title: Evaluation of the Quality of Prognosis Studies in Systematic Reviews Effect of Lesion Location on Upper Limb Motor Recovery After Stroke Ipsilateral Motor Responses to Focal Transcranial Magnetic Stimulation in Healthy Subjects and Acute-Stroke Patients Recovery of Motor Functions following Hemiparetic Stroke: A Clinical and Magnetic Resonance-Morphometric Study Probability of regaining dexterity in the flaccid upper limb: impact of severity of paresis and time since onset in acute stroke. Arm and leg paresis as outcome predictors in stroke rehabilitation. Inter-individual Variability in the Capacity for Motor Recovery After Ischemic Stroke Post-stroke reorganization of hand motor area: a 1-year prospective follow-up with focal transcranial magnetic stimulation Change of strength and rate of rise of tension relate to functional arm recovery after stroke. Comparison of TMS and DTT for predicting motor outcome in intracerebral hemorrhage Facilitation of motor evoked potentials in ischemic stroke patients: prognostic value and neurophysiologic correlations Prognostic value of motor evoked potentials in motor function recovery of upper limb after stroke. Publication bias in clinical research Comparison of the action research arm test and the Fugl-Meyer assessment as measures of upper-extremity motor weakness after stroke.
abstract: Prognosis studies are investigations of future events or the evaluation of associations between risk factors and health outcomes in population s of patients ( 1 ) . The results of such studies improve our underst and ing of the clinical course of a disease and assist clinicians in making informed decisions about how best to manage patients . Prognostic research also informs the design of intervention studies by helping define subgroups of patients who may benefit from a new treatment and by providing necessary information about the natural history of a disorder ( 2 ) . There has recently been a rapid increase in the use of systematic review methods to synthesize the evidence on research questions related to prognosis . It is essential that investigators conducting systematic review s thoroughly appraise the method ologic quality of included studies to be confident that a study 's design , conduct , analysis , and interpretation have adequately reduced the opportunity for bias ( 3 , 4 ) . Caution is warranted , however , because inclusion of method ologically weak studies can threaten the internal validity of a systematic review ( 4 ) . This follows abundant empirical evidence that inadequate attention to biases can cause invalid results and inferences ( 5 - 9 ) . However , there is limited consensus on how to appraise the quality of prognosis studies ( 1 ) . A useful framework to assess bias in such studies follows the basic principles of epidemiologic research ( 10 , 11 ) . We focus on 6 areas of potential bias : study participation , study attrition , prognostic factor measurement , confounding measurement and account , outcome measurement , and analysis . The main objectives of our review of review s are to describe methods used to assess the quality of prognosis studies and to describe how well current practice s assess potential biases . Our secondary objective is to develop recommendations to guide future quality appraisal , both within single studies of prognostic factors and within systematic review s of the evidence . We hope this work facilitates future discussion and research on biases in prognosis studies and systematic review s. Methods Literature Search and Study Selection We identified systematic review s of prognosis studies by search ing MEDLINE ( 1966 to October 2005 ) using the search strategy recommended by McKibbon and colleagues ( 12 ) . This strategy combines broad search terms for systematic review s ( systematic review .mp ; meta- analysis .mp ) and a sensitive search strategy for prognosis studies ( cohort , incidence , mortality , follow-up studies , prognos * , predict * , or course ) . We also search ed the reference lists of included review s and method ologic papers to identify other relevant publications . We restricted our search to English- language publications . One review er conducted the search and selected the studies . Systematic review s , defined as review s of published studies with a comprehensive search and systematic selection , were included if they assessed the method ologic quality of the included studies by using 1 or more explicit criteria . We excluded studies if they were meta-analyses of independent patient data only , if their primary goal was to investigate the effectiveness of an intervention or specific diagnostic or screening tests , or if they included studies that were not done on humans . Data Extraction and Synthesis Individual items included in the quality assessment of the systematic review s were recorded as they were reported in the publication ( that is , the information that would be available to readers and future review ers ) . We review ed journal Web sites and contacted the authors of the systematic review s for additional information when authors made such an offer in their original papers . When review s assessed different study design s by using different sets of quality items , we extracted only those items used to assess cohort studies . We constructed a comprehensive list of distinct items that the review s used to assess the quality of their included studies . The full text of each review was screened . All items used by the review authors to assess the quality of studies were extracted into a computerized spreadsheet by 1 review er . Two experienced review ers , a clinical epidemiologist and an epidemiologist , independently synthesized the quality items extracted from the prognosis review s to determine how well the systematic review s assessed potential biases . We did this in 3 steps : 1 ) identified distinct concepts or domains addressed by the quality items ; 2 ) grouped each extracted quality item into the appropriate domain or domains ; and 3 ) identified the domains necessary to assess potential biases in prognosis studies . We then used this information to assess how well the review s ' quality assessment included items from the domains necessary to assess potential biases . After completing each