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Advances in Upper Extremity Treatment of Stroke Survivors

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					                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.
Winstein.

Selected References

1. Barraca S, Wolf SL, Fasoli S, Bohannon R. Treatment interventions for the paretic upper limb of
    stroke survivors: A critical review. Neurorehabil Neural Repair. 2003;17:220-226.
2. Liepert J, Bauder H, Wolfgang HR, et al. Treatment-induced cortical reorganization after stroke in
    humans. Stroke. 2000; 31:1210-1216.
3. Luft AR, McCombe-Waller S, Whitall J, et al. Repetitive bilateral arm training and motor cortex
    activation in chronic stroke: a randomized controlled trial. JAMA. 2004; 292:1853-1861.
4. Page SJ, Levine P, Leonard A, et al. Modified constraint-induced therapy in chronic stroke: results
    of a single-blinded randomized controlled trial. Phys Ther. 2008; 88:333–340.
5. Schaechter JD, Kraft E, Hilliard TS, et al. Motor recovery and cortical reorganization after
    constraint-induced movement therapy in stroke patients: a preliminary study. Neurorehabil Neural
    Repair. 2002; 16:326-338.
6. Taub E. Somatosensory deafferentation research with monkeys: implications for rehabilitation
    medicine. In: Ince L, ed. Behavioral Psychology in Rehabilitation Medicine: Clinical Applications.
    Baltimore, Md: Williams & Wilkins; 1980;371-401.
7. Taub E, Uswatte G, Elbert T. New treatments in neurorehabilitation founded on basic research. Nat
    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.
    2008; 7:33-40.
            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
rehabilitation.

Selected References

1. Bandura A. Self-efficacy: the exercise of control. New York: Freeman, 1997.
2. Behavior Change Consortium Summary Report, The art of collaboration. The Science of Change.
    September, 1999-September, 2003, www1.of.nih.gov/behaviorchange/summary.htm
3. Campbell M, Fitzpatrick R, Haines A, et al. Framework for design and evaluation of complex
    interventions to improve health. BMJ. 2000; 321(7262):694-696.
4. Haynes RB, Devereaux PJ, Guyatt GH. Physicians’ and patients’ choices in evidence based
    practice. BMJ. 2002; 324(7350): 1350.
5. Kaplon R., Prettyman M., Kushi C. Winstein CJ. Six hours in the laboratory? A quantification of
    practice time during Constraint-Induced Therapy (CIT): Clin Rehab. 2007; 21(10): 950-958.
6. Lang CE, Wagner JM, Edwards DF, Dromerick AW. Upper extremity use in people with
    hemiparesis in the first few weeks after stroke. J Neurol Phys Ther. 2007; 31(2):56-63.
7. 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(1):3-10.
8. Nudo RJ. Functional and structural plasticity in motor cortex: implications for stroke recovery. Phys
    Med Rehabil Clin N Am. 2003;14(1 Suppl):S57-76.
9. Whyte J. Training and retention of rehabilitation researchers: A white paper for research summit:
    Building research capacity. Am J. Phys Med Rehabil. 2005; 84(12): 969-75.
10. Winstein C, Pate P, Ge T, et al. The Physical Therapy Clinical Research Network (PTClinResNet):
    Methods, efficacy and benefits of a rehabilitation research network. Am J Phys Med Rehabil. 2008;
    87:in press.
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.
12. Winstein CJ, Wing AM, Whitall J. Motor control and learning principles for rehabilitation of upper
    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;
    296:2095-2104.
14. Wolf SL, Winstein CJ, Miller PJ, et al. Retention of upper limb function in stroke survivors who have
    received constraint-induced movement therapy: the EXCITE randomized trial. Lancet Neurology.
    2008; 7(1): 33-40.
15. World Health Organization. International Classification of Functioning, Disability and Health.
    Geneva, World Health Organization, 2001.
                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.

Selected References

1. Ada L, Dean CM, Hall JM, et al. A treadmill and overground walking program improves walking in
   persons residing in the community after stroke: a placebo-controlled, randomized trial. Arch Phys
   Med Rehabil. 2003; 84(10):1486-91.
2. Dean CM, Richards CL, Malouin F. Task-related circuit training improves performance of locomotor
   tasks in chronic stroke: A randomized, controlled pilot trial. Arch Phys Med Rehabil. 2000;
   81(4):409-17.
3. Foley NT, Teasell R, Bhogal S. Evidence-Based Review of Stroke Rehabilitation: Mobility and the
   lower       extremity.      Canadian       Stroke     Network;     2007:1-105.     Web        access:
   http://www.ebrsr.com/modules/module9.pdf .
4. Stinear CM, Barber PA, Smale PA, et al. Functional potential in chronic stroke patients depends on
   corticospinal tract integrity. Brain. 2007;130(Pt 1):170-80.
5. Studenski S, Duncan PW, Perera S, Reker D, Lai SM, Richards L. Daily functioning and quality of
   life in a randomized controlled trial of therapeutic exercise for subacute stroke survivors. Stroke.
   2005; 36:1764-1770.
6. Sullivan KJ, Brown DA, Klassen T, et al. STEPS Research Team, Physical Therapy Clinical
   Research Network (PTClinResNet). Effects of task-specific locomotor and strength training in
   ambulatory stroke survivors: Results of the STEPS randomized clinical trial. Phys Ther. 2007;
   87(12):1580-1602.
7. Sullivan KJ. Therapy interventions for mobility impairments and motor skill acquisition after TBI. In:
   Zasler ND, Katz DI, Zafonte RD, eds. Brain Injury Medicine: Principles and Practice. New York:
   Demos Publishing, 2007; 929-946.
8. 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(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;
   296(17): 2095-2104.
           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.

