BY: EUSIVIA PASI MPT

MANAGEMENT OF UPPER LIMB POST STROKE WITH

RECENT ADVANCES

DEFINITION OF STROKE

Cerebral vascular accident has been defined as ‘a

sudden, non-convulsive loss of neurologic function

due to an ischemic or hemorrhagic intracranial

vascular event’ (pubmed [medline], mesh

database, 2005).

The world health organization (who) definition of stroke

is: “rapidly developing clinical signs of focal (or

global) disturbance of cerebral function, with

symptoms lasting 24 hours or longer or leading to

death, with no apparent cause other than of vascular

origin”

“Stroke or Brain Attack is the sudden loss of

neurological function caused by an interruption of

blood flow to the brain” by Susan B. O’Sullivan

“a focal (or at times global) neurological

impairment of sudden onset lasting more than 24

hours (or leading to death) and of presumed

vascular origin” by WHO Journal of the association of

physicians of India, October 2013, Vol. 61

“a sudden loss of brain function resulting from an

interference with blood supply to the brain” by

National Institute of Neurologic Disorders and Stroke

(NINDS), USA.

COMMON IMPAIRMENTS IN STROKE:

Altered consciousness/attention

Dysphagia

Dysphonia/Dysarthria/Dysphasia

Reduced muscle power/tone

Altered sensations

Reduced coordination

Loss of visual acquity

Reduced joint mobility/stability

Balance and Gait impairments

OUTCOME MEASURES Functional movement of the upper limb are categorised

into the following subgroups:

1. arm functional movement and

2. hand functional movement

And categorised motor impairment of the upper limb into

the following subgroups:

1. motor impairment scales

2. temporal outcomes,

3. spatial outcomes and

4. strength outcomes.

ABBREVIATION OUTCOMES

AMAT Arm Motor Ability Test

ARAT Action Research Arm Test

AS Ashworth Scale

BBT Box and Block Test

BI Barthel Index

CAHAI Chedoke Arm and Hand Activity Inventory

CMSA Chedoke-McMaster Stroke Assessment

EMG Electromyogram

EQ-5D EuroQol Quality of Life Scale

FAT Frenchay Arm Test

FIM Functional Independence Measure

FIM motor Functional Independence Measure motor subscale

FM Fugl-Meyer scale

FM motor Fugl-Meyer motor subscale

fMRI Functional Magnetic Resonance Imaging

MFT Manual Function Test

MAS Modified Ashworth Scale

Motor AS Motor Assessment Scale

MRC Medical Research Council

MSS Motor Status Score

NHPG Nine-Hole Peg Test

NSA Nottingham Sensory Assessment

RLAFT Rancho Los Amigos Functional Test

RMA Rivermead Motor Assessment

ROM Range of Motion/Movement

SCT Star Cancellation Test

SIS Stroke Impact Scale

TUG Timed Up and Go

TCT Trunk Control Test

UMAQS University of Maryland Arm Questionnaire for Stroke

VAS Visual Analogue Scale

WMFT Wolf Motor Function Test

TYPES OF STROKE

Ischaemic stroke:

Blood supply to part of the brain is decreased, leading to

dysfunction of the brain tissue in that area.

1) Thrombosis or embolism due to atherosclerosis of a

large artery

2) Embolism of cardiac origin

3) Occlusion of a small blood vessel

4) Other determined and undetermined cause

Abuser of stimulant drugs such as cocaine and

methamphetamine are at a high risk for ischemic strokes.

Haemorrhagic stroke:

is the accumulation of blood anywhere within the skull

vault.

(1) Intra-axial hemorrhage (blood inside the brain)

is due to intraparenchymal hemorrhage or intraventricular

hemorrhage (blood in the ventricular system)

(2) Extra-axial hemorrhage (blood inside the skull but outside

the brain).

epidural hematoma (bleeding between the dura mater and

the skull),

subdural hematoma (in the subdural space) and

subarachnoid hemorrhage (between the arachnoid mater

and pia mater).

UPPER LIMB IMPAIRMENTS:

Subluxation.

