Effect of constraint-induced movement therapy on upper extremity function 3 to 9 months after stroke: the EXCITE randomized clinical trial. Estimating minimal clinically important differences of upper-extremity measures early after stroke. Repetitive bilateral arm training and motor cortex activation in chronic stroke: a randomized controlled trial. Brain reorganization after bilateral arm training and distributed constraint-induced therapy in stroke patients: a preliminary functional magnetic resonance imaging study. Very Early Constraint-Induced Movement during Stroke Rehabilitation (VECTORS) Repetitive Bilateral Arm Training With Rhythmic Auditory Cueing Improves Motor Function in Chronic Hemiparetic Stroke Does the Application of Constraint-Induced Movement Therapy During Acute Rehabilitation Reduce Arm Impairment After Ischemic Stroke? Impact of Time on Improvement of Outcome After Stroke Active Finger Extension Predicts Outcomes After Constraint-Induced Movement Therapy for Individuals With Hemiparesis After Stroke Assessing the Motor Status Score: A Scale for the Evaluation of Upper Limb Motor Outcomes in Patients after Stroke Constraint-induced movement therapy: time for a little restraint? Unraveling interlimb interactions underlying bimanual coordination. Probability of regaining dexterity in the flaccid upper limb: impact of severity of paresis and time since onset in acute stroke. Forced use of the upper extremity in chronic stroke patients: results from a single-blind randomized clinical trial. A comparison of bilateral and unilateral upper-limb task training in early poststroke rehabilitation: a randomized controlled trial. Can simultaneous bilateral movement involve the undamaged hemisphere in reconstruction of neural networks damaged by stroke? The intra- and interrater reliability of the action research arm test: a practical test of upper extremity function in patients with stroke. Contribution of the shaping and restraint components of Constraint-Induced Movement therapy to treatment outcome. Forced use of hemiplegic upper extremities to reverse the effect of learned nonuse among chronic stroke and head-injured patients Effects of Constraint-Induced Therapy Versus Bilateral Arm Training on Motor Performance, Daily Functions, and Quality of Life in Stroke Survivors Constraint-Induced Movement Therapy Results in Increased Motor Map Area in Subjects 3 to 9 Months After Stroke Bilateral and unilateral movement training on upper limb function in chronic stroke patients: A TMS study Reliability of the PEDro scale for rating quality of randomized controlled trials. Individual Factors in Constraint-Induced Movement Therapy after Stroke Mesencephalic Corticospinal Atrophy Predicts Baseline Deficit but Not Response to Unilateral or Bilateral Arm Training in Chronic Stroke Comparison of constraint-induced movement therapy and bilateral treatment of equal intensity in people with chronic upper-extremity dysfunction after cerebrovascular accident. Using Kinematic Analysis to Evaluate Constraint-Induced Movement Therapy in Chronic Stroke Patients Predicting improvement in the upper paretic limb after stroke: a longitudinal prospective study. PEDro. A database of randomized trials and systematic reviews in physiotherapy. Constraint-Induced Therapy in Stroke: Magnetic-Stimulation Motor Maps and Cerebral Activation Temporal and spatial control following bilateral versus unilateral training. Comparison of Bilateral and Unilateral Training for Upper Extremity Hemiparesis in Stroke
CONTEXT Single-site studies suggest that a 2-week program of constraint-induced movement therapy ( CIMT ) for patients more than 1 year after stroke who maintain some h and and wrist movement can improve upper extremity function that persists for at least 1 year . OBJECTIVE To compare the effects of a 2-week multisite program of CIMT vs usual and customary care on improvement in upper extremity function among patients who had a first stroke within the previous 3 to 9 months . DESIGN AND SETTING The Extremity Constraint Induced Therapy Evaluation ( EXCITE ) trial , a prospect i ve , single-blind , r and omized , multisite clinical trial conducted at 7 US academic institutions between January 2001 and January 2003 . PARTICIPANTS Two hundred twenty-two individuals with predominantly ischemic stroke . INTERVENTIONS Participants were assigned to receive either CIMT ( n = 106 ; wearing a restraining mitt on the less-affected h and while engaging in repetitive task practice and behavioral shaping with the hemiplegic h and ) or usual and customary care ( n = 116 ; ranging from no treatment after concluding formal rehabilitation to pharmacologic or physiotherapeutic interventions ) ; patients were stratified by sex , prestroke dominant side , side of stroke , and level of paretic arm function . MAIN OUTCOME MEASURES The Wolf Motor Function Test ( WMFT ) , a measure of laboratory time and strength-based ability and quality of movement ( functional ability ) , and the Motor Activity Log ( MAL ) , a measure of how well and how often 30 common daily activities are performed . RESULTS From baseline to 12 months , the CIMT group showed greater improvements than the control group in both the WMFT Performance Time ( decrease in mean time from 19.3 seconds to 9.3 seconds [ 52 % reduction ] vs from 24.0 seconds to 17.7 seconds [ 26 % reduction ] ; between-group difference , 34 % [ 95 % confidence interval { CI } , 12%-51 % ] ; P<.001 ) and in the MAL Amount of Use ( on a 0 - 5 scale , increase from 1.21 to 2.13 vs from 1.15 to 1.65 ; between-group difference , 0.43 [ 95 % CI , 0.05 - 0.80 ] ; P<.001 ) and MAL Quality of Movement ( on a 0 - 5 scale , increase from 1.26 to 2.23 vs 1.18 to 1.66 ; between-group difference , 0.48 [ 95 % CI , 0.13 - 0.84 ] ; P<.001 ) . The CIMT group achieved a decrease of 19.5 in self-perceived h and function difficulty ( Stroke Impact Scale h and domain ) vs a decrease of 10.1 for the control group ( between-group difference , 9.42 [ 95 % CI , 0.27 - 18.57 ] ; P=.05 ) . CONCLUSION Among patients who had a stroke within the previous 3 to 9 months , CIMT produced statistically significant and clinical ly relevant improvements in arm motor function that persisted for at least 1 year . Trial Registration clinical trials.gov Identifier : NCT00057018 OBJECTIVE To estimate minimal clinical ly important difference ( MCID ) values of several upper-extremity measures early after stroke . DESIGN Data in this report were collected during the Very Early Constraint-induced Therapy for Recovery of Stroke trial , an acute , single-blind r and omized controlled trial of constraint-induced movement therapy . Subjects were tested at the prer and omization baseline assessment ( average days poststroke , 9.5d ) and the first posttreatment assessment ( average days poststroke , 25.9d ) . At each time point , the affected upper extremity was evaluated with a battery of 6 tests . At the second assessment , subjects were also asked to provide a global rating of perceived changes in their affected upper extremity . Anchor-based MCID values were calculated separately for the affected dominant upper extremities and the affected nondominant upper extremities for each of the 6 tests . SETTING Inpatient rehabilitation hospital . PARTICIPANTS Fifty-two people with hemiparesis poststroke . INTERVENTIONS Not applicable . MAIN OUTCOME MEASURES Estimated MCID values for grip strength , composite upper-extremity strength , Action Research Arm Test ( ARAT ) , Wolf Motor Function Test ( WMFT ) , Motor Activity Log ( MAL ) , and duration of upper-extremity use as measured with accelerometry . RESULTS MCID values for grip strength were 5.0 and 6.2 kg for the affected dominant and nondominant sides , respectively . MCID values for the ARAT were 12 and 17 points , for the WMFT function score were 1.0 and 1.2 points , and for the MAL quality of movement score were 1.0 and 1.1 points for the 2 sides , respectively . MCID values were indeterminate for the dominant ( composite strength ) , the nondominant ( WMFT time score ) , and both affected sides ( duration of use ) for the other measures . CONCLUSIONS Our data provide some of the first estimates of MCID values for upper-extremity st and ardized measures early after stroke . Future studies with larger sample sizes are needed to refine these estimates and to determine whether MCID values are modified by time poststroke CONTEXT Reorganization in central motor networks occurs during early recovery from hemiparetic stroke . In chronic stroke survivors , specific rehabilitation therapy can improve upper extremity function . OBJECTIVE To test the hypothesis that in patients who have chronic motor impairment following stroke , specific rehabilitation therapy that improves arm function is associated with reorganization of cortical networks . DESIGN , SETTING , AND PATIENTS A r and omized controlled clinical trial conducted in a US ambulatory rehabilitation program with 21 patients ( median [ IQR ] , 50.3 [ 34.8 - 77.3 ] months after unilateral stroke ) . Data were collected between 2001 and 2004 . INTERVENTIONS Patients were r and omly assigned to bilateral arm training with rhythmic auditory cueing ( BATRAC ) ( n = 9 ) or st and ardized dose-matched therapeutic exercises ( DMTE ) ( n = 12 ) . Both were conducted for 1 hour , 3 times a week , for 6 weeks . MAIN OUTCOME MEASURES Within 2 weeks before and after the intervention , brain activation during elbow movement assessed by functional magnetic resonance imaging ( fMRI ) and functional outcome assessed using arm function scores . RESULTS Patients in the BATRAC group but not in the DMTE group increased hemispheric activation during paretic arm movement ( P = .03 ) . Changes in activation were observed in the contralesional cerebrum and ipsilesional cerebellum ( P = .009 ) . BATRAC was associated with significant increases in activation in pre central ( P<.001 ) and post central gyri ( P = .03 ) and the cerebellum ( P<.001 ) , although 3 BATRAC patients showed no fMRI changes . Considering all patients , there were no differences in functional outcome between groups . When only BATRAC patients with fMRI response were included ( n = 6 ) , BATRAC improved arm function more than DMTE did ( P = .02 ) . CONCLUSIONS These preliminary findings suggest that BATRAC induces reorganization in contralesional motor networks and provide biological plausibility for repetitive bilateral training as a potential therapy for upper extremity rehabilitation in hemiparetic stroke BACKGROUND Bilateral arm training ( BAT ) and constraint-induced therapy ( CIT ) have shown beneficial effects in improving motor control and function of the upper extremities ( UE ) for patients with stroke . Thus far , no study has directly investigated the relative effects of BAT versus CIT on brain reorganization . This study compared the effects of BAT with distributed CIT ( dCIT ) on brain reorganization and motor function in 6 stroke patients . METHODS In a pre-post r and omized controlled trial , 6 stroke patients received BAT ( intensive bilateral simultaneous and symmetrical training ) or dCIT ( restraint of the unaffected UE combined with intensive training of the affected UE ) for a period of 3 weeks , 5 days per week . Functional magnetic resonance imaging ( fMRI ) examination and 3 clinical measures ( Fugl-Meyer Assessment , Action Research Arm Test , and Motor Activity Log ) were administered before and after the intervention . RESULTS After intervention , patients showed varied patterns of fMRI changes and improved motor function . Two well-recovered patients , one from each group , showed large increases in bilateral hemisphere activation , especially in the ipsilesional hemisphere during affected h and movement and in the contralesional hemisphere during unaffected h and movement . During bilateral elbow movement , 3 of the 4 BAT patients showed increased bilateral cerebellum activation , especially in the left cerebellum , whereas 2 dCIT patients showed decreased cerebellar activation . CONCLUSIONS The findings of this preliminary research revealed that neuroplastic changes after stroke motor rehabilitation may be specific to the intervention . Further research using a larger sample and more complex fMRI tasks is warranted to vali date the findings Background : Constraint-induced movement therapy ( CIMT ) is among the most developed training approaches for motor restoration of the upper extremity ( UE ) . Methods : Very Early Constraint-Induced Movement during Stroke Rehabilitation ( VECTORS ) was a single-blind phase II trial of CIMT during acute inpatient rehabilitation comparing traditional UE therapy with dose-matched and high-intensity CIMT protocol s. Participants were adaptively r and omized on rehabilitation admission , and received 2 weeks of study -related treatments . The primary endpoint was the total Action Research Arm Test ( ARAT ) score on the more affected side at 90 days after stroke onset . A mixed model analysis was performed . Results : A total of 52 participants ( mean age 63.9 ± 14 years ) were r and omized 9.65 ± 4.5 days after onset . Mean NIHSS was 5.3 ± 1.8 ; mean total ARAT score was 22.5 ± 15.6 ; 77 % had ischemic stroke . Groups were equivalent at baseline on all r and omization variables . As expected , all groups improved with time on the total ARAT score . There was a significant time x group interaction ( F = 3.1 , p < 0.01 ) , such that the high intensity CIT group had significantly less improvement at day 90 . No significant differences were found between the dose-matched CIMT and control groups at day 90 . MRI of a sub sample showed no evidence of activity-dependent lesion enlargement . Conclusion : Constraint-induced movement therapy ( CIMT ) was equally as effective but not superior to an equal dose of traditional therapy during inpatient stroke rehabilitation . Higher intensity CIMT result ed in less motor improvement at 90 days , indicating an inverse dose-response relationship . Motor intervention trials should control for dose , and higher doses of motor training can not be assumed to be more beneficial , particularly early after stroke Background and Purpose Chronic upper extremity hemiparesis is a leading cause of functional disability after stroke . We investigated the hypothesis that bilateral arm training with rhythmic auditory cueing ( BATRAC ) will improve motor function in the hemiparetic arm of stroke patients . Methods In this single group pilot study we determined the effects of 6 weeks of BATRAC on 14 patients with chronic hemiparetic stroke ( median time after stroke , 30 months ) immediately after training and at 2 months after training . Four 5-minute periods per session ( 3 times per week ) of BATRAC were performed with the use of a custom- design ed arm training machine . Results The patients showed significant and potentially durable increases in the following : Fugl-Meyer Upper Extremity Motor Performance Test of impairment ( P < 0.0004 ) , Wolf Motor Function Test ( performance time measure , P < 0.02 ) , and University of Maryl and Arm Question naire for Stroke measuring daily use of the hemiparetic arm ( P < 0.002 ) . Isometric strength improved in elbow flexion ( P < 0.05 ) and wrist flexion ( P < 0.02 ) for the paretic arm and in elbow flexion ( P < 0.02 ) and wrist extension ( P < 0.02 ) for the nonparetic arm . Active range of motion improved for paretic-side shoulder extension ( P < 0.01 ) , wrist flexion ( P < 0.004 ) , and thumb opposition ( P < 0.002 ) , and passive range of motion improved for paretic wrist flexion ( P < 0.03 ) . Conclusions Six weeks of BATRAC improves functional motor performance of the paretic upper extremity as well as a few changes in isometric strength and range of motion . These benefits are largely sustained at 8 weeks after training cessation 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 Background and Purpose — Longitudinal conducted studies show that neurologic and functional recovery show faster recovery in the first weeks poststroke . The aim of the present study was to study the effects of progress of time on observed improvements in motor strength , synergisms , and activities during the first 16 weeks poststroke . Methods — Based on data from a previous study , 101 patients with first-ever ischemic middle cerebral artery strokes were prospect ively investigated during the first 16 weeks after stroke . Progress of time was categorized into 8 biweekly time intervals and was used as the independent covariate in a first-order longitudinal regression model . The biweekly time change ( progress of time ) was related to improvement in upper and lower limb motor recovery assessed with Fugl-Meyer score and Motricity Index , reduction in visuospatial inattention based on the letter cancellation task , and improvement in walking ability , dexterity , and activities of daily living measured with the Functional Ambulation Categories , Action Research Arm test , and Barthel Index . Results — Time explained a significant change of 8.4 ( 42 % ) measurement units on the Barthel Index for the first 10 weeks poststroke , 1.1 ( 22 % ) measurement units on Functional Ambulation Categories , and 19 % on the Action Research Arm test for the first 6 and 8 weeks poststroke . Approximately 25 % ( for Fugl-Meyer – arm ) to 26 % ( for Motricity Index – arm ) of the significant change in measurements units was explained by time alone for the upper limb compared with 33 % for Fugl-Meyer – leg and 39 % for Motricity Index – leg of the lower limb . Time accounted for a reduction of 16 % in the letter cancellation task . Observed associations did not change after controlling for covariates such as age , gender , hemisphere of stroke , type of stroke , or intervention . Conclusion — Progress of time is an independent covariate that reflects spontaneous recovery of body functions and activities explaining ≈16 % to 42 % of the observed improvements in the first 6 to 10 weeks after stroke onset Background and Purpose — Constraint-induced movement therapy ( CIMT ) is a rehabilitative strategy used primarily with the post-stroke population to increase the functional use of the neurologically weaker upper extremity through massed practice while restraining the lesser involved upper extremity . Whereas research evidence supports CIMT , limited evidence exists regarding the characteristics of individuals who benefit most from this intervention . The goal of this study was to investigate the potential of 5 measures to predict functional CIMT outcomes . Methods — A convenience sample of 55 individuals , > 6 months after stroke , was recruited that met specific inclusion /exclusion criteria allowing for individuals whose upper extremity was mildly to severely involved . They participated in CIMT 6 hours per day . Pretest , post-test , and follow-up assessment s were performed to assess the outcomes for the Wolf Motor Function Test ( WMFT ) . The potential predictors were minimal motor criteria ( active extension of the wrist and 3 fingers ) , active finger extension/grasp release , grip strength , Fugl – Meyer upper extremity motor score , and the Frenchay score . A step-wise regression analysis was used in which the potential predictors were entered in a linear regression model with simultaneous entry of the dependent variables ’ pretest score as the covariate . Two regressions models were determined for the dependent variable , for immediate post-test , and for follow-up post-test . Results — Finger extension was the only significant predictor of WMFT outcomes . Conclusions — When using finger extension/grasp release as a predictor in the regression equations , one can predict individual ’s follow-up scores for  CIMT .  