D i s c u s s i o n A r t i c l e A r m F u n c t io n A f t e r S t r o k e - C a n W e M a k e A D if f e r e n c e ? A B S T R A C T : I m p a ir m e n t o f u p p e r lim b f u n c tio n is a s ig n ific a n t c a u s e o f f u n c tio n a l d is a b ility a fte r stro ke. B a s e d o n a r e v ie w o f th e lite ra tu re th is p a p e r d e fin e s u p p e r lim b f u n c t i o n a n d h ig h lig h ts s o m e o f th e r e le ­ v a n t r e c e n t d e v e lo p m e n ts in n e u ro p a th o lo g y . T h e e ffe c ts o f c h a n g e s in se n sa tio n , m u s c le r e c r u itm e n t a n d to n e a re d e sc rib e d . R e lia b le a n d v a lid o u tc o m e m e a s u r e s o f u p p e r lim b im p a ir m e n t a n d d is a b ility a re listed . T h e p r in c ip le s o f r e h a b ilita tio n a re d e s c r ib e d in te r m s o f tim in g o f re h a b ilita tio n , s e n s o r y re e d u c a tio n , m o to r c o n tr o l a n d fu n c tio n a l use. Q u e s tio n s a re r a is e d re g a rd in g th e n e e d f o r c o u n s e llin g f o r th e lo ss o f f i n e d is c r im in a tiv e h a n d f u n c tio n a n d f o r re se a rc h in to th is b e h a v io u r a l a s p e c t o f u p p e r lim b r e h a b ilita tio n . K E Y W O R D S : S T R O K E , U P P E R L IM B F U N C T IO N , R E H A B IL IT A T IO N . L FEARNHEAD’, CJ EALES', VU FRITZ2 1 Department of Physiotherapy, University of the Witwatersrand, Johannesburg 2 Department of Neurology, University of the Witwatersrand, Johannesburg Loss or limitation of upper limb func­ tional ability is a com m on result of stroke. Wade (1989) describes the fre­ quent but distressing experience o f meet­ ing stroke ‘patients nursing their “lost” arm and continually m ourning their loss’. H arwood et al (1997) researching the determ inants o f handicap one and three years after stroke dem onstrated the overriding importance of stroke severity (im pairm ent) and disability in determ in­ ing handicap ( ‘handicap’ is defined as the disadvantage resulting from ill-health and is an important measure of outcome in chronic disease). W yller et al (1997) found th at subjective w ell-being is decreased one year after stroke, and that it was mainly attributed to arm motor impairments. A study published in 1965 (Bard and Hirschberg) suggested that most upper limb recovery took place within the first three months follow ing the stroke. D un­ can et al (1994) concluded that recovery in mild to severely affected patients is alm ost com plete within one month and that more severely affected patients con­ tinue to show recovery up to 90 days and even up to six months provided they CORRESPONDENCE: Lynn Feam head Physiotherapy Department University o f the W itwatersrand Johannesburg 7 York Road, Parktown, 2193, South Africa showed some initial recovery within the first month. H ow ever as convincing as these statistics appear to be, in a small study by Taub et al in 1993, selected, motivated chronic stroke patients have demonstrated significant and long lasting improvements in upper limb function after a two week intensive rehabilitation programme. From the results of their controlled trials retraining the sensory function o f the hand in stroke patients Yekutiel and Guttm an (1993), and Carey et al (1993) concluded that som atosen­ sory deficit can be alleviated even years after stroke. This discussion paper defines upper limb function and highlights som e o f the relevant recent developm ents in neuro­ pathology, m easurem ent and rehabilita­ tion. DEFINITION OF UPPER LIMB FUNCTION: The primary function o f the upper limb is prehension which can be divided into two phases, reach and grasp. Ryerson and Levit (1997) suggest that the key com ponents of upper extremity function include (a) locating a target, requiring the co-ordination o f eye-head movements, (b) reaching, involving trans­ portation o f the arm and hand in space, (c) manipulation, including grip form a­ tion, grasp, and release, and (d) postural control. The coordination between reach and grasp is achieved by a sensorim otor process and is task specific (M arteniuk et al, 1990) e.g. catching a ball is quite different to picking up a glass o f water. For precision handling or ‘in-hand mani­ pulation’ the characteristic m uscle con­ traction is concentric, the pressure applied to the object is light and a major deter­ minant is that the position o f the object must change. Precision handling usually involves the index and middle fingers fingers and the thumb (Clarkson and Gilewich 1989). The hand has other functions. It is a sensory receptor, giving feedback for its own function. The hand also reinforces and trains visual appreciation o f shape, texture, space and thickness allowing the central nervous system to recognize objects by touch alone (stereognosis). Secondary functions o f the upper