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10. Upper Extremity Interventions Norine Foley MSc, Robert Teasell MD, Jeffrey Jutai PhD CPsych, Sanjit Bhogal MSc, Elizabeth Kruger Key Points The Evidence-Based Initial degree of motor impairment is the best predictor of motor Review of Stroke recovery following a stroke. Functional recovery goals are Rehabilitation (EBRSR) appropriate for those patients who are expected to achieve a greater reviews current amount of motor recovery in the arm and hand. Compensatory practices in stroke treatment goals should be pursued if there is an expected outcome of rehabilitation. poor motor recovery. Contacts: Dr. Robert Teasell Attempts to regain function in the affected upper extremity should be 801 Commissioners limited to those individuals already showing signs of some recovery. Road East London, Ontario, Neurodevelopment techniques are not superior to other therapeutic Canada approaches in treatment of the hemiparetic upper extremity. N6C 5J1 Phone: It is uncertain whether enhanced therapy results in improved short- 519.685.4000 term upper extremity functioning. Web: www.ebrsr.com It is uncertain whether repetitive task specific training techniques Email: improve upper extremity function. Robert.teasell@sjhc.lo ndon.on.ca It is uncertain whether sensorimotor training results in improved upper extremity function. It is uncertain whether mental practice results in improved motor and ADL functioning after stroke. Hand splinting does not improve motor function or reduce contractures in the upper extremity. Constraint-induced movement therapy is a beneficial treatment approach for those stroke patients with some active wrist and hand movement. Sensorimotor training with robotic devices improves functional and motor outcomes of the shoulder and elbow, however, it does not improve functional and motor outcomes of the wrist and hand. There is preliminary evidence that virtual reality therapy may improve motor outcomes post stroke. 10. Upper Extremity Interventions pg. 1 of 171 www.ebrsr.com Hand splints do not reduce spasticity nor prevent contracture. Botulinum Toxin decreases spasticity and increases range of motion; however, these improvements do not necessarily result in better upper extremity function. Botulinum Toxin in combination with electrical stimulation improves tone in the upper extremity. More research is needed to determine the effectiveness of Nerve Blocks for spasticity. Physical Therapy may not be effective for reducing spasticity in the upper extremity. EMG/Biofeedback therapy is not superior to other forms of treatment in the treatment of the hemiparetic upper extremity. Intermittent pneumatic compression is not an effective treatment for hand edema. It is uncertain whether transcutaneous electrical nerve stimulation improves outcomes post-stroke Functional Electrical Stimulation therapy improves hemiparetic upper extremity function. Antidepressant drugs may improve short-term motor performance. Last updated September 2012 10. Upper Extremity Interventions pg. 2 of 171 www.ebrsr.com Table of Contents 10.1 Consensus Panel Treatment and Recommendations .............................. 6 10.2 Upper Extremity Interventions .............................................................. 8 10.2.1 Neurodevelopmental Techniques ............................................................ 8 10.2.2 Therapy Approaches Used to Improve Dressing Performance ........................ 13 10.2.2 Bilateral Arm Training ....................................................................... 14 10.2.3 Additional/Enhanced Upper Extremity Therapy ......................................... 20 10.2.4 Strength Training ............................................................................. 25 10.2.5 Repetitive/Task- Specific Training Techniques .......................................... 26 10.2.6 Trunk Restraint ............................................................................... 30 10.2.7 Sensorimotor Training and Somatosensory Stimulation ............................... 33 10.2.8 Mental Practice ............................................................................... 40 10.2.9 Hand Splinting ................................................................................ 47 10.2.10 Constraint-Induced Movement Therapy ................................................ 49 10.2.11 Mirror Therapy .............................................................................. 71 10.2.12 Feedback .................................................................................... 74 10.2.13 Action Observation ......................................................................... 76 10.3 Robotic Devices for Movement Therapy .................................................... 77 10.3.1 MIT-Manus .................................................................................... 78 10.3.2 Mirror-Image Motion Enabler Robots (MIME) ............................................ 80 10.3.3 Assisted Rehabilitation and Measurement (ARM) Guide ............................... 82 10.3.4 Bi-Manu-Track ................................................................................ 82 10.3.5 Neuro-Rehabilitation-Robot (NeReBot) ................................................... 84 10.3.6 Continuous Passive Motion (CPM) ........................................................ 86 10.3.7 GENTLE/s ..................................................................................... 87 10.3.8 Other Devices ................................................................................ 87 10.4 Virtual Reality Technology ..................................................................... 91 10.5 Treatment for Spasticity or Contracture in the Upper Extremity ...................... 96 10.5.1 Splinting ....................................................................................... 97 10.5.2 Stretching Programs to Prevent Contracture ............................................. 99 10.5.3 Botulinum Toxin Injections ................................................................ 100 10.5.4 Electrical Stimulation Combined with Botulinum Toxin Injection .................... 111 10.5.5 Nerve Block and Spasticity ............................................................... 112 10.5.6 Physical Therapy in the Treatment of Spasticity ....................................... 112 10.5.7 Electrical Stimulation ...................................................................... 114 10.5.8 Shock Wave Treatment ................................................................... 114 10.5.8 Centrally Acting Muscle Relaxants (tolperisone) ...................................... 115 10.6 EMG/Biofeedback ............................................................................... 116 10.7 Electrical Stimulation .......................................................................... 120 10.7.1Transcutaneous Electrical Nerve Stimulation (TENS) ................................. 120 10.8 Neuromuscular electrical stimulation (NMES) ........................................... 125 10.9 Medications Used in Motor Recovery ...................................................... 139 10.9.1 Stimulants ................................................................................... 139 10.9.2 Levodopa .................................................................................... 141 10.9.3 Antidepressants ............................................................................ 141 10.10 Treatment of Hand Edema .................................................................. 143 10.11 Summary ........................................................................................ 146 10. Upper Extremity Interventions pg. 3 of 171 www.ebrsr.com References .............................................................................................. 149 10. Upper Extremity Interventions pg. 4 of 171 www.ebrsr.com
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