The Use of a The Use of a Functional Digit Functional Digit

Extension Splint to Extension Splint to Promote The Promote The

Integration of the Integration of the Hemiparetic Hand Hemiparetic Hand during Activities of during Activities of

Daily Living.Daily Living.Joseph R. Padova, OTR/LJoseph R. Padova, OTR/L

Courtney Knobl, MS OTR/LCourtney Knobl, MS OTR/L

Conflict of Interest Conflict of Interest Statement Statement

Joseph Padova, OTR/L made the Functional Joseph Padova, OTR/L made the Functional Low-profile Extension Assist Splint (RELEAS) Low-profile Extension Assist Splint (RELEAS) being used as a splint of discussion.being used as a splint of discussion.

Joseph has a vested interest in the splint.Joseph has a vested interest in the splint. However, the intention of this presentation is However, the intention of this presentation is

to review some of the problem solving used to review some of the problem solving used to design functional splinting for stroke to design functional splinting for stroke patients and the potential for using patients and the potential for using functional splinting as an additional option functional splinting as an additional option for rehabilitation.for rehabilitation.

Objectives:Objectives:

be able to identify at least three ways in be able to identify at least three ways in which neuromuscular imbalances after a which neuromuscular imbalances after a stroke can limit functional integration of stroke can limit functional integration of the affected upper extremity.the affected upper extremity.

Analyze distal upper extremity movement Analyze distal upper extremity movement patterns to help determine the potential for patterns to help determine the potential for functional splinting as an option to functional splinting as an option to improving hand function.improving hand function.

Apply at least one current neuromuscular Apply at least one current neuromuscular rehabilitative technique to maximize the rehabilitative technique to maximize the integration of the splinted hand during integration of the splinted hand during activities of daily activities of daily living.living.

Promote your own ideas and see if Promote your own ideas and see if they work.they work.

Research it and Write about Your Research it and Write about Your Results to add to the Clinical base of Results to add to the Clinical base of Knowledge.Knowledge.

Encourage to seek out ways to Encourage to seek out ways to patent and promote what you come patent and promote what you come up with.up with.

Conflict of Interest Conflict of Interest StatementStatement

Courtney Knobl, MS OTR/L has No Courtney Knobl, MS OTR/L has No conflict of interest.conflict of interest.

DemographicsDemographics According to the American Heart According to the American Heart

Association there are approximately Association there are approximately 780,000 new strokes in U.S.A each year 780,000 new strokes in U.S.A each year (Heart Disease and Stroke Statistics, 2008).(Heart Disease and Stroke Statistics, 2008).

By best estimates as of 2005 approximately By best estimates as of 2005 approximately 5,800,000 stroke survivors (Heart Disease 5,800,000 stroke survivors (Heart Disease and Stroke Statistics, 2008).and Stroke Statistics, 2008).

½ of stroke survivors are living with upper ½ of stroke survivors are living with upper and lower limb disabilities ( Levey, Nichols, and lower limb disabilities ( Levey, Nichols, Schmailbrock and Clark, 2001; Ottawa, Schmailbrock and Clark, 2001; Ottawa, 2007). 2007).

Rehabilitation has been more successful in restoring function in lower limb compared to the upper limb (Barreca, Wolf, Fasoli and Bohannon, 2003; Levey, Nichols, Levey, Nichols, Schmailbrock and Clark, 2001; Page, Schmailbrock and Clark, 2001; Page, 2007 Rosenstein, Ridgel Thota, 2007 Rosenstein, Ridgel Thota, Samameand Alberts, 2008).Samameand Alberts, 2008).

Even with Intensive Therapy

Studies indicate that proximal arm active range of motion make larger gains compared to the hand (Barreca, Fasoli and Bohannon, 2003; Levey, Nichols, Schmailbrock Levey, Nichols, Schmailbrock and Clark, 2001).and Clark, 2001).

