By: Jennifer Brauer, OTR/L, OTD
According to the Centers for Disease Control and Prevention (2014) stroke is the leading cause of death in the United States, as every four minutes someone dies of a stroke. Occupational Therapists work with individuals who have had a stroke to help regain the motor, cognitive, sensory perceptual, social and emotional regulation skills in order to resume performance of meaningful activities. This article will take a closer look at forced use as a treatment approach for remediating movement and promoting functional use of the affected upper extremity after stroke.
Neuroplasticity refers to the brain’s ability to reorganize and develop new neural connections through areas directly adjacent to an infarct in the brain or away from the infarct on either side of the brain. Research has shown that after an initial stroke, limitations caused by that stroke have recovered; yet when the individual had another stroke on the other side of the brain the limitations from the first stroke returned. This demonstrates neuroplasticity and the brain’s ability to reorganize as one side of the brain took over function for the side of the brain with the infarct; then the regained function was lost when the individual had another stroke on the other side of the brain. Other studies suggest that persons may be asymptomatic for a neurological condition as the brain has already began to reorganize (Krakauer, 2005). Research and investigation into neuroplasticity continues to be ongoing.
Occupational Therapists’ understanding of neuroplasticity helps to justify treatment approaches aimed at remediating lost function of the upper extremity after a stroke, versus treatment approaches that teach compensatory strategies. Forced use is one treatment approach that requires the affected extremity to engage in movement over a period of time or series of repetitions.
Prior to using this approach, therapists should consider and assess the person’s vision or visual perception, tissue length, joint mobility, degree of activation or hemiparesis and cognition (Nelson, n.d.). Vision is important to assess as persons with neglect will need to improve attention to the affected extremity prior to having the recognition of the affected extremity needed to perform forced use. Also a person’s vision plays a role in the feed forward loop of anticipatory reactions and movements of the affected extremity. Addressing vision and understanding the person’s vision will help the therapist make a successful treatment plan.
Understanding any limitations with the person’s tissue length and/or joint mobility will guide the therapist in preparatory activities like stretching, muscle energy techniques, and mobilizations that need to take place in order to achieve the desired movement of the affected extremity and to help reduce compensatory movement during treatment. Knowing the degree of movement or amount of activation will allow the therapist to appropriately grade forced use activities and determine if forced use is an appropriate treatment approach at that point in recovery. Insight into cognition helps the therapist choose an appropriate context for the activity and steps to the activity.
During forced use activities therapists may observe compensatory movement control strategies caused by the brain and body attempting to accommodate for hypertonicity, hypotonicity, changes in tissue extensibility and decreased neural transmission and cortical input (Lui, McCombe Waller, Kepple, Witall, 2013). Carr and Shepherd (2000) state that the use of compensatory strategies can cause long-term functional limitations. Upper extremity movements that are not facilitated by the therapist may contribute and reinforce compensatory movements (Jeyaraman, Kathiresan, Gopalsamy, 2010). Compensatory movement control strategies have been related to level of impairment after stroke and impaired shoulder contribution during reach activities. A review of studies looked at truncal restraint as a means for reducing compensatory movement control strategies during forced use reach activities. Only one of the studies reviewed was a randomized control study. It did however show the potential for truncal restraint to reduce compensatory movement of the trunk in order to regain a functional reach of the affected extremity (Jeyaraman, Kathiresan, Gopalsamy, 2010).
Further research delves into determining the difference in efficacy between forced use as massed practice or as variable practice. In massed practice, the affected upper extremity performs a single repetitive movement for a period of time. In variable practice the movement trajectory is changed during the forced use activity. Dr. Krakauer (2005), applies motor learning theory to remediating the function of the affected upper extremity after stroke. He states, “motor learning does not need to be rigidly defined . . . it includes skill acquisition, motor adaption, such as prism adaptation and decision making.” He further goes on to state that distributed practice and task variability help improve learning and retention while contributing to the generalization of a skill (Krakauer, 2006).
Understanding the principles of neuroplasticity can influence the structuring of forced use techniques integrated into occupational therapy intervention. Multiple considerations need to be taken into account when choosing forced use a treatment technique for the recovery of movement of an upper extremity after stroke.
