Evidence for Upper Extremity Training for the Lower Functioning

Patient Post Stroke 

Sandy McCombe Waller PT, PhD, NCSUniversity of Maryland, School of Medicine,

Department of Physical Therapy and Rehabilitation Science

Official satellite symposium of the 5th UK Stroke Forum

Organised byAnatomical Concepts (UK) Ltd

AcknowledgementsResearch Testing and Training

Bobby Asbury Melissa Mulcahy

Toye JenkinsAndrea GaetaDoug Savin

GRECC for Medical Screening

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

Faculty CollaboratorsJill Whitall PhD

Andreas Luft MDMark Rogers PhD, PTAndrew Goldberg MD

Daniel Hanley MD

Funding Resources

Claude D. Pepper Center Core Development Project PI/ NIA: S McCombe WallerNIH/ NCMRR R21: PI S McCombe Waller

Department of Physical Therapy and Rehabilitation Science Seed grant funding

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 NeurobiologyVolume 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, 2010Nudo 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

EatingDressingKeyboarding

Carrying

Driving

Arm-assisted functional mobility

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)

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

BATRAC (Non-progressive rate/ resistance)

Training took place 3x week for 6 weeks Original BATRAC device

*

(n= 14)

p <.001

(n= 11)

(n= 11)

Whitall et al.,2000 Stroke,

Gains in Support Role FunctionsCan 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

There were NONRESPONDERS

RCT Comparing Unilateral Dose Matched Therapy to BATRAC

McCombe Waller et al., 2008 Human Movement Science

Unilateral Therapeutic Exercise compared BATRAC Training

Movement time, Peak velocity, Peak Acceleration, Movement units, Ratio of

hand path

Unilateral Paretic Reach Bilateral Reach

Bilateral Training Improved Bilateral Spatial Temporal Control Not Seen with Unilateral

Training

Movement time Mean Peak Velocity

McCombe Waller et al., 2008 Human Movement Science

Mean Peak Acceleration

Movement Units Ratio of Hand Path

Whitall et al., 2006

BATRAC n=9

DMTE n=12

New sites of activation from BATRAC only

Contralesional more than Ipsilesional (premotor and M1)

Luft et al., 2004, JAMA

Whitall , McCombeWaller 2010

Results correlated with changes in Fugl Meyer and

WMFT

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 TrainingBilateral Arm Training with Progression

RateExcursion 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

0

33

65

98

130

S1 S2 S3 S4 S5 S6 S7 S8 S9 S10

Progression of Rate

Rat

e (b

pm)

Subjects

PrePost

0

11.3

22.5

33.8

45.0

S1 S2 S3 S4 S5 S6 S7 S8 S9 S10

Progression of Elevation

Hei

ght o

f BAT

RA

C (c

m)

Subjects

Pre Post

p< .0001 Mean 55.3 ->93.8 bpm

0

10

20

30

40

S1 S2 S3 S4 S5 S6 S7 S8 S9S10

Progression of Excursion

Dis

tanc

e (c

m)

Subjects

Pre Post

Mean 2.1->17.95

(2.1 -> 15.2 w/o subj 10)

p <. 0006

Mean 23.5->28.35 cmp< .007

Evidence of Progression and Progression Tolerance

p<. 005

0

14

29

43

57

1 2 3 4 5 6 7 8 9 10

Fugl-Meyer Upper ExtremitySc

ore

Subjects

PrePost

0

4

9

13

17

S1 S2 S3 S4 S5 S6 S7 S8 S9 S10

Paretic Grip Strength

Kilo

gram

s

Subjects

PrePost

0

27.5000

55.0000

82.5000

110.0000

S1 S2 S3 S4 S5 S6 S7 S8 S9 S10

Wolf Motor Functional Test (time) All Test Items

Mea

n to

tal t

ime

(sec

s)

Subjects

PrePost

p< .005

0

1.250

2.500

3.750

5.000

S1 S2 S3 S4 S5 S6 S7 S8 S9 S10

Wolf Modified (time) Items Patient Could Complete

Tim

e (s

ecs)

Subjects

PrePost

p < .15 p< .06

p<.005S1 S2 S3 S4 S5 S6 S7 S8 S9 S10

UMAQs Test of Functional Use

Scor

e

Subjects

• Able to hold objects in paretic hand (9)

• Can stabilize with paretic hand (7)

• Can use paretic hand to assist with dressing (5)!! ! !

• Can lift paretic arm up to place on table, on lap,

on surface (8)

• 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)!! ! !

base

line

6 w

eeks

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

• Bilateral and Unilateral• Proximal and Distal

In Patients with Moderate Severity Hemiparetic Stroke

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

Bilateral Arm Training

Decreased Activation of Injured Cortex

Disinhibit / Facilitation of Injured Hemisphere

Unilateral Training P ArmActivation Injured Hemi.

Improved Function P Arm/ Hand

Theoretical Model

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! ! BATRAC training

(6 weeks)! ! (6 weeks)

! ! ! !

! Interim testing (functional and fMRI)

! Saebo training! ! Saebo training (6 weeks)! ! ( 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

Preliminary Data Absolute Change

% change of scale or % of NP

Fugl-Meyer: Combo Saebo only

6 - 10 points 2 - 3 points

9 -15.0% *3 - 4.5% *

Mod. WMAT: Combo Saebo only

10 - 23.7 sec 3 - 4.5 sec

11 – 66%* 4- 6%

Grasp: Combo Saebo only

7- 14 kg4 – 5 kg

66 – 79% *53- 55% *

UMAQs: Combo Saebo only

9 – 21 points3 – 4 points

18 – 42% *6 – 8%

Box and blocks: Combo Saebo only

5 – 24 blocks 2 – 3 blocks

18 – 70% *7 – 11%

Changes were maintained at the retention time period

Functional Use Report on UMAQs

I am able to keep my arm on the table

My weak hand can hold placed objects

I notice my paretic arm swings

I can stabilise with my weak arm

I can put weight through my arm to stand

I am able to reach and grasp objects

I can independently hold things in my hand

I can let go of an object after holding it

I can hold a cup and bring it to my mouth

I can reach and still hold on to an object

Post Bilateral TrainingProgressive BATRAC

Post Combination TrainingProgressive BATRAC + Whole Arm

McCombe-Waller & Luft, unpublished

Brain activation changes

McCombe-Waller & Luft, unpublished

Brain activation changes

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)

–UNITRAC training! BATRAC training

! ! (6 weeks)! ! (6 weeks)

! ! One arm! ! Two arms !

! ! ! Interim testing (functional and fMRI)

Saebo training!! Saebo training

(6 weeks)! ! ( 6 weeks)

! ! Post training testing (functional and fMRI)

! ! Retention testing (functional and fMRI)

Combination Training

•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)•Premotor activation above normal is often observed in

subjects recovering after stroke (review Schaechter Prog Neurobiol

2004:73:61) •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

How do we integrate these approaches

into clinical practice and home use?

Research Lab

Clinics and Home

Accessibility

Translation to Home May Increase Practice

•BATRAC and Saebo training are accessible to clinics and patients and can translate to home use! ! ! www.anatomicalconcepts.com! ! ! www.saebo.com•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