Selected References

1. Bello-Haas VD. A framework for rehabilitation for neurodegenerative diseases. Managing
    progression and maximizing quality of life. Neurol Report 2002; 26:115-129
2. Echternach, JL, Rothstein JM. Hypothesis-oriented algorithms. Phys Ther. 1989; 69:559-64
3. Jette AM. Toward a common language for function, disability, and health. Phys Ther 2006; 86:726-
    734.
4. Nagi S. Some conceptual Issues in disability and rehabilitation. In: Sussman M, ed. Sociology and
    Rehabilitation. Washington DC: American Sociological Association, 1965;100-113.
5. Rothstein JM, Riddle DL. Echternach JL. The Hypothesis-Oriented Algorithm for Clinicians II
    (HOAC II): A guide for patient management. Phys Ther. 2003; 83:455-70.
6. Schenkman M, Bliss S, Day L, et al. A model for management of patients with neurological
    dysfunction: Update and case analysis. Neurol Report, 1999; 23:145-157.
7. Schenkman M, Butler RB. A model for evaluation, interpretation, and treatment of individuals with
    Parkinson's disease. Phys Ther. 69:932-943, 1989.
8. Schenkman M, Donovan J, Tsubota J, Kluss M, Stebbins P, Butler RB. Management of individuals
    with Parkinson's disease - Rationale and case studies. Phys Ther. 1989; 69:944-955.
9. Schenkman M, Deutsch J, Gill-Body K. An Integrated Framework for Decision Making in
    Neurological Physical Therapy Practice. Phys Ther 2006; 86;1681-1702
10. Schenkman M, Morey M, Kuchibhatla M. Spinal flexibility and physical performance of community-
    dwelling adults with and without Parkinson’s disease. J Gerontol MS. 2000; 55:M441-445.
11. Schenkman M, Shipp KM, Chandler J, Kuchibhatla M, Pieper C. Relationships between mobility of
    axial structures and physical performance. Phys Ther. 1996; 76:276-285
12. World Health Organization. International Classification of Impairments, Disabilities, and Handicaps:
    A manual of Classification Relating to the Consequences of Disease. Geneva, Switzerland: World
    Health Organization; 1980.
13. Verbrugge LM, Jette AM. The disablement process. Soc Sci Med. 1994; 38,1-14
             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.


Selected References

1. de Goede CJ, Keus SH, Kwakkel G, Wagenaar RC. The effects of physical therapy in Parkinson's
    disease: a research synthesis. Arch Phys Med Rehabil. 2001; 82(4):509-515.
2. Dibble LE, Hale TF, Marcus RL, Droge J, Gerber JP, LaStayo PC. High-intensity resistance
    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
    2008.
5. Goodwin VA, Richards SH, Taylor RS, Taylor AH, Campbell JL. The effectiveness of exercise
    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.
8. Lorig KR, Sobel DS, Ritter PL, Laurent D, Hobbs M. Effect of a self-management program on
    patients with chronic disease. Eff Clin Pract. 2001;4(6):256-262.
9. Morris ME. Movement disorders in people with Parkinson disease: a model for physical therapy.
    Phys Ther. 2000;80(6):578-597.
10. Morris ME. Locomotor training in people with Parkinson disease. Phys Ther. 2006; 86(10):1426-
    1435.
11. Nieuwboer A, Kwakkel G, Rochester L, et al. Cueing training in the home improves gait-related
    mobility in Parkinson's disease: the RESCUE trial. J Neurol Neurosurg Psychiatry. 2007;
    78(2):134-140.
12. Schenkman M, Hall D, Kumar R, Kohrt WM. Endurance exercise training to improve economy of
    movement of people with Parkinson disease: three case reports. Phys Ther. 2008; 88(1):63-76.
13. Schenkman M, Cutson TM, Kuchibhatla M, et al. Exercise to improve spinal flexibility and function
    for people with Parkinson's disease: a randomized, controlled trial. J Am Geriatr Soc. 1998;
    46(10):1207-1216.
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.
15. Thacker EL, Chen H, Patel AV, et al. Recreational physical activity and risk of Parkinson's disease.
    Mov Disord. 2008;23(1):69-74.
16. Tillerson JL, Caudle WM, Reveron ME, Miller GW. Exercise induces behavioral recovery and
    attenuates neurochemical deficits in rodent models of Parkinson's disease. Neuroscience. 2003;
    19(3):899-911.
           Opportunities and Challenges for Implementation of Evidence-based
                                   Neurorehabilitation


                        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.


Selected References

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.
7. Journal of Rehabilitation Research and Development. 2008; 45: vii-ix, 205-344.
     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
        hemiparetic stroke.
     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
        robotics.
8. Graham I, Logan, J, Harrison M, et al: Lost in knowledge translation: Time for a map? J Continuing
    Educ Health Prof. 2006; 26:13-24.
9. Bodenheimer T. Coordinating care – a perilous journey through the health care system. NEJM.
    2008; 358:1064-1071.
10. Haynes B, Haines A. Barriers and bridges to evidence based clinical practice. BMJ. 1998;
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