HTCC CCE cheat sheet

Upper limb recovery follows a proximal-to-distal and gross-to-fine sequence; proximal scapular and shoulder control typically precedes isolated hand function, so distal retraining is built on stable proximal mechanics.

Cortical representation of the hand is disproportionately large; task-specific, repetitive, and salient practice drives use-dependent plasticity, the theoretical basis for constraint-induced movement therapy (CIMT) and high-repetition dosing.

CIMT protocol parameters: restraint of the less-affected limb for ~90% of waking hours over 2 consecutive weeks, with shaping and task practice of the more affected limb; modified CIMT shortens restraint to ~6 h/day over 2-3 weeks.

Spasticity vs contracture: spasticity is velocity-dependent increased resistance to passive stretch (UMN sign); contracture is fixed loss of passive range. Measure spasticity with the Modified Ashworth Scale (0-4, with 1+), not goniometry.

Shoulder subluxation after stroke: assess with palpation of the acromion-to-humerus gap; manage with positioning, supportive sling during standing/transfers, and avoidance of overhead pulley exercises that risk impingement.

Upper limb motor recovery prediction: presence of voluntary finger extension and shoulder abduction within the first days post-stroke predicts meaningful upper limb recovery; absence of both predicts poor distal recovery (predictive rule used in prognostic models).

Fugl-Meyer Assessment Upper Extremity (FMA-UE) has 33 items, 66-point maximum; a change of ~5-6 points is commonly cited as clinically important. Action Research Arm Test (ARAT) has 19 items, 57-point maximum.

Rehabilitation dosing principle: greater intensity and repetitions produce better motor outcomes up to tolerance; sessions should include massed task practice (hundreds of repetitions) rather than passive-only interventions.

Neurofacilitation approaches (Bobath/NDT, PNF) emphasize handling and movement quality; current evidence favors task-specific, functional training over impairment-only facilitation, but PNF patterns (D1/D2 flexion-extension) remain useful for shoulder and scapular activation.

Mirror therapy and motor imagery recruit the mirror neuron system and contralateral motor networks; use when active movement is limited, with evidence strongest for post-stroke upper limb paresis as an adjunct.

Grading of resistance in early post-surgical/injury phases: isometric first, then isotonic concentric before eccentric; eccentric loading is avoided in acute tendon repair because of higher tensile load.

Peripheral nerve injury classification (Seddon): neurapraxia (conduction block, full recovery), axonotmesis (axon loss, intact sheath, good recovery), neurotmesis (complete disruption, requires surgery). Recovery follows Wallerian degeneration and axonal regeneration at ~1 mm/day.

Hand function assessment: grip strength with dynamometer (Jamar), pinch strength (lateral, pulp, three-point), and dexterity with the Nine-Hole Peg Test or Box and Block Test; compare bilaterally and use standardized positioning (shoulder adducted, elbow 90°, wrist neutral).

Range of motion norms for shoulder: flexion/abduction ~180°, external rotation ~90°, internal rotation ~70°; elbow flexion ~150°, extension 0°; wrist extension ~70°, flexion ~80°. Document active before passive.

Edema management in hand rehabilitation: elevation above heart, compression, retrograde massage, and active exercise; persistent edema causes stiffness and fibrosis and should be treated before aggressive mobilization.

Splinting principles: static splints for positioning/rest and prevention of contracture; dynamic or serial splints for controlled mobilization; check skin, circulation, and fit within the first hours of wear.

Rotator cuff rehabilitation phases: phase 1 pain control and isometrics, phase 2 active-assisted ROM and scapular stabilization, phase 3 progressive resistance, phase 4 functional/overhead tasks; progression guided by pain and movement quality, not calendar alone.

Frozen shoulder (adhesive capsulitis) staging: painful/freezing phase (2-9 months), frozen phase (4-12 months), thawing phase (5-24 months); aggressive stretching in the painful phase may worsen symptoms, so gentle mobility and pain control predominate.

Tendon transfer and nerve transfer post-operative protection: follow surgeon-specific immobilization and avoid active contraction of the transferred unit during early healing; neuromuscular electrical stimulation may be used to re-educate the transferred muscle.

