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  2. Contents • Definition • Risk factors of stroke • Aetiology • Classification • Signs and symptoms • Diagnosis • Treatment • Limb synergy • Orthotic management • Role of orthosis • Orthotic classification • Biomechanics • Advancement in orthosis • Robotics in stroke management • Adaptations • References
  3. Definition Stroke, or cerebrovascular accident (CVA), describes a variety of disorders characterized by the sudden onset of neurological deficits caused by vascular injury to the brain.
  4. Aetiology • There are 3 main causes of stroke:  a blocked artery (ischemic stroke)  leaking or bursting of a blood vessel (hemorrhagic stroke). temporary disruption of blood flow to the brain, known as a transient ischemic attack (TIA).
  5. Classification • Strokes are usually classified by the mechanism and location of the vascular damage. • The two broad types are Ischemic Hemorrhagic
  6. Ischemic stroke • Ischemic stroke is the most common form of stroke, mostly 85%. • This type of stroke is caused by blockage or narrowing of the arteries that provide blood to the brain, resulting in ischemia“severely reduced blood flow” Causation:- • These blockages are caused by the blood clots and clots can be caused by the fatty deposits within the arteries called plaque.
  7. Haemorraghic stroke • Hemorrhagic strokes result from a rupture of a weakened cerebral blood vessel. • Hemorrhagic strokes are either  intracerebral (bleeding into the brain itself) or  subarachnoid (bleeding into an area surrounding the brain) Causation: • Uncontrolled high blood pressure • Overtreatment with blood thinners (anticoagulants) • Bulges at weak spots in blood vessel walls (aneurysms) • Trauma (such as a car accident) • Protein deposits in blood vessel walls that lead to weakness in the vessel wall (cerebral amyloid angiopathy) • Ischemic stroke leading to hemorrhage.
  8. Transient ischemic attack • It is sometimes known as a ministroke - is a temporary period of symptoms similar to those in a stroke. • A TIA doesn't cause permanent damage. Causation:- • A TIA is caused by a temporary decrease in blood supply to part of the brain, which may last as little as five minutes. • Like an ischemic stroke, a TIA occurs when a clot or debris reduces or blocks blood flow to part of the nervous system
  9. SIGNS & SYMPTOMS OF STROKE • Sudden numbness or weakness in the face, arm, or leg, especially on one side of the body. • Sudden confusion, trouble speaking, or difficulty understanding speech. • Sudden trouble seeing in one or both eyes. • Sudden trouble walking, dizziness, loss of balance, or lack of coordination. • Sudden severe headache with no known cause.
  10. DIAGNOSIS • Stroke happens fast and will often occur before an individual can be seen by a doctor for a proper diagnosis. • B.E.F.A.S.T is the way to remember the signs of stroke and can help identify the onset of stroke more quickly:
  11. Medical diagnosis:- After seeing the preliminary signs & symptoms of stroke patient is shifted immediately to the hospital for further investigation to rule out the cause of stroke. 1.Physical examination: Blood pressure(BP) Heart rate(HR) Neurological tests 2.Blood tests 3.Computerized Tomography(CT)Scan 4.Magnetic resonance imagaing(MRI) 5.Carotid ultrasound 6.Cerebral angiogram 7.Echocardiogram
  12. TREATMENT 1.MEDICAL MANAGEMENT  Supportive management -Maintenance of airways and ventilation -Temperature -Blood sugar -Cardiac assessment  Thrombolysis -Intravenous/Intra-arterial  Administration of anti platelet and anticoagulant drugs  Hemodilution  Neuroprotective Agents  Edema reduction  Use of anasthetic nerve blocks and phenol nerve blocks  Chemodenervation Spasticity release
  13. 2.Surgical Management • Removal of a clot or shunting of ventricular fluid. • Intracranial or extra cranial bypass surgery. • Surgical decompression of cerebellar hematoma. 3.Therpeutic management • Techniques of Treatment: Approximately 48 hours after stroke, if patient is medically stable and alert, and there is no progression of the deficit, bedside physical and occupational therapy may be started. The program depends on the level of recovery of the patient.
