Title: Roles of Upper Limbs in Activity of Daily Living for Stroke Patients: Therapy for Arms and hands

Organization: Seiai Rehabilitation Hospital
Author: Masako Fuchi (OTR)
Key words: stroke patients, arm, hand, treatment

In post-stroke patient, hand disorders are often severe, and both the patient and the therapist often view it unlikely that the hands of the patient can resume functioning. According to the author's experience, however, it is sometimes possible for stroke patients to resume their hand functions if they receive active treatment. The author will describe the roles played by arms and hands in the activities of daily living (ADL) in individuals and will present the hand therapy employed in individual cases.
According to the author's view, the arms and hands play the following six roles: (1) Postural control (hands function as a support or a balancer when postural is changed or held); (2) walking assistance (hands serve as a support for complex walking, e.g., going upstairs/downstairs, mountaineering and changing direction), (3) manipulation (hands act on one's own body or outer environment and manipulate them; this is the most important function of hands), (4) communication (like eyes, hands help communication and play a central role in non-verbal communication), (5) hand predominance (the predominant hand can perform minute and precise manipulations and play a significant role in expressing concepts, intention and will; and (6) other functions (hands play a significant role not only in activity but also in the external appearance of an individual, and the presence of hands which do not hamper ADL is an important aspect of hand functions. Based on this classification of hand and arm functions, the author will present treatment for individual stroke patients in detail and discuss methods of treatment depending on the location of the brain injury.

Title: Approaches to arm and hand functions of stroke patients: Home visit rehabilitation

Organization: Yakumo General Hospital
Author: Nobuyuki Koiwai (OTR)
Key words: hand, corticospinal tract, home visit rehabilitation

Introduction: In stroke patients, recovery of arm and hand function is often less satisfactory than recovery of leg function or overall physical activity. For the patient presented in this paper, rehabilitation by occupational therapists was started one year after stroke, and the hands resumed functioning to a level causing hardly any problem in daily living. Treatment to facilitate recovery in arm and hand functions in stroke patients will be discussed, citing this case as an example.
Case report: The patient was a 71-year-old woman with right hemiplegia. She developed infarction of the left medulla oblongata on March 22, 2001. On April 24, 2002, her occupational therapist started once weekly rehabilitation at the patient's home.
Treatment: First the therapist helped the patient facilitate her auto reactions of the trunk and scapula ,and helped her improve her sense of BOP (base of support) and sensation of arm weight. Then, the alignment of the brachium, forearm and hand was improved. Subsequently, the therapist provided flexibility to the muscles within the hand through the use of a stick in order to enhance the discriminating function. The therapist compressed the MP joint for improve the coordination between the internal and external muscles for the prehension. The therapist guided the ventral side of the patient's fingers to fit a circular object. The therapist rotated the circular object and facilitate of the manipulating function that was adjustable of a lag between the ventral sides of fingers and the object.
Results: The reaching and manipulating function of the patient improved. The patient resumed the function of manipulating chopsticks and kitchen knives on the paralytic side. The patient's hands thus resumed functioning to a level causing hardly any problem in daily living. The patient was able to do various activities of daily living without difficulty.
Conclusion: So that arms and hands can function satisfactorily when making voluntary movment, it is essential that the functions associated with the corticospinal system work well under coordination of the ventromedial system, which plays a significant role in autonomic postural control. The author treated this case based on this theory. So that hands can function effectively as an effector organ, it is essential to administer rehabilitation which lays emphasis not only on finger movement but also on proprioceptive sense.

