PART TWO:
I just wanted to offer some treatment suggestions to all of the members
of the group so we can start to get out of the topic of philosophy and
into real world suggestions for OTs working with the stroke population.
I want to make it clear that I do not spend a lot of time working with
patient's impairments when they have completely flaccid arms and no
potential of recovery based on many prognostic scales. For those
patient's I tend to focus on a) compensatory ADL and IADL stretegies b)
maintaining joint and muscle integrity through home
stretching/escercise program education and training c) UE support
systems for a comfortable mobile arm d) The use of E-stim training.and
educating the family on how to use the unit for hope of movement
recovery. Some patient's have surpirsed me over the years. It is
usually the patient's who you think will not do too well.
I tend to use two phases when helping a patient regain UE movement
depending on how much movement that they have a) Restoration of
impairments (PROM, AROM, Strength, Motor control) b) Occupational
restoration using a modified constraint induced movement progrqam
(MCIMP). In order for a patient to qualify for the OT restoration
MCIMP they have to be able to use their hemiparetic arm to reach for a
wash cloth placed on a table squeeze the wash cloth and then release it.
Two illustrate these two different program I wil offer a case study of
a real life stroke patient named Tracy (not the real name). Tracey
comes to the outpatient clinic once week and has been coming for two
months now. She only comes once a week because she lives two hours
away from the clinic. So a lot of what I train in the clinic is so she
can apply it at home several hours a day. She is eight months post
stroke in which she went through the standard inpatient acute rehab and
outpatient OT. Her outpatient OT in her area DC'd her because of a
"plateau in functioning". Her right arm is affected Shoulder flexion
60 degrees, Elbow flexion 100 degrees, full digit flexion, no digit
extension making grasp and release impossible.
Impairments identified: AROM, Strength, PROM, pain, grip strength,
tone, Non-use
Imairment based goals that the patient wants to improve on: All of the
above
Occupational goals that the patient expressed during the evaluation:
She states that she has a brand new kichen which was built by her
husband prior to her stroke. Her main leisure activity is cooking.
She states that she has already learned to compensate in the kitchen
using one arm, but wants to be able to use both arms someday to make
cooking easier and less cumbersome in order to improve her quality of
life and self esteem (she states that she feels like a freak not being
able to use her arm).
Imairment based phase a) Slow stretching home program b) bilateral UE
supine exercises using dwoel rod home program c) Saebostretch night
splinting to decrease digit flexor soft tissue shortening d) Saeboflex
orthosis for grasp and release UE drlls (task specific training) e)
Saeboglide AAROM home program (essentially a gravity reduced sidelying
apporach f) E-stim for her digit extensors.
In two months meeting once a week and the patient working very hard at
home the patient has improved in shoulder flexion by 20 degrees and now
she is now able to extend her thumb and extend her index finger 1/4 of
the way. She is thilled by the progress so far in such lttile time
compared to the improvements in her prior OT pogram.
The next phase when she qualifies would be to start in in the MCIMP in
which cooking would be a key focus of the program The use of a
restraint on the strong arm would be used 4-6 hours per day for several
weeks. Shaping activites, estim, and task modification suggestions
would be used in the clinic.
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