The document discusses recent advances in managing upper limb impairments after stroke. It describes studies that evaluated the long-term use of static hand-wrist orthoses, the use of table-top exergames to improve arm function, and a pilot study combining virtual reality and a myoelectric limb orthosis to restore movement. It also summarizes a controlled trial finding that non-immersive virtual reality treatment can effectively restore upper limb motor function and impact daily living activities when combined with conventional upper limb therapy.

1. BY: EUSIVIA PASI
MPT
MANAGEMENT OF UPPER LIMB
POST STROKE WITH RECENT
ADVANCES

2. DEFINITION OF STROKE
Cerebral vascular accident has been defined as ‘a
sudden, non-convulsive loss of neurologic function due to
an ischemic or hemorrhagic intracranial vascular event’
(pubmed [medline], mesh database, 2005).
The world health organization (who) definition of stroke is:
“rapidly developing clinical signs of focal (or global)
disturbance of cerebral function, with symptoms lasting 24
hours or longer or leading to death, with no apparent cause
other than of vascular origin”

3.  “Stroke or Brain Attack is the sudden loss of neurological
function caused by an interruption of blood flow to the brain”
by Susan B. O’Sullivan
 “a focal (or at times global) neurological impairment of
sudden onset lasting more than 24 hours (or leading to
death) and of presumed vascular origin” by WHO Journal of
the association of physicians of India, October 2013, Vol. 61
 “a sudden loss of brain function resulting from an
interference with blood supply to the brain” by National
Institute of Neurologic Disorders and Stroke (NINDS), USA.

4. COMMON IMPAIRMENTS IN STROKE:
 Altered consciousness/attention
 Dysphagia
 Dysphonia/Dysarthria/Dysphasia
 Reduced muscle power/tone
 Altered sensations
 Reduced coordination
 Loss of visual acquity
 Reduced joint mobility/stability
 Balance and Gait impairments

5. OUTCOME MEASURES
 Functional movement of the upper limb are categorised into the
following subgroups:
1. arm functional movement and
2. hand functional movement
 And categorised motor impairment of the upper limb into the
following subgroups:
1. motor impairment scales
2. temporal outcomes,
3. spatial outcomes and
4. strength outcomes.

6. ABBREVIATION OUTCOMES
AMAT Arm Motor Ability Test
ARAT Action Research Arm Test
AS Ashworth Scale
BBT Box and Block Test
BI Barthel Index
CAHAI Chedoke Arm and Hand Activity Inventory
CMSA Chedoke-McMaster Stroke Assessment
EMG Electromyogram
EQ-5D EuroQol Quality of Life Scale
FAT Frenchay Arm Test
FIM Functional Independence Measure
FIM motor Functional Independence Measure motor
subscale
FM Fugl-Meyer scale

7. FM motor Fugl-Meyer motor subscale
fMRI Functional Magnetic Resonance
Imaging
MFT Manual Function Test
MAS Modified Ashworth Scale
Motor AS Motor Assessment Scale
MRC Medical Research Council
MSS Motor Status Score
NHPG Nine-Hole Peg Test
NSA Nottingham Sensory Assessment

8. RLAFT Rancho Los Amigos Functional Test
RMA Rivermead Motor Assessment
ROM Range of Motion/Movement
SCT Star Cancellation Test
SIS Stroke Impact Scale
TUG Timed Up and Go
TCT Trunk Control Test
UMAQS University of Maryland Arm
Questionnaire for Stroke
VAS Visual Analogue Scale
WMFT Wolf Motor Function Test

9. TYPES OF STROKE
Ischaemic stroke:
 Blood supply to part of the brain is decreased, leading to
dysfunction of the brain tissue in that area.
1) Thrombosis or embolism due to atherosclerosis of a large
artery
2) Embolism of cardiac origin
3) Occlusion of a small blood vessel
4) Other determined and undetermined cause
 Abuser of stimulant drugs such as cocaine and
methamphetamine are at a high risk for ischemic strokes.