Stroke upper limb assessment should include tone (Modified Ashworth), strength (MRC 0-5), sensation (light touch, proprioception), pain (shoulder pain screen), and function (ARAT or FMA-UE) to guide goal setting.

Task-specific practice is grounded in motor learning: blocked practice for early skill acquisition, random and variable practice for retention and transfer; feedback should be faded from frequent knowledge of results to intrinsic feedback.

Constraint-induced principles can be adapted when full CIMT is not tolerated: shaping, restraint of the less-affected limb during functional tasks, and a home program of repetitive task practice.

Shoulder pain after stroke often relates to subluxation, impingement, or complex regional pain syndrome; avoid overhead pulleys, forceful passive stretching, and traction on a flaccid shoulder.

Outcome measures should be reliable, valid, and responsive; for upper limb, combine a body-function measure (grip strength, ROM) with an activity measure (ARAT, Box and Block) to capture both impairment and function.

Motor control theories: reflex/hierarchical models, systems model (Bernstein) emphasizing degrees of freedom, and dynamical systems theory; contemporary practice favors task-oriented, ecological approaches over isolated reflex training.

Manual muscle testing (MRC 0-5): 0 no contraction, 1 trace, 2 active movement with gravity eliminated, 3 against gravity, 4 against gravity plus some resistance, 5 normal; document position and joint tested.

Proprioceptive neuromuscular facilitation (PNF) uses diagonal patterns, quick stretch, and resistance to facilitate weak muscles; D1 flexion includes shoulder flexion, adduction, external rotation, and elbow flexion.

Complex regional pain syndrome (CRPS) after stroke: disproportionate pain, edema, trophic changes, and allodynia; management includes gentle graded movement, desensitization, edema control, and pain education, avoiding forceful mobilization.

Brachial plexus injuries: Erb's palsy (C5-C6) affects shoulder abduction and elbow flexion; Klumpke's palsy (C8-T1) affects hand intrinsics and may include Horner syndrome. Assess myotomes and dermatomes to localize.

Carpal tunnel syndrome: median nerve compression at the wrist with nocturnal paresthesia in thumb-index-middle digits; provocative tests include Phalen and Tinel; conservative care includes splinting in neutral, activity modification, and nerve gliding.

Evidence-based dosing for upper limb after stroke: high-repetition, task-specific practice (often 300+ repetitions per session) outperforms low-dose conventional therapy for motor recovery.

Patient education and self-management: teach home exercise with clear frequency, symptom monitoring rules, and red flags (increasing pain, numbness, swelling) to support adherence and safety.

Sensory re-education after nerve injury: begin with protective sensation awareness, then localization, texture discrimination, and graded desensitization using progressively less irritant materials; avoid overstimulation in early hypersensitivity.

Grip and pinch norms: average adult grip ~30-45 kg men and ~20-30 kg women depending on age and device; pinch (lateral) ~7-10 kg; interpret against age- and sex-matched norms and the uninvolved side.

Shoulder impingement rehabilitation targets scapular upward rotation, posterior cuff strength, and thoracic posture; avoid painful arc loading and overhead pressing until pain-free motion is achieved.

Elbow rehabilitation after fracture or dislocation: prioritize early protected motion within surgeon limits, monitor for loss of extension, and avoid aggressive passive stretching that risks heterotopic ossification or instability.

Hand tendon repair rehabilitation (flexor): early controlled passive flexion with active extension protects the repair; avoid active flexion against resistance until cleared, per zone-specific protocols.

Wrist and hand osteoarthritis: joint protection, activity pacing, orthoses for thumb base OA, and strengthening of intrinsic and forearm muscles; avoid prolonged static gripping and repetitive loading.

Motor learning feedback: knowledge of performance (movement quality) is useful early for skill acquisition; knowledge of results (outcome) supports retention when faded over time.

Interdisciplinary coordination: communicate upper limb goals, precautions, and assistive device needs with nursing, occupational therapy, and orthotics to maintain carryover across the day.

Neuroplasticity mechanisms relevant to upper limb rehab include synaptic potentiation, cortical map reorganization, and dendritic sprouting; these are promoted by repetition, intensity, salience, and task specificity.