Changes in sensation.

Contracture.

Swelling.

Co-ordination problems.

Weakness.

Altered muscle power

Changes in muscle tone (called hypertonia or spasticity)

Hand dysfunction

RECENT ADVANCE

Search criteria : PubMed, APTA, COCHRANE,

Elsevier, Australian Journal Of Physiotherapy,

British Medical Journal, Clinical Rehabilitation,

Neuroscience and medicine, Journal of physical

therapy science, Journal of neurological physical

therapy

2009 to 2013

Abstract and full text articles

Systemic review, RCT, cohort studies, pilot studies

Keywords: stroke, stroke rehabilitation, upper limb

training, functional electrical stimulation, motor

recovery

LOE: PEDro

TITLE : LONG-TERM USE OF A STATIC HAND-WRIST ORTHOSIS IN CHRONIC STROKE

PATIENTS: A PILOT STUDY

AUTHOR :

1. Aukje Andringa

2. Ingrid van de Port and

3. Jan-WillemMeijer

JOURNAL : Stroke Research and Treatment

YEAR PUBLISHED : 31st January 2013

OBJECTIVES:. Evaluating long-term use of static hand-wrist

orthoses and experienced comfort in chronic stroke patients.

METHODS

11 stroke patients who were advised to use a static orthosis for at

least one year ago were included. Semistructured telephone

interviews were conducted to explore the long-term use and

experienced comfort with the orthosis. Data were analyzed using

descriptive statistics.

RESULTS

After at least one year, seven patients still wore the orthosis for the

prescribed hours per day. Two patients were unable to wear the

orthosis 8 hours per day, due to poor comfort. Two patients

stopped using the orthosis because of an increase in spasticity or

pain.

CONCLUSIONS.

These pilot data suggest that a number of stroke

patients cannot tolerate a static orthosis over a long-

term period because of discomfort. Without

appropriate treatment opportunities, these patients

will remain at risk of developing a clenched fist and

will experience problems with daily activities and

hygiene maintenance.

.

Example of a prefabricated static hand-wrist orthosis

TITLE : TABLE-TOP EXERGAMING IMPROVES ARM FUNCTION IN CHRONIC

STROKE

AUTHOR :

1. Kimberlee Jordan

2. Michael Sampson

3. Marcus King

METHOD Seven chronic stroke survivors (5 female) aged 59.4 –79.6 years

completed a 4 - 6 week upper limb training program using a table-

supported computer input device (the Able Reach) to play bespoke

computer games designed to encourage a large number of goal

oriented arm movements. Over the course of the intervention,

participants received between 9 (n = 4) and 16 (n = 3) hours of

game play. On average, Fugl-Meyer scores increased by 4.9 over the

course of the intervention, ranging up to 9 points. One participant

gradually deteriorated throughout the trial. These results suggest

that the Able Reach is a useful adjunct to regular physical therapy in

a stroke population

The Able Reach

CONCLUSION

Results provide evidence that the Able Reach in

conjunction with bespoke computer games can

significantly reduce upper limb impairment in

chronic stroke survivors, is well tolerated and found

to be motivating, useful and enjoyable. Future

research include a larger clinical trial to confirm

these results as well as automating the system so

that it can be used without direct supervision.

TITLE: COMBINING VIRTUAL REALITY AND A MYO-

ELECTRIC LIMB ORTHOSIS TO RESTORE ACTIVE

MOVEMENT AFTER STROKE: A PILOT STUDY

AUTHOR:

1. S Bermúdez i Badia

2. E Lewis

3. S Bleakley

JOURNAL , YEAR PUBLISHED

Proc. 9th Intl Conf. Disability, Virtual Reality & Associated

Technologies Laval, France, 10–12 Sept. 2012

METHOS A novel rehabilitation technology for upper limb

rehabilitation after stroke that combines a virtual reality training paradigm with a myo-electric robotic limb orthosis.

Rehabilitation system is based on clinical guidelines and is designed to recruit specific motor networks to promote neuronal reorganization.