Inability to actively open the hand for pre-grasp and release is a severe functional deficit of many stroke patients (Levey, Nichols, Levey, Nichols, Schmailbrock and Clark, 2001, Page, Schmailbrock and Clark, 2001, Page, Sisto, Levine, McGrath, 2004; Fritz, Sisto, Levine, McGrath, 2004; Fritz, Light, Patterson, Behrman and Light, Patterson, Behrman and Davis, 2005).Davis, 2005).

Medical Chemodenervations with

Botoxin Shown to be effective to reduce

motor over activity from spasticity in the wrist and finger flexors.

But many patients still have poor ability to recruit finger extensors and volitional open the hand for grasp and release ( Brashear and Meyer, 2008).

Is Dynamic Splinting an Option

for Functional Hand Integration?

Functional Functional Splinting for Splinting for

SpasticitySpasticityLiterature review showed Literature review showed

extremely limited informationextremely limited information

Interest in Functional Interest in Functional SplintingSplinting

New Interest in New Interest in an old idea.an old idea.

Currently not Currently not many options for many options for the hemiplegic the hemiplegic upper limb.upper limb.

Most splints are Most splints are static for static for positioning.positioning.

Functional SplintingFunctional Splinting

For the most part For the most part are large.are large.

Not designed for Not designed for full day ADL and full day ADL and self care useself care use

Functional Splinting for Functional Splinting for the Spastic Upper Limb the Spastic Upper Limb

has Multiple has Multiple ConsiderationsConsiderations

Hyper response of the Hyper response of the stretch receptor occurs stretch receptor occurs

when:when: The joint is moved too fast.The joint is moved too fast. The joint is moved too far.The joint is moved too far. The movement is too forceful.The movement is too forceful.

Contractures and soft Contractures and soft tissue tightnesstissue tightness

Will be a major component Will be a major component determining proximally the determining proximally the amount of distance a person can amount of distance a person can reach and place the hand.reach and place the hand.

Contractures in the Contractures in the hand hand

Will help determine how large the Will help determine how large the possible grip, or pinch will be possible grip, or pinch will be based on how wide the hand can based on how wide the hand can be opened.be opened.

Quality of Motion will Quality of Motion will help Determinehelp Determine

How well the patient can isolate How well the patient can isolate movement patterns within the movement patterns within the available AROMavailable AROM

What Joints in the Hand What Joints in the Hand Are Moving?Are Moving?

The fingers only?The fingers only? The thumb only?The thumb only? Both the fingers and the thumb?Both the fingers and the thumb?

How Is It Moving?How Is It Moving? Can the moving joints produce Can the moving joints produce

flexion and extension?flexion and extension? If only flexion can it relax the If only flexion can it relax the

grip?grip? If only active flexion and it can If only active flexion and it can

relax the grip can the person relax the grip can the person produce a relaxed release?produce a relaxed release?

If Fingers and Thumb If Fingers and Thumb Flexion, Flexion, Without Without

ExtensionExtension Functional Low-profile Functional Low-profile

Extension Assist Splint Extension Assist Splint ( RELEAS ) may be ( RELEAS ) may be appropriate.appropriate.

Uses a neoprene thumb Uses a neoprene thumb spica splint,spica splint,

Dorsal mounted flex rod, Dorsal mounted flex rod, or spring-loaded or spring-loaded outrigger.outrigger.

Buddy splints to support Buddy splints to support the index and long fingers.the index and long fingers.

The dynamic forces are The dynamic forces are use to open the thumb, use to open the thumb, index and long fingers index and long fingers following a crude pinch.following a crude pinch.

Works best with Modified Works best with Modified Ashworth of 2 or less.Ashworth of 2 or less.

Inclusion CriteriaInclusion Criteria

Be oriented. Be oriented. Able to follow at least 3 step verbal, Able to follow at least 3 step verbal,

written, or demonstrated written, or demonstrated instructions.instructions.

Have no more than a mild left Have no more than a mild left inattention to the affected body inattention to the affected body parts (this does not include learned parts (this does not include learned nonuse).nonuse).