10. Haemorrhagic stroke:
 is the accumulation of blood anywhere within the skull vault.
(1) Intra-axial hemorrhage (blood inside the brain)
 is due to intraparenchymal hemorrhage or intraventricular
hemorrhage (blood in the ventricular system)
(2) Extra-axial hemorrhage (blood inside the skull but outside the
brain).
 epidural hematoma (bleeding between the dura mater and the
skull),
 subdural hematoma (in the subdural space) and
 subarachnoid hemorrhage (between the arachnoid mater and pia
mater).

11. UPPER LIMB IMPAIRMENTS:
 Subluxation.
 Changes in sensation.
 Contracture.
 Swelling.
 Co-ordination problems.
 Weakness.
 Altered muscle power
 Changes in muscle tone (called hypertonia or spasticity)
 Hand dysfunction

12. RECENT ADVANCE
 Search criteria : PubMed, APTA, COCHRANE, Elsevier,
Australian Journal Of Physiotherapy, British Medical
Journal, Clinical Rehabilitation, Neuroscience and medicine,
Journal of physical therapy science, Journal of neurological
physical therapy
 2009 to 2013

13.  Abstract and full text articles
 Systemic review, RCT, cohort studies, pilot studies
 Keywords: stroke, stroke rehabilitation, upper limb
training, functional electrical stimulation, motor recovery
 LOE: PEDro

14. TITLE : LONG-TERM USE OF A STATIC HAND-
WRIST ORTHOSIS IN CHRONIC STROKE
PATIENTS: A PILOT STUDY
AUTHOR :
1. Aukje Andringa
2. Ingrid van de Port and
3. Jan-WillemMeijer
JOURNAL : Stroke Research and Treatment
YEAR PUBLISHED : 31st January 2013

15. OBJECTIVES:. Evaluating long-term use of static hand-wrist orthoses and
experienced comfort in chronic stroke patients.
METHODS
11 stroke patients who were advised to use a static orthosis for at least one
year ago were included. Semistructured telephone interviews were
conducted to explore the long-term use and experienced comfort with the
orthosis. Data were analyzed using descriptive statistics.
RESULTS
After at least one year, seven patients still wore the orthosis for the
prescribed hours per day. Two patients were unable to wear the orthosis 8
hours per day, due to poor comfort. Two patients stopped using the
orthosis because of an increase in spasticity or pain.

16. CONCLUSIONS.
These pilot data suggest that a number of stroke patients
cannot tolerate a static orthosis over a long-term period
because of discomfort. 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.

17. .
Example of a prefabricated static hand-wrist orthosis

18. TITLE : TABLE-TOP EXERGAMING IMPROVES
ARM FUNCTION IN CHRONIC STROKE
AUTHOR :
1. Kimberlee Jordan
2. Michael Sampson
3. Marcus King

19. METHOD
Seven chronic stroke survivors (5 female) aged 59.4 –79.6 years completed
a 4 - 6 week upper limb training program using a table-supported
computer input device (the Able Reach) to play bespoke computer
games designed to encourage a large number of goal oriented arm
movements. Over the course of the intervention, participants received
between 9 (n = 4) and 16 (n = 3) hours of game play. On average, Fugl-
Meyer scores increased by 4.9 over the course of the
intervention, ranging up to 9 points. One participant gradually
deteriorated throughout the trial. These results suggest that the Able
Reach is a useful adjunct to regular physical therapy in a stroke
population

20. The Able Reach

21. CONCLUSION
Results provide evidence that the Able Reach in
conjunction with bespoke computer games can
significantly reduce upper limb impairment in chronic
stroke survivors, is well tolerated and found to be
motivating, useful and enjoyable. Future research
include a larger clinical trial to confirm these results as
well as automating the system so that it can be used
without direct supervision.

