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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 ...

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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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