Stroke Management – the upper extremity

Addendum slides

Wider window of time?

• A very recent study of CIMT found that the treatment can be delivered to eligible patients from 3 to 9 months post stroke OR 15 to 21 months after stroke.

• The functional level at 24 months post enrollment will be about the same!

• This is GOOD NEWS….the timing is not the critical element in the intervention. It is likely the task-specific, intense activity!

High-intensity training

• A recent study described a task-specific training approach applied in the outpatient setting with persons with chronic stroke.

• Participants worked in one-hour sessions 3 times/week for 6 weeks. During each session they did an average of 322 repetitions of functional tasks!

High-intensity training

• Scores improved on the Action Research Arm test by an average of 8 points AND the gains were maintained at a 1-month follow-up.

• Reports of pain and fatigue were low.

High-intensity training

• Activities included such things as folding towels, writing, handling money, and stacking checkers.

• Activities were graded to make more difficult.• The percentage of sessions attended by the 15

patients was 97!

Other treatment options

• Thermal stimulation has been used with persons at least 3 months post stroke to promote motor recovery.

• Participants received 10 minutes of heat stimulation followed by 10 minutes of cold.– 15 seconds of heat– 30 seconds of cold – 30-second pauses between exposure

Thermal stimulation

• Participants who received the stimulation had greater scores on the UE portion of the STREAM and the Action Research Arm Test than a group that had stimulation to the LE (control group).

Wu, HC et al. Stroke 2010; Aug 26, V. 41)

Bimanual vs. CIMT???

• Two groups of six participants received 6 hours of OT for 10 days plus additional home practice. One group wore a mitt on the unimpaired hand and the other group was intrusively and repetitively cues to use both upper extremities.

• Participants were at least 6 months post stroke. They only needed to have trace movement in the hand.

Bimanual vs. CIMT

• Participants were reassessed 6 months after the conclusion of the treatment.

• Both groups made significant gains AND maintained the gains over time.

• The authors suggested that attentional focusing and intensive practice were the keys to the good outcomes.

• Hayner et al. Amer Journal of Occupational Therapy. 64: 528-539.

Active-passive bilateral therapy

• A new device called the Rocker was used with patients in the sub-acute phase of recovery.

• Participants received 10 minutes of APBT prior to motor training 5 days/week for 1-3 weeks.

APBT

• In the treatment the less affected hand moves the paretic hand passively in a mirror image.

• Participants who did the training made greater gains in the UE portion of the Fugl-Meyer test.

• It may be most beneficial for persons with greater impairment.

• (Stoykov ME, Stinear JW. Am J Phys Med Rehabil 2010)

Theoretical framework – genesis and maintenance of shoulder pain

From Sheffler LR, Chae J. Muscle & Nerve, 2007; 35: 562-590.

Shoulder pain• Research is needed to quantitatively

determine whether the use of modalities, gentle grade 1-2 mobilizations, NMES, stretching, pharmacological management and facilitation of movement are effective.

• A Cochrane Review (2001) concluded that NMES improves pain free passive ER and reduces subluxation, but does not improve shoulder pain or motor impairment.