limb are for com m unication, protection, balance and stabilizing for bilateral activities. The appearance o f the arm is also im por­ tant in terms o f body image. This must not be underestim ated as, according to the psychologist Schilder, ‘body image is not a blueprint o f geometric relations but has emotional and symbolic significance and lies at the core o f the personality’ (Heim, 1997). PATHOLOGY The specific localization o f the infarct i.e. cortex or ascending and descending pathw ays appears to be critical for recovery - a small lesion in the internal c a p su le w ill re su lt in sig n ific a n tly greater disability than a lesion o f the same size in the cortex. The role o f the pyramidal tract in determ ining upper limb function has been the subject o f 4 SA Jo u r n a l o f Ph y s io t h e r a p y 1999 V o l 55 No 2 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) intensive research recently. Corticomo- torneurons and their descending tracts play an essential role in precise distal hand function. Experiments conducted on m onkeys dem onstrated little gross movement deficit soon after com plete section of the pyramidal tracts bilaterally. The m onkeys were able to sit, run and clim b in their cage with their head erect. H ow ever although they were able to use a pow er grip, they exhibited substantial deficits in the control o f fine indepen­ dent finger movements (Rothwell 1994). Bastings et al (1997) using motor evoked potentials to measure conduction in cen­ tral motor pathways concluded that hand motor recovery will not occur after infarct i.e. the hand will not respond to motor retraining, unless there is a measurable conduction velocity through a dam aged but still functional pyramidal tract. Researching the effects o f cortical infarct N udo et al (1996) found that after local dam age to the hand section o f the m otor cortex o f adult primates “rehabili­ tative training can shape subsequent reorganization in the adjacent intact cor- tex”- the surrounding undam aged cortex learned to control the m ovements the m onkeys had lost through the experi­ mental damage. This is in keeping with research by Byl and M elnick (1997) in which progressively more refined and differentiated cortical representation of skin, muscle, jo in t afferents and m otor movem ents are described in the cortical hand areas following specific training. It appears that a certain am ount o f neural plasticity can occur within the dam aged sensorim otor cortex in response to func­ tional need or retraining. IMPAIRMENT Sensory loss as well as loss o f more com plex perceptual functions (higher- order m otor planning and the formation o f action plans) has been found to be a factor contributing to inferior levels o f functional recovery as well as longer rehabilitation in several studies (Carey et al 1993). After losing sensation pa­ tients tend to develop a learned disuse phenomenon that leads to a further dete­ rioration o f m otor ability. Sensation of the glabrous skin o f the pad o f the thumb and the tips o f the fingers is particularly important for hand function. There is evidence that m uscle w eak­ ness, due to inadequate agonist recruit­ ment and reduced firing rates o f motor neurons, plays a dom inant role in the disturbance o f all active voluntary m ove­ ment (Fellows et al 1994). H ow ever as Rothwell (1994) states ‘the m ajor pro­ blem facing the m otor control system is not only to contract the agonist, or the prim e moving m uscle by the correct amount and at the appropriate time but also to time and organize the pattern of agonist, fixator and postural m uscle con­ tractions which are necessary to accom ­ pany its action’. Although the extent to which spasticity impairs upper limb function is unknown, it is seen clinically that undue effort e.g. in walking or using the affected or unaf­ fected upper limb, can result in the rein­ forcem ent o f stereotyped abnormal pat­ terns o f m ovem ent which then prevent functional skilled movements particularly o f the hand (Bobath, 1990). It is also accepted that some o f the resistance o f a m uscle to lengthening is due to changes in the intrinsic properties of the m uscle fibres themselves. Muscles held in the lengthened position will gain sarcomeres w hilst those in the shortened position lose sarcom eres thus changing the normal resting length o f the muscle. This can make a significant difference functionally e.g. it is particularly im por­ tant at the w rist jo in t to maintain the position best adapted for grasp i.e. 40-45 d eg rees o f w rist e x ten sio n and 15 degrees o f ulnar deviation. This is the position of maxim um efficiency o f the muscles o f the fingers especially the flexors (K apandjil982). The relative im m obilization following stroke produces viscoelastic changes in connective and neural tissue structures