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  1. 1. Hemiparesis Research in Physical Therapy Treatment of the Upper Limb Chris Keating SPT Thomas Jefferson University
  2. 2. Outline <ul><li>Research </li></ul><ul><ul><li>Good or Bad </li></ul></ul><ul><li>Bimanual Task </li></ul><ul><ul><li>Research </li></ul></ul><ul><ul><li>Benefits </li></ul></ul><ul><ul><li>PT Implications </li></ul></ul><ul><li>Mirror Therapy </li></ul><ul><ul><li>Research </li></ul></ul><ul><ul><li>Benefits </li></ul></ul><ul><ul><li>PT Implications </li></ul></ul>
  3. 3. Reading Research <ul><li>Don’t read the entire article from cover to cover </li></ul><ul><li>Invest time wisely to make sure its worth your time </li></ul><ul><li>Abstract---Introduction---Methods---Results---Discussion---Data Analysis </li></ul><ul><li>Read one section then decide whether to continue reading </li></ul>
  4. 4. Evaluating Research See Attachment <ul><li>Is the problem clearly stated? </li></ul><ul><li>Is the problem probable based on the author’s review of the literature? </li></ul><ul><li>Were inclusion and exclusion criteria specified? </li></ul><ul><li>How many independent variables were examined, and how many levels do they have? </li></ul><ul><li>Have the authors documented the reliability and validity of the instruments? </li></ul><ul><li>Are operational definitions supplied for all independent and dependent variables? </li></ul><ul><li>Are the results statistically significant? </li></ul><ul><li>Regardless of the statistical outcome, are the results clinically important? </li></ul><ul><li>Is the evidence strong enough to suggest a change in clinical practice? </li></ul>
  5. 5. Bimanual Task <ul><li>Only 20% of patients with a flaccid upper limb after 2 weeks recover functional use </li></ul><ul><li>Research has taken place to explore the use of bimanual task therapy in order to increase the functional use of the paretic arm </li></ul><ul><li>Where do you start your search for the best research in order to provide the best care? </li></ul>
  6. 7. Cochrane Review <ul><li>Searched the Cochrane Database of Systematic Reviews </li></ul><ul><ul><li>Key words crossed </li></ul></ul><ul><ul><ul><li>Stroke </li></ul></ul></ul><ul><ul><ul><li>Bimanual </li></ul></ul></ul><ul><li>Found 1 article protocol </li></ul><ul><ul><li>Provided SRL blue print for aspiring researcher to develop and execute (not useful) </li></ul></ul><ul><ul><li>Provided background on the current evidence available (useful) </li></ul></ul>
  7. 8. Cochrane Review <ul><li>A small number of randomized controlled trials of bilateral training have been published, which appear to have inconsistent results </li></ul><ul><li>investigations of the impact of bilateral training on neural mechanisms provide equivocal results </li></ul><ul><li>In order to determine the effects of bilateral training compared to no treatment, placebo or other interventions for improving arm function after stroke, a systematic review of the relevant literature is required </li></ul>
  8. 9. Rose: Findings <ul><li>The purpose of this experiment is to investigate anticipatory planning and movement control processes involved in bimanual aiming for individuals with mild stroke-induced hemiparesis. </li></ul><ul><li>Nonparetic limb movement time was prolonged by 21% in the bimanual compared with the unimanual condition </li></ul><ul><li>Compared to the unimanual task the bimanual task exhibited a higher peak velocity in the paretic limb – This was not noted in the control </li></ul>
  9. 10. Rose: Benefits <ul><li>Individuals with mild paresis post stroke retain a level of bimanual coordination. This ability may be harnessed for rehabilitation interventions to benefit recovery of function </li></ul><ul><li>PT Implications </li></ul><ul><ul><li>Goal oriented bimanual tasks increase the feedback to the CNS increasing neuroplasticity and chance of remediation </li></ul></ul>
  10. 11. Cauraugh: Findings <ul><li>The leading question focused on within-limb transfer of coupled protocols on distal joints to a bimanual aiming task that involved proximal joints </li></ul><ul><li>This study determined that within-limb transfer from distal joints to a combination of proximal joints was feasible </li></ul>
  11. 12. Cauraugh: Benefits <ul><li>Peak velocity, variability in peak velocity, and deceleration time (adjustment phase) findings revealed a target aiming task advantage for the coupled bilateral group </li></ul><ul><li>PT Implications: </li></ul><ul><ul><li>Bimanual goal oriented task training improves kinetics of proximal joints thereby improving hand placement and function </li></ul></ul>
  12. 13. Dohle: Purpose <ul><li>The Purpose was to evaluate the potential beneficial effect of viewing the mirror image of the unaffected upper limb on recovery in patients with severe hemiparesis early after stroke </li></ul>
  13. 14. Dohle: Findings <ul><li>No difference in motor function, ROM, Pain or Motor FIM between the 2 groups (CT and MT) </li></ul><ul><li>MT had significant gains over the CT in Function, Neglect and Sensory outcome measures (ARAT and Light Touch) </li></ul>
  14. 15. Dohle: Benefits <ul><li>Watching a healthy moving arm and hand in the neglected hemifield provides a stronger stimulus for recovery from neglect than watching the attempted movements of a paretic side </li></ul><ul><li>MT most effective when person has no distal movement at onset of treatment compared to CIMT where functional gains are made but only when distal function is available </li></ul>PT Implications: This offers another option when treating a very difficult impairment
  15. 16. Reference <ul><li>Coupled Bimanual Movements and Active Neuromuscular Stimulation: Intralimb Transfer Evidence During Aiming . Cauraugh, Kim and Duley, Neuroscience Letters 382 (2005) 39-44. </li></ul><ul><li>The Co-Ordination of Bimanual Rapid Aiming Movements After Stroke . Rose and Winstein, Clinical Rehabilitation 19 (2005) 452-462. </li></ul><ul><li>Mirror Therapy Promotes Recovery From Severe Hemiparesis: A Randomized Control Trial . Dohle, Pullen and Nakaten, Neurorehabilitation and Neural Repair 23 (2009) 209-217 </li></ul><ul><li>Simultaneous Bilateral Training For Improving Arm Function After Stroke (Protocol). Couper, Van Wijck and Pollock 2009. </li></ul><ul><li>Portney LG, Watkins MP. Foundations of Clinical Research: Applications to Practice . Norwalk, CT: Appleton and Lange; 1993 </li></ul>