Effect of a therapeutic intervention for the hemiplegic upper limb in the acute phase after stroke: a single-blind, randomized, controlled multicenter trial. Effectiveness of an intensive outpatient rehabilitation program for postacute stroke patients. A randomized, controlled pilot study of a home-based exercise program for individuals with mild and moderate stroke. Forced use of the upper extremity in chronic stroke patients: results from a single-blind randomized clinical trial. Enhanced physical therapy for arm function after stroke: a one year follow up study. Enhanced physical therapy improves recovery of arm function after stroke. A randomised controlled trial. Randomized, controlled trial to evaluate increased intensity of physiotherapy treatment of arm function after stroke. Effect of severity of arm impairment on response to additional physiotherapy early after stroke Intensity of leg and arm training after primary middle-cerebral-artery stroke: a randomised trial Compensation in recovery of upper extremity function after stroke: the Copenhagen Stroke Study. Stroke rehabilitation: sensorimotor integrative treatment versus functional treatment. The results of clinical trials in stroke rehabilitation research. A novel approach to stroke rehabilitation
BACKGROUND AND PURPOSE Arm function recovery is notoriously poor in stroke patients . The effect of treatment modalities , particularly those directed at improving upper limb function , has been studied primarily in chronic stroke patients . The purpose of this study was to investigate the effect of a specific therapeutic intervention on arm function in the acute phase after stroke . METHODS In a single-blind , r and omized , controlled multicenter trial , 100 consecutive patients were allocated to either an experimental group that received an additional treatment of sensorimotor stimulation or to a control group . The intervention was applied for 6 weeks . Patients were evaluated for level of impairment ( Brunnström-Fugl-Meyer test ) and disability ( Action Research Arm test , Barthel Index ) before , midway , and after the intervention period and at follow-up 6 and 12 months after stroke . RESULTS Patients in the experimental group performed better on the Brunnström-Fugl-Meyer test than those in the control group throughout the study period , but differences were significant only at follow-up . Results on the Action Research Arm test and Barthel Index revealed no effect at the level of disability . The effect of the therapy was attributed to the repetitive stimulation of muscle activity . The treatment was most effective in patients with a severe motor deficit and hemianopia or hemi-inattention . No adverse effects due to the intervention were found . CONCLUSIONS Adding a specific intervention during the acute phase after stroke improved motor recovery , which was apparent 1 year later . These results emphasize the potential beneficial effect of therapeutic interventions for the arm The effectiveness of ongoing rehabilitation services for postacute stroke survivors is poorly documented . We design ed a r and omized control , single-blinded study to demonstrate the effectiveness of intensive outpatient therapy . The treatment intervention consisted of 1 hr each of physical and occupational therapy , four times per week , for 12 wk ; therapy focused on neuromuscular facilitation and functional tasks . All subjects were screened before the therapies and after 3 mo and 9 mo . Forty-nine stroke survivors , who were at least l yr ( mean , 2.9 yr ) poststroke , were r and omized with two treated patients to each control ( no treatment supplied ) . All patients had received inpatient rehabilitation at the time of their acute stroke , but no patient had any ongoing therapy  within the last 6 mo . The outcome measures included the Functional Independence Measure ( FIM ) , Brunnstrom stages of motor recovery , timed mobility tasks , and the Jebson h and evaluation . We also evaluated the level of depression , self-esteem , and socialization . The treated patients demonstrated an improvement of 6.6 points over the 3 mo of therapy compared with only 1.5 points in the control group in the FIM motor score transformed using Rasch analysis . The change from time 0 to 3 mo was significant in the treated group but not in the controls . Treated patients maintained their gains at the 9-mo follow-up , and controls lost ground . The treated group improved in terms of socialization and self-esteem as evidence d by a lower Sickness Impact Profile , whereas the controls tended to get worse . There was a trend toward less depression , but this did not reach a P = 0.05 level of significance . This study demonstrates that significant functional gains can still be