of the first 3 steps , the review ers met to attempt to reach a consensus . The consensus process involved each review er presenting his or her observations and results , followed by discussion and debate . A third review er was available in cases of persistent disagreement or uncertainty . In the first step , all domains addressed by the quality items were identified . The first review er iteratively and progressively defined the domains as items were extracted from the included review s. The second review er defined domains from a r and om list of all extracted quality items . Limited guidance was provided to the review ers so that their assessment s and definitions of domains would be independent . The review ers agreed on a final set of domains that adequately and completely defined all of the extracted items . In the second step , review ers independently grouped each extracted item into the appropriate domains . Review ers considered each extracted item by asking , What is each particular quality item addressing ? or What are the review 's authors getting at with the particular quality assessment item ? . Items were grouped into the domain or domains that best represented the concepts being addressed . For example , the extracted items at least 80 % of the group originally identified was located for follow-up and follow-up was sufficiently complete or does n't jeopardize validity were each independently classified by both review ers as assessing the domain completeness of follow-up adequate , whereas the extracted item quantification and description of all subjects lost to follow-up was classified as assessing the domain completeness of follow-up described . In the third step , we identified the domains necessary to assess potential biases . Each review er considered the ability of the identified domains to adequately address , at least in part , 1 of the following 6 potential biases : 1 ) study participation , 2 ) study attrition , 3 ) prognostic factor measurement , 4 ) confounding measurement and account , 5 ) outcome measurement , and 6 ) analysis . Domains were considered to adequately address part of the framework if information garnered from that domain would inform the assessment of potential bias . For example , both review ers judged that the identified domain study population represents source population or population of interest assessed potential bias in a prognosis study , whereas the domain research question definition did not , although the latter is an important consideration in assessing the inclusion of studies in a systematic review . Finally , on the basis of our previous ratings , we looked at whether each review included items from the domains necessary to assess the 6 potential biases . We calculated the frequency of systematic review s by assessing each potential bias and the number of review s that adequately assessed bias overall . From this systematic synthesis , we developed recommendations for improving quality appraisal in future systematic review s of prognosis studies . We used Microsoft Access and Excel 2002 ( Microsoft Corp. , Redmond , Washington ) for data management and SAS for Windows , version 9.1 ( SAS Institute , Inc. , Cary , North Carolina ) for descriptive statistics . Role of the Funding Sources The funding sources , the Canadian Institutes of Health Research , the Canadian Chiropractic Research Foundation , the Ontario Chiropractic Association , and the Ontario Ministry of Health and Long Term Care , did not have a role in the collection , analysis , or interpretation of the data or in the decision to su bmi t the manuscript for publication . Results We identified 1384 potentially relevant articles . Figure 1 shows a flow chart of studies that were included and excluded . Figure 2 shows the number of review s identified by year of publication . We excluded 131 systematic review s of prognosis studies that did not seem to include any quality assessment of the included studies ; this represented 44 % of prognosis review s. We included 163 review s of prognosis studies in our analysis ( 13 - 175 ) . The most common topics were cancer ( 15 % ) , musculoskeletal disorders and rheumatology ( 13 % ) , cardiovascular ( 10 % ) , neurology ( 10 % ) , and obstetrics ( 10 % ) . Other review s included a wide range of health and health care topics . Sixty-three percent of the review s investigated the association between a specific prognostic factor and a particular outcome ; the remainder investigated multiple prognostic factors or models . The number of primary studies included in each systematic review ranged from 3 to 167 ( median , 18 [ interquartile range , 12 to 31 ] ) . A complete description of the included review s is available from the authors on request . Figure 1 . Flow diagram of inclusion and exclusion criteria of systematic review s. Figure 2 . Number of systematic review s of prognosis studies identified over time . Quality Items One hundred fifty-three review s provided adequate detail to allow extraction of quality items . Eight hundred eighty-two distinct quality items were extracted from the review s. Most review s developed their own set of quality items , with only a few applying criteria from previous review s. Most quality items Background and Purpose — The purpose of this study was to assess the effects of stroke involvement of primary and secondary hemispheric motor systems and corticofugal tracts on arm and h and recovery . Methods — Forty-one patients participating in an inpatient stroke rehabilitation data base , admitted 17±2 ( SEM ) days after initial unilateral hemispheric ischemic stroke , with neuroimaging studies performed > 48 hours after stroke and with minimal upper limb ( UL ) movement ( admission Fugl-Meyer UL motor scores ≤9 ; normal score , 58 ) were studied . Patients were divided into 3 groups according to their UL discharge Fugl-Meyer score : 0 to 9 , no/poor recovery ; 10 to 18 , well-defined flexion-extension synergies ; and > 18 , synergies+isolated movements . Lesions affecting the following structures were recorded : primary motor cortex , premotor area , supplementary motor area , anterior half of the middle third of corona radiata ( secondary motor efferents ) , posterior half of the middle third of corona radiata ( primary