This experiment provides the most comprehensive investigation of predictors of  CIMT  outcomes to date The  Motor Status Scale ( MSS ) measures shoulder , elbow ( maximum score = 40 ) , wrist , h and , and finger movements ( maximum score = 42 ) , and exp and s the measurement of upper extremity impairment and disability provided by the Fugl-Meyer ( FM ) score . This work examines the interrater reliability and criterion validity of the MSS performed in patients admitted to a rehabilitation hospital 21 ± 4 days after stroke . Using the MSS and the FM , 7 occupational therapists masked to each other ’s judgments , evaluated 12 consecutive patients with stroke . Two therapists evaluated 6 additional patients on consecutive days . Intraclass correlation coefficients were significant for each group of raters for the shoulder/elbow and for the wrist/h and ( P < 0.0001 ) ; test-retest measures were also significant for the shoulder/elbow ( Pearson correlation coefficient r = 0.99 , P < 0.004 ) and for the wrist/h and ( Pearson correlation coefficient r = 0.99 , P < 0.003 ) . The internal item consistency for the overall MSS was significant ( Cronbach alpha = 0.98 , P < 0.0001 ) . Finally the correlation between the MSS and the FM ( R 2 = 0.964 ) was significant ( P < 0.0001 ) . The MSS affords a reliable and valid assessment of upper limb impairment and disability following stroke Our aim was to consider some issues surrounding constraint-induced movement therapy ( CIMT ) , and in particular , its theoretical basis , effectiveness , utility and composition . We examined selected articles and related publications concerning CIMT . Considerable evidence from case studies and case series has accumulated but only a limited number of r and omized controlled trials ( RCTs ) exist . The two most positive RCTs represent a combined total of 15 people undergoing CIMT .  Other issues include : how analogous deafferentation of an upper limb in monkeys is to cerebral infa rcts in humans ; teasing out the active components of CIMT ; a need for replication by groups not already strongly associated with CIMT ; and patient/therapist acceptability .  CIMT may hold considerable promise , but independent , large-scale , multicentre RCTs comparing its effectiveness with conventional therapy of equal intensity are required , as is the consideration of some associated issues Three sources of interlimb interactions have been postulated to underlie the stability characteristics of bimanual coordination but have never been evaluated in conjunction : integrated timing of feedforward control signals , phase entrainment by contralateral afference , and timing corrections based on the perceived error of relative phase . In this study , the relative contributions of these interactions were discerned through systematic comparisons of five tasks involving rhythmic flexion-extension movements about the wrist , performed bimanually ( in-phase and antiphase coordination ) or unimanually with or without comparable passive movements of the contralateral h and . The main findings were the following . 1 ) Contralateral passive movements during unimanual active movements induced phase entrainment to interlimb phasing of either 0 degrees ( in-phase ) or 180 degrees ( antiphase ) . 2 ) Entrainment strength increased with the passive movements ' amplitude , but was similar for in-phase and antiphase movements . 3 ) Coordination of unimanual active movements with passive movements of the contralateral h and ( kinesthetic tracking ) was characterized by similar bilateral EMG activity as observed in active bimanual coordination . 4 ) During kinesthetic tracking the timing of the movements of the active h and was modulated by afference-based error corrections , which were more pronounced during in-phase coordination . 5 ) Indications of in-phase coordination being more stable than antiphase coordination were most prominent during active bimanual coordination and marginal during kinesthetic tracking . Together the results indicated that phase entrainment by contralateral afference contributed equally to the stability of in-phase and antiphase coordination , and that differential stability of these patterns depended predominantly on integrated timing of feedforward signals , with only a minor role for afference-based error corrections BACKGROUND AND PURPOSE To improve the accuracy of early postonset prediction of motor recovery in the flaccid hemiplegic arm , the effects of change in motor function over time on the accuracy of prediction were evaluated , and a prediction model for the probability of regaining dexterity at 6 months was developed . METHODS In 102 stroke patients , dexterity and paresis were measured with the  Action Research Arm Test , Motricity Index , and Fugl-Meyer motor evaluation .  For model development , 23 c and i date determinants were selected . Logistic regression analysis was used for prognostic factors and model development . RESULTS At 6 months , some dexterity in the paretic arm was found in 38 % , and complete functional recovery was seen in 11.6 % of the patients . Total anterior circulation infa rcts , right hemisphere strokes , homonymous hemianopia , visual gaze deficit , visual inattention , and paresis were statistically significant related to a poor arm function . Motricity Index leg scores of at least 25 points in the first week and Fugl-Meyer arm scores of 11 points in the second week increasing to 19 points in the fourth week raised the probability of developing some dexterity ( Action Research Arm Test > or=10 points ) from 74 % ( positive predictive value [ PPV ] , 0.74 ; 95 % confidence interval [ CI ] , 0.63 to 0.86 ) to 94 % ( PPV , 0.83 ; 95 % CI , 0.76 to 0.91 ) at 6 months . No change in probabilities of prediction dexterity was found after 4 weeks . CONCLUSIONS Based on the Fugl-Meyer scores of the flaccid arm , optimal prediction of arm function outcome at 6 months can be made within 4 weeks after onset . Lack of voluntary motor control of the leg in the first week with no emergence of arm synergies at 4 weeks is associated with poor outcome at 6 months 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 compare the effects of bilateral task training with unilateral task training on upper-limb outcomes in early poststroke rehabilitation . DESIGN A single-blinded r and omized controlled trial , with outcome assessment s at baseline , postintervention ( 6 wk ) , and follow-up ( 18 wk ) . SETTING Inpatient acute and rehabilitation hospitals . PARTICIPANTS Patients were r and omized to receive