attained in the postacute stroke survivor , despite prior inpatient rehabilitation services BACKGROUND AND PURPOSE Many stroke survivors have minimal to moderate neurological deficits but are physically deconditioned and have a high prevalence of cardiovascular problems ; all of these are potentially modifiable with exercise . The purpose s of this r and omized , controlled pilot study were ( 1 ) to develop a home-based balance , strength , and endurance program ; ( 2 ) to evaluate the ability to recruit and retain stroke subjects ; and ( 3 ) to assess the effects of the interventions used . METHODS Twenty minimally and moderately impaired stroke patients who had completed inpatient rehabilitation and who were 30 to 90 days after stroke onset were r and omized to a  control group or to an experimental group that received a therapist-supervised , 8-week , 3-times-per-week , home-based exercise program . The control group received usual care as prescribed by the patients ' physicians . Baseline and postintervention assessment s included the Fugl-Meyer Motor Assessment , the Barthel Index of Activities of Daily Living ( ADL ) , the Lawton Scale of Instrumental ADL , and the Medical Outcomes Study -36 Health Status Measurement . Functional assessment s of balance and gait included a 10-m walk , 6-Minute Walk , and the Berg Balance Scale . Upper extremity function was evaluated by the Jebsen Test of H and Function . RESULTS Of 22 patients who met study criteria , 20 completed the study and 2 refused to participate . The experimental group tended to improve more than the control group in motor function ( Fugl-Meyer Upper Extremity : mean change in score , 8 . 4 versus 2.2 ; Fugl-Meyer Lower Extremity : 4.7 versus -0.9 ; gait velocity : median change , 0.25 versus .09 m/s ; 6-Minute Walk : 195 versus 114 ft ; Berg Balance Score : 7.8 versus 5 ; and Medical Outcomes Study -36 Health Status Measurement of Physical Function : 15 . 5 versus 9 ) . There were no trends in differences in change scores by the Jebsen Test of H and Function , Barthel Index , and Lawton Instrumental ADL Scale . CONCLUSIONS This study demonstrated that a r and omized , controlled clinical trial of a poststroke exercise program is feasible . Measures of neurological impairments and lower extremity function showed the most benefit . Effects of the intervention on upper extremity dexterity and functional health status were equivocal . The lasting effects of the intervention were not assessed BACKGROUND AND PURPOSE Of all stroke survivors , 30 % to 66 % are unable to use their affected arm in performing activities of daily living . Although forced use therapy appears to improve arm function in chronic stroke patients , there is no conclusive evidence . This study evaluates the effectiveness of forced use therapy . METHODS In an observer-blinded r and omized clinical trial , 66 chronic stroke patients were allocated to either forced use therapy ( immobilization of the unaffected arm combined with intensive training ) or a reference therapy of equally intensive bimanual training , based on Neuro-Developmental Treatment , for a period of 2 weeks . Outcomes were evaluated on the basis of the Rehabilitation Activities Profile ( activities ) , the Action Research Arm ( ARA ) test ( dexterity ) , the upper extremity section of the Fugl-Meyer Assessment scale , the Motor Activity Log ( MAL ) , and a Problem Score . The minimal clinical ly important difference ( MCID ) was determined at the onset of the study . RESULTS One week after the last treatment session , a significant difference in effectiveness in favor of the forced use group compared with the bimanual group ( corrected for baseline differences ) was found for the ARA score ( 3.0 points ; 95 % CI , 1.3 to 4.8 ; MCID , 5.7 points ) and the MAL amount of use score ( 0.52 points ; 95 % CI , 0.11 to 0.93 ; MCID , 0.50 ) . The other parameters revealed no significant differential effects . One-year follow-up effects were observed only for the ARA . The differences in treatment effect for the ARA and the MAL amount of use scores were clinical ly relevant for patients with sensory disorders and hemineglect , respectively . CONCLUSIONS The present study showed a small but lasting effect of forced use therapy on the dexterity of the affected arm ( ARA ) and a temporary clinical ly relevant effect on the amount of use of the affected arm during activities of daily living ( MAL amount of use ) . The effect of forced use therapy was clinical ly relevant in the subgroups of patients with sensory disorders and hemineglect , respectively Ninety seven patients with stroke who had participated in a r and omised trial of conventional physical therapy nu an enhanced therapy for arm function were