International Journal of Rehabilitation Research 16, 302-307 (1993)

Efficacy of orthokinetic orthotics for post-stroke upper
extremity hemiparetic motor dysfunction

RENATE L. NEEMAN and MO NEEMAN
Center for Orthokinetics Research and Education, 5 Sedgemoor Court, Williamsville, NY 14221, USA

Keywords: stroke; orthokinetics; motor disability
Introduction

Problem and objectives

The independence of post-stroke patients is often compromised by neuromuscular impairments of
the upper extremity (UE) (Garrison et al., 1988). As stated by Basmajian (1989), ‘we must find
improved research techniques to enhance stroke management after the immediate post-ictal period
. . helping the patient to achieve an optimal role back in the family and society’. Consonant with
this objective, the single-subject (idiographic) research technique for validation of clinical practice
utilizing orthokinetic orthotics treatment was developed (Neeman, 1988; Necman and Neeman,
1993; Payton, 1988). This methodology was addressed to rehabilitation studies of patients with
paretic motor dysfunction due to cerebral palsy (Neeman et al., 1988) and to stroke (Neeman et al.,
1988a,b; Neeman and Neeman, 1992a,b). This study’s purpose was to seek further substantiation of
the orthokinetic orthotics method for treatment of patients with central nervous system damage,
addressed to the validity of orthokinetic orthotics treatment, its generalizability and specificity.

The single-subject approach (reviewed by Payton, 1988) lends itself to hypothesis testing, with use
of statistical analysis (Neeman and Neeman, 1992b; Neeman et al., 1988). This single-subject design
provides protection from threats to internal validity (causality), by using single-blind or double-blind
procedures, with multiple crossover among non-treatment, placebo treatment, sham treatment, and
repeated orthokinetics treatment phases, in counterbalanced time-series (Neeman and Neeman,
1992b; Wood-Dauphinée, 1988). The external validity (generalizability) of the orthokinctics
treatment needs to be supported by systematic replications of single-subject experimental studies
(Barlow and Hersen, 1984; Neeman, 1988; Neeman and Neeman, 1992b). Accordingly, a systematic
replication of two earlier studies (Neeman ef al., 1988a,b; Neeman and Neeman, 1992b) is
presented. The dependent variable (criterion measure) chosen was active range of motion
(AROM), which was also used in the earlier studies.

Method

The method of orthokinetic orthotics has shown pronounced positive outcomes in the treatment of
persons with paretic limb musculatures, due to cerebral palsy (Exner and Bonder, 1983; Neeman
and Neeman, 1984; Neeman et al., 1988), and to stroke, as was demonstrated in multi-centre clinical
studies (Blashy and Fuchs-Neeman, 1959; Whelan, 1964), and in single-subject design efficacy
studies (Neeman et al., 1988a,b; Neeman and Neeman, 1992a,b, 1993).

Rationale

Research outcomes on the mechanism of post-stroke movement dysfunctions provide a rationale for
rehabilitation of persons with paretic limb musculatures. A study on quantitative electromyographic
evaluation of UE muscle co-contraction in patients with hemiparesis, has demonstrated dual
impairments of both agonist recruitment and of antagonist inhibition in the hemiparetic forearm
(Hammond et al., 1988). It was demonstrated that such pathokinesiology of paresis can serve as a

0342-5282/93 $03.00 +.12 © Chapman & Hall
Brief research reports 303

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Fig. 1. Fabrication of orthokinetic orthoses (cuffs) by the continuous foldover process: (a) from elastic roller
bandage material; (b) from ribbed elastic material (with measurements of cuffs used for the patient in this study);
(c) application of orthokinetic cuffs to the patient's upper extremity in orthokinetics treatment phases B1 and B2
(posterior view of the supinated left UE).

A = active field, I = inactive field, C = circumference of limb at placement site of the orthosis, E = extension
allowance for overlap closure of cuffs. T = total cuff length, Vh = velcro hook patches on inactive field I, V1 =
velcro loop patches underneath active field A.

Note: velcro loop patches are optional when fabricating orthokinetic cuffs (b) from material which is adherent to
velcro hook.

target for therapy by orthokinetic orthoses, applied to persons with disabling movement
dysfunctions of the paretic limb (Necman and Neeman, 1992a,b).