Virtual reality and telerehabilitation are adjuncts that increase repetition and engagement; evidence supports them as comparable or additive to conventional therapy when used with adequate dose and supervision.

Botulinum toxin for focal spasticity: effect peaks around 2-6 weeks and lasts ~3-4 months; pair injection with stretching, strengthening of antagonists, and functional training for best results.

Orthotic decision-making: use static progressive or dynamic splints for contracture management with low-load prolonged stretch; monitor skin and joint alignment and reassess ROM regularly.

Functional electrical stimulation (FES) for upper limb: can assist grasp and reduce subluxation; contraindications include implanted cardiac devices, pregnancy over the area, and active malignancy in the field.

Shoulder hemiarthroplasty/reverse total shoulder rehabilitation: early phases protect the implant with sling and passive motion per surgeon; avoid active elevation and resisted internal rotation early; progress to strengthening after protected healing.

Documentation should record objective measures (ROM in degrees, MRC grade, FMA-UE or ARAT score), assist level, and functional goals to demonstrate progress and justify continued skilled therapy.

Safety screening before upper limb exercise: check for unstable fractures, recent surgery precautions, uncontrolled pain, autonomic instability, and skin integrity; modify intensity and positioning accordingly.

Scapulohumeral rhythm: approximately 2:1 glenohumeral to scapulothoracic motion during elevation; loss of scapular upward rotation contributes to impingement and should be assessed and treated.

Rotator cuff force couple: deltoid and supraspinatus elevate, while infraspinatus, teres minor, and subscapularis compress the humeral head; rehabilitation aims to restore this compression to prevent superior migration.

Median, ulnar, and radial nerve distributions: median supplies thenar muscles and thumb-index-middle sensation; ulnar supplies most intrinsics and little finger sensation; radial supplies wrist/finger extensors and dorsal hand sensation.

Tone assessment: Modified Ashworth Scale grades 0 (no increase) through 4 (rigid); grade 1+ indicates catch then minimal resistance through less than half of range.

Motor recovery after stroke commonly follows a stereotyped sequence (Brunnstrom stages I-VI); staging guides exercise selection from synergy-based movement to isolated, out-of-synergy control.

Home program design uses the FITT principle: frequency, intensity, time, and type; specify repetitions, sets, and symptom limits to make the program measurable and safe.

Goal setting uses SMART criteria and collaborative goal-setting; align goals with patient priorities such as dressing, eating, or returning to work to improve engagement.

Outcome interpretation: a change exceeding the minimal clinically important difference supports meaningful improvement; for the FMA-UE, approximately 5-6 points is commonly used as a benchmark.

Proximal stability precedes distal mobility: proximal scapular and trunk control is a prerequisite for efficient reach and grasp; assess trunk control and sitting balance before intensive distal training.

Muscle imbalance patterns in shoulder dysfunction: tight pectoralis minor and upper trapezius with weak lower trapezius and serratus anterior contribute to forward head and rounded shoulder posture; address with stretching and targeted strengthening.

Post-stroke shoulder pain screening: assess at rest and with movement, palpate the subacromial space, check for subluxation, and screen for CRPS features (edema, color/temperature change, allodynia).

Electrical stimulation parameters for muscle re-education: pulsed current with sufficient amplitude to produce visible contraction, duty cycle allowing rest, and progression of intensity as tolerance improves.

Grip strength testing protocol: seated, shoulder adducted and neutrally rotated, elbow 90°, forearm neutral, wrist 0-30° extension; use the mean of three trials and the same device for comparison.

Handedness and dominance: assess the dominant limb first for reference values but treat the affected limb as the target; document which limb is dominant to interpret asymmetry.

Patient handling and positioning: support the affected arm on a table or lap during sitting to prevent dependent edema and subluxation; avoid pulling the arm during transfers.

Rehabilitation after distal radius fracture: early finger, thumb, and shoulder motion to prevent stiffness; progress wrist motion per surgeon; monitor for CRPS and median nerve symptoms.

Motor learning stages: cognitive (understand the task, high errors), associative (refine, fewer errors), and autonomous (automatic); match feedback and practice structure to the stage.