  14. WHAT ARE THE BRUNNSTROM STAGES OF STROKE RECOVERY? • The brunnstrom stages is one of the most well-known stroke recovery stages which is also known as the Brunnstrom approach. • Developed by physical therapist Signe Brunnstrom in the 1960’s. • This approach describes the sequence of motor development and reorganization of the brain after stroke.
  15. • Basic Limb Synergies  Synergy is a pattern of muscles contracting in a stereotyped predictable pattern in hemiplegics or cerebral palsy patients due to loss of inhibitory control normally exerted by higher centers in the brain.  In the upper limb the flexor synergy and in the lower limb the extensor synergy patterns are commoner. • The patterns are as follows: Upper Limb Synergy Patterns: Flexor Synergy Scapular retraction/elevation Elbow flexion Wrist and fingers flexion Lower Limb Synergy Pattern: Extensor Synergy Hip extension Hip adduction & internal rotation Knee extension Ankle plantar flexion and inversion, tending to equinovarus Toe plantar flexion
  16. Assessment and evaluation form
  17. Orthotic management  The use of orthotics is one set of tools in the effort to:-  Restore range of motion  Soft tissue flexibility  Agonist–antagonist muscle balance  Improves function of the upper extremity  Orthotic designs ranges from robust immobilization to incremental facilitation of range of motion on a joint-by-joint basis.  Robust immobilization, such as casting, is used early and has the benefits of  Overcoming severe spasticity.  Decreasing the amount of user error by the wearer or caregiver.
  18. BASIC ROLE OF ORTHOSIS • Use to maintain or increase the length of the soft tissues by preventing or lengthening shortened tissues. • Used to correct biomechanical malalignment, restoring muscles to normal resting length and protecting joint integrity. • Used to position the hand to assist in functional activities. • Used to promote independence in specific areas of occupation. • Compensate for weakness by providing external support .
  19. USES OF ORTHOTIC DEVICES • Contracture Prevention • Orthoses as Reinforcements after Chemodenervation • Contracture correction • Maintaining limb position • Functional aids
  20. a) Contracture Prevention Neurogenic shock often occurs directly after stroke or brain injury. Over the following few weeks, spasticity develops in parallel with neurologic recovery. • In this period, a combination of oral antispasmodics, peripheral nerve blocks, and casting or splinting techniques are commonly used to give temporary relief of spasticity. • Positioning a limb in a desired position is important. • Casting maintains muscle fiber length, protects the limb, and diminishes muscle tone by decreasing sensory input. • Cast are commonly used to treat pressure sore.
  21. b) Orthoses as Reinforcements After Chemodenervation • When a botulinum toxin injection is injected, an orthotic device can be used to maintain the injected muscles in a stretched position to enhance the effect of BT . • In this case, progressive or serial orthosis used to increase the amount of stretch. • The use of injection and orthosis can be an intermediate and transitory phase before surgery.
  22. c) Contracture correction •Restoration of joint range of motion or contracture correction can be achieved with serial casting at weekly intervals. •Surgical management helps in manipulating the joint under anesthesia beyond soft tissue endpoints. •After this, a cast may be applied to allow the limb to heal in its new position. • A major correction in joint position can be achieved directly through manipulation and application of orthosis.
  23. d) Maintaining Limb Position • When the desired limb position has been achieved by serial or dropout casts, bivalved casts are frequently used. • Bivalved cast or splint is important because it is more comfortable than a traditional circular cast and can be removed several times a day to perform joint range of motion and skin care. • Bivalved casts or splints are inadequate for severe spasticity because they do not have enough inherent stability and may increase the risk for skin and soft tissue injury.
  24. e)Functional aids •Orthotics can be used to improve or assist function by positioning the limb for use. • Lap boards, arm slings, and other positioning devices should be considered as well as more conventional orthoses. •These devices are usually very practical and often improve patient comfort.
