In this ppt we have included stroke and its types and causes and advanced orthotic management of stroke for upper extrimity. like shoulder orthosis, elbow orthosis, wrist and hand orthosis and also electrical stimulation. also the biomechanics of shoulder orthosis and elbow and wrist hand orthosis also included.

1. ADVANCED UPPER LIMB ORTHOTIC
MANAGEMENT IN STROKE
DIBYA RANJAN SWAIN
MPO
SVNIRTAR

2. Contents
• Definition
• Risk factors of stroke
• Aetiology
• Classification
• Signs and symptoms
• Diagnosis
• Treatment
• Limb synergy
• Orthotic management
• Role of orthosis
• Orthotic classification
• Biomechanics
• Advancement in orthosis
• Robotics in stroke management
• Adaptations
• References

3. Definition
Stroke, or cerebrovascular accident (CVA),
describes a variety of disorders characterized
by the sudden onset of neurological deficits
caused by vascular injury to the brain.

5. Aetiology
• There are 3 main causes of stroke:
 a blocked artery (ischemic stroke)
 leaking or bursting of a blood vessel
(hemorrhagic stroke).
temporary disruption of blood flow to the
brain, known as a transient ischemic attack
(TIA).

6. Classification
• Strokes are usually classified by the
mechanism and location of the vascular
damage.
• The two broad types are
Ischemic
Hemorrhagic

8. Ischemic stroke
• Ischemic stroke is the most common form of stroke, mostly 85%.
• This type of stroke is caused by blockage or narrowing of the
arteries that provide blood to the brain, resulting in
ischemia“severely reduced blood flow”
Causation:-
• These blockages are caused by the blood clots and clots can be
caused by the fatty deposits within the arteries called plaque.

9. Haemorraghic stroke
• Hemorrhagic strokes result from a rupture of a weakened cerebral blood
vessel.
• Hemorrhagic strokes are either
 intracerebral (bleeding into the brain itself) or
 subarachnoid (bleeding into an area surrounding the brain)
Causation:
• Uncontrolled high blood pressure
• Overtreatment with blood thinners (anticoagulants)
• Bulges at weak spots in blood vessel walls (aneurysms)
• Trauma (such as a car accident)
• Protein deposits in blood vessel walls that lead to weakness in the vessel
wall (cerebral amyloid angiopathy)
• Ischemic stroke leading to hemorrhage.

11. Transient ischemic attack
• It is sometimes known as a ministroke - is a temporary period of symptoms
similar to those in a stroke.
• A TIA doesn't cause permanent damage.
Causation:-
• A TIA is caused by a temporary decrease in blood supply to part of the brain,
which may last as little as five minutes.
• Like an ischemic stroke, a TIA occurs when a clot or debris reduces or blocks
blood flow to part of the nervous system

12. SIGNS & SYMPTOMS OF STROKE
• Sudden numbness or weakness in the face, arm, or leg,
especially on one side of the body.
• Sudden confusion, trouble speaking, or difficulty
understanding speech.
• Sudden trouble seeing in one or both eyes.
• Sudden trouble walking, dizziness, loss of balance, or lack of
coordination.
• Sudden severe headache with no known cause.

13. DIAGNOSIS
• Stroke happens fast and will often occur before an
individual can be seen by a doctor for a proper
diagnosis.
• B.E.F.A.S.T is the way to remember the signs of stroke
and can help identify the onset of stroke more quickly:

14. Medical diagnosis:-
After seeing the preliminary signs & symptoms of stroke patient is shifted
immediately to the hospital for further investigation to rule out the cause of stroke.
1.Physical examination:
Blood pressure(BP)
Heart rate(HR)
Neurological tests
2.Blood tests
3.Computerized Tomography(CT)Scan
4.Magnetic resonance imagaing(MRI)
5.Carotid ultrasound
6.Cerebral angiogram
7.Echocardiogram

