Clinimetric Properties of the Motor Activity Log for the Assessment of Arm Use in Hemiparetic Patients EMG feedback treatment of upper limb in hemiplegic stroke patients: a pilot study. MIME robotic device for upper-limb neurorehabilitation in subacute stroke subjects: A follow-up study. Training of Reaching in Stroke Survivors With Severe and Chronic Upper Limb Paresis Using a Novel Nonrobotic Device: A Randomized Clinical Trial Computerized Arm Training Improves the Motor Control of the Severely Affected Arm After Stroke: A Single-Blinded Randomized Trial in Two Centers Stroke motor recovery: active neuromuscular stimulation and repetitive practice schedules Positional feedback and electrical stimulation: an automated treatment for the hemiplegic wrist. Forced use of the upper extremity in chronic stroke patients: results from a single-blind randomized clinical trial. A pilot study of activity-based therapy in the arm motor recovery post stroke: a randomized controlled trial Early and Repetitive Stimulation of the Arm Can Substantially Improve the Long-Term Outcome After Stroke: A 5-Year Follow-up Study of a Randomized Trial Robot-assisted movement training compared with conventional therapy techniques for the rehabilitation of upper-limb motor function after stroke. Effects of movement imagery and electromyography-triggered feedback on arm—hand function in stroke patients in the subacute phase Robot training enhanced motor outcome in patients with stroke maintained over 3 years How to estimate treatment effects from reports of clinical trials. I: Continuous outcomes. A randomized controlled comparison of upper-extremity rehabilitation strategies in acute stroke: A pilot study of immediate and long-term outcomes. The Delphi list: a criteria list for quality assessment of randomized clinical trials for conducting systematic reviews developed by Delphi consensus. Intensive Sensorimotor Arm Training Mediated by Therapist or Robot Improves Hemiparesis in Patients With Chronic Stroke Electromyogram-triggered neuromuscular stimulation for improving the arm function of acute stroke survivors: a randomized pilot study. Does Shorter Rehabilitation Limit Potential Recovery Poststroke? Reliability of the PEDro scale for rating quality of randomized controlled trials. Rehabilitation of reaching after stroke: task-related training versus progressive resistive exercise. Home-based electromyography-triggered stimulation in chronic stroke A novel approach to stroke rehabilitation Mechanical Arm Trainer for the Treatment of the Severely Affected Arm After a Stroke: A Single-Blinded Randomized Trial in Two Centers Robotic-assisted rehabilitation of the upper limb after acute stroke. A novel robot device in rehabilitation of post-stroke hemiplegic upper limbs
Background and Purpose — The Motor Activity Log ( MAL ) is a semistructured interview for hemiparetic stroke patients to assess the use of their paretic arm and h and ( amount of use [ AOU ] ) and quality of movement [ QOM ] ) during activities of daily living . Scores range from 0 to 5 . The following clinimetric properties of the MAL were quantified : internal consistency ( Cronbach α ) , test – retest agreement ( Bl and and Altman method ) , cross-sectional construct validity ( correlation between AOU and QOM and with the Action Research Arm [ ARA ] test ) , longitudinal construct validity ( correlation of change on the MAL during the intervention with a global change rating [ GCR ] and with change on the ARA ) , and responsiveness ( effect size ) . Methods — Two baseline measurements 2 weeks apart and 1 follow-up measurement immediately after 2 weeks of intensive exercise therapy either with or without immobilization of the unimpaired arm ( forced use ) were performed in 56 chronic stroke patients . Results — Internal consistency was high ( AOU : α=0.88 ; QOM : α=0.91 ) . The limits of agreement were −0.70 to 0.85 and −0.61 to 0.71 for AOU and QOM , respectively . The correlation with the ARA score ( Spearman ρ ) was 0.63 ( AOU and QOM ) . However , the improvement on the MAL during the intervention was only weakly related to the GCR and to the improvement on the ARA , Spearman ρ was between 0.16 and 0.22 . The responsiveness ratio was 1.9 ( AOU ) and 2.0 ( QOM ) . Conclusion — The MAL is internally consistent and relatively stable in chronic stroke patients not undergoing an intervention . The cross-sectional construct validity of the MAL is reasonable , but the results raise doubt about its longitudinal construct validity Poor prognosis for upper limb recovery of stroke survivors has not changed in at least 28 years ; only 4 % to 5 % of patients regain arm function during or after the active