AROM RequirementsAROM Requirements

At least 20 degrees arm flexion and At least 20 degrees arm flexion and abduction.abduction.

Move the hand from midline to Move the hand from midline to neutral external rotation.neutral external rotation.

Move the elbow from at least 50 Move the elbow from at least 50 degrees flexion to -20 of extension degrees flexion to -20 of extension (extension can be eccentric or (extension can be eccentric or concentric).concentric).

Hand ROMHand ROM

Looking for the ability of the hand to Looking for the ability of the hand to produce either a lateral pinch, or a 3 produce either a lateral pinch, or a 3 jaw pinch once the index, long finger jaw pinch once the index, long finger and thumb are passively ranged into and thumb are passively ranged into supported low resistance extension.supported low resistance extension.

AROM RequirementsAROM Requirements

Forearm : Although desirable, not an Forearm : Although desirable, not an inclusion, or exclusion criteria as it inclusion, or exclusion criteria as it can be positioned by functional can be positioned by functional strapping if needed.strapping if needed.

Wrist : Although desirable, not an Wrist : Although desirable, not an inclusion, or exclusion criteria as it inclusion, or exclusion criteria as it can be positioned by adding a wrist can be positioned by adding a wrist support to the FLEAS if needed. support to the FLEAS if needed.

Inclusion CriteriaInclusion Criteria

Unable to volitionally open the hand.Unable to volitionally open the hand. Be able to squeeze the evaluators Be able to squeeze the evaluators

hand.hand. Be able to stop squeezing when Be able to stop squeezing when

gripping the evaluators hand.gripping the evaluators hand. Hand should not elicit spasticity Hand should not elicit spasticity

resistance greater than a 2 on the resistance greater than a 2 on the Modified Ashworth when the digits Modified Ashworth when the digits and fingers are passively opened.and fingers are passively opened.

SensationSensation

Not as clear cut yet.Not as clear cut yet. Of the 13 patients fit so far 1 could Of the 13 patients fit so far 1 could

only identify deep pressure and pain. only identify deep pressure and pain. Another only had pain perception.Another only had pain perception.

Both were able to visually Both were able to visually compensate and complete all the compensate and complete all the tasks except tying bows and holding tasks except tying bows and holding a fork.a fork.

All tasks took increased time and All tasks took increased time and physical effort.physical effort.

13 patients fitted with the 13 patients fitted with the RELEASRELEAS

4 < five years post CVA.4 < five years post CVA. 5 were five to seven years.5 were five to seven years. 3 between eight to 10 years.3 between eight to 10 years. 1 was 20 years post CVA1 was 20 years post CVA All had extensive acute All had extensive acute

rehabilitation and out patient rehabilitation and out patient physical and occupational therapy physical and occupational therapy through the years.through the years.

AROM Summary:AROM Summary:Amount of ranges varied:Amount of ranges varied:

Between 20 and 80 degrees arm flexionBetween 20 and 80 degrees arm flexion Between 20 to 60 degrees external Between 20 to 60 degrees external

rotationrotation Between 20 to 125 degrees elbow Between 20 to 125 degrees elbow

flexion.flexion. Supination from full pronation varied Supination from full pronation varied

from -15 degrees from neutral to 69 from -15 degrees from neutral to 69 degrees.degrees.

Varied from – 30 of a neutral wrist to Varied from – 30 of a neutral wrist to 45 degrees wrist extension.45 degrees wrist extension.

10 had a Modified Ashworth in the 10 had a Modified Ashworth in the finger flexors of two; 2 had one plus; 1 finger flexors of two; 2 had one plus; 1 had a one.had a one.

ContinuedContinued All could demonstrate the ability to All could demonstrate the ability to

control the movement patterns to touch control the movement patterns to touch the intact hand with the opposite hand the intact hand with the opposite hand at midline.at midline.

0 could open the hand.0 could open the hand. All could recruit and relax the flexors of All could recruit and relax the flexors of

the handthe hand 0 could integrate the hand other than a 0 could integrate the hand other than a

gross stabilizer with the fist.gross stabilizer with the fist.

