Measurement of Upper-Extremity Function Early After Stroke: Properties of the Action Research Arm Test

Changes in functional brain organization and behavioral correlations after rehabilitative therapy using a brain-computer interface

This study aims to examine the changes in task-related brain activity induced by rehabilitative therapy using brain-computer interface (BCI) technologies and whether these changes are relevant to functional gains achieved through the use of these therapies. Stroke patients with persistent upper-extremity motor deficits received interventional rehabilitation therapy using a closed-loop neurofeedback BCI device (n = 8) or no therapy (n = 6). Behavioral assessments using the Stroke Impact Scale, the Action Research Arm Test (ARAT), and the Nine-Hole Peg Test (9-HPT) as well as task-based fMRI scans were conducted before, during, after, and 1 month after therapy administration or at analogous intervals in the absence of therapy. Laterality Index (LI) values during finger tapping of each hand were calculated for each time point and assessed for correlation with behavioral outcomes. Brain activity during finger tapping of each hand shifted over the course of BCI therapy, but not in the absence of therapy, to greater involvement of the non-lesioned hemisphere (and lesser involvement of the stroke-lesioned hemisphere) as measured by LI. Moreover, changes from baseline LI values during finger tapping of the impaired hand were correlated with gains in both objective and subjective behavioral measures. These findings suggest that the administration of interventional BCI therapy can induce differential changes in brain activity patterns between the lesioned and non-lesioned hemispheres and that these brain changes are associated with changes in specific motor functions.

Changes in functional connectivity correlate with behavioral gains in stroke patients after therapy using a brain-computer interface device

Brain-computer interface (BCI) technology is being incorporated into new stroke rehabilitation devices, but little is known about brain changes associated with its use. We collected anatomical and functional MRI of nine stroke patients with persistent upper extremity motor impairment before, during, and after therapy using a BCI system. Subjects were asked to perform finger tapping of the impaired hand during fMRI. Action Research Arm Test (ARAT), 9-Hole Peg Test (9-HPT), and Stroke Impact Scale (SIS) domains of Hand Function (HF) and Activities of Daily Living (ADL) were also assessed. Group-level analyses examined changes in whole-brain task-based functional connectivity (FC) to seed regions in the motor network observed during and after BCI therapy. Whole-brain FC analyses seeded in each thalamus showed FC increases from baseline at mid-therapy and post-therapy (p < 0.05). Changes in FC between seeds at both the network and the connection levels were examined for correlations with changes in behavioral measures. Average motor network FC was increased post-therapy, and changes in average network FC correlated (p < 0.05) with changes in performance on ARAT (R² = 0.21), 9-HPT (R² = 0.41), SIS HF (R² = 0.27), and SIS ADL (R² = 0.40). Multiple individual connections within the motor network were found to correlate in change from baseline with changes in behavioral measures. Many of these connections involved the thalamus, with change in each of four behavioral measures significantly correlating with change from baseline FC of at least one thalamic connection. These preliminary results show changes in FC that occur with the administration of rehabilitative therapy using a BCI system. The correlations noted between changes in FC measures and changes in behavioral outcomes indicate that both adaptive and maladaptive changes in FC may develop with this therapy and also suggest a brain-behavior relationship that may be stimulated by the neuromodulatory component of BCI therapy.

Case report: post-stroke interventional BCI rehabilitation in an individual with preexisting sensorineural disability

Therapies involving new technologies such as brain-computer interfaces (BCI) are being studied to determine their potential for interventional rehabilitation after acute events such as stroke produce lasting impairments. While studies have examined the use of BCI devices by individuals with disabilities, many such devices are intended to address a specific limitation and have been studied when this limitation or disability is present in isolation. Little is known about the therapeutic potential of these devices for individuals with multiple disabilities with an acquired impairment overlaid on a secondary long-standing disability. We describe a case in which a male patient with congenital deafness suffered a right pontine ischemic stroke, resulting in persistent weakness of his left hand and arm. This patient volunteer completed four baseline assessments beginning at 4 months after stroke onset and subsequently underwent 6 weeks of interventional rehabilitation therapy using a closed-loop neurofeedback BCI device with visual, functional electrical stimulation, and tongue stimulation feedback modalities. Additional assessments were conducted at the midpoint of therapy, upon completion of therapy, and 1 month after completing all BCI therapy. Anatomical and functional MRI scans were obtained at each assessment, along with behavioral measures including the Stroke Impact Scale (SIS) and the Action Research Arm Test (ARAT). Clinically significant improvements in behavioral measures were noted over the course of BCI therapy, with more than 10 point gains in both the ARAT scores and scores for the SIS hand function domain. Neuroimaging during finger tapping of the impaired hand also showed changes in brain activation patterns associated with BCI therapy. This case study demonstrates the potential for individuals who have preexisting disability or possible atypical brain organization to learn to use a BCI system that may confer some rehabilitative benefit.

Arm and trunk movement kinematics during seated reaching within and beyond arm's length in people with stroke: a validity study

BACKGROUND

Kinematic analysis is commonly used to objectively measure upper extremity movement performance after stroke. However, the concurrent validity and predictive validity of arm-trunk kinematics during reaching within and beyond arm's length have not been studied.

OBJECTIVE

The aim of this study was to estimate the concurrent validity of kinematic measures before and after treatment and the predictive validity for reaching within and beyond arm's length after stroke.

DESIGN

This was a secondary analysis study.

METHODS

Ninety-seven participants with stroke (mean age=55.9 years [SD=10.9]) received intensive treatment every weekday for 3 to 4 weeks. Kinematic reaching tasks and the Wolf Motor Function Test (WMFT) were used before and after treatment. The validity of the kinematic measures was estimated in relation to WMFT scores.

RESULTS

Of the 8 kinematic variables that were measured, index movement time before treatment (R2=.227-.362) and trunk movement time and trunk displacement after treatment (R2=.095-.346) had the strongest association with the WMFT at both reaching distances. Trunk movement time and trunk displacement before treatment explained 6.9% to 14.9% of the variance in the WMFT after treatment. Kinematic variables explained 6.9% to 49.3% and 9.4% to 38.7% of the variance in the WMFT during a task within arm's length and beyond arm's length, respectively.

LIMITATIONS

The study has limited generalizability.

CONCLUSIONS

Different kinematic variables may partially reflect motor function before and after treatment to a limited degree. Although the predictive validity was modest, trunk movement may be considered a prognostic determinant of motor function after treatment. A reaching task within arm's length may be a more suitable measure of kinematic performance for describing motor function than a reaching task beyond arm's length.

