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

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

12/22/2015 2

Introduction

12/22/2015 3

• 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).

12/22/2015 4

• 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).

12/22/2015 5

• Physiotherapy management can help

to significantly reduce disabilities and

handicaps arising after stroke (Gbiri

and Akinpelu, 2011).

12/22/2015 6

Effects of Stroke on

the Upper Limb

12/22/2015 7

• ¾ of stroke survivors will have upper

limb symptoms;

– low tone,

– spasticity,

– weakness,

– loss of sensation

– and loss of awareness (Lawrence et al,

2001).

12/22/2015 8

• Predictor of long term outcome are;

– Initial severity

– anatomical change; subluxation, and

muscle injury (Coupar et al, 2013).

12/22/2015 9

• Potential predictors are;

– active finger extension

– and shoulder abduction (Smania et al,

2007; Houwink et al, 2013).

12/22/2015 10

Factors to Consider

in the Management

of Upper Limb after

Stroke

12/22/2015 11

Handling the Hemiplegic Upper limb

Slings

Positioning while sitting

Early passive range of motion

Trunk alignment

Low tone

Increased tone

Shoulder pain

12/22/2015 12

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).

12/22/2015 13

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).

12/22/2015 14

Shoulder Pain

– Limits mobility,

– functional recovery,

– ability to do activities of daily living,

– balance,

– transfers

– and ambulation (Jaraczewska and

Long Carol, 2006).

12/22/2015 15

• 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).

12/22/2015 16

Basic Management

Principles of the

Upper Limb after

Stroke

12/22/2015 17

• 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

12/22/2015 18

• 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)

12/22/2015 19

Upper Limb

Rehabilitation

Techniques

12/22/2015 20

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).

12/22/2015 21

• 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).

12/22/2015 22

• Bilateral training (figure 1)

approaches are:

• Repetitive reaching with hand

fixed protocols

• whole arm function training

12/22/2015 23

Figure 1: Bilateral arm training: A patient reaching with

both arms (Malebet et al, 2010).

12/22/2015 24

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).

12/22/2015 25

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).

12/22/2015 26

• It is therapeutically used to improve

motor performance and the

perception of the affected limb

(Rothgangel et al, 2011; Thieme et al,

2012).

12/22/2015 27

• 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).

12/22/2015 28

• 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.

12/22/2015 29

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)

12/22/2015 30

• 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).

12/22/2015 31

Constraint Induced Movement

Therapy (CIMT)

• CIMT (figure 3) is designed to

overcome learned non-use by

promoting cortical reorganization

(Taub et al, 2003).

12/22/2015 32

Figure 3: A patient engaging the affected upper limb

while unaffected is restrained in Mitts

12/22/2015 33

• 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).

12/22/2015 34

• 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).

12/22/2015 35

• 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).

12/22/2015 36

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).

12/22/2015 37

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).

12/22/2015 38

• 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).

12/22/2015 39

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).

12/22/2015 40

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).

12/22/2015 41

Figure 4: Hemiparetic arm reaching for objects placed

within arm’s length (Michaelsen & Levin, 2004)

12/22/2015 42

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).

12/22/2015 43

Figure 5: Static Volar Hand Splint (Lannin and Herbert,

2003)

12/22/2015 44

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).

12/22/2015 45

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.

12/22/2015 46

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.

12/22/2015 47

THANK YOU FOR

YOUR ATTENTION

12/22/2015 48