22. TITLE: COMBINING VIRTUAL REALITY AND A MYO-
ELECTRIC LIMB ORTHOSIS TO RESTORE ACTIVE
MOVEMENT AFTER STROKE: A PILOT STUDY
AUTHOR:
1. S Bermúdez i Badia
2. E Lewis
3. S Bleakley
JOURNAL , YEAR PUBLISHED
Proc. 9th Intl Conf. Disability, Virtual Reality & Associated
Technologies Laval, France, 10–12 Sept. 2012

23. METHOS
 A novel rehabilitation technology for upper limb rehabilitation
after stroke that combines a virtual reality training paradigm
with a myo-electric robotic limb orthosis.
 Rehabilitation system is based on clinical guidelines and is
designed to recruit specific motor networks to promote
neuronal reorganization.
 The main hypothesis is that the restoration of active
movement facilitates the full engagement of motor control
networks during motortraining.
 By using a robotic limb orthosis,the ablility to restore active
arm movement in severely affected stroke patients.
 In a pilot study, successfully deployed and evaluated
system with 3 chronic stroke patients by means of
behavioral data and self-report questionnaires.

24.  The results show that this system is able to restore up to
60% of the active movement capacity of patients.
 Further, it show that it can assess the specific contribution
of the biceps/triceps movement of the paretic arm to the
virtual reality bilateral training task.
 Questionnaire data show enjoyment and acceptance of the
proposed rehabilitation system and its VR training task.

25. Diagram of the proposed virtual reality and robotic limb orthosis training
paradigm showing the role of each technological component (numbered from 1
to 5).

26. 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.

27. TITLE : VIRTUAL REALITY FOR THE REHABILITATION OF THE
UPPER LIMB MOTOR FUNCTION AFTER STROKE: A
PROSPECTIVE CONTROLLED TRIAL
AUTHORS :
 Andrea Turolla
 Mauro Dam
 Laura Ventura
 Paolo Tonin1, Michela Agostini
 Carla Zucconi
 Pawel Kiper
 Annachiara Cagnin and
 Lamberto Piron

28. Key words: Stroke, Upper limb, Exercise therapy,
Virtual reality, Motor recovery, Treatment outcome
Journal: Journal of NeuroEngineering and
Rehabilitation
Year: 2013

29. OBJECTIVES:
To evaluate the effectiveness of non-immersive VR treatment for the
restoration of the upper limb motor function and its impact on the
activities of daily living capacities in post-stroke patients.
METHODS:
A pragmatic clinical trial of 376 subjects who had a motor arm
subscore on the Italian version of the National Institutes of Health
Stroke Scale (It-NIHSS) between 1 and 3 and without severe
neuropsychological impairments interfering with recovery. Patients
were allocated to two treatments groups, receiving combined VR
and upper limb conventional (ULC) therapy or ULC therapy alone.
The treatment programs consisted of 2 hours of daily
therapy, delivered 5 days per week, for 4 weeks.

30. Outcome Measures:
 Fugl-Meyer Upper Extremity (F-M UE) and
 Functional Independence Measure (FIM) scales.
Study design:
Cohort study

31. Group 1
• Virtual
Rehabilitation
• Upper limb
conventional
Therapy
Group 2
• Only Upper
limb
Conventional
Therapy

32. For 4 weeks
For 5
days/
week
2 hours

33. Results:
The improvement obtained with VR
rehabilitation was significantly greater than that achieved
with ULC therapy alone.
With F-M UE was 2.5 ± 0.5 (P < 0.001) and FIM scores
3.2 ± 1.2 (P = 0.007) respectively.
Conclusions:
VR rehabilitation in post-stroke patients seems more
effective than conventional interventions in restoring
upper limb motor impairments and motor related
functional abilities.
LOE:2b

34. represent: a) a simple reaching movement: the patient has to
raise the red glass and place it among the blue glasses on the
shelf, according to a pre-recorded path (yellow line); b) a complex
movement of increasing difficulty: the patient has to move the
blue ball through the orange circles. the green box represents the
start zone, while the yellow box represents the end zone to
reach, following the circular-like displayed path.