  25. Orthotic classification Function Region Static Orthoses Dynamic /Functional Orthoses Static progressive Orthoses Serial cast/Serial Orthoses Shoulder Orthoses Elbow Orthoses Wrist and Hand Orthoses Finger and Thumb Orthoss
  26. 1. Static orthosis  Rigidly immobilize one or more joints and do not allow any motion.  Used for fractures and nerve injuries in the postsurgical phase.  Able to overcome severe spasticity  Distribute pressure equally along all contact points.  Facilitates attachment point for assistive devices (eating utensils, pens)
  27. 2. Dynamic /Functional Orthoses  Allow a prescribed amount of motion across one or more joints.  Design- Hinged and may or may not have a spring or elastic force  Encourages rotation about the joint.  Use - Assist movement of relatively weak muscles. - Provide a corrective force across a joint to encourage normal movement patterns. - Agonist–antagonist muscle balance.
  28. 3. Static progressive Orthoses  Incorporate non-elastic components to apply force across a joint to hold it at its end range position to improve passive joint range of motion.  Allow incremental changes in joint position as the end range of the affected joint improves over time.
  29. 4. Serial cast/Serial Orthoses  These are static casts or splints applied over time.  Accomplishes a prolonged passive stretch over time and blends the durability and reliability of casting.
  30. HOW STROKE AFFECTS SHOULDER • Hemiplegia from stroke causes significant impairment of the shoulder girdle. • Painful shoulder syndromes, called hemiplegic shoulder pain (HSP) are more common in post stroke. • The weight of the hanging arm can cause shoulder to sublux inferiorly. • In the subacute to chronic phase of stroke, spasticity commonly develops, especially in the shoulder internal rotators and adductors.
  31. SHOULDER ORTHOSES 1. Lap Board 2. Arm Support 3. Sling 4. Humeral Cuff 5. Abduction pillow 6. Electrical stimulation
  32. Lap boards are placed over the arms of a wheelchair. Indication:- Post stroke patients using wheel chair. Advantages:- • Provide protection and ensure proper positioning of the hemiparetic shoulder and arm. • Assists the patient in maintaining an upright posture while sitting. 1. LAP BOARD
  33. A forearm trough device can be used to support and position the arm. Indication:- • This is useful when there is a mild-to-moderate degree of spasticity in the adductor and internal rotator muscles of the shoulder. • Patient using wheel chair . Location:- • The device can be attached directly to the arm of a wheelchair. • A forearm trough can be attached to a hinged mobile support on the arm of the chair. Advantages:- • The trough is used to statically position a non functional arm. • The patient’s forearm can be secured in position with padded straps. • This allows the arm to be placed in a variety of positions for functional use or training of the hand. • Positions the arm in slight abduction and neutral rotation. 2.Arm Supports
  34. It is a simplest and most common orthotic device to position the arm Indication:- Ambulatory hemiplegic patients. Contraindiaction:- Bilateral use. Advantages:- • It can be removed periodically to allow ROM, exercises of the shoulder and elbow. • Low cost • Easy to use • Lightweight • Portable 3.SLING
  35. BIOMECHANICAL DISADVANTAGES The simple sling is an inefficient method for exerting an upward force on the humerus because it exerts its force along the whole length of the forearm, wrist and hand rather than a single fulcrum point.
  36. Biomechanics • The action line of the effective suspension force of a shoulder sling or a hemisling lies distal to the center of gravity of the bent arm. • Therefore, no subluxation correcting force can exist.
  37. • Displacement of the action line of the suspension force proximal to the center of gravity results in an attractive orthosis structure. The total system acts like a balanced arm. The forearm and hand together force the upper arm upwards into the shoulder joint
  40. The different possibilities for the positioning of the fixed points are
  41. • The subsystems of forearm and upper arm are combined to the system of the complete arm. The force in the elbow is now an internal force of the system. • The resulting gravity force of the complete arm acts distally of the suspension force. • The reaction force in the shoulder ensures the equilibrium of forces and indicates the successful neutralization of the subluxation. Patient with orthosis, 1-textile tension band; 2- leather suspension strip; 3-stainless steel brace; 4- textile or leather shoulder cap.