Combining d-cycloserine with motor training does not result in improved general motor learning in neurologically intact people or in people with stroke

Neurological rehabilitation involving motor training has resulted in clinically meaningful improvements in function but is unable to eliminate many of the impairments associated with neurological injury. Thus there is a growing need for interventions that facilitate motor learning during rehabilitation therapy, to optimize recovery. d-Cycloserine (DCS), a partial N-methyl-d-aspartate (NMDA) receptor agonist that enhances neurotransmission throughout the central nervous system (Ressler KJ, Rothbaum BO, Tannenbaum L, Anderson P, Graap K, Zimand E, Hodges L, Davis M. Arch Gen Psychiatry 61: 1136-1144, 2004), has been shown to facilitate declarative and emotional learning. We therefore tested whether combining DCS with motor training facilitates motor learning after stroke in a series of two experiments. Forty-one healthy adults participated in experiment I, and twenty adults with stroke participated in experiment II of this two-session, double-blind study. Session one consisted of baseline assessment, subject randomization, and oral administration of DCS or placebo (250 mg). Subjects then participated in training on a balancing task, a simulated feeding task, and a cognitive task. Subjects returned 1-3 days later for posttest assessment. We found that all subjects had improved performance from pretest to posttest on the balancing task, the simulated feeding task, and the cognitive task. Subjects who were given DCS before motor training, however, did not show enhanced learning on the balancing task, the simulated feeding task, or the associative recognition task compared with subjects given placebo. Moreover, training on the balancing task did not generalize to a similar, untrained balance task. Our findings suggest that DCS does not enhance motor learning or motor skill generalization in neurologically intact adults or in adults with stroke.

Computer game-based upper extremity training in the home environment in stroke persons: a single subject design

BACKGROUND

The objective of the present study was to assess whether computer game-based training in the home setting in the late phase after stroke could improve upper extremity motor function.

METHODS

Twelve subjects with prior stroke were recruited; 11 completed the study.

DESIGN

The study had a single subject design; there was a baseline test (A1), a during intervention test (B) once a week, a post-test (A2) measured directly after the treatment phase, plus a follow-up (C) 16-18 weeks after the treatment phase. Information on motor function (Fugl-Meyer), grip force (GrippitR) and arm function in activity (ARAT, ABILHAND) was gathered at A1, A2 and C. During B, only Fugl-Meyer and ARAT were measured. The intervention comprised five weeks of game-based computer training in the home environment. All games were designed to be controlled by either the affected arm alone or by both arms. Conventional formulae were used to calculate the mean, median and standard deviations. Wilcoxon's signed rank test was used for tests of dependent samples. Continuous data were analyzed by methods for repeated measures and ordinal data were analyzed by methods for ordered multinomial data using cumulative logistic models. A p-value of < 0.05 was considered statistically significant.

RESULTS

Six females and five males, participated in the study with an average age of 58 years (range 26-66). FMA-UE A-D (motor function), ARAT, the maximal grip force and the mean grip force on the affected side show significant improvements at post-test and follow-up compared to baseline. No significant correlation was found between the amount of game time and changes in the outcomes investigated in this study.

CONCLUSION

The results indicate that computer game-based training could be a promising approach to improve upper extremity function in the late phase after stroke, since in this study, changes were achieved in motor function and activity capacity.

Resting-state functional connectivity and its association with multiple domains of upper-extremity function in chronic stroke

BACKGROUND

Recent work has shown that resting-state functional connectivity (rsFC) between homotopic, motor-related brain regions is associated with upper-extremity control early after stroke.

OBJECTIVES

This study examined various patterns of rsFC in chronic stroke, a time at which extensive neural reorganization has occurred. Associations between homotopic somatomotor connectivity and clinical measures, representing separate domains of upper-extremity function, were determined.

METHODS

A total of 19 persons ≥6 months poststroke participated. Four connectivity patterns within a somatomotor network were quantified using functional magnetic resonance imaging. Upper-extremity gross muscle activation, control, and real-world use were evaluated with the Motricity Index, Action Research Arm Test, and accelerometry, respectively.

RESULTS

Connectivity between homotopic regions was stronger than that in the contralesional and ipsilesional hemispheres. No differences in connectivity strength were noted between homotopic pairs, indicating that a specific brain structure was not driving somatomotor network connectivity. Homotopic connectivity was significantly associated with both upper-extremity control (r = 0.53; P= .02) and real-world use (r = 0.54; P= .02); however, there was no association with gross muscle activation (r = 0.23; P=.34). The combination of clinical measures accounted for 40% of the variance in rsFC (= .05).

CONCLUSIONS

The results reported here expand on previous findings, indicating that homotopic rsFC persists in chronic stroke and discriminates between varying levels of upper-extremity control and real-world use. Further work is needed to evaluate its adequacy as a biomarker of motor recovery following stroke.

Robotic therapy provides a stimulus for upper limb motor recovery after stroke that is complementary to and distinct from conventional therapy

BACKGROUND

Individuals with chronic stroke often have long-lasting upper extremity impairments that impede function during activities of daily living. Rehabilitation robotics have shown promise in improving arm function, but current systems do not allow realistic training of activities of daily living. We have incorporated the ARMin III and HandSOME device into a novel robotic therapy modality that provides functional training of reach and grasp tasks.

OBJECTIVE

To compare the effects of equal doses of robotic and conventional therapy in individuals with chronic stroke.

METHODS

Subjects were randomized to 12 hours of robotic or conventional therapy and then crossed over to the other therapy type after a 1-month washout period. Twelve moderate to severely impaired individuals with chronic stroke were enrolled, and 10 completed the study.

RESULTS

Across the 3-month study period, subjects showed significant improvements in the Fugl-Meyer (P = .013) and Box and Blocks tests (P = .028). The robotic intervention produced significantly greater improvements in the Action Research Arm Test than conventional therapy (P = .033). Gains in the Box and Blocks test from conventional therapy were larger than from robotic therapy in subjects who received conventional therapy after robotic therapy (P = .044).

CONCLUSIONS

Data suggest that robotic therapy can elicit improvements in arm function that are distinct from conventional therapy and supplements conventional methods to improve outcomes. Results from this pilot study should be confirmed in a larger study.

Predictors of return to driving after stroke

OBJECTIVE

Although returning to driving is a major concern for many survivors of stroke, predicting who will return to driving after a stroke is often difficult for rehabilitation professionals. The primary aim of this study was to identify patient factors present at admission to an inpatient rehabilitation hospital that can be used to identify which patients who have had acute stroke will and will not return to driving.