rehabilitation phase . This pilot study included 37 patients r and omly assigned to either an integrated behavioral-physical therapy treatment program including electromyographic feedback ( experimental group ) or a st and ard exercise physical therapy program of like duration and intensity ( control group ) . Both groups showed clinical ly significant improvements that exceeded previously reported experience . The experimental technique appears to be more effective when upper limb involvement is not severe in a late case , or when treatment is started early ( within 3 months poststroke ) in a severe case . The rehabilitation community should quickly investigate the improved prospect s of restoring a greater number of useful upper limbs in this often neglected group of hemiplegic patients This study presents results from a r and omized controlled clinical trial of the Mirror Image Movement Enabler ( MIME ) robotic device for shoulder and elbow neurorehabilitation in subacute stroke patients , including data on the use of its bilateral training mode . MIME incorporates a PUMA 560 robot ( Staubli Unimation Inc , Duncan , South Carolina ) that applies forces to the paretic limb during unilateral and bilateral movements in three dimensions . Robot-assisted treatment ( bilateral , unilateral , and combined bilateral and unilateral ) was compared with conventional therapy . Similar to a previous study in chronic stroke , combined unilateral and bilateral robotic training had advantages compared with conventional therapy , producing larger improvements on a motor impairment scale and a measure of abnormal synergies . However , gains in all treatment groups were equivalent at the 6-month follow-up . Combined unilateral and bilateral training yielded functional gains that were similar to the gains from equivalent doses of unilateral-only robotic training , although the combined group had more hypertonia and less movement out of synergy at baseline . Robot-assisted treatment gains exceeded those expected from spontaneous recovery . These results are discussed in light of the need for further device development and continued clinical trials Background and Purpose — Severe upper limb paresis is a major contributor to disability after stroke . This study investigated the efficacy of a new nonrobotic training device , the Sensorimotor Active Rehabilitation Training ( SMART ) Arm , that was used with or without electromyography-triggered electrical stimulation of triceps brachii to augment elbow extension , permitting stroke survivors with severe paresis to practice a constrained reaching task . Methods — A single-blind , r and omized clinical trial was conducted with 42 stroke survivors with severe and chronic paresis . Thirty-three participants completed the study , of whom 10 received training using the SMART Arm with electromyography-triggered electrical stimulation , 13 received training using the SMART Arm alone , and 10 received no intervention ( control ) . Training consisted of 12 1-hour sessions over 4 weeks . The primary outcome measure was “ upper arm function , ” item 6 of the Motor Assessment Scale . Secondary outcome measures included impairment measures ; triceps muscle strength , reaching force , modified Ashworth scale ; and activity measures : reaching distance and Motor Assessment Scale . Assessment s were administered before ( 0 weeks ) and after training ( 4 weeks ) and at 2 months follow-up ( 12 weeks ) . Results — Both SMART Arm groups demonstrated significant improvements in all impairment and activity measures after training and at follow-up . There was no significant difference between these 2 groups . There was no change in the control group . Conclusions — Our findings indicate that training of reaching using the SMART Arm can reduce impairment and improve activity in stroke survivors with severe and chronic upper limb paresis , highlighting the benefits of intensive task-oriented practice , even in the context of severe paresis Background and Purpose — To compare a computerized arm trainer ( AT ) , allowing repetitive practice of passive and active bilateral forearm and wrist movement cycle , and electromyography-initiated electrical stimulation ( ES ) of the paretic wrist extensor in severely affected subacute stroke patients . Method — A total of 44 patients , 4 to 8 weeks after stroke causing severe arm paresis ( Fugl – Meyer Motor Score [ FM , 0 to 66 ] < 18 ) , were r and omly assigned to either  AT or ES . All patients practice d 20 minutes every workday for 6 weeks . AT patients performed 800 repetitions per session with the robot and ES patients performed 60 to 80 wrist extensions per session . The primary outcome