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Stroke Management – the upper extremity

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.

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Stroke Management – the upper extremity

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  1. Stroke Management – the upper extremity Addendum slides

  2. 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!

  3. 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!

  4. 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.

  5. 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!

  6. 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

  7. 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. Stroke2010; Aug 26, V. 41)

  8. 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.

  9. 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.

  10. 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.

  11. 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)

  12. Theoretical framework – genesis and maintenance of shoulder pain From Sheffler LR, Chae J. Muscle & Nerve, 2007; 35: 562-590.

  13. 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.

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