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Intervention Techniques for the Hemiplegic Upper Limb Presenter: Christine Griffin, OTR/L, MS, BCPR 

OccupationalTherapy.com Course #3933                        

 

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- [Moderator] Welcome everyone to Continued and Occupational Therapy dot com. 

Our course today is Intervention Techniques for the Hemiplegic Upper Limb. Our 

presenter today is Christine Griffin. Christine has been an OT since 2000 and has 

practiced in inpatient rehabilitation skilled nursing facilities, acute care, and outpatient 

clinics and is currently a clinical instructor for the Ohio State University OT Department. 

Christine is AOTA Board-certified in physical rehabilitation an AOTA board certification 

reviewer, and recipient of the 2011 Ohio OT Association Model Practice Award in 

Physical Rehabilitation, 2014 Height Symposium Award and 2017 Ohio OT Association 

Continued Education Award. She has had extensive teaching experience in the OSU 

medical system, including OSU's Physical Medicine and Rehabilitation Residency 

Education Program. Furthermore, Christine has presented at multiple local state and 

national conferences. Welcome, Christine, so happy to have you. 

 

- [Christine] Thank you very much, I really appreciate it, and thank you everyone for 

joining us for today. So, today we're gonna be talking about Intervention Techniques 

for the Hemiplegic Upper Limb. So when you work with a patient that has had a stroke 

or brain injury, what are the techniques that you're going to do? How are you gonna be 

able to treat, and go through intervention for this population? So what we're gonna be 

talking about today, is that we're gonna be talking about treatment evidence, treatment 

techniques. We're gonna be talking about E-Stim, slings, splints, traditional 

neuro-rehab techniques and functional use. We're also gonna go through and talk 

about occupational performance for patients with hemiplegia and how we're going to 

address those underlying skills so that we can increase function. And the last thing 

we're gonna do is we're gonna make sure that you have four educational topics to be 

able to address with a patient and their caregivers, so that we know how to be able to 

have their increased function after they go through intervention for their hemiplegic 

upper limb. So what I'm gonna do today is I'm actually gonna talk briefly a lot about a 

different treatment approaches as we go throughout this talk. Each of these really 

could be their own full eight-hour course. What I'm gonna do is I'm gonna give you a 

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very brief synopsis of what each of them are, since you get an idea what they are, and 

be able to find more information after that, to be able to really go through. But just 

know that this course really is about a brief synopsis about many different interventions 

that you could do with patients.  

 

Okay, so first what I'm gonna talk about is that for many years, the foundation of 

intervention that we use with patients with hemiplegia is that we really worked on using 

neuro-facilitation techniques. And this for many years was like a really foundation on 

like the kind of like the go to intervention for what we did with our patients post stroke 

and post brain injury when they had hemiplegia. And so these techniques were like 

NDT and Bobath, PNF root and Bruhnstrom like of our foundational intervention and 

techniques and our facilitation techniques. As we've gone through the years, we've 

really been forced to look at what the evidence is behind a lot of our interventions. And 

so we're really required to look at what the science is telling us about these 

intervention techniques. NDT or the Bobath approach has really gotten a lot of 

research looking into it, simply because it has been very popular for a long time. And it 

is one of the more expensive methods to go through with treating, and so there's been 

a lot of like science to look into this area. When we look at the science that's been 

telling us about the specific technique, there was one study done in 2011. And they 

were comparing motor learning techniques versus the bobath approach. And what 

they found that motor learning was actually had a better outcome than the Bobath 

approach did.  

 

In 2005, there was another study that was done and they were specifically looking at 

patients who had severe hemiparesis. It's like our lower level patients who really don't 

get a lot of movement that happened within their arm. And they looked at the NDT 

Bobath approach compared to an exercise program of looking at concentric, eccentric, 

and isometric contraction and muscle exercises. And what they found that the exercise 

program was actually had better outcomes than the NDT program did. When we look 

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at some of the systematic reviews that had been done in 2009, we found that the 

overall statement for for this systematic review is that the overall Bobath approach is 

not superior to other approaches. So not worse, but not better. So not superior. So 

very equal on where that, that status is. There was, there's also been a systematic 

review that was been done and it was published in 2019. And we found that their their 

conclusion was is that the Bobath concept approaches may not be beneficial for upper 

limb rehab following stroke. So it was pretty big, significant information that came 

through that talked about how NDT might not necessarily be the best treatment when 

we come to upper limb recovery. And what they did in the NDT literature is that they 

broke it down into different areas they broke it down into trunk and sitting stability in 

upper limb and lower limb.  

 

So these studies are specifically talking about for upper limb. And they found that that 

might not necessarily be beneficial. When we look at our other neuro-facilitation 

techniques for PNF, and for root and Bruhnstrom, there is extremely limited or no 

research completed on these areas. PNF only has a few handful of studies that have 

been done for strokes of our patients with stroke. Rude has none and Bruhnstrom has 

very limited as well, only like a couple, one to two studies that have been done for 

upper limb. So there really is extremely limited or no research available on those other 

three areas. So when we're looking at like what are science is telling us and looking at 

traditional method of how we manage upper limb recovery post stroke, it really has 

been telling us that we need to kind of really examine what we're doing, and to really 

rethink about how this traditional approach is. So during this self examination, and 

really looking through like the concept of like evidence based practice, and evidence of 

supporting the research supporting the evidence that we do and the interventions that 

we do, it's really causing us to go through like a paradigm shift. And it's kind of really 

causing us to shift away from those traditional theories, and shift more into the motor 

control, motor learning, and task oriented approach that some of the science has been 

telling us to shift towards, because there was a couple of those studies that talked 

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about how motor learning had higher outcomes than it did for the NDT approach. So a 

lot of our research and a lot of our current research that's coming out is really shifting 

us more towards those motor control, motor learning, and task oriented approach.  

