Forced use on arm function after stroke : clinically rated and self-reported outcome and measurement during the sub-acute phase

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.