bilateral training ( n=56 ) or unilateral training ( n=50 ) at 2 to 4 weeks poststroke onset . INTERVENTION Supervised bilateral or unilateral training for 20 minutes on weekdays over 6 weeks using a st and ardized program . MAIN OUTCOME MEASURES Upper-limb outcomes were assessed by Action Research Arm Test ( ARAT ) , Rivermead Motor Assessment upper-limb scale , and Nine-Hole Peg Test ( 9HPT ) . Secondary measures included the Modified Barthel Index , Hospital Anxiety and Depression Scale , and Nottingham Health Profile . All assessment was conducted by a blinded assessor . RESULTS No significant differences were found in short-term improvement ( 0 - 6 wk ) on any measure ( P>.05 ) . For overall improvement ( 0 - 18 wk ) , the only significant between-group difference was a change in the 9HPT ( 95 % confidence interval [ CI ] , 0.0 - 0.1 ; P=.05 ) and ARAT pinch section ( 95 % CI , 0.3 - 5.6 ; P=.03 ) , which was lower for the bilateral training group . Baseline severity significantly influenced improvement in all upper-limb outcomes ( P<.05 ) , but this was irrespective of the treatment group . CONCLUSIONS Bilateral training was no more effective than unilateral training , and in terms of overall improvement in dexterity , the bilateral training group improved significantly less . Intervention timing , task characteristics , dose , and intensity of training may have influenced the results and are therefore areas for future investigation Normalization of upper limb movement remains a difficult problem for a significant sub population of hemiplegic stroke patients . Clinical observations prompted investigation of a novel approach using simultaneous identical bilateral movements performed independently . We briefly report 12 controlled single-case experiments using multiple-baseline design s across three separate grasp/reach activities . Unilateral performance tests with the hemiplegic arm using the bilaterally trained actions demonstrated clinical ly and statistically significant improvements in movement patterns . These improvements were specific to the trained movement and well maintained . Using recent literature we develop a theoretical model proposing that bilateral simultaneous movement promotes interhemispheric disinhibition likely to allow reorganization by sharing of normal movement comm and s from the undamaged hemisphere . Disinhibition may also encourage recruitment of undamaged neurones to construct new task-relevant neural networks . The potential contribution of spared ipsilateral pathways in the damaged hemisphere , indirect corticospinal pathways and ipsilateral pathways from the undamaged hemisphere is discussed OBJECTIVES To determine the intra- and interrater reliability of the Action Research Arm ( ARA ) test , to assess its ability to detect a minimal clinical ly important difference ( MCID ) of 5.7 points , and to identify less reliable test items . DESIGN Intrarater reliability of the sum scores and of individual items was assessed by comparing ( 1 ) the ratings of the laboratory measurements of 20 patients with the ratings of the same measurements recorded on videotape by the original rater , and ( 2 ) the repeated ratings of videotaped measurements by the same rater . Interrater reliability was assessed by comparing the ratings of the videotaped measurements of 2 raters . The result ing limits of agreement were compared with the MCID . PATIENTS Stratified sample , based on the intake ARA score , of 20 chronic stroke patients ( median age , 62yr ; median time since stroke onset , 3.6yr ; mean intake ARA score , 29.2 ) . MAIN OUTCOME MEASURES Spearman 's rank-order correlation coefficient ( Spearman 's rho ) ; intraclass correlation coefficient ( ICC ) ; mean difference and limits of agreement , based on ARA sum scores ; and weighted kappa , based on individual items . RESULTS All intra- and interrater Spearman 's rho and ICC values were higher than .98 . The mean difference between ratings was highest for the interrater pair ( .75 ; 95 % confidence interval , .02 - 1.48 ) , suggesting a small systematic difference between raters . Intrarater limits of agreement were -1.66 to 2.26 ; interrater limits of agreement were -2.35 to 3.85 . Median weighted kappas exceeded .92 . CONCLUSION The high intra- and interrater reliability of the ARA test was confirmed , as was its ability to detect a clinical ly relevant difference of 5.7 points Two important components of Constraint-Induced Movement therapy are thought to be intense training of the more-impaired arm and physical restraint of the less-impaired arm . This preliminary study examined the effects of type of training ( task- practice , shaping ) and restraint ( sling , half-glove , no restraint ) on treatment outcomes . Seventeen individuals at least 1-year post-stroke with mild/moderate upper extremity motor deficit were consecutively assigned to Sling and Task- practice , Sling and Shaping , Half-glove and Shaping , and Shaping Only groups . Task- practice involved repetitive more-impaired arm training on functional tasks for 6 hr/day for 10 consecutive weekdays . Shaping differed from task- practice in that task dem and s were progressively increased and immediate performance feedback was provided frequently and systematic ally . " Sling " groups placed the less-impaired arm in a resting h and -splint/sling assembly for most waking hours over the 2-week intervention , while the " Half-glove " group wore a modified gardening glove as a reminder not to use the more affected arm in the life situation . There were no between-group differences in outcome at post-treatment , although two-years afterwards Sling & Task- practice and Half-glove & Shaping participants showed larger and smaller retention of gains , respectively , than those in the Sling & Shaping group . Thus , long-term outcomes may have been affected by type of more-impaired arm motor training and less-impaired arm restraint . These variables , however , were confounded with between-group differences in training intensity , limiting confidence in this conclusion To test the clinical counterpart of the learned nonuse theory , 25 chronic hemiplegic stroke and head-injured patients with minimal to moderate upper extremity extensor muscle function were required to keep their uninvolved upper extremities within a h and -enclosed sling during waking hours over a 2-week interval . During this forced use period and for 1 year thereafter , changes in force or time-based measures among 21 functional tasks were compared to values at the sixth baseline session , a preintervention