Yu-wei Hsieh

Responsiveness and Validity of Three Outcome Measures of Motor Function After Stroke Rehabilitation

Background and Purpose— This study investigated and compared the responsiveness and validity of the Fugl-Meyer Assessment (FMA), the Action Research Arm Test (ARAT), and the Wolf Motor Function Test (WMFT) for patients after stroke rehabilitation. Methods— A total of 57 patients with stroke received 1 of 3 rehabilitation treatments for 3 weeks. At pretreatment and posttreatment, the 3 outcome measures, as well as the Functional Independence Measure (FIM) as the external criterion, were administered. The standardized response mean (SRM) and the Wilcoxon signed rank test were used to examine the responsiveness. Construct validity and predictive validity were examined by the Spearman correlation coefficient (&rgr;). Results— The responsiveness of the FMA, ARAT, and WMFT functional ability scores was large (SRM=0.95–1.42), whereas the WMFT performance time score was small (SRM=0.38). The responsiveness of the FMA was significantly larger than those of the ARAT and the WMFT-TIME, but not the WMFT functional ability scores. With respect to construct validity, correlations between the FMA and other measures were relatively high (&rgr;=0.42–0.76). The FMA and the WMFT performance time scores at pretreatment had moderate predictive validity with the FIM scores at posttreatment (&rgr;=0.42–0.47). In addition, the ARAT and the WMFT functional ability scores revealed a low predictive validity with the FIM (&rgr;=0.17–0.26). Conclusions— The results support the FMA and the WMFT-FAS are suitable to detect changes over time for patients after stroke rehabilitation. While simultaneously considering the responsiveness and validity attributes, the FMA may be a relatively sound measure of motor function for stroke patients based on our results. Further research based on a larger sample is needed to replicate the findings.

Effects of robot-assisted upper limb rehabilitation on daily function and real-world arm activity in patients with chronic stroke: a randomized controlled trial

Objective: To compare the outcome of robot-assisted therapy with dose-matched active control therapy by using accelerometers to study functional recovery in chronic stroke patients. Design: Prospective, randomized, controlled trial. Setting: Stroke units in three medical centres. Subjects: Twenty patients post stroke for a mean of 22 months. Intervention: Robot-assisted therapy (n = 10) or dose-matched active control therapy (n = 10). All patients received either of these two therapies for 90–105 minutes each day, 5 days per week, for four weeks. Main measures: Outcome measures included arm activity ratio (the ratio of mean activity between the impaired and unimpaired arm) and scores on the Fugl-Meyer Assessment Scale, Functional Independence Measure, Motor Activity Log and ABILHAND questionnaire. Results: The robot-assisted therapy group significantly increased motor function, hemiplegic arm activity and bilateral arm coordination (Fugl-Meyer Assessment Scale: 51.20 ± 8.82, P = 0.002; mean arm activity ratio: 0.76 ± 0.10, P = 0.026; ABILHAND questionnaire: 1.24 ± 0.28, P = 0.043) compared with the dose-matched active control group (Fugl-Meyer Assessment Scale: 40.90 ± 13.14; mean arm movement ratio: 0.69 ± 0.11; ABILHAND questionnaire: 0.95 ± 0.43). Conclusions: Symmetrical and bilateral robotic practice, combined with functional task training, can significantly improve motor function, arm activity, and self-perceived bilateral arm ability in patients late after stroke.

