1. The most effective interventions to decrease muscle tone and improve upper extremity function in stroke patients. Welcome

2. Table of Contents Introduction Background Purpose and Research Question Methods Study Design In- and Exclusion Criteria Article-flowchart Criteria List Results Treatment Approaches Outcomes Discussion Conclusion

3. Introduction Background Stroke residual neurological deficits spasticity functional recovery elements of rehabiliation restrictions aggrevate daily living Treatment approaches Neurodevelopmental Therapy (NDT) no evidence proving effectiveness

4. Introduction Purpose review effects/evidence of availble treatment regimes Research Question What are the most effective interventions to decrease muscle tone and improve upper extremity function in elderly stroke patients with arm spasticity?

5. Methods Study Design systematic review databases MeSH words 1. Research Session Stroke, Spasticity, Upper Extremity Function 2. Research Session Stroke AND Interventions - Botulinum toxin - Acupuncture - Constraint Induced Movement Therapy - Functional Electrical Stimulation

6. Methods In- and Exclusion Criteria Inclusion: - stroke - intervention to decrease muscle tone and/or improve upper extremity function - elderly stroke patients (50 – 85 years) - chronic state (> 3 months) Exclusion: - non-spastic patients - independent ADL level - < 7 study subjects - acute stroke (< 3 months)

7. Methods Article Flowchart Articles found (100) Included (23) AC (2) BTX A (5) EPM (1) Spasticity (8) Spasticity & Function (8) BTX A (4) EPM (4) AC (1) CIMT (4) EX (2) Function (7) Additional (77) AC (2) BTX A (3) CIMT (2) EPM (1) EX (5) Background (64) Reviews (13)

8. Methods Criteria List 3

9. Methods Interrater Reliability: α = 0.923 57 – 45 = high quality 44 – 32 = good quality

10. Results Treatment Approaches botulinum toxin type A (Btx A) acupuncture (traditional and electro) CIMT exercise therapy - BATRAC - motorized arm ergometer neuroprosthesis power-assisted FES shock wave

11. Results Measurement Tools Spasticity Modified Ashworth scale (MAS) Range of Motion (ROM) Function Action Research Arm Test (ARAT) Frenchay Arm Test (FAT) Motricity Index (MI) Amount of Arm Used Test (AAUT) Quality of Life Caregiver Motor Activity Log (MAL)

12. Results Outcomes - Spasticity Btx A - sign. reduction in spasticity - benefits until week 12 - no muscle strength loss (≠ 1500 MU) Acupuncuture - sign. reduction in spasticity Shock wave - sign. reduction in spasticity - sign. difference in pROM

13. Results Outcomes - Function CIMT - sign. improve in functional measurements - improvement in quality of life Exercise - sign. improvement in function (week 6 + 14) Acupuncture - sign. difference in active ROM and functional capacity (after 6 weeks)

14. Results Outcomes – Spasticity and Function Btx A - sign. reduction in spasticity (peak at week 4-6) - sign. increase in active and passive ROM - sign. increase in functional capacity - sign. improvement in quality of life Neuroprosthesis and power-assisted FES - sign. reduction in spasticity - sign. improvement in function

15. Discussion Btx A and Spasticity most effective intervention maintenance – 20 weeks similar studies placebo control group Acupuncture/Shock wave and Spasticity lacking similar studies small sample size no proper control group

16. Discussion CIMT and Function most effective intervention compulsive integration positive challenges task specificity Acupuncture/Exercise therapy and Function no task specific training no proper control group small sample size

17. Discussion Btx A and Spasticity and Function most effective intervention improved quality of life applied once in 3 months Electro physical modalities and Spasticity and Function lacking task specificity daily application increase in spasticity decrease in function

18. Discussion Physiotherapeutic interpretation multidisciplinary approach integration of affected arm Recommendations Btx A combined with CIMT effect on acute stroke intense vs. elongated studies proper control groups

19. Conclusion Decrease Spasticity Botulinum toxin type A Improve Function repetitive task specific training of affected arm (CIMT) Decrease Spasticity AND improve Function Combination of: Botulinum toxin type A AND task specific training of affected arm

20. Treatment Protocol Injection of Btx A Muscles being injected (total dose 1000 MU) Biceps brachii Brachioradialis Flexor Carpi Radialis andUlnaris Flexor Digitorum Longus, Profunuds and Superficialis Flexor Policis Opponans Repetitive Task Specific Training starting one week post-injection 3 x 45 min/week ADL training with affected arm Restraining unaffected arm 5 x 6 hrs/week at home and during task specific training session