DESIGN

After comparing returners and nonreturners on demographic and clinical characteristics, a logistic regression model with return to driving as the outcome variable was built using the backward stepwise method.

RESULTS

Thirty-one percent (48/156) of the patients who had been driving before their stroke returned to driving 6 mos after stroke. The final regression model, using Functional Independence Measure cognition and lower extremity Motricity Index scores, predicted the driving outcome with an accuracy of 75% (107/143).

CONCLUSIONS

Patients with lower Functional Independence Measure cognition and lower extremity Motricity Index scores at admission to inpatient rehabilitation are less likely to return to driving at 6 mos. This model could be used by rehabilitation professionals to help counsel patients and their families and focus treatment goals.

Transfer of training between distinct motor tasks after stroke: implications for task-specific approaches to upper-extremity neurorehabilitation

BACKGROUND

Although task-specific training is emerging as a viable approach for recovering motor function after stroke, there is little evidence for whether the effects of such training transfer to other functional motor tasks not directly practiced in therapy.

OBJECTIVE

The purpose of the current study was to test whether training on one motor task in individuals with chronic hemiparesis poststroke would transfer to untrained tasks that were either spatiotemporally similar or different.

METHODS

In all, 11 participants with chronic mild to moderate hemiparesis following stroke completed 5 days of supervised massed practice of a feeding task with their affected side. Performance on the feeding task, along with 2 other untrained functional upper-extremity motor tasks (sorting, dressing) was assessed before and after training.

RESULTS

Performance of all 3 tasks improved significantly after training exclusively on 1 motor task. The amount of improvement in the untrained tasks was comparable and was not dependent on the degree of similarity to the trained task.

CONCLUSIONS

Because the number and type of tasks that can be practiced are often limited within standard stroke rehabilitation, results from this study will be useful for designing task-specific training plans to maximize therapy benefits.

Assessment of upper extremity impairment, function, and activity after stroke: foundations for clinical decision making

The purpose of this review is to provide a comprehensive approach for assessing the upper extremity (UE) after stroke. First, common UE impairments and how to assess them are briefly discussed. Although multiple UE impairments are typically present after stroke, the severity of one's impairment, paresis, is the primary determinant of UE functional loss. Second, UE function is operationally defined and a number of clinical measures are discussed. It is important to consider how impairment and loss of function affect UE activity outside of the clinical environment. Thus, this review also identifies accelerometry as an objective method for assessing UE activity in daily life. Finally, the role that each of these levels of assessment should play in clinical decision making is discussed to optimize the provision of stroke rehabilitation services.

Comparison of unilateral versus bilateral upper extremity task performance after stroke

BACKGROUND

Previous studies have suggested that practicing functional tasks bilaterally instead of unilaterally may improve paretic limb performance after stroke.

OBJECTIVE

The purposes of this study were to determine whether the bilateral movement condition alters paretic limb performance of a functional task in people with poststroke hemiparesis and to identify specifically which parameters of performance may be affected.

METHODS

In this single-session study, we examined immediate effects of the bilateral versus unilateral movement condition on performance of a reach-grasp-lift-release task at preferred speed in 16 people with mild to moderate poststroke hemiparesis and in 12 healthy control subjects. Performance was quantified by using motion analysis variables, including duration of the reach and grasp phases, reach path straightness, maximum thumb-index finger aperture, efficiency of finger movement, peak grip force, and timing of release.

RESULTS

We found no evidence of immediate improvement in paretic limb performance in the bilateral condition. In both groups, release timing occurred later when participants moved bilaterally instead of unilaterally, possibly representing a divided attention effect. Other variables did not differ across conditions.

CONCLUSIONS

Our findings suggest little immediate impact of the bilateral condition on motor performance of a reach-grasp-lift-release task at preferred speed in people with mild to moderate hemiparesis.

Improvement after constraint-induced movement therapy: recovery of normal motor control or task-specific compensation?

BACKGROUND

Constraint-induced movement therapy (CIMT) has proven effective in increasing functional use of the affected arm in patients with chronic stroke. The mechanism of CIMT is not well understood.

OBJECTIVE

To demonstrate, in a proof-of-concept study, the feasibility of using kinematic measures in conjunction with clinical outcome measures to better understand the mechanism of recovery in chronic stroke patients with mild to moderate motor impairments who undergo CIMT.

METHODS

A total of 10 patients with chronic stroke were enrolled in a modified CIMT protocol over 2 weeks. Treatment response was assessed with the Action Research Arm Test (ARAT), the Upper-Extremity Fugl-Meyer score (FM-UE), and kinematic analysis of visually guided arm and wrist movements. All assessments were performed twice before the therapeutic intervention and once afterward.

RESULTS

There was a clinically meaningful improvement in ARAT from the second pre-CIMT session to the post-CIMT session compared with the change between the 2 pre-CIMT sessions. In contrast, FM-UE and kinematic measures showed no meaningful improvements.

CONCLUSIONS

Functional improvement in the affected arm after CIMT in patients with chronic stroke appears to be mediated through compensatory strategies rather than a decrease in impairment or return to more normal motor control. We suggest that future large-scale studies of new interventions for neurorehabilitation track performance using kinematic analyses as well as clinical scales.

Clinical reality of measuring upper-limb ability in neurologic conditions: a systematic review

OBJECTIVE

To review the psychometric properties and clinical utility of upper-limb measurement tools in people with neurologic conditions to provide recommendations for practice.

DATA SOURCES

MEDLINE, CINAHL, EMBASE, PEDro, and AMED.

STUDY SELECTION

Independent reviewers searched, selected, and extracted data from articles that assessed reliability, validity, ability to detect change, and clinical utility of measures of the upper limb in adult neurologic conditions.

DATA EXTRACTION

Measures with good psychometrics and 8 or higher (out of 10) clinical utility scores were recommended.

DATA SYNTHESIS

The searches identified 31 measures of the upper limb. However, only 2 measures fulfilled all of the psychometric and clinical utility criteria; the Box and Block Test and the Action Research Arm Test.

CONCLUSIONS

The Box and Block and the Action Research Arm Tests produce robust data and are feasible for use in clinical practice. Future development of new or existing measures should ensure the construct and content validity of the measure is clearly identified, standardized guidelines are easily available, and ensure that it is individualized and contemporary. Attention to measures of upper-limb activity for people who are unable to grip objects is also needed.

Virtual reality in the rehabilitation of the arm after hemiplegic stroke: a randomized controlled pilot study

OBJECTIVE

To assess the feasibility of a trial to investigate the effectiveness of virtual reality-mediated therapy compared to conventional physiotherapy in the motor rehabilitation of the arm following stroke, and to provide data for a power analysis to determine numbers for a future main trial.