measure was the blindly assessed FM ( 0 to 66 ) , and the secondary measures were the upper limb muscle power ( Medical Research Council [ MRC ] sum , 0 to 45 ) and muscle tone ( Ashworth score sum , 0 to 25 ) , assessed at the beginning and end of treatment and at 3-month follow-up . Results — The AT group had a higher Barthel Index score at baseline , but the groups were otherwise homogenous . As expected , FM and MRC sum scores improved overtime in both groups but significantly more in the robot AT group . The initial Barthel Index score had no influence . In the robot AT group , FM score was 15 points higher at study end and 13 points higher at 3-month follow-up than the control ES group . MRC sum score was 15 points higher at study end and at 3-month follow-up compared with the control ES group . Muscle tone remained unchanged , and no side effects occurred . Conclusion — The computerized active arm training produced a superior improvement in upper limb motor control and power compared with ES in severely affected stroke patients . This is probably attributable to the greater number of repetitions and the bilateral approach Objective : To investigate progress toward motor recovery in patients with chronic hemiparesis ( mean time since stroke 3.2 years ) , comparing different types of practice schedules . Design : To increase voluntary control of the upper extremity , active neuromuscular stimulation was administered during blocked and r and om practice schedules as patients performed three specific movements : wrist/finger extension , elbow joint extension , and shoulder joint abduction . Methods : 34 stroke subjects volunteered to participate and were r and omly assigned to one of three treatment groups : blocked practice ( the same movement was repetitively performed on successive trials ) combined with active neuromuscular stimulation ; r and om practice ( different movements on successive trials ) along with active stimulation ; or no active stimulation assistance control group . Subjects completed two days of 90 minute training for each of two weeks with at least 24 hours of rest between sessions . A session was three sets of 30 successful active neuromuscular stimulation trials with the three movements executed 10 times/set . Results : Mixed design analyses on three categories of behavioural measures indicated motor improvements for the blocked and r and om practice /stimulation groups in comparison with the control group during the post-test period , with a larger number of blocks moved , faster premotor and motor reaction times , and less variability in the sustained muscular contraction task . Conclusions : Upper extremity rehabilitation intervention of active stimulation and blocked practice performed as well as stimulation/r and om practice . Moreover , these purpose ful voluntary movement findings support and extend sensorimotor integration theory to both practice schedules 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 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 Objective : To determine the efficacy of activity-based therapies using arm ergometer or robotic or group occupational therapy for motor recovery of the paretic arm in patients with an acute stroke ( ≤4 weeks ) admitted to an inpatient rehabilitation facility , and to obtain information to plan a large r and omized controlled trial . Design : Prospect i ve , r and omized controlled study . Setting : Stroke unit in a rehabilitation hospital . Subjects : Thirty patients with an acute stroke ( ≤4 weeks ) who had arm weakness ( Medical Research Council grade 2 or less at the shoulder joint ) . Intervention : Occupational therapy ( OT ) group ( control ) ( n = 10 ) , arm ergometer ( n = 10 ) or robotic ( n = 10 ) therapy group . All patients received st and ard , inpatient , post-stroke rehabilitation training for 3 hours a day , plus 12 additional 40-minute sessions of the activity-based therapy . Main measures : The primary outcome measures were discharge scores in the Fugl-Meyer Assessment Scale for upper limb impairment , Motor Status Scale , total Functional Independence Measure ( FIM ) and FIM-motor and FIM-cognition subscores . Results : The three groups ( OT group versus arm ergometer versus robotic ) were comparable on clinical demographic measures except the robotic group was significantly older and there were more  haemorrhagic  stroke patients in the arm ergometer group . After adjusting for age , stroke type and outcome measures at baseline , a similar degree of improvement in the discharge scores was found in all of the primary outcome measures . Conclusion : This study suggests that activity-based therapies using an arm ergometer or robot