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Evidence for Upper Extremity Training for the Lower Functioning Patient Post Stroke  Sandy McCombe Waller PT, PhD, NCS University of Maryland, School of Medicine, Department of Physical Therapy and Rehabilitation Science

Official satellite symposium of the 5th UK Stroke Forum

Organised by Anatomical Concepts (UK) Ltd


Acknowledgements Research Testing and Training Bobby Asbury Melissa Mulcahy Toye Jenkins Andrea Gaeta Doug Savin GRECC for Medical Screening

Faculty Collaborators Jill Whitall PhD Andreas Luft MD Mark Rogers PhD, PT Andrew Goldberg MD Daniel Hanley MD

Funding Resources Claude D. Pepper Center Core Development Project PI/ NIA: S McCombe Waller NIH/ NCMRR R21: PI S McCombe Waller Department of Physical Therapy and Rehabilitation Science Seed grant funding

Disclosure: I am one of the inventors /hold patent of the Tailwind device described in our research which is licensed to Encore Path; I serve on the advisory board for Encore Path but receive no financial benefit or compensation for consultation or related to sales


Overview of Presentation • Neurophysiology and clinical presentation of moderate to severe motor impairment in stroke! ! ! ! ! ! ! ! ! ! • Upper Extremity Interventions: What is the Evidence? ! Bilateral arm training with rhythmic auditory cueing (using BATRAC/ Tailwind ®) ! Dynamic orthotic (Saeboflex) and Bilateral Arm training combination approaches !! ! • Integration of these interventions into clinical practice and home use


Neuroanatomy of More Severe Upper Extremity Paresis

Avoidance of paretic arm/hand use due to lack of function Use of nonparetic arm to accomplish tasks both unilateral and bilateral skills


Current Opinion in Neurobiology Volume 9, Issue 6, 1 December 1999, Pages 740-747


Issues related to Recovery with More Severe Paresis • Lack of use/ movement decreases somatosensory inputs to the nervous system

• Disuse leads to neural modifications • Reduced cortical motor maps (human and animal) • Reduced cortical excitability (human and animal) • Weakening of synapses (impairs synaptic plasticity, reduced release of NGF) (animal)

Jones 2007, 2008, 2010 Nudo 1996 !


Nudo et al. Muscle & Nerve Aug 2001


Training Concepts • Activity –dependent/ Use-dependent plasticity is reliant on active use • We need to find ways to actively include the paretic limb in daily activities!! ! ! ! ! • In lower functioning patients unilateral “use” of paretic arm will be limited - bilateral task training shows more promise for functional use in daily life


Rationale for Bilateral Training Approach Many if not most functions that the arms perform are bilateral

Keyboarding Driving

Eating

Arm-assisted functional mobility Carrying Pulling / Pushing


Clarifying Arm Function and Use


Upper Extremity Interventions for the Patient with More Severe Paresis Bilateral Arm Training with Rhythmic Auditory Cueing (BATRAC)


Bilateral Repetitive Training with Rhythmic Auditory Cueing (BATRAC) • Functionally relevant especially for patients with more severe paresis! ! ! ! ! • Bilateral deficits are seen in stroke survivors ! ! • Based on neural pathways and proposed control mechanisms for bilateral function! ! • Based on motor learning principles (task oriented, goals, challenging, repetition, feedback)


BATRAC (Non-progressive rate/ resistance) Training 5 mins in-phase 5 mins anti-phase 5 mins in-phase 5 mins anti-phase Progression No increase in rate – preferred rate No added resistance Excursion progressed to tolerance

Training took place 3x week for 6 weeks

Original BATRAC device


(n= 14)

(n= 11)

* (n= 11) Gains in Support Role Functions Can push with paretic arm Use paretic arm as support Can rest paretic arm on the table and support plate Can open a door Can carry objects with both arms

p <.001 There were NONRESPONDERS

Whitall et al.,2000 Stroke,


RCT Comparing Unilateral Dose Matched Therapy to BATRAC Unilateral Therapeutic Exercise compared BATRAC Training

Unilateral Paretic Reach Movement time, Peak velocity, Peak Acceleration, Movement units, Ratio of hand path

Bilateral Reach

McCombe Waller et al., 2008 Human Movement Science


Bilateral Training Improved Bilateral Spatial Temporal Control Not Seen with Unilateral Training Movement time

Movement Units

Mean Peak Velocity

Mean Peak Acceleration

Ratio of Hand Path

McCombe Waller et al., 2008 Human Movement Science


New sites of activation from BATRAC only Contralesional more than Ipsilesional (premotor and M1)

Whitall et al., 2006

Results correlated with changes in Fugl Meyer and WMFT

BATRAC n=9

DMTE n=12 Luft et al., 2004, JAMA Whitall , McCombeWaller 2010


Summary • Bilateral arm training with rhythmic auditory cueing provides repetition, goal directed practice! ! ! • Changes in function to correlate with changes in neural activation that involves bilateral hemispheric activation! ! ! ! ! ! • Gross motor gains predominate although they are meaningful to patients – in both bilateral and unilateral training!! ! ! ! ! ! ! • Bilateral functions are improved only with bilateral training!! ! ! ! ! ! ! ! • There are responders and nonresponders! !


