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CURRENT
TECHNIQUES FOR
REHABILITATION OF THE
UPPER LIMB AFTER STROKE
ADEYEMO, ADEMOLA OLUYOMI
MSC SEMINAR PRESENTATION AT THE
DEPARTMENT OF PHYSIOTHERAPY,
SCHOOL OF POSTGRADUATE STUDIES,
UNIVERSITY OF LAGOS.12/22/2015 1
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Outline
• Introduction
• Effects of Stroke on the Upper Limb
• Factors to Consider in the
Management of Upper Limb after
Stroke
• Basic Management Principles of the
Upper Limb after Stroke
• Upper Limb Rehabilitation Techniques
• Conclusion
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Introduction
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• Stroke is the third most common
cause of death and permanent
disability among older adults (Lo et al,
2003; Donnan et al, 2008).
• Upper limb impairment after stroke is
a considerable problem with
significant consequences (Fregni et
al, 2006).
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• Rehabilitation of the hemiplegic upper
limb remains difficult to achieve.
• Only 5% of stroke survivors who have
complete paralysis regain functional
use of their impaired upper limb
(Dombovy, 1993; Duncan, 1999;
Kwakkel, 2000).
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• Physiotherapy management can help
to significantly reduce disabilities and
handicaps arising after stroke (Gbiri
and Akinpelu, 2011).
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Effects of Stroke on
the Upper Limb
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• ¾ of stroke survivors will have upper
limb symptoms;
– low tone,
– spasticity,
– weakness,
– loss of sensation
– and loss of awareness (Lawrence et al,
2001).
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• Predictor of long term outcome are;
– Initial severity
– anatomical change; subluxation, and
muscle injury (Coupar et al, 2013).
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• Potential predictors are;
– active finger extension
– and shoulder abduction (Smania et al,
2007; Houwink et al, 2013).
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Factors to Consider
in the Management
of Upper Limb after
Stroke
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Handling the Hemiplegic Upper limb
Slings
Positioning while sitting
Early passive range of motion
Trunk alignment
Low tone
Increased tone
Shoulder pain
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Low Tone
• Low tone in the upper limb can
contribute to:
– Lack of scapular mobility and lack of
scapular stability (Turner-Stokes and
Jackson, 2002; Edwards, 2002;
Jaraczewska and Long Carol, 2006).
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Increased Tone
• Increased tone can contribute to:
– Retracted scapula,
– Elbow flexion,
– Loss of scapular mobility
– Risk of contracture formation (Edwards,
2002; Jaraczewska and Long Carol,
2006).
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Shoulder Pain
– Limits mobility,
– functional recovery,
– ability to do activities of daily living,
– balance,
– transfers
– and ambulation (Jaraczewska and
Long Carol, 2006).
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• The causes of shoulder pain are:
Impingement
– Spasticity in Subscapularis and pectoralis
can pull the arm into internal rotation.
Age related changes
– degenerative changes in joints, and
changes in posture – thoracic kyphosis
(Turner-stokes and Jackson, 2002).
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Basic Management
Principles of the
Upper Limb after
Stroke
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• Support the flaccid upper limb to
prevent trauma to soft tissues
• Use positioning programs to maintain
muscle length.
• Passive range of motion exercises
with proper technique
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• Bring the affected arm into the visual
field
• Start in positions of support in supine
on a table for a low functioning upper
extremity.
• Work on trunk alignment and postural
control (Jaraczewska and Long Carol,
2006)
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Upper Limb
Rehabilitation
Techniques
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Bilateral Arm Training
• Bilateral arm training incorporates
– task-oriented and motor relearning
strategies
– including intense practice,
– intrinsic feedback,
– bimanual coordination,
– and goal-focused movements (Stewart et
al, 2006; Latimer et al, 2010).
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• It is based on the assumption that
symmetrical bilateral movements can
activate similar neural networks in
hemispheres, promoting neural
plasticity and cortical repair
(Summers et al, 2007; Morris et al,
2008).
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• Bilateral training (figure 1)
approaches are:
• Repetitive reaching with hand
fixed protocols
• whole arm function training
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Figure 1: Bilateral arm training: A patient reaching with
both arms (Malebet et al, 2010).
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Mirror Therapy
• In mirror therapy, a mirror is placed in
patient’s mid-saggital plane, reflecting
movements of the non-paretic side as
if it was the affected side, blocking
their view of the affected limb,
creating the illusion that both limbs
are working normally (Altschuler et al,
1999; Thieme et al, 2012).
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Figure 2: A mirror placed in patient’s mid-saggital plane, reflecting
movements of the non-paretic side (Altschuler et al, 1999; Thieme
et al, 2012).
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• It is therapeutically used to improve
motor performance and the
perception of the affected limb
(Rothgangel et al, 2011; Thieme et al,
2012).
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• Mirror Therapy activates superior
temporal gyrus associated with:
– enhanced self-awareness,
– spatial attention
– and recovery from neglect (Matthys et al,
2009; Michielsen et al, 2011; Dohle et al,
2011).
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• Existing evidence (Doyle et al, 2010;
Rothgangel et al, 2011; Thieme et
al, 2012) supports;
– improving motor function and activities
of daily living ADLs,
– reducing pain,
– reducing neglect,
– reducing sensory impairment in stroke
survivors.
