Unlocking the Hand: The Changing Technology of Upper-Limb Orthotic Management for Stroke Patients

NESS H200. Photograph courtesy of Bioness . The human hand, with its intricate complex of functions and sensitivity, serves as a kind of key to the human world. Without it, we have limited access to an endless array of human tools—doorknobs and shirt buttons, steering wheels and credit cards. Without use of the forearm and shoulder, we lose our long primate reach, the use of the limb to defend ourselves, and even the ability to hug. For survivors of stroke, paralysis and spasticity of the upper limb are two of the most common and frustrating results of the event. In a survey published in International Rehabilitation Medicine , 24 percent of stroke survivors were found to have moderate or severe upper-limb paralysis three months after the event; five percent had shoulder pain; eight percent had restricted passive shoulder movement, and 17 percent had some paralysis of the dominant arm (Parker VM, Wade DT, Langton Hewer R. Loss of arm function after stroke: measurement, frequency, and recovery. Int Rehabil Med. 1986;8(2):69-73). However, this is a serendipitous time in the world of upper-limb orthotic care for post-stroke patients. A variety of game-changing technologies are becoming more available, and static splinting of the affected limb, perhaps the most common orthotic treatment, is now being critically re-evaluated. This article provides a window into some important current research and techniques for upper-limb post-stroke treatment. Two-Tiered Perspective Steve Page Steve Page, PhD, is an associate professor in the departments of Rehabilitation Sciences, Physical Medicine and Rehabilitation, Neurosciences, and Neurology at the University of Cincinnati Academic Medical Center, Ohio, and is the author of more than 60 peer-reviewed papers on innovative post-stroke management of the upper limb. Page sees post-stroke care as requiring two fundamental priorities: first, to prevent negative secondary effects of the stroke from progressing, and second, to regain function. "Once you have contractures and spasticity, people probably won't use the arm a heck of a lot, and you can see reduced bone density, with the bones and muscles actually getting smaller.... So the first thing that you want to do is to prevent that. And the second thing is to have function returned—you want the patients to still use the arm functionally so that the brain rewires and you see changes in its function. Those are the two things that you're shooting for." Keith M. Smith Keith M. Smith, CO, LO, FAAOP, president of the American Academy of Orthotists and Prosthetists (the Academy) says, speaking as an individual practitioner and not for the Academy, "The orthotist needs to focus on using the best orthosis to get the patient back to as much function as possible. This does not mean to force the joint into a position that the joint won't go to. Rather, it means to be very efficient with orthosis design. It means to take a step back and look at the tools available and develop a plan to gain or maintain ROM [range of motion] and then to use orthoses also to increase function.... The most important aspect for an orthotist to remember is that goals need to be established by the rehab team—the physiatrist, the physical therapist, and the orthotist." He emphasizes, "The most common mistake that orthotists make is to ignore the ROM issues.... My position is that when treating the upper extremity in CVA, it is essential to address any lack of ROM and/or hypertonicity prior to setting goals of functional positioning or functional use. This approach prevents the error of fitting an orthosis that is uncomfortable or causes too much pressure from trying to position a joint that is not ready to be in that position." A Tarnished Gold Standard? Perhaps the most commonly used devices for post-stroke upper-limb treatment are static hand and arm splints. According to Ramon Lansang, MD, consulting staff member of the department of Orthopedics at the Charleston Area Medical Center, North Carolina, both dynamic (functional) and static orthoses are designed to help serve Pages' two priorities. Static devices for the hand, such as thumb spica splints, are meant to prevent deterioration by reducing flexor tone, thereby preventing and correcting contractures. Devices that are static but flexible, such as antispasticity ball splints for the hand and Lycra-based orthoses for the arm, may prevent tissue damage by allowing safe, but controlled, spasms while also preventing contractures ("Upper Limb Orthotics," emedicine.com, emedicine.medscape.com/article/314774-overview . Accessed August 3, 2009). FirstFlex. Photograph courtesy of Ultraflex Systems . However, whether any of these devices actually prevent deterioration and increase functional ability in the long term stands as a bone of contention in the profession. Page says, "Splinting's really the gold standard treatment that everyone uses, but the research is showing it doesn't do a thing, at least in stroke.... There is no evidence to suggest it reduces spasticity; in fact, there is negative evidence that shows that it does not reduce spasticity." Smith does emphasize that dynamic orthoses, particularly in conjunction with