Following RELEAS Following RELEAS fabrication and average of fabrication and average of

15 training sessions15 training sessions AROM of the proximal U.E. and AROM of the proximal U.E. and

the Modified Ashworth the Modified Ashworth measurement remained measurement remained approximately unchanged.approximately unchanged.

However with the RELEAS all However with the RELEAS all could integrate the affected hand could integrate the affected hand for grasp, pinch, placement and for grasp, pinch, placement and release.release.

Out of 13 Fitted with Out of 13 Fitted with RELEAS for assisted pre-RELEAS for assisted pre-grasp, active grasp and grasp, active grasp and

assisted releaseassisted releaseAble to complete task with RELEAS

Unable to complete task with RELEAS

Able to complete task without RELEAS

Hold paper while folding 9 4 0

Hold open and stuff envelope 9 4 0

Hold coupon sheets while cutting 9 4 0

Pinch and rip open salt/sugar packets

9 4 0

Open and apply bandage 9 4 0

Hold and pull up pants/underpants

9 4 0

Stabilize bowl while mixing 9 4 0

Hold and release clothing/linen when folding

9 4 0

ContinuedContinued

Able to complete task with RELEAS

Unable to complete task with RELEAS

Able to complete task without RELEAS

Stabilize various sized boxes, paper, tape dispenser while wrapping packages

9 4 0

Hold fork and stabilize thin meats when cutting

6 7 0

Stabilize handles of pots and pans when cooking at the stove

6 7 0

Integrate the hand to help push a shopping cart

6 7 0

Tie bows on sneakers 2 11 0

Training TimeTraining Time

Variable due to patients personal goals.Variable due to patients personal goals. Ranged from 12 to 26 sessions Ranged from 12 to 26 sessions

depending on the complexity of the depending on the complexity of the case to achieve independent case to achieve independent integration level for appropriate tasks.integration level for appropriate tasks.

Relatively short time span considering Relatively short time span considering not being able integrate a volitional not being able integrate a volitional hand component for years since the hand component for years since the initial stroke.initial stroke.

Case study 1: Case study 1: R.H. R.H.

The patientThe patient

33 year old female s/p L CVA (04/05)33 year old female s/p L CVA (04/05) Resulting R hemi paresisResulting R hemi paresis

R hand dominantR hand dominant

R UE presentationR UE presentation

Decreased isolated active Decreased isolated active movement, increased spasticitymovement, increased spasticity

Good attention to R UEGood attention to R UE

Sensation grossly intact to light Sensation grossly intact to light touchtouch

In the past, pt has…In the past, pt has…

Been through extensive in/outpatient rehabBeen through extensive in/outpatient rehab

Trialed multiple interventions (Saebo, Trialed multiple interventions (Saebo, Neuromove)Neuromove) Reported improved arm motion, but not hand Reported improved arm motion, but not hand

functionfunction

Had botox injections in finger flexorsHad botox injections in finger flexors Produced no volitional extension for pre Produced no volitional extension for pre

grasp/releasegrasp/release

Video of R UE ROMVideo of R UE ROM

Clinical Reasoning for Clinical Reasoning for Initiating RELEAS Initiating RELEAS

Training:Training:

““It is the hand that guides the It is the hand that guides the arm rather than the other way arm rather than the other way around” (Gordon, 1987).around” (Gordon, 1987).

Enable Functional Task Enable Functional Task ParticipationParticipation

Functional task participation more favorable than Functional task participation more favorable than exercise programexercise program

Positive changes in hemiparetic UE when Positive changes in hemiparetic UE when incorporated into tasksincorporated into tasks

Functional tasks typically require use of both Functional tasks typically require use of both handshands Recovery maximized through bimanual task trainingRecovery maximized through bimanual task training

Simultaneously address other impairments (Davis, Simultaneously address other impairments (Davis, 2006).2006).