15. TREATMENT
1.MEDICAL MANAGEMENT
 Supportive management
-Maintenance of airways and ventilation
-Temperature
-Blood sugar
-Cardiac assessment
 Thrombolysis
-Intravenous/Intra-arterial
 Administration of anti platelet and anticoagulant drugs
 Hemodilution
 Neuroprotective Agents
 Edema reduction
 Use of anasthetic nerve blocks and phenol nerve blocks
 Chemodenervation
Spasticity release

16. 2.Surgical Management
• Removal of a clot or shunting of ventricular fluid.
• Intracranial or extra cranial bypass surgery.
• Surgical decompression of cerebellar hematoma.
3.Therpeutic management
• Techniques of Treatment: Approximately 48 hours after stroke, if patient is
medically stable and alert, and there is no progression of the deficit, bedside
physical and occupational therapy may be started. The program depends on
the level of recovery of the patient.

17. WHAT ARE THE BRUNNSTROM STAGES OF
STROKE RECOVERY?
• The brunnstrom stages is one of the most well-known stroke
recovery stages which is also known as the Brunnstrom approach.
• Developed by physical therapist Signe Brunnstrom in the 1960’s.
• This approach describes the sequence of motor development and
reorganization of the brain after stroke.

19. • Basic Limb Synergies
 Synergy is a pattern of muscles contracting in a stereotyped predictable pattern
in hemiplegics or cerebral palsy patients due to loss of inhibitory control
normally exerted by higher centers in the brain.
 In the upper limb the flexor synergy and in the lower limb the extensor synergy
patterns are commoner.
• The patterns are as follows:
Upper Limb Synergy Patterns: Flexor Synergy
Scapular retraction/elevation
Elbow flexion
Wrist and fingers flexion
Lower Limb Synergy Pattern: Extensor Synergy
Hip extension
Hip adduction & internal rotation
Knee extension
Ankle plantar flexion and inversion, tending to equinovarus
Toe plantar flexion

21. Assessment and evaluation form

22. Orthotic management
 The use of orthotics is one set of tools in the effort to:-
 Restore range of motion
 Soft tissue flexibility
 Agonist–antagonist muscle balance
 Improves function of the upper extremity
 Orthotic designs ranges from robust immobilization to incremental
facilitation of range of motion on a joint-by-joint basis.
 Robust immobilization, such as casting, is used early and has the benefits of
 Overcoming severe spasticity.
 Decreasing the amount of user error by the wearer or caregiver.

23. BASIC ROLE OF ORTHOSIS
• Use to maintain or increase the length of the soft tissues by
preventing or lengthening shortened tissues.
• Used to correct biomechanical malalignment, restoring muscles to
normal resting length and protecting joint integrity.
• Used to position the hand to assist in functional activities.
• Used to promote independence in specific areas of occupation.
• Compensate for weakness by providing external support .

24. USES OF ORTHOTIC DEVICES
• Contracture Prevention
• Orthoses as Reinforcements after Chemodenervation
• Contracture correction
• Maintaining limb position
• Functional aids

25. a) Contracture Prevention
Neurogenic shock often occurs directly after stroke or brain injury. Over the
following few weeks, spasticity develops in parallel with neurologic recovery.
• In this period, a combination of oral antispasmodics, peripheral nerve blocks,
and casting or splinting techniques are commonly used to give temporary relief
of spasticity.
• Positioning a limb in a desired position is important.
• Casting maintains muscle fiber length, protects the limb, and diminishes
muscle tone by decreasing sensory input.
• Cast are commonly used to treat pressure sore.

26. b) Orthoses as Reinforcements After
Chemodenervation
• When a botulinum toxin injection is injected, an orthotic device can be
used to maintain the injected muscles in a stretched position to enhance the
effect of BT .
• In this case, progressive or serial orthosis used to increase the amount of
stretch.
• The use of injection and orthosis can be an intermediate and transitory
phase before surgery.