Progressive BATRAC Training Bilateral Arm Training with Progression Excursion

Rate

Resistance


Training Protocol • Five minutes inphase training (platform flat) • Five minutes antiphase training (platform flat) • Five minutes inphase training (platform elevated) • Five minutes antiphase training (platform elevated)

Rate is progressed in the first two training bouts, !

Platform elevation is progressed in the second two training bouts

!

Progression is specific to each patient based on tolerance

!

Patient pushed as hard as they can go


Subjects in Preliminary Data Set • 10 subjects all receiving Progressive BATRAC training (bilateral) • Moderate severity paresis of the arm !

Mean Fugl-Meyer 17.6 SD 12 (13.6 ±6 w/subj 10 removed)! ! !

• Patients are not using the paretic arm functionally in daily activities


Evidence of Progression and Progression Tolerance Progression of Elevation

Progression of Rate 45.0

Rate (bpm)

98

65

Pre Post 33

0

Height of BATRAC (cm)

130

33.8

22.5

Pre Post 11.3

0

S1

S2

S3

S4

S5

S6

S7

S8

S9

S10

S1

S2

S3

S4

S5

S6

S7

S8

S9

S10

Subjects

Subjects

p< .0001 Mean 55.3 ->93.8 bpm Progression of Excursion

p <. 0006 Mean 2.1->17.95 (2.1 -> 15.2 w/o subj 10)

40

20

Pre Post

10

Subjects

S1 0

S9

S8

S7

S6

S5

S4

S3

S2

0

S1

Distance (cm)

30

p< .007

Mean 23.5->28.35 cm


Paretic Grip Strength 17

43

13 Kilograms

57

29 Pre Post

14

9 Pre Post

4

0

0

1

2

3

4

5

6

7

8

9

10

S1

S2

S3

S4

Subjects

S5

S6

S7

S8

S9

S10

Subjects

p<. 005

p< .005

Wolf Motor Functional Test (time) All Test Items

Wolf Modified (time) Items Patient Could Complete

110.0000

5.000

82.5000

3.750 Time (secs)

Mean total time (secs)

Score

Fugl-Meyer Upper Extremity

55.0000

27.5000

2.500

1.250 Pre Post

0 S1

S2

S3

S4

S5

S6

S7

S8

S9

S10

Pre Post

0 S1

S2

S3

S5

S6

Subjects

Subjects

p < .15

S4

p< .06

S7

S8

S9

S10


UMAQs Test of Functional Use

• Able to hold objects in paretic hand (9) • Can stabilize with paretic hand (7)

Score

• Can use paretic hand to assist with dressing (5)!! ! ! • Can lift paretic arm up to place on table, on lap, on surface (8) S1

S2 p<.005

S3

S4

S5

S6

Subjects

S7

S8

S9

S10

• Notice a swing of my arm during walking (2)!! ! ! • Can push a door open with paretic arm (3)!! ! ! • Arm rests down at my side better (5)! • No change (1)!!

!

!


6 weeks

baseline

Paretic Elbow

Bilateral Activations Seen with Functional Imaging


Progressive BATRAC Summary • Patients with lower levels of function can be progressed and tolerate progression well • A “progressive” training approach seems to have similar functional gains as “non-progressive” BATRAC but there are a greater number of responders! ! ! ! ! ! ! • Gains in bilateral arm use; small scale gains but meaningful to patients - limited to gross motor skills only


Combining Training Strategies In Patients with Moderate Severity Hemiparetic Stroke

â&#x20AC;˘ Bilateral and Unilateral â&#x20AC;˘ Proximal and Distal


Introduction • Patients with Moderate Severity Stroke show limited benefit and return of hand function • Why a poor response? –Proximal training predominates –Hard to actively involve hands of those with moderate severity –Potential need for a priming of the brain due to a potential state of inhibition and/ or decreased facilitation


Chronic Injury Moderate Severity Paresis

Decreased Activation of Injured Cortex

Bilateral Arm Training

Theoretical Model

Disinhibit / Facilitation of Injured Hemisphere Unilateral Training P Arm Activation Injured Hemi. Improved Function P Arm/ Hand


Hand Cannot actively Participate


Active (Assisted) Use of Hand


Saeboflex Orthosis


Proposed Intervention Sequential combination of proximal bilateral arm training and unilateral whole arm training with Saeboflex orthosis


! !

