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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.
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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
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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
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References .............................................................................................. 149
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