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Forced use on arm function after stroke: clinically rated and self-reported outcome and measurement during the sub-acute phase
Örebro University, School of Health and Medical Sciences.
2010 (English)Doctoral thesis, comprehensive summary (Other academic)Alternative title
”Forced use” för armfunktion efter stroke : kliniskt bedömda och självrapporterade resultat samt mätmetoder i subakut fas (Swedish)
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. , p. 101
Series
Örebro Studies in Medicine, ISSN 1652-4063 ; 39
Keywords [en]
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: urn:nbn:se:oru:diva-9601ISBN: 978-91-7668-715-4 (print)OAI: oai:DiVA.org:oru-9601DiVA, id: diva2:292186
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: 2017-10-18Bibliographically approved
List of papers
1. Effects of forced use on arm function in the subacute phase after stroke: a randomized, clinical pilot study
Open this publication in new window or tab >>Effects of forced use on arm function in the subacute phase after stroke: a randomized, clinical pilot study
2009 (English)In: Physical Therapy, ISSN 0031-9023, E-ISSN 1538-6724, Vol. 89, no 6, p. 526-539Article 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
National Category
Physiotherapy
Research subject
Medicine
Identifiers
urn:nbn:se:oru:diva-7194 (URN)10.2522/ptj.20080017 (DOI)000266457500001 ()19372172 (PubMedID)2-s2.0-66749146212 (Scopus ID)
Available from: 2009-06-09 Created: 2009-06-09 Last updated: 2017-12-13Bibliographically approved
2. Is forced use of the paretic upper limb beneficial?: A randomized pilot study during subacute post-stroke recovery
Open this publication in new window or tab >>Is forced use of the paretic upper limb beneficial?: A randomized pilot study during subacute post-stroke recovery
2009 (English)In: Clinical Rehabilitation, ISSN 0269-2155, E-ISSN 1477-0873, Vol. 23, no 5, p. 424-433Article in journal (Refereed) Published
Abstract [en]

Objective: To evaluate the effect of two weeks of forced use of the paretic upper limb, as a supplement to the rehabilitation programme in the subacute phase after stroke, on self-rated use of that limb.

Design: A randomized, non-blind, parallel group, clinical, before-and-after trial. A forced use group and a conventional group were followed up one and three months after intervention.

Setting: In- and outpatient units of rehabilitation at a University Hospital.Subjects: Thirty patients were allocated to two groups, 15 in each, 1-6 months (mean 2.4) after stroke onset. Twenty-six patients completed the study.

Interventions: The patients of both groups participated in two weeks of daily training on weekdays. In addition, the forced use group wore a restraining sling on the non-paretic arm for up to 6 hours per weekday.

Main measure: The Motor Activity Log; patients scored 0-5 for 30 daily tasks concerning both amount of use and quality of movement.

Results: The forced use group tended to achieve larger improvements immediately post-intervention, but this was not clearly demonstrated. The small differences also levelled out up to the three-month follow-up, with both groups earning an approximately 1.0 score point on both scales of the Motor Activity Log.

Conclusions: This pilot study did not reveal any additional benefit of forced use on self-rated performance in daily use of the paretic upper limb. Both groups performed fairly extensive, active training with a similar duration, amount and content.

Place, publisher, year, edition, pages
London: Sage Publications, 2009
National Category
Physiotherapy
Research subject
Medicine
Identifiers
urn:nbn:se:oru:diva-7192 (URN)10.1177/0269215508101734 (DOI)000266292300005 ()19321522 (PubMedID)2-s2.0-65549124035 (Scopus ID)
Available from: 2009-06-09 Created: 2009-06-09 Last updated: 2017-12-13Bibliographically approved
3. Responsiveness and validity of the Motor Activity Log in patients during the subacute phase after stroke
Open this publication in new window or tab >>Responsiveness and validity of the Motor Activity Log in patients during the subacute phase after stroke
2010 (English)In: Disability and Rehabilitation, ISSN 0963-8288, E-ISSN 1464-5165, Vol. 32, no 14, p. 1184-1193Article in journal (Refereed) Published
Abstract [en]

Purpose: To investigate the responsiveness and cross-sectional and longitudinal validity of the Motor Activity Log (MAL) in the subacute phase after stroke.

Method: Data were collected pre-intervention, post-intervention, and at 3-month follow-up evaluations from 30 patients with stroke participating in a randomized trial of forced use. Assessments included MAL, the Fugl-Meyer test, the 16-hole peg test, grip strength, the Action Research Arm Test, and the Motor Assessment Scale. Measurements of responsiveness were effect size, standardized response mean (SRM), and responsiveness ratio (RR). Relationships between the MAL and the other measures were determined with Spearman correlations.

Results: The MAL is responsive to change, with effect size, SRM, and RR ›1.0 at the 3-month follow-up, and SRM and RR ›1.0 at post-intervention. Correlations at the separate test occasions between MAL and the other measures were mostly close to 0.50, which shows fair to moderate construct validity. Correlations between changes in MAL and in the other measures were weaker than cross-sectional relationships.

Conclusions: The MAL is a responsive measure of daily hand use in patients participating in rehabilitation in the subacute phase after stroke. Correlations of construct validity indicate that daily hand use may need to be measured separately from body function and activity capacity, in line with the underlying constructs of International Classification of Functioning, Disability and Health. To strengthen our findings, they should be repeated in larger samples of patients.

Place, publisher, year, edition, pages
London, United Kingdom: Informa Healthcare, 2010
Keywords
Stroke, motor activity log, upper limb
National Category
Physiotherapy Medical and Health Sciences
Research subject
Medicine
Identifiers
urn:nbn:se:oru:diva-9597 (URN)10.3109/09638280903437253 (DOI)000278592900007 ()20128630 (PubMedID)2-s2.0-77952932502 (Scopus ID)
Available from: 2010-02-04 Created: 2010-02-04 Last updated: 2018-04-19Bibliographically approved
4. Test-retest intra-rater reliability of grip force in patients with stroke
Open this publication in new window or tab >>Test-retest intra-rater reliability of grip force in patients with stroke
2003 (English)In: Journal of Rehabilitation Medicine, ISSN 1650-1977, E-ISSN 1651-2081, Vol. 35, no 4, p. 189-194Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: Coefficients of repeatability and reproducibility can be guides in differentiating between real changes and measurement error. The aim was to evaluate test-retest intra-rater reliability of a clinical procedure measuring grip force with Grippit in stroke patients, to assess relationship between grip force of the hands and between sustained and peak grip force. PATIENTS AND METHODS: Eighteen patients were tested using the Grippit at two occasions one hour apart. Each occasion comprised three consecutive trials per hand. RESULTS: The paretic hand needs to score a 50 N change within and between occasions to exceed the measurement error in 95% of the observations, irrespective of calculation method. Expressed by CV(within) the measurement error was 10%. There was no learning or fatigue effect during measuring. There was a wide variation between subjects but the mean ratio between sides was 0.66. The mean ratio between sustained and peak grip force was 0.80-0.84. CONCLUSION: The measurement errors were acceptable and the instrument can be recommended for the use in stroke patients at a department of rehabilitation medicine.

National Category
Physiotherapy Medical and Health Sciences
Research subject
Medicine
Identifiers
urn:nbn:se:oru:diva-7195 (URN)12892246 (PubMedID)
Available from: 2009-06-09 Created: 2009-06-09 Last updated: 2017-12-13Bibliographically approved

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