35. TITLE : SCAPULAR AND HUMERAL MOVEMENT
PATTERNS OF PEOPLE WITH STROKE DURING
RANGE-OF-MOTION EXERCISES
Authors:
Dustin D. Hardwick, PT, PhD, and Catherine E. Lang,
Journal: Journal of Neurological Physiotherapy 35: 18–25
Year:2011
KEY WORDS:
kinematics, rehabilitation, shoulder pain, stroke

36. PURPOSE:
Range-of-motion (ROM) exercises may contribute to hemiparetic
shoulder pain, but the underlying mechanisms are unknown. This
study examined scapular and humeral movement patterns in people
with poststroke hemiparesis as they performed commonly
prescribed ROM exercises.
OUTCOMES MEASURES:
 Stroke Impact Scale(Hand Function subscale)
 Numeric pain rating scale (0-10 points)
 Modified Ashworth scale.
STUDY DESIGN: Pilot study

37. Group 1
• 13 subjects with
hemiparesis
• Are given 3
types of ROM
exercises
Group 2
• 12 healthy
subjects
• Are given normal
shoulder
elevation
exercises

38. Group 1
• Person
assisted
• Self
assisted
Group 2
• Cane
assisted
• Normal
shoulder
elevation

39.  Where pain is assessed by pain rating scale
 And kinematic measurements by electro magnetic tracking system.
RESULTS:
Person assisted ROM exercises are found to be more effective than Self
assisted and cane assisted exercises.
CONCLUSION:
There appears to be little relationship between the severity of pain
experienced with exercise and the extent of movement abnormality.
LOE:4

40. TITLE: MIRROR THERAPY PROGRAM IN PATIENTS
WITH STROKE.
AUTHOR: Lee, Myung Mo; Cho, Hwi-young; Song, Chang Ho
JOURNAL: American Journal of Physical Medicine &
Rehabilitation.
YEAR: March 2012
OUTCOME MEASURES:
Fugl-Meyer Assessment
Brunnstrom stages for upper limb and hand
Manual Function Test

41.  PURPOSE: To evaluate the effects of the mirror therapy
program on upper-limb motor recovery and motor function in
patients with acute stroke
 STUDY DESIGN: Randomized control trail
 LOE:1c

42. Method : Assigned into 2 groups
Experimental group controlled group
13 participants 13 participants
Standard Rehab standard Rehab
only
Mirror Therapy for 25 min twice a day, 5 times a week, for 4
weeks.

43. RESULTS:
In upper-limb motor recovery, the scores of Fugl-
Meyer Assessment, Brunnstrom stages for upper limb
and hand and Manual Function Test scores were
improved more in the experimental group than in the
control group.
Whereas no significant differences were found
between the groups for the coordination items in
Fugl-Meyer Assessment.

44. TITLE:ENGAGE: GUIDED ACTIVITY-BASED GAMING IN
NEUROREHABILITATION AFTER STROKE
AUTHORS:
Ann Reinthal, Kathy Szirony, Cindy Clark, Jeffrey
Swiers, Michelle Kellicker and Susan Linder
JOURNAL:
Hindawi Publishing Corporation Stroke Research and
Treatment

45. YEAR: 2012
PURPOSE: to assess the feasibility and outcomes of a novel
video gaming repetitive practice paradigm, (ENGAGE)
enhanced neurorehabilitation guided activity-based gaming
exercise.
OUTCOME MEASURES:
 Wolf motor function test (WMFT)
 Fugl-Meyer assessment (FMA)
 Intrinsic Motivation Inventory
STUDY DESIGN: Pilot study

46. METHODS:
Playing Bubblepop on the PlayStation II with EyeToy

47.  It uses a game selection algorithm that provides focused, carefully
graded activity-based repetitive practice of cognitive-perceptual motor
tasks.
 It uses a limited number of gaming system platforms and games.
 It is guided by the neuromuscular rehabilitation clinician.
RESULT:
 The use of ENGAGE protocol was feasible in a clinical environment.
 There was a statistically significant improvement in upper extremity
function as measured by the upper extremity portion of the FMA and by
the WMFT, and participants were motivated to use this gaming protocol.
LOE:4

48. TITLE:THERAPY INCORPORATING A DYNAMIC WRIST-
HAND ORTHOSIS VERSUS MANUAL ASSISTANCE IN
CHRONIC STROKE
Author: Joni G. Barry, PT, DPT, NCS, Sandy A. Ross, PT, DPT,
MHS, PCS, and Judy Woehrle, PT, PhD, OCS
Journal: Journal of Neurological Physical therapy, Volume 36
Year: 2012
Keywords: arm, function, orthosis, recovery, rehabilitation, repetition,
stroke
Objectives: To compare the effect of therapy using a wrist-hand
orthosis (WHO) versus manual-assisted therapy (MAT) for
individuals with chronic, moderate-to-severe hemiparesis.

