide to rehabilitation treatment after stroke. Neurorehabil Neural Repair. 2001;15:229–237.
35 Michaelsen SM, Luta A, Roby-Brami A, Levin MF. Effect of trunk restraint on the recovery of reaching movements in hemiparetic patients. Stroke. 2001;32:1875–1883.
36 Taub E. Constraint-induced movement therapy and massed practice. Stroke. 2000;31:986–988.
37 Taub E, Morris DM. Constraint-induced movement therapy to enhance recovery after stroke. Curr Atheroscler Rep. 2001;3:279–286.
task specific training; observational movement analysis; CVA; rehabilitation; learning
© 2004 Neurology Section, APTA