Title: Approach for Autonomous Activity of Arms and Hands in Daily Life: Intervention with Sensory-Exploratory Activity Training (from Hands-on to Hands-off)

Organization: Yamanashi Spa Hospital
Author: Shinichi Yamamoto (OTR)
Key words: arm function, sensory-exploratory activity, handling

We were recently in charge of a patient with right hemiplegia after intracerebral bleeding. We guided this patient in perceptive-explorative activity involving manipulations of the fingers towards the goal of facilitating automatic arm and hand activity of the patient during daily life. During the five-day treatment period, tasks to facilitate adjusting and predicting mechanisms were provided on the basis of the motor learning strategy. To implement these tasks, the capability of engaging in selective movement based on coordinated postural control was required as a background. That is, it was necessary to facilitate coordination of each systems in the central nervous system activating by exploration of the proprioceptive sense, instead of relying on intentional excessive compensatory activity. Then, it was necessary required to approach the center that serves as the base for arm and finger activity.
To put it concretely, it was first necessary to modulate the alignment of the paralyzed hand in preparation for inducing the perceptive-explorative function. Next, since the palm was in a condition difficult for spatial orientation, we directly guided the palm drastic changes in sensory information and to promote activity of the elbow and scapula. The activity was then switched to reaching, to grasping-releasing and to bilateral activity. The therapist confirmed that the resistance produced by the activity of using scissors on papers was appropriate for the ability level of the patient before the task was given to the patient. During this process, the therapist laid primary emphasis on changing the patient's activity level from hands-on to hands-off. By providing appropriate sensory information in an uninterrupted manner, the patient experienced continuous perception.
These results indicate that the handling placed the CNS-based coordinated postural control in harmony with the patient's challenge. We interpret that success in this process led to automatic arm and hand activity of the patient during daily life.

Title: Walking as Approached from the Viewpoint of Hand Function

Organization: Hovers Memorial Hospital
Author: Nobuhiro Hiura (RPT)
Key words: walking, arm function, associated reaction

Author studied the relationship between the walking function and the arm function and approaches to the improvement of the walking function through modification of the arm function.
The study was based on the hypothesis that unless the arm function improves, gait is unlikely to improve in many cases. Walking requires two steps of activity, i.e., the righting reaction to changes in the supportive plane and control of muscular tone to permit such reaction (reciprocal innervation). The use of a pattern generator guides the patient to acquire autonomous walking. And rhythmic rotation of the area from the scapula to the trunk can be achieved by treatment of the arms. In patients after stroke, ipsilateral control of the intact side of the brain is likely to occur, leading to reduced input of somatic sense to the paralyzed arm and hand and to compromised suppressive mechanism of the propriospinal interneurons, which results in hypertonia. This can lead to non-neural shortness or atrophy and reinforce associated reactions. In the sensorimotor field on the paralyzed side, this can lead to change of the arm and hand mapping.
Treatment for this case includes control of abnormal postural tone surrounding the scapula and trunk as well as reconstruction of reciprocal innervation. Sensory input to the fingers and hands or the internal muscles are performed, and stimuli are given from the peripheral sensory organs to the ascending inhibitory interneurons. If treated in this way, it is expected that the inhibitory mechanism will resume working and the circuit for associated reactions will be blocked. As upper extremity function improve, it is able to adapt walking and balance reaction. After treatment of the basic circuit, the circuit will continue working and the response to the treatment will extend to the daily living of the patient.

Title: Hand Function, Sitting Posture and Play of Children with Cerebral Palsy

Organization: National Rehabilitation Center for Disabled Children
Author: Hiromi Abe (OTR)
Key words: hand function, sitting, play

The hand function was studied in a child with cerebral palsy who presented with spastic diplegia. At age 1 year, this boy was able to crawl on elbows. He was not able to sit unassisted. His upper and lower extremities were rigid. He tended to use his right hand alone. He tended to grasp strongly with his left hand. Once he held a toy with his left hand, it was difficult for him to release it. The author started occupational therapy for this child, with the goal set at stabilization of the sitting posture and acquisition of the ability to play with both hands. As a result of treatment, the child became able to sit stably and play in a natural manner using both hands at age 4. The occupational therapy for this child can be divided into the following four phases: (1) age 1 year to 1 year and 2 months (1-1Y2M): guiding the child to use his arms for systemic motion, (2) 1Y3M-2Y5M: elevating the ability of both arms to manipulate objects through various activities, (3) 2Y6M-3Y9M: guiding the child to elevate the ability to make delicate finger motions, and (4) 3Y10M-4Y: promoting the use of hands during play that would satisfy the child. Our experience with this child allows us to identify the following three major factors that promote the development of arm function: (1) establishment of stable sitting position (guiding the child to assume a sitting position which makes hand use easier and to reproduce this position during daily life), (2) teaching appropriate play matched to the child's stage of development (play is analyzed from the aspects of motor, sensory and cognition, and the desirable activity incorporated into play), and (3) satisfying the child's interest (giving the child a tool of play that the patient will want to see or touch).