49. Outcome Measures:
 Action Research Arm Test (ARAT)
 Box and Blocks (B&B) test
 Stroke Impact Scale (SIS)
Study Design: A Pilot Study
METHODS:
Group 1: wrist-hand orthosis (WHO)-19 participants
Group 2: Manual-Assisted Therapy (MAT)-19 participants
 Both groups participated in 1 hour of therapy per week for 6 weeks and
were prescribed exercises to perform at home 4 days per week.
 Pre- and post training assessments were taken according to the scales
mentioned.

50. Dynamic wrist-hand orthosis (SaeboFlex).

51. Results:
 There were no significant between-group differences for any of the
measures.
 Within-group differences showed that theWHO group had a significant
improvement in the ARAT score (mean =2.2; P = 0.04).
 The MAT group had a significant improvement on the percent recovery on
the SIS (mean=9.3%; P=0.03)
Conclusion:
 Small improvements in function and perception of recovery were observed
in both groups, with no definite advantage of the WHO.
 Adds to the evidence that individuals with chronic stroke can improve arm
use with therapy incorporating functional hand training.
LOE:4

52. TITLE: EFFECTS OF ROBOT-ASSISTED THERAPY
ON UPPER LIMB RECOVERY AFTER
STROKE: A SYSTEMATIC REVIEW
AUTHOR :Gert Kwakkel, Boudewijn J. Kollen, and Hermano I.
Krebs
JOURNAL :Neurorehabil Neural Repair.
YEAR PUBLISHED: 2008
PURPOSE: To present a systematic review of studies that
investigates the effects of robot-assisted therapy on motor
and functional recovery in patients with stroke.

53. Summary of Review—A database of articles published up to
October 2006 was compiled using the following MEDLINE
key words: cerebral vascular accident, cerebral vascular
disorders, stroke, paresis, hemiplegia, upper extremity, arm
and robot.
 Studies that satisfied the following selection criteria were
included:
1) patients were diagnosed with cerebral vascular accident
2) effects of robot-assisted therapy for the upper limb were
investigated
3) the outcome was measured in terms of motor and/or
functional recovery of the upper paretic limb
 The study was a randomised clinical trial (RCT).

54.  For each outcome measure, the estimated effect size (ES) and the
summary effect size (SES) expressed in standard deviation units
(SDU) were calculated for motor recovery and functional ability (ADL)
using fixed and random effect models. Ten studies, involving 218
patients, were included in the synthesis.
 Their methodological quality ranged from 4 to 8 on a (maximum) 10
point scale.
 Meta-analysis showed a non-significant heterogeneous SES in terms
of upper limb motor recovery.
 Sensitivity analysis of studies involving only shoulder-elbow robotics
subsequently demonstrated a significant homogeneous SES for motor
recovery of the upper paretic limb.
 No significant SES was observed for functional ability (ADL).

55. CONCLUSION—
 No overall significant effect in favour of robot-assisted therapy was
found in the present 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 function.
 The administered ADL scales in the reviewed studies fail to
adequately reflect recovery of the paretic upper limb and valid
instruments that measure outcome of dexterity of the paretic arm
and hand are mostly absent in selected studies.
 Future research on the effects of robot-assisted therapy to
distinguish between upper and lower robotics arm training and
concentrate on kinematical analysis to differentiate between
genuine upper limb motor recovery and functional recovery due to
compensation strategies by proximal control of the trunk and upper
limb.

56.  Robotics has been defined as: ‘The application of electronic,
computerized control systems to mechanical devices
designed to perform human functions’. (PubMed [Medline],
MeSH database, 2005).

