Advances in Upper Extremity Treatment of Stroke Survivors:
Implications for Motor Neurorehabilitation
Steven L. Wolf, PT, PhD, FAPTA, FAHA
During the past 20 years, considerable evidence has been gathered to suggest that physiotherapeutic
interventions which emphasize various forms of repetitive task practice can produce substantial
improvements in both impairments and function if the intervention is directed toward the upper
extremities of patients who have sustained first time strokes that can also be characterized as mild to
moderate. Much of this effort has used unimanual training in the form of forced use or constraint
induced movement therapy. Other efforts have explored the value of limb strengthening and bimanual
task practice. Even more contemporary approaches are exploring the application of robotics, virtual
environment and combined movement with electrical stimulation. The primary purposes of this
presentation are to provide a brief review of the historical basis of constraint induced movement
therapy, while providing evidence to support its effectiveness, introduce tools to examine its underlying
mechanisms, and provide perspective on its limitations. The success in applying this and other new
approaches requires better patient involvement and empowerment. These important considerations
should be included in our treatment methodologies and will be addressed in next presentation by Dr.
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stroke survivors: A critical review. Neurorehabil Neural Repair. 2003;17:220-226.
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activation in chronic stroke: a randomized controlled trial. JAMA. 2004; 292:1853-1861.
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of a single-blinded randomized controlled trial. Phys Ther. 2008; 88:333–340.
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constraint-induced movement therapy in stroke patients: a preliminary study. Neurorehabil Neural
Repair. 2002; 16:326-338.
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Rev Neurosci. 2002; 3:228-236.
8. Winstein CJ, Miller JP, Blanton S, et al. Methods for a multi-site randomized trial to investigate the
effect of constraint-induced movement therapy in improving upper extremity function among adults
recovering from a cerebrovascular stroke. Neurorehabil Neural Repair. 2003;17:137-52.
9. Winstein CJ, Rose DK, Tan SM, et al. A randomized controlled comparison of upper- extremity
rehabilitation strategies in acute stroke: a pilot study of immediate and long-term outcomes. Arch
Phys Med Rehabil. 2004; 85:620–628.
10. Wolf SL, Catlin PA, Ellis M, et al. Assessing the Wolf motor function test as an outcome measure
for research with patients post-stroke. Stroke. 2001; 32:1635-39.
11. Wolf SL, Blanton S, Baer H, Breshears J, Butler AJ. The emergence of repetitive task practice in
upper extremity neurorehabilitation of patients with stroke: A critical review of constraint induced
movement therapy and mechanisms related to TMS, Neurologist. 2002; 8:325-338.
12. Wolf SL, Butler AJ, Alberts J, Kim M-W. Contemporary linkages between EMG, kinetics and stroke
rehabilitation. JEMG and Kinesiol. 2005; 15:229-239.
13. Wolf SL, Winstein C, Miller JP, Taub E, Uswatte G, Morris D, Giuliani C, Light K, Nichols-Larsen D,
for the EXCITE investigators. Improving Upper extremity function among patients 3-9 months post-
stroke: The EXCITE national randomized clinical trial. JAMA. 2006; 296:2095-2104.
14. Wolf SL. Constraint-Induced Movement Therapy: Are we too smitten with the mitten, is all non-use
learned and other quandaries. Phys Ther. 2007; 87:1212-1223.
15. Wolf SL, Winstein C, Miller JP, et al. Retention of upper limb function in stroke survivors who have
received constraint-induced movement therapy: The EXCITE randomized trial. Lancet Neurology.
Social Cognitive Neuroscience: Implications for Neurorehabilitation
Carolee J. Winstein, PT, PhD, FAPTA
Considerable effort has been directed toward the development of innovative approaches to capitalize
on the plastic adaptive properties of the adult brain and to modify the recovery trajectory post-stroke
(Nudo, 2003). In particular, task-oriented training has emerged as the dominant approach to motor
restoration after stroke. This presentation describes the implementation of the Accelerated Skill
Acquisition Program, a newly developed and complex intervention to promote upper extremity recovery
after stroke that is theoretically defensible, evidence-based and patient-centered. We propose that skill
(motor learning and self-management), capacity (impairment mitigation), and motivation (intrinsic
drive), when used together, form the foundation for effective incorporation of the paretic upper extremity
into life activities. Using the International Classification of Functioning and Disability (WHO, 2001) as a
framework, we use video clips to illustrate how task-specific practice (motor learning), impairment
mitigation (strength, motor control) and motivational enhancements (self-efficacy and participation) can
be harnessed to promote upper extremity recovery during the immediate post-acute phase of
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practice time during Constraint-Induced Therapy (CIT): Clin Rehab. 2007; 21(10): 950-958.
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hemiparesis in the first few weeks after stroke. J Neurol Phys Ther. 2007; 31(2):56-63.
