Electrical stimulation of wrist extensors in poststroke hemiplegia. Does the Application of Constraint-Induced Movement Therapy During Acute Rehabilitation Reduce Arm Impairment After Ischemic Stroke? Repetitive Practice of a Single Joint Movement for Enhancing Elbow Function in Hemiparetic Patients Positional feedback and electrical stimulation: an automated treatment for the hemiplegic wrist. Chronic motor dysfunction after stroke: recovering wrist and finger extension by electromyography-triggered neuromuscular stimulation. Prevention of shoulder subluxation after stroke with electrical stimulation. 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. The effects of functional electrical stimulation on shoulder subluxation, arm function recovery, and shoulder pain in hemiplegic stroke patients. 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. Robot training enhanced motor outcome in patients with stroke maintained over 3 years Intensity of leg and arm training after primary middle-cerebral-artery stroke: a randomised trial The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. Comparison of TENS treatments in hemiplegic shoulder pain. Stimulation with low frequency (1.7 Hz) transcutaneous electric nerve stimulation (low-tens) increases motor function of the post-stroke paretic arm. Electromyogram-triggered neuromuscular stimulation for improving the arm function of acute stroke survivors: a randomized pilot study. Stroke rehabilitation: sensorimotor integrative treatment versus functional treatment. Low TENS treatment on post-stroke paretic arm: a three-year follow-up A novel approach to stroke rehabilitation Protocol to prevent shoulder-hand syndrome after stroke. A randomized controlled trial of strapping to prevent post-stroke shoulder pain A randomized efficacy and feasibility study of imagery in acute stroke Stroke treatment: comparison of integrated behavioral-physical therapy vs traditional physical therapy programs.
BACKGROUND AND PURPOSE It has been suggested that cyclic neuromuscular electrical stimulation ( ES ) may enhance motor recovery after stroke . We have investigated the effects of ES of the wrist extensors on impairment of wrist function and on upper-limb disability in patients being rehabilitated after acute stroke . METHODS We recruited 60 hemiparetic patients ( mean age , 68 years ) 2 to 4 weeks after stroke into a r and omized , controlled , parallel-group study comparing st and ard rehabilitation treatment with st and ard treatment plus ES of wrist extensors ( 3 times 30 minutes daily for 8 weeks ) . Isometric strength of wrist extensors was measured using a device built for that purpose . Upper-limb disability was assessed with use of the  Action Research Arm Test ( ARAT ) . Observations were continued for 32 weeks ( 24 weeks after the finish of ES or the control intervention phase ) . RESULTS The change in isometric strength of wrist extensors ( at an angle of 0 degrees extension ) was significantly greater in the ES group than the control group at both 8 and 32 weeks ( P=0.004 , P=0.014 by Mann Whitney U test ) . At week 8 the grasp and grip subscores of the ARAT increased significantly in the ES group compared with that in the control group ( P=0.013 and P=0.02 , respectively ) ; a similar trend was seen for the total ARAT score ( P=0.11 ) . In the subgroup of 33 patients with some residual wrist extensor strength at study entry ( moment at 0 degrees extension > 0 ) , the ARAT total score had increased at week 8 by a mean of 21.1 ( SD , 12.7 ) in the ES group compared with 10.3 ( SD , 9.0 ) in the control group ( P=0.024 , Mann Whitney U test ) ; however , at 32 weeks the differences between these 2 subgroups were no longer statistically significant . CONCLUSIONS ES of the wrist extensors enhances the recovery of isometric wrist extensor strength in hemiparetic stroke patients .  Upper-limb disability was reduced after 8 weeks of ES therapy , with benefits most apparent in those with some residual motor function at the wrist . However , it is not clear how long the improvements in upper-limb disability are maintained after ES is discontinued Background and Purpose Motor dysfunction after unilateral deafferentation in primates can be overcome by restraining the unaffected limb . We asked whether a constraint-induced movement ( CIM ) program could be implemented within 2 weeks after stroke and whether CIM is more effective than traditional upper-extremity ( UE ) therapies during this period . Methods Twenty-three persons were enrolled in a pilot r and omized , controlled trial that compared CIM with traditional therapies . A blinded observer rated the primary end point , the Action Research Arm Test ( ARA ) .  