Prevent NONUSE And USE paralyzed arm

Birgitte Gammeltoft
Activity and
participation important.
Low-tech tools can
make it possible to use
affected hand in ADL
Prevent NONUSE
And USE paralyzed
arm
PANat prevent shortening of paralysed muscles under daily
activities when non affected hand are used
Therapeutic tools makes it possible to use affected arm
as support under daily activities
Pictures from the PANat script Silves
june 2011
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Birgitte Gammeltoft
Depression
Rght hemiplegia
No handfunction
Hemianopia
Principle:
as easy as possible
Gibson
Task:
Environment:
Pushing blocks using
Outward rotation, abduction
Bench, balance stick
Eliminate gravity
Johnstone Air splints and
Therapeutic tools can
Help the patient to recruit
weak muscles and assist
”Use” of paralysed arm.
Pictures from the PANat script Silves
june 2011
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Birgitte Gammeltoft
Influence length-associated tissue changes and muscle tone
Inflatable Johnstone air splints are used for:
1. Biomechanical advantages:
Stabilisation of joints for early weight bearing
Mobilisation of joints and muscles
2. Dynamic boost to sensory input
Johnstone air splints are used for:
Weight bearing
Limb loading
Dynamic weight transfer
Task oriented
Fun training is most efficient
Pictures from the PANat script Silves
june 2011
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Birgitte Gammeltoft
Using Johnstone air splints and therapeutic tools we can
prevent learned disuse and Prevent and treat muscle contractures
PANat
PRO-Active approach for
Self-directed practice
Home based rehab
Repetition/ variation
PANat focus on Stroke patients with severely
impaired motor control (Chedoke Mc Master 1-4)
Pictures from the PANat script Silves
june 2011
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Birgitte Gammeltoft
Push up to A - shoulder protraction
Push up til B - selective adduction
Push up til C – flexion
Auditive + visual feedback
HANDS OFF
Part practice
reaching ”shaping”
Distal control of fingers
Keeps the fingers in alignment
USE instead of NONUSE
Pictures from the PANat script Silves
june 2011
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Birgitte Gammeltoft
“Shaping” self directed shoulder protraction
Wolf
Limiting the degrees of freedom of movements
using Johnstone splint, the wall and packs
Bernstein
Elongation of finger and arm flexors
Learn the patient to turn paralyzed hand in supine
Pictures from the PANat script Silves
june 2011
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Birgitte Gammeltoft
Bilateral activity – ”cobbling effect” in brain SMA
Using paralysed open hand for support under
activity with non affected hand
The extension strap
supports the hand into
outward rotation
and extension
Prevent soft tissue
contraction
Pictures from the PANat script Silves
june 2011
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Birgitte Gammeltoft
”Shaping”
selective elbow
Flexion- extension
In a blocked chain
and outward-rotation
Using the ”Swiffer”: Idea from Franziska Wälder
Task specific part training “shaping”
with visual and proprioceptive feedback
Pictures from the PANat script Silves
june 2011
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Birgitte Gammeltoft
Stabilising enables
the hand to join the activity
Preventing learned nonuse
Bilateral activity
”cobbling effect” in brain
Before and after the splint
- mobilise all joints
• Scapula mobilisation
and arm outward
rotated
• Stretch elbow and
turn forearm – palm
up
• Bend the elbow
• Hand to face
Pictures from the PANat script Silves
june 2011
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Birgitte Gammeltoft
Long arm bandage
• The shoulder is outward
rotated, elbow extended,
wrist in 10° extension,
the thumb is abducted
(outward and straight)
and the fingers are
straight.
• The zip lies parallel to
the 5th finger.
• The client turns his head
and looks towards the
hemiplegic hand.
Pt. supine
Exercises with the long arm splint
Pushing against the therapist’s hand, or the wall.
Support the arm on pillows to maintain
the neutral position of the shoulder.
The client moves the hemiplegic arm actively
assisted by the non affected arm to an
external focus (the markers on the wall).
Different activities (e.g. balancing a rubber ball
on the air splint for x seconds) can be encouraged
using the long arm air splint to stabilise the elbow,
wrist and hand.