Practice structure: massed practice is efficient for early acquisition but fatiguing; distributed practice supports retention; variable and random practice improve transfer and retention compared with blocked practice.

Bimanual training is used when unilateral capacity is limited; it can improve coordination and engagement, but the less-affected limb should not compensate for the affected limb during functional tasks.

Strengthening principles: overload, specificity, and progression; begin with low load and high repetitions for endurance and motor control, then progress load for strength once movement quality is stable.

Pain neuroscience education can reduce fear-avoidance and improve adherence; combine with graded activity and pacing rather than rest alone.

Assistive technology and adaptive equipment (universal cuffs, plate guards, built-up handles) support independence; train the patient in their use and reassess as function improves.

Falls and safety: screen upper limb weight-bearing capacity before using the arm for support during transfers; a painful or unstable shoulder should not be loaded.

Interprofessional communication and discharge planning: document functional gains, home program, equipment needs, and follow-up to support continuity of care.

Neuroanatomy relevant to upper limb: corticospinal tract mediates voluntary distal movement; damage produces weakness and loss of dexterity; the rubrospinal and reticulospinal tracts contribute to flexor and postural tone.

Sensory pathways: dorsal columns carry proprioception and fine touch; spinothalamic tract carries pain and temperature; assess both to localize lesions and guide sensory re-education.

Cerebellar signs in the upper limb include intention tremor, dysmetria, and dysdiadochokinesia; training emphasizes coordination, feedback, and weighted or guided tasks.

Basal ganglia disorders produce rigidity, bradykinesia, and resting tremor; upper limb training focuses on amplitude, cueing, and functional task practice.

Multiple sclerosis upper limb rehabilitation: manage fatigue with energy conservation, use cooling and pacing, and prescribe moderate-intensity exercise with rest intervals.

Parkinson's disease upper limb training: use amplitude-based training (LSVT BIG principles), external cueing, and dual-task practice to improve reach and grasp.

Traumatic brain injury upper limb: address tone, contracture prevention, positioning, and functional task practice; monitor for heterotopic ossification and spasticity.

Outcome measure selection: choose measures matched to the domain of the ICF model (body function, activity, participation) and to the patient's goals and stage of recovery.

Tendon gliding exercises for the hand use five positions (straight, hook, full fist, tabletop, straight fist) to promote tendon excursion and reduce adhesion after injury or surgery.

Nerve gliding exercises (median, ulnar, radial) use graded tension positions; perform gently and stop if symptoms increase, as aggressive gliding can irritate a sensitized nerve.

Joint protection principles for arthritis: respect pain, balance rest and activity, use larger joints and two hands, avoid prolonged static positions, and use adaptive equipment.

Scar management after hand surgery: massage, silicone, and compression once the wound is stable; monitor for hypertrophic scarring and contracture.

Wound and skin care in splinting: inspect skin before and after splint wear, avoid pressure over bony prominences, and adjust straps to maintain fit without compromising circulation.

Patient adherence strategies: simplify the home program, link exercises to daily routines, use a written log, and review progress at each visit.

Cultural and linguistic considerations: provide education in the patient's preferred language and confirm understanding with teach-back to support safe self-management.

Documentation of skilled intervention: record the intervention, response, and progress toward goals to demonstrate medical necessity and guide plan of care updates.

Upper limb amputation rehabilitation: early prosthetic fitting and training, desensitization, and residual limb care; myoelectric and body-powered prostheses require different control training.

Phantom limb pain management includes mirror therapy, graded motor imagery, desensitization, and relaxation; avoid reinforcing avoidance behaviors.

Complex hand injuries: coordinate with hand surgery on tendon, nerve, and bone repair timelines; follow zone-specific protocols and monitor for infection and stiffness.

Burns to the upper limb: position in anti-deformity (shoulder abduction, elbow extension, wrist extension, MCP flexion), splint, and exercise to maintain range; scar management with compression and silicone.

Rheumatoid arthritis hand care: gentle ROM, isometric strengthening, joint protection, and resting splints during flares; avoid aggressive stretching of unstable joints.

Osteoarthritis hand care: strengthening of intrinsics, thumb stability exercises, and activity modification; heat may help stiffness while cold helps acute inflammation.