 

So let's start to take look at what's going on here and what are these areas? So task 

oriented approach is based on the models of motor control and motor learning, 

meaning that how does the neurological system respond to movement, and how does 

it respond to the learning process that it goes to so that you can have improved motor 

components and then function ultimately. This area of science has really evolved 

through neuro psychology, neuroscience, sports psychology, and it has its own area 

with rehab as well, and how motor control and motor learning and a task oriented 

approach is very effective for people post neurological injury. And so what we're really 

looking at is how do we get neural muscular recovery to occur in patients who have 

had some type of central nervous injury. When we look at the task oriented approach, 

we really had to think of like the therapist as like creating the environment in teaching 

motor skills. It has to be a contextually appropriate functional task. So meaning that if 

we're working on grooming with a patient, it can't be at a bedside table with a basin 

and a standup mirror. that's like propped up on the table there, it's got to be in the 

bathroom in front of the sink with a mirror right there in front of them. Or if we're 

working on meal prep, it can't be at a table while they're sitting, and they're chopping 

vegetables or chopping, you know, fruit or meat or whatever they might be working on. 

They've got to be like in the kitchen at the right height with all of like the different 

environment, the environmental things that are going on around them. So it has to be 

contextually appropriate. So that it's just it's not an environment that you wouldn't 

typically do this functional task in.  

 

You also have to vary the task and increase the transfer of learning, meaning we've got 

to have a lot of different tasks going on. So like in the example of like a meal prep, like 

you're working on all of these different components that go along with it. Like when 

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we're talking about meal prep, here it's like, open up the refrigerator door, there's 

chopping food, there's like turning on the stove and like getting like water ready to go 

to boil pasta, all of these different components that go along with it to this larger task 

of meal preparation. So you really want to vary the task so that we can have different 

application to other areas. And we can have this bigger impact on the overall task that 

we're working on. And then the therapist is gonna give lots and lots of feedback. The 

therapist is giving the patient instruction on how to be able to do these tasks. And 

that's really teaching them how to be able to look at what they're doing. So if, if a task 

didn't go well, like if they were trying to be able to reach for reach for a cup that was in 

front of them, so that they can do self-feeding, if their hand wasn't turned the correct 

direction, Then that feedback is gonna be pretty detailed. Like okay, so how you 

reached out for that cup, it didn't go well, so make sure that next time that your thumb 

is turned up so that your palm is more open, so that you can get a better hold on that 

cup you reach out for it. So it's a very detailed feedback on how they perform so that 

the patient can understand the problem solving process that goes along with how 

they're moving.  

 

So this, this approach of like motor learning, motor control, task oriented approach, it's 

really learning about problem solving and how to be able to move through those 

movement components and be able to do functional tasks. There's lots of positive 

evidence out there that talks on how well task oriented approach works with stroke 

and upper limb on the impairment level. So on just in that movement, motor 

impairment level, but also in the functional level as well on how they're able to perform 

tasks. So there is very, very well support in the literature and the positive effects on 

how well task oriented works with these patients. There was also a systematic review 

that was completed, but written by Hubbard in 2009. And it was written specifically for 

OT's. It gave them big kudos for OT's on how to be able to do these tasks. And it gave 

a direct statement in their in their abstract it was said that we recommend that task 

specific training be routinely applied. So and they emphasized routinely, like we should 

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be doing this on a daily, routinely basis with all of our patients. As a component of their 

neural motor interventions, particularly in management related to post stroke, upper 

limb recovery because it has such a positive effect on how well it works. And it's a 

fantastic article that really talks through the different components and the 

recommendations on how you apply task oriented approach. So it's a really, really 

good intervention to be able to apply. When we talk about using non-functional task 

using functional tasks.  

 

There's actually a very interesting set of studies that have been done that talk about 

the difference in between when you actually have a functional task there compared to a 

non-functional task. And these studies were really interesting. Like there was one of 

them that was in there that was talking about chopping vegetables and how there was 

one group of patients that they had like this button to push on it was a very large 

vegetable chopper, and they would press on the button, and then they would chop 

vegetables as they pressed on this button. And there was another group in this study 

that they also did the same motion, same resistance, and they were pressing on a 

button. But the difference was is that it was not a vegetable chopper, it was a button 

that they pressed on, and there were no vegetables in there. When they looked at the 

outcomes, the patients that actually chopped the vegetables that had that response 

have seeing like what was going on with that vegetable and being able to like have the 

resistance of that that actual vegetable in there, they actually had higher performance 

and higher outcomes than the group that didn't have those vegetables in there. So it 

was really talking about the difference in between when you look at a functional task 

versus a non functional task. Patients are having better performance and better 

outcomes when they actually do that functional task performance.  

 

So what they were finding out when we look at these, these studies that talk about non 

functional activity versus functional activity. Patients are really not making the 

connection between these non functional activities and functional outcomes. They're 

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not connecting the dots. And then what was interesting about these studies is that they 

even explain to the patient's who in that non-functional group, why they were doing it 

just like we do in therapy every day. So we were, they were explaining to them like we 

are working on these pegs, so you can place them in the pegboard so that you can 

increase your pincer grasp so it will help you with tying your shoes. And so patients 

would did it, would have done it. And they didn't have the same recovery as patients 

who would have actually have tied their shoes. So it made a big difference on that, 

working on that non functional versus that functional component. So what we're 

finding out is that there's these patients really are not connecting the dots, they're not 

making that connection between this non functional stuff as opposed to the functional 

outcomes that we're expecting to be able to get out of this. So we really have to have 

this big push to be able to really focus on these functional activities, because 

addressing these underlying impairments, really is not getting us the outcomes that 

we're looking for.  