Cortical reorganizationCortical reorganization

Use dependent cortical reorganization Use dependent cortical reorganization (Gillan, G., 2011)(Gillan, G., 2011) Results from increased use of body partResults from increased use of body part Leads to enhanced representation in cerebral Leads to enhanced representation in cerebral

cortex and reverses disadvantageous cortical cortex and reverses disadvantageous cortical reorganizationreorganization

Structural cortical changes (Gauthier, et al. Structural cortical changes (Gauthier, et al. 2007)2007) Amount of UE use can alter brain activity or Amount of UE use can alter brain activity or

activation patternactivation pattern

Facilitate Repetition for Facilitate Repetition for Motor LearningMotor Learning

Repetitions of specific UE Repetitions of specific UE movements produce lasting neural movements produce lasting neural changes and optimize motor changes and optimize motor learning (Lang, et al., 2009).learning (Lang, et al., 2009).

Outpatient OT GoalsOutpatient OT Goals

Pt will:Pt will: Demonstrate increased right shoulder Demonstrate increased right shoulder

flexion AROM by ≥20°flexion AROM by ≥20° Be I with updated HEPBe I with updated HEP

And…And…

With RELEAS, pt will With RELEAS, pt will integrate R UE to integrate R UE to

bimanually:bimanually: Open small ziploc bags and water Open small ziploc bags and water

bottlesbottles Open and apply bandagesOpen and apply bandages Open sealed envelopeOpen sealed envelope Fold paper and stuff into envelopeFold paper and stuff into envelope Apply toothpaste to toothbrushApply toothpaste to toothbrush

Within 10 sessions, pt Within 10 sessions, pt able to:able to:

Rip sugar packetsRip sugar packets Cut coupons with scissorsCut coupons with scissors Rip and apply bandageRip and apply bandage Open toothpaste container and apply to Open toothpaste container and apply to

toothbrushtoothbrush Fold paper and stuff into envelopeFold paper and stuff into envelope Open sealed envelopeOpen sealed envelope Stabilize pot on stove and stirStabilize pot on stove and stir Manipulate zipper and zip/unzip jacketManipulate zipper and zip/unzip jacket

Cutting with ScissorsCutting with Scissors

Opening bandageOpening bandage

Within 15 sessionsWithin 15 sessions

Pt was able to:Pt was able to: Hang shirt on hanger and removeHang shirt on hanger and remove Use R hand to stabilize bowl while Use R hand to stabilize bowl while

stirringstirring Fold towel and shirtFold towel and shirt Sweep floor holding broom with Sweep floor holding broom with

both handsboth hands

SweepingSweeping

Pt’s subjective view…Pt’s subjective view…

““This splint is so functional”This splint is so functional”

Reported previously unable to Reported previously unable to incorporate right upper extremity into incorporate right upper extremity into functional tasksfunctional tasks

““And now I don’t have to think about And now I don’t have to think about it - I just incorporate my right hand it - I just incorporate my right hand into tasks”into tasks”

Case 2 H.Case 2 H.

Case Study 3: Case Study 3: M.N.M.N.

The patient…The patient…

49 year old right handed female s/p R CVA 49 year old right handed female s/p R CVA (10/08) with resulting left hemiparesis(10/08) with resulting left hemiparesis

Mod I ambulation with quad cane, transfersMod I ambulation with quad cane, transfers

Mod I ADLs (one handed techniques)Mod I ADLs (one handed techniques)

Intermittent A with IADLsIntermittent A with IADLs

Performance deficitsPerformance deficits

L hemi: no integration of L UE into any L hemi: no integration of L UE into any taskstasks

Gaze preference to right sideGaze preference to right side

Deficits with attention, problem solving, Deficits with attention, problem solving, memory, organizationmemory, organization

Deficits with visual organization, visual Deficits with visual organization, visual memorymemory

