Effectiveness of constraint-induced movement therapy in chronic stroke patients. Clinimetric Properties of the Motor Activity Log for the Assessment of Arm Use in Hemiparetic Patients Assessing Wolf Motor Function Test as Outcome Measure for Research in Patients After Stroke Evidence for physiotherapy practice: a survey of the Physiotherapy Evidence Database (PEDro). Does the Application of Constraint-Induced Movement Therapy During Acute Rehabilitation Reduce Arm Impairment After Ischemic Stroke? Modified constraint induced therapy: a randomized feasibility and efficacy study. Forced use of the upper extremity in chronic stroke patients: results from a single-blind randomized clinical trial. Longer versus shorter daily constraint-induced movement therapy of chronic hemiparesis: an exploratory study. Effects of modified constraint induced therapy on upper limb function in subacute stroke patients. Modified Constraint-Induced Therapy in Acute Stroke: A Randomized Controlled Pilot Study Reliability of the PEDro scale for rating quality of randomized controlled trials. Methods for a Multisite Randomized Trial to Investigate the Effect of Constraint-Induced Movement Therapy in Improving Upper Extremity Function among Adults Recovering from a Cerebrovascular Stroke The Effects of Constraint-Induced Therapy on Precision Grip: A Preliminary Study Can forced-use therapy be clinically applied after stroke? An exploratory randomized controlled trial. Modified Constraint-Induced Therapy after Subacute Stroke: A Preliminary Study Constraint-Induced Therapy in Stroke: Magnetic-Stimulation Motor Maps and Cerebral Activation Efficacy of modified constraint-induced movement therapy in chronic stroke: a single-blinded randomized controlled trial.
OBJECTIVE The purpose of this study was to evaluate the effectiveness of constraint-induced movement therapy ( CIMT ) in dexterity with Action Research Arm Test ( ARA test ) , h and grip strength , pinch strength of affected upper extremity in chronic stroke patients . MATERIAL AND METHOD An observer-blinded r and omized control trial , 69 chronic stroke patients were allocated either to constraint-induced movement technique ( n = 33 ) or conservative treatment ( n = 36 ) . The CIMT group received 6 hours of daily affected-upper-extremity training and restrained unaffected upper extremities for 5 days per week , totally 2 weeks . The control group received bimanual-upper-extremity training by conservative neurodevelopmental technique without restrained unaffected upper extremities for 2 weeks . RESULTS The CIMT group had ARA scores , pinch strength of affected upper extremities statistically significant higher than the control group at p < 0.05 , but the h and grip strength had no statistically significant difference , p > 0.05 . CONCLUSIONS CIMT of unaffected upper extremities has an advantage for chronic stroke patients which may be an efficacious technique of improving motor activity and exhibiting learned nonuse 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 Background and Purpose — The Wolf Motor Function Test ( WMFT ) is a new time-based method to evaluate upper extremity performance while providing insight into joint-specific and total limb movements . This study addresses selected psychometric attributes of the WMFT applied to a chronic stroke population . Methods — Nineteen individuals after stroke and with intact cognition and sitting balance were age- and sex-matched with 19 individuals without impairment . Subjects performed the WMFT and the upper extremity portion of the Fugl-Meyer Motor Assessment ( FMA ) on 2 occasions ( 12 to 16 days apart ) , with scoring performed independently by 2 r and om raters . Results — The  WMFT and FMA demonstrated agreement ( P < 0.0001 ) between raters at each session .  WMFT  scores for the dominant and nondominant extremities of individuals without impairment were different ( P ≤0.05 ) from the more and less affected extremities of subjects after stroke . The FMA score for the more affected extremity of subjects after stroke was different ( P ≤0.05 ) from the dominant and nondominant extremities . However , the FMA score for the less affected upper extremity of individuals after stroke was not different ( P > 0.05 ) from the dominant and nondominant extremities of individuals without impairment . The WMFT and FMA scores were related ( P < 0.02 ) for the more affected extremity in individuals after stroke . Conclusions — The interrater reliability , construct validity , and criterion validity of the WMFT , as used in these subject sample s , are supported Evidence -based practice involves the use of evidence from systematic review s and r and omised controlled trials , but the extent of this evidence in physiotherapy has not previously been surveyed . The aim of this survey is to describe the quantity and quality of r and omised controlled trials and