 

Now, along with that the difficulty is, is that in the clinical setting, we have very, very 

busy lives as a clinician. There's a lot going on. We have a lot of high productivity 

standards, we have a lot of non-productive time that's required of us like 

documentation and meetings. We have very complex patients that we're working with, 

very complex family members that we're working with. And so this creates a very 

complex environment that we're working in. We're trying to be able to do these tasks. 

And so when we work with our patients, it's really like we have to make sure that we 

have this cultural shift that occurs and be able to have ourselves armed and ready to 

be able to do these tasks. So it was interesting, one of the hospitals that I work in, we 

actually we were reading these articles, and we were like okay, we're gonna be 

dedicated towards being able to do task oriented approach in our clinic because we 

really want to have these good outcomes. And we opened up our closets that we have 

all of our treatment in for our treatment equipment in and we looked at it and what we 

found in our clinics is we had a lot of pegs, we had a lot of theraputty, we had a couple 

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bins of sand that you could scoop, some bean bags, and for some reason, a lot of 

plastic fruit. I'm not sure why we had that, and a fair amount of cones in there as well. 

So we looked at everything that was in our closet. And we were like, we are not armed 

and ready and prepared to be able to do these functional tasks. Our closet, our 

treatment activities are just not ready for that. We're setup to do all of this 

non-functional stuff.  

 

So what we did is that our therapy staff, our OTS, we got together and we 

brainstormed all the functional activities that we wanted to have in our clinic and things 

that we wanted to do. And we came up with a big list of 'em. And what we did then is 

that we came up with all of these different treatment kits that we could have in our 

clinic so that we were armed and ready so that we could have all of these different 

functional activities ready for us to go because as a clinician, you don't have a lot of 

transition time in between all of these different patients 'cause you're you're scheduled 

really close to together like on a half hour block and an hour block. And so you get like 

one to two minutes in between each patient to really think about what you're doing. 

And if all of you have in your closet is all of that non functional stuff, that's what you're 

immediately gonna go to 'cause it's there and it's available. And so if you change the 

culture of what's in your clinic to shift towards these functional activities, then that 

changes your whole approach on how you address what you're doing in your therapy 

session. So we brainstormed, we came up with all of these different kits that we 

wanted to work with.  

 

We went shopping at different stores, like we would go to every day. So we were going 

to you know, Big Lots and Target and Walmart and once over, we found our some of 

our stuff, and we created kits and so we put everything into these plastic bins. And we 

had all of these different kits available so that we could have our clinic ready to be able 

to do this. And these are just some of the ideas that we came up with that we had so 

that we could be able to do this. And these were more designed for the lower level 

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patient 'cause we're really focusing on gross grasp. Like placing eating utensils into an 

organizer like you'd toss out all the different spoons, knives, forks onto a table, and 

then they had to pick them up and place them into the organizer. Or grasping 

magazines and putting them into an organizer. Or one bin had the place sitting for eight 

people. So it had eight plates and eight forks, knives, spoons and cups and napkins 

and place mats, and they'd had to spread that all across the table. But it was pretty 

much making sure that we had all of this stuff available in the bins, we could just grab it 

and be able to work with it for that lower level patient. We also came up with ideas for 

higher level people. So like having that folding laundry in the in the clothes basket or 

hanging clothes on a retractable clothesline, or packing a suitcase. Putting a batteries 

into a remote control.  

 

For some reason in our clinic putting toilet paper on a toilet paper holder and pulling off 

a sheet was very popular. Many people found that very, very funny. Or installing the 

toilet paper holder onto the base. Just like different things that are out there. But these 

are more higher level fine motor coordination, bilateral coordination activities that gets 

that hand on the hemiplegic arm really involved, so that we're really working on that 

low level piece, and then that high level piece. So it was really just making sure that 

we're doing that cultural shift. We're doing that cultural change, and we're getting our 

clinics ready to be able to do that task oriented approach. I do, I have had a 

conversation with a fair amount of clinicians that have talked with me and had said, I 

have a really, really low level people and I can't do task oriented with them. Like we're 

just working on emerging motion and it's just not an option to be able to do functional 

tasks with them. And we really have to make sure that we're matching the functional 

task to them. Because if when we have our really low level people, they're not gonna 

be appropriate for like stuffing envelopes and sorting paper clips and wrapping a gift 

package. That's too high level for them. So when we look at like our, our low level 

activities, them being able to just reach out and touch their hand to some of the 

utensils and coming back, that's function for them because they're doing that 

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movement, and they're reaching out, and they're placing their hand. Or just grabbing a 

washcloth and bringing and like having that washcloth placed across their hand for 

them, and then bringing that hand up to their up to their face, and just really working on 

that functional movement. That is task oriented activity for them. So just because we 

have really low level people doesn't mean we can't do it with them, we just have to 

tailor those activities to them. So this is just one way of really just creating that cultural 

change and that cultural shift, so that we can do functional activities and task oriented 

approach with our patients. So that was the first intervention that we were gonna talk 

about today was task oriented approach.  

 

The next intervention that we're gonna talk about today is mental practice or mental 

imagery. So what this is, it is rehearsing mentally a cognitive rehearsal, a functional 

task, but not physically performing it. So how a lot of people do this is that they listen 

to an audio recording and the audio recording talks them through the entire process on 

how they're gonna mentally imagine how they are doing these tasks. This approach 

actually had a start in sports psychology, it's used with a lot of athletes. And you know, 

there's, I remember seeing a couple years ago at the Olympics, on how they would 

show athletes getting ready to be able to go out and compete. And they were you 

know, sitting quietly in their chairs, and they had like their headphones on or their 

earbuds in their ears. And they would be asking the, you know, the athletes like, what 

are you getting ready to do before you go out and you like, you go out and you swim in 

the pool, and they were saying well, I have what I'm doing is that I have real low level 

music on and I'm rehearsing how I do my my swimming strokes in my head, I'm 

mentally practicing that. And it was really interesting to know that like, mental practice 

has its original basis in sports psychology and with athletes, and it's evolved into 

working with stroke survivors and working on neural recovery also. This is something 

that supplemental to conventional therapy. So it's something that you set up for them 

so that they can do outside of therapy time.  

