EPISODE TITLE:  Reconnecting With Your Hand After Stroke Parts 1 & 2

EPISODE SUMMARY: In this episode of NOGGINS & NEURONS: Brain Injury Recovery Simplified, Deb and her level II fieldwork student Zoe talk with two D’Youville students Abigail and Olivia  about all topics regarding hands after stroke with emphasis on recovery. We covered: 

  • Introduction from Deb’s level II fieldwork students Zoe: D’Youville student introductions
  • Topic introduction: Students discuss different hand impairments discussed seen during fieldwork placements 
  • Introduction of flaccidity and static splinting:
    • Use as natural as possible if using one
      • Deb and students discussed shoulder girdle for upper extremity during therapy and uses during fieldwork
    • Deb made note to “never pull on arm/upper extremity during activities or transfers”
    • Schedules and proper don-doff procedures
    • Deb made note about not liking low muscle tone splinting unless possibility for subluxation (popping out of shoulder socket) or injury prone with neglect/forgetfullness of that limb
    • Neglect and sensory impairment briefly noted with concern for injury
    • Strategies with slings for the upper extremity to prevent subluxation of limb if applicable
    • Abigail discussed use of trays for UE positioning to prevent injury
    • Fear of transferring: getting limb with low sensation and muscle tone stuck
    • Discussion of injury prevention seen with untrained providers in hospital settings and the need to train mobilization of patients during transfers for safety
    • Deb and students mention the use of kinesiotape (KT) tape for incorporating sensory and awareness of hand positioning for strategy in joint positioning and decrease contracture
    • Slight introduction and awareness of preparatory activities and how they are used in OT
    • Importance of education for any strategies or interventions is needed for families/caregivers and patients
  • Spasticity introduction with a statistic found from students research provided
    • One combined flexed pattern (shoulder lift, bend elbow, wrist bends) causes shortening of muscles --> possible leading to contracture
    • Due to weak extensors flexors dominate leading to limitations of opening the hand for fine motor/precise movements
    • 80 % of post-stroke patients present with Upper limb limitations, motor deficits, and hemiplegia (https://www.mdpi.com/2077-0383/12/23/7497)
    • ”Upper limb spasticity affects 17–40% of people” 
    • Abigail and Olivia discuss about patient treatment with spasticity post stroke seen in fieldwork placement
    • Olivia and Deb describe vibration technique use within clinics to facilitate muscles that were not activating during movements that were considered “stuck” in this phase of recovery
    • Flexors are stronger more often than extensors causing contractures within hands  and development of flexion synergy
    • Gross grasp/release patterns and statistic found from students research provided
  • Introduction of electrical stimulation (ESTIM):
    • Examples: lifting and dropping towels during cleaning activity; picking up blocks and moving from one side of table to other
    • Deb and students explain how electrical stimulation (ESTIM/FES) was used within an intervention/prep activity for gross motor grasp/release patterns and how these can be used during ADL activities 
  • Range of motion (ROM) education and activities to maintain muscle length in order to prevent contractures within the hand and shoulder/upper extremity
    • Took not how important to not over work or stretch muscles with force, it can cause more harm than good 
    • Theraputty is a good tool to use for hand strengthening exercises
    • Importance of handouts, caregiver training, and education/mass practice 
    • Discussed that if patient is bored within room during recovery, to increase mass practice of exercises to regain range of motion (ROM) and strength
  • Deb mentioned strategies to improve active movement using hand-over-hand (HOH) techniques and resistive training 
    • Corticospinal tract (26:30) introduction and how it is important with movement within the hand/upper extremity
    • This is how flexion synergy can occur due to this impairment
  • Deb mentioned use of mirror therapy for these patients as a form of intervention to improve fine motor movements using repetition for brain to create neuroplasticity and reorganize brain patterns 
    • Importance of evidence-based practice for motor relearning strategies and excitement for participation in activities with patients
    • Abigail discussed use of mirror therapy in fieldwork placement with shoulder/upper extremity strategies
    • Olivia discussed her use of seeing mirror therapy in her fieldwork placements including applying a mirror therapy activity presentation for her final project at her fieldwork placement 
    • How important is to look back at our biases based on interventions and research to make sure up-to-date and specifically changing
  • Range of motion (ROM) and thumb exercise importance to regain function within hand 
  • Conclusion of first episode

