Guest Speak at 3rd Annual national conference of Indian Federation of Neurorehabilitation (IFNRCON 2015) at Mumbai by Phinoj K. Abraham, Neuro Occupational Therapy on "Post Stroke Upper Extremity rehabilitation - A Clinical Perspective" For Video: http://youtu.be/uCnwdzLtPSQ

1. Post-Stroke Upper Extremity
Rehabilitation –
A Clinical Perspective
Phinoj K. Abraham,
MOTh., (Neuro-Occupational Therapist)
NewRo, Bengaluru

2. Learning Objectives
To share some views and experience of
What to do?
How to do?
in post stroke upper extremity Rehabilitation from
an OccupationalTherapy Perspective
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3. What to do first?
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4. What to do?
‘Diagnosis specific’
&
‘Prognosis Oriented’
Evidence based
treatment planning
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5. A) Diagnosis Specificity
• Therapy planning SHOULD be based on the
precise diagnosis of Stroke
– Ex:
A 28 year old male civil engineer with left hemiparesis
C/c : Difficulty in eating in ‘buffet’ system
Brunnstrom's recovery Stage for Hand : Stage 6/7
Power : ~ 4+/5
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6. Diagnosis Specificity Contd…
• ‘Activity Analysis’ showed
– Inability to maintain the plate steadily (horizontally) in his
left hand especially while serving dishes / while talking to
others.At the same time he can describe what is the
‘correct’ way of holding
• Why?
– Right MCA territory Infarct
– Involvement of Rt. Parietal Lobe
‘Perceptual – Motor’ aspect is usually a neglected domain in
early post stroke U/E rehab
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7. Need of Diagnosis specificity in
treatment planning…
• An infarct at ganglio-capsular region usually produce
‘Plastic Rigidity’. (Paul Kaplan,1940) This will be helpful to
train the U/E to be a ‘supportive hand’.
• The probability of recovery of isolated UE movement
decreases progressively with lesion location as
follows:cortex, corona radiata, and Post. Limb of
Internal Capsule (Shelton and Reding- 2001)
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8. B) Prognosis Oriented
• Why?
“You must always be able to predict what's next
and then have the ‘flexibility to evolve’.”
Marc Benioff
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9. B) Prognosis Oriented Contd…
• How?  based on
• Area and/or type of brain damage 1
» Patients with anterior circulation infarcts, right
hemispheric strokes, visual gaze deficits etc… were
associated with poor arm function.
• Initial degree of motor Impairment2
» Severe paresis vs. mild paresis
» Active finger extension & shoulder abduction
• Other factors
» Time of initial ‘Medical Intervention’
» Presence / absence of cognitive impairment 1) EBRSR,2013
2) EBRSR,,2014,

10. 1) EBRSR, 4,Rehab of hemiplegic U/E, 2014
2) EBRSR, 10, Upper extremity Interventions, 2013
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Group 1 Group 2 Group 3
Functional
Hand
Supportive Hand
Non functional
Hand
Complete to
'functionally
adequate'
Recovery
Partial Recovery,
predominantly in the
proximal upper extremity.
Functionally, weight bearing
& gross grasp/lift can be
possible
Poor recovery
14% - 38%1,2 30%1,2 - 50% --
Remediating
Intervention
Remediating and
Compensatory
Intervention
Compensatory
Interventions and
interventions to
prevent 20
Complication.

11. How to do it?
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12. Overview
• Interventions for Group 1
• Interventions for Group 2
• Interventions for Group 3
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13. Intervention for Group 1
• It’s a continuous process with considerable
overlap between each step
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1111 2222 3333 4444 5555 66aa66aa 66bb66bb 66cc66ccStep

14. Intervention For Group 1
–
• Deficits like,
– Diplopia, Photosensitivity, hemianopia etc…
– Neglect, Visual Inattention etc…
– Emotional Lability, attention deficits etc…
Step – 1 : Understand / Management of 'Key'Visual,
Perceptual and cognitive Deficits to make the patient
'Ready' for rehabilitation
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15. Intervention For Group 1 Contd…
Step 2 : Eye- Head - Trunk CoordinationTraining : to
locate a target in space (Visual Regard)
Conventional Method
• Training the different control
system separately
Contemporary Methods
• Virtual Reality
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16. Intervention For Group 1 Contd…
Two key challenges at this phase are
– Effect of Gravity
– Weight of the upper extremity on relatively
unstable shoulder joint
Step-3 : Training for Reach
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17. Upper Extremity Un-weighing
System (UEUS)
• Highlights
– Offer partial to complete
Un-weighing of U/E
– Simple & Affordable
– Virtual Reality Compatible
• Limitations
– Allows only 2D Movements.
– Graded Un-weighing is not
present
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Coscia et al. Journal of Neuro Engineering and Rehabilitation 2014, 11:22