27. c) Contracture correction
•Restoration of joint range of motion or contracture correction can be achieved
with serial casting at weekly intervals.
•Surgical management helps in manipulating the joint under anesthesia beyond
soft tissue endpoints.
•After this, a cast may be applied to allow the limb to heal in its new position.
• A major correction in joint position can be achieved directly through manipulation
and application of orthosis.

28. d) Maintaining Limb Position
• When the desired limb position has been achieved by serial or
dropout casts, bivalved casts are frequently used.
• Bivalved cast or splint is important because it is more comfortable
than a traditional circular cast and can be removed several times a day
to perform joint range of motion and skin care.
• Bivalved casts or splints are inadequate for severe spasticity because
they do not have enough inherent stability and may increase the risk
for skin and soft tissue injury.

29. e)Functional aids
•Orthotics can be used to improve or assist function by positioning
the limb for use.
• Lap boards, arm slings, and other positioning devices should be
considered as well as more conventional orthoses.
•These devices are usually very practical and often improve patient
comfort.

30. Orthotic classification
Function Region
Static Orthoses
Dynamic /Functional Orthoses
Static progressive Orthoses
Serial cast/Serial Orthoses
Shoulder Orthoses
Elbow Orthoses
Wrist and Hand Orthoses
Finger and Thumb Orthoss

31. 1. Static orthosis
 Rigidly immobilize one or more joints
and do not allow any motion.
 Used for fractures and nerve injuries in
the postsurgical phase.
 Able to overcome severe spasticity
 Distribute pressure equally along all
contact points.
 Facilitates attachment point for
assistive devices (eating utensils, pens)

32. 2. Dynamic /Functional Orthoses
 Allow a prescribed amount of motion across
one or more joints.
 Design- Hinged and
may or may not have a spring or
elastic force
 Encourages rotation about the joint.
 Use
- Assist movement of relatively weak
muscles.
- Provide a corrective force across a joint
to encourage normal movement
patterns.
- Agonist–antagonist muscle balance.

33. 3. Static progressive Orthoses
 Incorporate non-elastic components to apply force across a joint to hold it
at its end range position to improve passive joint range of motion.
 Allow incremental changes in joint position as the end range of the
affected joint improves over time.

34. 4. Serial cast/Serial Orthoses
 These are static casts or splints applied
over time.
 Accomplishes a prolonged passive stretch
over time and blends the durability and
reliability of casting.

35. HOW STROKE AFFECTS SHOULDER
• Hemiplegia from stroke causes significant impairment of the shoulder
girdle.
• Painful shoulder syndromes, called hemiplegic shoulder pain (HSP) are
more common in post stroke.
• The weight of the hanging arm can cause shoulder to sublux inferiorly.
• In the subacute to chronic phase of stroke, spasticity commonly develops,
especially in the shoulder internal rotators and adductors.

37. SHOULDER ORTHOSES
1. Lap Board
2. Arm Support
3. Sling
4. Humeral Cuff
5. Abduction pillow
6. Electrical stimulation

38. Lap boards are placed over the arms of a
wheelchair.
Indication:-
Post stroke patients using wheel chair.
Advantages:-
• Provide protection and ensure proper
positioning of the hemiparetic shoulder and
arm.
• Assists the patient in maintaining an
upright posture while sitting.
1. LAP BOARD

39. A forearm trough device can be used to support and position the
arm.
Indication:-
• This is useful when there is a mild-to-moderate degree of
spasticity in the adductor and internal rotator muscles of the
shoulder.
• Patient using wheel chair .
Location:-
• The device can be attached directly to the arm of a wheelchair.
• A forearm trough can be attached to a hinged mobile support
on the arm of the chair.
Advantages:-
• The trough is used to statically position a non functional arm.
• The patient’s forearm can be secured in position with padded
straps.
• This allows the arm to be placed in a variety of positions for
functional use or training of the hand.
• Positions the arm in slight abduction and neutral rotation.
2.Arm Supports

40. It is a simplest and most common orthotic device to
position the arm
Indication:-
Ambulatory hemiplegic patients.
Contraindiaction:-
Bilateral use.
Advantages:-
• It can be removed periodically to allow ROM,
exercises of the shoulder and elbow.
• Low cost
• Easy to use
• Lightweight
• Portable
3.SLING

41. BIOMECHANICAL DISADVANTAGES
The simple sling is an inefficient
method for exerting an upward
force on the humerus because it
exerts its force along the whole
length of the forearm, wrist and
hand rather than a single fulcrum
point.