followed up at one year . Despite the emphasis of the enhanced therapy approach on continued use of the arm in everyday life , the advantage seen for some patients with enhanced therapy at six months after stroke had diminished to a non-significant trend by one year . This was due to some late improvement in the conventional therapy group whereas the enhanced therapy group remained static or fell back slightly . It is recommended that trials should be conducted comparing very intensive therapy for the arm with controls without treatment . This would provide a model of the effects of therapy on intrinsic neural recovery that would be relevant to all areas of neurological rehabilitation Previous research on stroke rehabilitation has not established whether increase in physical therapy lead to better intrinsic recovery from hemiplegia . A detailed study was carried out of recovery of arm function after acute stroke , and compares orthodox physiotherapy with an enhanced therapy regime which increased the amount of treatment as well as using behavioural methods to encourage motor learning . In a single-blind r and omised trial , 132 consecutive stroke patients were assigned to orthodox or enhanced therapy groups . At six months after stroke the enhanced therapy group showed a small but statistically significant advantage in recovery of strength , range and speed of movement . This effect seemed concentrated amongst those who had a milder initial impairment . More work is needed to discover the reasons for this improved recovery , and whether further development of this therapeutic approach might offer clinical ly significant gains for some patients BACKGROUND AND PURPOSE Many patients have impaired arm function after stroke , for which they receive physiotherapy . The aim of the study was to determine whether increasing the amount of physiotherapy early after stroke improved the recovery of arm function and to compare the effects of this therapy when administered by a qualified therapist or a trained , supervised assistant . The physiotherapy followed a typical British approach , which is Bobath derived . Ten hours of additional therapy were given over a 5-week period . METHODS The study design was a single-blind , r and omized , controlled trial . Stroke patients were recruited from those admitted to the hospital in the 5 weeks after stroke . They were r and omly allocated to routine physiotherapy , additional treatment by a qualified physiotherapist , or additional treatment by a physiotherapy assistant . Outcome was assessed after 5 weeks of treatment and at 3 and 6 months after stroke on measures of arm function and of independence in activities of daily living . RESULTS There were 282 patients recruited to the study . The median initial Barthel score was 6.5 , and the median age of the patients was 73 years . The median initial Rivermead Motor Assessment Arm score was 1 . There were no significant differences between the groups at r and omization or on any of the outcome measures . Only half of the patients allocated to the 2 additional-therapy groups completed the program . CONCLUSIONS This increase in the amount of physiotherapy for arm impairment with a typical British approach given early after stroke did not significantly improve the recovery of arm function in the patients studied . A number of other studies of interventions aim ed at rehabilitation of arm function have reported positive results . Such findings may have been due to the content of these interventions , to the greater intensity of the interventions , or to the selection of patients to whom the treatments were applied Objective : To investigate effect of initial severity of arm impairment on response to additional physiotherapy for the arm after stroke . Design : In this controlled trial , patients were r and omized into one of three groups :  routine physiotherapy ( RPT ) patients received no additional physiotherapy ; qualified physiotherapy ( QPT ) patients received additional treatment from a qualified physiotherapist ; assistant physiotherapy ( APT ) patients received additional treatment from a trained supervised assistant . Comparisons between the whole groups found no significant differences and have been reported elsewhere . In a post hoc analysis , the groups were subdivided according to severity of initial arm impairment . The subgroups were then compared . Setting : A general hospital with acute and rehabilitation facilities for stroke patients . Subjects : Patients ( n= 282 ) between one and five weeks after stroke . Interventions : Ten hours additional physiotherapy were given over a five-week period . The treatment approach reflected current usual British practice . ‘ Blind ’ outcome assessment was performed