Inclusion criteria were the following : ischemic stroke within 14 days , persistent hemiparesis , evidence of preserved cognitive function , and presence of a protective motor response . Differences between the groups were compared by using Student ’s t tests , ANCOVA , and Mann-Whitney U tests . Results Twenty subjects completed the 14-day treatment . Two adverse outcomes , a recurrent stroke and a death , occurred in the traditional group ; 1 CIM subject met rehabilitation goals and was discharged before completing 14 inpatient days . The CIM treatment group had significantly higher scores on total ARA and pinch subscale scores ( P < 0.05 ) . Differences in the mean ARA grip , grasp , and gross movement subscale scores did not reach statistical significance . UE activities of daily living performance was not significantly different between groups , and no subject withdrew because of pain or frustration . Conclusions A clinical trial of CIM therapy during acute rehabilitation is feasible . CIM was associated with less arm impairment at the end of treatment . Long-term studies are needed to determine whether CIM early after stroke is superior to traditional therapies The primary goal of this study was to assess whether repetitive practice of flexion-extension movements of the affected elbow in hemiparetic patients enhances performance and to compare the effects of this practice mode to the effects of the physical therapy variable exercise program which is routinely applied during sessions . Subjects were 27 poststroke hemiparetic patients , residents of a rehabilitation institute , divided into an experimental ( n= 15 ) and a control group ( n = 12 ) . The former were treated with 800 repeated elbow movements in a maximal predetermined amplitude of 80 ° , provided in 8 equal sessions every other day . The latter received 10 min . of conventional physical therapy for the paretic upper extremity at similar time intervals . Pre- and posttreatment assessment s included the bilateral measurements of kinematic variables and activation latencies of the biceps and triceps brachi muscles as well as motor and functional tests . For all criterion variables , the findings pointed to comparable improvement in both groups . It was concluded that repetitive elbow movements had no unique training effect on the kinematics of movement and on activation latencies of the primary muscles controlling elbow function in hemiparetic patients . Further , transfer of the effects of training to execution of movements towards and from the mouth was also comparable in both groups , pointing again to there being no particular advantage in using repetitive movements as a training mode for enhancement of elbow function in hemiparetic patients Positional feedback ( PF ) and electrical stimulation were combined in a new treatment modality for facilitating wrist extension in stroke patients . Thirty adult hemiparetic patients lacking normal voluntary wrist extension were r and omly placed in control and study groups . The control group received conventional therapy while the study group received positional feedback stimulation training ( PFST ) in addition to conventional treatment . At the end of the 4-week program , study patients showed a 280 % increase in isometric extension torque when the wrist was positioned in 30 degrees of extension and 70 % increase when positioned in 30 degrees of flexion . Control patients showed no significant changes in torque . Study patients made an average 200 % gain in selective range of motion over their starting levels while controls made only a 50 % increase . Treatment using automated PFST equipment allows controlled repetitive isotonic exercise and facilitation of wrist extension without continuous one-on-one therapist/patient supervision BACKGROUND AND PURPOSE After stroke , many individuals have chronic unilateral motor dysfunction in the upper extremity that severely limits their functional movement control . The purpose of this study was to determine the effect of electromyography-triggered neuromuscular electrical stimulation on the wrist and finger extension muscles in individuals who had a stroke > or = 1 year earlier . METHODS Eleven individuals volunteered to participate and were r and omly assigned to either the electromyography-triggered neuromuscular stimulation experimental group ( 7 subjects ) or the control group ( 4 subjects ) . After completing a pretest involving 5 motor capability tests , the poststroke subjects completed 12 treatment sessions ( 30 minutes each ) according to group assignments . Once the control subjects completed 12 sessions attempting wrist and finger extension without any external assistance and were posttested , they were then given 12 sessions of the rehabilitation treatment . RESULTS The Box and Block test and the force-generation task ( sustained muscular contraction ) revealed significant findings ( P<0 . 05 ) . The experimental group moved significantly more blocks and displayed a higher isometric force impulse after the rehabilitation treatment . CONCLUSIONS Two lines of evidence clearly support the use of the electromyography-triggered neuromuscular electrical stimulation treatment to rehabilitate wrist and finger extension movements of hemiparetic individuals > or = 1 year after stroke . The treatment program decreased motor dysfunction and improved the motor capabilities in this group of poststroke individuals BACKGROUND AND PURPOSE Subluxation is a significant problem in poststroke hemiplegia , result ing in pain and loss of function . Current treatments are not proved and not considered effective . It has been demonstrated that cyclical electrical stimulation of the shoulder muscles can reduce existing subluxation . The purpose of this study was to determine whether electrical stimulation could prevent subluxation in both the short and long terms . METHODS A prospect i ve , r and omized controlled study was used to determine the efficacy of electrical stimulation in