Definitions

The term orthokinetic orthosis describes a cuff-shaped dynamic orthopaedic applicance (Fig. 1),
which docs not include rigid polymer or metal components. It does not apply any extraneous
modulating mechanical force or constraint, in contrast to the typical splint, which ‘serves as the
external force to counteract the imbalances of the internal forces’ (Duncan, 1989). The orthokinetic
cuff was designed (Blashy and Fuchs-Neeman, 1959; Neeman, 1971, 1973, 1988; Neeman et al.,
1988a,b) to obviate the adverse effects of muscle disuse through immobility (Halar and Bell, 1988).
In contrast to application of external force (Duncan, 1989), the action of orthokinetic orthoses is
exerted through internal restoration of neuromuscular balance between agonist and antagonist
musculatures, by input of mild neural stimuli to mechanoreceptors in specifically targeted skin areas.
Orthokinetics treatment is applied to persons with muscle weakness, muscle paresis and resulting
agonist-antagonist imbalance. The input of constant stimuli of mild friction to cutaneous
low-threshold, slowly adapting mechanorcceptors (e.g., Merkel’s disks. Iggo and Muir, 1969) is
effected by close skin contact with the orthokinetic cuff surface. The neurophysiological mechanism
of the orthokinesis cffect, invoking differential activation of paretic agonist musculatures, and
304 Ming and Jixiang

reciprocal inhibition of antagonist musculatures, was proposed in recent publications (Neeman and
Neeman, 1992a,b, 1993).

Subject

The patient, a 49-year-old man with right dominance, 171 cm tall, weighing 81 kg, was referred for
orthokinetics treatment of left hemiparesis 26 months following a right thrombotic cerebral vascular
accident (CVA). For 6 wecks post-CVA, the patient had received inpatient treatment of
physiotherapy and occupational therapy, with balance and transfer training, and retraining in
activities of daily living. He continued in outpatient physiotherapy for 6 months, when treatment
outcomes had reached a platcau, with no functional control of the paretic UE.

Independent Variable

Non- Placebo Non- Orthokinet. Non. Sham Non- Orthokinet.
Treatment | Treatment | Treatment Treatment | Treatment Treatment Treatment | Treatment

Orthoses
Applications

4 = nde

Phases A1 — C1 — A2 — Bi — AZ — C2 — A4 — B2

Fig. 2. Independent variable in the pilot study of single-subject design Al-C1-A2-Bl-A3-C2-A4-B2.
Posterior view of the patient's supinated left UE (A = active field, I = inactive field, PB = plain bandage).

Al through A4 = non-treatment phases; Cl = placebo treatment phase; C2 = sham treatment phase; BI and B2
= orthokinetics treatment phases. For details, see text.

Orthokinetic orthotics treatment

In the first stage, a short-duration pilot study was carried out to assess the patient's responsiveness to
orthokinetics treatment. The experimental single-subject pilot study comprised double-blind
application of three orthokinctic cuffs to the affected UE paretic musculatures, designed to
compensate for impairments both of agonist recruitment, and antagonist inhibition (Figs Ic and 2).
The pilot study used a counterbalanced interrupted time-series design, which included non-
treatment, placebo treatment, sham treatment, and two orthokinctics treatment phases (Figs 2 and
3). The positive outcomes on the criterion measure of elbow AROM, were tested (i) by Bartlett's
test for variance homogencity, and (ii) by t-test comparing means of contiguous phases, two at a
time. All phases showed absence of significant scrial dependency on test (i). Hence, test (ii) was
appropriate (Barlow and Hersen, 1984; Payton, 1988). It showed no significant differences on
AROM between placebo phase Cl and non-treatment phases Al and A2 (i.c. placebo effect). In
contrast, the differences on AROM between orthokinctics treatment phases B1 and B2 versus
contiguous non-treatment phases were statistically significant (p <0.01), and hence supported
specificity and causality (internal validity) of the orthokinetic orthotics treatment for this patient.
These inferences led to the clinical decision to implement, in the second stage, a course of clinical
treatment for one hour twice weekly, which was based on the orthokinctics technique in the pilot
Brief research reports 305

Independent Variable

Phases

Ai e1 a2 B1 AZ c2 Aa B2
1354
1304 °

Cd
1 bd **
*% .

m4 .
WS 4 °
104 I i

Dependent Var
Elbow AROM/degrees

wrcescereesedenne M+ 2SD

j--=+ M= 2 SO

Time/min

Fig. 3. Treatment of the patient's paretic left UE in single-subject design time-series Al-C1-A2-B1-A3-C2-
A4-B2. © = non-treatment phases Al-A4; © = placebo treatment phase C1; @ = sham treatment phase C2;
and @ = orthokinetics treatment phases B1 and B2; * = mean M of AROM in cach phase.