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therapy for people with hemiparesis post-stroke. J Neurol Phys Ther. 2007; 31(1):3-10.
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11. Winstein CJ, Miller JP, Blanton S, et al. Methods for a multi-site randomized trial to investigate the
effect of constraint-induced movement therapy in improving upper extremity function among adults
recovering from a cerebrovascular stroke. Neurorehab Neural Repair. 2003; 17:137-152.
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limb movements after brain injury. In: Boller F, Grafman J, eds. Handbook of Neuropsychology. Vol
9. 2ed. Amsterdam: Elsevier Science B.V.; 2003:77-137.
13. Wolf SL, Winstein CJ, Miller JP, et al. Effect of constraint induced movement therapy on upper
extremity function 3-9 months after stroke: The EXCITE randomized clinical trial. JAMA, 2006;
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received constraint-induced movement therapy: the EXCITE randomized trial. Lancet Neurology.
2008; 7(1): 33-40.
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Innovations in Neurorehabilitation for Patients with Stroke:
Application of Neuroscience & Therapeutic Principles to Clinical Practice
Katherine J. Sullivan, PT, PhD, FAHA
Recent advance in neuroscience consistently demonstrate that the brain has the remarkable capability
to adapt and change over the course of ones life or after brain injury. Activity-dependent neuroplasticity
is the adaptation that occurs in the brain as an individual learns new motor skills or relearns previously
acquired movements that may have been impaired after brain injury such as stroke. What would
innovations in physical therapy look like if interventions were based on these scientific findings? The
session will focus on direct application of neuroscience and therapeutic principles into clinical practice
with examples of clinical interventions that are specifically designed to drive changes in the nervous
system in adults after stroke. Video cases will be presented to illustrate examples of task-specific
training intervention strategies to promoter upper limb function and walking recovery after stroke.
Discussion will include the evidence for stroke recovery as it is impacted by neurorehabilitation and the
challenges of being an evidence-based clinician in today’s healthcare system.
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corticospinal tract integrity. Brain. 2007;130(Pt 1):170-80.
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life in a randomized controlled trial of therapeutic exercise for subacute stroke survivors. Stroke.
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Phys Med Rehabil. 2004; 85(4):620-8.
9. Wolf SL, Winstein CJ, Miller JP, et al. Effect of constraint-induced movement therapy on upper
extremity function 3 to 9 months after stroke: the EXCITE randomized clinical trial. JAMA. 2006;
An Integrated Framework for Decision making in Neurorehabilitation:
Examples from Parkinson’s Disease
Margaret Schenkman, PT, PhD, FAPTA
Decisions regarding intervention for specific individuals with neurological disorders are likely to be most
effective if they are based on a combination of best evidence and sound clinical reasoning. Clinical
reasoning, in turn, is enhanced by using a systematic process of integrating all of the relevant factors
including patient specific issues as well as best evidence. In this session, strategies will be presented
for reasoning that are based on published models and frameworks. An integrated framework is used to
structure the discussion. Specific areas of the framework will be emphasized including the following: 1)
patient centered care, 2) incorporation of both enablement and disablement perspectives; 3)
incorporation of prognosis in setting goals; 4) use of evidence in determining the plan of care. Patient
examples will be used to focus the discussion.
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progression and maximizing quality of life. Neurol Report 2002; 26:115-129
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Rehabilitation. Washington DC: American Sociological Association, 1965;100-113.
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Neurological Physical Therapy Practice. Phys Ther 2006; 86;1681-1702
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dwelling adults with and without Parkinson’s disease. J Gerontol MS. 2000; 55:M441-445.
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Efficacy of Physical Therapy in Patients with Parkinson’s Disease:
Rationale for Recovery
Terry Ellis, PT, PhD, NCS
There is a growing body of research supporting the benefits of rehabilitation for people with Parkinson’s
disease. Although Parkinson’s disease is a chronic, progressive, degenerative disease, the results of
several meta-analyses reveal improvements in daily function and quality of life following participation in
an exercise program. How do we explain the benefits of rehabilitation in the context of a progressive,
degenerative disease? There is accumulating evidence which suggests that task specific training,
cueing strategies, strengthening, stretching and fitness training contribute to enhanced function. In
addition, recent studies using animal models of Parkinsonism suggest a potential neuroprotective effect
of exercise. Preliminary results of prospective epidemiological studies suggest that physical activity
may decrease the risk of Parkinson’s disease. This session will synthesize the literature supporting the
benefits of rehabilitation for people with Parkinson’s disease and suggest potential mechanisms which
underlie these benefits. Implications for current clinical practice will be discussed.
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disease: a research synthesis. Arch Phys Med Rehabil. 2001; 82(4):509-515.
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training amplifies muscle hypertrophy and functional gains in persons with Parkinson's disease.
Mov Disord. 2006; 21(9):1444-1452.