DESIGN

Pilot randomized controlled trial.

SETTING

Clinical research facility.

PARTICIPANTS

Eighteen people with a first stroke, 10 males and 8 females, 7 right and 2 left side most affected. Mean time since stroke 10.8 months.

INTERVENTIONS

Participants were randomized to a virtual reality group or a conventional arm therapy group for nine sessions over three weeks.

MAIN MEASURES

The upper limb Motricity Index and the Action Research Arm Test were completed at baseline, post intervention and six weeks follow-up.

RESULTS

Outcome data were obtained from 95% of participants at the end of treatment and at follow-up: one participant withdrew. Compliance was high; only two people reported side-effects from virtual reality exposure. Both groups demonstrated small (7-8 points on upper limb Motricity Index and 4 points on the Action Research Arm Test), but non-significant, changes to their arm impairment and activity levels.

CONCLUSION

A randomized controlled trial of virtual reality-mediated therapy comparable to conventional therapy would be feasible, with some suggested improvements in recruitment and outcome measures. Seventy-eight participants (39 per group) would be required for a main trial.

The bilateral movement condition facilitates maximal but not submaximal paretic-limb grip force in people with post-stroke hemiparesis

OBJECTIVES

Although healthy individuals have less force production capacity during bilateral muscle contractions compared to unilateral efforts, emerging evidence suggests that certain aspects of paretic upper limb task performance after stroke may be enhanced by moving bilaterally instead of unilaterally. We investigated whether the bilateral movement condition affects grip force differently on the paretic side of people with post-stroke hemiparesis, compared to their non-paretic side and both sides of healthy young adults.

METHODS

Within a single session, we compared: (1) maximal grip force during unilateral vs. bilateral contractions on each side, and (2) force contributed by each side during a 30% submaximal bilateral contraction.

RESULTS

Healthy controls produced less grip force in the bilateral condition, regardless of side (-2.4% difference), and similar findings were observed on the non-paretic side of people with hemiparesis (-4.5% difference). On the paretic side, however, maximal grip force was increased by the bilateral condition in most participants (+11.3% difference, on average). During submaximal bilateral contractions in each group, the two sides each contributed the same percentage of unilateral maximal force.

CONCLUSIONS

The bilateral condition facilitates paretic limb grip force at maximal, but not submaximal levels.

SIGNIFICANCE

In some people with post-stroke hemiparesis, the paretic limb may benefit from bilateral training with high force requirements.

Disparity between functional recovery and daily use of the upper and lower extremities during subacute stroke rehabilitation

BACKGROUND

Although inpatient rehabilitation may enhance an individual's functional ability after stroke, it is not known whether these improvements are accompanied by an increase in daily use of the arms and legs.

OBJECTIVES

To determine the change in daily use of the upper and lower extremities of stroke patients during rehabilitation and to compare these values with that of community-dwelling older adults.

METHODS

A total of 60 stroke patients underwent functional assessments and also wore 3 accelerometers for 3 consecutive weekdays on admission to rehabilitation and 3 weeks later prior to hospital discharge. The number of steps and upper-extremity activity counts were measured over the waking hours and during daily use for occupational therapy (OT) and physical therapy (PT) sessions. Healthy older adults (n = 40) also wore 3 accelerometers for 5 consecutive days.

RESULTS

Stroke patients demonstrated a significant increase in mobility function, and this was accompanied by an increase in daily walking over the entire day as well as in PT. However, increases in daily walking were found predominantly in patients who were wheelchair users (and not walkers) at the time of admission. Control walking values (5202 steps) were more than 17 times that of stroke patients. Despite significant improvements in paretic hand function, no increase in daily use of the paretic or nonparetic hand was found over the entire day or in PT.

CONCLUSIONS

A disparity between functional recovery and increases in daily use of the upper and lower extremities was found during inpatient stroke rehabilitation.

Predictive ability of 2-day measurement of active range of motion on 3-mo upper-extremity motor function in people with poststroke hemiparesis

OBJECTIVE. We determined (1) whether active range of motion (AROM) of shoulder flexion and wrist extension measured at the initial therapy evaluation in the acute hospital predicted upper-extremity (UE) motor function 3 mo after stroke and (2) whether the presence of nonmotor impairments influenced this prediction. METHOD. We collected AROM data from 50 people with stroke during their initial acute hospital therapy evaluation and UE motor function data 3 mo later. Multiple regression techniques determined the predictive ability of initial AROM on later UE motor function. RESULTS. Initial AROM explained 28% of the variance in UE motor function 3 mo poststroke. Nonmotor deficits did not contribute to the variance. CONCLUSION. Compared with later AROM measurements, initial values did not adequately predict UE motor function 3 mo after stroke. Clinicians should use caution when informing clients of UE functional prognosis in the early days after stroke.

Toronto rehabilitation institute-hand function test: assessment of gross motor function in individuals with spinal cord injury

PURPOSE

The objective of this study was to evaluate the interrater reliability, construct validity, and sensitivity of Toronto Rehabilitation Institute-Hand Function Test (TRI-HFT), within an interventional randomized control trial.

METHOD

Twenty-one participants with subacute C4 to C7 spinal cord injury (SCI) were recruited. Based on randomization, participants were allocated to either the functional electrical stimulation therapy group or the conventional occupational therapy group. Baseline and follow-up assessments of participants were videotaped. For testing interrater reliability, videotaped images were transferred to DVDs that were later observed by 2 observers. Construct validity was determined by comparing total scores on TRI-HFT to self-care subscore components of the Spinal Cord Independence Measure (SCIM) and FIM. To establish sensitivity of TRI-HFT, we compared pre- and posttreatment scores on all 3 measures (ie, TRI-HFT, FIM, and SCIM).

RESULTS

TRI-HFT was found to have high interrater reliability with an intercorrelation coefficient (ICC) of 0.98. Moderate to strong correlations were found between TRI-HFT total scores and self-care components of FIM and SCIM for both hands individually post therapy. Due to a floor effect of the FIM and SCIM, there was weak correlation between pretherapy scores of the said measures and TRI-HFT. TRI-HFT was found to be highly sensitive in determining difference in function pre and post therapy.

CONCLUSIONS

This study demonstrated that the TRI-HFT is a reliable and sensitive measure to assess unilateral hand gross motor function in persons with tetraplegia, with moderate to strong construct validity.

Need for speed: better movement quality during faster task performance after stroke

BACKGROUND

. Although slow and insufficient muscle activation is a hallmark of hemiparesis poststroke, movement speed is rarely emphasized during upper-extremity rehabilitation. Moving faster may increase the intensity of task-specific training, but positive and/or negative effects on paretic-limb movement quality are unknown.