 

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So our skilled service is that we are gonna pick the appropriate recordings for them to 

listen to, and that we're doing that physical practice in therapy time. And they listen to 

these mental practice recordings outside of physical of therapy time. It can be used at 

any stage in recovery. This can be low level and also high level patients. So we have 

that variation that's in there. Now what's really interesting about mental practice, is that 

when a patient's, they've had a couple different studies that have been done about 

this, there was one study that did fMRI's. So they had patients lay, lay in an fMRI, and 

so an fMRI measures brain activity. So the different areas are gonna light up when 

different areas of the brain become more active. And so what they had patients do is 

that they would lay in the MRI, and they would actively move their arm or actively move 

their leg and that motor strip in their brain would light up because they're actively 

moving. They would also ask the patients to not physically move, but just mentally 

imagine that they are moving, moving their arm or moving their leg, and the same area 

lights up within their brain without physical movement. That is crazy that we have that 

brain activity, but then we don't have that physical activity. So it decreases that 

possibility of fatigue, that muscle fatigue, because we have that additional neuro 

plastic effect of giving that repetition.  

 

There's also a few studies that have been shown that when they hit mentally, so they're 

an EMG studies so measuring how much muscle activity is, so when so have someone 

physically move they will have the EMG activity that will pick up and then when you 

have them mentally imagine that they are moving, you will see activity happen on that 

muscle, on those muscles for EMG activity, and which is crazy because they're not 

physically moving. But then you see that EMG activity happen when they're mentally 

imagining that they're moving. So it does improve learning and performance. And it 

also helps with neural plasticity, because they're getting additional practice. And it 

helps reorganize the motor cortex. So it has some pretty interesting outcomes to that. 

The most plausible mechanism to explain it is that we have stored motor plans and 

executing movements that can be assessed and reinforced during mental practice. So 

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we don't necessarily have to have the physical practice of it. We're reinforcing that by 

doing that mental practice and that mental rehearsal. So how is mental practice done?  

 

It is an audio recording, it lasts about 15 minutes long in that area. The first couple 

minutes, like those first three to five minutes is just a period of deep relaxation. So it 

sounds like a relaxation tape. Like it's gonna start out with your pleasant music and 

you know, there'll be someone they'll be telling you know, relax. Imagine that you're in 

your favorite room or your favorite location, and it's like, it really talks you through that 

relaxation, because you really need to be in a relaxed state. For this to be the most 

effective. And then once it gets into that relaxed state, then it actually talks you through 

that mental practice portion and it involves every aspect and it's also multi sensory, it 

has you really imagine a fully very rich environment, and how you mentally rehearse 

this. So it talks about like talking about, imagine the size of the room and the full 

description of it, you know, imagine that you're sitting in your favorite chair and the 

room is quiet, and there's a table in front of your chair. And so then imagine that 

you're, there's a table in front of you with fresh apple juice in it. And so the kinesthetic 

part, feel yourself reaching out for the cup, and then that the sensation, the touch, feel 

the weight of your arm as you reach out and feel your elbow straighten. And then as 

your hand opens, feel the cool china as you grasp it, bring the cup up to your mouth 

and taste the sweet apple juice.  

 

So this recording includes all of like these multi sensory things you can really, really 

imagine what's going on in there. As you then you go through that, go through that 

experience. and at last about 15 minutes long. And then the last one to two minutes of 

that recording is coming back up into full awareness. So you come out of that 

relaxation recording. And then the third step of the mental practice process is to 

practice in real world. So you want to have three listening sessions to one practice 

session. So that you really have that reinforcement 'cause you do have to be able to 

find to be able to functionally perform that task along with that mental practice. So you 

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there's a lot of options on how you can find these recordings, and you can recreate 

your own recordings, it's very easy to be able to do on your phone or on your laptop. 

And I have also found a fair amount of recordings out on YouTube as well. So there's 

wide open on how you can be able to track down these mental practice recordings 

that are available out there.  

 

Here's some of the studies that talk about how effective mental practice is. So, this 

author had done a couple of different studies of a series of studies about mental 

practice. And what they found is that they looked at, looked at the mental practice 

recording along with traditional therapy versus just a placebo recording of either 

relaxation or education with therapy. And we found that there was a significant 

improvement in Fugl-Meyer scores and ARAT scores in the mental practice group 

compared to the non mental practice group. So there's the placebo group. So it's 

really interesting that mental practice does have good functional outcomes. When we 

look at performance in stroke patients. There was another study that was done in 2005. 

And this one was really interesting because they looked at mental practice plus, 

traditional therapy. And then they had another group that did functional training of a 

specific task in traditional therapy. So the difference was, is that everybody got 

traditional therapy, just that one group that mentally rehearsed a task and the other 

group functionally physically performed the task. And so when they looked at the end 

of the protocol when they got all the way done, surprisingly enough, the mental 

imagery group had higher ADL function than the functional training group. So a group 

that never performed the task had higher performance because they mentally imagined 

it compared to the group that actually performed it. That is crazy that they would have 

a higher performance and not actually do it, that they mentally rehearsed it. So it's one 

of those studies which is pretty powerful for when we look at how well mental practice 

can work.  