botulinum-toxin (Botox®) injections, allow the care team to address ROM issues as part of the care plan. Botox reduces flexor tone without causing the systemic effects that Baclofen causes, and it creates a window of opportunity in which range of motion can be increased. Then, Smith contends, "Dynamic orthoses, such as the Ultraflex, allow the patient or caretaker to don an orthosis, unlock it, and allow a constant force to be applied to the affected joint with the goal being to increase ROM. Another option is to use a static progressive orthosis such as a Step-Lock™ design or Monodos™ design that allows the patient or caretaker to don an orthosis in one position and then to manually place it into a better position of stretch. A short time later, the position can further change as increased ROM is achieved. The difference between the two scenarios is that the dynamic allows the orthosis to be donned and unlocked while the static progressive relies on the patient or caretaker to position it under stretch." Newer Options Neuromove. Photograph courtesy of Zynex . Page and his colleagues at the University of Cincinnati Academic Medical Center have conducted extensive research on the promise of what Page calls "restorative technologies," rehabilitation techniques and devices that can both improve function and prevent deterioration in stroke patients' upper-limb function. Functional Electrical Stimulators One device that shows clinical benefit in increasing function is the NESS H200, by Bioness, Valencia, California. The NESS H200 is a functional electrical stimulation (FES) device comprising an orthosis and a controller. Electrodes in the orthosis stimulate peripheral nerves to activate forearm and hand muscles, helping to eventually restore some independent movement. A similar device, FirstFlex, is a brace by Ultraflex Systems, Pottsdown, Pennsylvania, that is designed for pediatric patients with cerebral-palsy-induced spastic hemiplegia. Page says that he and his team have shown in still-unpublished research that it can also reduce spasticity and increase function in adult patients. Robot-Mediated Therapies Armeo. Photograph courtesy of Hocoma AG . Robot-mediated therapies also show some promise for stroke patients. Robotic devices can assist a weakened arm through a movement without using electrical stimulation. Over periods of as little as three weeks with three hours of therapist-guided treatment per weekday, such devices have been shown to provide long-lasting improvement in range of motion, spasticity, and task-completion rates. A large-scale, office-based device with proven effectiveness is the Armeo® by Hocoma AG, Volketswil, Switzerland. The Myomo® by Myomo Inc., Boston, Massachusetts, provides results similar to the Armeo's but in a lightweight, portable device that costs as little as two percent of the price of office-based devices. Modified Constraint-Induced Therapy Another relatively inexpensive technique that has been repeatedly shown to improve function for stroke patients is modified constraint-induced therapy (mCIT), also pioneered by Page and his colleagues. In mCIT, hemiplegic stroke patients practice using their affected hand under the direction of a trained therapist for 30 minutes, three days a week. At home, they wear a mitt and brace on their unaffected hand, curbing its use during the busiest five hours of their waking day, five days per week. The regimen lasts ten weeks and provides as much benefit as the original constraint-induced movement therapy (CIMT), which required 12 times as much in-office practice and about three times as much home practice. (Editor's note: For more information on CIMT, see " Post-Stroke Recovery: Helping the Brain Fight Back ," Mind-Based Therapies A number of important innovations are "all in the patient's head." For example, Page's team recently combined mCIT with mental practice to generate even stronger results. Page says, "We've known since the 1930s or '40s that the same muscles are fired during mental imagery as during physical practice...and with the advent of neuroimaging, we now know that the same parts of the brain are lighting up as well." Biofeedback, in which patients use a monitor to track and improve very weak muscle signals, has also been shown to be effective. The Cleveland Clinic, Ohio, recently conducted a phase 3 trial in which 89 patients successfully used the Neuromove® by Zynex, Littleton, Colorado, to significantly improve post-stroke arm functioning. The Neuromove is used in a clinical or home setting, where the patient, wearing electrodes attached to the Neuromove, concentrates on moving the muscle until their neural signals reach a "goal" threshold and the Neuromove stimulates the muscle to finish the movement. These technologies, from the device-based to the purely mental, are only a glimpse of the devices and methods that are currently providing stroke patients with better lives than at any previous time in history. With their help, stroke patients have a better chance to unlock the upper limb and all its capabilities. Morgan Stanfield can be reached at linkEmail('morgan','opedge.com');

Unlocking the Hand: The Changing Technology of Upper-Limb Orthotic Management for Stroke Patients

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