Chronic post strok survivor

[Mashly]

Hi There
i am an intern Student so i need ur advice about one of the cases i am treating
i have a 27 Female,she had 2 years ago stroke after delivering her baby
she has been receiving an extensive PT for her Lower limb, so now she can walk normally
about her Upper limb, shes better proximally than distally.
her shoulder, elbow muscles are grossly graded 3+ but her wrist flexors/extensors 2- ! i could give her some isomteric wrist flextion/extension exs but she keeps exerting the power from her forearm not her wrist !so defintely there was no improvement ! what do u suggest for me to do? my supervisor told me since there was no improvement in the previous 2 years, that means shes not willing to be better ! but i really want to try anything with her . thus, i was thinking about ES ( electrical stimulation)! what do u think about that, and does anyone have another suggestion or advice?
thanks in Advance

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[gcoe]

Is she able to actively extend her wrist by 20 degrees AND Flex AND Extend her fingers by 10 degrees? If she can manage these three things then a constraint-induced movement programme may help and this programme offers the best evidence for being effective in a patient with chronic stroke. Given her age this definitely would be worth trying. Such programmes are intensive and demanding but don't go on for more than a few weeks. So if she is going to make gains she will know fairly early on. You will need to be able to provided the time and energy as these programmes involved several hours of practice a day. There is quite a lot to administering such a programme but you may get a good idea if you look at the EXCITE trial.

However if she can't extend her wrist by 20 degrees and/or can't flex and/or extend her fingers by 10 degrees then the prognosis may not be that good. While this doesn't mean she can't benefit it greatly reduces the probability of gaining adequate arm function to be useful to her. If this is the case and as she is at the two year mark post-stroke it may not be appropriate to offer therapy. Personally I think it is not really fair on patients to try anything if the results are highly likely to be disappointing. Obviously it is ultimately her choice but nothing is achieved by offering patients false hope. the key here is to adequately assess her prognosis for functional recovery.

As for using FES as part of a task-based programme this may have a role but again it depends how much voluntary movement she has in her wrist and hand already. If there is not much already happening after two years then you could trial it but I would limit the trial if you are getting nowhere. As an adjunct to increase functional activity it may have a place but it needs to be paired up with specific hand tasks, not just using the muscles in isolation.