42. Biomechanics
• The action line of the effective
suspension force of a shoulder
sling or a hemisling lies distal to
the center of gravity of the bent
arm.
• Therefore, no subluxation
correcting force can exist.

43. • Displacement of the action line of the
suspension force proximal to the center of
gravity results in an attractive orthosis
structure. The total system acts like a
balanced arm. The forearm and hand
together force the upper arm upwards into
the shoulder joint

44. FORCES ON ARM AND FOREARM INDIVIDUALLY

45. COMBINING FORCES ACTING
ON ARM AND FOREARM
SECTION WE GET

46. The different possibilities for the positioning of the
fixed points are

47. • The subsystems of forearm and
upper arm are combined to the
system of the complete arm. The
force in the elbow is now an internal
force of the system.
• The resulting gravity force of the
complete arm acts distally of the
suspension force.
• The reaction force in the shoulder
ensures the equilibrium of forces
and indicates the successful
neutralization of the subluxation.
Patient with orthosis, 1-textile tension band; 2-
leather suspension strip; 3-stainless steel brace; 4-
textile or leather shoulder cap.

48. • A cuff applied circumferentially around the
proximal humerus can be attached to a shoulder
harness.
Indication:-
Hemiplegic patients with shoulder subluxation.
Advantages:-
• The cuff has the advantage of leaving the elbow
and hand free.
• It also allows motion of the glenohumeral joint
with limited flexion, abduction, and rotation while
maintaining adequate glenohumeral reduction
4. HUMERAL CUFFS

49. Indication:-
• A bed-bound patient with paralysis or
spasticity of the shoulder musculature is prone
to develop an adduction and internal rotation
contracture of the shoulder from prolonged
immobility.
Advantages:-
• A foam pillow is useful for positioning the
shoulder in slight abduction and neutral
rotation.
• This position facilitates care and prevents
contractures and hygiene difficulties in axilla.
5.ABDUCTION PILLOW

50. • Electrical stimulation units can be
considered dynamic orthotic device
Indication:-
• If the muscle weakness is believed to be
transient, electrical stimulation of the deltoid
and supraspinatus muscles can be used to
prevent shoulder subluxation
• Treatment of chronic subluxation .
Advantages:-
• Decrease pain and increase range of motion.
• Facilitates functional use of the affected
limb.
Disadvantages:-
• Current intensity and frequency can cause
an electrical buzzing discomfort to the
patient
6. ELECTRICAL STIMULATION

51. HOW STROKE AFFECTS ELBOW
• Flexor spasticity is common &
frequently severe in stroke.
• Flexion contracture are common.
• Painful elbow lead to maceration of
anticubital skin
• Compression neuropathy of the ulnar
nerve is seen in 10% of patient with
stroke.

52. ELBOW ORTHOSES
1. Long arm cast
2. Drop out cast
3. Bivalved long arm cast
4. Dynamic elbow orthosis

53. Indication
• It is an excellent static orthosis for positioning the
elbow & used for correcting flexion contracture.
Procedure of application
• After spasticity has been diminished by neurolytic or
surgical techniques, the elbow is casted in maximum
extension.
• The cast used in a serial manner to gain further ROM
• The cast is changed every 5-7 days
Trimlines
• The cast is applied at the midhumerus and extends to
the metacarpophalangeal joints with the wrist in
neutral rotation.
• Once full extension has been achieved the cast is
bivalved and a clamshell splint is fabricated to allow
periodic removal of the splint and daily range-of-
motion exercises
1.LONG ARM CAST