OBJECTIVE

. To determine whether moving quickly instead of at a preferred speed either enhances or impairs paretic-limb task performance after stroke.

METHODS

. A total of 16 people with poststroke hemiparesis and 11 healthy controls performed reach-grasp-lift movements at their preferred speed and as fast as possible, using palmar and 3-finger grip types. The authors measured durations of the reach and grasp phases, straightness of the reach path, thumb-index finger separation (aperture), efficiency of finger movement, and grip force.

RESULTS

. Reach and grasp phase durations decreased in the fast condition in both groups, showing that participants were able to move more quickly when asked. When moving fast, the hemiparetic group had reach durations equal to those of healthy controls moving at their preferred speed. Movement quality also improved. Reach paths were straighter, and peak apertures were greater in both groups in the fast condition. The group with hemiparesis also showed improved efficiency of finger movement. Differences in peak grip force across speed conditions did not reach significance.

CONCLUSIONS

. People with hemiparesis who can perform reach-grasp-lift movements with a 3-finger grip can move faster than they choose to, and when they do, movement quality improves. Simple instructions to move faster could be a cost-free and effective means of increasing rehabilitation intensity after stroke.

Person-specific changes in motor performance accompany upper extremity functional gains after stroke

In animal models, hundreds of repetitions of upper extremity (UE) task practice promote neural adaptation and functional gain. Recently, we demonstrated improved UE function following a similar intervention for people after stroke. In this secondary analysis, computerized measures of UE task performance were used to identify movement parameters that changed as function improved. Ten people with chronic poststroke hemiparesis participated in high-repetition UE task-specific training 3 times per week for 6 weeks. Before and after training, we assessed UE function with the Action Research Arm Test (ARAT), and evaluated motor performance using computerized motion capture during a reach-grasp-transport-release task. Movement parameters included the duration of each movement phase, trunk excursion, peak aperture, aperture path ratio, and peak grip force. Group results showed an improvement in ARAT scores (p = .003). Although each individual changed significantly on at least one movement parameter, across the group there were no changes in any movement parameter that reached or approached significance. Changes on the ARAT were not closely related to changes in movement parameters. Since aspects of motor performance that contribute to functional change vary across individuals, an individualized approach to upper extremity motion analysis appears warranted.

Instrumentos de avaliação da função de membros superiores após acidente vascular encefálico: uma revisão sistemática

O objetivo desta revisão sistemática da literatura foi analisar os instrumentos de avaliação da função de membros superiores em indivíduos que sofreram acidente vascular encefálico (AVE), bem como suas propriedades psicométricas e adaptação cultural para o Brasil. A busca nas bases de dados eletrônicas Medline, Lilacs e Scielo levaram à seleção de 57 artigos sobre instrumentos de avaliação da função motora global, da função específica da extremidade superior, bem como os relativos à validação e avaliação das propriedades psicométricas das escalas. Foram encontrados 11 instrumentos de avaliação da função de membros superiores. Destes, a escala de Fugl-Meyer, o teste de habilidade motora do membro superior e a medida de independência funcional são traduzidos e validados para a língua portuguesa e têm sua validade, confiabilidade e reprodutibilidade determinadas e adequadas. Esses instrumentos mostram-se complementares na avaliação da função de membros superiores de pacientes que sofreram AVE, pois incluem aspectos relativos à estrutura e função corporal, à capacidade de execução de tarefas, e ao cuidado pessoal e relações interpessoais, respectivamente, sendo portanto recomendáveis para o uso clínico.

Motor imagery after stroke: relating outcome to motor network connectivity

OBJECTIVE

Neuroplasticity is essential for recovery after stroke and is the target for new stroke therapies. During recovery from subcortical motor stroke, brain activations associated with movement may appear normal despite residual functional impairment. This raises an important question: how far does recovery of motor performance depend on the processes that precede movement execution involving the premotor and prefrontal cortex, rather than recovery of the corticospinal system alone?

METHODS

We examined stroke patients with functional magnetic resonance imaging while they either imagined or executed a finger-thumb opposition sequence. In addition to classical analyses of regional activations, we studied neuroplasticity in terms of differential network connectivity using structural equation modeling. The study included 8 right-handed patients who had suffered a left-hemisphere subcortical ischemic stroke with paresis, and 13 age-matched healthy controls.

RESULTS

With good functional recovery, the regional activations had returned to normal in patients. However, connectivity within the extended motor network remained abnormal. These abnormalities were seen predominantly during motor imagery and correlated with motor performance.

INTERPRETATION

Our results indicate that neuroplasticity can manifest itself as differences in connectivity among cortical areas remote from the infarct, rather than in the degree of regional activation. Connection strengths between nodes of the cortical motor network correlate with motor outcome. The altered organization of connectivity of the prefrontal areas may reflect the role of the prefrontal cortex in higher order planning of movement. Our results are relevant to the assessment and understanding of emerging physical and neurophysiological therapies for stroke rehabilitation.

Psychometric comparisons of 4 measures for assessing upper-extremity function in people with stroke

BACKGROUND

Functional limitation of the upper extremities is common in patients with stroke. An upper-extremity measure with sound psychometric properties is indispensable for clinical and research use.

OBJECTIVE

The purpose of this study was to compare the psychometric properties of 4 clinical measures for assessing upper-extremity motor function in people with stroke: the upper-extremity subscale of the Fugl-Meyer Motor Test (UE-FM), the upper-extremity subscale of the Stroke Rehabilitation Assessment of Movement, the Action Research Arm Test (ARAT), and the Wolf Motor Function Test.

DESIGN

This was a prospective, longitudinal study.

METHODS

Fifty-three people with stroke were evaluated with the 4 measures at 4 time points (14, 30, 90, and 180 days after stroke). Thirty-five participants completed all of the assessments. The ceiling and floor effects, validity (concurrent validity and predictive validity), and responsiveness of each measure were examined. Interrater reliability and test-retest reliability also were examined.

RESULTS

All measures, except for the UE-FM, had significant floor effects or ceiling effects at one or more time points. The Spearman rho correlation coefficient for each pair of the 4 measures was > or =.81, indicating high concurrent validity. The predictive validity of the 4 measures was satisfactory (Spearman rho, > or =.51). The responsiveness of the 4 measures at 14 to 180 days after stroke was moderate (.52 < or = effect size < or = .79). The 4 measures had good interrater reliability (intraclass correlation coefficient [ICC], > or =.92) and test-retest reliability (ICC, > or =.97). Only the minimal detectable changes of the UE-FM (8% of the highest possible score) and the ARAT (6%) were satisfactory.

