Joseph R. Padova , OTR/L Courtney Knobl , MS OTR/L

1. The Use of a Functional Digit Extension Splint to Promote The Integration of the Hemiparetic Hand during Activities of Daily Living. Joseph R. Padova, OTR/L Courtney Knobl, MS OTR/L

2. Conflict of Interest Statement Joseph Padova, OTR/L made the Functional Low-profile Extension Assist Splint (RELEAS) being used as a splint of discussion. Joseph has a vested interest in the splint. However, the intention of this presentation is to review some of the problem solving used to design functional splinting for stroke patients and the potential for using functional splinting as an additional option for rehabilitation.

3. Objectives: be able to identify at least three ways in which neuromuscular imbalances after a stroke can limit functional integration of the affected upper extremity. Analyze distal upper extremity movement patterns to help determine the potential for functional splinting as an option to improving hand function. Apply at least one current neuromuscular rehabilitative technique to maximize the integration of the splinted hand during activities of daily living.

4. Promote your own ideas and see if they work. Research it and Write about Your Results to add to the Clinical base of Knowledge. Encourage to seek out ways to patent and promote what you come up with.

5. Conflict of Interest Statement Courtney Knobl, MS OTR/L has No conflict of interest.

6. Demographics According to the American Heart Association there are approximately 780,000 new strokes in U.S.A each year (Heart Disease and Stroke Statistics, 2008). By best estimates as of 2005 approximately 5,800,000 stroke survivors (Heart Disease and Stroke Statistics, 2008). ½ of stroke survivors are living with upper and lower limb disabilities ( Levey, Nichols, Schmailbrock and Clark, 2001; Ottawa, 2007).

7. Rehabilitation has been more successful in restoring function in lower limb compared to the upper limb (Barreca, Wolf, Fasoli and Bohannon, 2003; Levey, Nichols, Schmailbrock and Clark, 2001; Page, 2007 Rosenstein, Ridgel Thota, Samameand Alberts, 2008).

8. Even with Intensive Therapy • Studies indicate that proximal arm active range of motion make larger gains compared to the hand (Barreca, Fasoli and Bohannon, 2003; Levey, Nichols, Schmailbrock and Clark, 2001).

9. Inability to actively open the hand for pre-grasp and release is a severe functional deficit of many stroke patients (Levey, Nichols, Schmailbrock and Clark, 2001, Page, Sisto, Levine, McGrath, 2004; Fritz, Light, Patterson, Behrman and Davis, 2005).

10. Medical Chemodenervations with Botoxin • Shown to be effective to reduce motor over activity from spasticity in the wrist and finger flexors. • But many patients still have poor ability to recruit finger extensors and volitional open the hand for grasp and release ( Brashear and Meyer, 2008).

11. Is Dynamic Splinting an Option for Functional Hand Integration?

12. Functional Splinting for Spasticity Literature review showed extremely limited information

13. Interest in Functional Splinting • New Interest in an old idea. • Currently not many options for the hemiplegic upper limb. • Most splints are static for positioning.

14. Functional Splinting • For the most part are large. • Not designed for full day ADL and self care use

15. Functional Splinting for the Spastic Upper Limb has Multiple Considerations

16. Hyper response of the stretch receptor occurs when: • The joint is moved too fast. • The joint is moved too far. • The movement is too forceful.

17. Contractures and soft tissue tightness • Will be a major component determining proximally the amount of distance a person can reach and place the hand.

18. Contractures in the hand • Will help determine how large the possible grip, or pinch will be based on how wide the hand can be opened.

19. Quality of Motion will help Determine How well the patient can isolate movement patterns within the available AROM

20. What Joints in the Hand Are Moving? • The fingers only? • The thumb only? • Both the fingers and the thumb?

21. How Is It Moving? • Can the moving joints produce flexion and extension? • If only flexion can it relax the grip? • If only active flexion and it can relax the grip can the person produce a relaxed release?

22. If Fingers and Thumb Flexion, Without Extension • Functional Low-profile Extension Assist Splint ( RELEAS ) may be appropriate. • Uses a neoprene thumb spica splint, • Dorsal mounted flex rod, or spring-loaded outrigger. • Buddy splints to support the index and long fingers. • The dynamic forces are use to open the thumb, index and long fingers following a crude pinch. • Works best with Modified Ashworth of 2 or less.

24. Inclusion Criteria • Be oriented. • Able to follow at least 3 step verbal, written, or demonstrated instructions. • Have no more than a mild left inattention to the affected body parts (this does not include learned nonuse).

25. AROM Requirements • At least 20 degrees arm flexion and abduction. • Move the hand from midline to neutral external rotation. • Move the elbow from at least 50 degrees flexion to -20 of extension (extension can be eccentric or concentric).