The main hypothesis is that the restoration of active movement facilitates the full engagement of motor control networks during motortraining.

By using a robotic limb orthosis,the ablility to restore active arm movement in severely affected stroke patients.

In a pilot study, successfully deployed and evaluated system with 3 chronic stroke patients by means of behavioral data and self-report questionnaires.

The results show that this system is able to restore up

to 60% of the active movement capacity of patients.

Further, it show that it can assess the specific

contribution of the biceps/triceps movement of the

paretic arm to the virtual reality bilateral training task.

Questionnaire data show enjoyment and acceptance of

the proposed rehabilitation system and its VR training

task.

Diagram of the proposed virtual reality and robotic limb orthosis training paradigm showing the role of each technological component (numbered from 1 to 5).

prototype of the myo-electric based interactive system for

rehabilitation. left panel:an adaptive training in the form

of a game defines the training parameters for a bimanual

coordination motor task. the training offers augmented

feedback on performance, sustains motivation, and

automatically modifies the level of motor assistance

offered by the limb orthosis. right panel: the different

components of the system (robotic device, tracking setup,

and training game task) while being used by a stroke

patient.

TITLE : VIRTUAL REALITY FOR THE REHABILITATION OF

THE UPPER LIMB MOTOR FUNCTION AFTER STROKE:

A PROSPECTIVE CONTROLLED TRIAL

AUTHORS :

Andrea Turolla

Mauro Dam

Laura Ventura

Paolo Tonin1, Michela Agostini

Carla Zucconi

Pawel Kiper

Annachiara Cagnin and

Lamberto Piron

Key words: Stroke, Upper limb, Exercise

therapy, Virtual reality, Motor recovery,

Treatment outcome

Journal: Journal of NeuroEngineering and

Rehabilitation

Year: 2013

OBJECTIVES:

To evaluate the effectiveness of non-immersive VR treatment for

the restoration of the upper limb motor function and its impact

on the activities of daily living capacities in post-stroke patients.

METHODS:

A pragmatic clinical trial of 376 subjects who had a motor arm

subscore on the Italian version of the National Institutes of Health

Stroke Scale (It-NIHSS) between 1 and 3 and without severe

neuropsychological impairments interfering with recovery.

Patients were allocated to two treatments groups, receiving

combined VR and upper limb conventional (ULC) therapy or ULC

therapy alone. The treatment programs consisted of 2 hours of

daily therapy, delivered 5 days per week, for 4 weeks.

Outcome Measures:

Fugl-Meyer Upper Extremity (F-M UE) and

Functional Independence Measure (FIM) scales.

Study design:

Cohort study

Group 1• Virtual

Rehabilitation• Upper limb

conventional Therapy

Group 2• Only Upper limb

Conventional Therapy

For 4 weeks

For 5 days/ week

2

hours

Results:

The improvement obtained with VR

rehabilitation was significantly greater than that achieved with ULC therapy alone.

With F-M UE was 2.5 ± 0.5 (P < 0.001) and FIM scores 3.2 ± 1.2 (P = 0.007) respectively.

Conclusions:

VR rehabilitation in post-stroke patients seems more effective than conventional interventions in restoring upper limb motor impairments and motor related functional abilities.

LOE:2b

figure 1 motor exercises in the virtual environment. the

two scenarios (vrrsw khymeia group, ltd. noventa

padovana. italy) represent: a) a simple reaching

movement: the patient has to raise the red glass and

place it among the blue glasses on the shelf, according to

a pre-recorded path (yellow line); b) a complex movement

of increasing difficulty: the patient has to move the blue

ball through the orange circles. the green box represents

the start zone, while the yellow box represents the end

zone to reach, following the circular-like displayed path.