 

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When we look at some of the systematic reviews that have been done, our study in 

2010 shown that mental practice reduces impairment and improves functional recovery 

in the upper limb. So it's something that should be used in post stroke recovery. Our 

study in 2001, all this data from psychophysical, neuro physical, and brain imaging 

studies show that that there is an improvement in mentally rehearsed imagined actions 

and so that there is that high improvement in there. When we also look at another 

systematic review that there is level 1a evidence, that mental practice may produce 

greater improvements and motor function than conventional rehab or sham 

intervention. So really talking about how this is better than a conventional rehab 

approach. And but there was another piece to this that there was conflicting evidence 

about the effects of mental practice to improve performance of ADL's when compared 

to conventional. So there was a couple of studies that were included in there that kind 

of had mixed results. So just have an awareness that we have that mix that goes on 

there in this particular systematic review that was done.  

 

Okay, our next treatment method that we're gonna talk about is E-Stim after stroke. So 

there are three main types of E-Stim or neural muscular electrical stimulation that we 

use after stroke. The first two are cyclic E-Stim and EMG triggered E-Stim. So cyclic 

E-Stim, it's the traditional E-Stim unit that we see that has has a channel on it and then 

the E-Stim turns on and that activates the muscle. And then it turns off. So it just 

contracts the muscle on a preset schedule, it does not require any active participation. 

So essentially when you turn the E-Stim unit on, it activates the muscle and when you 

turn it off, it deactivates. So that's essentially what cyclic NMES is. There is one style 

called EMG triggered E-Stim. So this was does require active movement because it 

combines EMG along with the end the E-Stim unit, and the EMG is what triggers the 

E-Stim to become active. So how this works for EMG triggered E-Stim is that you 

establish an EMG threshold, so the EMG what it is, is that it measures how much 

muscle activity that someone is doing, and then you establish that threshold so that 

you have to have a certain amount of active muscle activity before that stimulation 

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from the E-Stim is gonna kick in. So you establish the threshold for what you want. 

That active movement to be and how much reinforcement you want that E-Stim to be, 

that E-Stim stimulation, the EMG electrodes are gonna sense how much muscle 

contraction that there is. And they can also sense trace muscle activity to be able to 

increase movement. So even if the smallest amount of movement, you're not seeing 

the range in the joint, but you're getting trace muscle activity, it will sense that as well. 

And once it reaches a specific threshold, then the E-Stim is gonna kick in, and then it's 

gonna reinforce and have that movement follow through. And then you have you repeat 

the sequence throughout that session. So it goes through that process. So this is just 

what one of the units looks like. So and there's many units out there, that just happens 

to be one of them.  

 

There are three electrodes to this type, because these two right here, these are the 

E-Stim pads and the EMG centers. And then this one right here in the center is the 

ground for that. And then on the screen, these little squiggly lines right here, that is the 

EMG. That's the sensing of the muscle activity. So kind of like getting some 

biofeedback. And then this threshold set right here. That's the threshold that set up 

that we want the EMG to reach up to. And then once that EMG reaches that level, then 

the stimulation is gonna kick in. And so then it's gonna reinforce that movement with 

the E-Stim that's been set up. So what we're gonna do is that I have some video of 

this. So we're gonna go and we're gonna take a look at the video. And so here's our 

first one. So this is really just showing on how the EMG sensors work and how the 

EMG triggered works. So here's our patient, she has the the pads on and she's actively 

moving. And so here's the E-Stim pad and then the ground right there. So we can see 

on the unit over here. That it's gonna tell her to relax to not move. And then this is the 

actual biofeedback that's going on right there. And that's gonna tell her ready and it 

wants her to actively move. So then it's sensing that she's actively moving. And then it 

hit that threshold. Boom, there we go. And then the stimulation is gonna kick on. So 

she has to reach that certain level before that E-Stim comes on. So it's requiring her to 

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actively move before that E-Stim comes on. So it's requiring that participation. Okay, 

and I have another video. So that one just showed like the cycle of how things work.  

 

This one shows on how we can do this with a functional task. So her instructions were 

I want you to open up your hand and reach for the cup. But the patient really has to 

understand like how the device works, you got to work with a cycle of it. Because what 

she did is that she opens up her hand and then she reaches for the cup. And then so 

the E-Stim kicked in and we're working digit extension with that one. But now what's 

going on is that she's reaching for the cup, and then she's trying to fight it a little bit. 

Okay, so now she's going through the relaxation part of it. So relax. Okay, and now 

ready. And so now is when she's supposed to open up her hand. And then she opens 

up her hand, but then she's trying to grasp the cup and do that digit flexion at the 

same time that simulating her for digit extension. So this is just an example of you can 

during do this during functional tests, it's just the patient has to understand the cycle of 

how it moves. Like you can't fight the actual movement of it, that it's gonna open up 

her hand she can't grasp until the device goes out of cycle. Okay, so let's go back to 

the PowerPoint.  

 

Okay, so the third type of E-Stim that we have available Functional E-Stim. So 

essentially what this is, is that this is cyclic E-Stim, meaning that you turn the unit on 

and then the muscles activate and then you turn the unit off. It is cyclic E-Stim, but use 

during functional tasks and a functional activity. And you can use this in a couple of 

different ways. So essentially what it is it's cyclic E-Stim that's been set up with a 

neural prosthetic. So essentially, it's a splint that has the E-Stim units embedded into 

it. And then you what you do is that you have these different channels turn on at 

different times. You can add a couple different approaches on how you use this. You 

can use the functional E-Stim as an adaptive method. So use it like an adaptive device 

for use during functional tasks, so that you can have it so that'll help with grasp when 

you want to be able to grasp food or grasp clothes or turn a key in a door. So use it as 

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a part of like an adaptive equipment. Another option is to use it for a therapeutic 

approach. So use during your intervention therapy sessions, so that you can gonna 

work on retraining of the upper limb So doing it during specific functional tasks. And 

you can also do it as a supplemental piece. So you can do that complete it at home as 

part of their home exercise program, so that they can work on these activities outside 

of their therapy time. And that's just a patient that you have this unit set up with, so 

that they can do this as a part of their regular routine at home.  