time when relearning had plateaued . Significant ( P less than 0.05 , Friedman 's repeated measures followed by Tukey multiple comparison tests ) changes were seen in 19 of the 21 tasks with most persisting at the 1-year follow-up . There were no apparent differences between right- and left-sided involvement or between stroke versus head injury clients ( Mann-Whitney procedure ) . Ratings for quality of movement scored from videotapes presented in r and om order showed no change over time . These data suggest that learned nonuse does occur in select neurological patients and that this behavior can be reversed through application of a forced use paradigm Background and Objective . This study investigated the relative effects of distributed constraint-induced therapy ( CIT ) and bilateral arm training ( BAT ) on motor performance , daily function , functional use of the affected arm , and quality of life in patients with hemiparetic stroke . Methods . A total of 60 patients were r and omized to  distributed CIT , BAT , or a control intervention of less specific but active therapy . Each group received intensive training for 2 hours/day , 5 days/week , for 3 weeks . Pretreatment and posttreatment measures included the Fugl — Meyer Assessment ( FMA ) , Functional Independence Measure ( FIM ) , Motor Activity Log ( MAL ) , and Stroke Impact Scale ( SIS ) . The proximal and distal scores of FMA were used to examine separate upper limb ( UL ) elements of movement . Results . The distributed CIT and BAT groups showed better performance in the overall and the distal part score of the FMA than the control group . The BAT group exhibited greater gains in the proximal part score of the FMA than the distributed CIT and control groups . Enhanced performance was found for the distributed CIT group in the MAL , the subtest of locomotion in the FIM , and certain domains of the SIS ( eg , ADL/IADL ) . Conclusion . BAT may uniquely improve proximal UL motor impairment . In contrast , distributed CIT may produce greater functional gains for the affected UL in subjects with mild to moderate chronic hemiparesis Background . Constraint-induced movement therapy ( CIMT ) has received considerable attention as an intervention to enhance motor recovery and cortical reorganization after stroke . Objective . The present study represents the first multi-center effort to measure cortical reorganization induced by CIMT in subjects who are in the subacute stage of recovery . Methods . A total of 30 stroke subjects in the subacute phase ( > 3 and < 9 months poststroke ) were recruited and r and omized into experimental ( receiving CIMT immediately after baseline evaluation ) and control ( receiving CIMT after 4 months ) groups . Each subject was evaluated using transcranial magnetic stimulation ( TMS ) at baseline , 2 weeks after baseline , and at 4-month follow-up ( ie , after CIMT in the experimental groups and before CIMT in the control groups ) . The primary clinical outcome measure was the Wolf Motor Function Test . Results . Both experimental and control groups demonstrated improved h and motor function 2 weeks after baseline . The experimental group showed significantly greater improvement in grip force after the intervention and at follow-up ( P = .049 ) . After adjusting for the baseline measures , the experimental group had an increase in the TMS motor map area compared with the control group over a 4-month period ; this increase was of borderline significance ( P = .053 ) . Conclusions . Among subjects who had a stroke within the previous 3 to 9 months , CIMT produced statistically significant and clinical ly relevant improvements in arm motor function that persisted for at least 4 months . The corresponding enlargement of TMS motor maps , similar to that found in earlier studies of chronic stroke subjects , appears to play an important role in CIMT-dependent plasticity The use of activity-dependent interventions has shown some success in promoting recovery of upper limb function in chronic stroke patients . This study compared the neurophysiological and behavioural changes associated with two such rehabilitation protocol s : unilateral and bilateral movement training .  Twelve chronic stroke patients were r and omly assigned to the two training protocol s involving six daily practice sessions . Each session consisted of 50 trials of a dowel placement task performed either with both impaired and unimpaired arm moving synchronously ( bilateral training group ) or with only the impaired arm moving ( unilateral training ) . Kinematic measurements of upper limb movements were made in four unilateral test trials performed prior to and following each practice session . Functional assessment s of the impaired upper limb and neurophysiological assessment s , using transcranial magnetic stimulation ( TMS ) , of the affected and non-affected cortical hemispheres were made prior to and following the intervention sessions . Individuals receiving bilateral training showed a reduction in movement time of the impaired limb and increased upper limb functional ability compared to individuals receiving unilateral training . In some patients changes to upper limb function were associated with changes to the cortical representation of a target muscle in the non-affected hemisphere . Overall , these findings suggest that a short-term bilateral training intervention may be effective in facilitating upper limb motor function in chronic stroke patients 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 . Objectives . Constraint-induced movement therapy ( CIMT ) has been shown to be effective in chronic stroke patients . It is worthwhile to investigate the influence of individual factors for two reasons : to find out whether they influence outcome and to see whether they support the theory underlying CIMT . Methods . Agroupof26 patients were treated with CIMT  and followed over 6 months . In total , 14 individual factors were identified . Patients were assessed with 6 tests , including 2 commonly used after stroke ( Frenchay Arm Test , 9 Hole Peg Test ) . Results . There were individual differences , but as a group , patients improved after therapy . There were no individual factors that influenced improvement in more than one test . Conclusions . CIMT is an effective therapy in patients with moderate impairment after stroke , also in tests commonly used in stroke rehabilitation . Factors that could have expected to make a difference on the basis of the theory behind CIMT ( e.g. , time since stroke , previous therapy , sensory deficit ) did not influence results . Patients with hemorrhagic lesions and those with a high level of performance ( Motor Activity Log > 2.5 ) profit as well . Pairwise therapy is as effective as individual therapy Objective . Stroke survivors with motor deficits often have pyramidal tract atrophy caused by degeneration of corticospinal fibers . The authors hypothesized that the degree of atrophy correlates with severity of motor impairment in patients with chronic stroke and predicts the response to rehabilitation training . Methods . They performed a post hoc analysis of 42 hemiparetic patients ( > 6 months ) who had been r and omized to either 6 weeks of bilateral arm training with rhythmic auditory cueing ( BATRAC ) or dose-matched therapeutic exercise ( DMTE ) .  