  42. • A cuff applied circumferentially around the proximal humerus can be attached to a shoulder harness. Indication:- Hemiplegic patients with shoulder subluxation. Advantages:- • The cuff has the advantage of leaving the elbow and hand free. • It also allows motion of the glenohumeral joint with limited flexion, abduction, and rotation while maintaining adequate glenohumeral reduction 4. HUMERAL CUFFS
  43. Indication:- • A bed-bound patient with paralysis or spasticity of the shoulder musculature is prone to develop an adduction and internal rotation contracture of the shoulder from prolonged immobility. Advantages:- • A foam pillow is useful for positioning the shoulder in slight abduction and neutral rotation. • This position facilitates care and prevents contractures and hygiene difficulties in axilla. 5.ABDUCTION PILLOW
  44. • Electrical stimulation units can be considered dynamic orthotic device Indication:- • If the muscle weakness is believed to be transient, electrical stimulation of the deltoid and supraspinatus muscles can be used to prevent shoulder subluxation • Treatment of chronic subluxation . Advantages:- • Decrease pain and increase range of motion. • Facilitates functional use of the affected limb. Disadvantages:- • Current intensity and frequency can cause an electrical buzzing discomfort to the patient 6. ELECTRICAL STIMULATION
  45. HOW STROKE AFFECTS ELBOW • Flexor spasticity is common & frequently severe in stroke. • Flexion contracture are common. • Painful elbow lead to maceration of anticubital skin • Compression neuropathy of the ulnar nerve is seen in 10% of patient with stroke.
  46. ELBOW ORTHOSES 1. Long arm cast 2. Drop out cast 3. Bivalved long arm cast 4. Dynamic elbow orthosis
  47. Indication • It is an excellent static orthosis for positioning the elbow & used for correcting flexion contracture. Procedure of application • After spasticity has been diminished by neurolytic or surgical techniques, the elbow is casted in maximum extension. • The cast used in a serial manner to gain further ROM • The cast is changed every 5-7 days Trimlines • The cast is applied at the midhumerus and extends to the metacarpophalangeal joints with the wrist in neutral rotation. • Once full extension has been achieved the cast is bivalved and a clamshell splint is fabricated to allow periodic removal of the splint and daily range-of- motion exercises 1.LONG ARM CAST
  48. It can be used as a dynamic orthosis controlling therapeutic range of motion of the elbow. Indication Patient in an upright position for much of the day. Features • It is a modified long arm cast in which the posterior portion of the cast above the elbow has been removed, allowing for full extension but limiting flexion . • This cast is purposely made heavy, or weights are added at the wrist to encourage elbow extension. • The cast is changed periodically as elbow extension is gained. 2. DROPOUT CAST
  49. • It is another modification of long arm cast in which two longitudinal cuts are made from the biceps to radial styloid and from the triceps to distal ulna • The clamshell cast is lined with stockinette to provide smooth inner surface • Straps are added to secure anterior & posterior halves of the cast together. • It can be removed several times daily to allow active/passive joint motion of elbow to prevent stiffness Contraindication:- • It can not be used in severe spasticity. 3.BIVALVED LONG ARM CAST/CLAM SHELL CAST/ORTHOSIS
  50. • A dynamic elbow orthosis creates a rotational force across the joint to increase joint motion Indication • This is particularly useful when high-energy trauma results in both brain injury and lower motor neuron injury of the upper extremity. Contraindication • Severe spasticity Mechanism of action • It has elastic or spring-assisted mechanism to increase intended range of motion, biasing either flexion or extension. Function • Assist or substitute for weak muscles. 4.DYNAMIC ELBOW ORTHOSES
  51. 5.PRESSURE ORTHOSIS (AIR ORTHOSIS) • It reduces tone. • Facilitate muscle activity around a joint. • Facilitate sensory input. • Control edema, and reduce pain.
  52. 6.TONE AND POSITIONING ORTHOSIS Function • It supports the thumb in abduction and extension with a neoprene glove. • It includes an elastic strap that is wrapped spirally up the forearm, providing a dynamic assist into pronation and supination of wrist.
  53. WRIST & HAND ORTHOSIS • Spastic forearm flexor muscles causing wrist and finger flexion deformities are common.  Boutonniere Deformity  Swan neck Deformity • Cast & orthotic devices are used to correct residual contracture or to position the wrist & hand. • Specific type of forearm WHO include - Cast - Static wrist & hand splints - Dynamic wrist orthosis & finger orthosis.
