Simone Budding, Renovo occupational therapist, reflects on how technology and client-centred therapy help stroke survivors to recover.
A year ago, I had the privilege of working with a middle-aged gentleman who had survived a stroke. Upon arrival at our neuro rehab hospital service, he presented with many limitations on his ability to care for himself and he was dependent on support from others to complete all meaningful tasks.
As a team, we knew that prior to his stroke, this gentleman was a talented musician, capable of playing multiple instruments and living independently in London without any concerns. It was no surprise that his goal during his occupational therapy sessions was to have a functional upper limb again.
We discussed that this might be a difficult to achieve. He had severely increased tone in his bicep and wrist, a contracture in the left elbow (70 degree extension lag), stiffness in the wrist and fingers due to non-use and no to limited active movement in the affected upper limb (general muscle power 2/5 Oxford) and pain in the shoulder with movement.
He did, of course, have other occupational therapy goals but his personal focus was related to his upper limb.
We agreed to improve the left elbow’s extension from 110o to 180o by providing an elbow ranger splint and continuously upgrading the elbow stretching as the joint’s range, to improve the left-hand’s passive extension range of motion of the fingers and thumb by providing an appropriate splint and maintain the intact skin integrity and hand hygiene of his left hand and elbow crease.
Early in his stay, the doctors administered Botox to his upper limb and the appropriate splints were provided to capitalise on the more normalise muscle tone. Within three months his elbow extension lag was reduced from 700 to 500. This automatically helped with maintaining the skin integrity of the client’s cubital fossa.
By doing daily passive stretches along with the splinting we were able to restore the full passive ranges of motion of the wrist.
However, improving the active use of the fingers was a bit more of a challenge. Because he had achieved some active movement in the wrist, he required a splint that would only immobilise his fingers while providing low-load long duration stretch.
Each one of his fingers could extend to a different end range and his first webspace’s range of motion had to be increased. Making a standard paddle splint was therefore not suitable for his needs.
We ordered thermoplastic pellets that could be melted in the microwave and be applied to a thermoplastic hand cone to reach the end range of each individual finger.
A few weeks later when the client gained some active finger flexion, but limited finger extension, we were fortunate enough to acquire a Seabo Glove for him. It should be noted that Seabo do not recommend the use of their glove with a hand with increased muscle tone.
At first I must admit it did take me 30 -45 minutes to apply the glove, but when I discovered the tricks of the trade, such as using tenodesis to extend the fingers, I eventually could apply the glove within five minutes. The Saebo glove provided resistance training for his finger flexors while assisting finger extension.
During the active rehabilitation of grasp and release, the client was asked to flex and extend his fingers as many times as he could, to apply the neuroplasticity principle of repetition in his session. However, he struggled with motivation and fatigue, taking him 30 minutes to complete 20 repetitions.
Realising that his pace was not going to cut it, I had to go back to the drawing board. After discussions, my supervisor sent me a few details about a new-to-market device that she had seen advertised. After my own research, I was convinced this would be more appropriate for the client’s needs and I went about sourcing it.
A few weeks later the GripAble arrived and a profile was set up for him. The initial assessments – active range of motion, grip strength and release – were completed to calibrate the task difficulty to his specific needs before choosing an activity to participate in.
To my surprise, my client was completing 230 grasp and release repetitions in just 12 minutes – the time it took to play the game from level 1 – 10. It was incredible to see how the right activity could motivate a client to complete 10 times more repetitions than he usually was able to do and in 30 per cent less time.
He was also motivated to complete the activity frequently during the day increasing not only just the repetitions, but the intensity of his sessions too. At the time of his discharge his grip strength had improved to one kilogram.
Although at the time of his discharge this gentleman was not yet using his hand functionally, the underlying components that would allow him to potentially achieve this were being improved by daily use of the affected upper limb.
On reflection of my work with this client, I was reminded of the importance of discussions with colleagues about current practice, keeping up to date with the most recent technology and innovations as well as the importance of patient-centred therapy and its impact on motivation in therapy sessions.
For more info, visit renovocare.co.uk.
