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Effects of forced use on arm function in the subacute phase after stroke: a randomized, clinical pilot study
Örebro University, School of Health and Medical Sciences.
Uppsala Universitet.
2009 (English)In: Physical Therapy, ISSN 0031-9023, E-ISSN 1538-6724, Vol. 89, no 6, 526-539 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND AND OBJECTIVE: Following stroke, it is common to exhibit motor impairments and decreased use of the upper limb. The objective of the present study was to evaluate forced use on arm function during the subacute phase after stroke.

DESIGN: A comparison of standard rehabilitation only and standard rehabilitation together with a restraining sling was made through a randomized, nonblinded, clinical pilot trial with assessments before intervention, after intervention, and at 1- and 3-month follow-ups.

SETTING: The present study took place at the departments of rehabilitation medicine, geriatrics, and neurology at a university hospital.

PARTICIPANTS: A convenience sample of 30 people 1 to 6 months (mean, 2.4 mo) after stroke was randomized into 2 groups (forced-use group and standard training group) of 15 people each. Twenty-six participants completed the 3-month follow-up.

INTERVENTION: All participants received their standard rehabilitation program with training 5 days per week for 2 weeks as inpatients or outpatients. The forced-use group also wore a restraining sling on the nonparetic arm with a target of 6 hours per day.

MEASUREMENTS: The Fugl-Meyer (FM) test, the Action Research Arm Test, the Motor Assessment Scale (MAS) (sum of scores for the upper limb), a 16-hole peg test (16HPT), a grip strength ratio (paretic hand to nonparetic hand), and the Modified Ashworth Scale were used to obtain measurements. RESULTS: The changes in the forced-use group did not differ from the changes in the standard training group for any of the outcome measures. Both groups improved over time, with statistically significant changes in the FM test (mean score changed from 52 to 57), MAS (mean score changed from 10.1 to 12.4), 16HPT (mean time changed from >92 seconds to 60 seconds), and grip strength ratio (mean changed from 0.40 to 0.55).

LIMITATIONS: The limitations of this pilot study include an extended study time, a nonblinded assessor, a lack of control of treatment content, and a small sample size.

CONCLUSIONS: The results of the present pilot study did not support forced use as a reinforcement of standard rehabilitation in the subacute phase after stroke. Forced use did not generate greater improvements with regard to motor impairment and capacity than standard rehabilitation alone. The findings of this effectiveness study will be used to help design future clinical trials with the aim of revealing a definitive conclusion regarding the clinical implementation of forced use for upper-limb rehabilitation.

Place, publisher, year, edition, pages
Alexandria, VA.: American Physical Therapy Association , 2009. Vol. 89, no 6, 526-539 p.
National Category
Physiotherapy
Research subject
Medicine
Identifiers
URN: urn:nbn:se:oru:diva-7194DOI: 10.2522/ptj.20080017ISI: 000266457500001PubMedID: 19372172Scopus ID: 2-s2.0-66749146212OAI: oai:DiVA.org:oru-7194DiVA: diva2:222538
Available from: 2009-06-09 Created: 2009-06-09 Last updated: 2017-02-23Bibliographically approved
In thesis
1. Forced use on arm function after stroke: clinically rated and self-reported outcome and measurement during the sub-acute phase
Open this publication in new window or tab >>Forced use on arm function after stroke: clinically rated and self-reported outcome and measurement during the sub-acute phase
2010 (English)Doctoral thesis, comprehensive summary (Other academic)
Alternative title[sv]
”Forced use” för armfunktion efter stroke : kliniskt bedömda och självrapporterade resultat samt mätmetoder i subakut fas
Abstract [en]

The overall aim was to evaluate the effectiveness of forced use on arm and hand recovery after stroke by applying a restraining sling on the non-affected arm and to investigate psychometric properties of selected upper limb measures.

Papers I and II reported a randomised trial with 1- and 3-month follow-ups. Thirty patients 1 to 6 months after stroke were included and received regular training for 2 weeks of intervention. The forced-use group had in addition a restraining sling on the non-paretic arm. Outcome measures were the Fugl-Meyer Assessment, the Modified Ashworth scale, the 16-hole peg test, grip force, the Action Research Arm test, and the Motor Assessment Scale (Paper I), and the Motor Activity Log (MAL) (Paper II). Results in Papers I and II showed no statistical difference in change between groups. Both groups improved over time.

Paper III assessed the responsiveness of the MAL and its cross-sectional and longitudinal validity. The MAL was responsive to change, with Standardised Response Means and Responsiveness Ratios larger than 1.0. Correlations between the MAL and the other measures were mostly close to 0.50.

Paper IV investigated test–retest intra-rater reliability of measuring grip force with Grippit, and assessed relationships between grip forces of both hands, and between sustained and peak grip force. The paretic hand needs to score a change of 10% or 50 N to exceed the measurement error. The mean ratio between sides was 0.66, and between sustained and peak grip force, 0.80–0.84.

In conclusion, this thesis provides preliminary evidence that forced use does not generate greater improvement on upper limb motor impairment, capacity, and performance of activity than regular rehabilitation. The findings indicate that the MAL is a responsive measure of daily hand use in patients with stroke. Correlations of construct validity indicated that daily hand use might need to be measured separately from body function and activity capacity. The coefficients calculated for repeatability and reproducibility were acceptable, and the Grippit instrument can be recommended.

Place, publisher, year, edition, pages
Örebro: Örebro universitet, 2010. 101 p.
Series
Örebro Studies in Medicine, ISSN 1652-4063 ; 39
Keyword
stroke, upper limb, reliability, validity, ICF, forced use, motor function, effectiveness, rehabilitation, physiotherapy, grip force
National Category
Medical and Health Sciences
Research subject
Medicine
Identifiers
urn:nbn:se:oru:diva-9601 (URN)978-91-7668-715-4 (ISBN)
Public defence
2010-03-19, Wilandersalen, Universitetssjukhuset Örebro, M-huset, Örebro, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2010-02-09 Created: 2010-02-04 Last updated: 2013-05-16Bibliographically approved

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