when used over shortened training periods have the same effect as OT group therapy in decreasing impairment and improving disability in the paretic arm of severely affected stroke patients in the subacute phase Background and Purpose — Several studies have investigated the effect of therapeutic interventions for the arm in the acute phase after stroke , with follow-ups at a maximum of 12 months . The aim of this study was to examine the effect of repetitive sensorimotor training of the arm at 5 years after stroke . Subjects and Methods — One hundred consecutive stroke patients were r and omly allocated either to an experimental group that received daily additional sensorimotor stimulation of the arm or to a control group . The intervention period was 6 weeks . Assessment s of the patients were made before , midway , and after intervention , and at 6 and 12 months after stroke . In this study , 62 patients were reassessed at 5 years after stroke . The Brunnström-Fugl-Meyer ( BFM ) test , Action Research Arm ( ARA ) test , and Barthel index ( BI ) were used as the primary outcome measures . Results — At the 5-year follow-up , there was a statistically significant difference for both the BFM and ARA tests in favor of the experimental group . The mean differences in improvement between the groups from the initial evaluation to the 5-year assessment corresponded to 17 points on the BFM and 17.4 on the ARA . No effect was found for the BI . The treatment was most effective in patients with a severe initial motor deficit . Conclusions — Adding a specific intervention for the arm during the acute phase after a stroke result ed in a clinical ly meaningful and long-lasting effect on motor function . The effect can be attributed to early , repetitive , and targeted stimulation OBJECTIVE To compare the effects of robot-assisted movement training with conventional techniques for the rehabilitation of upper-limb motor function after stroke . DESIGN R and omized controlled trial , 6-month follow-up . SETTING A Department of Veterans Affairs rehabilitation research and development center . PARTICIPANTS Consecutive sample of 27 subjects with chronic hemiparesis ( > 6mo after cerebrovascular accident ) r and omly allocated to group . INTERVENTIONS All subjects received twenty-four 1-hour sessions over 2 months . Subjects in the robot group practice d shoulder and elbow movements while assisted by a robot manipulator . Subjects in the control group received neurodevelopmental therapy ( targeting proximal upper limb function ) and 5 minutes of exposure to the robot in each session . MAIN OUTCOME MEASURES Fugl-Meyer assessment of motor impairment , FIMtrade mark instrument , and biomechanic measures of strength and reaching kinematics . Clinical evaluations were performed by a therapist blinded to group assignments . RESULTS Compared with the control group , the robot group had larger improvements in the proximal movement portion of the Fugl-Meyer test after 1 month of treatment ( P<.05 ) and also after 2 months of treatment ( P<.05 ) . The robot group had larger gains in strength ( P<.02 ) and larger increases in reach extent ( P<.01 ) after 2 months of treatment . At the 6-month follow-up , the groups no longer differed in terms of the Fugl-Meyer test ( P>.30 ) ; however , the robot group had larger improvements in the FIM ( P<.04 ) . CONCLUSIONS Compared with conventional treatment , robot-assisted movements had advantages in terms of clinical and biomechanical measures . Further research into the use of robotic manipulation for motor rehabilitation is justified Objective : To investigate the effects of movement imagery-assisted electromyography (EMG)-triggered feedback ( focused on paretic wrist dorsiflexors ) on the arm — h and function of stroke patients . Design : Single-blinded , longitudinal , multicentre r and omized controlled trial . Measurements were performed ( on average ) 54 days post stroke ( baseline ) , three months later ( post training ) and at 12 months post baseline . Setting : Two rehabilitation centres . Subjects : Twenty-seven patients with a first-ever , ischaemic , subacute stroke . Interventions : A reference group received conventional electrostimulation , while the experimental group received arm — h and function training based on EMG-triggered feedback combined with movement imagery . Both groups were trained for three months , 5 days/week , 30 minutes/day , in addition to their therapy as usual . Main measures : Arm — h and function was evaluated using the upper extremity-related part of the Brunnstrom Fugl-Meyer test and the Action Research Arm test . Results : During training , Brunnstrom Fugl-Meyer scores improved 8.7 