57. TITLE : CONCURRENT NEUROMECHANICAL AND
FUNCTIONAL GAINS
FOLLOWING UPPER-EXTREMITY POWER TRAINING
POST-STROKE
AUTHOR : Carolynn Patten, Elizabeth G Condliffe, Christine A
Dairaghi and Peter S Lum
JOURNAL : Journal of NeuroEngineering and Rehabilitation
2013,

58. PURPOSE :
 Investigated how power training (i.e., high-
intensity, dynamic resistance training) affects recovery of
upper-extremity motor function post-stroke.
 Hypothesized that power training, as a component of
upper-extremity rehabilitation, would promote greater
functional gains than functional task practice without
deleterious consequences.

59. METHOD:
 Nineteen chronic hemiparetic individuals using a crossover design.
 All participants received both functional task practice (FTP) and
HYBRID (combined FTP and power training) in random order.
 Blinded evaluations performed at baseline, following each intervention
block and 6-months post-intervention included:
1. Wolf Motor Function Test (WMFT-FAS, Primary Outcome)
2. Upper-extremity Fugl-Meyer Motor Assessment, AshworthScale and
3. Functional Independence Measure.
 Neuromechanical function was evaluated using isometric and dynamic
joint torques and concurrent agonist EMG. Biceps stretch reflex
responses were evaluated using passive elbow stretches ranging from
60 to 180º/s and determining: EMG onset position threshold, burst
duration, burst intensity and passive torque at each speed.

60.  RESULTS:
 Primary outcome: Improvements in WMFT-FAS were significantly greater following HYBRID vs.
FTP (p = .049), regardless of treatment order. These functional improvements were retained 6-
months post-intervention (p = .03).
 Secondary outcomes: A greater proportion of participants achieved minimally important
differences (MID) following
 HYBRID vs. FTP (p = .03). MIDs were retained 6-months post-intervention. Ashworth scores
were unchanged (p > .05).
 Increased maximal isometric joint torque, agonist EMG and peak power were significantly
greater following HYBRID
 vs. FTP (p < .05) and effects were retained 6-months post-intervention (p’s < .05). EMG position
threshold and burst
 duration were significantly reduced at fast speeds (≥120º/s) (p’s < 0.05) and passive torque was
reducedpost-washout (p < .05) following HYBRID.

61. CONCLUSIONS:
 Functional and neuromechanical gains were greater following
HYBRID vs. FPT. Improved stretch reflex modulation and
increased neuromuscular activation indicate potent neural
adaptations.
 Importantly, no deleterious consequences, including
exacerbation of spasticity or musculoskeletal complaints, were
associated with HYBRID.
 These results contribute to an evolving body of contemporary
evidence regarding the efficacy of high-intensity training in
neurorehabilitation and the physiological mechanisms that
mediate neural recovery.

63. TITLE: STRENGTH TRAINING IMPROVES UPPER-
LIMB FUNCTION IN
INDIVIDUALS WITH STROKE
AUTH0R : Jocelyn E. Harris; Janice J.
JOURNAL :
American Heart Association
YEAR PUBLISHED : 2009

64. PURPOSE
After stroke, maximal voluntary force is reduced in the arm
and hand muscles, and upper-limb strength training is 1
intervention with the potential to improve function.
METHODS
 a meta-analysis of randomized controlled trials.
 Electronic databases were searched from 1950 through
April 2009.
 Strength training articles were assessed according to
outcomes: strength, upper-limb function, and activities of
daily living.
 The standardized mean difference (SMD) was calculated
to estimate the pooled effect size with random-effect
models.

65. RESULTS
From the 650 trials identified, 13 were included in this
review, totaling 517 individuals. A positive outcome for
 strength training was found for grip strength
(SMD0.95, P0.04) and upper-limb function
(SMD0.21, P0.03). No
 treatment effect was found for strength training on measures
of activities of daily living. A significant effect for strength
 training on upper-limb function was found for studies
including subjects with moderate (SMD0.45, P0.03) and
mild
 (SMD0.26, P0.01) upper-limb motor impairment. No trials
reported adverse effects.
CONCLUSIONS
 There is evidence that strength training can improve upper-
limb strength and function without increasing