1 Upper Limb Retraining A1er Stroke Karl Schurr Physiotherapist BankstownLidcombe Hospital 2016 Plan • Review essenFal components and analysis of: – Reaching and Grasping • Review Evidence: – Overview of effecFve intervenFons – Examples of intervenFons for stroke survivors who are: • Weak • Stronger • PracFce intensity • Outcomes: – Measurement is essenFal • Discussion/QuesFons TakeHome Messages • EssenFal to analyse causes of movement problems carefully • Know, seek and train essenFal muscle acFons for grasp and reaching (essenFal components) • The hand drives the shoulder • High doses of pracFce are required • PracFce doesn’t have to be perfect • Discuss pracFce and achievements with stroke survivors • Expect people to improve: measurement! EssenFal Components 1
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Upper Limb Retraining A1er Stroke
Karl Schurr Physiotherapist
Bankstown-‐Lidcombe Hospital 2016
Plan • Review essenFal components and analysis of:
– Reaching and Grasping • Review Evidence:
– Overview of effecFve intervenFons – Examples of intervenFons for stroke survivors who are:
• Weak • Stronger
• PracFce intensity • Outcomes:
– Measurement is essenFal • Discussion/QuesFons
Take-‐Home Messages • EssenFal to analyse causes of movement problems carefully
• Know, seek and train essenFal muscle acFons for grasp and reaching (essenFal components)
• The hand drives the shoulder • High doses of pracFce are required • PracFce doesn’t have to be perfect • Discuss pracFce and achievements with stroke survivors
• Expect people to improve: measurement!
EssenFal
Components 1
2
Essen%al Components
“Those elements upon which the ac1vity depends ” [Carr, 1987]
• Common features across individuals • KinemaFc features (what you see) • KineFc requirements (forces that produce what you see) • Environmental/physical constraints will modify task performance
Essential Components of Reaching for a Glass Transport:
Shoulder internal rotaFon & trunk rotaFon when reaching for a glass in front
Why?
ANALYSIS
Comparison of
reaching forward
TesFng
External rotaFon
Where to start with someone who is paralysed/very weak?
Where to start…..? • Which muscles? • Seek muscle acFvity at any joint
Training strategies/ideas • Establish a training ethos from the beginning
• Reduce demands of gravity • Minimise fricFon Main goal? • Find muscle acFvity somewhere!
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Current Evidence: • Task-‐Specific Training • Goals • Strength Training • Mirror Therapy • Electrical SFmulaFon • Constraint Induced Movement Therapy (CIMT)
3 2014
Pollock et al (2014)
Moderate quality evidence suggests that the following intervenFons may be effecFve: constraint-‐induced movement therapy (CIMT), mental prac%ce, mirror therapy, task specific interven%ons for sensory impairment, virtual reality and rela%vely high dose or repe%%ve task prac%ce. Moderate quality evidence also evidence also indicates that unilateral arm training (exercise for the affected arm) may be more effecFve than bilateral arm training.
Pollock et al (2014)
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Evidence of EffecFveness: Motor/ Physical RehabilitaFon 2014
Conclusions: There is strong evidence for PT intervenFons favoring intensive high repeFFve task-‐oriented and task specific training in all phases post-‐stroke. Effects are mostly restricted to the actually trained funcFons and acFviFes.
Mental PracFce -‐ 2013 -‐
Conclusions: Mental pracFce might have posiFve effects on performance of acFviFes in paFents with neurological diseases, but this review reports less posiFve results than earlier published ones.
Electrical sFmulaFon
2014
Conclusions: Cyclical electrical sFmulaFon increases strength and improves acFvity a1er stroke. These benefits were maintained beyond the intervenFon period with small-‐to-‐moderate effect size. The sustained effect on acFvity suggests that the benefits were incorporated into daily life.
2015
Volume 95, Issue 5, pp 934-‐943
Conclusions: FES appears to moderately improve acFvity compared with both no intervenFon and training alone. These findings suggest that FES should be used in stroke rehabilitaFon to improve the ability to perform acFviFes
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Lancet Neurology 2015
CIMT
2015 42 RCTs
51 RCTs
Conclusions: The original and modified types of CIMT have beneficial effects on motor funcFon, arm–hand acFviFes, and self-‐reported arm–hand funcFoning in daily life, immediately a1er treatment and at long-‐term follow-‐up, whereas there is no evidence for the efficacy of constraint alone (as used in forced use therapy).
