Trials of a SaeboFlex and SaeboGlove

For Saeboflex components nomenclature see http://www.saebo.com/saeboflex-saeboreach-details/

5 October 2016

On 16 Huly 2016 P had a left MCA stroke rendering her temporarily hemiplegic on her right side. Twelve weeks later her walking is greatly improved and some right arm mobility has been regained, but paresis and spasticity of the right hand remains. A Saeboflex was indicated and was fitted on a trial basis on 5 October 2016. After the fitting, P was able to pick up a ball placed in front of her with her right hand and put it down again in the same place. All four digits flexed and extended satisfactorily. Instructions were to do this exercise for the first three days and then when putting the ball down, do so by extending the arm to the right.

Photos: typical flexed and extended positions of P's hand.

flexed.jpg (83926 bytes) extended.jpg (97349 bytes)

6 October 2016

Fitting the Saeboflex took about 20 minutes. The main snag was that the index finger cap did not fit P's injured index finger. The cap is marked 'E'. Its internal diameter at 'D' in the photo below is 20 mm. The diameter to the left by the strap is 19.2 mm. The index finger has a swelling at the DIP joint due to an injury many years ago. However the finger's diameter at this point is only 19.2 mm, which does not explain why it would fully insert. Fitting a slightly larger cap would solve the problem, say 21 mm i.d. 

index_finger_cup.jpg (70119 bytes)

P was unable to flex her thumb, despite being able to grasp a ball with the Saeboflex the previous day. The thumb lead mount was rotated about 40 degrees to reduce the gap between thumb and index finger. The original position was marked. P managed 290 flex/extension cycles throughout the day in 2 sessions, one morning (160) and one afternoon (130). After a session, there is generally reddening of the pressure points due to the Saeboflex. This clears in an hour or so after removing the orthosis.

saeboflex_marks.jpg (154035 bytes)

7 October 2016

First session 10.00-11.20 136 cycles until fatigue set in.

In the afternoon P could not flex her thumb enough to grasp a ball, even though the Saeboflex was fitted as in previous sessions. The thumb spring seemed too strong. Therefore the thumb mount was moved 4.5 mm towards the thumb to reduce the spring tension and the bead chain slackened by 4 beads. This enabled the ball to be grasped repetitively.

Second session 16.37-17.25 214 cycles. Total for day: 350

8 October 2016

At the morning fitting it was noted that three of the fingers are misaligned by the pull of the Saeboflex. There seems to be no obvious adjustment for this apart from reducing the tension. The orthosis appeared to be correctly fitted.

finger_misalignment.jpg (160440 bytes)

Accordingly, the number of unused beads in the lines was noted and the 3rd and 4th lines (counting from the thumb) slackened by one bead.

Beads not under tension (excluding anchor bead)
Thumb 10
Index 10
Middle 10
3rd finger 15
Little finger 13

P reached her target of 400 cycles, 151 in the morning and 249 in the afternoon. A total of 51 cycles were without the ball. The rest were done by grasping, lifting, replacing and releasing the ball.

9 October 2016

Commenced next stage of exercises: pick up ball and put down to right.

10.10-11.35 120 cycles
12.05-12.45 83 cycles
Early eve 61 cycles         DAY'S TOTAL 264 cycles, time: 2 hours 5 min.

Table of current bead line tensions (counting beads not under tension)

  Original Today
Thumb 10 6
Index 10 9
2nd finger 10 9
3rd finger 15 11
4th finger 13 15

10 October 2016

Flexing the thumb continues to be a problem although it flexes satisfactorily without the Saeboflex. The thumb spring seems too strong in comparison to the strength in P's thumb. Three much weaker springs were substituted for the Saeboflex's thumb spring. This allowed good flexing of the thumb but still extended it fully on the relax phase. In fitting the thumb cap P experienced pain on the IP joint, mainly due to the joint attempting to flex within the constraint of the cap. This and neural fatigue were the main reasons for ending the first session of the day.

thumb_pressure_point_101016.jpg (55094 bytes)

10.00-10.20 Fitting and replacing thumb spring
10.20-11.35 Picking up ball and putting down to right  side. 225 cycles (includes 5 without ball and 5 where ball was dropped prematurely)

Early evening: 147 cycles. DAY's TOTAL: 372 cycles, approx. 2 hours.