study, and lasted 26 weeks (Gonella, 1989). The outcomes of this orthokinetics treatment were
increase in left elbow AROM to 145°, with carry-over upon removal of the orthokinetic cuffs.
Forearm pronation achicved normal limits, with active supination return to the neutral position at 0°.
Active wrist extension of 15° was achieved from 15° flexion to 0°; metacarpophalangeal extension of
20° from 90° to 70° in all five fingers, and 15° extension from 90° to 75° at the proximal interphalangeal
joints of the 2nd to Sth fingers. This permitted opening the closed left fist to hold and stabilise objects
for manipulation with the right hand. Additional gains were demonstrated in active left shoulder
flexion to 110°, and abduction to 90° with elbow flexed. Active mobility ranges of horizontal
abduction, with elbow extended, of 0° to 80°, and adduction 0° to 30° were attained. The
orthokinetics treatment outcomes were partial restoration of voluntary mobility to the patient's
paretic UE and assistive functional use in occupation.

Prior to stroke, the patient had operated a florist shop and greenhouse, which continued to be run
by his family members. At 18 weeks of rehabilitation treatment, he asked to resume working in the
greenhouse. The therapist proposed needed workplace adaptations, allowing the paticnt to
ambulate safely along the plant flats, and to carry out watering, pruning, grafting and transplanting
tasks while comfortably scated. The patient was taught safe work techniques, with emphasis on
reach, balance and prevention of falls. At 26 wecks, the patient’s endurance level in greenhouse
work, while wearing orthokinetic cuffs, had reached 5 hours daily. His rehabilitation goals were
attained upon resumption of part-time occupation, with assistive functional usc of the affected UE.
306 Ming and Jixiang

Discussion

The positive outcome of late postacute rehabilitation with orthokinetics treatment, after a time-lag
of over two years since onset of hemiparesis, was not attributable to a maturation effect (Lind, 1982)
of spontancous neural recovery from stroke (Davidoff et al., 1991), and hence causality (internal
validity) of the orthokinetics therapy was supported, as well as its specificity. As posited, the
theory-based orthokinetics treatment (B1 and B2) resulted in pronounced restoration of agonist-
antagonist muscle balance, in contrast to sham treatment (C2), with reverse orientation of the
orthokinetic orthoses, which resulted in significant augmentation of muscle imbalance (Figs 2 and 3).
These outcomes represent ‘direct replication’ of orthokinetics treatment in phases BI and B2, and
‘theoretical replication’ in phase C2 (Yin, 1989). Thus, comparison of the outcomes of this study with
the preceding one (Neeman and Neeman, 1992a,b), showed correspondence in the specificity of
internal validity supported by the respective single-subject pilot studies, as well as in the positive
rehabilitation outcomes of the two clinical orthokinetics treatment courses, with achievement of
each patient's rehabilitation goal.

Conclusions

The two-stage approach of an initial evaluation by a short, scientifically valid pilot trial, is designed to
subserve the objectivity of selection criteria for patients’ admission to clinical rehabilitation, based
on their demonstrated responsiveness to the planned orthokinetics treatment. The double-blind
screening of patients, and the consequent gain in objectivity, provides a safeguard for the patient’s
right to treatment, while also protecting the care provider, and the physician or other professional
acting as ‘gatekeeper’ to the rehabilitation service (Haas, 1988). Selection of patients for
rehabilitation by the two-stage approach, has predictive value for the treatment outcome, thus
preventing admission of ‘cost outliers’ who would not benefit from rehabilitative therapy (Osberg et
al., 1990). The single-subject paradigm, in a double-blind trial design, may serve the unfilled needs of
rehabilitation professionals to validate their own clinical practices in a cost-effective, yet
scientifically rigorous manner (Basmajian and Gowland, 1987; Eakin, 1991a,b; Fess, 1992; Gonella,
1989; Neeman and Neeman, 1992a,b, 1993; Payton, 1988; Wood-Dauphinée, 1988).

Implications for further study

This interdisciplinary study, which integrated clinical care by use of orthokinetic orthotics with
treatment efficacy studies, is responsive to calls for action in stroke research (Basmajian, 1989;
Basmajian and Gowland, 1987). It implies the need for additional, systematic replications, designed
to enlarge the scope of applicability of orthokinetic orthotics. In particular, rehabilitation studies are
needed on the therapeutic use of orthokinetic orthoses for patients with paretic limb dysfunction,
secondary to central nervous system damage in conditions of stroke and head injury, and congenital
diseases of the brain and spinal cord (United States Department of Health and Human Services,
1990). Cooperative studies addressed to such issues are under way (Neeman and Neeman, 1992a,b).

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