Kathleen Hardy, Kacia Suever, Amie Sprague, Valerie Hermann, Peter Levine, Stephen J. Page; Combined Bracing, Electrical Stimulation, and Functional Practice for Chronic, Upper-Extremity Spasticity. Am J Occup Ther 2010;64(5):720-726. doi: 10.5014/ajot.2010.08137.
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OBJECTIVE. Conventional methods for managing upper-extremity (UE) spasticity are invasive, usually require readministration after a certain time period, and do not necessarily increase UE function. This study examined efficacy of combining two singularly efficacious modalities—UE bracing and electrical stimulation—with functional training to reduce UE spasticity and improve function.
METHOD. Two chronic stroke patients exhibiting UE spasticity were administered the Modified Ashworth Scale (MAS), the upper-extremity section of the Fugl-Meyer Impairment Scale (FM), the Box and Block Test (B&B), and the Arm Motor Ability Test (AMAT). They were then individually fitted for a brace and subsequently participated in treatment sessions occurring 2 days/wk for 5 wk, consisting of (1) 30-min clinical sessions, during which the UE was braced in a functional position while cyclic electrical stimulation was applied to the antagonist extensors of the tricep and forearm, and (2) 15-min, clinically based training sessions, occurring directly after the clinical session.
RESULTS. After intervention, participants exhibited 1-point reductions in MAS scores for the affected fingers, FM score increases, and increased ability to perform AMAT activities,. Three months later, both participants retained these changes.
CONCLUSION. Data point to a noninvasive, promising method of managing spasticity and rendering functional changes.
The UE items of the Modified Ashworth Scale (MAS; Bohannon & Smith, 1987) are based on an ordinal-level scale (0–4) to assess spasticity at the elbow, wrist, fingers, and thumb.
The UE section of the Fugl-Meyer Impairment Scale (FM; Fugl-Meyer, Jääskö, Leyman, Olsson, & Steglind, 1975 ) assessed isolated movement at each joint (UE impairment). Data are drawn from a 3-point ordinal scale (0 = cannot perform; 2 = can perform fully) applied to each item, and items are summed to provide a maximum score of 66.
The Box and Block test (B&B) is used to measure disability and has been found to be both valid and reliable (Platz, Eichhof, Nuyens, & Vuadens, 2005). It is a timed grasp-and-release test in which participants are seated in front of a box with a large partition separating the box into two equal squares. Colored blocks are situated on one side of the partition, and participants are asked to move as many blocks as possible from one side to the other with the affected hand.
The Arm Motor Ability Test (AMAT; Kopp et al., 1997) was used to determine whether changes occurred in activity limitation. The AMAT is a 13-item test in which ADLs are rated according to a functional ability scale that examines affected limb use (0 = does not perform with affected arm; 5 = does use arm at a level comparable to unaffected side) and a Quality of Movement Scale (0 = no movement initiated; 5 = normal movement). ADLs, which are further subdivided into subactivities to be rated, included use of a knife and fork, eating with a spoon, combing hair, and tying shoelaces. Given the lack of distal movement among participants and the goals of the intervention, AMAT Items IV (“drink from mug”), IX (“wipe up spilled water”), XII (“prop on extended affected arm”), and XIII (“light switch/door”) were omitted. In addition, a button-down shirt was substituted for a cardigan in Item X, because none of the participants had experiences with or owned cardigans, but all owned button-down shirs. Thus, use of a button-down shirt was more occupationally meaningful to our participants.
We also administered the Canadian Occupational Performance Measure (COPM; Law et al., 1990) to measure perceptions of current task performance and satisfaction with that performance. Through a standardized interview, clients identify on a scale ranging from 1 to 10 the importance of, perception of, and satisfaction with their performance. Once the top five performance behaviors are determined, they are used to guide treatment and determine changes in client perception.
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