Tania Romeu Ces

1. HandFun Meeting 2013
THERAPEUTIC
CONSIDERATIONS ABOUT THE
HYPOTONIC UPPER LIMB
TANIA ROMEU CES

2. HandFun Meeting 2013
Hypotonic Upper Limb
• Acute phase
• After this phase, the development of hypertonia
in the anti-gravity musculature is expected.
▫ Upper motorneuron syndrome
• Prolonged Muscular Flaccidity after stroke
 negative indicator in the prognosis of the
final outcome for stroke patients (Formisano,
2005)

3. HandFun Meeting 2013
Shoulder subluxation
• Frequent complication of motor impairment, soft tissue
damage, joint capsule, rotator cuff injury and in some
cases pain. (Dohle 2013, Hesse 2013)
• Increased risk during the acute phase
• Subluxation of the shoulder can cause
▫ Painful shoulder
▫ Reflex Sympathetic Dystrophy (Dohle 2003)
Dohle 2013, Murie-Fdez 2012

4. HandFun Meeting 2013
Brain Plasticity
• Cerebral plasticity: dynamic potential of the
brain to reorganize itself during biological
development or following damage (Duffau, 2006)
• Reorganisation of cortical sensorimotor maps
after cerebral injuries (Duffau, 2001)
• CNS is malleable and can be modified in
response to practice (Duffau, 2006; Daly & Ruff,
2007)

5. HandFun Meeting 2013
Neuromuscula
r system
Executive
system
Visual
system
Postural
system
Somatosensor
y
system

6. HandFun Meeting 2013
Motor Cortex
• Multiple cortical representations for hand and forearm
movements in primary motor cortex (Duffau 2001)
• Improvements in arm and hand
motor function during recovery
post-stroke have been related to
reorganisation in primary and
secondary sensoriomotor areas
(Lindberg et al, 2003)
• Pathways

7. HandFun Meeting 2013
Paradigm
Treatment focused on the compensation
of deficits
Treatment as recovery of functions
(Duffau; 2006; Behrman et al, 2006; Daly & Ruff, 2007)

8. HandFun Meeting 2013
Facilitation techniques
• Fast brushing
• Cold stimulation
• Quick stretch
• Fast tapping
• Vibration
Proprioceptive Neuromuscular Facilitation (FNP)
(Pop T, 2013)

9. HandFun Meeting 2013
ORTESIS
• Omo Neurexa (Ottobock)
▫ Hesse S, 2013
Hesse S, Herrmann C, Bardeleben A, Holzgraefe M, Werner C, Wingendorf
I, Kirker SG. A new orthosis for subluxed, flaccid shoulder after stroke facilitates
gait symmetry: a preliminary study. J Rehabil Med. 2013;45(7):623-9.
• Soporte de hombro unilateral
(Orliman)

10. HandFun Meeting 2013
Robotics
• Anti-gravity robot
• Compensatory torso
movements
• Visual Feedback
• Significantly reduced shoulder
instability
• Increased motor power (the control of scapular
protraction and retraction and shoulder flexion and
extension)
Dohle CI, Rykman A, Chang A, Volpe BT. Pilot study of a robotic protocol to treat shoulder subluxation in patients with
chronic stroke. J Neuroeng Rehabil. 2013; 10: 88.

11. HandFun Meeting 2013
Electrical stimulation
• Electrical stimulacion and Bobath concept (Fil 2011)
• Prospective randomized controlled trial. N=48
• Supraspinatus muscle, mid and posterior portions of the
deltoid muscle.
• It approach proved to be efficient in preventing inferior and
anterior shoulder subluxation in the acute stages of stroke.
Fil A, Armutlu K, Atay AO, Kerimoglu U, Elibol B. The effect of electrical stimulation
in combination with Bobath techniques in the prevention of shoulder subluxation in
acute stroke patients. Clin Rehabil. 2011;25(1):51-9.

12. HandFun Meeting 2013
Shoulder subluxation
• Normalization of muscle tone of the trunk to reduce
the risk of shoulder subluxation (Murie-Fdez 2012)
Hand
• Encourage the use of the hand in day to day
activities to increase the postural depth tone of the
scapular waist and trunk (Díaz-Arribas 2006)
• Dorsiflexion

13. HandFun Meeting 2013
• Treatment focused on the task
• Specificity activity
• Bimanual exercise
• Intensive use
• Dual task
• Patterns of movement/ avoid compensations
 Intensity vs task specificity (Page, 2003)

14. HandFun Meeting 2013
Affolter Model
• Perception  Information
• Reality
Guiding
• Elementary
• guiding
• Nursery

15. HandFun Meeting 2013
Recovery is a dynamic process that cannot be
encapsulated at one timepoint (Langhorne 2001)
Thank you!!
taniaromeuces@gmail.com
@tania_romeu