Transcript The most effective interventions to decrease muscle tone

Welcome
The most effective interventions
to decrease muscle tone and
improve upper extremity function
in stroke patients.
Table of Contents
Introduction
Background
Purpose and Research Question
Methods
Study Design
In- and Exclusion Criteria
Article-flowchart
Criteria List
Results
Treatment Approaches
Outcomes
Discussion
Conclusion
Introduction
Background
Stroke
residual neurological deficits
spasticity
functional recovery
elements of rehabiliation
restrictions aggrevate daily living
Treatment approaches
Neurodevelopmental Therapy (NDT)
no evidence proving effectiveness
Introduction
Purpose
review effects/evidence of availble treatment regimes
Research Question
What are the most effective interventions
to decrease muscle tone
and improve upper extremity function
in elderly stroke patients with arm spasticity?
Methods
Study Design
systematic review
databases
MeSH words
1. Research Session
Stroke, Spasticity, Upper Extremity Function
2. Research Session
Stroke AND Interventions
- Botulinum toxin
- Acupuncture
- Constraint Induced Movement Therapy
- Functional Electrical Stimulation
Methods
In- and Exclusion Criteria
Inclusion:
- stroke
- intervention to decrease muscle tone and/or improve
upper extremity function
- elderly stroke patients (50 – 85 years)
- chronic state (> 3 months)
Exclusion:
- non-spastic patients
- independent ADL level
- < 7 study subjects
- acute stroke (< 3 months)
Methods
Article Flowchart
Articles found
(100)
Additional
(77)
Included
(23)
Spasticity
(8)
Spasticity &
Function
(8)
AC (2)
Function
(7)
Reviews
(13)
AC (1)
AC (2)
CIMT (4)
BTX A (3)
EX (2)
CIMT (2)
BTX A (4)
BTX A (5)
EPM (4)
EPM (1)
EPM (1)
EX (5)
Background
(64)
Methods
Criteria List
3
Methods
Criteria List
57 – 45 = high quality
44 – 32 = good quality
Interrater Reliability:
α = 0.923
Results
Treatment Approaches
botulinum toxin type A (Btx A)
acupuncture (traditional and electro)
CIMT
exercise therapy
- BATRAC
- motorized arm ergometer
neuroprosthesis
power-assisted FES
shock wave
Results
Measurement Tools
Spasticity
Modified Ashworth scale (MAS)
Range of Motion (ROM)
Function
Action Research Arm Test (ARAT)
Frenchay Arm Test (FAT)
Motricity Index (MI)
Amount of Arm Used Test (AAUT)
Quality of Life
Caregiver Motor Activity Log (MAL)
Results
Outcomes - Spasticity
Btx A
- sign. reduction in spasticity
- benefits until week 12
- no muscle strength loss (≠ 1500 MU)
Acupuncuture
- sign. reduction in spasticity
Shock wave
- sign. reduction in spasticity
- sign. difference in pROM
Results
Outcomes - Function
CIMT
- sign. improve in functional measurements
- improvement in quality of life
Exercise
- sign. improvement in function (week 6 + 14)
Acupuncture
- sign. difference in active ROM and functional capacity (after 6
weeks)
Results
Outcomes – Spasticity and Function
Btx A
- sign. reduction in spasticity (peak at week 4-6)
- sign. increase in active and passive ROM
- sign. increase in functional capacity
- sign. improvement in quality of life
Neuroprosthesis and power-assisted FES
- sign. reduction in spasticity
- sign. improvement in function
Discussion
Btx A and Spasticity
most effective intervention
maintenance – 20 weeks
similar studies
placebo control group
Acupuncture/Shock wave and Spasticity
lacking similar studies
small sample size
no proper control group
Discussion
CIMT and Function
most effective intervention
compulsive integration
positive challenges
task specificity
Acupuncture/Exercise therapy and Function
no task specific training
no proper control group
small sample size
Discussion
Btx A and Spasticity and Function
most effective intervention
improved quality of life
applied once in 3 months
Electro physical modalities and Spasticity and Function
lacking task specificity
daily application
increase in spasticity
decrease in function
Discussion
Physiotherapeutic interpretation
multidisciplinary approach
integration of affected arm
Recommendations
Btx A combined with CIMT
effect on acute stroke
intense vs. elongated studies
proper control groups
Conclusion
Decrease Spasticity
Botulinum toxin type A
Improve Function
repetitive task specific training of affected arm (CIMT)
Decrease Spasticity AND improve Function
Combination of:
Botulinum toxin type A
AND
task specific training of affected arm
Treatment Protocol
Injection of Btx A
Muscles being injected (total dose 1000 MU)
Biceps brachii
Brachioradialis
Flexor Carpi Radialis andUlnaris
Flexor Digitorum Longus, Profunuds and Superficialis
Flexor Policis Opponans
Repetitive Task Specific Training
starting one week post-injection
3 x 45 min/week
ADL training with affected arm
Restraining unaffected arm
5 x 6 hrs/week at home
and during task specific training session