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Upper Limb Evaluation / Assessments and Treatment
At RHP rehabilitation therapy emphasizes functional activity in training, and makes use of international research guidelines for the use of therapeutic tools and principles. Both the occupational therapist and physiotherapist need to assess the upper limb (UL) for possible return of function. Therapy also focusseson teaching the patient to know how to maintain a pain free shoulder and to mobilize their UL to maintain range of movement. Our treatment does not consist of a number of exercises, but rather preparation of each patient for daily life and to be able to perform movement in real life functional positions which are meaningful.
Therapy must be motivating to the patient and within their frame of reference to maximise their participation. Working on the appropriate functional activities in daily life situations ensures that contextual factors are taken into consideration and allows the occupational therapist and physiotherapist to measure meaningful outcomes.
Occupational therapists and physiotherapists at Rita Henn and Partners use clinical reasoning in their task/movement or cognitive / perceptual analysis to enable them to identify the specific underlying impairments. During rehabilitation significant emphasis is placed on patients regaining as much functional independence as possible in all ADLs (activities of daily living) and IADLs (instrumental activities of daily living). Reasoning needs to be related to what functional activities are limited and what key impairments are impacting on this function. Therapy needs to address both the key impairment and the functional activity within appropriate environments.
Key Principles in Assessment / Evaluation and Treatment
The following are key principles in upper limb assessment / evaluation and treatment:
- Patients with arm injuries and some movement should be given every opportunity to practice functional activities or participate in task-specific training. These , tasks are graded to challenge individual capabilities, practiced repeatedly, and progressed in difficulty on a frequent basis. These activities may be bilateral (using both arms) or unilateral (using one arm) depending on the task.
- Strengthening exercises are reasonable to consider as an adjunct to functional task practice.
- Sensory retraining to improve the ability of the patient to feel different textures, strength may be considered for patients withsensory lossPassive and active assisted range of motion (ROM) exercises to maintain a painfree ROM of the UL and to prevent hand oedema (swelling)
- Sensory retraining and UL awareness
- Education on care of the UL
- Electrical stimulation for hand oedema (if not contraindicated).
Always train the patient to place the affected UL in a variety of positions and situations where it would normally be in a task within their visual field, so that they become more aware of the affected arm and start using it automatically.
Where absolutely no recovery is occurring, the patient should be taught compensatory techniques and environmental adaptations that enable performance of important tasks and activities with the less affected arm and hand.
Once the occupational therapist / physiotherapist has completed a comprehensive assessment of the upper limb, including (but not limited to) history, movement analysis, range of movement, sensation, muscle strength, ability to complete functional tasks, and work-related tasks, the occupational therapist / physiotherapist can then plan an appropriate treatment for the patient.
The following is a list of possible treatment options for the upper limb:
- Repetitive Task Training – repetitive and intense use of novel tasks
- Sensori- Motor Retraining – using robotic devices, CPM(Continuous Passive Movement), deep pressure
- NeuroMuscular Electrical Stimulation – Transcutaneous electrical nerve stimulation or NMES
- Strength training – strength training involves progressive active exercises against resistance which may be indicated for the UL and hand, provided that the quality of movement is not affected, and tone is not worsened
- Spasticity Management
- Oedema Management
- Shoulder Pain Management – MFR (Myofascial Release), strapping, NMES, dry needling, education and home programmes
- Graded Motor Imagery: Mirror Therapy/ Mental Practice / Imagery / Virtual Reality
- CIMT (Constraint Induced Therapy) – appropriate for a very select few patients
- Slings and Splints – this area of rehabilitation is controversial for stroke patients. All patients (no matter their impairment) will be assessed for the appropriateness of assistive devices.
The occupational therapists and physiotherapists at RHP frequently use the GRASP and the DYOR (Drive Your Own Rehab) Programme as an approach to rehabilitation of the upper extremity, particularly in neurological disorders. These programmes both emphasize the need for the patient to direct their own rehabilitation and practice to reach the intensity required for neural plasticity and optimal recovery. Goals of these programmes include:
- Strengthening the affected arm
- Improving range of motion
- Improving use of the affected arm in daily activities
- Decreasing pain, and
- Improving life satisfaction