54. It can be used as a dynamic orthosis controlling
therapeutic range of motion of the elbow.
Indication
Patient in an upright position for much of the day.
Features
• It is a modified long arm cast in which the
posterior portion of the cast above the elbow has
been removed, allowing for full extension but
limiting flexion .
• This cast is purposely made heavy, or weights are
added at the wrist to encourage elbow extension.
• The cast is changed periodically as elbow
extension is gained.
2. DROPOUT CAST

55. • It is another modification of long arm cast in which two longitudinal cuts are
made from the biceps to radial styloid and from the triceps to distal ulna
• The clamshell cast is lined with stockinette to provide smooth inner surface
• Straps are added to secure anterior & posterior halves of the cast together.
• It can be removed several times daily to allow active/passive joint motion of
elbow to prevent stiffness
Contraindication:-
• It can not be used in severe spasticity.
3.BIVALVED LONG ARM CAST/CLAM SHELL
CAST/ORTHOSIS

56. • A dynamic elbow orthosis creates a rotational force across the joint to increase
joint motion
Indication
• This is particularly useful when high-energy trauma results in both brain injury
and lower motor neuron injury of the upper extremity.
Contraindication
• Severe spasticity
Mechanism of action
• It has elastic or spring-assisted mechanism to increase intended range of motion,
biasing either flexion or extension.
Function
• Assist or substitute for weak muscles.
4.DYNAMIC ELBOW ORTHOSES

57. 5.PRESSURE ORTHOSIS (AIR ORTHOSIS)
• It reduces tone.
• Facilitate muscle activity
around a joint.
• Facilitate sensory input.
• Control edema, and reduce
pain.

58. 6.TONE AND POSITIONING ORTHOSIS
Function
• It supports the thumb in
abduction and extension with a
neoprene glove.
• It includes an elastic strap that
is wrapped spirally up the
forearm, providing a dynamic
assist into pronation and
supination of wrist.

59. WRIST & HAND ORTHOSIS
• Spastic forearm flexor muscles causing wrist and finger flexion
deformities are common.
 Boutonniere Deformity
 Swan neck Deformity
• Cast & orthotic devices are used to correct residual contracture or to
position the wrist & hand.
• Specific type of forearm WHO include
- Cast
- Static wrist & hand splints
- Dynamic wrist orthosis & finger orthosis.

60. Indication
• Wrist flexion contracture .
Timlines
• It usually starts 2 cm distal to the lateral upper condyle and extends to just before
the metacarpophalangeal joints, leaving the thumb in neutral opposition and
abduction.
• The wrist is casted in a neutral position.
Procedure of application
• The cast is changed every 7 days. With each change, the wrist is gently manipulated
into further extension.
• The cast can be bivalved and a clamshell splint fabricated once full extension has
been achieved.
• The wrist should remain immobilized in full extension for an additional 4 weeks to
prevent recurrent deformity.
1.SHORT ARM CAST

61. 2.BIVALVED SHORT ARM CAST
• It is a modification of a short arm cast.
• Lined with stockinette to provide a smoother inner surface.
• Straps are added to secure the ant. & post. halves of the cast together.
Contraindication
Severe spasticity of wrist and hand.

62. Indication
• Surgical lengthening of spastic extrinsic finger flexor muscles in a
hand.
Contraindication
• Patient with severe flexion deformity.
Advantages
• Useful for maintaining the wrist in extended position.
• By holding the wrist in slight extension, patient can perform
occupational therapy & functional training of finger motion.
3.VOLAR WRIST ORTHOSIS
Volar cock up splint

63. Resting wrist–hand orthoses are one of the most commonly used static intermediate
devices.
Features
• It can be premade or custom fabricated out of many different types of materials.
• It immobilize the wrist alone or more often can include the thumb and fingers.
• The raised lateral palmer ridges of orthosis prevent radial or ulnar deviation &
reinforce the orthosis to accommodate muscle tone & spasticity.
4.RESTING WRIST–HAND ORTHOSES

