10.8.2.1 Repetitive Transcranial Magnetic Stimulation (rTMS) Chapter 10 UPPER EXTREMITY MOTOR REHABILITATION INTERVENTIONS Marcus Saikaley BSc Griffin Pauli, MSc Jerome Iruthayarajah, MSc Magdalena Mirkowski, MSc MScOT OT Reg. (Ont.) Alice Iliescu, BSc Sarah Caughlin, PhD Niko Fragis, BSc Candidate Roha Alam, BHSc Candidate Joceyln Harris, PhD OT Sean Dukelow, MD John Chae, MD Jayme Knutson, PhD Tom Miller, MD Robert Teasell, MD www.ebrsr.com Page 1 Chapter 10: Upper Extremity Motor Rehabilitation Interventions Table of contents Key Points ................................................................................................................................... 4 Modified Sackett Scale ............................................................................................................... 7 New to the 19th Edition of the Evidence-based Review of Stroke Rehabilitation .................. 9 Outcome Measures Definitions ............................................................................................... 11 Motor Function ............................................................................................................ 11 Dexterity ..................................................................................................................... 15 Activities of Daily Living .............................................................................................. 17 Spasticity .................................................................................................................... 21 Range of Motion ......................................................................................................... 23 Proprioception ............................................................................................................ 24 Stroke Severity ........................................................................................................... 25 Muscle Strength .......................................................................................................... 26 Therapy based interventions ................................................................................................... 27 Neurodevelopmental Techniques ............................................................................... 27 Bilateral Arm Training ................................................................................................. 32 Exercise and Strength Training .................................................................................. 41 Task-Specific Training ................................................................................................ 51 Constraint-Induced Movement Therapy (CIMT) ......................................................... 58 Trunk Restraint ........................................................................................................... 73 Stretching Programs ................................................................................................... 77 Orthotics ..................................................................................................................... 80 Mirror Therapy ............................................................................................................ 87 Mental Practice ........................................................................................................... 99 Action Observation ................................................................................................... 106 Music Therapy .......................................................................................................... 110 Technology based interventions ........................................................................................... 114 Telerehabilitation ...................................................................................................... 114 Robotics.................................................................................................................... 116 Virtual Reality ........................................................................................................... 140 Brain Computer Interfaces ........................................................................................ 152 EMG Biofeedback ..................................................................................................... 157 Sensorimotor stimulation ...................................................................................................... 162 Neuromuscular Electrical Stimulation (NMES) ......................................................... 162 Transcutaneous Electrical Nerve Stimulation (TENS) .............................................. 182 Thermal Stimulation .................................................................................................. 187 Muscle Vibration ....................................................................................................... 190 Additional Afferent and Peripheral Stimulation Methods ........................................... 196 Invasive central nervous system stimulation ............................................................................. 200 Invasive Cortical and Nerve Electrode Implant Stimulation ...................................... 200 Non-invasive brain stimulation .............................................................................................. 203 Repetitive Transcranial Magnetic Stimulation (rTMS) ............................................... 203 Theta Burst Stimulation (TBS) .................................................................................. 215 www.ebrsr.com Page 2 Transcranial Direct Current Stimulation (tDCS) ........................................................ 221 Pharmaceuticals ..................................................................................................................... 236 Botulinum Toxin ........................................................................................................ 236 Steroids .................................................................................................................... 248 Cerebrolysin ............................................................................................................. 250 Levodopa .................................................................................................................. 252 Statins and Antihypertensives .................................................................................. 254 Antidepressants ........................................................................................................ 257 Central Nervous System Stimulants ......................................................................... 261 Neuroprotectants ...................................................................................................... 264 Complementary and alternative medicine ............................................................................ 267 Acupuncture ............................................................................................................. 267 Electroacupuncture and Transcutaneous Electrical Acupoint Stimulation ................ 275 Meridian Acupressure and Massage Therapy .......................................................... 280 References ............................................................................................................................... 283 www.ebrsr.com Page 3 Key Points Bobath concept approaches and motor relearning programmes may not be beneficial for upper limb rehabilitation following stroke. Brunnstrom movement therapy may be more beneficial than motor relearning programmes for upper limb function. The literature is mixed regarding bilateral arm training for upper limb rehabilitation following stroke. Bilateral arm training may not be beneficial compared to unilateral training for upper limb function. Bilateral arm training in combination with other therapy approaches may not be beneficial for upper limb rehabilitation. The literature is mixed regarding strength training and functional strength training for upper limb rehabilitation following stroke. Task-specific training, alone or in combination with other therapy approaches, may be beneficial for some aspects of upper limb function following stroke. Higher and lower intensity task-specific training may have similar effects on upper limb function. Constraint-induced movement therapy may be beneficial for upper limb rehabilitation in the chronic phase following stroke. The literature is mixed regarding constraint-induced movement therapy for upper limb rehabilitation in the subacute/acute phase following stroke. Modified constraint-induced movement therapy may be beneficial for upper limb rehabilitation in the chronic phase following stroke. Modified constraint-induced movement therapy may not be beneficial for upper limb rehabilitation in the subacute/acute phase following stroke. Higher and lower intensity constraint-induced movement therapy may have similar effects on upper limb function in the chronic phase following stroke. The literature is mixed regarding constraint-induced movement therapy in combination with other therapy approaches for upper limb rehabilitation following stoke. Trunk restraint with reaching training or distributed constraint induced therapy may improve some aspects of upper limb function following stroke, but the effect of combining trunk restraint with constraint-induced movement therapy is less clear.