11 October 2016

Morning fitting took 9 minutes. From 10.05-12.00 am 200 cycles. A pad of foam neoprene was inserted in the thumb cap to prevent pressure pain from the thumb cap at the thumb IP joint.

thumb_IP_joint_pad.jpg (54413 bytes)

After this morning session the hand tone was noticeably reduced. The photo below shows both hands when relaxed.

hand_tone_111016.jpg (81394 bytes)

Without the help of her left hand, P was able to guide her right hand onto one of the tubes of the physio aid shown below, grasp the tube, remove it and replace it. This was also achieved with a cone resting on another cone. This was not possible before using the Saeboflex. It was more due to the reduction in tone of the thumb and fingers than any voluntary extension of them. She was able to push the tube between thumb and fingers before grasping.

rods_tubes.jpg (29126 bytes)

Therapy session at Ysbyty Bryn Beryl: practice of exercise for week 2 of the trial, namely pick up in front (centre), put down to right, pick up and put down to left, pick up and return to centre. Approx. 15 pick up/put down cycles completed.

Adjustments made following suggestions of therapists at Ysbyty Bryn Beryl: index, 2nd & 3rd finger bead lines tightened by 1 bead; thumb lead mount and thumb mount reverted to the original positions as received on 5 October.

thumb_mounts_reverted_111016.jpg (91117 bytes)

From the above photo it should be clear that this resulted in a pull on the thumb lateral to the normal trajectory of the thumbs grasp/release, thus bending the thumb. To overcome this, the thumb lead mount was retracted by 14 mm towards the elbow and rotated about 50 degrees clockwise (viewed from elbow) resulting in the thumb being straight when in the relaxed position. This placed the eye of the thumb lead mount over the thumb cap midline.

thumb_mount_retracted_111016.jpg (75169 bytes)  

Beads not under tension

  Original Today
Thumb 10 9
Index 10 10
2nd finger 10 10
3rd finger 15 12
4th finger 13 15

Early evening session with this configuration: pick up centre, put down to right, pick up from right, put down to centre -- 112 grasp/releases. P noted that her finger extension after release is now quicker. TOTAL GRASP RELEASES FOR DAY: 327.

12 October 2016

Morning: 384 grasp/releases  with right hand (128 repeats of grasp centre, release to right, grasp from right, release to centre, grasp from centre release to left (move ball back to centre with left hand)

Afternoon: 164 grasp/releases (82 repeats of up from centre, down to right, up from right, down to left (move ball back to centre with left hand).
TOTAL GRASP RELEASES FOR DAY: 548

13 October 2016

100 repeats of up from centre, down to right, up from right, down to left, up from left, down to centre with no left hand involvement.
TOTAL GRASP/RELEASES FOR DAY: 300

Lump noticed on thumb IP joint, despite use of padding.

14 October 2016

The problem with the index finger cap not allowing the index finger to enter fully was largely resolved today by lifting the tip if the finger by the nail as the finger was inserted. Compare the following photo with the one for 6 October.

index_cap.jpg (39316 bytes)

TOTAL GRASP/RELEASES FOR DAY: 303 (two sessions of 141 & 162) In the afternoon, the right ball tray was raised 50 mm.

15 October 2016

To improve finger extension when relaxed, all finger bead lines were shortened by one bead.

Beads not under tension

  Original Today
Thumb 10 9
Index 10 11
2nd finger 10 11
3rd finger 15 13
4th finger 13 16

Varying the height of pick up and put down was started. Initially the right position was raised 50 mm and the left 80 mm, keeping the centre at table level.

Morning session (1 hour): 135
Afternoon session:150
TOTAL GRASP/RELEASES FOR DAY: 285

16 October 2016 

After the first fitting of the day, despite tightning all bead lines by one bead the day before, the fingers did not extend fully for the first few releases.

Also, to test whether thumb strength had increased enough to extend the thumb spring supplied with the Saeboflex, that spring was substituted for the three weaker springs used on 10 October.

Ball height was further varied with the right position raised to 210 mm whereas centre and left positions were at table level.

The duration of Saeboflex exercises was reduced to 45 minutes, in line with advice in the published Saeboflex trials.

Morning: 99
Early afternoon: 138
Late afternoon: 105
TOTAL GRASP/RELEASES FOR DAY: 342

17 October 2016

The exercise setup further altered to provide raised positions for ball put down and pick up to both the right and the left (210 mm high both sides). Note that all the exercises so far do not involve merely releasing the ball into a crate, but instead positioning it on the anti-roll supports shown at the left, centre, and right positions in the photo below.

exercise_setup_171016.jpg (101672 bytes)

Morning: 126
Afternoon: 132
Late afternoon 96

TOTAL GRASP/RELEASES FOR DAY: 342

18 October 2016

Morning session (45 min): 153
Afternoon session (40 min): 160
TOTAL GRASP/RELEASES FOR DAY: 313

Routine changed for afternoon session. The cycle went: pick up centre; put down to right on raised surface (190 mm above table); pick up from right and drop into crate on left; pick up next  ball with left hand from tray to front and place on support immediately in front.