after intervention , and at three and six months after stroke . Main outcome measures : Rivermead Motor Assessment Arm Scale , Action Research Arm Test . Results : In more severe patients , no benefits of additional treatment were detected . In less severe patients , significant benefits were found in those who completed treatment with the trained assistant . However , a considerable number of patients did not complete the additional treatment . The content of treatment differed between the QPT and APT groups . Treatment of less severe APT patients emphasized repetitive supervised practice of movements and functional tasks . No significant effects of additional treatment were found in terms of shoulder pain or spasticity . Conclusions : Regardless of whether additional physiotherapy was given or not , patients with severe arm impairment improved very little in arm function . Enabling adaptation to loss of arm function may be an appropriate rehabilitation strategy for some patients . Trends in the data confirm findings of some previous studies that intensive treatment for patients with some motor recovery of the upper limb is effective . Following patient assessment and treatment planning by a qualified physiotherapist , it may be appropriate for guidance of repetitive practice of motor and functional tasks to be delegated to trained and closely supervised assistant staff BACKGROUND We investigated the effects of different intensities of arm and leg rehabilitation training on the functional recovery of activities of daily living ( ADL ) , walking ability , and dexterity of the paretic arm , in a single-blind r and omised controlled trial . METHODS Within 14 days after stroke onset , 101 severely disabled patients with a primary middle-cerebral-artery stroke were r and omly assigned to : a rehabilitation programme with emphasis on arm training ; a rehabilitation programme with emphasis on leg training ; or a control programme in which the arm and leg were immobilised with an inflatable pressure splint . Each treatment regimen was applied for 30 min , 5 days a week during the first 20 weeks after stroke . In addition , all patients underwent a basic rehabilitation programme . The main outcome measures were ability in ADL ( Barthel index ) , walking ability ( functional ambulation categories ) , and dexterity of the paretic arm ( Action Research arm test ) at 6 , 12 , 20 , and 26 weeks . Analyses were by intention to treat . FINDINGS At week 20 , the leg-training group ( n=31 ) had higher scores than the control group ( n=37 ) for ADL ability ( median 19 [ IQR 16 - 20 ] vs 16 [ 10 - 19 ] , p<0.05 ) , walking ability ( 4 [ 3 - 5 ] vs 3 [ 1 - 4 ] , p<0.05 ) , and dexterity ( 2 [ 0 - 56 ] vs 0 [ 0 - 2 ] , p<0.01 ) . The arm-training group ( n=33 ) differed significantly from the control group only in dexterity ( 9 [ 0 - 39 ] vs 0 [ 0 - 2 ] , p<0.01 ) . There were no significant differences in these endpoints at 20 weeks between the arm-training and leg-training groups . INTERPRETATION Greater intensity of leg rehabilitation improves functional recovery and health-related functional status , whereas greater intensity of arm rehabilitation results in small improvements in dexterity , providing further evidence that exercise therapy primarily induces treatment effects on the abilities at which training is specifically aim ed Compensation by the unaffected upper extremity ( UE ) was studied in stroke patients who were unable to use the affected UE . The main aim was to evaluate the need of teaching compensatory techniques to stroke patients during rehabilitation of UE function . The study was prospect i ve and community based and included 636 consecutive acute stroke patients .  UE function and UE paresis were assessed weekly using the Barthel Index subscores for feeding and grooming and the  Sc and inavian Stroke Scale ( SSS ) subscores for arm and h and . Rehabilitation was performed according to the Bobath technique . Initially , 214 had severe UE paresis according to  SSS ; the arm could not move against gravity and the fingertips could not reach palm . In 64 of the 115 patients discharged alive , the affected UE definitely remained useless despite intensive and longst and ing rehabilitation . Improvement of UE function was seen in 25 of these patients ( 39 % ) and was possible only through compensation by the unaffected UE . Patients who gained UE function by compensation were younger ( p < 0.01 ) , had less severe stroke ( p < 0.01 ) , smaller ( p < 0.01 ) , and subcortically located ( p = 0.02 ) lesions and less affection of higher cortical function ( p = 0.01 ) . Recovery of UE function in more than half of the stroke patients with initial severe UE paresis can be achieved only by compensation