Features of effec%ve UL motor interven%ons
Ø Task specificity
Ø Intensity of training
Ø Enable high repeFFons
Strength Training
Mirror Therapy
Electrical SFmulaFon
[Mental pracFce]
CIMT
Training Reaching Examples of ideas for people with profoundly weak muscles
• ProtracFon • External rotaFon • Elbow extension
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Protrac%on
Goal: ‘Can you touch the table with the straw?’
Cylinder to reduce fricFon on the table
Cardboard cylinder to hold elbow in extension
Straw atached to side of cylinder – to touch goal marked on table
– 100+ repeFFons per task x 3 tasks/session – 3 x 1 hr sessions for 6 weeks (18 hrs) – Reaching, grasping, moving, releasing – Eg WriFng, typing, Connect 4, folding towels
• Average 332 reps (95%CI 285-‐358) /session • ARAT mean change +8 pts (95% CI 4 to 12)
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Measuring Change 9
EssenFal to measure
• Accuracy of analysis • Dosage of pracFce • Establish measureable goals:
– Person’s knowledge of achievements
– Feedback about progress within sessions as well as long term
• Determine effecFveness of intervenFons
Measuring Change
• Tasks of provide in-‐built measurements: – Time / speed (eg 1me to perform 2 reps)
– Accuracy of performance – Limb trajectory – Size of object grasped (mm) – Distance moved (mm) – % of correct atempts
• Keep measures simple and immediate
Standardised measures that capture change in people who are very weak :
n Motor Assessment Scale
n Box and block test
Concentrate on intensifying pracFce ….NOT assessing….
Measuring Change
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Roles 10
How rehab specialists can assist with implementaFon of evidence for stroke survivors
• Contribute to development of team environments where ongoing examinaFon of evidence is established
• Team decisions/agreement regarding implementaFon of evidence: (eg Botulinum injecFons)
• Regular review of success of implementaFon • Expect measurement of change and clear goal se|ng at all stroke survivor progress reviews
• Don’t destroy stroke survivors’ hopes • Don’t refer to “my paFents” or “my staff”
Reference List Barclay-‐Goddard E et al (2011). Mental pracFce for treaFng upper extremity deficits in individuals with
hemiparesis a1er stroke. Cochrane Database of SystemaFc Reviews, Issue 1, Art No CD005950. Birkenmeier RL, Prager EM & Lang CE (2010). TranslaFng animal doses of task-‐specific training to people with
chronic stroke in 1-‐hour therapy sessions: A proof-‐of-‐concept study. NeurorehabilitaFon and Neural Repair, 24(7), 620-‐635.
Braun S, et al (2013) The effects of mental pracFce in neurological rehabilitaFon; a systemaFc review and meta-‐analysis. Front. Hum. Neurosci., 02 August
Howlet A et al (2015) FuncFonal electrical sFmulaFon improves acFvity a1er stroke: A systemaFc review with meta-‐analysis. Archives of Physical Medicine and Rehabilita1on. 96 (5), 934-‐943.
Katalinic OM, Harvey LA, Herbert RD, Moseley AM, Lannin NA, Schurr K (2010). Stretch for the treatment and prevenFon of contractures. Cochrane Database of SystemaFc Reviews, Issue 9, Art no. CD007455.
Kwakkel G Veerbeek J, van Wegen E & Wolf S (2015) Constraint-‐induced movement therapy a1er stroke. The Lancet Neurology. Volume 14, Pp 224–234
Lannin N.A., & Ada, L. (2011). Neurorehabilitaton splinFng: Theory and principles of clinical use. NeuroRehabilita1on. 28, 21-‐28.
Lohse, K.R., Lang, C.R., & Boyd, L.A. (2014 -‐ online early). Is more beter? Using metadata to explore dose-‐response relaFonships in stroke rehabilitaFon. Stroke, 45, 00-‐00.
Nascimento R et al (2014). Cyclical electrical sFmulaFon increases strength and improves acFvity a1er stroke: A systemaFc review. Journal of Physiotherapy, 60, 22-‐30.
Ross, L.F., Harvey, L.A., & Lannin, N.A. (online early, 2016). Strategies for increasing the intensity of upper-‐limb task-‐specific pracFce a1er acquire brain impairment: A secondary analysis from a randomised controlled trial. Bri1sh Journal of Occupa1onal Therapy.
Veerbeek M, et al (2014). What is the evidence for physical therapy post-‐stroke? A systemaFc review and meta-‐analysis. PLOS One, 9 (2, Feb), e87987.