the quantity of systematic review s relevant to physiotherapy . The Physiotherapy Evidence Data base ( PEDro ) was search ed . The quality of trials was assessed with the PEDro scale . The search identified a total of 2,376 r and omised controlled trials and 332 systematic review s. The first trial was published in 1955 and the first review was published in 1982 . Since that time , the number of trials and review s has grown exponentially . The mean PEDro quality score has increased from 2.8 in trials published between 1955 and 1959 to 5.0 for trials published between 1995 and 1999 . There is a substantial body of evidence about the effects of physiotherapy . However , there remains scope for improvements in the quality of the conduct and reporting of clinical trials 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 This case series examined the feasibility and efficacy of a modified constraint induced therapy ( CIT ) protocol administered on an outpatient basis . The Fugl-Meyer Assessment of Motor Recovery After Stroke ( Fugl ) , Action Research Arm Test ( ARA ) , Wolf Motor Function Test ( WMFT ) , and  Motor Activity Log  ( MAL ) were administered to six patients between 2 and 6 months poststroke ( CVA ) exhibiting stable motor deficits and learned nonuse of the affected limb . Two patients then participated in half-hour physical and occupational therapy sessions three times/week for 10 weeks . During the same period , their unaffected arms and h and s were restrained 5 days/week during 5 hours identified as times of frequent use . Two other patients received regular therapy and two control patients received no therapy . The ARA , Fugl , WMFT , and MAL were again administered after 10 weeks . Patients receiving modified CIT exhibited substantial improvements on the Fugl , ARA , and WMFT , as well as increases in amount and quality of use of the limb using the MAL . Patients receiving traditional or no therapy exhibited no improvements . Results suggest that modified CIT may be an efficacious method of improving function and use of the affected arms of patients exhibiting learned nonuse 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 evaluate and compare the effects of 3-hour versus 6-hour daily training sessions in constraint-induced movement therapy ( CIMT ) . DESIGN Intervention study , 2-group r and omized trial ; baseline , pretreatment , and posttreatment measures ; 1-month follow-up ( weekly measures ) . SETTING University department of psychology in Germany . PARTICIPANTS A convenience sample of 15 adults with chronic hemiparesis ( 13 stroke , 2 traumatic brain injury ) . INTERVENTION CIMT ( 14 consecutive days ; constraint of unaffected h and for a target of 90 % of waking hours ) with either 6 hours ( 6h/d group , n=7 ) or 3 hours ( 3h/d group , n=8 ) of shaping training with the affected h and per day . MAIN OUTCOME MEASURES The Motor Activity Log and Wolf Motor Function Test . RESULTS Significant improvements in motor function in the laboratory and increased use of the affected h and in the real-world environment were found in both groups . The beneficial effects were significantly greater in the 6h/d group than in the 3h/d group . CONCLUSION The 3-hour CIMT training schedule significantly improved motor function in chronic hemiparesis , but it was less effective than the 6-hour training schedule OBJECTIVE To examine the feasibility and efficacy of a modified constraint induced therapy protocol on stroke patients . METHODS This study was carried out during the period from August 2001 to January 2002 at the Riyadh Medical Complex , Riyadh , Kingdom of Saudi Arabia . Six stroke patients with subacute cerebrovascular accident ( < 6 months ) were included in the study . Three male and 3 female patients with a mean age of 54.3+/-6.9 years ( range 45 - 67 years ) , and mean duration of hemiparesis of 4.7 months ( range 2.3 - 5.8 months ) . They were divided r and omly into 3 groups of 2 patients . The first 2 patients ( constraint induced therapy group ) participated in half an hour of physical and occupational therapy sessions 3 times per week for 10 weeks . During the same period , their unaffected arms and h and s were restrained 5 days per week for 5 hours identified as times of frequent use . The second 2 patients ( traditional therapy group ) received regular therapy administered after 10 weeks . The last 2 patients ( control group ) received no therapy . The Fugl-Meyer Assessment of Motor Recovery After Stroke ( Fugl ) , Action Research Arm Test ( ARA ) , Wolf Motor Function Test ( WMFT ) , and Motor Activity Log ( MAL ) were administered to the patients . RESULTS Patients receiving modified constraint induced therapy exhibited substantial improvement on the Fugl , ARA , and WMFT , as well as increases in amount and quality of use of the limb using the MAL . While patients receiving traditional physical and