Second Episode

  • Deb presents information about a document that should be used when working with stroke providers from Chapter 10 of the EBRSR for motor rehab interventions filled with multiple articles about need for repetition
    • In 2017 by Waddle et al. discussing the intensity of task-specific rehab (13.6 hours of task-specific training with x100 reps) 
    • In 2016 by Lang et al., discussed using 3200 reps of upper limb training 
  • If unable to physically move, patients want to do repetitions for brain engagement and if physically able to move use interventions giving ability to move with repetitions is even better 
    • ”If you can handle a little bit of frustration, it really helps your outcome!” - Olivia
    • Olivia provided small introduction of CIMT acknowledging safety, behaviors, and frustration
  • Frustration strategies and how to handle these situations with certain patients and stroke survivors using OT knowledge and core principles
  • Deb mentioned her new private practice with mirror therapy programs and acknowledged her level II fieldwork student Zoe helping with creating mental practice recordings to go along with the action observation videos for patients to use when at home during recovery
    • Mentioned Pete and his previous research with Dr. Paige about completing interventions cohesively with time control to improve stroke survivor mobility of the upper limb.
  • Students discuss two gaming articles on integrating fun and passion with therapy goals by improving fine motor control in hand movement and gross motor patterns with active engagement
  • Important article of sensory feedback leads to mastered fine motor movements (Post-stroke sensory deficits and re-education (https://www.cuh.nhs.uk/patientinformation/post-stroke-sensory-deficits-and-re-education/)
    • Sensory remediation: retrain and understand sensory input coming in using stereognosis which is the use of feeling and guessing what you are holding or touching without seeing and increase complexity as it becomes easier with less complex items
    • Sensorimotor article using vibration stimulation and mass practice (https://pmc.ncbi.nlm.nih.gov/articles/PMC9918228/): tried to increase threshold for less sensory input to feel what is being touched and increase motor outcomes at the end of the trial
    • Students talk about sensory integration interventions seen in fieldwork (sensory bins, prep activities)
  • Discussed safety within the kitchen such as using utensils, working with hot water, and heat appliances due to decrease sensation or impulsiveness
  • Interventions and compensatory strategies:
    • Different use of adaptive equipment: universal cuffs/built-up handles/dressing tools
    • Button hook used buttons and zippers for decreased fine motor movement
    • Slip-on shoes and elastic shoe laces for decrease hand strength and coordination
    • Women dressing adaptive styles 
    • Kitchen utensils to assist with hand movement
    • Use of dysem for small activities and safety along with during weight bearing activities
  • Recovery time periods: different for everyone
    • Deb’s article (A critical time period of recovery goes beyond 1 year post-stroke by Ballister et al.) 
    • 3-6 month critical window of heightened neuroplasticity post-stroke, but uncover gradient of enhanced sensitivity to treatment that expands farther beyond the "critical window”
    • Student article listed Recovery Time Periods below in Resources 
    • Deb and students provide articles that can show multiple timelines of recovery time periods
    • Neuroplasticity continuously occurs with constant recovery and engagement
  • Hope is always there for survivors and caregivers if you have positive mindsets to recovery and treatments; not all survivors experience spontaneous recovery or recover at the same time so take your time and remain open-minded
  • Final remarks for survivors and caregivers from Olivia, Abigail, Zoe & Deb

We hope you enjoyed this episode of Noggins And Neurons. As always, we want to hear from you! Email us at Nogginsandneurons@gmail.com

Show References

-Objectifying Measures of Post Stroke Hand Rehabilitation through Multidisciplinary Scales (https://www.mdpi.com/2077-0383/12/23/7497)

-Effect of Sensory Impairment on Hand Functional Improvement Through Therapy and Sensory Stimulation 

(https://pmc.ncbi.nlm.nih.gov/articles/PMC9918228/)

-Post Stroke Sensory Deficits and Re-education (https://www.cuh.nhs.uk/patientinformation/post-stroke-sensory-deficits-and-re-education/)

-Hand Resistive Therapy Exercises (https://journals.lww.com/ijpt/fulltext/2024/06010/therapeutic_putty_based_hand_strengthening.7.aspx)

-Hand Exercises for Finger and Thumb for Stroke Recovery (https://www.baystatehealth.org/articles/handexercises-for-strokerecovery)(https://journals.physiology.org/doi/full/10.1152/jn.91310.2008)

-Isometric and Voluntary Action movements for Hand Post Stroke (https://sci-hub.ru/10.1179/1945511915Y.0000000023)

-Video Gaming Article with Leap Motion Controller for Fine Motor Improvement (https://www.frontiersin.org/journals/neurology/articles/10.3389/fneur.2017.00654/full)

-Another Gaming Article for Hand Recovery (https://journals.sagepub.com/doi/abs/10.3233/NRE-192829)

-Recovery Time Periods and Critical Window (https://www.hopkinsmedicine.org/health/conditions-and-diseases/stroke/stroke-recovery-timeline)

- A critical time period of recovery goes beyond 1 year post-stroke by Ballister et al.

THERAPY PRACTICE RESOURCES:

DEB’S RESOURCES

PETE’S blog and book, “Stronger After Stroke: Your Roadmap to Recovery” 3rd edition: 

 

DORO’S OT PRACTICE – The Neuro Hub

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