that in turn com prom ise normal m ove­ ment. MEASUREMENT An important aspect o f the research relating to stroke has been the develop­ ment o f valid and reliable m easurem ent tools of impairm ent, activities and par­ ticipation in life situations. It is essential to choose a measure that can detect the change expected from the process and outcom e o f rehabilitation e.g. the m easurem ent of grip strength is a very sensitive single measure after stroke (H eller et al, 1987). Sunderland et al (1989) described a correlation between grip strength and the degree o f functional m otor capacity according to several out­ com e measures ( M otricity Index, M otor Club Assessm ent, Frenchay Arm Test, 9- H ole Peg Test). The M odified Ashworth Scale is com m only used to assess m us­ cle tone (Bohannon and Smith 1987). The Barthel Index and the FIM have been criticized for not being specifically sensitive to upper limb disability (Feys et al, 1998) although they are both valid, reliable m easures o f stroke outcome. There are a num ber o f tests o f m ove­ ment and function that include sections for the upper limb. The M otricity Index, the Brunnstrom - Fugl-M eyer test, the M otor Assessm ent Scale, the Riverm ead M otor Assessment, the Nine Hole Peg test and the C hedoke-M cM aster Stroke A ssessm ent are fully described in ‘Phy­ sical R ehabilitation O utcom e M easures’ (1994) or ‘ M easurem ent in neurological rehabilitation’ (Wade, 1992). REHABILITATION A personal definition o f rehabilitation has the power to focus and direct therapy and while there are numerous definitions o f rehabilitation, the following, by Wade (1993) is com prehensive and in accor­ dance with the World Health O rganiza­ tions 1998 IC ID H -2 classification o f impairment, activities and participation. ‘Rehabilitation should aim: a) to maximize the patient’s role ful­ fillm ent and his independence in his environm ent, all within the limitations im posed by the underlying pathology and impairments and by the availability o f resources. b) to help the person to make the best adaptation possible to any difference be­ tween the roles achieved and the roles desired’. This is particularly important in upper limb rehabilitation as skilled hand function frequently cannot be achieved. TIMING OF REHABILITATION Ernst (1990) in his review o f physio­ therapy and stroke rehabilitation sug­ gested that “studies aimed at clarifying the issue o f optimal rehabilitation should begin therapy in the very early phase after the acute event” . Although there is no hard evidence to support a better functional outcom e if active therapy is begun early it is generally accepted that early therapy is im portant to maintain the biom echanical alignm ent necessary for potential recovery and to prevent SA Jo u r n a l o f P h y s io t h e r a p y 1999 V o l 55 No 2 5 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) com plications such as subluxation o f the glenohum eral joint, shoulder-hand syn­ drom e, and shoulder pain. There is evidence that suppression of movem ent or ‘learned disuse’ can occur post stroke (Taub et al, 1993). The cause o f this is explained in terms o f diaschisis - the functional depression o f intact neu­ rons in regions remote from damaged neurons although anato m ically c o n ­ nected. The implication is that rehabili­ tation can only occur after resolution of this shock-like state (weeks or months in monkeys). SENSORY RE-EDUCATION A five stage sensory re-education pro­ gram m e has been devised by Nakada and Uchida (1997) which can be used as a guideline for stroke hand rehabilita­ tion. The stages are; 1) F eature detection and recognition of objects, vision occluded, 2) Correction of the pattern o f prehen­ sion o f the hand, 3) Control of precise force for grasping objects, 4) Maintenance o f grasping force during m ovements o f more proximal joints, 5) M anipulation of objects. Yekutiel and Guttm ann(1993) in their study o f sensory function emphasized use o f sensory tasks which the patient can do and which he finds interesting, to promote learning. They also used vision and the ‘good’ hand to teach tactics of perception. MOTOR CONTROL Butefisch et al (1995) m easured the effects o f a stereotyped repetitive active training program m e o f the affected hand in 27 patients using a m ultiple baseline approach across individuals. They achieved a significant im provem ent in grip strength and the Riverm ead M otor assessm ent score. H um m elsheim et al (1997) com pared the use o f supra- threshold electrical stimulation o f wrist m uscles with the same training pro­ gram m e used by Butefisch in a small group o f stroke patients. Only the repeti­ tive training program m e produced a sig­ nificant im provem ent in the m ovement param eters. They ascribe the im prove­ ment being due to the proprioceptive