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The Use of a Functional Digit Extension Splint to Promote The Integration of the Hemiparetic Hand during Activities of Daily Living. Joseph R. Padova,

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Presentation on theme: "The Use of a Functional Digit Extension Splint to Promote The Integration of the Hemiparetic Hand during Activities of Daily Living. Joseph R. Padova,"— Presentation transcript:

1 The Use of a Functional Digit Extension Splint to Promote The Integration of the Hemiparetic Hand during Activities of Daily Living. Joseph R. Padova, OTR/L Courtney Knobl, MS OTR/L

2 Conflict of Interest Statement Joseph Padova, OTR/L made the Functional Low-profile Extension Assist Splint (RELEAS) being used as a splint of discussion. Joseph Padova, OTR/L made the Functional Low-profile Extension Assist Splint (RELEAS) 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 to review some of the problem solving used to design functional splinting for stroke patients and the potential for using functional splinting as an additional option for rehabilitation. However, the intention of this presentation is to review some of the problem solving used to design functional splinting for stroke patients and the potential for using functional splinting as an additional option for rehabilitation.

3 Objectives: be able to identify at least three ways in which neuromuscular imbalances after a stroke can limit functional integration of the affected upper extremity. be able to identify at least three ways in which neuromuscular imbalances after a stroke can limit functional integration of the affected upper extremity. Analyze distal upper extremity movement patterns to help determine the potential for functional splinting as an option to improving hand function. Analyze distal upper extremity movement patterns to help determine the potential for functional splinting as an option to improving hand function. Apply at least one current neuromuscular rehabilitative technique to maximize the integration of the splinted hand during activities of daily living. Apply at least one current neuromuscular rehabilitative technique to maximize the integration of the splinted hand during activities of daily living.

4 Promote your own ideas and see if they work. Promote your own ideas and see if they work. Research it and Write about Your Results to add to the Clinical base of Knowledge. Research it and Write about Your Results to add to the Clinical base of Knowledge. Encourage to seek out ways to patent and promote what you come up with. Encourage to seek out ways to patent and promote what you come up with.

5 Conflict of Interest Statement Courtney Knobl, MS OTR/L has No conflict of interest. Courtney Knobl, MS OTR/L has No conflict of interest.

6 Demographics According to the American Heart Association there are approximately 780,000 new strokes in U.S.A each year (Heart Disease and Stroke Statistics, 2008). According to the American Heart Association there are approximately 780,000 new strokes in U.S.A each year (Heart Disease and Stroke Statistics, 2008). By best estimates as of 2005 approximately 5,800,000 stroke survivors (Heart Disease and Stroke Statistics, 2008). By best estimates as of 2005 approximately 5,800,000 stroke survivors (Heart Disease and Stroke Statistics, 2008). ½ of stroke survivors are living with upper and lower limb disabilities ( Levey, Nichols, Schmailbrock and Clark, 2001; Ottawa, 2007). ½ of stroke survivors are living with upper and lower limb disabilities ( Levey, Nichols, Schmailbrock and Clark, 2001; Ottawa, 2007).

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

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

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

10 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).

11 Is Dynamic Splinting an Option for Functional Hand Integration?

12 Functional Splinting for Spasticity Literature review showed extremely limited information

13 Interest in Functional Splinting New Interest in an old idea. New Interest in an old idea. Currently not many options for the hemiplegic upper limb. Currently not many options for the hemiplegic upper limb. Most splints are static for positioning. Most splints are static for positioning.

14 Functional Splinting For the most part are large. Not designed for full day ADL and self care use

15 Functional Splinting for the Spastic Upper Limb has Multiple Considerations

16 Hyper response of the stretch receptor occurs 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.

17 Contractures and soft tissue tightness Will be a major component determining proximally the amount of distance a person can reach and place the hand. Will be a major component determining proximally the amount of distance a person can reach and place the hand.

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

19 Quality of Motion will help Determine How well the patient can isolate movement patterns within the available AROM

20 What Joints in the Hand 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?

21 How Is It Moving? Can the moving joints produce flexion and extension? Can the moving joints produce flexion and extension? If only flexion can it relax the grip? If only flexion can it relax the grip? If only active flexion and it can relax the grip can the person produce a relaxed release? If only active flexion and it can relax the grip can the person produce a relaxed release?

