Neuro Physiotherapy Treatment for Control of Movements of the Arm in Stroke

TREATMENT FOR CONTROL OF MOVEMENTS OF THE ARM:

The patient has great difficulty in lifting and holding his arm up against gravity ,because flexor spasticity of the trunk and shoulder girdle with shoulder girdle with pressure downwards prevents the action of the extensors, i.e. serratus anterior, deltoid and supraspinatus.

Inhibition of spasticity can be achieved more easily in supine, as already described in the first stage of treatment and this has to be continued in preparation for working in the upright posture. It is easily obtained in standing, rather than in sitting,because in standing extension of the hips facilitates lifting of the arm whereas, in sitting, flexion of the hips and trunk make inhibition of flexor spasticity more difficult.In order to make lifting of the arm possible, the patient must first be able to hold it at various stages when lowering it. 

He should extend his elbow and keep it extended all the way down. But extension alone is not sufficient.The arm should be in external rotation and supination, as internal rotation and pronation are part of the flexor pattern which counteracts lifting and holding the arm up. Control for holding the arm up at the shoulder is easier when it is held sideways rather than forward and down.  T

his is because extension with external rotation and supination can be maintained more easily sideways than forward.In supine, standing and sitting, it is easier for the patient to hold his arm against gravity than to lift it up. 

If he can control the weight of his arm all the way downward, he can also learn to lift it up from any downward point at which he is able to hold it. If the arm pulls down at any stage of the downward movement, the therapist will feel downward pressure against her support and the movement should then immediately be reversed upward, either by the therapist or better if possible by the patient. He soon learns to recognize the moment when flexor spasticity occurs and his elbow tends to bend.  

To begin with the therapist holds the patient’s hand with wrist and fingers extended, the thumb abducted. The patient extends his elbow, pushing against the therapist’s hand. She would be able to use some intermittent pressure to stimulate active extension. 

When he can hold his elbow in full extension, she moves his hand slowly sideways and down, but only as long as he is able to keep his elbow extended. He is then asked to move his arm up again. Gradually, the whole range of movement sideways for full horizontal abduction is performed. The movement is then done diagonally forward, as long as external rotation can be maintained. 

As a progression, the therapist holds the patient’s fingers but only lightly to prevent the occurrence of flexion until she is able to take he hand away at various points of the downward movement and the patient is able to control his arm at each stage. This is called placing.If the patient’s arm is more flaccid than spastic, contraction of the deltoid, for holding the arm up in horizontal abduction, can be facilitated by suddenly and without warning dropping the arm, but letting it fall only a little way down, then moving it up again. Letting it fall may produce a protective holding reaction through sudden stretch in the inner range of the deltoid and supraspinatus. 

The patient can then use this contraction immediately, i.e. before its effect has subsided, for lifting his arm up again.This manoeuvre will not work, however, if there is any flexor spasticity. Another way of stimulating active extension of the flaccid arm is a technique which we call (pull- push). With the patient’s hand held with wrist and fingers extended, his arm is raised sideways to the horizontal and a quick pull followed by a push against his extended arm, is given through his hand.

This stimulates mobile extension of the elbow and a holding action at the shoulder. The patient now feels that he can extend his arm without it stiffening, and through the pull, followed quickly by pushing against the extended arm, the therapist inhibits flexor spasticity. This combination of inhibition and stimulation is very useful and should be done with the patient’s arms in any direction, sideways, forward and diagonally, and also gradually downwards. 

When sufficient activation has been obtained at shoulder and elbow,the therapist lets go of the patient’s hand and he should hold his arm up unaided. Inhibition of flexor  spasticity has to be done during and if necessary, in between all the placing maneuvers described above, i.e. when the patient’s arm becomes heavy and uncontrolled, or when a pull downwards is noticed by the therapist.

The patient may now be able to lift and hold his arm at the shoulder,provided he keeps his elbow extended. The moment he is asked to bend his elbow so that he can bring his hand to his body or face, the whole pattern of flexion, pronation and downward pressure of the side flexors of his trunk and retraction of his shoulder girdle may come into play and he can no longer hold his arm up. 

For functional use, i.e. for feeding, dressing and other activities, it is essential that he should be enabled to bend and supinate his elbow and open his hand to grasp, while holding and stabilizing his raised arm at the shoulder. Treatment therefore, should be advanced towards obtaining independent movements of the elbow without letting the arm fall.