18. UEUS - Components
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19. UEUS & Virtual Reality - Video
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20. Step 3 Contd…
Reach against gravity
Key Challenge here is the smooth, graded transition
of reach movement from eliminated gravity to
against gravity
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21. ‘Hydraulic’ cut-out table with
‘Flip-Up’ top
Highlights
• Flip-up table top with
graded adjustment(0-700)
• Hydraulic height
adjustment mechanism
• Cut-out top
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22. How does it work?
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23. Intervention For Group 1 Contd…
• Synergy patterns can be reversed if movement
takes place in the weaker synergy first
Ref: Chedoke McMaster Stroke Impairment Inventory : Stage 4
Step 4 : Training for Grasp Release
(Extension of fingers and thumb)
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24. Intervention For Group 1 Contd…
• Initially starts with Gross grasp
• Incorporated with ‘Meaningful activities’
• In a meaningful ‘Context’ (i.e.,Task Oriented)
– Eg: holding a glass of water
Step 5 : Training for Grasp (Flexion of fingers and
thumb)
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25. Intervention For Group 1 Contd…
Key Consideration:
 Occupational Performance
Step – 6a : Training for Hand Manipulation Skills
ADLADL
LeisureLeisureWorkWork
Environment
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(One’s ability to carry out ROLES
and ROUTINES efficiently)

26. Therapy through ‘Occupation’
Job specific training (Work) Task specific training (ADL)
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27. Therapy through ‘Occupation’
Leisure
Diagnosis Specific
PrevocationalTraining
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28. Intervention For Group 1 Contd…
• Most of the ADL (Activities of Daily Living)
• Eye-Hand Coordination is a ‘key’ here
Step – 6b : Bilateral hand coordination training
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29. Intervention For Group 1 Contd…
The fruitfulness of rehabilitation lies when the learning
at ‘ideal’ environment transforms to the ‘real’
environment
Transfer of Learning
– To ADL
– ToWork
– To Lesiure
Step – 6c : Transfer of learning
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30. Intervention For Group 1 Contd…
PrevocationalTraining Unit
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31. Intervention For Group 1 Contd…
Kitchen & Homemaking skills Simulation Unit
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32. 6c. Transfer of learning
Hand Function with Different
Types / levels of Reach
Homemaking Skills
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33. Overview
• Interventions for Group 1
• Interventions for Group 2
• Interventions for Group 3
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34. Interventions for Group 2
• For the Affected Hand
– Step 1-3 are same
– Training for sustained gross grasp (at least ½
range of digit flexion)
– Independent weight bearing on affected hand
– Technology /equipments like SaeboFlex™
• For the Un-affected Hand
– Compensatory strategy training like ‘one handed
techniques for dressing’
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35. Overview
• Interventions for Group 1
• Interventions for Group 2
• Interventions for Group 3
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36. Interventions for Group 3
Flaccid Hand
For the affected Hand:
• To prevent secondary
complication like T/C/D’s
• ‘Shoulder subluxation’
management
• Teaching Proper handling
techniques of affected U/E
• Prescription of sling, if
required
Hypertonic hand
For the affected Hand
• To prevent secondary
complication like T/C/Ds,
• To ease ADL activities &
maintain hygiene
• Teach routine passive range
of motion exercises
• Some PROM exercises
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Compensatory techniques to un-affected hand

37. Take Home Message
• Post-stroke U/E rehabilitation should be based on
diagnosis specific and prognostic oriented treatment
planning
• The focus of the therapy SHOULD be on functional
Independence NOT confined to reach, grasp release
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38. Key References
• Stroke Rehabilitation Clinician Handbook 2014; Chapter 4. Motor
Rehabilitation; Section 4b. Rehab of Hemiplegic Upper Extremity Post
Stroke by RobertTeasell and Norhayati Hussein | www.ebrsr.com
• EBRSR (Evidence-Based Review of Stroke Rehabilitation) 2013, Module10,
Upper Extremity Interventions by Norine Foley et al | www.ebrsr.com
• ‘Rehabilitation of stroke’ by Paul E Kaplan and Rene Cailliet- Butterworth
Heinemann publication
• Effect of Lesion Location on Upper Limb Motor Recovery After Stroke by
Fátima de N.A.P. Shelton, MD; Michael J. Reding, MD (Stroke. 2001;32:107-
112.) http://stroke.ahajo1u0r7nals.org
• The effect of arm weight support on upper limb muscle synergies during
reaching movements by Coscia et al. Journal of NeuroEngineering and
Rehabilitation 2014, 11:22
http://www.jneuroengrehab.com/content/11/1/22
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39. Acknowledgement
My sincere gratitude to the directors of NewRo,®
my colleagues and friends for their support
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40. The Art & Science of Empowering Lives…
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41. About the Speaker
• Mr. Phinoj K. Abraham has done his Bachelor of occupational
therapy from KMCH college of OccupationalTherapy, Coimbatore
and his Master of OccupationalTherapy (MOTh) in Neurosciences
from ‘All India Institute of Physical Medicine and Rehabilitation’
(AIIPMR),Mumbai
• He is currently working as Chief Neuro OccupationalTherapist at at
NewRo, Bengaluru, India.
• He was working as Asst. Professor in OccupationalTherapy at SRM
College of Occupational Therapy, Chennai.
• He has designed several therapy gadgets and devices like Upper
Extremity Un-weighing System (UEUS), Hemiplegic Upper Extremity
Orthosis (HUEO), Hydraulic cut-out table with flip up top,
prevocational evaluation and workstation etc..
• Contact Email: phinojot@gmail.com
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