22 If Fingers and Thumb Flexion, Without Extension Functional Low-profile Extension Assist Splint ( RELEAS ) may be appropriate. Functional Low-profile Extension Assist Splint ( RELEAS ) may be appropriate. Uses a neoprene thumb spica splint, Uses a neoprene thumb spica splint, Dorsal mounted flex rod, or spring-loaded outrigger. Dorsal mounted flex rod, or spring-loaded outrigger. Buddy splints to support the index and long fingers. Buddy splints to support the index and long fingers. The dynamic forces are use to open the thumb, index and long fingers following a crude pinch. The dynamic forces are use to open the thumb, index and long fingers following a crude pinch. Works best with Modified Ashworth of 2 or less. Works best with Modified Ashworth of 2 or less.

23

24 Inclusion Criteria Be oriented. Be oriented. Able to follow at least 3 step verbal, written, or demonstrated instructions. Able to follow at least 3 step verbal, written, or demonstrated instructions. Have no more than a mild left inattention to the affected body parts (this does not include learned nonuse). Have no more than a mild left inattention to the affected body parts (this does not include learned nonuse).

25 AROM Requirements At least 20 degrees arm flexion and abduction. At least 20 degrees arm flexion and abduction. Move the hand from midline to neutral external rotation. Move the hand from midline to neutral external rotation. Move the elbow from at least 50 degrees flexion to -20 of extension (extension can be eccentric or concentric). Move the elbow from at least 50 degrees flexion to -20 of extension (extension can be eccentric or concentric).

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

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

28 Inclusion Criteria Unable to volitionally open the hand. Unable to volitionally open the hand. Be able to squeeze the evaluators hand. Be able to squeeze the evaluators hand. Be able to stop squeezing when gripping the evaluators hand. Be able to stop squeezing when gripping the evaluators hand. Hand should not elicit spasticity resistance greater than a 2 on the Modified Ashworth when the digits and fingers are passively opened. Hand should not elicit spasticity resistance greater than a 2 on the Modified Ashworth when the digits and fingers are passively opened.

29 Sensation Not as clear cut yet. Not as clear cut yet. Of the 13 patients fit so far 1 could only identify deep pressure and pain. Another only had pain perception. Of the 13 patients fit so far 1 could only identify deep pressure and pain. Another only had pain perception. Both were able to visually compensate and complete all the tasks except tying bows and holding a fork. Both were able to visually compensate and complete all the tasks except tying bows and holding a fork. All tasks took increased time and physical effort. All tasks took increased time and physical effort.

30 13 patients fitted with the RELEAS 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 CVA 1 was 20 years post CVA All had extensive acute rehabilitation and out patient physical and occupational therapy through the years. All had extensive acute rehabilitation and out patient physical and occupational therapy through the years.

31 AROM Summary: Amount of ranges varied: AROM Summary: Amount of ranges varied: Between 20 and 80 degrees arm flexion Between 20 and 80 degrees arm flexion Between 20 to 60 degrees external rotation Between 20 to 60 degrees external rotation Between 20 to 125 degrees elbow flexion. Between 20 to 125 degrees elbow flexion. Supination from full pronation varied from -15 degrees from neutral to 69 degrees. Supination from full pronation varied from -15 degrees from neutral to 69 degrees. Varied from – 30 of a neutral wrist to 45 degrees wrist extension. Varied from – 30 of a neutral wrist to 45 degrees wrist extension. 10 had a Modified Ashworth in the finger flexors of two; 2 had one plus; 1 had a one. 10 had a Modified Ashworth in the finger flexors of two; 2 had one plus; 1 had a one.

32 Continued All could demonstrate the ability to control the movement patterns to touch the intact hand with the opposite hand at midline. All could demonstrate the ability to control the movement patterns to touch the intact hand with the opposite hand at midline. 0 could open the hand. 0 could open the hand. All could recruit and relax the flexors of the hand All could recruit and relax the flexors of the hand 0 could integrate the hand other than a gross stabilizer with the fist. 0 could integrate the hand other than a gross stabilizer with the fist.

33 Following RELEAS fabrication and average of 15 training sessions AROM of the proximal U.E. and the Modified Ashworth measurement remained approximately unchanged. AROM of the proximal U.E. and the Modified Ashworth measurement remained approximately unchanged. However with the RELEAS all could integrate the affected hand for grasp, pinch, placement and release. However with the RELEAS all could integrate the affected hand for grasp, pinch, placement and release.