26. Hand ROM • Looking for the ability of the hand to produce either a lateral pinch, or a 3 jaw pinch once the index, long finger and thumb are passively ranged into supported low resistance extension.

27. AROM Requirements • Forearm : Although desirable, not an inclusion, or exclusion criteria as it can be positioned by functional strapping if needed. • Wrist : Although desirable, not an inclusion, or exclusion criteria as it can be positioned by adding a wrist support to the FLEAS if needed.

28. Inclusion Criteria • Unable to volitionally open the hand. • Be able to squeeze the evaluators hand. • Be able to stop squeezing when gripping the evaluators hand. • Hand should not elicit spasticity resistance greater than a 2 on the Modified Ashworth when the digits and fingers are passively opened.

29. Sensation • Not as clear cut yet. • Of the 13 patients fit so far 1 could only identify deep pressure and pain. Another only had pain perception. • Both were able to visually compensate and complete all the tasks except tying bows and holding a fork. • All tasks took increased time and physical effort.

30. 13 patients fitted with the RELEAS • 4 < five years post CVA. • 5 were five to seven years. • 3 between eight to 10 years. • 1 was 20 years post CVA • All had extensive acute rehabilitation and out patient physical and occupational therapy through the years.

31. AROM Summary:Amount of ranges varied: • Between 20 and 80 degrees arm flexion • Between 20 to 60 degrees external rotation • Between 20 to 125 degrees elbow flexion. • Supination from full pronation varied from -15 degrees from neutral to 69 degrees. • Varied from – 30 of a neutral wrist to 45 degrees wrist extension. • 10 had a Modified Ashworth in the finger flexors of two; 2 had one plus; 1 had a one.

32. Continued • All could demonstrate the ability to control the movement patterns to touch the intact hand with the opposite hand at midline. • 0 could open the hand. • All could recruit and relax the flexors of the hand • 0 could integrate the hand other than a gross stabilizer with the fist.

33. Following RELEAS fabrication and average of 15 training sessions • AROM of the proximal U.E. and the Modified Ashworth measurement remained approximately unchanged. • However with the RELEAS all could integrate the affected hand for grasp, pinch, placement and release.

34. Out of 13 Fitted with RELEAS for assisted pre-grasp, active grasp and assisted release

35. Continued

36. Training Time • Variable due to patients personal goals. • Ranged from 12 to 26 sessions depending on the complexity of the case to achieve independent integration level for appropriate tasks. • Relatively short time span considering not being able integrate a volitional hand component for years since the initial stroke.

37. Case study 1: R.H.

38. The patient • 33 year old female s/p L CVA (04/05) • Resulting R hemi paresis • R hand dominant

39. R UE presentation Decreased isolated active movement, increased spasticity Good attention to R UE Sensation grossly intact to light touch

40. In the past, pt has… • Been through extensive in/outpatient rehab • Trialed multiple interventions (Saebo, Neuromove) • Reported improved arm motion, but not hand function • Had botox injections in finger flexors • Produced no volitional extension for pre grasp/release

41. Video of R UE ROM

42. Clinical Reasoning for Initiating RELEAS Training: “It is the hand that guides the arm rather than the other way around” (Gordon, 1987).

43. Enable Functional Task Participation • Functional task participation more favorable than exercise program • Positive changes in hemiparetic UE when incorporated into tasks • Functional tasks typically require use of both hands • Recovery maximized through bimanual task training • Simultaneously address other impairments (Davis, 2006).

44. Cortical reorganization • Use dependent cortical reorganization (Gillan, G., 2011) • Results from increased use of body part • Leads to enhanced representation in cerebral cortex and reverses disadvantageous cortical reorganization • Structural cortical changes (Gauthier, et al. 2007) • Amount of UE use can alter brain activity or activation pattern

45. Facilitate Repetition for Motor Learning Repetitions of specific UE movements produce lasting neural changes and optimize motor learning (Lang, et al., 2009).

46. Outpatient OT Goals • Pt will: • Demonstrate increased right shoulder flexion AROM by ≥20° • Be I with updated HEP • And…

47. With RELEAS, pt will integrate R UE to bimanually: Open small ziploc bags and water bottles Open and apply bandages Open sealed envelope Fold paper and stuff into envelope Apply toothpaste to toothbrush

48. Within 10 sessions, pt able to: Rip sugar packets Cut coupons with scissors Rip and apply bandage Open toothpaste container and apply to toothbrush Fold paper and stuff into envelope Open sealed envelope Stabilize pot on stove and stir Manipulate zipper and zip/unzip jacket

49. Cutting with Scissors

50. Opening bandage