TITLE : SCAPULAR AND HUMERAL MOVEMENT PATTERNS OF PEOPLE WITH STROKE DURING

RANGE-OF-MOTION EXERCISESAuthors:

Dustin D. Hardwick, PT, PhD, and Catherine E. Lang,

Journal: Journal of Neurological Physiotherapy 35: 18–

25

Year:2011

KEY WORDS:

kinematics, rehabilitation, shoulder pain, stroke

PURPOSE:

Range-of-motion (ROM) exercises may contribute to

hemiparetic shoulder pain, but the underlying mechanisms

are unknown. This study examined scapular and humeral

movement patterns in people with poststroke hemiparesis

as they performed commonly prescribed ROM exercises.

OUTCOMES MEASURES:

Stroke Impact Scale(Hand Function subscale)

Numeric pain rating scale (0-10 points)

Modified Ashworth scale.

STUDY DESIGN: Pilot study

Group 1• 13 subjects with

hemiparesis• Are given 3 types of

ROM exercises

Group 2• 12 healthy subjects• Are given normal

shoulder elevation exercises

Group 1

• Person assisted

• Self assisted

Group 2

• Cane assisted

• Normal shoulder elevation

Where pain is assessed by pain rating scale

And kinematic measurements by electro magnetic tracking

system.

RESULTS:

Person assisted ROM exercises are found to be more effective than

Self assisted and cane assisted exercises.

CONCLUSION:

There appears to be little relationship between the severity of pain

experienced with exercise and the extent of movement abnormality.

LOE:4

TITLE: MIRROR THERAPY PROGRAM IN PATIENTS WITH STROKE.

AUTHOR: Lee, Myung Mo; Cho, Hwi-young; Song,

Chang Ho

JOURNAL: American Journal of Physical Medicine &

Rehabilitation.

YEAR: March 2012

OUTCOME MEASURES:

Fugl-Meyer Assessment

Brunnstrom stages for upper limb and hand

Manual Function Test

PURPOSE: To evaluate the effects of the mirror

therapy program on upper-limb motor recovery and

motor function in patients with acute stroke

STUDY DESIGN: Randomized control trail

LOE:1c

Method : Assigned into 2 groups

Experimental group controlled group

13 participants 13 participants

Standard Rehab standard Rehab

only

Mirror Therapy for 25 min twice a day, 5 times a

week, for 4 weeks.

RESULTS:

In upper-limb motor recovery, the scores of Fugl-Meyer Assessment, Brunnstrom stages for upper limb and hand and Manual Function Test scores were improved more in the experimental group than in the control group.

Whereas no significant differences were found between the groups for the coordination items in Fugl-Meyer Assessment.

TITLE:ENGAGE: GUIDED ACTIVITY-BASED GAMING IN

NEUROREHABILITATION AFTER STROKE

AUTHORS:

Ann Reinthal, Kathy Szirony, Cindy Clark,

Jeffrey Swiers, Michelle Kellicker and Susan

Linder

JOURNAL:

Hindawi Publishing Corporation Stroke

Research and Treatment

YEAR: 2012

PURPOSE: to assess the feasibility and outcomes of a

novel video gaming repetitive practice paradigm,

(ENGAGE) enhanced neurorehabilitation guided

activity-based gaming exercise.

OUTCOME MEASURES:

Wolf motor function test (WMFT)

Fugl-Meyer assessment (FMA)

Intrinsic Motivation Inventory

STUDY DESIGN: Pilot study

METHODS:

Playing Bubblepop on the PlayStation II with EyeToy

It uses a game selection algorithm that provides focused,

carefully graded activity-based repetitive practice of cognitive-

perceptual motor tasks.

It uses a limited number of gaming system platforms and games.

It is guided by the neuromuscular rehabilitation clinician.

RESULT:

The use of ENGAGE protocol was feasible in a clinical

environment.

There was a statistically significant improvement in upper

extremity function as measured by the upper extremity portion

of the FMA and by the WMFT, and participants were motivated to

use this gaming protocol.