points and Action Research Arm scores by 19.4 points ( P < 0.0001 ) in both groups relative to baseline results , rising to 13.3 and 28.4 points respectively at one year follow-up ( P < 0.0001 ) . No between-group differences were found at any time . Conclusions : EMG-triggered feedback stimulation did not lead to more arm — h and function improvement relative to conventional electrostimulation . However , in contrast to many clinical reports , a significant improvement was still observed in both groups nine months after treatment ceased 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 Properly conducted r and omised trials can aid clinical decision-making by providing unbiased estimates of the average size of treatment effects . This paper , the first of two , discusses how readers of clinical trials can extract simple estimates of treatment effect size from trial reports when trial outcomes are measured on a continuous scale . When making decisions about therapy for individual patients , these estimates can be modified on the basis of patient characteristics . Modified estimates of treatment effect size can be used to determine if the effect of treatment is likely to be large enough to be " clinical ly worthwhile " . This approach optimises clinical decision-making by combining unbiased estimates of the size of treatment effect from clinical trials with clinical intuition and patient preferences OBJECTIVE To evaluate the immediate and long-term effects of 2 upper-extremity rehabilitation approaches for stroke compared with st and ard care in participants stratified by stroke severity . DESIGN Nonblinded , r and omized controlled trial ( baseline , postintervention , 9mo ) design . SETTING Inpatient rehabilitation hospital and outpatient clinic . PARTICIPANTS Sixty-four patients with recent stroke admitted for inpatient rehabilitation were r and omized within severity strata ( Orpington Prognostic Scale ) into 1 of 3 intervention groups . Forty-four patients completed the 9-month follow-up . INTERVENTIONS St and ard care ( SC ) , functional task practice ( FT ) , and strength training ( ST ) . The FT and ST groups received 20 additional hours of upper-extremity therapy beyond st and ard care distributed over a 4- to 6-week period . MAIN OUTCOME MEASURES Performance measures of impairment ( Fugl-Meyer Assessment ) , strength ( isometric torque ) , and function ( Functional Test of the Hemiparetic Upper Extremity [ FTHUE ] ) . RESULTS Compared with SC participants , those in the FT and ST groups had significantly greater increases in Fugl-Meyer motor scores ( P=.04 ) and isometric torque ( P=.02 ) posttreatment . Treatment benefit was primarily in the less severe participants , where improvement in FT and ST group Fugl-Meyer motor scores more than doubled that of the SC group . Similar results were found for the FTHEU and isometric torque . During the long term , at 9 months , the less severe FT group continued to make gains in isometric muscle torque , significantly exceeding those of the ST group ( P<.05 ) . CONCLUSIONS Task specificity and stroke severity are important factors for rehabilitation of arm use in acute stroke . Twenty hours of upper extremity-specific therapy over 4 to 6 weeks significantly affected functional outcomes . The immediate benefits of a functional task approach were similar to those of a resistance-strength approach , however , the former was more beneficial in the long-term Most systematic review s rely substantially on the assessment of the method ological quality of the individual trials . The aim of this study was to obtain consensus among experts about a set of generic core items for quality assessment of r and omized clinical trials ( RCTs ) . The invited participants were experts in the field of quality assessment of RCTs . The initial item pool contained all items from existing criteria lists . Subsequently , we reduced the number of items by using the Delphi consensus technique . Each Delphi round comprised a question naire , an analysis , and a feedback report . The feedback report included staff team decisions made on the basis of the analysis and their justification . A total of 33 international experts agreed to participate , of whom 21 completed all question naires . The initial item pool of 206 items was reduced to 9 items in three Delphi rounds . The final criteria list ( the Delphi list ) was satisfactory to all participants . It is a starting point on the way to a minimum reference st and ard for RCTs on many different research topics . This list is not intended to replace , but rather to be used alongside , existing criteria lists Investigators have demonstrated that a variety of intensive