(Stroke. 1999;30:2369-2375.)
© 1999 American Heart Association, Inc.
Original Contributions |
Forced Use of the Upper Extremity in Chronic Stroke Patients
Results From a Single-Blind Randomized Clinical Trial
From the Departments of Rehabilitation Medicine (J.H. van der L., G.J.L., T.W.V.) and Physical Therapy (R.C.W.), University Hospital Vrije Universiteit, and Institute for Research in Extramural Medicine, Vrije Universiteit (J.H. van der L., G.J.L., W.L.D., L.M.B.), Amsterdam, the Netherlands.
Correspondence to J.H. van der Lee, MD, Department of Rehabilitation Medicine, University Hospital Vrije Universiteit, PO Box 7057, 1007 MB Amsterdam, Netherlands. E-mail jh.vanderlee{at}azvu.nl
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Abstract |
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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.
Key Words: arm • clinical trials • disability • hemiplegia • rehabilitation
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Introduction |
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Stroke is a major cause of disablement in many western countries. In the Netherlands, the standardized annual incidence rate for stroke in men and women is 1.74 and 1.96 per thousand, respectively.1 Approximately 80% of stroke patients survive the acute phase, and although most patients regain their walking ability, 30% to 66% of the survivors are no longer able to use the affected arm.2 The recovery process of upper extremity function is often slower than the recovery process of lower extremity function.3 4 According to the theory of "learned nonuse," repeated disappointment in attempts to use the affected arm in the acute and subacute phase can lead to negative reinforcement of using the affected arm.5 Although motor function may gradually return as the result of a combination of spontaneous recovery and rehabilitation, actual use often seems to be much less than potential use.6
Rehabilitation methods have been developed in which patients were either forced to use the affected arm, by means of immobilization of the unaffected arm (forced use),5 7 8 or strongly encouraged to do so by a therapist who constantly corrected the patient when he/she tried to use the unaffected arm (constraint induction).9 10 In 1993, Taub et al5 reported promising results of forced use therapy in a randomized clinical trial involving 9 patients. The contrast between the experimental and the reference interventions consisted of both specific factors (ie, use of a splint and a sling) and cointerventions (eg, intensive outpatient therapy, only applied in the experimental group), which differed substantially between the experimental and the reference interventions. In the present study the effects of forced use therapy were investigated in a larger group of stroke patients, with similar cointerventions in both treatment conditions.
The main research question addressed in the present study is whether forced use therapy for 2 consecutive weeks is more effective than bimanual training based on Neuro-Developmental Treatment (NDT)11 in restoring dexterity and improving activities of daily living (ADL) functioning in chronic stroke patients. Although the NDT method has never been proven to be more effective than other treatment modalities in stroke patients,12 13 it is widely applied in stroke rehabilitation in the Netherlands. Therefore, it appears to be an adequate reference condition.
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Subjects and Methods |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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Design
In an observer-blinded randomized clinical trial, patients were randomized individually into 2 groups by means of computer-generated randomly permuted blocks of 8. Treatment allocation was performed by one of the authors, who was unaware of the information obtained during the intake examination. One group of patients received forced use treatment for 2 weeks; the other group received an equally intensive bimanual training based on NDT for 2 weeks. All patients were treated in groups of 4. Because the experimental and reference treatments could not be applied simultaneously, the time intervals between treatment allocation and the start of the intervention varied. The sequence of the 2 treatment modalities within a block of 8 patients was determined by chance (coin-tossing) to avoid a systematic difference in the time interval between allocation and the start of the treatment. This procedure also helped to ensure that the observer was unaware of the treatment allocation.
Baseline measurements were performed 2 weeks and 3 to 5 days before the start of the treatment (M1 and M2, respectively). During the first and the second weeks of the treatment phase, measurements were performed in the second half of the week (M3 and M4, respectively). Follow-up assessments took place 3 and 6 weeks after the start of the treatment period (short-term follow-up; M5 and M6, respectively) and again after 6 months and 1 year (long-term follow-up; M7 and M8, respectively).
