View
962
Download
0
Category
Tags:
Preview:
Citation preview
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
Recommended