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Motor Imagery/Mental practise
• Mental imagery involves rehearsing a
specific task or series of tasks
mentally to improve upper extremity;
stored motor plans for executing
movements that can be accessed and
reinforced (Page et al, 2001a, b, c,
2005, 2007)
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• Mental practice in combination with
other rehabilitation treatment appears
to be beneficial in improving upper
extremity function after stroke as
compared with other rehabilitation
treatment without Mental practise
(Zimmermann-Schlatter et al, 2008).
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Constraint Induced Movement
Therapy (CIMT)
• CIMT (figure 3) is designed to
overcome learned non-use by
promoting cortical reorganization
(Taub et al, 2003).
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Figure 3: A patient engaging the affected upper limb
while unaffected is restrained in Mitts
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• The two key features of CIMT are
restraint of the unaffected hand/arm
and increased practice /use of the
affected hand/arm (Fritz et al, 2005).
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• Suitable candidates for CIMT are
patients with at least 20°active wrist
extension and 10° active finger
extension, with minimal sensory or
cognitive deficits (Miltner et al, 1999;
Liepert et al, 2000; Levy et al, 2001).
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• Chronic hemiplegia significantly
benefit from CIMT with reductions in
disuse complications, spasticity and
improved function with increased use
of the hemiplegic limb in activities of
daily life (Siebers et al, 2010).
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Robotic Devices for Movement
Therapy
• Robotic training offers advantages in
good repeatability, precisely
controllable assistance or resistance
during movements, and quantifiable
measures of subject performance
• Specifically the shoulder, elbow and
wrist movements (Belda-Lios et al,
2011).
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Functional Electrical Stimulation in
Hemiparetic Upper Limb (FES)
• The defining feature of FES
stimulation from TENS is that it
provokes muscle contraction and
produces a functionally useful
movement during stimulation
(Schuhfried et al, 2012).
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• FES improves neuromuscular function
in patients with stroke by
– strengthening muscles,
– increasing motor control,
– reducing spasticity,
– decreasing pain,
– and increasing range of motion
(Schuhfried et al, 2012).
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Strength training of the Hemiparetic
Upper limb
– Upper limb strength training improves,
– grip strength,
– peak shoulder and arm extension,
– peak force of isometric hand extensions
– and peak acceleration of isotonic hand
extensions (Harris and Eng, 2010).
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Trunk Restraint Therapy
• Post stroke reaching is
characterised by compensatory
excessive trunk motion and
abnormal shoulder-elbow
coordination during task practise
(Woodbury et al, 2009; Wee et al,
2014).
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Figure 4: Hemiparetic arm reaching for objects placed
within arm’s length (Michaelsen & Levin, 2004)
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Orthosis in Hemiparetic Upper
Limb
• Hand Splinting (Figure 5)may be
applied to achieve reduction in
spasticity, pain, improvement in
functional outcome, prevention of
contracture and edema (Lannin
and Herbert, 2003).
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Figure 5: Static Volar Hand Splint (Lannin and Herbert,
2003)
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Stretching Programs to Prevent
Contracture
• Stretching may help to prevent
contracture formation
• Well-accepted as a treatment
strategy, it has not been well-
studied (EBRSR, 2013).
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Conclusion
• There are growing evidences supporting
the current techniques, for effective
recovery of upper limb function after
stroke.
• Therefore, there is a call for effective
deployment of the techniques such as
mirror therapy, mental imagery, robot
therapy, constraint induced movement
therapy, and trunk restraint therapy in
this clime to reduce functional
dependency and disabilities.
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References
• Donnan GA, Fisher M, Macleod M, Davis SM (2008). Stroke. Lancet 371:1612-1623.
• Fregni F, Pascual-Leone A (2006). Hand motor recovery after stroke: Tuning the orchestra to
improve hand motor function. Cognitive and Behavioral Neurology 19: 21-33.
• Gbiri CA, Akinpelu AO (2011). Pattern of post-stroke functional recovery among Nigerian stroke
survivors in the first 12 months. Nigerian Quarterly Journal of Hospital Medicine 21: 245-248.
• Jaraczewska E and Long Carol (2006). KinesioR Taping in Stroke: Improving Functional Use of the
Upper Extremity in Hemiplegia. Top Stroke Rehabilitation 13:31-42.
• Kwakkel G, Kollen BJ, Wagenaar PC (2000). Therapy Impact on functional recovery in stroke
rehabilitation: a critical review of the literature. Physiotherapy 13:457-470.
• Page SJ (2003). Intensity versus task-specificity after stroke: how important is intensity? Am
Journal of Physical Medical Rehabilitation 82:730-732.
• Rothgangel AS, Braun SM, Beurskens AJ, Seitz RJ, Wade DT (2011).The clinical aspects of mirror
therapy in rehabilitation: a systematic review of the literature. International Journal of
Rehabilitation Research 1: 1-13.
• Schuhfried O, Crevenna R, Fialka-Moser V, Paternostro-Sluga T (2012). Non-invasive neuromuscular
electrical stimulation in patients with central nervous system lesions: an educational review.
Journal of Rehabilitation Medicine 44:99–105.
• Turner-Stokes L, Jackson D (2002). Shoulder Pain After Stroke: A Review of the Evidence Base to
Inform the Development of an Integrated Care Pathway. Clinical Rehabilitation 16:276-298.
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THANK YOU FOR
YOUR ATTENTION
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