Subjects
Patients were recruited from the files of the Department of
Rehabilitation Medicine of the University Hospital Vrije Universiteit
in Amsterdam and the 4 nearest located rehabilitation centers in that
area. In addition, the research project was advertised in the
newsletter of the national stroke patient organization. From these
sources, 66 chronic stroke patients were included; they all met the
following inclusion criteria: (1) a history of a single stroke, at
least 1 year before the start of the study, resulting in a hemiparesis
on the dominant side; (2) a minimum of 20 degrees of active wrist
extension and 10 degrees of finger extension; (3) Action Research Arm
(ARA) test score <51 (maximum score, 57)14 ; (4) age 18 to
80 years; (5) ability to walk indoors without a stick, indicating
no major balance problems; (6) no severe aphasia (score >P50 on the
Stichting Afasie Nederland (SAN) test15 ; and (7) no severe
cognitive impairments (Mini-Mental State Examination score
22.16 All patients gave their written informed consent.
The research protocol was approved by the medical ethics committee of
the University Hospital Vrije Universiteit.
Treatment
Patients were treated in groups of 4 in the outpatient clinic of
the Department of Rehabilitation Medicine of the University Hospital
Vrije Universiteit. All 4 patients in each group received the same
treatment for 2 consecutive weeks, 5 days a week, 6 hours a day. All
patients in the experimental groups had their healthy arm
immobilized by a resting splint and a closed arm sling,
which was attached to the waist. Patients were encouraged to wear the
splint at home during the 12 days of treatment, whereas the sling was
only used during treatment hours. Every day the use of the splint at
home was registered by the patients in a logbook. As instructed, the
patients did not wear the splint when traveling, sleeping, dressing, or
during toilet activities. In the reference groups the patients were
treated according to the NDT method.11 All activities were
performed bimanually and, if necessary, the affected arm was supported
with the unaffected hand. Symmetry of posture and inhibition of
inappropriate "synergistic" movements were emphasized.
The contrast between the intervention conditions was focused on the presence or absence of forced use. Therefore, the cointerventions, consisting of group activities, exercises, and therapist attention, were kept equal between groups. In accordance with the concept that practice should be aimed at functional goals,17 the treatment was focused on housekeeping activities, handicrafts, and games. Physical therapists selected the most appropriate activities for each individual patient on the basis of the patient's residual sensorimotor capacity. The groups were always supervised by 1 or 2 physical or occupational therapists, and patients received continuous verbal feedback and stimulation and, if necessary, hands-on facilitation of movements and inhibition of inappropriate muscle contraction. Much attention was paid to the avoidance of associated proximal movements and to relaxation, by means of verbal guidance. A more detailed description of the schedule of activities can be obtained on request from the corresponding author.
Measurements
Intake Measures
In addition to the measurements related to the inclusion
criteria, sensory disorders and hemineglect were also recorded
during intake (2 to 64 weeks before the first baseline measurement M1;
median, 11 weeks). Sensory disorders were rated on a dichotomous scale.
Any sensory deviations reported by the patient during the interview, or
in a test involving alternating and simultaneous touching
of both hands (with eyes closed), were rated as positive. Hemineglect
was defined as a difference of at least 2 letters between the
unaffected and the affected side in the letter cancellation
test18 or a significant (P<0.05) deviation
from the center in a line bisection test consisting of 10 lines of 10
cm, assessed by means of a Wilcoxon signed rank sum test.
Primary Outcome Measures
The subscales of the domains Personal Care and Occupation of the
Rehabilitation Activities Profile (RAP) were applied for the
measurement of activities.19 The RAP is an International
Classification of Impairments, Disabilities, and
Handicaps–based instrument (semistructured interview) to assess
disabilities and handicaps, consisting of 21 items in 5 domains. Each
of the items is subdivided into a number of subitems. Items and
subitems can be scored on a 4-point scale, ranging from 0 (performs
activity without difficulty) to 3 (does not perform activity). The
validity,20 reliability,21 and
responsiveness22 of the RAP in a subacute stroke
population have been established. The subitem scores of each of the
domains Personal Care19 and Occupation10 were
added, resulting in sum scores with a maximum of 57 and 30 points,
respectively.