Responsiveness and validity of three dexterous function measures in stroke rehabilitation

In this study, we compared the responsiveness and validity of the Box and Block Test (BBT), the Nine-Hole Peg Test (NHPT), and the Action Research Arm Test (ARAT). We randomized 59 patients with stroke into one of three rehabilitation treatments for 3 weeks. We administered six outcome measures (BBT, NHPT, ARAT, Fugl-Meyer Assessment [FMA], Motor Activity Log [MAL], and Stroke Impact Scale [SIS] hand function domain) pretreatment and posttreatment. We used the standardized response mean (SRM) to examine responsiveness and the Spearman rank correlation coefficient (rho) to examine concurrent validity. The BBT, NHPT, and ARAT were moderately responsive to change and not significantly different (SRM = 0.64-0.79). The correlations within the BBT, NHPT, and ARAT were moderate to good at pretreatment (rho = -0.55 to -0.80) and posttreatment (rho = -0.57 to -0.71). The BBT and ARAT showed fair to moderate correlations with the FMA, MAL, and SIS hand function domain at pretreatment and posttreatment (rho = 0.31-0.59), whereas the NHPT demonstrated low to fair correlations with the FMA and MAL (rho = -0.16 to -0.33) and moderate correlations with the SIS hand function domain (rho = -0.58 to -0.66). Our results indicate that the BBT, NHPT, and ARAT are suitable to detect changes over time. While simultaneously considering the responsiveness and validity attributes, the BBT and ARAT can be considered more appropriate for evaluating dexterous function than the NHPT. Further studies with larger samples are needed to validate these findings.

Effects of Treatment Intensity in Upper Limb Robot-Assisted Therapy for Chronic Stroke A Pilot Randomized Controlled Trial

Background and Objectives. Robot-assisted therapy (RT) is a current promising intervention in stroke rehabilitation, but more research is warranted for examining its efficacy and the dose–benefit relation. The authors investigated the effects of higher intensity versus lower intensity RT on movements of forearm pronation–supination and wrist flexion–extension relative to conventional rehabilitation (CR) in patients poststroke for a mean of 21 months. Methods. In this pilot study, 18 patients with initial mean Fugl-Meyer Assessment (FMA) of 37 to 44 for the upper extremity were randomized to higher intensity RT, lower intensity RT, or CR intervention for 4 weeks. The dose of the higher intensity RT was twice the number of repetitions in the lower intensity RT. Outcome measures at pretreatment and posttreatment were administered to patients to evaluate beneficial and adverse effects of interventions. Primary outcomes were the FMA and Medical Research Council scale. Results. There were significant differences in motor function (P = .04) and daily performance (P = .03) among the 3 groups. The higher intensity RT group showed better improvement in motor function, muscle strength, performance of daily activities, and bimanual ability than the other 2 groups. The intensive RT intervention did not induce higher levels of an oxidative DNA biomarker. Conclusions. Higher intensity of RT that assists forearm and wrist movements may lead to greater improvement in motor ability and functional performance in stroke patients. A sample size of only 20 to 25 in each arm of a larger randomized controlled trial is needed to confirm the findings for similar subjects.

Constraint-induced therapy versus control intervention in patients with stroke: A functional magnetic resonance imaging study

Lin K-C, Chung H-Y, Wu C-Y, Liu H-L, Hsieh Y-W, Chen I-H, Chen C-L, Chuang L-L, Liu J-S, Wai Y-Y: Constraint-induced therapy versus control intervention in patients with stroke: a functional magnetic resonance imaging study. Objective:This study compared the effects of a distributed form of constraint-induced therapy with control intervention in motor recovery and brain reorganization after stroke. Design:A two-group randomized controlled trial with pretreatment and posttreatment measures was conducted. Thirteen patients with stroke were randomly assigned to the distributed form of constraint-induced therapy (n = 5) or the control intervention group (n = 8). Outcome measures included the Fugl-Meyer Assessment, the Motor Activity Log, and functional magnetic resonance imaging examination. The number of activation voxels and laterality index were determined from the functional magnetic resonance imaging data for the study of brain reorganization. Results:The distributed form of constraint-induced therapy group exhibited significantly greater improvements in the Fugl-Meyer Assessment and Motor Activity Log than the control intervention group. The functional magnetic resonance imaging data showed that distributed form of constraint-induced therapy significantly increased activation in the contralesional hemisphere during movement of the affected and unaffected hand. The control intervention group showed a decrease in primary sensorimotor cortex activation of the ipsilesional hemisphere during movement of the affected hand. Conclusions:The preliminary findings indicate that brain adaptation may be modulated by specific rehabilitation practices, although generalization of the functional magnetic resonance imaging findings is limited by sample size. Further research is needed to identify the specific neural correlates of the behavioral gains achieved after rehabilitation therapies.