34 Out of 13 Fitted with RELEAS for assisted pre-grasp, active grasp and assisted release Able to complete task with RELEAS Unable to complete task with RELEAS Able to complete task without RELEAS Hold paper while folding940 Hold open and stuff envelope940 Hold coupon sheets while cutting940 Pinch and rip open salt/sugar packets940 Open and apply bandage940 Hold and pull up pants/underpants940 Stabilize bowl while mixing940 Hold and release clothing/linen when folding 940

35 Continued 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 940 Hold fork and stabilize thin meats when cutting 670 Stabilize handles of pots and pans when cooking at the stove 670 Integrate the hand to help push a shopping cart 670 Tie bows on sneakers2110

36 Training Time Variable due to patients personal goals. Variable due to patients personal goals. Ranged from 12 to 26 sessions depending on the complexity of the case to achieve independent integration level for appropriate tasks. Ranged from 12 to 26 sessions depending on the complexity of the case to achieve independent integration level for appropriate tasks. Relatively short time span considering not being able integrate a volitional hand component for years since the initial stroke. Relatively short time span considering not being able integrate a volitional hand component for years since the initial stroke.

37 Case study 1: R.H.

38 The patient 33 year old female s/p L CVA (04/05) 33 year old female s/p L CVA (04/05) Resulting R hemi paresis Resulting R hemi paresis R hand dominant R hand dominant

39 R UE presentation Decreased isolated active movement, increased spasticity Decreased isolated active movement, increased spasticity Good attention to R UE Good attention to R UE Sensation grossly intact to light touch Sensation grossly intact to light touch

40 In the past, pt has… Been through extensive in/outpatient rehab Been through extensive in/outpatient rehab Trialed multiple interventions (Saebo, Neuromove) Trialed multiple interventions (Saebo, Neuromove) Reported improved arm motion, but not hand function Reported improved arm motion, but not hand function Had botox injections in finger flexors Had botox injections in finger flexors Produced no volitional extension for pre grasp/release Produced no volitional extension for pre grasp/release

41 Video of R UE ROM

42 Clinical Reasoning for Initiating RELEAS Training: It is the hand that guides the arm rather than the other way around (Gordon, 1987). It is the hand that guides the arm rather than the other way around (Gordon, 1987).

43 Enable Functional Task Participation Functional task participation more favorable than exercise program Functional task participation more favorable than exercise program Positive changes in hemiparetic UE when incorporated into tasks Positive changes in hemiparetic UE when incorporated into tasks Functional tasks typically require use of both hands Functional tasks typically require use of both hands Recovery maximized through bimanual task training Recovery maximized through bimanual task training Simultaneously address other impairments (Davis, 2006). Simultaneously address other impairments (Davis, 2006).

44 Cortical reorganization Use dependent cortical reorganization (Gillan, G., 2011) Use dependent cortical reorganization (Gillan, G., 2011) Results from increased use of body part Results from increased use of body part Leads to enhanced representation in cerebral cortex and reverses disadvantageous cortical reorganization Leads to enhanced representation in cerebral cortex and reverses disadvantageous cortical reorganization Structural cortical changes (Gauthier, et al. 2007) Structural cortical changes (Gauthier, et al. 2007) Amount of UE use can alter brain activity or activation pattern Amount of UE use can alter brain activity or activation pattern

45 Facilitate Repetition for Motor Learning Repetitions of specific UE movements produce lasting neural changes and optimize motor learning (Lang, et al., 2009). Repetitions of specific UE movements produce lasting neural changes and optimize motor learning (Lang, et al., 2009).