Dexterity was assessed by means of the ARA test,14 23 which is an observational test consisting of 19 items focusing on grasping objects of different shapes and sizes, and gross movements in the vertical and horizontal planes. The performance of each motor task is rated on a 4-point scale, ranging from 0 (no movement possible) to 3 (movement performed normally).23 The scores on the individual items are added, yielding an overall sum score; the maximum obtainable sum score is 57 points. The validity and reliability of the ARA test have been found to be high in several studies.14 23
Secondary Outcome Measures
The upper extremity motor section of the Fugl-Meyer Assessment
(FMA) scale was applied to measure the ability to move the hemiparetic
arm outside the synergistic pattern (impairment level) on a 3-point
scale (maximum score, 66 points). The FMA scale has been found to be
valid,24 reliable,25 and responsive in the
first 6 months after stroke.26
Amount of use (AOU) and quality of movement (QOM) of the affected arm were assessed by means of the Motor Activity Log (MAL), a questionnaire evaluating 25 specific activities on a 6-point scale. This is an adapted version of the MAL used by Taub et al,5 which consisted of 14 items. The AOU scale ranges from 0 (never use the affected arm for this activity) to 5 (always use the affected arm for this activity), and the QOM scale also ranges from 0 (inability to use the affected arm for this activity) to 5 (ability to use the affected arm for this activity just as well as before the stroke). The sum of the ratings on the MAL was divided by the number of specified daily activities that the patient actually performed, resulting in a mean score per item. The patients also rated a Problem Score for the 3 most important activities they themselves selected from the MAL. These scores range from 0 (no problem) to 6 (a very big problem), and the maximum sum score is 18.
In the literature, no estimates were found of minimal clinically important differences (MCID) for any of the outcome measures used in this study. On the basis of clinical experience and estimates reported for similar outcome measures in different domains, the MCID was set at 10% of the total range of the scale.27 The MCID for the RAP is a difference between 3 (Occupation) or 6 (Personal Care) activities performed with or without difficulty. The MCID for the ARA test is 5.7 points, which reflects the difference between, for instance, not being able to grasp and lift 3 objects, and the ability to move 3 objects to a standardized (higher) level.
Statistical Analysis
The General Linear Models for Repeated Measures option in SPSS
8.0 for Windows 95 was used to analyze each outcome measure.
Separate analyses were performed for 4 different periods, ie,
(1) the baseline period (M1 and M2), (2) the treatment period (M2
through M5), (3) the short-term follow-up period (M5 and M6), and (4)
the long-term follow-up period (M5, M7, and M8). All patients for whom
data were available for all measurements within a specific period were
included in the analysis of that period. Analysis of
the baseline period was performed to allow for adjustment for
significant changes resulting from a possible learning effect due to
repeated testing or from a possible influence of the patient's
knowledge of treatment allocation. The other 3 periods were
analyzed separately to obtain insight into the course of the
treatment effect. An on-treatment analysis as well as an
intention-to-treat analysis was performed. The covariables
found to be statistically significant in the on-treatment
analysis (as explained below) were also included in the
intention-to-treat analysis.
At first, all associations with possible covariables were studied by means of univariate analysis of the treatment period (comprising M2 through M5). For each outcome measure, the first measurement (M1) was the first independent variable to be studied in the univariate analysis to control for baseline differences between groups. The other independent variables were as follows: (1) time since stroke; (2) presence or absence of sensory disorders; (3) side of the lesion; (4) presence or absence of hemineglect; (5) age; (6) sex; (7) diagnosis (infarction or hemorrhage); (8) FMA score at intake; and (9) ARA score at intake. The rationale for studying FMA and ARA intake scores as potential covariables was 2-fold: (1) the groups differed on these variables (although in the case of the ARA score, this was not significant at the 0.05 level) and (2) both parameters were regarded as important prognostic indicators. Only those independent variables for which the P values of the F tests between treatment conditions (to control for baseline differences) or change over time (within-subject effects) were <0.20 were selected as possible covariables in the definitive model. Covariables were retained in the model if the inclusion of the specific covariable changed the F test of treatment or if the F test of the covariable in the bivariate analysis (containing treatment) was significant (P<0.05). Subsequently, the interaction between treatment and the covariable was investigated. All covariables included in the model were taken into account in the analysis of the other 3 periods. If the repeated-measures analysis indicated a significant main or interaction effect, differential improvements between posttreatment and pretreatment (M5-M2) with 95% CIs were estimated by means of an ANCOVA, controlling for the same covariables as in the repeated-measures analysis. The level of statistical significance was set at 0.05.
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Results |
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Thirty-six men and 30 women were included in the study (median age, 61 years; range, 22 to 80 years). The median time since stroke onset was 3 years (range, 1 to 20 years). Some randomized patients could not accept the assigned treatment period because of home duties or transportation problems. This resulted in 21 aberrations from the randomization schedule (11 patients who should have received the experimental treatment, according to the randomization schedule, were allocated to the reference group, and 10 vice versa). Only a limited number of patients and treatment periods were available. Table 1
shows the intake characteristics in the
experimental and reference groups according to the randomization
schedule and according to the allocation. Statistically significant
differences at intake were found between both groups with regard to
time since stroke and intake FMA score.