Dose–Response Relationship of Robot-Assisted Stroke Motor Rehabilitation The Impact of Initial Motor Status

Background and Purpose— The increasing availability of robot-assisted therapy (RT), which provides quantifiable, reproducible, interactive, and intensive practice, holds promise for stroke rehabilitation, but data on its dose–response relation are scanty. This study used 2 different intensities of RT to examine the treatment effects of RT and the effect on outcomes of the severity of initial motor deficits. Methods— Fifty-four patients with stroke were randomized to a 4-week intervention of higher-intensity RT, lower-intensity RT, or control treatment. The primary outcome, the Fugl-Meyer Assessment, was administered at baseline, midterm, and posttreatment. Secondary outcomes included the Medical Research Council scale, the Motor Activity Log, and the physical domains of the Stroke Impact Scale. Results— The higher-intensity RT group showed significantly greater improvements on the Fugl-Meyer Assessment than the lower-intensity RT and control treatment groups at midterm (P=0.003 and P=0.02) and at posttreatment (P=0.04 and P=0.02). Within-group gains on the secondary outcomes were significant, but the differences among the 3 groups did not reach significance. Recovery rates of the higher-intensity RT group were higher than those of the lower-intensity RT group, particularly on the Fugl-Meyer Assessment. Scatterplots with curve fitting showed that patients with moderate motor deficits gained more improvements than those with severe or mild deficits after the higher-intensity RT. Conclusions— This study demonstrated the higher treatment intensity provided by RT was associated with better motor outcome for patients with stroke, which may shape further stroke rehabilitation. Clinical Trial Registration— URL: http://clinicaltrials.gov. Unique identifier: NCT00917605.

Development and Validation of a Short Form of the Fugl-Meyer Motor Scale in Patients With Stroke

Background and Purpose— The 50-item Fugl-Meyer motor scale (FM) is commonly used in outcome studies. However, the lengthy administration time of the FM keeps it from being widely accepted for routine clinical use. We aimed to develop a short form of the FM (the S-FM) with sound psychometric properties for stroke patients. Methods— The FM was administered to 279 patients. It was then simplified based on expert opinions and the results of Rasch analysis. The psychometric properties (including Rasch reliability, concurrent validity, predictive validity, and responsiveness) of the S-FM were examined and were compared with those of the FM. The concurrent validity and responsiveness of the S-FM were further validated in a sample from the Netherlands. Results— We selected 6 items for each subscale to construct a 12-item S-FM. The S-FM demonstrated high Rasch reliability, high concurrent validity with the original scale, moderate responsiveness, and moderate predictive validity with the comprehensive activities of daily living function. The S-FM also showed sufficient concurrent validity and responsiveness on the Dutch sample. Conclusions— Our results provide strong evidence that the psychometric properties of the S-FM are comparable with those of the FM. The S-FM contains only 12 items, making it a very efficient measure for assessing the motor function of stroke patients in both clinical and research settings.