Initial L UE status – 3/09Initial L UE status – 3/09

Decreased active movementDecreased active movement

Available active movement was not Available active movement was not functionalfunctional Poor isolationPoor isolation Increased toneIncreased tone Able to grasp flat object when placed into Able to grasp flat object when placed into

handhand Unable to release objectUnable to release object

Sensation to light touch grossly intactSensation to light touch grossly intact

GoalsGoals

Pt’s goal: “To use this left arm”Pt’s goal: “To use this left arm”

Goals agreed upon with pt:Goals agreed upon with pt: Increase L UE PROM/AROMIncrease L UE PROM/AROM I with home programI with home program Utilize L UE as gross A with basic Utilize L UE as gross A with basic

functional bimanual tasks (ie: opening functional bimanual tasks (ie: opening containers)containers)

By discharge, with By discharge, with RELEAS, pt was able to:RELEAS, pt was able to:

Bring left upper extremity to midline Bring left upper extremity to midline

Grasp/release objects with left handGrasp/release objects with left hand

Maintain grasp on container with left Maintain grasp on container with left hand while placing object in container hand while placing object in container with right handwith right hand

Open containers bimanually at midlineOpen containers bimanually at midline

Functional Task Functional Task Completion without Completion without

RELEASRELEAS

Functional Task Functional Task Completion with RELEASCompletion with RELEAS

Plan of care following Plan of care following dischargedischarge

Instructed to continue with use of Instructed to continue with use of RELEAS program at home RELEAS program at home

Patient to return to outpatient OT Patient to return to outpatient OT several months later to further several months later to further progress her L UEprogress her L UE

Referred to OT again in 10/09Referred to OT again in 10/09

Goals established on OT Goals established on OT eval, 10/09eval, 10/09

““To get my left hand and arm better…”To get my left hand and arm better…”

Goals agreed upon with patient on eval:Goals agreed upon with patient on eval: Utilize L UE to carry bag (≤ 5#) for ≥ twenty Utilize L UE to carry bag (≤ 5#) for ≥ twenty

feetfeet Utilize B UEs to manipulate zipperUtilize B UEs to manipulate zipper Utilize B UEs to consistently cut coupons Utilize B UEs to consistently cut coupons Utilize B UEs to complete ironing taskUtilize B UEs to complete ironing task Utilize L UE to A with cooking taskUtilize L UE to A with cooking task

Functional task Functional task completioncompletion

Patient’s active range of Patient’s active range of motionmotion10/30/09 4/12/10

Shoulder flexion 30° 89°

Shoulder external rotation 7° 38°

Elbow flexion 111° 124°

Elbow extension -16° -16°

Digit extension ¼ range second digit; 0° remaining digits

½ range second digit; ¼ range remaining digits

Thumb extension ¼ range ¾ range

Effective bimanual completion of Effective bimanual completion of functional tasksfunctional tasks

10/30/09 RELEAS

4/12/10 RELEAS

4/12/10 no RELEAS

Open containers

Rip sugar packets

Cut paper with scissors

Iron

Stir a pot on the stove

Stabilize zipper

Open and carry bag

Fold paper

Hang shirt on hanger

= unable = able

Patient’s subjective Patient’s subjective view…view…

Patient “loved coming to OT.”Patient “loved coming to OT.”

Frustration with slow recovery of L UE Frustration with slow recovery of L UE functionfunction

However, reported working with RELEAS gave However, reported working with RELEAS gave her “hope for this hand…”her “hope for this hand…”

Patient increasingly able to problem solve with Patient increasingly able to problem solve with OT on ways to incorporate L UE into tasksOT on ways to incorporate L UE into tasks

Final FindingsFinal Findings

Increased initiation and use of L UE with Increased initiation and use of L UE with functional tasksfunctional tasks

Improved L UE active range of motionImproved L UE active range of motion

Able to learn all tasksAble to learn all tasks Increased time required, but pt improved on Increased time required, but pt improved on

all tasks with repetition and practiceall tasks with repetition and practice

ImplicationsImplications

Improved digit extension as a result Improved digit extension as a result of consistent use of L UE?of consistent use of L UE?