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After randomization, before the start of the treatment, 2 patients
withdrew from the study because of changes in their personal
circumstances, and another 2 withdrew because of serious health
problems. Information about these 4 patients is included in Table 1
. In the reference group, 1 patient dropped out shortly after
treatment because of a second stroke, and 1 dropped out because of a
hip fracture. One patient in each treatment group could not be
contacted for the 1-year follow-up measurement. Consequently, data were
obtained from 60 of the 62 patients who had completed the treatment
period until 6 months after treatment. A complete data set (8
measurements) was obtained from 58 patients. A t test
revealed no significant difference in the time interval between intake
and the start of treatment between the intervention groups.
Multivariate analysis of each outcome measure
in the baseline period (M1 and M2) revealed no significantly different
changes over time between treatment groups, indicating the absence of a
learning effect, influence of a patient's knowledge of treatment
allocation, or spontaneous recovery.
Differences in Effectiveness
Table 2 shows means and SDs of all
outcome measures before and after treatment, at 3 weeks, 6 weeks, and 1
year after the start of the treatment period.
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Action Research Arm Test
The intake ARA score and the presence or absence of sensory
disorders were significant covariables. During the intervention
period, a significant main effect of treatment was found. The mean
difference in gain between the intervention groups was 3.0 points (95%
CI, 1.3 to 4.8) in favor of the experimental group, which is less than
the MCID of 5.7 points. An interaction effect between treatment and
sensory disorders was found, indicating a differential effect of
treatment in patients with and without sensory disorders:
F3,168=5.95, P=0.001 (Figure 1). The mean improvement in patients with
sensory disorders receiving forced use treatment (n=16) exceeded the
mean improvement in patients with sensory disorders who received the
bimanual training (n=11) by 6.7 points, which is in excess of the MCID.
Analysis of the short-term (M5 and M6) and long-term follow-up
periods (M5, M7, M8) revealed that the mean differences in gain between
groups remained during the 1-year follow-up period.
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Rehabilitation Activities Profile
The intake ARA score was found to be a significant covariable
for the domain Personal Care. No significant covariables were found
for the domain Occupation. Separate analyses of the treatment
period and the follow-up period revealed no statistically significant
differences between the 2 treatment conditions for the domains Personal
Care and Occupation. In addition, no significant within-subject effects
were found, indicating no significant change over time in either
group.
Fugl-Meyer Assessment Scale
The intake FMA score was a significant covariable. The
multivariate analysis revealed no significant
differences between the 2 treatment conditions or any within-subject
changes over time during any of the study periods, indicating no
treatment effect on this scale.
Motor Activity Log: Amount of Use Scale
The baseline MAL AOU score and the presence or absence of
hemineglect were significant covariables. During the treatment
period (M2 through M5), patients in the experimental group showed
significantly more improvement than patients in the reference group.
The mean difference in gain was 0.52 points (95% CI, 0.11 to 0.93),
which marginally exceeds the MCID of 0.50 points. Within both groups
the improvements exceeded the MCID. A significant interaction effect
between treatment and neglect was found, indicating a differential
effect of treatment in patients with and without hemineglect:
F3,165= 4.93, P=0.003 (Figure 2). Patients with hemineglect who
received forced use treatment (n=3) showed a mean improvement that
exceeded the mean improvement in patients with hemineglect who received
bimanual training (n=4) by 1.16 points, which exceeds the MCID. During
the short-term (M5 and M6) and long-term follow-up periods (M5, M7,
M8), no significantly different changes over time were found between
the treatment groups. However, a significant interaction effect between
treatment and hemineglect during both these periods indicates that the
differences in MAL AOU scores in favor of the forced use treatment
group were not maintained over the 1-year follow-up period.
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Motor Activity Log: Quality of Movement Scale
The baseline MAL QOM score and hemineglect were significant
covariables. During the treatment period (M2 through M5),
improvement did not differ significantly between the treatment
conditions. During the short-term (M5 and M6) and long-term follow-up
periods (M5, M7, M8), no significantly different changes over time were
found between the treatment groups.
Problem Score
No significant covariables were found for the Problem Score.
Analysis of the separate periods revealed no statistically
significant differences between the 2 treatment conditions or any
within-subject changes over time. Although a gradual decrease was
observed in the Problem Score during the entire study period in both
groups, this change did not reach the level of statistical significance
during any of the time periods.