  54. Indication • Wrist flexion contracture . Timlines • It usually starts 2 cm distal to the lateral upper condyle and extends to just before the metacarpophalangeal joints, leaving the thumb in neutral opposition and abduction. • The wrist is casted in a neutral position. Procedure of application • The cast is changed every 7 days. With each change, the wrist is gently manipulated into further extension. • The cast can be bivalved and a clamshell splint fabricated once full extension has been achieved. • The wrist should remain immobilized in full extension for an additional 4 weeks to prevent recurrent deformity. 1.SHORT ARM CAST
  55. 2.BIVALVED SHORT ARM CAST • It is a modification of a short arm cast. • Lined with stockinette to provide a smoother inner surface. • Straps are added to secure the ant. & post. halves of the cast together. Contraindication Severe spasticity of wrist and hand.
  56. Indication • Surgical lengthening of spastic extrinsic finger flexor muscles in a hand. Contraindication • Patient with severe flexion deformity. Advantages • Useful for maintaining the wrist in extended position. • By holding the wrist in slight extension, patient can perform occupational therapy & functional training of finger motion. 3.VOLAR WRIST ORTHOSIS Volar cock up splint
  57. Resting wrist–hand orthoses are one of the most commonly used static intermediate devices. Features • It can be premade or custom fabricated out of many different types of materials. • It immobilize the wrist alone or more often can include the thumb and fingers. • The raised lateral palmer ridges of orthosis prevent radial or ulnar deviation & reinforce the orthosis to accommodate muscle tone & spasticity. 4.RESTING WRIST–HAND ORTHOSES
  58. Indication • Patient with a relatively flexible wrist flexion deformity. Function • Dynamic wrist–hand orthoses provide greater functional movement and are often better tolerated by patients compared with static orthoses. 5.DYNAMIC WRIST ORTHOSES
  59. 6.SERPENTINE ORTHOSIS • It provides sufficient thumb abduction support, positions the hand and wrist in a more optimal position for function. • It allows active wrist function in the child with moderately increased tone.
  60. 7.INFLATABLE HAND ORTHOSIS • This orthosis consists of an adjustable volar-based wrist support that is easily adjusted to achieve the desired range of extension. • The palmar aspect of the orthosis is an air bladder that can be inflated or deflated easily, depending on the desired stretch and level of contracture. • It is easily donned and is comfortable.
  61. • Finger positioning devices can be static or dynamic & it can be used for maintaining a position or enhancing functional use of the hand • Electrical stimulation devices are available & used mainly as training aids. FINGER & THUMB ORTHOSIS
  62. 1.Static Hand Splints • Used to maintain the position of the fingers and provide protection. • They are less useful for improving the arc of motion. • Soft hand rolls or splints are useful for preventing contracture. -Absorbs perspiration -Prevents nail bed infection -Avoids worsening of contracture
  63. Firm cone
  64. 2.Dynamic Hand Splints • Many stroke patients regain active finger flexion and are capable of grasping objects. • Chemodenervation or surgical lengthening can restore relaxation of excessive finger flexor tone and allow weak extensors to open the hand. • Finger extension can be supplied by dynamic orthoses with elastic mechanisms. • Mainly it is categorised into 2 varieties:-  Outrigger splint  Leaf spring glove
  65. A) OUTRIGGER SPLINT Mechanism of action • It uses elastic mechanisms i.e rubber bands or slings placed beneath the proximal phalanx of the thumb and finger. • This elastic tension causes the fingers to be held in an open position with the thumb abducted. • The patient can more easily position the hand to grasp an object
  66. • Consists of flexible strips incorporated into the glove overlying the extensor surface of each finger. • These strips provide active finger extension while allowing the patient to grasp actively. • The fingertips of the glove are removed to improve sensation. B) LEAF SPRING GLOVE
  67. 3.THUMB SPICA CAST Indication Thumb in palm deformity and contracture. Role • It is an excellent orthotic device for positioning the thumb in abduction. • The cast initially is applied as a circular device and later can be serially recasted or modified to a bivalved splint.