3. Ellis T, de Goede CJ, Feldman RG, Wolters EC, Kwakkel G, Wagenaar RC. Efficacy of a physical
therapy program in patients with Parkinson's disease: a randomized controlled trial. Arch Phys Med
Rehabil. 2005; 86(4):626-632.
4. Ellis T, Katz DI, White DK, Depiero TJ, Hohler AD, Saint-Hilaire M. Effectiveness of an Inpatient
Multidisciplinary Rehabilitation Program for People With Parkinson Disease. Phys Ther. Apr 24
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interventions for people with Parkinson's disease: a systematic review and meta-analysis. Mov
Disord. 2008; 23(5):631-640.
6. Keus SH, Bloem BR, Hendriks EJ, Bredero-Cohen AB, Munneke M. Evidence-based analysis of
physical therapy in Parkinson's disease with recommendations for practice and research. Mov
Disord. 2007; 22(4):451-460; quiz 600.
7. Lim I, van Wegen E, de Goede C, et al. Effects of external rhythmical cueing on gait in patients
with Parkinson's disease: a systematic review. Clin Rehabil. 2005; 19(7):695-713.
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patients with chronic disease. Eff Clin Pract. 2001;4(6):256-262.
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mobility in Parkinson's disease: the RESCUE trial. J Neurol Neurosurg Psychiatry. 2007;
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movement of people with Parkinson disease: three case reports. Phys Ther. 2008; 88(1):63-76.
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for people with Parkinson's disease: a randomized, controlled trial. J Am Geriatr Soc. 1998;
14. Smith AD, Zigmond MJ. Can the brain be protected through exercise? Lessons from an animal
model of parkinsonism. Exp Neurol. 2003;184(1):31-39.
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Mov Disord. 2008;23(1):69-74.
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attenuates neurochemical deficits in rodent models of Parkinson's disease. Neuroscience. 2003;
Opportunities and Challenges for Implementation of Evidence-based
Pamela Woods Duncan, PT, PhD, FAPTA, FAHA
Implementing evidence based models of stroke care into routine clinical care is complex. Interventions
to improve walking recovery post stroke will be used to highlight the opportunities and the challenges to
implementing evidence based programs into clinical care. A synthesis of existing evidence for walking
recovery programs will be used to demonstrate methods to guide best practice. Patient, clinician, and
health systems factors that influence implementation of best practices for walking recovery will be
reviewed. Finally, specific recommendations will be made to increase the probability of translating
evidence base programs across the continuum of care from hospital to home.
1. Eng, JJ, Tang PF. Gait training strategies to optimize walking ability in people with stroke: a
synthesis of the evidence. Expert Rev Neurother. 2007; 7(10):1417-36.
2. Duncan P, Studenski S, Richards L, et al. Randomized clinical trial of therapeutic exercise in
subacute stroke. Stroke. 2003; 34(9):2173–80.
3. Duncan PW, Sullivan KJ, Behrman AL, et al. Protocol for the Locomotor Experience Applied Post-
stroke (LEAPS) trial: a randomized controlled trial. BMC Neurol. 2007;7:39.
4. Schmid A, Duncan PW, Studenski S, et al. Improvements in speed-based gait classifications are
meaningful. Stroke. 2007; 38(7):2096-100.
5. Lang CE, MacDonald JR, Gnip C: Counting repetitions: An observational study of outpatient
therapy for people with hemiparesis post-stroke. J Neurol Phys Ther 2007; 31:3-10.
6. Sullivan KJ, Brown DA, Klassen T, et al. Physical Therapy Clinical Research Network
(PTClinResNet). Effects of task-specific locomotor and strength training in adults who were
ambulatory after stroke: Results of the STEPS randomized clinical trial. Phys Ther. 2007;
87(12):1580-602; discussion 1603-7.
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Macko RF. Hidler J. Guest editorial. Exercise after stroke and spinal cord injury: Common
biological mechanisms and physiological targets of training.
Forrester LW, Wheaton LA, Luff AR. Exercise-mediated locomotor recovery and lower-limb
neuroplasticity after stroke.
Patterson SL, Rodgers MM, Macko RF, Forrester LW. Effect of treadmill exercise training on
spatial and temporal gait parameters in subjects with chronic stroke: A preliminary report.
Ivey FM, Hafer-Macko CE, Macko RF. Task-oriented treadmill exercise training in chronic
Eng JJ, Pang MYC, Ashe MC. Balance, falls, and bone health: Role of exercise in reducing
fracture risk after stroke
Rimmer JH, Wang E, Smith D. Barriers associated with exercise and community access for
individuals with stroke.
Macko RF, Benvenuti F, Stanhope S, et al. Adaptive physical activity improves mobility
function and quality of life in chronic hemiparesis.
Stuart M, Chard S, Roettger S. Exercise for chronic stroke survivors: A policy perspective.
Hidler J, Hamm LF, Lichy A, Groah SL. Automating activity-based interventions: The role of
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