Pictures from the PANat script Silves
june 2011
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Birgitte Gammeltoft
Hand and elbow splint
Only hypertone arms
Danger for wrist
if low tone
Exercises with
the hand and elbow splint
Use task oriented activities – repetition/variation
Pictures from the PANat script Silves
june 2011
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Birgitte Gammeltoft
Strength training rotator cuff
Change environment
To limit degrees of freedom
to move
Small movements in
Shoulder
flexion/extension
Abduction/ adduction
Rotation is strength training
of rotator cuff muscles
Stability training of shoulder with extended arm
Much easier for the pt. to find the muscles from supine
Scapula are stabile and gravity minimised
Pictures from the PANat script Silves
june 2011
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Birgitte Gammeltoft
3 years post stroke self assisted
Left shoulder working alone – right arm with
ring is supporting for security
Long arm splint for mobilisation and
weight bearing
• Use a corner to limit
degrees of freedom to
move
Use environment
to stabilize
Repetition to get
stabilisation
Pictures from the PANat script Silves
june 2011
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Birgitte Gammeltoft
Reinforcement of weak muscles
Strength training serratus anterior in protraction
Visual feedback on task.
Intrinsic feedback.
True recovery
Scapula setting
Plan activities with reaching:
• Shorten trunk- reach down,
• Lengthen trunk– reach up,
• Rotation- reach in front or behind.
• Neck and head activities
Pictures from the PANat script Silves
june 2011
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Birgitte Gammeltoft
Reaching after a goal in front
The patient has to actively work on his own
to get intrinsic feedback
Reaching up after a goal in a task oriented activity
Lengthening pectoralis major
Elongating nervous system
Elongation of long finger flexors
Standing activities can stimulate
better arm/hand function
Pictures from the PANat script Silves
june 2011
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Birgitte Gammeltoft
Elongation latissimus dorsi
Daily activity –
going down to the flor,
putting on socks.
Outward rotation humerus
Elongating long finger flexors
Activity: Knees to the wall.
Elongate latissimus dorsi and pectoralis major
Mobilise neuroaxis -
Change environment and task
Pictures from the PANat script Silves
june 2011
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Birgitte Gammeltoft
Self directed mobilisation
Be sure humerus is centred in cavitas – work on
stability
Put a little weight through the elbow
Elongating triceps. Mobilise soft tissues
The patient can put on the hand splint alone
and continue exercises at home
Pictures from the PANat script Silves
june 2011
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Birgitte Gammeltoft
Shoulder mobilisation
Mobilise Scapula first
Any sign of shortening?
- ELONGATE muscles!
Is angulus inferior
following out?
If not – more rotation of trunk
Scapula mobilisation
Realign scapula
Up to the nose.
Down to
opposite button
Scapula setting
Teres major lengthening
Pictures from the PANat script Silves
june 2011
pectoralis minor lengthening
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Birgitte Gammeltoft
Realignment glenohumeral joint
Without table
With table
Sufficient support on table minimise inferior subluxation.
Let the arm be ”punktum fiksum” and body ”punktum mobile”.
Move body away from the arm – different movements
Gravity can help to get
Extension – outward rotation,
using the balance stick
Elongate biceps
and pectoralis.
Without the hand splint
the fingers
are tightly locked in flexion
most of the day at
this person
HANDS OFF
Pictures from the PANat script Silves
june 2011
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Birgitte Gammeltoft
Memory play as goal oriented activity.
Reaching for a card
Elongate long finger flexors
Supination to see the card
Self assisted extension, protraction
Pictures from the PANat script Silves
june 2011
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Birgitte Gammeltoft
Half arm splint
• Close the zip. Put the air splint
onto your arm (the right arm if it’s
the clients’ right arm) then clasp
the clients hand and draw it over
their arm. The air splint should be
at least 3 fingers width below the
elbow, the zip lies alongside the
5th finger.
• Place the inflation tube in your
mouth; this leaves both hands
free to maintain the position of the
limb in the air splint.
Exercises with the half arm
splint
Floor exercises with the half arm air
splint in combination with various
external foci: e.g. in side lying.
Prior to rolling into prone lying always
check range of movement, pain and
the active stability of the shoulder.
Roll into prone through the non plegic side
The forearm is positioned with the thumb
uppermost in the air splint. Insert a spoon
into the air splint and place a marble or small
ball on it. Turn the forearm in supination
to drop the ball into the bowl.
Pictures from the PANat script Silves
june 2011
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Birgitte Gammeltoft
Hand/wrist splint
• Aims of Use:
• To maintain finger extension and
thumb abduction to allow a firm
weight bearing base for the hand.
• To maintain finger and thumb
position in activities requiring an
open hand.
• To assist weight bearing activities
of the hand in sitting, standing and
crawling.