Pediatric upper limb rehabilitation: use play-based, task-specific practice, involve caregivers, and monitor developmental milestones and tone.

Geriatric considerations: account for sarcopenia, balance, and cognition; prescribe lower-load, higher-frequency programs and ensure safe home setup.

Assessment of reach and grasp: observe transport, grasp, manipulation, and release; identify compensatory trunk movement and proximal instability that limit distal function.

Grip types: power, precision (pulp, lateral, three-point), and hook; train the specific grip required by the patient's functional tasks rather than generic strengthening alone.

Constraint-induced movement therapy evidence: strongest for patients with some voluntary wrist and finger extension; screen with the Motor Activity Log and Wolf Motor Function Test.

Mirror therapy protocol: place the mirror between limbs, move the unaffected limb while attending to the mirror image; perform for ~30 minutes daily as an adjunct.

Mental practice: guided imagery of a specific task before physical practice can enhance motor learning; use when cognition and attention allow.

Biofeedback and EMG training can improve awareness and recruitment of weak muscles; use with clear goals and avoid overreliance on the device.

Aquatic therapy can support early upper limb motion with reduced load; monitor for fatigue and skin integrity.

Community reintegration: practice real-world tasks (cooking, shopping, work) and address environmental barriers to generalize gains.

Neuromuscular electrical stimulation (NMES) can reduce shoulder subluxation and improve motor recovery when applied early after stroke; place electrodes over the posterior deltoid and supraspinatus with adequate intensity.

Transcutaneous electrical nerve stimulation (TENS) is used for pain modulation; evidence for shoulder pain after stroke is mixed, so use as an adjunct with active therapy.

Ultrasound and thermal modalities are adjuncts for soft tissue extensibility; avoid over bone growth plates in children and over areas of impaired sensation.

Cryotherapy reduces pain and edema after acute injury; monitor skin and limit duration to avoid cold injury, especially with sensory loss.

Thermotherapy increases collagen extensibility before stretching; combine with prolonged low-load stretch for contracture management.

Taping and kinesiology tape may support scapular positioning and proprioception; evidence is limited, so use as an adjunct and monitor skin.

Orthotic and prosthetic team coordination ensures proper fit and function; reassess fit as tone, edema, or strength changes.

Quality improvement: track outcome measures over time to evaluate program effectiveness and adjust interventions.

Upper limb rehabilitation after stroke should begin early, with positioning, passive motion, and active-assisted exercise to prevent complications while recovery emerges.

Shoulder-hand syndrome (CRPS) after stroke: recognize early signs (pain, edema, vasomotor changes) and initiate gentle movement, edema control, and pain management to prevent progression.

Spasticity management includes positioning, stretching, strengthening of antagonists, and focal chemodenervation; assess goals and function before and after intervention.

Contracture prevention: regular passive range, positioning, and splinting; monitor for skin breakdown and pain with prolonged stretch.

Functional task training should be graded from part-task to whole-task practice and from simulated to real environments to promote transfer.

Patient-centered care: incorporate preferences, values, and cultural context into goal setting and intervention selection.

Interprofessional collaboration with occupational therapy, nursing, and orthotics supports carryover and safety across settings.

Program evaluation: use standardized measures and patient-reported outcomes to demonstrate value and guide quality improvement.

Motor control and motor learning principles guide upper limb rehabilitation: task specificity, repetition, salience, and feedback drive neuroplastic change.

Assessment should be multidimensional: impairment (ROM, strength, tone, sensation), activity (ARAT, Box and Block), and participation (patient-reported outcomes).

Rehabilitation dosing should be intensive and progressive, with task practice prioritized over passive modalities.

Safety screening and precautions (fracture, surgery, pain, skin, autonomic instability) must precede upper limb exercise.

Patient education and self-management support adherence and long-term outcomes.

Interprofessional coordination and documentation demonstrate medical necessity and support continuity of care.

Outcome measures should be reliable, valid, responsive, and matched to the patient's goals and stage of recovery.

Evidence-based practice integrates best evidence, clinical expertise, and patient values in upper limb rehabilitation.