Baseline testing (functional and fMRI)

Saebo training! (6 weeks)! !

!

! !

!

!

BATRAC training (6 weeks)

! Interim testing (functional and fMRI)

! Saebo training! ! ( 6 weeks)

Saebo training (6 weeks)!

!

!

Post training testing (functional and fMRI)

!

!

Retention testing (functional and fMRI)

!


Video of training tasks for whole arm training with Saeboflex orthosis


Combination training shows larger changes on functional/ impairment measures * p<.05 Absolute Change

% change of scale or % of NP

Combo

6 - 10 points

9 -15.0% *

Saebo only

2 - 3 points

3 - 4.5% *

Combo

10 - 23.7 sec

11 – 66%*

Saebo only

3 - 4.5 sec

4- 6%

7- 14 kg

66 – 79% *

4 – 5 kg

53- 55% *

Combo

9 – 21 points

18 – 42% *

Saebo only

3 – 4 points

6 – 8%

Box and blocks: Combo

5 – 24 blocks

18 – 70% *

Saebo only

2 – 3 blocks

7 – 11%

Preliminary Data Fugl-Meyer:

Mod. WMAT:

Grasp:

Combo Saebo only

UMAQs:

Changes were maintained at the retention time period


Functional Use Report on UMAQs Post Bilateral Training Progressive BATRAC

Post Combination Training Progressive BATRAC + Whole Arm

I am able to keep my arm on the table

I am able to reach and grasp objects

My weak hand can hold placed objects

I can independently hold things in my hand

I notice my paretic arm swings

I can let go of an object after holding it

I can stabilise with my weak arm

I can hold a cup and bring it to my mouth

I can put weight through my arm to stand

I can reach and still hold on to an object


Brain activation changes

McCombe-Waller & Luft, unpublished


Brain activation changes

McCombe-Waller & Luft, unpublished


Video tape of patient outcomes in functional use of the paretic arm Pre FM: 30 Post FM :40

After BATRAC Training

After Combination Training


! !

Baseline testing (functional and fMRI)

â&#x20AC;&#x201C;UNITRAC training! ! !

(6 weeks)! !

!

One arm!

!

!

!!

!

BATRAC training (6 weeks) Two arms !

Interim testing (functional and fMRI)

Saebo training!! (6 weeks)! !

Saebo training ( 6 weeks)

!

!

Post training testing (functional and fMRI)

!

!

Retention testing (functional and fMRI)


Combination Training â&#x20AC;˘ There is a suggestion that there is a neural priming effect with bilateral proximal training in this population involving premotor cortices bilaterally(still under investigation) â&#x20AC;˘ Premotor activation above normal is often observed in subjects recovering after stroke (review Schaechter Prog Neurobiol 2004:73:61)

â&#x20AC;˘ Others do also observe premotor recruitment after task specific training (e.g. Nelles Neuroimage 2001, 13:1146; Johansen-Berg 2002,

!

125:2731)


• In moderately impaired subjects proximal reach / return training (BATRAC) followed by functional whole arm reaching – shapes the reaching behaviour ! ! ! ! • Use of the Saeboflex orthosis permits active training of the hand and appears to lead to gains in hand function


Accessibility How do we integrate these approaches into clinical practice and home use? Research Lab

Clinics and Home


Translation to Home May Increase Practice â&#x20AC;˘ BATRAC and Saebo training are accessible to clinics and patients and can translate to home use ! ! ! www.anatomicalconcepts.com ! ! ! www.saebo.com â&#x20AC;˘ Leads to potentially more time practicing which may be particularly necessary in patients with more severe paresis from stroke


Suggestions for integration • These approaches should augment current practice adding intensity and practice time • Given limited time in therapy empowering patients to work independently may increase self –initiation important for long term engagement in training • Follow-up training with examples of functional use of the arms in daily tasks (consider bilateral for lower level patients)


Final Comments • No single training approach is best for everyone! ! ! ! ! ! ! • More than one approach may be needed – used concurrently or in sequence!! ! ! ! • There is promise to facilitate meaningful change in functional use of the paretic arm and hand in the lower functioning patient! ! ! ! ! ! ! ! • Significant practice is needed !! • Increased time on task practice in the clinic is needed as well as use of new technology to increase home training (essential in for lower functioning patients)


Thank You

Stroke Forum Presentation - Tailwind  

Presentation by Professor Sandy McCombe Waller from the 5th UK Stroke Forum meeting held in Glasgow. Topic is Evidence for Upper Extremity R...

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