preventing shoulder subluxation in patients after cerebrovascular accidents . Forty patients were selected and r and omly assigned to a control or treatment group . They had their first assessment within 48 hours of their stroke , and those in the treatment group were immediately put on a regimen of electrical stimulation for 4 weeks . All patients were assessed at 4 weeks after stroke and then again at 12 weeks after stroke . Assessment s were made of shoulder subluxation , pain , and motor control . RESULTS The treatment group had significantly less subluxation and pain after the treatment period , but at the end of the follow-up period there were no significant differences between the 2 groups . CONCLUSIONS Electrical stimulation can prevent shoulder subluxation , but this effect was not maintained after the withdrawal of treatment 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 The purpose of this study was to evaluate the effectiveness of a functional electrical stimulation ( FES ) treatment program design ed to prevent glenohumeral joint stretching and subsequent subluxation and shoulder pain in stroke patients . Twenty-six recent hemiplegic stroke patients with shoulder muscle flaccidity were r and omly assigned to either a control group ( n = 13 ; 5 female , and 8 male ) or experimental group ( n = 13 ; 6 female , and 7 male ) . Both groups received conventional physical therapy . The experimental group received additional FES therapy where two flaccid/paralyzed shoulder muscles ( supraspinatus and posterior deltoid ) were induced to contract repetitively up to 6 hours a day for 6 weeks . Duration of both the FES session and muscle contraction/relaxation ratio were progressively increased as performance improved . The experimental group showed significant improvements in arm function , electromyographic activity of the posterior deltoid , range of motion , and reduction in subluxation ( as indicated by x-ray ) compared with the control group . We concluded that the FES program was effective in reducing the severity of shoulder subluxation and pain , and possibly facilitating recovery of arm function 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 Article abstract In an attempt to improve motor recovery of the upper limb after stroke , we added a robot ( MIT-Manus ) experience that provided additional goal -directed sensorimotor activity to st and ard rehabilitation treatments . The first trial produced a significant decrease in motor impairment in the upper limb for the treated group . In re-evaluating 12 of those 20 patients , nearly 3 years later , robot-trained patients showed further significant decreases in impairment measures of the affected limb . The groups were comparable at the start of the study 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 OBJECTIVE : To test the feasibility of creating a valid and reliable checklist with the following features : appropriate for assessing both r and omised and non-r and omised studies ; provision of both an overall score for study quality and a profile of scores not only for the quality of reporting , internal validity ( bias and confounding ) and power , but also for external validity . DESIGN : A pilot version was first developed , based on epidemiological principles , review s , and existing checklists for r and omised studies . Face and content validity were assessed by three experienced review ers and reliability was determined using two raters assessing 10 r and omised and 10 non-r and omised studies . Using different raters , the checklist was revised and tested for internal consistency ( Kuder-Richardson 20 ) , test-retest and inter-rater reliability ( Spearman correlation coefficient and sign rank test ; kappa statistics ) , criterion validity , and respondent burden . MAIN RESULTS : The performance of the checklist improved considerably after revision of a pilot version . The Quality Index had high internal consistency ( KR-20 : 0.89 ) as did the subscales apart from external validity ( KR-20 : 0.54 ) . Test-retest ( r 0.88 ) and inter-rater ( r 0.75 ) reliability of the Quality Index were good . Reliability of the subscales varied from good ( bias ) to poor ( external validity ) . The Quality Index correlated highly with an existing , established instrument for assessing r and omised studies ( r 0.90 ) . There was little difference between its performance with non-r and omised and with r and omised studies . Raters took about 20 minutes to assess each paper ( range 10 to 45 minutes ) . CONCLUSIONS : This study has shown that it is feasible to develop a checklist that can be used to assess the method ological quality not only of r and omised controlled trials but also non-r and omised studies . It has also shown that it is possible to produce a checklist that provides a profile of the paper , alerting review ers to its particular method ological strengths and weaknesses . Further work is required to improve the checklist and the training of raters in the assessment of external validity The aim of this paper is to evaluate the effectiveness of high-intensity versus low-intensity transcutaneous electrical nerve stimulation ( TENS ) and versus placebo for treatment of hemiplegic shoulder pain . Three groups of 20 patients each ( A , B , C ) were studied . In group A high-intensity TENS was delivered at 3 times the