Intention-to-Treat Analysis
This analysis revealed no statistically significant
treatment effects between the 2 groups.
Subjective Evaluation of the Treatments
With 1 exception, all patients in both groups expressed a very
positive opinion about the treatment. The most frequently appreciated
components of the treatment program were as follows: (1) intensity of
the treatment; (2) no waiting times; (3) therapist attention
(particularly important to patients who had not participated in a
rehabilitation program for a long time); and (4) interaction with
fellow patients and sharing of similar experiences. Although all
patients completed the 2-week treatment period, for most of them the
effort was strenuous. The reported adverse effects were second-degree
burns (1 patient in the experimental group during occupational therapy
and 1 patient in the reference group while ironing at home) and minor
skin lesions (1 patient in the reference group who tried to shave with
his affected hand at home). In 1 case a potentially harmful adverse
effect could be prevented when a patient reported using his affected
hypertonic hand to open the throttle of his scooter. All these adverse
effects were the result of imprudent actions of the patients or
overestimation of their own capabilities.
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Discussion |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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The present study showed a small but lasting effect of forced use therapy on the dexterity of the affected arm, as measured by means of the ARA test, in comparison to bimanual training. In patients with sensory disorders, this effect was clinically relevant. Furthermore, a positive effect was found on the subjective amount of use of the affected arm in ADL (measured by the MAL), especially in patients with hemineglect. However, this effect was no longer found during follow-up. The present study showed no significant effects of forced use therapy on the other ADL outcome measures (RAP and Problem Score) or on the impairment level (FMA score).
The positive effects found in the on-treatment analysis were not replicated in the intention-to-treat analysis. In the intention-to-treat analysis, groups were analyzed according to the randomization schedule. The rationale for an intention-to-treat analysis is to ignore protocol violations that have occurred after randomization.28 The protocol violations in the present study involved the randomization process itself, rendering the intention-to-treat-state to be completely virtual. However, the possibility that these violations of the randomization protocol may have had an effect on the distribution of prognostic determinants (variables that were measured as well as unknown variables) cannot be entirely precluded.
The differences in treatment effect, as measured by the ARA test in patients with sensory disorders and by the MAL AOU for patients with hemineglect, were not postulated in advance. However, it is plausible that patients with sensory disorders and hemineglect do not use the full motion potential of their hemiplegic arm and that their arm function may therefore be more amendable. These subgroup findings must be interpreted with caution because of a lack of power resulting from the small number of patients with hemineglect (n=7) included in the study. Future research should focus on the importance of sensory disorders and neglect as determinants of recovery of upper extremity function or dexterity after stroke.
The fact that the only notable improvement was found in patients with sensory disorders suggests that patients with no sensory disorders had already reached the upper limit of dexterity. These findings are intriguing, given the fact that the learned nonuse theory was originally developed in research on monkeys that had undergone deafferentation with no permanent motor impairment but only a severe sensory deficit.29 In the descriptions of earlier studies on constraint-induced movement therapy or forced use, the patients included were reported to have no severe sensory disorders,5 7 8 or no information was provided about the presence or absence of sensory disorders in the included patients.10 It is conceivable that forced use can result in improvement in patients with sensory disorders if they learn to compensate for the sensory deficits, for instance, by means of visual correction. Possibly, the forced use treatment has an effect on the awareness of sensory perception, which is claimed to be liable to treatment even in chronic patients.30 31 32 Sensory disorders were measured in a crude way in this study, and treatment was not explicitly aimed at ameliorating sensation. Future research should focus on clarifying this issue.
The domains of the RAP (activities) and the ARA (dexterity) differ.20 33 It might be hypothesized that the lack of a differential effect on the RAP, if not due to true ineffectiveness of forced use therapy, may be due to the inadequate responsiveness of this instrument when applied to a chronic stroke population. However, in a population within 6 months after stroke, the RAP was shown to be a more responsive measurement instrument than the Barthel Index.22
The FMA scale also failed to reveal any difference in effectiveness. This finding may be caused by a lack of responsiveness of the FMA scale in chronic stroke patients. Its responsiveness in the first 6 months after stroke has been established.26 The findings of this study are in accord with the clinical knowledge that improvement at impairment level in the chronic phase after stroke is unusual.34
The MAL measures the AOU and the QOM of the affected arm in ADL, as perceived by the patient. It should be noted that in both the experimental and the reference groups, mean improvement was statistically significant and greater than the MCID. In the opinion of the authors, this reflects the effect of cointervention or bimanual training; both groups received physical and occupational therapy. This may be an explanation for the greater differences found by Taub et al5 regarding this outcome measure, given the intervention contrast in their study. In addition, the patient ratings may have been influenced by their own ideas about the effect of treatment and by the expectations of the observer, as perceived by the patient. In general, the positive appreciation of the treatment by the patients may have influenced their assessment of their own behavior. Although the MAL has been claimed to measure "real-world arm use,"10 35 its validity has not been established, and it should be borne in mind that it is essentially a subjective measure.