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Functional Treatment Ideas and Strategies in Adult Hemiplegia By: Jan Davis, MS, OTR/L
The Hemiplegic Shoulder: Practical Assessment and Intervention Strategies By: J.J. Mowder-Tinney, PT, PhD, NCS, C/NDT, CSRS
About the Author
Jennifer Brauer, OTR/L, OTD, obtained her Doctorate Degree from Creighton University. She has been an Occupational Therapist for over 5 years, with experience in inpatient rehab and acute care. Most of her clinical experience includes working with individuals who have had a brain injury or stroke. She is certified in Neuro-IFRAH. She has been published in Informa Healthcare and OT Practice. She presented a poster at NOTA on the use of the ArmeoSpring as a treatment intervention for stroke survivors. She is currently practicing on a stroke team at Immanuel Medical Center in Omaha, NE, where she is also actively involved in the education committee.
Carr, J & Shepherd, R. (2000). Movement science: Foundations for physical therapy in rehabilitation (2nd ed.). Aspen Publishers, MD: Gaithersburg.
Centers for Disease Control and Prevention. (2014). Stroke Fact Sheet. Retrieved from http://www.cdc.gov/dhdsp/data_statistics/fact_sheet/docs/fs_stroke.pdf
Jeyaraman, S., Katiresan, G., & Gopalsamy, K. (2010). Normalizing the arm reaching patterns after stroke through forced use therapy – A systematic review. Neuroscience & Medicine, 1, 20-29.
Krakauer, J. (2005). Arm function after stroke: From physiology to recovery. Seminars in Neurology, 25(4), 384-395.
Krakauer, J. (2006). Motor learning: Its relevance to stroke recovery and neurorehabilitation. Current Opinion in Neurology, 19, 84-90.
Liu, W., McCombe Waller, S., Kepple, T., & Whitall, J. (2013). Compensatory arm reaching strategies after stroke: Induced position analysis. Journal of Rehabilitation Research and Development, 50(1), 71-84.
Nelson, C. (n.d.) The concept of forced use as an element of therapy handling. Retrieved from www.clinicians-view.com/Articles/Article005.pdf
The Core Values of Occupational Therapy: Supported by Evidence-Based Task-Oriented Training for Clients with Stroke
By: Sara E. Benham, OTD, OTR/L, ATP
Upper extremity impairment is a strong focus of occupational therapy treatment for clients who have experienced stroke. It is estimated that there are over 700,000 incidents of stroke in the United States each year with 4.8 million stroke survivors alive today (AHA, 2003). Approximately 70-80% of the survivors experience upper extremity impairment (Parker, Wade, & Hewer, 1986) which impacts occupational participation. Driven by AOTA’s Centennial Vision (AOTA, 2007) members are motivated to meet the occupational needs of clients with science-driven and evidence-based interventions. Occupational therapists have multiple treatment options from which to choose regarding upper extremity impairment mitigation. Recent high-level evidence from randomized control trials (RCTs) has supported novel approaches, such as robot-assisted therapy (Wu, Yang, Chuang, Lin, Chen, Chen, & Huang, 2012) and constraint-induced movement therapy (CIMT) (Wolf, Thompson, Winstein, Miller, Blanton, Nichols-Larsen, Morris, Uswatte, Taub, Light, & Sawaki, 2010). Emerging neuroplasticity-based exercise treatments may address and improve impairment; however occupational therapy long-term goals are usually related to the client’s participation in occupation. Task-oriented training is an intervention that focuses directly on client-centered participation in functional activities.
While task-oriented training may be more aligned with the values of occupational therapy (AOTA, 2008), clients may expect to participate in traditional and potentially beneficial exercise and strength training. Motivated by the profession’s core values to integrate task-oriented occupation, this author completed a Critically Appraised Topic (CAT) focusing on how task-oriented training compares with traditional strength training to improve upper extremity function for persons with stroke. It is important to note the limitation of this CAT: It has been individually prepared and not peer-reviewed.
