Forced Use of the Upper Extremity in Chronic Stroke Patients

Abstract

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 randomized 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 clinically 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 clinically 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 clinically 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 clinically relevant in the subgroups of patients with sensory disorders and hemineglect, respectively.

The intra- and interrater reliability of the action research arm test: A practical test of upper extremity function in patients with stroke

“…12 Had the limits of agreement been greater than the MCID of 5.7, this would suggest that the ARA test would not be reliable enough to detect a difference that is considered to be clinically relevant. 18 The difference between groups that was found in the RCT exceeds the intrarater limits of agreement, which supports the validity of this finding as a "signal" surmounting the "noise" because of the variability of ratings.…”

“…12 The randomized clinical trial included 66 subjects who met the following inclusion criteria: (1) a history of a single stroke, at least 1 year previously, resulting in hemiparesis on the dominant side; (2) a minimum of 20°of active extension in the wrist and 10°of finger extension; (3) ARA test score below 51 (max score, 57); (4) age between 18 and 80 years; (5) ability to walk indoors without a cane, indicating no major balance problems; (6) no severe aphasia (score ϾP50 on the Stichting Afasie Nederland test 15 ); and (7) no severe cognitive impairments (Mini-Mental State score Ն22). 16 The protocol was approved by the hospital's medical ethics committee, and all patients gave written informed consent.…”

“…11 For the intrarater ICC, the formula treating rater as a fixed effect was applied because there was only 1 rater involved in this particular trial. 12 The Bland and Altman-defined limits of agreement (D Ϫ 2s, D ϩ 2s) have been put into standard mathematical expression as ⌬ Ϫ 2SD and ⌬ ϩ 2SD, in which ⌬ is the mean of the differences between 2 ratings of the same subject, and SD is the standard deviation of the differences. Because the measurement errors will very likely follow a Gaussian distribution, 95% of the differences will lie between these limits of agreement (or more precisely, between ⌬ Ϫ 1.96SD and ⌬ ϩ 1.96SD).…”

“…10,11 The ARA test was administered as a primary outcome measure in a clinical trial evaluating the effectiveness of forced-use therapy of the hemiplegic arm in chronic stroke patients. 12 The minimal clinically important difference (MCID) was set at 10% of the scale's total range of 57 points, based on clinical experience and estimates reported in the literature for similar outcome measures in different domains. 13,14 One of the prerequisites for usefulness of the ARA test is that its measurement error is smaller than the estimated MCID.…”

Robot-assisted movement training compared with conventional therapy techniques for the rehabilitation of upper-limb motor function after stroke

“…CIT has recently been shown to have advantages relative to neurodevelopmental treatment of equal intensity. 9 Other studies have reported that repetitive practice of hand and finger movements against loads resulted in greater improvements in motor performance and functional scales than Bobath-based treatment, 10 transcutaneous electric nerve stimulation, 10 and suprathreshold electric stimulation of hand and wrist muscles. 11 Parry et al 12 reported that additional treatment, in the form of repetitive practice of movements and functional activities with a trained assistant, was more effective than additional conventional treatment from a physical therapist that focused on teaching techniques and encouraging self-practice.…”