occupational therapy , and no therapy patients exhibited few improvements . CONCLUSION Modified constraint induced therapy may be an efficacious method of improving function and use of the affected arms in stroke patients exhibiting learned nonuse To determine modified constraint-induced therapy ( mCIT ) feasibility and compare its efficacy to traditional rehabilitation ( TR ) in acute stroke patients exhibiting upper limb hemiparesis . Method . Before-after , multiple baseline , r and omized controlled pilot study . Setting . Rehabilitation hospital . Patients . Ten stroke patients < 14 d poststroke and exhibiting upper limb hemiparesis and affected limb nonuse . Interventions . Five patients were administered mCIT , consisting of structured therapy emphasizing more affected arm use in valued activities 3 d/week for 10 weeks and less affected arm restraint 5 d/week for 5 h. Five other patients received 1/2 sessions of traditional motor rehabilitation for the affected arm , which included affected limb manual dexterity exercises and stretching , as well as compensatory strategies with the unaffected limb . The TR regimens occurred 3 d/week for 10 weeks . Main Outcome Measures . The Fugl-Meyer Assessment of Motor Recovery ( Fugl-Meyer ) , Action Research Arm Test ( ARA ) , and Motor Activity Log ( MAL ) . Results . Before intervention , all patients exhibited stable motor deficits and more affected arm nonuse . After intervention , mCIT patients displayed increased affected arm use ( + 2.43 on the MAL amount of use scale ) , uniformly exhibited increases on the Fugl-Meyer and ARA ( mean change scores = + 18.7 and + 21.7 , respectively ) , and were able to again perform valued activities .  TR patients exhibited nominal change in affected limb use ( + 0.07 on the MAL amount of use scale ) and modest changes on the Fugl-Meyer and ARA ( + 4.4 and + 4.8 , respectively ) . Fugl-Meyer and ARA changes were significant for the mCIT group only ( P < 0.01 ) . Conclusions . mCIT is a promising regimen for improving more affected limb use and function in acute cerebrovascular accident . However , larger confirmatory studies need to be performed 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 . This article describes the study design , method ological considerations , and demographic characteristics of a phase III RCT to determine if 1 ) constraint-induced therapy ( CI therapy ) can be applied with therapeutic success 3 to 9 months after stroke across different sites , 2 ) gains that might occur persist over 2 years , 3 ) initial level of motor ability determines responsiveness to CI therapy , and 4 ) the treatment effect differs between those treated before 9 months and after 1 year . Six sites will screen and recruit poststroke survivors stratified on initial level of motor ability and after r and omization allocate participants to immediate or delayed intervention . Primary outcomes include a laboratory-based measure of function ( Wolf Motor Function Test [ WMFT ] ) and a real-world participant-centered functional use measure ( Motor Activity Log [ MAL ] ) . Secondary outcomes concern function , behavior , and compliance . This is the first multisite , single-blind RCT of a formal training intervention for upper extremity rehabilitation in subacute stroke in the United States Objective . This preliminary study examines the effects of a 2-week constraint-induced therapy ( CIT ) intervention on the force-producing capabilities of the hemiparetic h and during the performance of a functional dexterous manipulation task . Methods . A 6-degree-of-freedom force/torque transducer that was embedded into the h and le of a key allowed for the quantification of grasping forces and torques produced during the performance of a functional key-turning task . Clinical and kinetic data were collected from 10 subacute patients ( 3 - 9 months poststroke ) who were participating in an ongoing national clinical study ( EXCITE trial ) examining the effects of CIT on upper extremity motor performance . Investigators were blinded to treatment design ation . Five patients receiving treatment immediately completed 2 weeks of intensive CIT , whereas a group r and omized to treatment 1 year later did not receive any therapy during a similar 2-week span . Results . Results indicated that 4 of the 5 patients in the CIT group , compared to the delayed group , showed significant clinical improvements in h and function , increased maximum precision grip force , improved force and torque regulation , and reduced variability in rate of force production during task performance . Conclusions . Improved force control may be a mechanism contributing to the observed improvements in dexterous function in those patients undergoing CIT OBJECTIVE To determine the efficacy , safety , and compliance with forced-use therapy ( FUT ) applied without additional " shaping " therapy