and cutaneous impulses generated repeti­ tively and tim e-locked to the voluntary movem ent as being the basis for motor learning. A study by Feys et al (1998) to inves­ tigate the effects o f a specific therapeutic intervention on arm function in the acute stage after stroke only found motor recovery to be significantly better in the experimental group and ascribed this to the repetitive stimulation of m uscle acti­ vity in the arm. The therapeutic im pli­ cation o f these studies is that interven­ tions should be directed at recruitm ent o f muscle activity. O ther strategies have been used in an attem pt to improve m otor function for example, EMG biofeedback (M oreland and Thomson 1994), rapid brushing and vibration. Results of trials using these techniques has not consistently dem on­ strated their value in rehabilitation. (Good, 1994). Neuromuscular stimulation has been used effectively to reduce hand oedem a after stroke (Faghri, 1997) and there is some evidence that it enhances upper lim b m otor recovery o f acute stroke survivors (Chae et al, 1998). FUNCTIONAL USE It is generally accepted and research has dem onstrated that many stroke sur­ vivors have considerably more motor ability available than they make use of. (Taub et al, 1993; Rohrs and Graham 1996). In this latter study all subjects had a Brunnstrom stage 5-6 or 6 classifi­ cation im plying that they could perform normal m ovem ent patterns. H ow ever their quality o f movem ent was affected by speed, com plexity and co-ordination components. Patients had difficulty with activities such as handling money, fas­ tening a buckle, manipulating pegs and lacing a shoe. In the studies by W olf et al (1989) and Taub et al (1993) using strategies to overcome the learned disuse o f the hem i­ plegic arm in chronic stroke patients W olf and co-workers only restrained the unaffected upper limb. In T aub’s small study they combined restraint o f the unaffected limb with an intensive 14 day retraining program m e for the affected upper limb. There are two facts o f par­ ticular note in this research. Firstly the significant movem ent gains were main­ tained during a two year follow-up period and secondly a key selection criterion was that patients, seated with the fore­ arm supported, had to dem onstrate 20 degrees of active extension at the wrist jo int and 10 degrees extension at the me- tacarpo-phalangeal and proximal inter- phalangeal joints respectively. This could be used to identify chronic patients who may benefit from intensive short term rehabilitation. T aub’s research suggested that the deficit can be m inim ized by inhibiting the unaffected upper limb (restraint) com bined with intensive practice o f functional m ovement with the impaired limb. SUMM ARY Through the research that has been devoted to the functional recovery o f the upper limb after stroke in recent years the following com ponents in the rehabi­ litation process have been identified. • Measurement - sensori-motor, function. • Goal setting with the patient and team. • Prevention o f com plications (therapy and self-responsibility) - maintenance o f range o f movem ent, prevention o f pain and gleno-hum eral subluxation. • Sensory re-training - discrim inative, vision occluded, functional activity. • M otor re-training - muscle recruitment, repetition, reach and grasp, m anipula­ tion. • Functional reintegration - task orien­ tated, sensorimotor, repetition. S pecific rehabilitation program m es based on these com ponents still need to be developed and researched with the em phasis on m easurem ent of functional outcome, how ever there are indications that discrim inative sensory re-education, m ovem ent repetition and short intensive program m es may be particularly im por­ tant factors. It appears essential that we revise the com m on clinical practice o f the physio­ therapist treating the patients shoulder and arm with the occupational therapist treating the hand to one o f more shared responsibility for both reach and grasp. If it becom es evident that there is a poor prognosis for recovery o f fine dis­ crim inative hand function i.e. there is no im provem ent in sensorim otor function at six weeks post stroke or a month after starting therapy according to the pro­ gram m e outlined above, the focus of rehabilitation should shift towards the secondary functions o f the upper limb and counselling for the loss o f fine dis­ crim inative hand function must be con­ sidered. W hat is the best way o f helping our patients com e to terms with this 6 SA Jo u r n a l o f Ph y s io t h e r a p y 1999 V o l 55 No 2 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) loss? Will patient education help? Is ‘time the only healer’? This behavioural aspect has received little attention in the literature. 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