sensory threshold with frequency of 100 Hz ; in group B low-intensity TENS was delivered at the sensory threshold with frequency of 100 Hz . Group C received placebo stimulation . The treatment protocol consisted of 12 sessions ( 4 weeks ) . Before treatment , at the end of it and one month after , passive range of motion ( PROM ) for flexion , extension , abduction and external rotation were evaluated . Statistically significant improvements of PROMs were recorded for group A , but not for groups B or The object of this study is to determine if the functional motor capacity of the paretic extremity can be improved by stimulation with low intensity low frequency ( 1.7 Hz ) transcutaneous electric nerve stimulation ( Low-TENS ) , started 6 - 12 months after a stroke . Forty-four patients who had a paretic arm as a consequence of their first stroke were included and r and omly assigned to either a treatment group ( n = 26 ) or a control group ( n = 18 ) . Patients in both groups received physiotherapy at a day-care center , usually twice a week . The treatment group received , in addition , Low-TENS for 60 min , five days a week for three months . Results showed that motor function increased significantly in the treatment group , compared to controls . The Low-TENS did not decrease either pain or spasticity . It is concluded that stimulation by means of Low-TENS could be a valuable complement to the usual training of arm and h and function in the rehabilitation of stroke patients OBJECTIVE To assess the efficacy of electromyogram (EMG)-triggered neuromuscular stimulation ( EMG-stim ) in enhancing upper extremity motor and functional recovery of acute stroke survivors . DESIGN A pilot r and omized , single-blinded clinical trial . SETTING Freest and ing inpatient rehabilitation facility . PATIENTS Nine subjects who were within 6 weeks of their first unifocal , nonhemorrhagic stroke were r and omly assigned to either the EMG-stim ( n = 4 ) or control ( n = 5 ) group . All subjects had a detectable EMG signal ( > 5 microV ) from the surface of the paretic extensor carpi radialis and voluntary wrist extension in synergy or in isolation with muscle grade of < 3/5 . INTERVENTION All subjects received two 30-minute sessions per day of wrist strengthening exercises with EMG-stim ( experimental ) or without ( control ) for the duration of their rehabilitation stay . MAIN OUTCOME MEASURES Upper extremity Fugl-Meyer motor assessment and the feeding , grooming , and upper body dressing items of the Functional Independence Measure ( FIM ) were assessed at study entry and at discharge . RESULTS Subjects treated with EMG-stim exhibited significantly greater gains in Fugl-Meyer ( 27.0 vs 10.4 ; p = .05 ) , and FIM ( 6.0 vs 3.4 ; p = .02 ) scores compared with controls . CONCLUSION Data suggest that EMG-stim enhances the arm function of acute stroke survivors 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 Objective : To determine whether stroke patients with initial increases in arm motor recovery following low-frequency transcutaneous electrical nerve stimulation ( low TENS ) treatment go on to show long-term benefits . Also whether the same therapy results in long-term improvements in motor function , spasticity or activities of daily living ( ADL ) . Design : A three-year follow-up study . Subjects : Twenty-eight stroke patients , who had participated in a r and omized trial of daily treatment with low-frequency ( 1.7 Hz ) transcutaneous electrical nerve stimulation ( low TENS ) on the paretic arm for three months starting 6–12 months after stroke . Outcomes : Fugl-Meyer Motor Performance Scale for evaluation of changes in arm motor function . A 6-point Ashworth Scale to measure spasticity . Barthel Index to evaluate performance in ADL . Results : Motor function of the paretic arm had deteriorated in both treatment and control groups . Increased spasticity was seen in both groups . ADL score remained at a similar level in the low TENS group , whereas the control group had deteriorated during the same time period . Conclusions : Low TENS stimulation started 6–12 months after stroke may not have a specific effect on arm motor function years after completion of treatment 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 To determine the effectiveness of a protocol design ed to restrict passive movement of affected upper extremity on the incidence of shoulder-h and syndrome ( SHS ) after stroke . DESIGN Before- and -after trial : follow-up duration of subject group and historical control group 231.6 and 257.2 days , respectively . SETTING Rehabilitation medicine department in a hospital in Japan . PARTICIPANTS SUBJECTS 81 stroke patients treated with the protocol from 1994 to 1996 who were followed for at least 4 months from the onset of stroke ; controls : 71 stroke patients treated without the protocol from 1991 to 1994 who were followed for same length of time . INTERVENTION Use of a set protocol for controlled passive movement by trained therapists and restriction of passive movement by the patients for 4 months after stroke . The SHS criterion used to detect early signs of SHS has not yet been vali date d. Corticosteroids were given to all subjects diagnosed with SHS . MAIN OUTCOME MEASURES Swelling index , SHS diagnostic criteria applied in physical exam , Brunnstrom stage , and sensory