 

This is an example of one of the units, there's many out there, this is happens to be 

one of them. And so it's a neural prosthetic. And so back here we have a panel set up 

for a digit extension. And then in here, there's the panels that has electrodes 

embedded in it for digit flexion and then we have one for thumb as well. And then we 

just have the console that controls all of it, but we just have panel different panels, for 

digit extension and then also for digital flexion and for the thumb as well. So we've got 

those different panels. So let's take a look on how we use this during the therapy 

session. So Let's go to the video. The first one that I have this is for more of a higher 

level patient. And so her issue was that she had really good elbow and shoulder 

movement. She really was not that good with digit extension, on how to be able to 

move her hand. So what we worked on is that we really just wanted her to be able to 

work on grasp. So this is just showing the cycle first of her being able to go through 

digit extension and then digit flexion. And this is another moment where the patient 

really has to learn to work with the timing of the device. So every time that grasps I 

want her to be able to move those washcloths from one location to another. And 

whenever it opens, go back and get ready to grasp another one. And then here we go 

again, it's gonna grasp and then she's gonna take it over and then when her hand 

opens up, she's gonna go back to the other ones.  

 

So because her shoulder and her elbow movement are really good this is really just 

working on that distal component of her being able to grasp and release, she gets a 

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little greedy also she takes more than one. But this is where the patients really got to 

understand the cycle of the device and how to be able to work with it. So you're doing 

a lot of coaching the first couple times that you use this so they understand when to be 

able to open their hand and when to be able to close their hand and when that 

matches up with a movement. And then we just have her come back and she's just 

showing this how how the cycle of the device works and how it works on grasping, and 

then opening their hand. And I found that this, this repetition of this, of having go 

through this cycle is really good for functional tasks that you're especially trying to do 

repetitively. Okay, so I've got another video to go to. And this is a lower level patient.  

 

So his issue is that he really want, with him I really wanted to work on that shoulder 

stability. And I really wanted him on being able to reach forward and grasp items. But 

what I found is that when I was working with him on being able to reach forward, he 

really wasn't getting that very good motion, because he just couldn't grasp onto 

anything. So what I did with him is that I got him into gravity minimize have him lay on 

his side. And then what we're really working on is I'm supporting his arm and I'm 

having him reach forward and try to grasp an item, but the intention is working on 

increasing his shoulder and his elbow motion. So I've got him reaching so so his 

instructions were every time that it opens up your hand, I want you to reach forward, 

and every time it closes, I want you to reach back. So we're really working on that 

shoulder and that scapula humeral rhythm. So the device opening his hand, so he's 

reaching out towards it. Okay, so we went through the cycle it closed. So he is gonna 

come back. He's gonna pull that hand all the way back. Okay, open up again, he's 

gonna reach further out. But notice that as we keep going and as he keeps reaching, 

he gets further and further out and gets more and more shoulder and elbow motion as 

we keep going through the cycle. So that hand opens, we're reaching really far out and 

we almost get that washcloth. So the intention for this, this was a lower level patient 

really working on that proximal movement and then having him be able to have a 

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functional outcome with reaching for his hands. Okay, so let's go back to the 

PowerPoint.  

 

Okay, so some of our evidence when we look at our research that's been done for 

E-Stim. What we found is that this was a systematic review, what we found for 

functional E-Stim and cyclic NMES is it's gonna help improve impaired upper limb, 

upper extremity motor function during all phases of stroke. So you can use this in low 

and high level patients, and in acute and in chronic. So you can use this any for any 

patient to be able to improve their their movement and their function in their arm. 

Functional E-Stim may be more beneficial at improving impairment when delivered 

early. So starting out in that first six months compared to late over six months, it was 

still effective with patients that were that post six month mark and enter that chronic 

phase. So it is still very effective, it still works for them. And it is absolutely an 

intervention that you can use it just had more of an impact on patients who were within 

that first six month area. So it is a good idea that if you work in that phase of patient 

recovery where you see a lot of 'em in like inpatient rehab, sniffs, acute care, where 

you're seeing them within that first six months to really start to use functional E-Stim 

because it's gonna have a really big impact on them. And there's level 1a evidence and 

level 2a evidence that both EMG triggered and Cyclic approaches may improve upper 

limb function. So everything seems to have its own habits on improvement, just you 

know, just knowing which way to which method to use for the appropriate patient. 

Systematic review done in 2019 says that there's mixed literature regarding the cyclic 

and the EMG. As well as functional E-Stim alone or combined with other therapies for 

upper limb rehab following. 

 

So there's a couple studies that didn't have as strong as some of the other previous 

studies. And the various types of NMES may not be more beneficial compared to one 

another. So they kind of all have that equal outcome. So there's no real one to like 

migrate more towards they all have positive effects. So really just which one is gonna 

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match your patient the best? Okay, next intervention that we're gonna talk about is 

slings. Slings is a frequent question that we get a lot from many people. From our 

colleagues, from physicians, from family members and from patients themselves. So 

what we really are aware of is that patients are conscious that that arm is hanging 

down, and they're very aware that they want to protect that arm. So it's a common 

question that we get. But we gotta also be keep in mind that with patients that are post 

stroke, we want to look at what are our science is telling us and where to be able to 

look at, because there's a lot of controversy that's going on with the topic of slings. It's 

highly debated in literature, and the main reason why it's highly debated is because 

there's a wide variety of slings that are out there that look at different positions and 

different pulls in different directions. There's a definitely a controversy regarding the 

effectiveness on how well these work. And so we're not exactly sure how, when and 

how sling should be used and there's a possibility that slings could add to 

complications as to helping to remediate, or help to improve situations that are going 

on. So we really got to look and see what's going on here with slings and look at our 

literature, because it's very highly debated. And there's many, many people that are 

asking us about slings on when they should be used and if they should be used and 

how they should be used.  