Improved attention to left, although Improved attention to left, although no objective testing done pre and no objective testing done pre and postpost Active movement as a means to improve Active movement as a means to improve

unilateral neglect (Gillan, G., 2009)unilateral neglect (Gillan, G., 2009)

ConclusionConclusion Functional splinting is a relatively new Functional splinting is a relatively new

concept in stroke and brain injury concept in stroke and brain injury rehabilitation.rehabilitation.

Due to the diverse symptoms of hemiplegia, Due to the diverse symptoms of hemiplegia, including weakness, orthopedic including weakness, orthopedic considerations, spasticity variations and considerations, spasticity variations and cognitive/perceptual and sensory deficits it is cognitive/perceptual and sensory deficits it is unlikely that one type of splint will be unlikely that one type of splint will be appropriate for all.appropriate for all.

Appropriate splint choice and functional Appropriate splint choice and functional outcome is enhanced by a team approach to outcome is enhanced by a team approach to manage complex cases.manage complex cases.

The type of splint that once was appropriate The type of splint that once was appropriate may change as the patient changes over time.may change as the patient changes over time.

ConclusionConclusion Functional splinting is a relatively new Functional splinting is a relatively new

concept in stroke and brain injury concept in stroke and brain injury rehabilitation.rehabilitation.

Due to the diverse symptoms of hemiplegia, Due to the diverse symptoms of hemiplegia, including weakness, orthopedic including weakness, orthopedic considerations, spasticity variations and considerations, spasticity variations and cognitive/perceptual and sensory deficits it is cognitive/perceptual and sensory deficits it is unlikely that one type of splint will be unlikely that one type of splint will be appropriate for all.appropriate for all.

Appropriate splint choice and functional Appropriate splint choice and functional outcome is enhanced by a team approach to outcome is enhanced by a team approach to manage complex cases.manage complex cases.

The type of splint that once was appropriate The type of splint that once was appropriate may change as the patient changes over time.may change as the patient changes over time.

ReferencesReferences 1. Heart Disease and Stroke Statistics — 2008 Update, American Heart Association, 1. Heart Disease and Stroke Statistics — 2008 Update, American Heart Association,

Dallas, Texas, 2008.Dallas, Texas, 2008. 2. Levey CE, Nichols DS, Schmalbrock PM, Chaker DW. Functional MRI Evidence of 2. Levey CE, Nichols DS, Schmalbrock PM, Chaker DW. Functional MRI Evidence of

Cortical Reorganization in Upper Limb Stroke Hemiplegia Treated with Constraint-Cortical Reorganization in Upper Limb Stroke Hemiplegia Treated with Constraint-Induced Movement Therapy. American Journal of Physical Medicine and Induced Movement Therapy. American Journal of Physical Medicine and Rehabilitation. 2001;80:4-12.Rehabilitation. 2001;80:4-12.

3. Ottawa Panel Evidence-Based Clinical Practice Guide Post Stroke Rehabilitation. 3. Ottawa Panel Evidence-Based Clinical Practice Guide Post Stroke Rehabilitation. Available atAvailable at http://www.accessmylibary.com/com/coms2/summary_0286-17446379_ITM. Accessed May 22,2007..

4. Page S, Levine D. Modified Constraint-Induced Movement Therapy in Patients With 4. Page S, Levine D. Modified Constraint-Induced Movement Therapy in Patients With Chronic Stroke Exhibiting Minimal Movement Ability in the Affected Arm. Physical Chronic Stroke Exhibiting Minimal Movement Ability in the Affected Arm. Physical Therapy. 2007;87:872-878.Therapy. 2007;87:872-878.

5. Functional Tone Management Arm Training Program featuring the Saeboflex TM 5. Functional Tone Management Arm Training Program featuring the Saeboflex TM Orthosis, A Novel Approach for Treating the Neurologically Impaired Upper Extremity. Orthosis, A Novel Approach for Treating the Neurologically Impaired Upper Extremity. Workshop at MossRehab Hospital Elkins Park, 2006.Workshop at MossRehab Hospital Elkins Park, 2006.