disturbance evaluations . RESULT The incidence of SHS in the subject group was 18.5 % ( n = 15 ) , whereas the incidence of SHS in the control group was 32.4 % ( n = 23 ) . The difference between the 2 groups was statistically significant ( chi(2 ) = 3.885 , p < .05 ) . CONCLUSION The protocol helped to prevent development of SHS Objective : To determine whether strapping the shoulder in hemiplegic stroke patients : ( 1 ) prevents the development , or reduces the severity , of shoulder pain , ( 2 ) preserves range of movement in the shoulder , and ( 3 ) improves the functional outcomes for the arm and patient overall . Design : A prospect i ve , r and omized , single-blind controlled trial of shoulder strapping versus no strapping . Setting : Care of the elderly wards in a teaching hospital , Christchurch , New Zeal and . Subjects : All patients admitted with an acute hemiplegic stroke , who had persisting weakness of shoulder abduction . Intervention : The treatment group had their affected shoulder strapped for six weeks from r and omization in addition to st and ard physiotherapy . Main outcome measures : All subjects were assessed at entry ( week 0 ) , at end of the treatment phase ( week 6 ) and two months later ( week 14 ) . A visual analogue scale ( VAS ) was used to assess shoulder pain severity whereas shoulder range of movement to the point of pain ( SROMP ) assessed passive range of movement and pain . Functional Independence Measure ( FIM ) , Motor Assessment Scale ( MAS ) and Rankin Disability Index measured functional outcomes . Results : Ninety-eight subjects participated ( 49 strapped , 49 controls ) . Intention to treat analysis showed no significant difference in pain , range of movement or functional outcomes after the intervention phase or at the final assessment . However there were trends for less pain at six weeks ( VAS , p = 0.11 ) and better final upper limb function ( MAS , p = 0.16 ) in strapped patients . Skin reactions were uncommon ( 6.1 % ) . The presence of neglect or sensory loss , but not subluxation , at baseline was independently associated with poor outcome . Range of movement was lost early ( mean difference SROMP between hemiplegic and contralateral shoulders at baseline = 15.2 ° ( 95 % CI 10.9–19.5 ) ) and continued throughout the study . Shoulder strapping did not alter the rate at which range of movement was lost . Conclusions : No significant benefit with shoulder strapping was demonstrated and reasons for this are discussed . Range of movement in the hemiplegic shoulder is lost very early and any preventive treatments need to begin within the first 1–2 days after a stroke Objective : To compare the feasibility and efficacy of a programme combining imagery and occupational therapy with a programme of therapy only . Design : R and omized , controlled case series . Setting : Subacute outpatient clinic . Subjects : Thirteen consecutively admitted patients between four weeks and one year post stroke exhibiting stable motor deficits in their affected upper limbs . Intervention : All patients received an hour of therapy three times a week for six weeks administered by the same physical and occupational therapists . During the same period , eight patients participated in 10-minute guided imagery sessions after each therapy session , as well as practising imagery at home twice each week . Five patients participated in a control intervention consisting of exposure to stroke information . Main outcome measures : The Fugl-Meyer Assessment of Motor Recovery ( Fugl-Meyer ) and Action Research Arm Test ( ARA ) . Results : After intervention , Fugl-Meyer and ARA scores of patients in the therapy only group remained virtually the same ; therapy plus imagery group scores improved by 13.8 and 16.4 points , respectively , on the Fugl-Meyer and ARA . Conclusions : Imagery is a clinical ly feasible , cost-effective complement to therapy that may improve outcomes more than participation in therapy only This was a controlled study of the efficacy of two forms of therapy on upper limb functions of hemiparetic patients --one  heavily behavioral and the other based on Bobath therapeutic exercises . It arose from an earlier pilot study comparing EMG biofeedback with physical therapy from which it was concluded that both the elapsed time since the acute stroke and the severity of residual disability were particularly important factors . Of 29 patients included and r and omly assigned to one or the other heavily systematized therapies  , 18 were classified as having early-severe and 11 as late-mild conditions . Multiple function tests by a " blinded " special technician in another location revealed that overall both forms of therapy obtained worthwhile clinical and statistical improvement , which was maintained at nine-month recheck testing ; but there was no statistically significant superiority of one therapy over the other under the very specific circumstances of the research design . Ease of delivering care and other socioeconomic considerations become important factors in choosing either or both of these methods
Despite a threefold increase in treatment interventions studies during the past 10 years , “ best practice ” for the rehabilitation of the paretic upper limb is still unclear .
This review aims to lessen uncertainty in the management of the poststroke upper limb .