movement training protocol s for persistent upper limb paralysis in patients with chronic stroke ( 6 months or more after stroke ) improve motor outcome . This r and omized controlled study determined in patients with upper limb motor impairment after chronic stroke whether movement therapy delivered by a robot or by a therapist using an intensive training protocol was superior . Robotic training ( n = 11 ) and an intensive movement protocol ( n = 10 ) improved the impairment measures of motor outcome significantly and comparably ; there were no significant changes in disability measures . Motor gains were maintained at the 3-month evaluation after training . These data contribute to the growing awareness that persistent impairments in those with chronic stroke may not reflect exhausted capacity for improvement . These new protocol s , rendered by either therapist or robot , can be st and ardized , tested , and replicated , and potentially will contribute to rational activity-based programs 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 Objective . To examine retrospectively the recovery of patients engaged in robotic research during a 6- to 7-week course of inpatient rehabilitation . Because timing of the Interim evaluation at 31/2 weeks was comparable to the present length of inpatient stroke rehabilitation , the authors assessed whether significant gains in motor abilities occurred after the time when most stroke patients today are discharged home . Methods . Fifty-six in patients with a single , unilateral stroke were r and omly assigned to a robot therapy or robot exposure group . Therapists blinded to group assignment administered the Fugl-Meyer , Motor Status Score , and MRC motor power test . Results . Significant improvements in upper-limb motor abilities occurred throughout a period approximately twice the present length of stay in inpatient rehabilitation . However , in the latter half of this period , patients who received conventional therapy showed little improvement , whereas patients who received robot training plus conventional therapy continued to improve . Conclusion . Further opportunities for recovery after stroke are possible by extending intensive therapy beyond present inpatient rehabilitation stays BACKGROUND AND PURPOSE Assessment of the quality of r and omized controlled trials ( RCTs ) is common practice in systematic review s. However , the reliability of data obtained with most quality assessment scales has not been established . This report describes 2 studies design ed to investigate the reliability of data obtained with the Physiotherapy Evidence Data base ( PEDro ) scale developed to rate the quality of RCTs evaluating physical therapist interventions . METHOD In the first study , 11 raters independently rated 25 RCTs r and omly selected from the PEDro data base . In the second study , 2 raters rated 120 RCTs r and omly selected from the PEDro data base , and disagreements were resolved by a third rater ; this generated a set of individual rater and consensus ratings . The process was repeated by independent raters to create a second set of individual and consensus ratings . Reliability of ratings of PEDro scale items was calculated using multirater kappas , and reliability of the total ( summed ) score was calculated using intraclass correlation coefficients ( ICC [ 1,1 ] ) . RESULTS The kappa value for each of the 11 items ranged from.36 to.80 for individual assessors and from.50 to.79 for consensus ratings generated by groups of 2 or 3 raters . The ICC for the total score was.56 ( 95 % confidence interval=.47-.65 ) for ratings by individuals , and the ICC for consensus ratings was.68 ( 95 % confidence interval=.57-.76 ) . DISCUSSION AND CONCLUSION The reliability of ratings of PEDro scale items varied from " fair " to " substantial , " and the reliability of the total PEDro score was " fair " to " good . OBJECTIVE To evaluate the effectiveness of 2 rehabilitative approaches for improving paretic limb reaching by chronic stroke subjects . DESIGN Pre- and posttest reaching to targets ipsilateral , midline , and contralateral to the impaired side . SETTING Training in subjects ' homes ; testing in a laboratory setting . PARTICIPANTS Twelve poststroke volunteers were matched using the Motor Assessment Scale ( MAS ) and then were r and omly assigned to 1 of 2 training conditions . Subjects were subsequently categorized as at a high or low functional level , using the reaching pretest movement time scores . INTERVENTIONS Training ( trunk unrestrained ) using the paretic limb was 4 weeks ( 12 sessions ) . Task-related training ( TRT ) involved reaching to objects placed across the workspace . Progressive