  68. Indication  Swan neck Deformity  Boutonniere Deformity Function  Increase coordinated grip strength. Advantages • Low profile • Well ventilated • Lightweight • Easy to don • Well tolerated by patients. 4.SPLIT RING ORTHOSES
  69. Indication Thumb in palm deformity. Function • It is lightweight splint that holds the thumb metacarpal in an abducted and slightly opposed position • It can be used to improve thumb function and pinch. • Improves the opposition position. 5.THUMB ABDUCTION SPLINT
  70. 6.THUMB LOOPAND THUMB ABDUCTION ORTHOSIS • It is a semi dynamic orthosis. Role  Positioning of the thumb and wrist alignment.  The strapping material used in the fabrication of this orthosis positions the thumb in abduction & aligns the wrist in a position of slight radial wrist extension.  The hand is placed in a position that enhances prehension, manipulation, and release of objects.
  71. 7.FINGER SPREADER (FINGER ABDUCTION ORTHOSIS) • It is a fabricated of foam rubber and positions the fingers and thumb in abduction. Function • According to Bobath the purpose of the orthosis is to “obtain extension of wrist and fingers”. • It reduces the possibility of edema.
  72. 8.HAND-BASED THUMB ABDUCTION ORTHOSIS • The orthosis is custom fabricated from thermoplastic material. • It positions the thumb in an enhanced prehension pattern for manipulation of objects during grasp and release activities.
  73. 9.MACKINNON ORTHOSIS • It includes a dorsal-based forearm support(orthokinetic cuff) that wraps 3/4th of the distal half of the forearm • A dowel placed in the palm of the hand to provide pressure on the MCP heads • Rubber tubing attaching the dowel to the dorsal forearm support the fingers are left free to assume functional patterns.
  74. 10.BELLY GUTTER ORTHOSIS Indication  Effective for flexion contractures of the PIP joint from approximately 15 degrees of contracture to 35 degrees of contracture. Function • The belly gutter orthosis provides the 90-degree angle pull by incorporating a convex belly in the middle of the gutter. • It is used at the beginning of treatment for 1 hour on and 1 hour off. • Gradually, as the contracture decreases, the time may be extended to as much as 4 hours.
  75. Advancements in orthosis for stroke STUDY-1 Long-Term Use of a Static Hand-Wrist Orthosis in Chronic Stroke Patients: A Pilot Study Objective Evaluating long-term use of static WHO and experienced comfort in chronic stroke patients. Conclusion  Number of chronic stroke patients cannot tolerate a static orthosis for at least 8 hours per day during a long-term period of at least one year. Without appropriate treatment opportunities, these patients will remain at risk of developing a clenched fist and will experience problems with daily activities and hygiene maintenance. Prefabricated static hand-wrist orthosis Journal-Stroke research and management(January 2013)
  76. • STUDY-2 Combining virtual reality and a myoelectric limb orthosis to restore active movement after stroke: a pilot study (International journal of disability and human development -2014) Diagram of the developed virtual reality and robotic limb orthosis training paradigm showing the role of each technological component
  77. Prototype of the myoelectric-based interactive system for rehabilitation.  Left panel: an adaptive training in the form of a game defines the training parameters for a bimanual coordination motor task.  The training offers augmented feedback on performance, sustains motivation, and automatically modifies the level of motor assistance offered by the limb orthosis. Right panel: the different components of the system (robotic device, tracking setup, and training game task) while being used by a stroke patient.
  78. • STUDY-3 Therapy Incorporating a Dynamic Wrist-Hand Orthosis Versus Manual Assistance in Chronic Stroke A Pilot Study (Journal of Neurologic Physical Therapy-2012) Objective: To compare the effect of therapy using a wrist-hand orthosis (WHO) vs manual-assisted therapy (MAT) for individuals with chronic, moderate-to-severe hemiparesis. Dynamic wrist-hand orthosis (SaeboFlex).
  79. • Conclusion  Small improvements in function and perception of recovery were observed in both the groups.  Adds to the evidence that individuals with chronic stroke can improve arm use with therapy incorporating functional hand training.