LIMITATIONS

The sample size was too small to conduct data analysis according to type or severity of stroke. In addition, the timed component of the Wolf Motor Function Test was not used in this study.

CONCLUSIONS

All 4 measures showed sufficient validity, responsiveness, and reliability in participants with stroke. The UE-FM for assessing impairment and the ARAT for assessing disability had satisfactory minimal detectable changes, supporting their utility in clinical settings.

Relationships and responsiveness of six upper extremity function tests during the first six months of recovery after stroke

BACKGROUND

Knowing how clinical tests are related to each other and whether tests are responsive to change are critical to evidence-based practice and sound research.

OBJECTIVE

To determine (1) relationships between six clinical tests of upper extremity function and (2) responsiveness for each test during the first six months after stroke.

METHODS

Grip strength test, pinch strength test, Action Research Arm Test, Jebsen-Taylor Hand Function Test, Nine-Hole Peg Test, and the Stroke Impact Scale-Hand domain were administered to 33 subjects within one, three, and six months after stroke. Spearman correlations were used to analyze relationships between tests. Responsiveness was calculated using the single population effect size method.

RESULTS

All tests were correlated with each other with absolute r-values ranging from 0.54 to 0.92 at one month, 0.57 to 0.97 at three months, and 0.41 to 0.97 at six months. All tests were at least moderately responsive to change, with effect sizes ranging from 0.50 to 1.02 from one to three months, and 0.56 to 0.86 (d) from one to six months.

CONCLUSIONS

Our data can assist clinicians and researchers in making decisions to use specific tests for measuring upper extremity function in people with hemiparesis in the first six months of recovery.

Active range of motion predicts upper extremity function 3 months after stroke

BACKGROUND AND PURPOSE

After stroke, 80% of patients experience acute paresis of the upper extremity and only approximately one-third achieve full functional recovery. Predicting functional recovery for these patients is highly important to provide focused, cost-effective rehabilitation. Our purpose was to examine if early measures of upper extremity active range of motion (AROM) could predict recovery of upper extremity function, and to describe the trajectory of upper extremity AROM recovery over time.

METHODS

Thirty-three subjects were tested at 1 month and then at 3 months after stroke. Upper extremity function was measured with 6 standardized clinical tests that were synthesized into a single, sensitive score for upper extremity function using principal component analysis. The ability to move each segment (AROM) was measured using a 3-dimensional electromagnetic tracking system.

RESULTS

Stepwise multiple regression revealed that AROM of the shoulder and middle finger segments taken at 1 month could predict 71% of the variance in upper extremity function at 3 months. All segments of the upper extremity recover similarly and no evidence of a proximal to distal gradient in motor deficits appeared over time.

CONCLUSIONS

Simple AROM measurements of the upper extremity taken within 1 month after stroke can be used to predict upper extremity function at 3 months. This information is important for determining the prognosis of upper extremity functional recovery.

A self-administered Graded Repetitive Arm Supplementary Program (GRASP) improves arm function during inpatient stroke rehabilitation: a multi-site randomized controlled trial

BACKGROUND AND PURPOSE

More than 70% of individuals who have a stroke experience upper limb deficits that impact daily activities. Increased amount of upper limb therapy has positive effects; however, practical and inexpensive methods of therapy are needed to deliver this increase in therapy.

METHODS

This was a multi-site single blind randomized controlled trial to determine the effectiveness of a 4-week self-administered graded repetitive upper limb supplementary program (GRASP) on arm recovery in stroke. 103 inpatients with stroke were randomized to the experimental group (GRASP group, n=53) or the control group (education protocol, n=50). The primary outcome measure was the Chedoke Arm and Hand Activity Inventory (CAHAI), a measure of upper limb function in activities of daily living. Secondary measures were used to evaluate grip strength and paretic upper limb use outside of therapy time. Intention-to-treat analysis was performed. Group differences were tested using analysis of covariance.

RESULTS

At the end of the 4-week intervention (approximately 7 weeks poststroke), the GRASP group showed greater improvement in upper limb function (CAHAI) compared to the control group (mean difference 6.2; 95% CI: 3.4 to 9.0; P<0.001). The GRASP group maintained this significant gain at 5 months poststroke. Significant differences were also found in favor of the GRASP protocol for grip strength and paretic upper limb use. No serious adverse effects were experienced.

CONCLUSIONS

A self-administered homework exercise program provides a cost-, time-, and treatment-effective delivery model for improving upper limb recovery in subacute stroke.

Responsiveness and validity of three outcome measures of motor function after stroke rehabilitation

BACKGROUND AND PURPOSE

This study investigated and compared the responsiveness and validity of the Fugl-Meyer Assessment (FMA), the Action Research Arm Test (ARAT), and the Wolf Motor Function Test (WMFT) for patients after stroke rehabilitation.

METHODS

A total of 57 patients with stroke received 1 of 3 rehabilitation treatments for 3 weeks. At pretreatment and posttreatment, the 3 outcome measures, as well as the Functional Independence Measure (FIM) as the external criterion, were administered. The standardized response mean (SRM) and the Wilcoxon signed rank test were used to examine the responsiveness. Construct validity and predictive validity were examined by the Spearman correlation coefficient (rho).

RESULTS

The responsiveness of the FMA, ARAT, and WMFT functional ability scores was large (SRM=0.95-1.42), whereas the WMFT performance time score was small (SRM=0.38). The responsiveness of the FMA was significantly larger than those of the ARAT and the WMFT-TIME, but not the WMFT functional ability scores. With respect to construct validity, correlations between the FMA and other measures were relatively high (rho=0.42-0.76). The FMA and the WMFT performance time scores at pretreatment had moderate predictive validity with the FIM scores at posttreatment (rho=0.42-0.47). In addition, the ARAT and the WMFT functional ability scores revealed a low predictive validity with the FIM (rho=0.17-0.26).

CONCLUSIONS

The results support the FMA and the WMFT-FAS are suitable to detect changes over time for patients after stroke rehabilitation. While simultaneously considering the responsiveness and validity attributes, the FMA may be a relatively sound measure of motor function for stroke patients based on our results. Further research based on a larger sample is needed to replicate the findings.

Review of upper limb ability assessments in acute stroke care, from a practice perspective

Aims: The purpose of this study was to compare three upper limb ability assessments - the Action Research Arm Test (ARAT), Arm Motor Ability Test (AMAT), and Chedoke Arm and Hand Activity Inventory (CAHAI) - in acute stroke occupational therapy practice during a 6-month period, to identify whether any or all were appropriate for use in acute stroke care.