64. Indication
• Patient with a relatively flexible wrist flexion deformity.
Function
• Dynamic wrist–hand orthoses provide greater functional movement and are often
better tolerated by patients compared with static orthoses.
5.DYNAMIC WRIST ORTHOSES

65. 6.SERPENTINE ORTHOSIS
• It provides sufficient thumb
abduction support, positions
the hand and wrist in a more
optimal position for
function.
• It allows active wrist
function in the child with
moderately increased tone.

66. 7.INFLATABLE HAND ORTHOSIS
• This orthosis consists of an adjustable
volar-based wrist support that is easily
adjusted to achieve the desired range of
extension.
• The palmar aspect of the orthosis is an
air bladder that can be inflated or
deflated easily, depending on the
desired stretch and level of contracture.
• It is easily donned and is comfortable.

67. • Finger positioning devices can be static or dynamic & it can be
used for maintaining a position or enhancing functional use of
the hand
• Electrical stimulation devices are available & used mainly as
training aids.
FINGER & THUMB ORTHOSIS

68. 1.Static Hand Splints
• Used to maintain the position of the fingers
and provide protection.
• They are less useful for improving the arc of
motion.
• Soft hand rolls or splints are useful for
preventing contracture.
-Absorbs perspiration
-Prevents nail bed infection
-Avoids worsening of contracture

69. Firm cone

70. 2.Dynamic Hand Splints
• Many stroke patients regain active finger flexion and are capable of
grasping objects.
• Chemodenervation or surgical lengthening can restore relaxation of
excessive finger flexor tone and allow weak extensors to open the hand.
• Finger extension can be supplied by dynamic orthoses with elastic
mechanisms.
• Mainly it is categorised into 2 varieties:-
 Outrigger splint
 Leaf spring glove

71. A) OUTRIGGER SPLINT
Mechanism of action
• It uses elastic mechanisms i.e rubber
bands or slings placed beneath the
proximal phalanx of the thumb and finger.
• This elastic tension causes the fingers to be
held in an open position with the thumb
abducted.
• The patient can more easily position the
hand to grasp an object

72. • Consists of flexible strips
incorporated into the glove
overlying the extensor surface of
each finger.
• These strips provide active finger
extension while allowing the
patient to grasp actively.
• The fingertips of the glove are
removed to improve sensation.
B) LEAF SPRING GLOVE

73. 3.THUMB SPICA CAST
Indication
Thumb in palm deformity and contracture.
Role
• It is an excellent orthotic device for positioning the thumb in abduction.
• The cast initially is applied as a circular device and later can be serially
recasted or modified to a bivalved splint.

74. Indication
 Swan neck Deformity
 Boutonniere Deformity
Function
 Increase coordinated grip strength.
Advantages
• Low profile
• Well ventilated
• Lightweight
• Easy to don
• Well tolerated by patients.
4.SPLIT RING ORTHOSES

75. Indication
Thumb in palm deformity.
Function
• It is lightweight splint that holds
the thumb metacarpal in an
abducted and slightly opposed
position
• It can be used to improve thumb
function and pinch.
• Improves the opposition position.
5.THUMB ABDUCTION SPLINT

76. 6.THUMB LOOPAND THUMB ABDUCTION ORTHOSIS
• It is a semi dynamic orthosis.
Role
 Positioning of the thumb and
wrist alignment.
 The strapping material used in
the fabrication of this orthosis
positions the thumb in abduction
& aligns the wrist in a position
of slight radial wrist extension.
 The hand is placed in a position
that enhances prehension,
manipulation, and release of
objects.

77. 7.FINGER SPREADER (FINGER ABDUCTION ORTHOSIS)
• It is a fabricated of foam rubber and
positions the fingers and thumb in
abduction.
Function
• According to Bobath the purpose of
the orthosis is to “obtain extension
of wrist and fingers”.
• It reduces the possibility of edema.