  80. • STUDY-4 Effects of Robot-Assisted Therapy on Upper Limb Recovery After Stroke: A Systematic Review (Neurorehabilitation and neural repair-2008) Objective To present a systematic review of studies that investigates the effects of robot assisted therapy on motor and functioanl recovery in patients with stroke. Conclusion  No overall significant effect in favour of robot assisted therapy was found in the meta analysis.  Sensitivity analysis showed a significant improvement in upper limb motor function after stroke for upper arm robotics.  No significant improvement was found in ADL functions.
  81. Robotics in stroke rehabilitation • Robotic devices appear to be suitable for application under certain conditions and modalities that allow: • i) individually adjust the rehabilitative training protocol with due accuracy, • ii) obtain replication and congruity with residual motor function and treatment targets • iii) quantitatively assess baseline conditions and monitor changes during training.
  82. • A robotic system traditionally comprises some major components:-  a mechanical structure with degrees of freedom consistent with the tasks to be executed  joint-controlling actuators, either electric or pneumatic;  Proprioceptive and exteroceptive sensors providing information on the machine functional status and interaction with environment  sequences of tasks to be executed as detailed by the system computer in suitable language  a computer generating the signals that control the robot joints, processing the signals transmitted by the sensors and instructing the motor controllers  man/machine interface receiving information/instructions from users (therapist/patient) and providing online feedback
  83. • . According to the control strategy, robots can be programmed to assist patient’s motion in different modes: i) passive- the robot moves patient’s arm ii) active unassisted-the subject executes the exercise and the robot provide no help iii) active assisted: the subject attempts to move and the robot provides assistance when there 208 Muscles, Ligaments and Tendons are some voluntary but inadequate movements, iv) resistive: the subjects is required to perform an exercise against an antagonist force provided by the robot.
  84. • According to their mechanical characteristics, robots can be classified into, at least, three main groups a) exoskeletons b) end-effectors (also called “operational type machines” or “manipulators”) c) and cable-driven.
  85. Armeo® Spring: an ergonomic arm exoskeleton with integrated springs Armeo® Power: an exoskeleton based on the ARMin technology
  86. Armeo® Boom: a simplified cable- driven manipulator designed for out- patient clinics and home settings
  87. • STUDY-5 A Novel Functional Electrical Stimulation Treatment for Recovery of Hand Function in Hemiplegia: 12-Week Pilot Study (Neurorehabilitation and Neural Repair-2009) Objective:- This study aimed to evaluate the feasibility of achieving greater and more persistent gains with CCFES(Contralaterally controlled functional electrical stimulation) by increasing the treatment period to 12 weeks.  CCFES uses neuromuscular electrical stimulation to open the paretic hand in direct proportion to the degree of volitional opening of the unimpaired contral- ateral hand, which is detected by an instrumented glove. Conclusion:-  Greater reductions in hand impairment were achieved by extending the treatment period.  The effect and its longevity may be related to baseline impairment level.
  88. (CCFES) Volitional Opening of the Unaffected Hand Produces a Proportional Intensity of Stimulation to the Paretic Hand Extensors
  89. CCFES stimulator, command glove, and electrodes ©2012 Cleveland FES Center
  92. REFERENCES • Webster B.Joseph,Murphy P Douglash,Atlas of orthoses and assistive devices(5th Edition),Chapter-13(Upper Limb Orthoses for the Stroke- and Brain-Injured Patient) • Fess,Gettele,Phillips,Jason,Hand and upper extremity splinting Principles and Methods(3rd Edition),Chapter-19(Splinting for Patients with UpperExtremity Spasticity) • Stroke Rehabilitation Function-Based Approach Glen Gillen, EdD, OTR, FAOTA • Hunter,Mackin,Callahan, Rehabilitation of the hand and upper extremity,5th Edition, Chapter-8(Clinical evaluation of hand ),Chapter-9(Diagnosis imaging of the upper extremity) • Catherine A.Trombly,Mary Vining Radomski,(Occupational therapy for physical dysfunction),5TH Edition, Section-4,Chapter-42(Hand Impairments) • S Sunder, Text book of rehabilitation,Chapter-18,Stroke rehabilitation • Robotics in shoulder rehabilitation(Review article) • Combining virtual reality and a myoelectric limborthosis to restore active movement after stroke:a pilot study • Biomechanics of orthoses for the subluxed shoulder,J. C. Cool