LOE:4

TITLE:THERAPY INCORPORATING A DYNAMIC WRIST-HAND ORTHOSIS VERSUS MANUAL ASSISTANCE IN CHRONIC STROKE

Author: Joni G. Barry, PT, DPT, NCS, Sandy A. Ross, PT, DPT,

MHS, PCS, and Judy Woehrle, PT, PhD, OCS

Journal: Journal of Neurological Physical therapy, Volume 36

Year: 2012

Keywords: arm, function, orthosis, recovery, rehabilitation,

repetition, stroke

Objectives: To compare the effect of therapy using a wrist-hand

orthosis (WHO) versus manual-assisted therapy (MAT) for

individuals with chronic, moderate-to-severe hemiparesis.

Outcome Measures:

Action Research Arm Test (ARAT)

Box and Blocks (B&B) test

Stroke Impact Scale (SIS)

Study Design: A Pilot Study

METHODS:

Group 1: wrist-hand orthosis (WHO)-19 participants

Group 2: Manual-Assisted Therapy (MAT)-19 participants

Both groups participated in 1 hour of therapy per week for 6

weeks and were prescribed exercises to perform at home 4 days

per week.

Pre- and post training assessments were taken according to the

scales mentioned.

Dynamic wrist-hand orthosis (SaeboFlex).

Results:

There were no significant between-group differences for any of

the measures.

Within-group differences showed that theWHO group had a

significant improvement in the ARAT score (mean =2.2; P = 0.04).

The MAT group had a significant improvement on the percent

recovery on the SIS (mean=9.3%; P=0.03)

Conclusion:

Small improvements in function and perception of recovery were

observed in both groups, with no definite advantage of the WHO.

Adds to the evidence that individuals with chronic stroke can

improve arm use with therapy incorporating functional hand

training.

LOE:4

TITLE: EFFECTS OF ROBOT-ASSISTED THERAPY ON UPPER LIMB RECOVERY AFTER

STROKE: A SYSTEMATIC REVIEW

AUTHOR :Gert Kwakkel, Boudewijn J. Kollen, and

Hermano I. Krebs

JOURNAL :Neurorehabil Neural Repair.

YEAR PUBLISHED: 2008

PURPOSE: To present a systematic review of studies

that investigates the effects of robot-assisted therapy

on motor and functional recovery in patients with

stroke.

Summary of Review—A database of articles published up to October 2006 was compiled using the following MEDLINE key words: cerebral vascular accident, cerebral vascular disorders, stroke, paresis, hemiplegia, upper extremity, arm and robot.

Studies that satisfied the following selection criteria were included:

1) patients were diagnosed with cerebral vascular accident

2) effects of robot-assisted therapy for the upper limb were investigated

3) the outcome was measured in terms of motor and/or functional recovery of the upper paretic limb

The study was a randomised clinical trial (RCT).

For each outcome measure, the estimated effect size (ES) and the

summary effect size (SES) expressed in standard deviation units

(SDU) were calculated for motor recovery and functional ability (ADL)

using fixed and random effect models. Ten studies, involving 218

patients, were included in the synthesis.

Their methodological quality ranged from 4 to 8 on a (maximum) 10

point scale.

Meta-analysis showed a non-significant heterogeneous SES in terms

of upper limb motor recovery.

Sensitivity analysis of studies involving only shoulder-elbow robotics

subsequently demonstrated a significant homogeneous SES for motor

recovery of the upper paretic limb.

No significant SES was observed for functional ability (ADL).

CONCLUSION— No overall significant effect in favour of robot-assisted

therapy was found in the present meta-analysis. Sensitivity analysis showed a significant improvement in

upper limb motor function after stroke for upper arm robotics.

No significant improvement was found in ADL function. The administered ADL scales in the reviewed studies fail to

adequately reflect recovery of the paretic upper limb and valid instruments that measure outcome of dexterity of the paretic arm and hand are mostly absent in selected studies.

Future research on the effects of robot-assisted therapy to distinguish between upper and lower robotics arm training and concentrate on kinematical analysis to differentiate between genuine upper limb motor recovery and functional recovery due to compensation strategies by proximal control of the trunk and upper limb.

Robotics has been defined as: ‘The application of electronic, computerized control systems to mechanical devices designed to perform human functions’. (PubMed [Medline], MeSH database, 2005).