Arm function was measured using the Fugl-Meyer ( FM ) and modified Wolf Motor Function Test ( WMFT ) . Structural MRI and diffusion tensor imaging ( DTI ) on the pontine level measured corticospinal tract ( CST ) atrophy by planimetric measurement of the mesencephalon ( mesencephalic atrophy ratio ) and fractional anisotropy ( FA ) , respectively . Voxel-based lesion symptom mapping ( VLSM ) was used to determine the lesions associated with highest degrees of atrophy . The predictive value of CST atrophy for impairment and training response was analyzed . Results . CST atrophy predicted baseline motor arm function measured by the FM and WMFT . The authors found only a trend for the correlation with FA . No measure of atrophy predicted response to either BATRAC or DMTE . CST atrophy was higher with larger lesions and those that affected the CST . VLSM identified internal capsule lesions as being associated with highest CST atrophy . Conclusion . Larger lesions , internal capsule lesions , and those overlapping the pyramidal tract are associated with greater CST atrophy . CST atrophy explains in part the variability of baseline deficits but does not seem to predict the response to BATRAC or unilateral arm training on upper-extremity function OBJECTIVE We compared the effectiveness of constraint-induced movement therapy ( CIMT ) with bilateral treatment of equal intensity for chronic upper-extremity ( UE ) dysfunction caused by cerebrovascular accident ( CVA ) . DESIGN We conducted a 2-group , r and omized intervention trial with stratification by severity of UE dysfunction . Twelve community-dwelling adults were provided with 6 hr of occupational therapy for 10 days plus additional home practice . Six participants wore a mitt on the unimpaired UE , and 6 participants were intrusively and repetitively cued to use both UEs . The Wolf Motor Function Test ( WMFT ) and the Canadian Occupational Performance Measure ( COPM ) were administered before and after treatment and at 6-mo follow-up . RESULTS Significant improvements were found in WMFT and COPM scores across time in both groups . No significant between-group differences were found on the WMFT . CONCLUSION High-intensity occupational therapy using a CIMT or a bilateral approach can improve UE function  in people with chronic UE dysfunction after CVA . Treatment intensity rather than restraint may be the critical therapeutic factor Objective . This preliminary study aims to verify if the method of kinematic analysis proposed here may be suitable for evaluating the effects of constraint-induced movement therapy ( CIMT ) in chronic stroke patients and may be of help in the study of the mechanisms underlying functional improvement following CIMT . Methods . Clinical and kinematic data were collected from a group of chronic stroke patients and from an age-matched healthy control group . Affected and less affected upper-limb kinematics related to h and -to-mouth and reaching movements were acquired before and immediately after 2 weeks of CIMT . Healthy subjects were su bmi tted to kinematic analysis of the nondominant side and reevaluated after 2 weeks . Results . The clinical results were consistent with those reported in the literature and showed motor function improvement of the hemiparetic limb after CIMT . Kinematic data of the healthy control group showed high test-retest reliability . Statistically significant differences between the affected limb and both the less affected limb and the healthy subjects ' nondominant limb were observed . After CIMT , kinematic data showed improvement in the speed of movement and in measures related to the capacity for coordination . Conclusions . The method of kinematic analysis was sensitive for an assessment of motor recovery induced by CIMT . The kinematic results suggest that the increase in the use of the paretic limb in activities of daily living after the intervention is not only attributable to the patient 's increased attention to it and better h and dexterity , but it is also a consequence of the improved speed of movement and better coordination between shoulder and elbow joints PURPOSE A number of longitudinal studies show that about one third of all patients regain dexterity following a stroke . However , the determinants of improvement of upper limb function are largely unknown . The aim of the present study was to investigate the longitudinal relationship of functional change in the upper paretic limb and change in time-dependent covariates in order to develop a multivariable regression model to predict improvement in dexterity . METHODS Based on 18 repeated measurements over time during the first post-stroke year , 101 stroke patients with first-ever ischemic middle cerebral artery strokes were investigated . Baseline characteristics as well as longitudinal information from  Action Research Arm Test ( ARAT ) , Fugl-Meyer arm and h and score ( FM-arm and FM-h and )  ,  Motricity Index arm and leg score ( MI-arm and MI-leg ) , letter cancellation task ( LCT ) , Fugl-Meyer balance score ( FM-balance ) and progress of time  were obtained prospect ively . Outcome constituted of change scores on the ARAT over first year post stroke . Adjoining measurements of time-dependent variables were used to calculate time-dependent changes producing change scores . RESULTS In total 1570 of the 1717 change scores were available for longitudinal regression analysis . The regression model shows that FM-h and change scores was the most important relative factor in predicting improvement on ARAT ( st and ardized beta=0.357 ; p<0.001 ) followed by change scores on FM-arm ( beta=0.007 ; p<0.001 ) , whereas progress of time was significantly negatively associated with improvement on ARAT ( beta=-0.001 ; p<0.001 ) . CONCLUSIONS Functional improvement of the upper paretic limb is