during the rehabilitation phase of stroke . DESIGN Prospect i ve , r and omized controlled trial . SETTING Tertiary mixed rehabilitation center . PARTICIPANTS Consecutive sample of 30 in patients or out patients with first stroke showing minimal movement of the arm and h and . Subjects who scored below 26 on the Mini-Mental State Examination were excluded . Seven subjects either did not provide consent or withdrew from the study . The remaining subjects were r and omized into the  control group ( n=13 ) and the FUT group ( n=10 ) . INTERVENTION FUT involved wearing a thick constraint mitten on the sound arm for as many as 6 hours a day . MAIN OUTCOME MEASURES The Chedoke McMaster Impairment Inventory for arm , h and , postural control , and shoulder pain ; Action Research Arm Test ; grip strength ; and FIM instrument . RESULTS FUT subjects experienced 20 % more recovery of the arm than did control subjects and more recovery of postural control ( P=.04 ) . Men benefited most from the program , and there was a tendency for FUT subjects to have more shoulder pain . Compliance was related to cognitive status . CONCLUSIONS FUT , without shaping therapy , appears to augment arm recovery , but a larger sample is required to confirm these findings . The FUT mitten was safe and well tolerated ; however , more research is needed to determine the relation between FUT and hemiplegic shoulder pain Objective : To determine the efficacy of a modified constraint-induced therapy ( mCIT ) administered to patients with subacute stroke . Design : Prospect i ve , multiple-baseline , before-after , r and omized clinical trial . Setting : Subacute outpatient clinic . Subjects : Fourteen patients with subacute stroke who exhibited learned nonuse and stable motor deficits in their affected upper limbs . Intervention : Four patients participated in half-hour , structured physical and occupational therapy sessions that emphasized affected arm use in valued functional activities , 3 times per week for 10 weeks . Their less affected upper limbs were restrained 5 days per week during 5 hours identified as times of frequent use ( mCIT ) . Five patients received regular therapy ( TR ) with similar therapeutic contact time to mCIT , and 5 patients received no therapy ( CON ) . Main Outcome Measures : The Fugl-Meyer Assessment of Motor Recovery ( Fugl ) , Action Research Arm ( ARA ) test , and Motor Activity Log ( MAL ) . Results : After intervention , Fugl , ARA , and MAL scores remained virtually the same for TR and CON groups ; scores improved by 11.4 and 11.5 points , respectively , on the Fugl and ARA for the mCIT group . Amount and quality of arm use , as measured by the MAL , also improved for mCIT patients ( 2.49 and 0.47 , respectively ) . Conclusions : mCIT may be an efficacious method of improving affected arm function and use in stroke patients exhibiting learned nonuse 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 OBJECTIVE To determine efficacy of a modified constraint-induced movement therapy ( mCIMT ) protocol for patients with chronic stroke . DESIGN Multiple-baseline , pre-post , single-blinded r and omized controlled trial . SETTING Outpatient clinic . PARTICIPANTS Seventeen patients who experienced stroke more than 1 year before study entry and who had upper-limb hemiparesis and learned nonuse . INTERVENTION Seven patients participated in structured therapy sessions emphasizing more affected arm use in valued activities , 3 times a week for 10 weeks . Their less affected arms were also restrained 5d/wk for 5 hours ( mCIMT ) . Four patients received regular therapy with similar contact time to mCIMT . Six patients received no therapy ( control ) . MAIN OUTCOME MEASURES The Fugl-Meyer Assessment of Motor Recovery ( FMA ) , Action Research Arm ( ARA ) Test , and Motor Activity Log ( MAL ) . RESULTS The mCIMT patients exhibited greater motor changes on the FMA and ARA ( 18.4 , 11.4 ) than regular therapy ( 6.0 , 7.1 ) or control ( -2.9 , -4.5 ) . Statistical analyses showed significant differences in motor improvement on the FMA ( F(2,12)=11.2 , P=.002 ) and the ARA ( F(2,12)=14.0 , P=.001 ) . Post hoc analyses showed that , when pretreatment motor differences are controlled , mCIMT result ed in substantially higher posttreatment FMA and ARA scores . Amount and quality of arm use , measured by the MAL , improved only in mCIMT patients . CONCLUSIONS mCIMT may be an efficacious method of improving function and use of the more affected arms of chronic stroke patients . Findings further affirm that repeated , task-specific practice is critical to reacquisition of function , whereas practice schedule intensity is less critical
This systematic review investigated the effects on function , quality of life , health care costs , and patient/carer satisfaction of constraint-induced movement therapy ( CIMT ) for upper limb hemiparesis following stroke .