78. 8.HAND-BASED THUMB ABDUCTION ORTHOSIS
• The orthosis is custom
fabricated from
thermoplastic material.
• It positions the thumb in an
enhanced prehension pattern
for manipulation of objects
during grasp and release
activities.

79. 9.MACKINNON ORTHOSIS
• It includes a dorsal-based forearm
support(orthokinetic cuff) that wraps 3/4th
of the distal half of the forearm
• A dowel placed in the palm of the hand to
provide pressure on the MCP heads
• Rubber tubing attaching the dowel to the
dorsal forearm support the fingers are left
free to assume functional patterns.

80. 10.BELLY GUTTER ORTHOSIS
Indication
 Effective for flexion contractures of
the PIP joint from approximately 15
degrees of contracture to 35 degrees
of contracture.
Function
• The belly gutter orthosis provides the
90-degree angle pull by incorporating
a convex belly in the middle of the
gutter.
• It is used at the beginning of
treatment for 1 hour on and 1 hour
off.
• Gradually, as the contracture
decreases, the time may be extended
to as much as 4 hours.

81. Advancements in orthosis for stroke
STUDY-1
Long-Term Use of a Static Hand-Wrist Orthosis in Chronic Stroke Patients: A Pilot Study
Objective
Evaluating long-term use of static WHO and experienced comfort in chronic stroke patients.
Conclusion
 Number of chronic stroke patients cannot tolerate a static orthosis for at least 8 hours per day
during a long-term period of at least one year.
Without appropriate treatment opportunities, these patients will remain at risk of developing a
clenched fist and will experience problems with daily activities and hygiene maintenance.
Prefabricated static hand-wrist orthosis
Journal-Stroke research and
management(January 2013)

82. • STUDY-2
Combining virtual reality and a myoelectric limb orthosis to
restore active movement after stroke: a pilot study
(International journal of disability and human development -2014)
Diagram of the developed virtual reality and robotic limb orthosis training
paradigm showing the role of each technological component

83. Prototype of the myoelectric-based interactive system for rehabilitation.
 Left panel: an adaptive training in the form of a game defines the training
parameters for a bimanual coordination motor task.
 The training offers augmented feedback on performance, sustains motivation,
and automatically modifies the level of motor assistance offered by the limb
orthosis.
Right panel: the different components of the system (robotic device, tracking
setup, and training game task) while being used by a stroke patient.

84. • STUDY-3
Therapy Incorporating a Dynamic Wrist-Hand
Orthosis Versus Manual Assistance in Chronic Stroke
A Pilot Study
(Journal of Neurologic Physical Therapy-2012)
Objective:
To compare the effect of therapy using a wrist-hand
orthosis (WHO) vs manual-assisted therapy (MAT) for
individuals with chronic, moderate-to-severe
hemiparesis. Dynamic wrist-hand orthosis
(SaeboFlex).

85. • Conclusion
 Small improvements in function and perception of recovery
were observed in both the groups.
 Adds to the evidence that individuals with chronic stroke can
improve arm use with therapy incorporating functional hand
training.

86. • STUDY-4
Effects of Robot-Assisted Therapy on Upper Limb Recovery
After Stroke: A Systematic Review
(Neurorehabilitation and neural repair-2008)
Objective
To present a systematic review of studies that investigates the effects of
robot assisted therapy on motor and functioanl recovery in patients with
stroke.
Conclusion
 No overall significant effect in favour of robot assisted therapy was found
in the meta analysis.
 Sensitivity analysis showed a significant improvement in upper limb motor
function after stroke for upper arm robotics.
 No significant improvement was found in ADL functions.

87. Robotics in stroke rehabilitation
• Robotic devices appear to be suitable for application under
certain conditions and modalities that allow:
• i) individually adjust the rehabilitative training protocol with
due accuracy,
• ii) obtain replication and congruity with residual motor
function and treatment targets
• iii) quantitatively assess baseline conditions and monitor
changes during training.