 

So let's look at our science and what it's telling us. So there was actually a key seminal 

study that was done in 74. And what they looked at was the full arm sling. So this 

particular sling was looking at it's that the one that we see for someone who's had an 

orthopedic injury, it holds that arm across their body and it holds it into full internal 

rotation up against their body. And what they did is that they had two groups of 

patients in this study. So they had all of the patients had had a stroke and they all had 

hemiplegia. So there was one group of patients that wore this sling and one group of 

patients who did not wear the sling. And they wore it for a fair amount of time they 

wore the sling for about nine weeks. So they were really looking at how how much of 

an effect this sling has on their arm. When they looked at their outcome data after the 

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whole protocol was done, they found absolutely no difference in between these two 

groups of patients, so no difference in between if they had a sling, or if they did not 

have a sling. In shoulder range of motion, shoulder pain, or subluxation. And there was 

no evidence of increased incidence of peripheral nerve or Plexus injury. So there was 

essentially no difference whatsoever in between these two groups. Didn't matter if they 

had a sling or they didn't have a sling. So this is really telling us that this type of sling, it 

does not make a difference. There's no difference in between these two groups. So 

really, that full arm sling is not giving us the results that we think it's giving us it's not 

making any difference.  

 

What we also find out about in this study is that the patients who did not have a sling, 

that arm was hanging down the entire time of that nine week span. There was no 

support to that arm and there was no any orthotic or device holding it there, and there 

was still no difference. So this tells us that this arm half post stroke can hang down 

next to their side and they will nothing bad will happen, there will be no limitation in 

range of motion, there will be no increase in pain, there will be no increase in 

subluxation. And there will be no evidence of incidents of peripheral nerve or Plexus 

injury because that's what that arm was doing that whole time. So it's this is one of 

those studies that really tells us we can take a sigh of relaxation and I know a breath of 

fresh air to know and to be able to relax and know that there's nothing bad that's 

gonna happen when this arm is hanging down beside them and not being supported.  

 

There was another study done in 95 and this looked at a couple different styles of 

slings. That single strap hemistring or the bobath roll, the cavalier support, they all kind 

of had like the same concept, they all kind of had a cuff that sat on the proximal, 

proximal humerus of the Hemi side. And then it had an attachment on to the opposite 

side. So essentially kind of had this cuff or maybe another roll, but and then it wouldn't 

be kind of the opposite side. So they kind of had the same idea of what was going on. 

And so what they did is their measurement is that they did x rays to be able to measure 

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the subluxation symmetry to see what was going on between the different slings. The 

total symmetry is significantly reduced only with the Roylan and humeral cuff sling. But 

when and so it did change the distance when they put on that sling. But you keep in 

mind that there was no absolute evidence that supports, prevent, or reduce long term 

subluxation or the support will prevent complications of the subluxation. So what they 

found is that did it reduce it? Yes, it did. But it really didn't make a difference on how 

well that response was to the shoulder subluxation. So essentially what happened as 

soon as they took that sling off, that sublux was still there. And that didn't prevent any 

complications of the shoulder subluxation either. So it really didn't make too much of a 

difference.  

 

When we look at the study in 2005, about the GivMohr sling that one was, it's a little 

misleading a little bit when we talk about the GivMohr sling. So the GivMohr sling, it's a 

type of sling that the roll sits into, there's like this little bar that sits in the hand, and it's 

a long sling that comes around to the opposite side. And that arm is kind of held into 

an elbow extension position down by their sides, but it supports their arm while they're 

standing up. What they did with this study is that they looked at patients who had a 

sling or had a subluxation. And then they measured that subluxation without the sling 

on and then they put it on. And then what they did in this study is that they found that 

the GivMohr sling did reduce the subluxation for the duration of an X ray. That's all the 

this study says 'cause their measurement was an X ray. So all it says is that for the 

duration of an X ray when they had this sling on, it did reduce the subluxation. There 

was no comment on long term effects. So anything past one second, there was no 

comment on the long term effects, and no comment on functional outcomes, range of 

motion, or pain, so that nothing else is said about that. So that's the only real outcome 

that we have that talks about the GivMohr sling. When we look at a Cochrane 

Database systematic review that was done, I see there that there was insufficient 

evidence to conclude whether slings and wheelchair attachments prevent a 

subluxation, decrease pain, increased function, or adversely increased fracture in a 

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shoulder after a stroke. And then our 2019 systematic review, their final statements on 

slings is that slings are not likely, are likely not beneficial for shoulder hemiplegia 

following stroke.  

 

So what we're really finding is that the slings they really aren't doing what we think that 

they're gonna do, they're really not making a difference in that sublux, in pain, in range 

of motion or in function. There really is no difference in between these two groups. So 

when it really comes down to the use of slings, we really want to minimize their use, 

because they're really not doing anything. If we are using them, you want to make sure 

that they're removed right away. So the few times that I do use a sling is when it's a 

difficult transfer, and you're just worried about that arm getting caught on the on the 

wheelchair, or being able to be pulled in some way. So what I do is that I put that sling 

on them for that transfer and then I get their bottom from one location to another. And 

then after that transfer is done, I get that sling out of there. Reason being is because 

patients become very dependent on their sling, because when it's in that internally 

rotated position, that's a position of comfort, and so patients get really, really attached 

to that. And so it's really hard to convince a patient to not have their sling once they 

get it because they come very dependent on the use of that. You also really want to 

avoid slings that put that shoulder into internal rotation. And why that is, is because 

there's an increased association with shoulder pain with increased internal rotation or 

decreased external rotation.  