46 Outpatient OT Goals Pt will: Pt will: Demonstrate increased right shoulder flexion AROM by 20° Demonstrate increased right shoulder flexion AROM by 20° Be I with updated HEP Be I with updated HEP And… And…

47 With RELEAS, pt will integrate R UE to bimanually: Open small ziploc bags and water bottles Open small ziploc bags and water bottles Open and apply bandages Open and apply bandages Open sealed envelope Open sealed envelope Fold paper and stuff into envelope Fold paper and stuff into envelope Apply toothpaste to toothbrush Apply toothpaste to toothbrush

48 Within 10 sessions, pt able to: Rip sugar packets Rip sugar packets Cut coupons with scissors Cut coupons with scissors Rip and apply bandage Rip and apply bandage Open toothpaste container and apply to toothbrush Open toothpaste container and apply to toothbrush Fold paper and stuff into envelope Fold paper and stuff into envelope Open sealed envelope Open sealed envelope Stabilize pot on stove and stir Stabilize pot on stove and stir Manipulate zipper and zip/unzip jacket Manipulate zipper and zip/unzip jacket

49 Cutting with Scissors

50 Opening bandage

51 Within 15 sessions Pt was able to: Pt was able to: Hang shirt on hanger and remove Hang shirt on hanger and remove Use R hand to stabilize bowl while stirring Use R hand to stabilize bowl while stirring Fold towel and shirt Fold towel and shirt Sweep floor holding broom with both hands Sweep floor holding broom with both hands

52 Sweeping

53 Pts subjective view… This splint is so functional This splint is so functional Reported previously unable to incorporate right upper extremity into functional tasks Reported previously unable to incorporate right upper extremity into functional tasks And now I dont have to think about it - I just incorporate my right hand into tasks And now I dont have to think about it - I just incorporate my right hand into tasks

54 Case 2 H.

55 Case Study 3: M.N.

56 The patient… 49 year old right handed female s/p R CVA (10/08) with resulting left hemiparesis 49 year old right handed female s/p R CVA (10/08) with resulting left hemiparesis Mod I ambulation with quad cane, transfers Mod I ambulation with quad cane, transfers Mod I ADLs (one handed techniques) Mod I ADLs (one handed techniques) Intermittent A with IADLs Intermittent A with IADLs

57 Performance deficits L hemi: no integration of L UE into any tasks L hemi: no integration of L UE into any tasks Gaze preference to right side Gaze preference to right side Deficits with attention, problem solving, memory, organization Deficits with attention, problem solving, memory, organization Deficits with visual organization, visual memory Deficits with visual organization, visual memory

58 Initial L UE status – 3/09 Decreased active movement Decreased active movement Available active movement was not functional Available active movement was not functional Poor isolation Poor isolation Increased tone Increased tone Able to grasp flat object when placed into hand Able to grasp flat object when placed into hand Unable to release object Unable to release object Sensation to light touch grossly intact Sensation to light touch grossly intact

59 Goals Pts goal: To use this left arm Pts goal: To use this left arm Goals agreed upon with pt: Goals agreed upon with pt: Increase L UE PROM/AROM Increase L UE PROM/AROM I with home program I with home program Utilize L UE as gross A with basic functional bimanual tasks (ie: opening containers) Utilize L UE as gross A with basic functional bimanual tasks (ie: opening containers)

60 By discharge, with RELEAS, pt was able to: Bring left upper extremity to midline Bring left upper extremity to midline Grasp/release objects with left hand Grasp/release objects with left hand Maintain grasp on container with left hand while placing object in container with right hand Maintain grasp on container with left hand while placing object in container with right hand Open containers bimanually at midline Open containers bimanually at midline

61 Functional Task Completion without RELEAS

62 Functional Task Completion with RELEAS

63 Plan of care following discharge Instructed to continue with use of RELEAS program at home Instructed to continue with use of RELEAS program at home Patient to return to outpatient OT several months later to further progress her L UE Patient to return to outpatient OT several months later to further progress her L UE Referred to OT again in 10/09 Referred to OT again in 10/09

64 Goals established on OT eval, 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 feet Utilize L UE to carry bag ( 5#) for twenty feet Utilize B UEs to manipulate zipper Utilize 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 task Utilize B UEs to complete ironing task Utilize L UE to A with cooking task Utilize L UE to A with cooking task

65 Functional task completion

66 Patients active range of motion 10/30/094/12/10 Shoulder flexion30°89° Shoulder external rotation7°38° Elbow flexion111°124° Elbow extension-16° Digit extension¼ range second digit; 0° remaining digits ½ range second digit; ¼ range remaining digits Thumb extension¼ range¾ range