A focused clinical question guided the CAT: Among people with unilateral upper extremity hemiparesis, how does task-oriented upper extremity treatment compare with upper extremity strength training on improving functional upper extremity motor return as measured on the Wolf Motor Function Test (WMFT), the Fugl-Meyer (FM), and/or the Functional Test of the Hemiparetic Upper Extremity (FTHUE)? The question was summarized from a PICO question (Patient, Intervention, Comparison, and Outcome) (Lou & Durando, 2008) to intentionally guide a client-centered search for the accurate, relevant, and high-quality evidence. Clinicians should seek the highest-quality evidence from a systematic review rather than a primary RCT, if it is available.
The CAT summarized a total of five relevant, Level I studies that included two systematic reviews. A study that investigated task-oriented training as compared to strength training was identified as ‘best evidence’ because it directly related to the PICO question (Winstein, Rose, Tan, Lewthwaite, Chui, & Azen, 2004). Both functional task practice and strength training (in addition to standard occupational therapy sessions) are superior to standard occupational therapy alone with regard to improvements in functional impairment and strength. Subjects with less stroke severity demonstrated greater improvements in both functional task practice and strength training groups. Subjects who participated in functional task training continued to improve strength at follow-up.
Two publications included in the CAT concluded that task-oriented training is an effective intervention to improve functional upper extremity performance for individuals with stroke (Timmermans, Spooren, Kingma, & Seelen, 2010) at post-intervention and follow-up (Arya, Verma, Garg, Sharma, Monia, & Aggarwal, 2012). With regard to strength training, one publication concluded that it is an effective intervention to improve grip strength and upper extremity function for individuals with stroke, however does not improve ADL performance. (Harris & Eng, 2010). Another randomized control trial concluded that self-directed exercise was effective with statistical significance to improve functional use of the upper extremity at post-intervention for subjects with chronic stroke. The amount of improvement was comparable to other novel treatment approaches previously mentioned such as CIMT and robot-aided exercise training (Pang, Harris, & Eng, 2006).
The clinical bottom line is that both task-oriented training and strength training are effective treatment interventions to improve upper extremity function after stroke. The evidence suggests that task-oriented training contributes to greater functional long-term results. Emerging evidence supports task-oriented training that includes clear functional goals and random practice components to improve functional performance at follow-up (Timmermans, Spooren, Kingma, & Seelen, 2010). These findings are most significant for clients who demonstrate mild to moderate upper extremity functional impairments.
These findings support that client-directed occupational therapy treatment with a functional task focus is an effective intervention for clients with stroke. The profession of occupational therapy is built on solid principles that support goal-directed functional participation. Therefore, it seems intuitive for occupational therapists to integrate functional, task-oriented practice in neurological treatment interventions. The advantages are easy to see: The intervention is cost-effective, statistically significant, and can be applied in any treatment setting. However, the potential disadvantages of occupational therapists overlooking the consistent utilization of task-oriented treatment may be detrimental in the near future. In an editorial of the Journal of American Physical Therapy Association, Jette and Latham (2011) reported that “task-oriented training is significantly more effective at improving function than standard impairment-focused training” (p. 1709). Now, the American Physical Therapy Association’s guidelines for practice include the alleviation of impairment and functional limitation, including “functional training in self-care and home management” (APTA, 2011, p. 57). As we progress toward the Centennial Vision of 2017, it is imperative for occupational therapists to meet society’s occupational needs. It is the responsibility of every occupational therapist to protect our unique contribution of integrating occupational, task-oriented treatment in upper extremity impairment mitigation.
About the Author
Sara Benham, OTD, OTR/L, ATP is presently assistant professor at the University of the Sciences in Philadelphia. She graduated with her master’s degree in occupational therapy from the University of Indianapolis in 2006, and in 2014, obtained her doctorate degree in occupational therapy from Thomas Jefferson University. She has 8 years experience in rehabilitation; in addition, her specialization is in assistive technology and stroke rehabilitation. She obtained an advanced certification in assistive technology from the Rehabilitation Engineering and Assistive Technology Society of North America (RESNA). She has instructed an OT neuro-rehabilitation course for a rehab technician program in Haiti in the recent past. She presented at the Annual AOTA Conference in Baltimore on wellness apps appropriate for clients in an inpatient rehabilitation program.
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