mainly determined by improvement of the paretic h and , followed by synergistic independent movement of the paretic arm . Progress of time itself is an independent covariate that is negatively associated with upper limb function suggesting that most pronounced improvements occur earlier after stroke This paper describes PEDro , the Physiotherapy Evidence Data base . PEDro is a web-based data base of r and omized controlled trials and systematic review s in physiotherapy . It can be accessed free of charge at http://ptwww.cchs.usyd.edu.au/pedro . The data base contains bibliographic details and abstract s of most English- language r and omized trials and systematic review s in physiotherapy , and of many trials and review s in other language s. Trials on the data base are rated on the basis of their method ological quality so that users of the data base can quickly identify trials of high quality . Trials and systematic review s are extensively indexed to facilitate search ing . PEDro provides an important information re source to support evidence -based clinical practice Constraint-induced movement therapy ( CI ) , a st and ardized intensive rehabilitation intervention , was given to patients a year or more following stroke . The goal was to determine if CI was more effective than a less-intensive control intervention in changing motor function and /or brain physiology and to gain insight into the mechanisms underlying this recovery process . Subjects were recruited and r and omized more than 1 year after a single subcortical infa rct ion . Clinical assessment s performed before and after the intervention and at 6 months postintervention included the Wolf Motor Function Test ( WMFT ) , the Motor Activity Log ( MAL ) , and the Assessment of Motor and Process Skills ( AMPS ) .  Transcranial magnetic stimulation was used to map the motor cortex . Positron emission tomography was used to measure changes in motor task-related activation due to the intervention . MAL increased by 1.08 after CI therapy and decreased by 0.01 after control therapy . The difference between groups was significant ( P < 0.001 ) . Changes in WMFT and AMPS were not significantly different between groups . Cerebral activation during a motor task decreased significantly , and motor map size increased in the affected hemisphere motor cortex in CI patients but not in control patients . Both changes may reflect improved ability of upper motor neurons to produce movement Principles of motor control and learning such as bilateral coordination and task-specificity , are increasingly incorporated in the design of upper extremity rehabilitation protocol s for stroke survivors . Yet most studies investigating the efficacy of new protocol s report composite scores of st and ardized tests , such as the Fugl-Meyer Upper Extremity test ( FM ) and the Wolf Motor Arm Test , rather than determining how the motor control and coordination of arm movements has changed . Here we present a sub- study of a larger r and omized controlled trial comparing a bilateral and unilateral training protocol where participants were assessed on bilateral and unilateral arm reaching . Eligible participants for the arm reaching analysis were 9 ( FM=37 ) and 9 ( FM=34 ) in Bilateral Arm Training with Rhythmic Auditory Cueing ( BATRAC ) and Dose Matched Therapeutic Exercises ( DMTE ) , respectively . Participants undertook 18 sessions of training for 6 weeks with 20min of active training per session . For bilateral arm reaching , participants after BATRAC were faster , with increased peak acceleration , fewer movement units , and smoother h and paths for each arm . The BATRAC training group showed greater improvements with training than the DMTE group during bilateral reaching for parameters of movement units and smoothness of h and path . For unilateral arm reaching , participants were faster after DMTE for paretic arm reaching ; however , this group did not improve to a greater extent than the BATRAC training group . Within group functional gains were seen after BATRAC on FM , Wolf Motor Arm Test ( time and weight ) and after DMTE on FM and Wolf Weight . There was a positive correlation between movement units and the time component of the Wolf Motor Arm Test . The reaching analysis demonstrates task-specificity in training since BATRAC improves performance in bilateral reaching and DMTE improves performance in unilateral reaching . Temporal/spatial control outcomes in studies of post-stroke interventions can identify functionally relevant motor control changes that are not captured by traditional st and ardized tests Background . Upper extremity hemiparesis is the most common poststroke disability . Longitudinal studies have indicated that 30 % to 66 % of stroke survivors do not have full arm function 6 months poststroke . One promising treatment approach is bilateral training . To date , no r and omized , blinded study of efficacy comparing 2 groups ( bilateral training vs unilateral training ) using analogous tasks has been performed in chronic stroke survivors with moderate upper extremity impairment . Objective . To compare the effectiveness of bilateral training with unilateral training for individuals with moderate upper limb hemiparesis . The authors hypothesized that bilateral training would be superior to unilateral training in the proximal extremity but not the distal one . Methods . Twenty-four subjects participated in a r and omized , single-blind training study . Subjects in the bilateral group ( n = 12 ) practice d bilateral symmetrical activities , whereas the unilateral group ( n = 12 ) performed the same activity with the affected arm only . The activities consisted of reaching-based tasks that were both rhythmic and discrete . The Motor Assessment Scale ( MAS ) , Motor Status Scale ( MSS ) , and muscle strength were used as outcome measures . Assessment s were administered at baseline and posttraining by a rater blinded to group assignment . Results . Both groups had significant improvements on the MSS and measures of strength . The bilateral group had significantly greater improvement on the Upper Arm Function scale ( a subscale of the MAS-Upper Limb Items ) . Conclusion . Both bilateral and unilateral training are efficacious for moderately impaired chronic stroke survivors .  Bilateral training may be more advantageous for proximal arm function
OBJECTIVE To compare the effects of unilateral and bilateral training on upper limb function after stroke with regard to two key factors : severity of upper limb paresis and time of intervention post-stroke .