Methods: Medical records of clients with stroke admitted to an acute stroke unit were reviewed retrospectively. Inclusion criteria were: (a) admission between March and August 2006, (b) new diagnosis of stroke, (c) upper limb involvement, and (d) assessed by an occupational therapist with ARAT, AMAT or CAHAI. Included records were reviewed and the following noted: diagnosis, upper limb weakness, gender, age, assessment score, when assessed, time to administer, test items completed, and qualitative notations.

Findings: Thirty three records satisfied the inclusion criteria. A range of stroke subtypes were assessed. The mean ARAT score was 21.4/45, CAHAI was 66.5/91 and AMAT was 3.0/5. The median number of days post-stroke when assessed was 9 days.

Conclusions: Overall, ARAT, CAHAI and AMAT were useful for assessment of upper limb ability. The results cannot specifically identify which assessment is most suited to the acute stroke setting. The findings do support the inclusion of ARAT, CAHAI and AMAT in standard clinical care.

Estimating minimal clinically important differences of upper-extremity measures early after stroke

OBJECTIVE

To estimate minimal clinically important difference (MCID) values of several upper-extremity measures early after stroke.

DESIGN

Data in this report were collected during the Very Early Constraint-induced Therapy for Recovery of Stroke trial, an acute, single-blind randomized controlled trial of constraint-induced movement therapy. Subjects were tested at the prerandomization baseline assessment (average days poststroke, 9.5d) and the first posttreatment assessment (average days poststroke, 25.9d). At each time point, the affected upper extremity was evaluated with a battery of 6 tests. At the second assessment, subjects were also asked to provide a global rating of perceived changes in their affected upper extremity. Anchor-based MCID values were calculated separately for the affected dominant upper extremities and the affected nondominant upper extremities for each of the 6 tests.

SETTING

Inpatient rehabilitation hospital.

PARTICIPANTS

Fifty-two people with hemiparesis poststroke.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Estimated MCID values for grip strength, composite upper-extremity strength, Action Research Arm Test (ARAT), Wolf Motor Function Test (WMFT), Motor Activity Log (MAL), and duration of upper-extremity use as measured with accelerometry.

RESULTS

MCID values for grip strength were 5.0 and 6.2 kg for the affected dominant and nondominant sides, respectively. MCID values for the ARAT were 12 and 17 points, for the WMFT function score were 1.0 and 1.2 points, and for the MAL quality of movement score were 1.0 and 1.1 points for the 2 sides, respectively. MCID values were indeterminate for the dominant (composite strength), the nondominant (WMFT time score), and both affected sides (duration of use) for the other measures.

CONCLUSIONS

Our data provide some of the first estimates of MCID values for upper-extremity standardized measures early after stroke. Future studies with larger sample sizes are needed to refine these estimates and to determine whether MCID values are modified by time poststroke.

Absence of a proximal to distal gradient of motor deficits in the upper extremity early after stroke

OBJECTIVE

Our first purpose was to determine whether there was a proximal to distal gradient in motor deficits in nine segments of the affected upper extremity (shoulder, elbow, forearm, wrist, and five fingers) post-stroke. Our second purpose was to determine which upper extremity segments made the greatest contributions to hand function.

METHODS

Thirty-three subjects were tested on average 18.6 (+/-5.6) days after stroke. The ability to move each segment was measured by active range of motion (AROM). Hand function was measured by a battery of standardized clinical tests which were synthesized into a single, sensitive score for hand function using principal component analysis.

RESULTS

AROM at all nine segments of the upper extremity was reduced and there was no evidence of a proximal to distal gradient in AROM values. Strength of each segment was reduced and there was also no evidence of a gradient in strength values. AROM at each segment was strongly correlated with hand function scores (range 0.76-0.94). General multiple regression analysis showed that AROM explained 82% of the variance in hand function, with most of the variance shared across proximal, middle, and distal segments. Hierarchical regression analysis showed that shoulder AROM alone could explain 88% of the variance in hand function.

CONCLUSIONS

Early after stroke a proximal to distal gradient of motor deficits was not present, and loss of hand function was due to a loss of ability to move many segments of the upper extremity and not just the distal ones.

SIGNIFICANCE

These results suggest that a change in the clinical perception of motor deficits post-stroke is needed. Our finding that shoulder AROM predicted almost all the variance in hand function opens up the possibility that this quick, simple measure may be predictive of future hand function. This would be of high economic and clinical utility compared to other ongoing efforts attempting to predict outcomes post-stroke (e.g. fMRI, MEG).

Upper extremity use in people with hemiparesis in the first few weeks after stroke

The purposes of this report were to: 1) determine the amount of upper extremity use in people with hemiparesis post stroke during their inpatient rehabilitation stay, and 2) to examine the relationships between upper extremity use and impairments and activity limitations at this early time point after stroke. We studied 34 subjects with mild-to-moderate acute hemiparesis (mean time since stroke = 9.3 days) and 10 healthy control subjects. Upper extremity use was measured over 24 hours using bilateral wrist accelerometers. Upper extremity impairments and activity limitations were measured using standard clinical techniques and tests. We found that healthy control subjects use their dominant and nondominant upper extremities 8-9 hours per day. Hemiparetic subjects used their affected and unaffected upper extremities substantially less than control subjects, 3.3 and 6.0 hours per day, respectively. Seven of ten impairment level measures and each of the activity level measures were related to affected upper extremity use. The impairment measures that were related to upper extremity use were those measures that assessed the ability to activate muscles (ie active range of motion and force production) and the measurement of shoulder pain. Our data show that affected upper extremity use is minimal during the inpatient rehabilitation stay, especially given that patients in this setting are required to have 3 hours of therapy per day. We speculate that accelerometer measurements of upper extremity use could be used in a variety of settings and that the objective information they provide would be of great value to clinicians as they select treatments and evaluate progress.

Effect of training on upper-extremity prosthetic performance and motor learning: a single-case study

OBJECTIVES

To examine the impact of a new prosthesis on an experienced and highly motivated prosthetic limb user, to evaluate the effects of training and the ability of clinical measures to detect change, and to gain insight into the mechanisms by which improvement occurs.

DESIGN

A single-case study.

SETTING

An outpatient clinic.

PARTICIPANT

A bilateral high-arm amputee (right shoulder disarticulation, left above elbow).

INTERVENTIONS

Provision of new prosthesis and occupational therapy.

