Trunk Restraint: Physical Intervention for Improvement of Upper-Limb Motor Impairment and Function

Abstract

Children and adults with hemiparesis use excessive trunk movement to compensate for limitations in arm movement during reaching activities. Reaching and grasping with physical limitation (trunk restraint) of or feedback about excessive trunk movements leads to improvements in the quality of arm motor patterns (shoulder and elbow range, endpoint trajectory), reduction of excessive trunk movement, and decreased upper-limb impairment. In children, the intervention consists of task-oriented upper-limb therapy performed while movements of the trunk are limited by strapping the trunk to the back of a chair. The trunk restraint limits forward and lateral trunk displacement and rotation but allows scapular movement.

The physical intervention discussed here is task-related training combined with trunk restraint to limit motor compensation during reaching-and-grasping training.

Clinical Case Study of Jason: Quality of Unimanual Arm Function in Child with Cerebral Palsy

Keywords: Grasping, motor compensations, reaching, recovery, training, upper limb

Introduction

The theme of this case study concerns the development of a treatment approach to improve arm and hand function in child with hemiplegic cerebral palsy.

The student’s task includes:

• 1. To recommend an occupational therapy intervention and provide a rationale for its use

• 2. To summarize the evidence for the effectiveness of the intervention

As a starting point, students should use the following references to gather background information.

For a description of the Content and Clinical Application of the Intervention

• Michaelsen SM, Dannenbaum R, Levin MF (2006) Task-specific training with trunk restraint on arm recovery in stroke: randomized control trial. Stroke 37:186–192

• Schneiberg S, McKinley P, Sviestrup H, Gisel E, Mayo NE, Levin MF (2010) The effectiveness of task-oriented intervention and trunk restraint on upper limb movement quality in children with cerebral palsy. Dev Med Child Neurol 52:e245–e253

For Fundamental Concepts on Which the Intervention Is Based

• Cirstea MC, Levin MF (2000) Compensatory strategies for reaching in stroke. Brain 123:940–953

• Levin MF (2000) A model of sensorimotor deficits in clients with central nervous system lesions. Hum Mov Sci 19:107–132

• Levin MF, Michaelsen S, Cirstea C, Roby-Brami A (2002) Use of the trunk for reaching targets placed within and beyond the reach in adult hemiparesis. Exp Brain Res 143:171–180

• Michaelsen SM, Levin MF (2004) Short-term effects of practice with trunk restraint on reaching movements in clients with chronic stroke: a controlled trial. Stroke 35:1914–1919

• Michaelsen SM, Luta A, Roby-Brami A, Levin MF (2001) Effect of trunk restraint on the recovery of reaching movements in hemiparetic clients. Stroke 32:1875–1883

• Michaelsen SM, Jacobs S, Roby-Brami A, Levin MF (2004) Compensation for distal impairments of grasping in adults with hemiparesis. Exp Brain Res 157:162–173

• van der Lee JH Wagenaar RC, Lankhorst GJ, Vogelaar TW, Deville WL, Bouter LM (1999) Forced use of the upper extremity in chronic stroke clients: results from a single-blind randomized clinical trial. Stroke 30:2369–2375

Overview of the Content

Aim: To choose an occupational therapy (OT) intervention that will facilitate the learning and reinforcement of optimal movement patterns of the upper limb for unimanual reaching and grasping tasks.

Background History of Clinical Case Study

Personal Data

Jason is a boy, aged 5 years 6 months. He is attending a specialized school because of his mobility impairment but his academic performance is equivalent to typically developing children of his age. He enjoys music and playing with friends.

Medical Diagnosis and Function

Jason was born from a normal pregnancy. At 2.2 months, his parents noticed that he used his left hand less than his right hand and by 10 months of age, a diagnosis of left-sided hemiparesis due to antenatal stroke was confirmed with CT scan. The specific diagnosis is a left hemispheric atrophy with parietal encephalomalacia suggesting a left middle cerebral artery stroke. He has moderate spasticity in the flexor muscles in the left upper limb and the arm tends to adopt a flexor synergy with the hand closed and the thumb adducted at rest or on exertion. Active elbow and shoulder joint ranges are moderately reduced as is the range of active finger flexion with the wrist extended. When he tries to reach his left arm forward, he leans the trunk forward. However, when his left arm is supported by the therapist, it is possible for him to actively extend his elbow and flex his shoulder over a greater range than that which he can produce himself when reaching unassisted. Functionally, he can eat independently using his fingers or a spoon placed in the right hand and can drink from a glass using both hands. He can use his left hand to manipulate objects if required but movements are not coordinated and he has difficulty grasping and releasing objects.

The reason of seeking occupational therapy consultation was to improve the use of the left arm during play and activities of daily living.

Occupational Therapy Intervention

Practice of upper-limb movements in different parts of the arm workspace while wearing a trunk-restraint system should be offered during play activities and during therapy sessions . It is recommended to practice for 1–2 h per day in therapeutic/play situations. Play situations can include interaction with video games that encourage full arm movements such as IREX, Sony Eye-Toy, Wii, Nintendo, etc. For therapist-supervised activities, movements of the arm should be encouraged in which the arm is extended far from the body, into the ipsilateral and contralateral workspace, both below and above shoulder level (see Figs. 39.1 and 39.2). Bimanual activities should also be included.

Questions for Students

• 1. Which occupational therapy intervention is recommended and why?

• 2. What is the evidence for the effectiveness of the intervention in this population and age group?

• 3. What alternative occupational therapy interventions are available?

• 4. What is the role of the occupational versus the physical therapist for this intervention?