resistive exercise ( PRE ) involved whole-arm pulling against resistive therapeutic tubing in planes and distances similar to that in TRT . Main outcome measures Kinematic analysis of arm trajectory and trunk motion using the Peak Performance System , as well as scores on the MAS and the Rivermead Motor Assessment ( RMA ) . RESULTS For low-level groups , TRT result ed in increased substitutive trunk use at the target ipsilateral to the moving arm , and for midline and contralateral targets after PRE . Only low-level , TRT subjects straightened h and paths , which suggested better coordination of elbow-shoulder motion , and improved on the RMA . High-level subjects decreased trunk use at ipsilateral target after PRE , which was not observed after TRT . No significant differences between training conditions were found for other kinematic variables . CONCLUSIONS Training benefits appear to depend on initial level of functioning . Although compensatory trunk use was evident , low-level subjects seemed to benefit most from TRT . High-level subjects , whose kinematics showed fairly normal movement organization , demonstrated less compensatory movement after PRE Objectives : ( 1 ) To determine the feasibility of a home-based electromyography triggered neuromuscular stimulation ( ETMS ) programme ; and ( 2 ) to determine ETMS efficacy in increasing affected wrist extension and reducing affected arm impairment . Design : R and omized , controlled , pre-lpost , cross-over design . Setting : Outpatient rehabilitation hospital . Patients : Twelve chronic stroke patients with palpable muscle contraction in their affected wrist extensors but no movement ( 7 males ; mean age=59.75 years , age range 44 - 75 years ; mean time since stroke=52.75 months , range 13 - 131 months ) . Intervention : Subjects were r and omly assigned to receive either : ( a ) ETMS use twice every weekday in 35-min increments during an eight-week period followed by an eight-week home exercise programme ( ETMS/home exercise programme ) ( n=8 ) ; or ( b ) an eight-week home exercise programme followed by use of ETMS twice every weekday in 35-min increments during an eight-week period ( home exercise programme ) ( n=4 ) . Main outcome measures : The Fugl-Meyer , Action Research Arm Test and goniometry . Results : After home exercise programme participation , subjects showed nominal or no changes on any of the outcome measures . After ETMS , patients showed modest impairment reductions , as shown by the Fugl-Meyer , and no Action Research Arm Test changes . However , both groups showed a 218 increase in active affected wrist extension after ETMS use . Conclusion : ETMS use is feasible in the home environment . Neither participation in a traditional home exercise programme nor ETMS use conveyed changes on the Fugl-Meyer or Action Research Arm Test . However , ETMS use increased active affected limb extension . This new movement may provide a potential pathway for subjects to participate in other interventions , such as modified constraint induced therapy 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 Hesse S , Werner C , Pohl M , Mehrholz J , Puzich U , Krebs HI : Mechanical arm trainer for the treatment of the severely affected arm after a stroke : a single-blinded r and omized trial in two centers . Am J Phys Med Rehabil 2008;87:779–788 . Objective : To test whether training with a new mechanical arm trainer leads to better outcomes than electrical stimulation of the paretic wrist extensors in subacute stroke patients with severe upper limb paresis . Electrical stimulation is a st and ard and reimbursable form of therapy in Germany . Design : R and omized controlled trial of 54 in patients enrolled 4–8 wks from stroke onset , mean upper-extremity subsection of Fugl-Meyer assessment ( 0–66 ) at admission less than 18 . In addition to st and ard care , all patients practice d 20–30 mins arm trainer or electrical stimulation every workday for 6 wks , totaling 30 sessions . Primary outcome was the Fugl-Meyer assessment , secondary outcomes were the Box and Block test , the Medical Research Council and the modified Ashworth scale , blindly assessed at enrollment , after 6 wks , and at 3-mo follow-up . Results : Both groups were homogeneous at study onset . Shoulder pain occurred in two arm trainer patients . The primary Fugl-Meyer assessment outcome improved for both groups over time ( P < 0.001 ) , but this improvement did not differ between groups . The initial ( terminal ) mean Fugl-Meyer assessment scores were 8.8 ± 4.8 ( 19.2 ± 14.5 ) for the arm trainer and 8.6 ± 3.5 ( 13.6 ± 7.9 ) for the electrical stimulation group . No patient could transport a block initially , but