 

So actually, when you have that arm into that internally rotated position, it's actually an 

increase cause of pain as opposed to supporting their arm and decreasing pain. So 

have to be very conscious to avoid that internally rotated position. I also have a lot of 

people ask me how about when you're standing, you try to do gait after that 

hemiplegic, after stroke and trying to support their arm, if the weight of their arm is 

throwing off their balance so when they stand up and that arm is just really throwing off 

their balance, and they don't know how to be able to stand, then for a short amount of 

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time so they can learn how to do static stand. It's okay to support that arm during that 

short amount of time during that therapy session only But then that patient's gotta 

learn how to be able to ambulate with that arm down to the side and be able to how to 

be able to have that dynamic movement and that shift when that arms hanging down 

to the side. And you got to remember we had that study that told us that that arm was 

down to the side without being supported and nothing bad happened. And so we're 

it's okay to have that arm down to the side and nothing bad will happen to that arm. 

We also want to really investigate alternate methods of supporting that arm, like when 

they're sitting in a wheelchair to have a half lap tray to be able to support their arm, or 

when they're in bed just to support their arms to know where it's at. So that it's not 

getting caught on in the side rail or being pulled or twisted in anyway. So really look at 

alternate means of support instead of a sling. So it really comes down to slings aren't 

doing a heck of a lot for our patients. So really minimize the use, they're not really 

having that much of an effect.  

 

Okay, the last thing that we're gonna talk about today are resting hand splits. So, 

resting hand splints, or hand splints that we typically use for patients post stroke 

recovery or post central nervous injury recovery, and they're widely used prevent 

contracture and reduce spasticity and the patient's hand and wrist. It positions the 

wrist in a neutral or an extended position. So we're really looking at just like slight 

10-15 degrees in the extension of the wrist, and then digit extension so that that hand 

can be open. The typical recommended protocol is that hand to be worn overnight for 

an average of about nine to 12 hours is the average amount of time that that splint is 

worn. And why they have why we have patients wear it during the night time is 

because we're trying to win increase functional use during the daytime so that they 

wear their hand at night or wear their hand split at nighttime. So we're this has been an 

interesting look into what's going on with resting hand splints is that there's been a 

couple studies have been done that really look at how effective are these splints for 

someone post stroke. So this was a study that was done. And what it did is it looked at 

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the resting hand splint or in also called the functional position at night versus not 

wearing a splint at all, but getting passive range of motion included in their standard of 

care.  

 

So, during the daytime, they would get passive range of motion program completed to 

their wrist into their hand, so that they would not have any limitations when they had 

patients go through the protocol and they looked at one group versus the other. So 

one group where the hand split at nighttime the other group got passive range of 

motion with no splint, what they found is that there was no significant difference in 

between the two groups. There was no difference whatsoever. But the effect of 

splinting versus gaining that passive range of motion program. So what they found is 

that an overnight split wearing regimen with the affected hand does not produce 

clinically benefit effects in adults with acquired brain injury, brain impairment. So that 

meant that there was no difference if they wore there at splint or if they didn't wear the 

splint, as long as they got that passive range of motion, they were fine. They didn't 

have to have that material that went along with it. There was another study that was 

done, same group in 2007. And they looked at two different splits. They looked at the 

resting hand splint with the wrist and neutral position, worn overnight. They also looked 

at one they had the wrist in more of an extended position. So it had digit extension and 

wrist extension. So we're trying to figure out, is it the splint? Or is it the position or the 

type of splint that we have? Is it splinting in general, or is it the type of splint that's 

being provided. And then again, we had our group of no splint at nighttime, and then 

they had passive range of motion to the wrist and hand.  

 

So we looked at these three different groups. So one group that had the traditional 

wrist and hand splint, one that had the one digit extension and wrist extension, and 

then no splint with passive range of motion, and what they found four weeks later after 

they looked at the outcomes, That they found that there was no difference in between 

these groups, and that it did not reduce the risk contracture after stroke. So they what 

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they found is it suggests that the practice of routine wrist splinting and hand splinting 

should be discontinued, that it's really not doing much. So essentially save your 

money, save your materials, save your time. And really stick with a passive range of 

motion program, because that really has the better benefit for it that it should not be 

something that should be applied on a routine basis. Now, if your patient truly has 

limitation in their hand like they have some type of range of motion limitation or 

contraction forming, then yes, you need a split for that to be able to decrease the 

occurrence of that getting worse or decreasing that range of motion, but hand splinting 

should not be something that should be automatically routinely applied to all patients. 

Because it we're finding that it really does not make much difference that the most 

important part is that they get their passive of range of motion applied to their wrist and 

hand during through that program and that is the most important part.  

 

So, save, save the patients time, save your money, save your material, and no need to 

routinely issue a hand splint. Okay, when we look at another study that was done also 

this was like the prevention of secondary impairments When we talked about splints. 

There was another statement that was said that despite numerous studies, level two, 

level one systematic reviews reported that there is insufficient evidence to support the 

use of wrist and hand splints as routine intervention. And then we had our systematic 

review done in 2019. And what they found is that orthotics referring to splints may not 

be beneficial for upper limb rehab following stroke. So it's one of those there really 

might not be beneficial as something that we should not be applying on a routine 

basis. Okay, so that's what I had for today to talk about interventions for the upper 

limb. So I wanted to thank everybody for coming in today and listening, and I hope you 

guys have a great rest of the day. 

 

- [Moderator] Thank You Christine for a great talk. I hope everyone has a great rest of 

the day and you join us again on continued and occupational therapy dot com. Thanks, 

everyone. 

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