The improvement in arm function a long time after stroke is an important finding of the present study, which contradicts the clinical concept that improvement in arm function is only possible within the first year after stroke. However, since the inclusion criteria were defined with the intention to select only those patients who were most likely to benefit from this treatment, the generalizability of these results is uncertain. The influence of sensory disorders and hemineglect on arm function and its apparent accessibility to treatment deserve further investigation.
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Acknowledgments |
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This study was supported by the Netherlands Organization for Scientific Research (NWO) Council for Medical and Health Research (project 904-65-045). Splints were provided by Kamer & Van Zaanen BV, Amsterdam. Recruitment of patients was made possible by the cooperation of the following rehabilitation centers: Revalidatie Centrum Amsterdam, Heliomare in Wijk aan Zee, De Hoogstraat in Utrecht, and De Trappenberg in Huizen. We wish to express our gratitude for the endurance, compliance, and loyalty of all the patients who were willing to participate in this trial. We also gratefully acknowledge the work of I. Burgers-Bots (physical therapist), E. Heckman, and A. Maasdam (occupational therapists), and M. Boerma and B. Hoeks (nurses), who applied the treatment protocol very professionally and with great enthusiasm. Furthermore, we would like to thank H. Beckerman, PT, PhD, for her comments on earlier versions of this manuscript.
Received May 4, 1999; revision received July 9, 1999; accepted August 2, 1999.
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I-P. Hsueh, M.-M. Lee, and C.-L. Hsieh The Action Research Arm Test: is it necessary for patients being tested to sit at a standardized table? Clinical Rehabilitation, April 1, 2002; 16(4): 382 - 388. [Abstract] [PDF]
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E. Panturin, S. J Page, P. Levine, S. A. Sisto, and M. V Johnston Mental Practice Physical Therapy, January 1, 2002; 82(1): 93 - 94. [Full Text]
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J. M Fritz and R. S Wainner Examining Diagnostic Tests: An Evidence-Based Perspective Physical Therapy, September 1, 2001; 81(9): 1546 - 1564. [Abstract] [Full Text] [PDF]
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M. Penta, L. Tesio, C. Arnould, A. Zancan, and J.-L. Thonnard The ABILHAND Questionnaire as a Measure of Manual Ability in Chronic Stroke Patients : Rasch-Based Validation and Relationship to Upper Limb Impairment Stroke, July 1, 2001; 32(7): 1627 - 1634. [Abstract] [Full Text] [PDF]
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J. H van der Lee, I. A. Snels, H. Beckerman, G. J Lankhorst, R. C Wagenaar, and L. M Bouter Exercise therapy for arm function in stroke patients: a systematic review of randomized controlled trials Clinical Rehabilitation, January 1, 2001; 15(1): 20 - 31. [Abstract] [PDF]
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F. d. N. A. P. Shelton and M. J. Reding Effect of Lesion Location on Upper Limb Motor Recovery After Stroke Stroke, January 1, 2001; 32(1): 107 - 112. [Abstract] [Full Text] [PDF]
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A. W. Dromerick, D. F. Edwards, and M. Hahn Does the Application of Constraint-Induced Movement Therapy During Acute Rehabilitation Reduce Arm Impairment After Ischemic Stroke? Stroke, December 1, 2000; 31(12): 2984 - 2988. [Abstract] [Full Text] [PDF]
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J. H van der Lee, H. Beckerman, G. J Lankhorst, L. M Bouter, S. Blanton, and S. L Wolf Constraint-Induced Movement Therapy Physical Therapy, July 1, 2000; 80(7): 711 - 713. [Full Text]
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E. Taub, G. Uswatte, J. H. van der Lee, G. J. Lankhorst, L. M. Bouter, and R. C. Wagenaar Constraint-Induced Movement Therapy and Massed Practice • Response Stroke, April 1, 2000; 31 (4): 983 - 991. [Full Text]
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