Mobilisation of the hand before and
after
Ensure the client is sitting with
weight evenly distributed through
the buttocks and feet.
The feet must be flat on the floor.
Prior to application passive
movements of the shoulder girdle
and arm are carried out;
at the same time muscle pliability
and joint ranges are assessed.
Direct the client’s attention to
the hand so he can watch and
feel the movement.
Pictures from the PANat script Silves
june 2011
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Birgitte Gammeltoft
Finger splint
• Aim of use:
• To maintain finger
extension during
functional activities of the
hand (prehensile grip).
• To encourage
exercises/activities with
the open hand.
• To stimulate sensory
awareness of the finger
tips.
Finger splint can be used inside
long arm splint with hypertone
Pictures from the PANat script Silves
june 2011
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Birgitte Gammeltoft
Contractures
Prevention is best – but still after many years you can
influence and lengthening my mobilizing and use of tools
Typical hand position by
Flexor hypertonicity:
Wrist flexion
Finger flexion
Adduktion
Ulnar deviation.
+
Shoulder flexed, adducted
Inward rotated
Elbow flexed
Plastazote rolls can keep
fingers stretched and adducted
Finger bandage
Keeps fingers aligned.
Long arm splint can be
used on top of finger
splint.
Pictures from the PANat script Silves
june 2011
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Birgitte Gammeltoft
Prevent – treat contractures
Pictures from the PANat script Silves
june 2011
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Birgitte Gammeltoft
Preparation before applying splints
Mobilise the ankle joint by sliding the foot
backwards and forwards.
Ensure the heel and sole of the foot are flat
on the floor.
Direct the client’s attention to the movement.
Gently mobilise the small muscles of the foot
(intrinsic muscles and plantar fascia).
The toes are passively lengthened.
Food splint
• Aims of use:
• To support the weak
ankle during non weight
bearing activities.
• To enhance heel strike in
lying (e.g. bridging).
• Use in chair to floor
transfers to minimise
injury to the foot and
maintain alignment of the
heel, forefoot and toes.
Pictures from the PANat script Silves
june 2011
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Birgitte Gammeltoft
Double chamber foot splint
• Aims of use:
• To stabilise the ankle
joint during dynamic
weight bearing
exercise/activity.
• To stabilise the ankle
joint and maintain
alignment of the forefoot
during balance, walking
(slow/fast) and jumping.
• To encourage heel strike
in gait.
Leg gaiter
• Aims of use:
• To support and stabilise the
hemiplegic leg in standing
(weight bearing and limb
loading).
• To assist in trunk alignment
and to maintain both heels on
the floor in standing.
• To enable the following
activities: squats, weight
transfer from side to side,
single leg stance and side
stepping.
• To stretch Soleus and
Gastrocnemius.
Pictures from the PANat script Silves
june 2011
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Birgitte Gammeltoft
Balance is necessary for all daily
activities
Playing ball
Balance-stick
helps the arm
into
Outward rotation
Remembering
The hill
Touches wall
And closet
Pictures from the PANat script Silves
june 2011
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Birgitte Gammeltoft
Activity goal:
– hold a ski stick
problem – flexor hypertone
Corner
Feel the wall and
the closet behind
Reach for the bench
Reach the wall
Handsplint and extensor strap
can be used for the food also
Pictures from the PANat script Silves
june 2011
29
Birgitte Gammeltoft
The Leg and Foot splint for resting
Designed for MS
• Aims of use:
• To maintain muscle
length and elasticity and
reduce the risk of
adaptive soft tissue
changes in the lower
limbs.
• To treat adaptive
changes and/or flexor
withdrawal, apply the leg
and foot splint twice a day
for 30 minutes.
The Leg and Foot air splint for standing
(specially designed for M S)
OBS Not
For Strokes
As it facilitates
extension
Pictures from the PANat script Silves
june 2011
• Aims of use:
• To maintain muscle length and
elasticity and reduce the risk of
adaptive soft tissue changes in
the lower limbs.
• To promote standing and
improve balance.
• To support and stabilise the
legs in standing (weight
bearing and limb loading).
• To assist in trunk alignment
and to maintain both heels on
the floor in standing.
• To enable the following
activities: squats, weight
transfer from side to side,
single leg stance and side
stepping.
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Birgitte Gammeltoft
Johnstone splints combined
with intermittent pressure
Can be used while resting
Combining intermittent pressure with
Rocking chair to stimulate balance and positioning of arm i abduction
to lengthen muscles – prevent contracture
Pictures from the PANat script Silves
june 2011
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