by the unaffected UE This study compares the effectiveness of two occupational therapy approaches to treating cerebrovascular accident patients --the functional and sensorimotor integrative approaches . Subjects were 90 patients admitted to Holy Family Hospital in Vancouver , Canada , within 12 weeks after a first stroke . Consenting subjects were r and omly assigned on admission to one of two occupational therapy treatment groups . All subjects received similar medical and nursing care and physical therapy . An independent clinical evaluator assessed subjects ' function in self-care and mobility , meal preparation , and sensorimotor integration at specified times after admission . Neither the evaluator nor the subjects were aware of the treatment group to which they had been assigned . Results showed no statistically significant differences between the two treatment groups on the three outcome measures . We therefore concluded that any differences between the effectiveness of the two approaches are small UNLABELLED RESEARCH PROBLEM AND METHODS : There are currently 1.5 million stroke survivors in the United States . More than half of these individuals have significant residual physical disability and functional impairment .  Survivors of stroke constitute the largest group of patients receiving rehabilitation services in this country . We examined existing clinical trials investigating the effectiveness of stroke rehabilitation programs to improve functional outcomes and discharge destination .  One hundred twenty-four research reports were initially identified . From this sample , 36 trials meeting selected criteria were evaluated by the methods of meta- analysis . RESULTS A total of 3717 patients participated in the 36 clinical trials included in the meta- analysis . The results revealed a mean d-index of 0.40 + /- 0.33 . This effect size index was converted to a U3 value of 65.5 , indicating that the average patient receiving a program of focused stroke rehabilitation performed better than approximately 65.5 % of those patients in comparison groups ( 95 % confidence interval , 63.6 % to 67.3 % ) . The results also revealed a significant interaction between type of research design and method of recording the outcome of a clinical trial . Blind recording of the outcome measure appears to be an essential design characteristic in clinical trials that do not r and omize patients to conditions . CONCLUSIONS Programs of focused stroke rehabilitation may improve functional performance for some patients who have experienced a stroke . The improvement in performance appears related to early initiation of treatment , but not to the duration of intervention . Improvements are also associated with the patient 's age and the type of design . Research design should be considered an important moderator variable in planning and interpreting future clinical trials of treatment effectiveness in stroke rehabilitation Objective : In patients with stroke , the authors tested whether additional sensorimotor training of the paralyzed or paretic upper limb delivered by a robotic device enhanced motor outcome . Methods : Fifty-six patients with stroke and hemiparesis or hemiplegia received st and ard poststroke multidisciplinary rehabilitation  , and were r and omly assigned either to receive robotic training ( at least 25 hours ) or exposure to the robotic device without training . Outcomes were assessed by the same masked raters , before treatment began and at the end of treatment , with the upper extremity component of the Fugl-Meyer Motor Assessment , the Motor Status score , the Motor Power score , and Functional Independence Measurement . Result : The robot treatment and control group had comparable clinical characteristics , lesion size , and pretreatment impairment scores . By the end of treatment , the robot-trained group demonstrated improvement in motor outcome for the trained shoulder and elbow ( Motor Power score , p < 0.001 ; Motor Status score , p < 0.01 ) that did not generalize to untrained wrist and h and . The robot-treated group also demonstrated significantly improved functional outcome ( Functional Independence Measurement – Motor , p < 0.01 ) . Conclusion : Robot-delivered quantitative and reproducible sensorimotor training enhanced the motor performance of the exercised shoulder and elbow . The robot-treated group also demonstrated improved functional outcome . When added to st and ard multidisciplinary rehabilitation , robotics provides novel therapeutic strategies that focus on impairment reduction and improved motor performance
Objective : Assessment of the available evidence for the effectiveness of exercise therapy to improve arm function in patients who have suffered from a stroke .