Title: Activities and Therapeutic Services Enhancing Hand Function

Organization: Kobe Para-Medic College
Author: Yoshiharu Hara (OTR)
Key words: hand, activity, communication

Development of hand and finger skill is associated with the development of ability to play, use tools, groom oneself and make communication, as well as with intellectual development. Development of these skills is achieved under the support and cooperation of other people. In other words, it is a process in which the individual becomes aware of sensory elements common to oneself and other people.
During hand skill development, coordination between hands and eyes develops. As the ability to reach objects through visual guide is acquired, the individual learns to manipulate the object with both hands. During this stage of development, the individual learns to see the object with both eyes, becomes able to make opposing movements of the thumbs, and develops preshaping of the hands in reaching for objects. The motor disfunction from the central nervous system (CNS) injury cannot make satisfactory achievements in using both hands to make various learning and experiments. When we deal with such cases, the therapy must devise a detailed plan of hand manipulation and plays while taking into account hand-related sensory information and the involvement of the center of the body.
Once preshaping of the hands is achieved, the hand functions become tools and symbolic functions. Then, hands can be actively utilized as a means of communication based on the related functions which have developed. When providing treatment to such children, it is essential to improve the ambiguous, weak reactions into more definite ones, and these reactions should be memorized as episodes pertaining to development of the child's relationship to other people.
Based on the author's experience mentioned above, the author will discuss support to hand manipulation and expression in children with retarded development. Emphasis is laid on the process of extracting sensory information during activities to objects and on the relationship with the development of related functions, citing clinical cases as examples.

Title: Therapy for Arms and Hands to Help a Child with Spastic Diplegia Learn Walking

Organization: Hokkaido Sapporo Habilitation Center for Disabled Children
Author: Shoko Ishikura (RPT)
Key words: walking, arm, posture and motion control

Adequate mobility of the upper extremities (including the upper trunk and scapula) is needed for children with cerebral palsy to acquire a practical level of walking function. To achieve this goal, posture and motor control of the arms under coordination with the trunk and legs is important. The author will present the course of treatment for a child who acquired the ability to walk after undergoing muscle-freeing surgery of the legs. The patient was a 5-year-old boy diagnosed with spastic diplegia associated with cerebral palsy. Before surgery, the boy was only able to crawl on the floor or transfer to the toilet, and used a wheelchair when moving on an indoor flat floor. Since he was not able to keep his posture stable while sitting, he required assistance when putting on or removing stockings and braces. After surgery, in casting period, we provided handling to the child aimed at normalization of systemic postural tone (especially in the legs) and at acquisition of the ability to make separate movements of the arms and the trunk during the arm's reaching activity. After the cast was removed, the child practiced ball kicking exercise while keeping the arms fixed and a balanced walking exercise along lines with a cane, as we expect to separate voruntary movement of limbs with out put system of postural control. In this way, the child was guided to acquire motor control system (adjusting the timing and direction of motion to cope with changes in the center of gravity or exposure to external disturbing factors) and to learn adjustment of muscular output. As a result, the child became able to walk with a cane on an indoor flat floor and to put on and remove stockings and braces unassisted in the sitting position. Thus, the activities of daily living in this child were improved. This improvement is probably attributable to acquisition of the capability to use his arms for balance-keeping purposes and to plan appropriate motor output patterns prior to making motion.