67 Effective bimanual completion of functional 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

68 Patients subjective view… Patient loved coming to OT. Patient loved coming to OT. Frustration with slow recovery of L UE function Frustration with slow recovery of L UE function However, reported working with RELEAS gave her hope for this hand… However, reported working with RELEAS gave her hope for this hand… Patient increasingly able to problem solve with OT on ways to incorporate L UE into tasks Patient increasingly able to problem solve with OT on ways to incorporate L UE into tasks

69 Final Findings Increased initiation and use of L UE with functional tasks Increased initiation and use of L UE with functional tasks Improved L UE active range of motion Improved L UE active range of motion Able to learn all tasks Able to learn all tasks Increased time required, but pt improved on all tasks with repetition and practice Increased time required, but pt improved on all tasks with repetition and practice

70 Implications Improved digit extension as a result of consistent use of L UE? Improved digit extension as a result of consistent use of L UE? Improved attention to left, although no objective testing done pre and post Improved attention to left, although no objective testing done pre and post Active movement as a means to improve unilateral neglect (Gillan, G., 2009) Active movement as a means to improve unilateral neglect (Gillan, G., 2009)

71 Conclusion Functional splinting is a relatively new concept in stroke and brain injury rehabilitation. Functional splinting is a relatively new concept in stroke and brain injury rehabilitation. Due to the diverse symptoms of hemiplegia, including weakness, orthopedic considerations, spasticity variations and cognitive/perceptual and sensory deficits it is unlikely that one type of splint will be appropriate for all. Due to the diverse symptoms of hemiplegia, including weakness, orthopedic considerations, spasticity variations and cognitive/perceptual and sensory deficits it is unlikely that one type of splint will be appropriate for all. Appropriate splint choice and functional outcome is enhanced by a team approach to manage complex cases. Appropriate splint choice and functional outcome is enhanced by a team approach to manage complex cases. The type of splint that once was appropriate may change as the patient changes over time. The type of splint that once was appropriate may change as the patient changes over time.

72 Conclusion Functional splinting is a relatively new concept in stroke and brain injury rehabilitation. Functional splinting is a relatively new concept in stroke and brain injury rehabilitation. Due to the diverse symptoms of hemiplegia, including weakness, orthopedic considerations, spasticity variations and cognitive/perceptual and sensory deficits it is unlikely that one type of splint will be appropriate for all. Due to the diverse symptoms of hemiplegia, including weakness, orthopedic considerations, spasticity variations and cognitive/perceptual and sensory deficits it is unlikely that one type of splint will be appropriate for all. Appropriate splint choice and functional outcome is enhanced by a team approach to manage complex cases. Appropriate splint choice and functional outcome is enhanced by a team approach to manage complex cases. The type of splint that once was appropriate may change as the patient changes over time. The type of splint that once was appropriate may change as the patient changes over time.