Potential Predictors of Motor and Functional Outcomes After Distributed Constraint-Induced Therapy for Patients With Stroke

Background. Selection of patients who are most and least likely to benefit from constraint-induced therapy (CIT) for the upper extremity is uncertain. Objective. This study investigated demographic and clinical characteristics that may predict outcomes for a distributed form of CIT. Methods. A group of 57 patients were treated with distributed CIT, and 7 potential predictors were identified, including age, sex, side of stroke, time since stroke, spasticity, neurologic status, and movement performance of the distal part of the upper extremity. Treatment outcome was assessed in terms of motor performance, perceived functional ability of the affected hand, and functional performance of daily activities, measured by Fugl-Meyer Assessment (FMA), Motor Activity Log (MAL), and Functional Independence Measure (FIM), respectively. Results. Motor ability of the distal part of the upper extremity and time since stroke were significantly predictive of outcomes on the FMA (adjusted R 2 = 0.18, P = .002) and the MAL subtest quality of movement (adjusted R 2 = 0.43, P < .0001). Motor ability and age were significant predictors of amount of use measured by the MAL (adjusted R 2 = 0.20, P = .001). None of the variables exhibited a predictive relationship with the FIM. Conclusions. The best predictor for motor outcomes after distributed CIT was greater motor ability of the distal part of the upper extremity, which is consistent with the presence of residual motor pathways that may respond to training. The FMA may be of value in stratifying patients for their likelihood to benefit from distributed CIT protocols.

Validity, Responsiveness, Minimal Detectable Change, and Minimal Clinically Important Change of the Pediatric Motor Activity Log in Children with Cerebral Palsy.

This study examined criterion-related validity and clinimetric properties of the Pediatric Motor Activity Log (PMAL) in children with cerebral palsy. Study participants were 41 children (age range: 28-113 months) and their parents. Criterion-related validity was evaluated by the associations between the PMAL and criterion measures at baseline and posttreatment, including the self-care, mobility, and cognition subscale, the total performance of the Functional Independence Measure in children (WeeFIM), and the grasping and visual-motor integration of the Peabody Developmental Motor Scales. Pearson correlation coefficients were calculated. Responsiveness was examined using the paired t test and the standardized response mean, the minimal detectable change was captured at the 90% confidence level, and the minimal clinically important change was estimated using anchor-based and distribution-based approaches. The PMAL-QOM showed fair concurrent validity at pretreatment and posttreatment and predictive validity, whereas the PMAL-AOU had fair concurrent validity at posttreatment only. The PMAL-AOU and PMAL-QOM were both markedly responsive to change after treatment. Improvement of at least 0.67 points on the PMAL-AOU and 0.66 points on the PMAL-QOM can be considered as a true change, not measurement error. A mean change has to exceed the range of 0.39-0.94 on the PMAL-AOU and the range of 0.38-0.74 on the PMAL-QOM to be regarded as clinically important change.

Predicting Clinically Significant Changes in Motor and Functional Outcomes After Robot-Assisted Stroke Rehabilitation

OBJECTIVE To investigate the predictors of minimal clinically important changes on outcome measures after robot-assisted therapy (RT). DESIGN Observational cohort study. SETTING Outpatient rehabilitation clinics. PARTICIPANTS A cohort of outpatients with stroke (N=55). INTERVENTIONS Patients with stroke received RT for 90 to 105min/d, 5d/wk, for 4 weeks. MAIN OUTCOME MEASURES Outcome measures, including the Fugl-Meyer Assessment (FMA) and Motor Activity Log (MAL), were measured before and after the intervention. Potential predictors include age, sex, side of lesion, time since stroke onset, finger extension, Box and Block Test (BBT) score, and FMA distal score. RESULTS Statistical analysis showed that the BBT score (odds ratio[OR]=1.06; P=.04) was a significant predictor of clinically important changes in the FMA. Being a woman (OR=3.9; P=.05) and BBT score (OR=1.07; P=.02) were the 2 significant predictors of clinically significant changes in the MAL amount of use subscale. The BBT score was the significant predictor of an increased probability of achieving clinically important changes in the MAL quality of movement subscale (OR=1.07; P=.02). The R(2) values for the 3 logistic regression models were low (.114-.272). CONCLUSIONS The results revealed that patients with stroke who had greater manual dexterity measured by the BBT appear to have a higher probability of achieving clinically significant motor and functional outcomes after RT. Further studies are needed to evaluate other potential predictors to improve the models and validate the findings.