at completion significantly more arm trainer patients were able to transport at least three blocks ( five vs. zero , P = 0.023 ) . No significant differences were observed between the groups on the secondary Box and Block outcome at follow-up ( eight vs. four patients ) . All Box and Block responders had an initial Fugl-Meyer assessment ≥10 . Conclusions : Arm trainer training did not lead to a superior primary outcome  over electrical stimulation training . However , “ good performers ” on the secondary outcome seemed to benefit more from the arm trainer training OBJECTIVE To investigate whether early therapy with a novel robotic device can reduce motor impairment and enhance functional recovery of poststroke patients with hemiparetic and hemiplegic upper limb . DESIGN A single-blind r and omized controlled trial , with an 8-month follow-up . SETTING Neurologic department and rehabilitation hospital . PARTICIPANTS Thirty-five patients with acute ( < or = 1 wk of onset ) , unilateral , ischemic embolic , or thrombotic stroke . INTERVENTIONS Patients of both groups received the same dose and length per day of st and ard poststroke multidisciplinary rehabilitation . Patients were r and omly assigned to 2 groups . The experimental group ( n=17 ) received additional early sensorimotor robotic training , 4 hours a week for 5 weeks ; the control group ( n=18 ) was exposed to the robotic device , 30 minutes a week , twice a week , but the exercises were performed with the unimpaired upper limb . Training by robot consisted of peripheral manipulation of the shoulder and elbow of the impaired limb , correlated with visual stimuli . MAIN OUTCOME MEASURES The Fugl-Meyer Assessment ( FMA ) of upper-extremity function ( shoulder/elbow and coordination and wrist/h and subsections ) to measure each trained limb segment ; the Medical Research Council ( MRC ) score to measure the strength of muscle force during 3 actions : shoulder abduction ( MRC deltoid ) , elbow flexion ( MRC biceps ) , and wrist flexion ( MRC wrist flexors ) ; the FIM instrument and its motor component ; and the Trunk Control Test ( TCT ) and Modified Ashworth Scale ( MAS ) . RESULTS Compared with the patients in the control group , the experimental group showed significant gains in motor impairment and functional recovery of the upper limb after robot therapy , as measured by the MRC deltoid ( P < or = .05 ) and biceps ( P<.05 ) scores , the FMA for the proximal upper arm ( P<.05 ) , the FIM instrument ( P<.05 ) , and the FIM motor score ( P<.01 ) ; these gains were also sustained at the 3- and 8-month follow-up . The FMA and MRC wrist flexor test findings did not differ statistically either at the end of training or at the follow-up sessions . We found no significant differences in MAS and TCT in either group in any of the evaluations . No adverse effects occurred and the robotic approach was very well accepted . CONCLUSIONS Patients who received robotic therapy in addition to conventional therapy showed greater reductions in motor impairment and improvements in functional abilities . Robotic therapy may therefore effectively complement st and ard rehabilitation from the start , by providing therapeutic support for patients with poststroke plegic and paretic upper limb Background and aims : In this pilot study , we introduce the “ NeReBot ” , a novel robotic device design ed and programmed for clinical neurological applications . The aim of the study was to test whether additional sensorimotor training of paralyzed or paretic upper limbs , delivered by NeReBot , enhanced motor and functional outcome in stroke patients . Methods : Twenty patients with post-stroke hemiparesis or hemiplegia received st and ard post-stroke multidisciplinary rehabilitation , and were r and omly assigned either to exposure to the robotic device without training or to additional sensorimotor robotic training ( about 4 h/week ) for 4 weeks . Robot training consisted of peripheral manipulation of the shoulder and elbow of the impaired limb , correlated with visual stimuli . Results : At hospital discharge , impairment and disability had declined in all patients , but the group with robot training showed higher gains on motor impairment and functional recovery , which were maintained at the 3-month follow-up . No adverse events result ed from robot-assisted therapy . Conclusions : According to our results , NeReBot therapy may efficaciously complement st and ard post-stroke multidisciplinary rehabilitation and offer novel therapeutic strategies for neurological rehabilitation
PURPOSE To investigate the effect of interventions that promote upper limb ( UL ) recovery in stroke survivors with severe paresis .