19 October 2016

The exercise setup was further varied: centre pick up, put down to right (height 190 mm above table level); pick up from right and drop into crate on left, place next ball at centre with left hand.

exercise_setup_191016.jpg (91199 bytes)

Morning session: 108
Afternoon session 132
TOTAL GRASP/RELEASES FOR DAY: 240

20 October 2016

Photos of the current status of fitting the Saeboflex:

fitting_201016.jpg (206653 bytes) finger_caps_201016.jpg (107585 bytes)

thumb_fitting_201016.jpg (148549 bytes)

Morning session: 104
Afternoon: 118
Early evening: 142
TOTAL GRASP/RELEASES FOR DAY: 364

Height of put down / pick up point on right increased to 230 mm above table level. The ball is dropped into a crate on the left and retreived with the left hand.

Milestone: With right hand pronated, P picked up tennis ball and let it drop.

21 October 2016

With increasing strength in the thumb, to improve grip angle, the thumb lead mount was rotated a little anticlockwise to 315 degrees viewed from the elbow end of the rod. At the same time, the thumb lead mount was extended 11 mm towards the thumb resulting in the end of the rod projecting 11 mm from the mounting block.

thumb_lead_mount_angle_211016.jpg (132169 bytes)  thumb_lead_mount_projection_211016.jpg (42809 bytes)

At the recommendation of Amy Bean some tightning of the finger lines was done:

Beads not under tension

  Original Today
Thumb 10 9
Index 10 12
2nd finger 10 12
3rd finger 15 13
4th finger 13 16

Morning session: 152
Late morning: 128
Early evening: 72
TOTAL GRASP/RELEASES FOR DAY: 352

Review of progress and adjustments to Saeboflex by physiotherapist KJ: the excessively tight index finger cap was changed from an 'E' to a 'F2'. An authentic Saeboflex (yellow) thumb spring was substituted for the three improvised weaker thumb springs. This change increased the flex effort needed for the thumb. A thumb strap was fitted for optional use to neutralise the metacarpophalangeal joint of the thumb. An optional stronger (red)finger spring was cfitted. Additional exercises were prescribed for the coming week.
Examination of the hand showed less flexor tone than on the fitting date (5.10.16) and weak extension of the thumb and fingers.

With the stronger thumb spring fitted, the bead line had to be slackened a one bead to allow thumb movement. The index finger bead line setting was also slackened one bead because of the changed cap.

Beads not under tension

  Original Today
Thumb 10 8
Index 10 11
2nd finger 10 12
3rd finger 15 13
4th finger 13 16

22 October 2016

Milestones: With the right hand, P 1) picked up a thimble from a table with thumb and index finger and placed it on little finger of assistant; 2) picked up mug and drank from it; 3) picked up measuring jug of water and pured contents into kettle. Otherwise, hand still very weak.

Morning session: 152
Late morning: 108
Early evening: 84 (new exercise: side-stepping between grasp/release)
TOTAL GRASP/RELEASES FOR DAY: 344

New exercise: ball picked up from table, three side steps to right (~2 m), release into crate, return ball to original (centre) position with left hand, pick up ball. three side steps to left, release into crate, return ball to original (centre) position with left hand. This reduces the number of grasp/releases possible per session. This exercise was done for one of the sessions each day.

P experienced some pain on the IP joints of 1st, 3rd &4th digits due to pressure of caps.

23 October 2016

Morning session: 196
Early evening: 118 (side-stepping between grasp/release)
TOTAL GRASP/RELEASES FOR DAY: 314

24 October 2016

Morning session: 146 (side-stepping between grasp/release)
Early evening: 212
TOTAL GRASP/RELEASES FOR DAY: 358

25 October 2016

Morning session: 144 (walking between grasp/release)
Early evening: 284
TOTAL GRASP/RELEASES FOR DAY: 428

26 October 2016

Morning session: 132
Early evening: 220 (walking between grasp/release)
TOTAL GRASP/RELEASES FOR DAY: 352

27 October 2016

Morning session: 202
Early evening: 213
TOTAL GRASP/RELEASES FOR DAY: 415

All with right hand: pick up from centre and put down to right at 190 mm above table; pick up and put down to left; pick up from left and put down centre. No walking today. 

