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Hemiparesis

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This document outlines research on physical therapy treatments for upper limb hemiparesis following stroke. It discusses bimanual task research which found that such tasks can increase functional use of the paretic arm by providing feedback to the central nervous system. Mirror therapy research is also summarized, finding that having patients watch movements of their unaffected limb can improve outcomes like function and sensation more than conventional therapy alone. The document provides guidance on evaluating the quality of research studies.

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Hemiparesis Research in Physical Therapy Treatment of the Upper Limb Chris Keating SPT Thomas Jefferson University
Outline Research Good or Bad Bimanual Task Research Benefits PT Implications Mirror Therapy Research Benefits PT Implications
Reading Research Don’t read the entire article from cover to cover Invest time wisely to make sure its worth your time Abstract---Introduction---Methods---Results---Discussion---Data Analysis Read one section then decide whether to continue reading
Evaluating Research See Attachment Is the problem clearly stated? Is the problem probable based on the author’s review of the literature? Were inclusion and exclusion criteria specified? How many independent variables were examined, and how many levels do they have? Have the authors documented the reliability and validity of the instruments? Are operational definitions supplied for all independent and dependent variables? Are the results statistically significant? Regardless of the statistical outcome, are the results clinically important? Is the evidence strong enough to suggest a change in clinical practice?
Bimanual Task Only 20% of patients with a flaccid upper limb after 2 weeks recover functional use Research has taken place to explore the use of bimanual task therapy in order to increase the functional use of the paretic arm Where do you start your search for the best research in order to provide the best care?
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Cochrane Review Searched the Cochrane Database of Systematic Reviews Key words crossed Stroke Bimanual Found 1 article protocol Provided SRL blue print for aspiring researcher to develop and execute (not useful) Provided background on the current evidence available (useful)
Cochrane Review A small number of randomized controlled trials of bilateral training have been published, which appear to have inconsistent results investigations of the impact of bilateral training on neural mechanisms provide equivocal results In order to determine the effects of bilateral training compared to no treatment, placebo or other interventions for improving arm function after stroke, a systematic review of the relevant literature is required
Rose: Findings The purpose of this experiment is to investigate anticipatory planning and movement control processes involved in bimanual aiming for individuals with mild stroke-induced hemiparesis. Nonparetic limb movement time was prolonged by 21% in the bimanual compared with the unimanual condition Compared to the unimanual task the bimanual task exhibited a higher peak velocity in the paretic limb – This was not noted in the control
Rose: Benefits Individuals with mild paresis post stroke retain a level of bimanual coordination. This ability may be harnessed for rehabilitation interventions to benefit recovery of function PT Implications Goal oriented bimanual tasks increase the feedback to the CNS increasing neuroplasticity and chance of remediation
Cauraugh: Findings The leading question focused on within-limb transfer of coupled protocols on distal joints to a bimanual aiming task that involved proximal joints This study determined that within-limb transfer from distal joints to a combination of proximal joints was feasible
Cauraugh: Benefits Peak velocity, variability in peak velocity, and deceleration time (adjustment phase) findings revealed a target aiming task advantage for the coupled bilateral group PT Implications: Bimanual goal oriented task training improves kinetics of proximal joints thereby improving hand placement and function
Dohle: Purpose The Purpose was to evaluate the potential beneficial effect of viewing the mirror image of the unaffected upper limb on recovery in patients with severe hemiparesis early after stroke
Dohle: Findings No difference in motor function, ROM, Pain or Motor FIM between the 2 groups (CT and MT) MT had significant gains over the CT in Function, Neglect and Sensory outcome measures (ARAT and Light Touch)
Dohle: Benefits Watching a healthy moving arm and hand in the neglected hemifield provides a stronger stimulus for recovery from neglect than watching the attempted movements of a paretic side MT most effective when person has no distal movement at onset of treatment compared to CIMT where functional gains are made but only when distal function is available PT Implications: This offers another option when treating a very difficult impairment
Reference Coupled Bimanual Movements and Active Neuromuscular Stimulation: Intralimb Transfer Evidence During Aiming . Cauraugh, Kim and Duley, Neuroscience Letters 382 (2005) 39-44. The Co-Ordination of Bimanual Rapid Aiming Movements After Stroke . Rose and Winstein, Clinical Rehabilitation 19 (2005) 452-462. Mirror Therapy Promotes Recovery From Severe Hemiparesis: A Randomized Control Trial . Dohle, Pullen and Nakaten, Neurorehabilitation and Neural Repair 23 (2009) 209-217 Simultaneous Bilateral Training For Improving Arm Function After Stroke (Protocol). Couper, Van Wijck and Pollock 2009. Portney LG, Watkins MP. Foundations of Clinical Research: Applications to Practice . Norwalk, CT: Appleton and Lange; 1993

