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. Stroke 2010; 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:

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:

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.