28 October 2016

Morning session: 212 (walking)
Early evening: 171
TOTAL GRASP/RELEASES FOR DAY: 383

Right and left positions in walking exercise raised to 900 and 1030 mm respectively above floor level. Left and right pick up points were shallow supports for the ball (jar lids), each cycle involved four pairs of grasp/releases.

29 October 2016

Shoulder pain, possibly due to lying awkwardly at night, limited use of the Saeboflex today.

Morning session: 231
TOTAL GRASP/RELEASES FOR DAY: 231

30 October 2016

Morning session: 296 (walking, same setup as 28 Oct.)
Early evening: 164
TOTAL GRASP/RELEASES FOR DAY: 460

31 October 2016

Morning session: 159

grasp_release_graph.jpg (52482 bytes)

Average daily grasp/releases to date 348 (range 231-548)
Total 55 sessions
8848 grasp/release repetitions

Suspension of Saeboflex trial pending a decision on whether to continue with Saeboflex therapy.

Main observations:

* Improved movement and coordination of shoulder and arm.
* Scapula more parallel to chest, i.e. not 'winging'.
* Trace of voluntary finger extenstion after making a fist.
* Thumb waggle at DIP joint replaced by waggle at CMC joint.
* With right arm/hand can pick up and put down tennis ball, eat a banana, drink from a mug, pick up a thimble and pit it on someone's finger.
* Pain due to pressure of the caps at the DIP joints a continuing problem.

Trial of SaeboGlove -- 15 November 2016

P was supplied with a M-medium SaeboGlove. It was quickly fitted by KJ and P was able to grasp a ball or fine motor cube and release them in  a different place.

16 November 2016

Fitting the glove and adjusting it to get full finger extension took about one hour.

Main issues:

1) Where to position the glove's flap.
2) Difficulty of getting bent fingers into glove.
3) Thumb not opposite any fingers even with biggest tensioner

Below: glove, showing thumb position

glove_thumb.jpg (98921 bytes)

4) Instructions say place splint as proximal as possible but does not make it clear where is ideal in relation to the glove.
5) Needed small tensioners on MCP joints to get fingers extended.
6) The splint tends to slide towards the hand, causing a fold in the glove and reducing the effectiveness of the tensioners.

Below: fold in glove

glove_rear.jpg (111561 bytes)

17 November 2016

The glove took 12 minutes to fit. This time the splint was applied to the proximal flap of the glove before fitting. This ensured that the whole splint had the padding offered by the glove flap between the splint and the forearm. A further 8 minutes were needed for adjustments to improve finger extension after a few grasp/release cycles. The solution was to add extra tensioners to the MCP joints.

65 grasp/release cycles wee performed using the ball in the kind of exercises described above for the Saeboflex. P was also able to stack all four fine motor cubes one upon the other. Numerous functional tasks were performed with the glove until mid afternoon when it was removed. There were some pressure marks, though less pronounced than with the Saeboflex.

19 November 2016

Glove worn until early afternoon. Exercises included grasp/move/releases with the Saebo ball provided and functional tasks. Even with double tensioners on MCP joints the fingers did not always fully extend sufficiently to facilitate the next grasp. The glove also reduced tactile sensing of the objects to be grasped. As P could anyway grasp things between finger and thumb without the glove and perform finer manipulations this way, the glove did not enhance this faculty.

21 November 2016

Glove worn morning only. Fitting still a problem due to bent fingers and high tone. The general impression was that hand tone was still too high for the glove's capacity to extend the fingers.

22 November 2016

Phone discussion with KJ. Decision to abandon the glove for a fortnight and decide on hand rehab strategy thereafter.

25 November 2016

Wore Saeboglove 2 hours after increasing the tension where possible. The uncertainty over positioning the flap (see 16 Nov) on the proximal end of the glove was overcome by fitting the splint exactly over it before applying the glove to the limb. In this session, again finger extension force from the tensioners was insufficient. Also, the thick hand strap tended to make grasping small objects difficult.

29 November 2016

Last attempt with Saeboglove. Used it to stack the rubber cubes. Otherwise same issues as before.

Summary of main issues:

1) Tone in P's hand too great for the tensioners.
2) Glove tends to slide distally and create a fold over knuckles.
3) Thumb had to be without a tensioner so as to allow it to move opposite the fingers.

Suggestion:

The distal migration of the splint and proximal part of the glove arises because the forearm tapers to a smaller diameter towards the wrist and the friction pads in the glove's flap are insufficient to prevent the splint from sliding distally. A better anchorage for the splint might be achieved by having a strap round the wrist. The palm strap was tried in this position and seemed to give better finger extension.

12 December 2016

Fitted for SaeboFlex by KJ.