MAIN OUTCOME MEASURES

Action Research Arm Test, box and block test of manual dexterity, Jebsen-Taylor Hand Function Test, and speed and accuracy of reaching movements with and without visual guidance.

RESULTS

In this experienced prosthesis user, provision of a new prosthesis led to an immediate worsening in functional limitation. With training, the subject recovered his baseline status and then exceeded it in both proximal and distal function. All study clinical measures detected change, but the change detected varied as much as 300-fold depending on the measure chosen. The clinical improvements were associated with modest improvements in the speed of reaching but not the accuracy of reaching under visual guidance. Improvements in reaching accuracy without visual guidance were seen after 10 trials, suggesting that some motor learning had occurred.

CONCLUSIONS

Provision of a new prosthesis can cause functional decline even in an experienced user; this decline can be reversed with training. There is wide variability in sensitivity to change among functional limitation measures. Although some training-related improvements may have been due to increased speed and accuracy of reaching without visual guidance, skill in prosthesis use also plays a role.

Reproducibility and minimal detectable change of three-dimensional kinematic analysis of reaching tasks in people with hemiparesis after stroke

BACKGROUND AND PURPOSE

Three-dimensional kinematic analysis of reaching has emerged as an evaluative measure of upper-extremity motor performance in people after stroke. However, the psychometric properties supporting the use of kinematic data for evaluating longitudinal change in motor performance have not been established. The objective of this study was to determine, in a test-retest reliability manner, the reproducibility and minimal detectable change for reaching kinematics in people after stroke.

SUBJECTS AND METHODS

Fourteen participants with hemiparesis after stroke performed forward reaching tasks on 2 occasions 37.3 (SD=9.8) days apart. At each session, participants performed 4 forward reaching tasks produced by the combination of 2 target heights (low and high [109 and 153 cm from the floor, respectively]) and 2 instructed movement speeds (self-selected and as fast as possible). Two analytical methods were used to calculate kinematic parameters.

RESULTS

Relative reliability (intraclass correlation coefficient) ranged from .04 to .99, and absolute reliability (standard error of measurement) ranged from 2.7% to 76.8%, depending on the kinematic variable, the demands of the motor task (target height and movement speed), and the analytical method. Bland-Altman analysis, a statistical method used to assess the repeatability of a method, revealed few systematic errors between sessions. The minimal detectable change ranged from 7.4% to 98.9%.

DISCUSSION AND CONCLUSION

Depending on the demands of the motor task and the analytical method, most kinematic outcome measures (such as peak hand velocity, endpoint error, reach extent, maximum shoulder flexion range of motion, and minimum elbow extension range of motion) are reliable measures of motor performance in people after stroke. However, because of the magnitude of within-subject measurement error, some variables (such as peak hand velocity, time to peak hand velocity, and movement time) must change considerably (>50%) to indicate a real change in individual participants. The results of our reliability analysis, which are based on our cohort of participants with hemiparesis after stroke and our specific paradigm, may not be generalizable to different subpopulations of people with hemiparesis after stroke or to the myriad movement tasks and kinematic variables used for the assessment of reaching performance in people after stroke.

Constraint-induced movement therapy for severe upper-extremity impairment after stroke in an outpatient rehabilitation setting: a case report

PURPOSE

Laboratory studies confirm that constraint-induced movement therapy (CIMT) improves upper-extremity (UE) function after stroke. Due to strict patient criteria and the intensive resources required, CIMT has been slow to become part of rehabilitation practice. Our purpose was to determine the feasibility and effectiveness of an adapted experimental protocol within an outpatient clinical setting for a patient with moderate to severe UE impairment who did not meet traditional CIMT criteria.

PATIENT DESCRIPTION

AJ, a 16-year-old male, experienced a left middle cerebral artery ischemic stroke due to carotid artery dissection one year before beginning CIMT. He demonstrated some proximal movement but no wrist or finger extension. He had received intensive rehabilitation for 12 months prior to beginning CIMT.

INTERVENTION

Two occupational therapists and two physiotherapists collaborated to provide CIMT task training for 6 hours daily for 2 weeks. A knitted mitten extending to the elbow restrained the less-involved UE during 90% of waking hours. Tasks were tailored to AJ's interests, with the goal of integrating his affected UE into his behavioural repertoire. MEASURES AND OUTCOMES: After 2 weeks of CIMT, AJ improved in all measures (grip and lateral pinch strength, Action Research Arm Test [ARAT], and Box and Block Test) except the Chedoke McMaster Impairment Inventory. Greatest gains were seen at 6 months in the ARAT and Box and Block Test, which coincided with patient and family reports of AJ's using his arm in everyday functional tasks.

IMPLICATIONS

Shared workload, emphasis on relevant functional tasks, and complete family participation likely influenced the success of CIMT. Our findings suggest that the strict CIMT criteria used in previous studies may exclude patients who might benefit from the treatment. Controlled trials should be undertaken to examine the effects of CIMT in patients with moderate to severe UE impairment.

Kinematic and Clinical Analyses of Upper-Extremity Movements After Constraint-Induced Movement Therapy in Patients With Stroke: A Randomized Controlled Trial

OBJECTIVE

To study the effects of constraint-induced movement therapy (CIMT) relative to traditional intervention on motor-control strategies for upper-arm reaching and motor performance at the impairment and functional levels in stroke patients.

DESIGN

Two-group randomized controlled trial (RCT); pretreatment and posttreatment measures.

SETTING

Rehabilitation clinics.

PARTICIPANTS

Forty-seven stroke patients (mean age, 55y) 3 weeks to 37 months postonset of a first-ever cerebrovascular accident.

INTERVENTIONS

Forty-seven patients received either CIMT (restraint of the less affected hand combined with intensive training of the more affected upper extremity) or traditional intervention (control treatment) during the study. The treatment intensity was matched between the 2 groups (2h/d, 5d/wk for 3wk).

MAIN OUTCOME MEASURES

Outcomes were evaluated using (1) kinematic variables of reaching movement used to describe the control strategies for reaching, (2) the Fugl-Meyer Assessment (FMA) of motor-impairment severity, and (3) the Motor Activity Log (MAL) evaluating the functional ability of the upper extremity.

RESULTS

After treatment, the CIMT group showed better strategies of reaching control than the control group (P<.03). The CIMT group also showed less motor impairment on the FMA (P=.019) and higher functional ability on the MAL (P<.001).

CONCLUSIONS

This study is the first RCT to show differences in motor-control strategies as measured by kinematic variables after CIMT versus traditional intervention. In addition to improving motor performance at the impairment and functional levels, CIMT conferred therapeutic benefits on control strategies determined by kinematic analysis.