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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; 317(7153):273-276.
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