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Hemiparesis

  • 1. Hemiparesis Research in Physical Therapy Treatment of the Upper Limb Chris Keating SPT Thomas Jefferson University
  • 2. Outline Research Good or Bad Bimanual Task Research Benefits PT Implications Mirror Therapy Research Benefits PT Implications
  • 3. Reading Research Don’t read the entire article from cover to cover Invest time wisely to make sure its worth your time Abstract---Introduction---Methods---Results---Discussion---Data Analysis Read one section then decide whether to continue reading
  • 4. Evaluating Research See Attachment Is the problem clearly stated? Is the problem probable based on the author’s review of the literature? Were inclusion and exclusion criteria specified? How many independent variables were examined, and how many levels do they have? Have the authors documented the reliability and validity of the instruments? Are operational definitions supplied for all independent and dependent variables? Are the results statistically significant? Regardless of the statistical outcome, are the results clinically important? Is the evidence strong enough to suggest a change in clinical practice?
  • 5. Bimanual Task Only 20% of patients with a flaccid upper limb after 2 weeks recover functional use Research has taken place to explore the use of bimanual task therapy in order to increase the functional use of the paretic arm Where do you start your search for the best research in order to provide the best care?
  • 7. Cochrane Review Searched the Cochrane Database of Systematic Reviews Key words crossed Stroke Bimanual Found 1 article protocol Provided SRL blue print for aspiring researcher to develop and execute (not useful) Provided background on the current evidence available (useful)
  • 8. Cochrane Review A small number of randomized controlled trials of bilateral training have been published, which appear to have inconsistent results investigations of the impact of bilateral training on neural mechanisms provide equivocal results In order to determine the effects of bilateral training compared to no treatment, placebo or other interventions for improving arm function after stroke, a systematic review of the relevant literature is required
  • 9. Rose: Findings The purpose of this experiment is to investigate anticipatory planning and movement control processes involved in bimanual aiming for individuals with mild stroke-induced hemiparesis. Nonparetic limb movement time was prolonged by 21% in the bimanual compared with the unimanual condition Compared to the unimanual task the bimanual task exhibited a higher peak velocity in the paretic limb – This was not noted in the control
  • 10. Rose: Benefits Individuals with mild paresis post stroke retain a level of bimanual coordination. This ability may be harnessed for rehabilitation interventions to benefit recovery of function PT Implications Goal oriented bimanual tasks increase the feedback to the CNS increasing neuroplasticity and chance of remediation
  • 11. Cauraugh: Findings The leading question focused on within-limb transfer of coupled protocols on distal joints to a bimanual aiming task that involved proximal joints This study determined that within-limb transfer from distal joints to a combination of proximal joints was feasible
  • 12. Cauraugh: Benefits Peak velocity, variability in peak velocity, and deceleration time (adjustment phase) findings revealed a target aiming task advantage for the coupled bilateral group PT Implications: Bimanual goal oriented task training improves kinetics of proximal joints thereby improving hand placement and function
  • 13. Dohle: Purpose The Purpose was to evaluate the potential beneficial effect of viewing the mirror image of the unaffected upper limb on recovery in patients with severe hemiparesis early after stroke
  • 14. Dohle: Findings No difference in motor function, ROM, Pain or Motor FIM between the 2 groups (CT and MT) MT had significant gains over the CT in Function, Neglect and Sensory outcome measures (ARAT and Light Touch)
  • 15. Dohle: Benefits Watching a healthy moving arm and hand in the neglected hemifield provides a stronger stimulus for recovery from neglect than watching the attempted movements of a paretic side MT most effective when person has no distal movement at onset of treatment compared to CIMT where functional gains are made but only when distal function is available PT Implications: This offers another option when treating a very difficult impairment
  • 16. Reference Coupled Bimanual Movements and Active Neuromuscular Stimulation: Intralimb Transfer Evidence During Aiming . Cauraugh, Kim and Duley, Neuroscience Letters 382 (2005) 39-44. The Co-Ordination of Bimanual Rapid Aiming Movements After Stroke . Rose and Winstein, Clinical Rehabilitation 19 (2005) 452-462. Mirror Therapy Promotes Recovery From Severe Hemiparesis: A Randomized Control Trial . Dohle, Pullen and Nakaten, Neurorehabilitation and Neural Repair 23 (2009) 209-217 Simultaneous Bilateral Training For Improving Arm Function After Stroke (Protocol). Couper, Van Wijck and Pollock 2009. Portney LG, Watkins MP. Foundations of Clinical Research: Applications to Practice . Norwalk, CT: Appleton and Lange; 1993