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  2. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 17. . Example of a prefabricated static hand-wrist orthosis
  18. 18. TITLE : TABLE-TOP EXERGAMING IMPROVES ARM FUNCTION IN CHRONIC STROKE AUTHOR : 1. Kimberlee Jordan 2. Michael Sampson 3. Marcus King
  19. 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. 20. The Able Reach
  21. 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. 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. 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. 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. 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. 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. 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. 28. Key words: Stroke, Upper limb, Exercise therapy, Virtual reality, Motor recovery, Treatment outcome Journal: Journal of NeuroEngineering and Rehabilitation Year: 2013
  29. 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. 30. Outcome Measures:  Fugl-Meyer Upper Extremity (F-M UE) and  Functional Independence Measure (FIM) scales. Study design: Cohort study
  31. 31. Group 1 • Virtual Rehabilitation • Upper limb conventional Therapy Group 2 • Only Upper limb Conventional Therapy
  32. 32. For 4 weeks For 5 days/ week 2 hours
  33. 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. 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. 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. 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. 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. 38. Group 1 • Person assisted • Self assisted Group 2 • Cane assisted • Normal shoulder elevation
  39. 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. 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. 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. 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. 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. 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. 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. 46. METHODS: Playing Bubblepop on the PlayStation II with EyeToy
  47. 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. 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. 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. 50. Dynamic wrist-hand orthosis (SaeboFlex).
  51. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 63. 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.
  64. 64. 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