73 References 1. Heart Disease and Stroke Statistics 2008 Update, American Heart Association, Dallas, Texas, 2008. 1. Heart Disease and Stroke Statistics 2008 Update, American Heart Association, Dallas, Texas, 2008. 2. Levey CE, Nichols DS, Schmalbrock PM, Chaker DW. Functional MRI Evidence of Cortical Reorganization in Upper Limb Stroke Hemiplegia Treated with Constraint-Induced Movement Therapy. American Journal of Physical Medicine and Rehabilitation. 2001;80:4-12. 2. Levey CE, Nichols DS, Schmalbrock PM, Chaker DW. Functional MRI Evidence of Cortical Reorganization in Upper Limb Stroke Hemiplegia Treated with Constraint-Induced Movement Therapy. American Journal of Physical Medicine and Rehabilitation. 2001;80:4-12. 3. Ottawa Panel Evidence-Based Clinical Practice Guide Post Stroke Rehabilitation. Available at http://www.accessmylibary.com/com/coms2/summary_0286-17446379_ITM. Accessed May 22,2007. 3. Ottawa Panel Evidence-Based Clinical Practice Guide Post Stroke Rehabilitation. Available at http://www.accessmylibary.com/com/coms2/summary_0286-17446379_ITM. Accessed May 22,2007. http://www.accessmylibary.com/com/coms2/summary_0286-17446379_ITM. Accessed May 22,2007 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 Chronic Stroke Exhibiting Minimal Movement Ability in the Affected Arm. Physical Therapy. 2007;87:872-878. 4. Page S, Levine D. Modified Constraint-Induced Movement Therapy in Patients With Chronic Stroke Exhibiting Minimal Movement Ability in the Affected Arm. Physical Therapy. 2007;87:872-878. 5. Functional Tone Management Arm Training Program featuring the Saeboflex TM Orthosis, A Novel Approach for Treating the Neurologically Impaired Upper Extremity. Workshop at MossRehab Hospital Elkins Park, 2006. 5. Functional Tone Management Arm Training Program featuring the Saeboflex TM Orthosis, A Novel Approach for Treating the Neurologically Impaired Upper Extremity. Workshop at MossRehab Hospital Elkins Park, 2006. 6. Saebo No Plateau in Sight. Available at http://www.saebo.com/seaboflex.html. Accessed January 6,2008. 6. Saebo No Plateau in Sight. Available at http://www.saebo.com/seaboflex.html. Accessed January 6,2008.http://www.saebo.com/seaboflex.html 8. Ness H200TM. Available at http://www.bionessinc.com/products/h200.htm. Accessed January 6,2008. 8. Ness H200TM. Available at http://www.bionessinc.com/products/h200.htm. Accessed January 6,2008.http://www.bionessinc.com/products/h200.htm. Accessed January 6http://www.bionessinc.com/products/h200.htm. Accessed January 6 9. Phelan C. The Journey of a New Product Designed and Invented by an O.T. Exploring Hand Therapy. Available at http://www.handtherapy.com/magazine.asp. Accessed January 8,2007. 9. Phelan C. The Journey of a New Product Designed and Invented by an O.T. Exploring Hand Therapy. Available at http://www.handtherapy.com/magazine.asp. Accessed January 8,2007.http://www.handtherapy.com/magazine.asp. Accessed January 8,2007http://www.handtherapy.com/magazine.asp. Accessed January 8,2007 9. Bohannon RW, Smith MB: Interrater reliability of a modified Ashworth Scale of muscle spasticity. Phys Ther 1987; 67(2);206-207. 9. Bohannon RW, Smith MB: Interrater reliability of a modified Ashworth Scale of muscle spasticity. Phys Ther 1987; 67(2);206-207. 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: 220-227, 1992. 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: 220-227, 1992.

74 References Davis, J.Z. (2006). Task selection and enriched environments: a functional upper extremity training program for stroke survivors. Topics in Stroke Rehabilitation, 13(3), 1-11. Davis, J.Z. (2006). Task selection and enriched environments: a functional upper extremity training program for stroke survivors. Topics in Stroke Rehabilitation, 13(3), 1-11. Gauthier, L.V., et al. (2007). Remodeling the Brain: Plastic Structural Brain Changes Produced by Different Motor Therapies After Stroke. Stroke, 39(5): 1520-1525. Gauthier, L.V., et al. (2007). Remodeling the Brain: Plastic Structural Brain Changes Produced by Different Motor Therapies After Stroke. Stroke, 39(5): 1520-1525. Gillan, G. (2009). Adult Onset Apraxia and Unilateral Neglect Syndromes: An Overview. Presented on Sept 19, 2009 at Moss Rehab Hospital, Philadelphia PA. Gillan, G. (2009). Adult Onset Apraxia and Unilateral Neglect Syndromes: An Overview. Presented on Sept 19, 2009 at Moss Rehab Hospital, Philadelphia PA. 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), 1000-1019. 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), 1000-1019. Schweghofer, N., et al., (2009). A Functional Threshold for Long-Term Use of Hand and Arm Function Can be Determined: Predictions From A Computational Model and Supporting Data From the Extremity Constraint-Induced Therapy Evaluation (EXCITE)Trial. Physical Therapy. Schweghofer, N., et al., (2009). A Functional Threshold for Long-Term Use of Hand and Arm Function Can be Determined: Predictions From A Computational Model and Supporting Data From the Extremity Constraint-Induced Therapy Evaluation (EXCITE)Trial. Physical Therapy. Woldag, H and Hummelsheim, H. (2002). Evidence-based physiotherapeutic concepts for improving arm and hand function in stroke patients. Journal of Neurology, 249:5, pp 518-528. Woldag, H and Hummelsheim, H. (2002). Evidence-based physiotherapeutic concepts for improving arm and hand function in stroke patients. Journal of Neurology, 249:5, pp 518-528.


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