88. • A robotic system traditionally comprises some
major components:-
 a mechanical structure with degrees of freedom consistent with the tasks
to be executed
 joint-controlling actuators, either electric or pneumatic;
 Proprioceptive and exteroceptive sensors providing information on the
machine functional status and interaction with environment
 sequences of tasks to be executed as detailed by the system computer in
suitable language
 a computer generating the signals that control the robot joints, processing
the signals transmitted by the sensors and instructing the motor controllers
 man/machine interface receiving information/instructions from users
(therapist/patient) and providing online feedback

89. • . According to the control strategy, robots can
be programmed to assist patient’s motion in
different modes:
i) passive- the robot moves patient’s arm
ii) active unassisted-the subject executes the exercise and the robot provide no
help
iii) active assisted: the subject attempts to move and the robot provides
assistance when there 208 Muscles, Ligaments and Tendons are some
voluntary but inadequate movements,
iv) resistive: the subjects is required to perform an exercise against an
antagonist force provided by the robot.

90. • According to their mechanical characteristics,
robots can be classified into, at least, three
main groups
a) exoskeletons
b) end-effectors (also called “operational type
machines” or “manipulators”)
c) and cable-driven.

91. Armeo® Spring: an
ergonomic arm
exoskeleton with
integrated springs
Armeo® Power:
an exoskeleton
based on the
ARMin
technology

92. Armeo® Boom: a simplified cable-
driven manipulator designed for out-
patient clinics and home settings

93. • STUDY-5
A Novel Functional Electrical Stimulation Treatment for Recovery of Hand
Function in Hemiplegia: 12-Week Pilot Study
(Neurorehabilitation and Neural Repair-2009)
Objective:-
This study aimed to evaluate the feasibility of achieving greater and more
persistent gains with CCFES(Contralaterally controlled functional electrical
stimulation) by increasing the treatment period to 12 weeks.
 CCFES uses neuromuscular electrical stimulation to open the paretic hand in
direct proportion to the degree of volitional opening of the unimpaired contral-
ateral hand, which is detected by an instrumented glove.
Conclusion:-
 Greater reductions in hand impairment were achieved by extending the
treatment period.
 The effect and its longevity may be related to baseline impairment level.

94. (CCFES)
Volitional Opening of the Unaffected Hand
Produces a Proportional Intensity of Stimulation
to the Paretic Hand Extensors

95. CCFES stimulator, command glove, and
electrodes
©2012 Cleveland FES Center

96. FINGER
ORTHSIS
DYNAMIC WRIST AND
FINGER ORTHOTICS

97. ADAPTATIONS

98. REFERENCES
• Webster B.Joseph,Murphy P Douglash,Atlas of orthoses and assistive devices(5th
Edition),Chapter-13(Upper Limb Orthoses for the Stroke- and Brain-Injured Patient)
• Fess,Gettele,Phillips,Jason,Hand and upper extremity splinting Principles and
Methods(3rd Edition),Chapter-19(Splinting for Patients with UpperExtremity Spasticity)
• Stroke Rehabilitation Function-Based Approach Glen Gillen, EdD, OTR, FAOTA
• Hunter,Mackin,Callahan, Rehabilitation of the hand and upper extremity,5th Edition,
Chapter-8(Clinical evaluation of hand ),Chapter-9(Diagnosis imaging of the upper extremity)
• Catherine A.Trombly,Mary Vining Radomski,(Occupational therapy for physical
dysfunction),5TH Edition, Section-4,Chapter-42(Hand Impairments)
• S Sunder, Text book of rehabilitation,Chapter-18,Stroke rehabilitation
• Robotics in shoulder rehabilitation(Review article)
• Combining virtual reality and a myoelectric limborthosis to restore active movement after
stroke:a pilot study
• Biomechanics of orthoses for the subluxed shoulder,J. C. Cool

99. THANK YOU