TITLE : CONCURRENT NEUROMECHANICAL AND FUNCTIONAL GAINS

FOLLOWING UPPER-EXTREMITY POWER TRAININGPOST-STROKE

AUTHOR : Carolynn Patten, Elizabeth G Condliffe,

Christine A Dairaghi and Peter S Lum

JOURNAL : Journal of NeuroEngineering and

Rehabilitation 2013,

PURPOSE :

Investigated how power training (i.e., high-intensity,

dynamic resistance training) affects recovery of

upper-extremity motor function post-stroke.

Hypothesized that power training, as a component

of upper-extremity rehabilitation, would promote

greater functional gains than functional task practice

without deleterious consequences.

METHOD: Nineteen chronic hemiparetic individuals using a crossover

design. All participants received both functional task practice (FTP)

and HYBRID (combined FTP and power training) in random order.

Blinded evaluations performed at baseline, following each intervention block and 6-months post-intervention included:

1. Wolf Motor Function Test (WMFT-FAS, Primary Outcome)2. Upper-extremity Fugl-Meyer Motor Assessment,

AshworthScale and 3. Functional Independence Measure. Neuromechanical function was evaluated using isometric and

dynamic joint torques and concurrent agonist EMG. Biceps stretch reflex responses were evaluated using passive elbow stretches ranging from 60 to 180º/s and determining: EMG onset position threshold, burst duration, burst intensity and passive torque at each speed.

RESULTS:

Primary outcome: Improvements in WMFT-FAS were significantly greater

following HYBRID vs. FTP (p = .049), regardless of treatment order. These

functional improvements were retained 6-months post-intervention (p = .03).

Secondary outcomes: A greater proportion of participants achieved

minimally important differences (MID) following

HYBRID vs. FTP (p = .03). MIDs were retained 6-months post-intervention.

Ashworth scores were unchanged (p > .05).

Increased maximal isometric joint torque, agonist EMG and peak power were

significantly greater following HYBRID

vs. FTP (p < .05) and effects were retained 6-months post-intervention (p’s <

.05). EMG position threshold and burst

duration were significantly reduced at fast speeds (≥120º/s) (p’s < 0.05) and

passive torque was reducedpost-washout (p < .05) following HYBRID.

CONCLUSIONS:

Functional and neuromechanical gains were greater

following HYBRID vs. FPT. Improved stretch reflex

modulation and increased neuromuscular activation

indicate potent neural adaptations.

Importantly, no deleterious consequences, including

exacerbation of spasticity or musculoskeletal complaints,

were associated with HYBRID.

These results contribute to an evolving body of

contemporary evidence regarding the efficacy of high-

intensity training in neurorehabilitation and the

physiological mechanisms that mediate neural recovery.

TITLE: STRENGTH TRAINING IMPROVES UPPER-LIMB FUNCTION IN

INDIVIDUALS WITH STROKE

AUTH0R : Jocelyn E. Harris; Janice J.

JOURNAL :

American Heart Association

YEAR PUBLISHED : 2009

PURPOSE

After stroke, maximal voluntary force is reduced in the arm and hand muscles, and upper-limb strength training is 1 intervention with the potential to improve function.

METHODS a meta-analysis of randomized controlled trials. Electronic databases were searched from 1950 through

April 2009. Strength training articles were assessed according to

outcomes: strength, upper-limb function, and activities of daily living.

The standardized mean difference (SMD) was calculated to estimate the pooled effect size with random-effect models.

RESULTSFrom the 650 trials identified, 13 were included in this

review, totaling 517 individuals. A positive outcome for strength training was found for grip strength

(SMD0.95, P0.04) and upper-limb function (SMD0.21, P0.03). No

treatment effect was found for strength training on measures of activities of daily living. A significant effect for strength

training on upper-limb function was found for studies including subjects with moderate (SMD0.45, P0.03) and mild

(SMD0.26, P0.01) upper-limb motor impairment. No trials reported adverse effects.

CONCLUSIONS There is evidence that strength training can improve

upper-limb strength and function without increasing