6. Saebo No Plateau in Sight. Available at 6. Saebo No Plateau in Sight. Available at http://www.saebo.com/seaboflex.html. Accessed. Accessed January 6,2008.January 6,2008.

8. Ness H200TM. Available at 8. Ness H200TM. Available at http://www.bionessinc.com/products/h200.htm. Accessed January 6 ,2008.,2008.

9. Phelan C. The Journey of a New Product Designed and Invented by an O.T. Exploring 9. Phelan C. The Journey of a New Product Designed and Invented by an O.T. Exploring Hand Therapy. Available at Hand Therapy. Available at http://www.handtherapy.com/magazine.asp. Accessed January 8,2007 . .

9. Bohannon RW, Smith MB: Interrater reliability of a modified Ashworth Scale of 9. Bohannon RW, Smith MB: Interrater reliability of a modified Ashworth Scale of muscle spasticity. Phys Ther 1987; 67(2);206-207.muscle spasticity. Phys Ther 1987; 67(2);206-207.

10. Kraft GH, Fitts SS, Hammond MC: Techniques to improve function of the arm and 10. Kraft GH, Fitts SS, Hammond MC: Techniques to improve function of the arm and hand in chronic hemiplegia. Archives of Physical Medicine and Rehabilitation 73: 220-hand in chronic hemiplegia. Archives of Physical Medicine and Rehabilitation 73: 220-227, 1992.227, 1992.

ReferencesReferences Davis, J.Z. (2006). Task selection and enriched environments: a functional Davis, J.Z. (2006). Task selection and enriched environments: a functional

upper extremity training program for stroke survivors. Topics in Stroke upper extremity training program for stroke survivors. Topics in Stroke Rehabilitation, 13(3), 1-11.Rehabilitation, 13(3), 1-11.

Gauthier, L.V., et al. (2007). Remodeling the Brain: Plastic Structural Brain Gauthier, L.V., et al. (2007). Remodeling the Brain: Plastic Structural Brain Changes Produced by Different Motor Therapies After Stroke. Stroke, 39(5): Changes Produced by Different Motor Therapies After Stroke. Stroke, 39(5): 1520-1525.1520-1525.

Gillan, G. (2009). Adult Onset Apraxia and Unilateral Neglect Syndromes: An Gillan, G. (2009). Adult Onset Apraxia and Unilateral Neglect Syndromes: An Overview. Presented on Sept 19, 2009 at Moss Rehab Hospital, Philadelphia Overview. Presented on Sept 19, 2009 at Moss Rehab Hospital, Philadelphia PA.PA.

Nudo, R.J, Plautz, E.J., Frost, S.B. (2001). Role of Adaptive Plasticity in Nudo, R.J, Plautz, E.J., Frost, S.B. (2001). Role of Adaptive Plasticity in Recovery of Function After Damage to Motor Cortex. Muscle Nerve, 24(8), Recovery of Function After Damage to Motor Cortex. Muscle Nerve, 24(8), 1000-1019.1000-1019.

Schweghofer, N., et al., (2009). A Functional Threshold for Long-Term Use of Schweghofer, N., et al., (2009). A Functional Threshold for Long-Term Use of Hand and Arm Function Can be Determined: Predictions From A Hand and Arm Function Can be Determined: Predictions From A Computational Model and Supporting Data From the Extremity Constraint-Computational Model and Supporting Data From the Extremity Constraint-Induced Therapy Evaluation (EXCITE)Trial. Physical Therapy.Induced Therapy Evaluation (EXCITE)Trial. Physical Therapy.

Woldag, H and Hummelsheim, H. (2002). Evidence-based physiotherapeutic Woldag, H and Hummelsheim, H. (2002). Evidence-based physiotherapeutic concepts for improving arm and hand function in stroke patients. Journal of concepts for improving arm and hand function in stroke patients. Journal of Neurology, 249:5, pp 518-528. Neurology, 249:5, pp 518-528.