motor efferents ) , genu , anterior and posterior limbs of the internal capsule ( PLIC ) , basal ganglia , and thalamus . & khgr;2 Analysis and ANOVA were used to study the significance of stroke location on UL motor recovery . Results — The effect of involvement of primary , premotor , or supplementary motor areas on motor recovery did not reach statistical significance . Patients with purely cortical stroke were likely to recover UL isolated movement ( 3 of 4 ) compared with purely subcortical ( 1 of 17 ) or mixed cortical-subcortical stroke location ( 2 of 20 ) ( P = 0.009 ) . Of those with cortical , subcortical , or mixed cortical plus subcortical lesions sparing the PLIC , 5 of 13 recovered isolated UL movement ( P = 0.01 ) . Only 1 of 28 patients with involvement of the PLIC plus adjacent corona radiata , basal ganglia , or thalamus recovered isolated UL movement ( P = 0.01 ) . Patients with small lacunar strokes affecting only the PLIC did not have sufficient motor deficits 2 weeks after stroke to meet inclusion criteria . Conclusions — The probability of recovery of isolated UL movement decreases progressively with lesion location as follows : cortex , corona radiata , and PLIC . This is consistent with our current underst and ing of redundant cortical motor representation and convergence of corticofugal motor efferents as they pass through the corona radiata to the PLIC Background and Purpose — Prevalence and characteristics of ipsilateral upper limb motor-evoked potentials ( MEPs ) elicited by focal transcranial magnetic stimulation ( TMS ) were compared in healthy subjects and patients with acute stroke . Methods — Sixteen healthy subjects and 25 patients with acute stroke underwent focal TMS at maximum stimulator output over motor and premotor cortices . If present , MEPs evoked in muscles ipsilateral to TMS were analyzed for latency , amplitude , shape , and center of gravity ( ie , preferential coil location to elicit them ) . In stroke patients , possible relationships between early ipsilateral responses and functional outcome at 6 months were sought . Results — With relaxed or slightly contracting target muscle , maximal TMS over the motor cortex failed to elicit ipsilateral MEPs in the first dorsal interosseous ( FDI ) or biceps of any of 16 normal subjects . In 5 of 8 healthy subjects tested , ipsilateral MEPs with latencies longer than contralateral MEPs were evoked in FDI muscle ( in biceps , 6 of 8 subjects ) during strong ( > 50 % maximum ) contraction of the target muscle . In 15 of 25 stroke patients , ipsilateral MEPs in the unaffected relaxed FDI ( in biceps , 6 of 25 stroke patients ) were evoked by stimulation of premotor areas of the affected hemisphere . Their latencies were shorter than those that MEPs evoked in the same muscle by stimulation of the motor cortex of the contralateral unaffected hemisphere . Such responses were never obtained in normal subjects and were mostly observed in patients with subcortical infa rcts . Patients harboring these responses had slightly better bimanual dexterity after 6 months . Conclusions — Ipsilateral MEPs obtained in healthy individuals and stroke patients have different characteristics and probably different origins . In the former , they are probably conveyed via corticoreticulospinal or corticopropriospinal pathways , whereas in the latter , early ipsilateral MEPs could originate in hyperexcitable premotor areas Predictors for the degree of clinical recovery after stroke are still poorly defined . In this study we tried to assess the predictive value of clinical data and of lesion size for motor recovery after ischemic stroke . In 52 hemiparetic patients we monitored the course of clinical recovery by a dedicated score of sensorimotor h and function after their first stroke . The course of the lesion size was measured in proton density magnetic resonance images . Three groups of patients were identified . Patients with moderate initial motor deficit recovered almost completely within 9 days ( 17/17 , group 1 ) . From the patients with severe initial motor deficit , about equal numbers recovered ( 16/35 , group 2 ) or remained severely impaired during the entire observation period of more than 6 months ( 19/35 , group 3 ) . There was no correlation between changes of lesion size and motor deficit . Logistic regression of probability of good clinical outcome on initial lesion size , initial motor score and subcortical versus cortical location of lesion showed that only the initial motor score was predictive ( p = 0.006 ) . A relative improvement of the initial motor score of about 20 % in the first 4 weeks after stroke appeared to be a relevant cut point for good outcome . The data indicate that patients with mild initial motor deficits recover well , whereas severely affected patients may differ in outcome . Since lesion size was not correlated with outcome the amount of spared residual function appeared as major determinant for the capacity for motor recovery BACKGROUND AND PURPOSE To improve the accuracy of early postonset prediction of motor recovery in the flaccid hemiplegic arm , the effects of change in motor function over time on the accuracy of prediction were evaluated , and a prediction model for the probability of regaining dexterity at 6 months was developed . METHODS In 102 stroke patients , dexterity and paresis were measured with the  Action Research Arm Test , Motricity Index , and Fugl-Meyer motor evaluation .  For model development , 23 c and i date determinants were selected . Logistic regression analysis was used for prognostic factors and model development . RESULTS At 6 months , some dexterity in the paretic arm was found in 38 % , and complete functional recovery was seen in 11.6 % of the patients . Total anterior circulation infa rcts , right hemisphere strokes , homonymous hemianopia , visual gaze deficit , visual inattention , and paresis were statistically significant related to a poor arm function . Motricity Index leg scores of at least 25 points in the first week and Fugl-Meyer arm scores of 11 points in the second week increasing to 19 points in the fourth week raised the probability of developing some dexterity ( Action Research Arm Test > or=10 points ) from 74 % ( positive predictive value [ PPV ] , 0.74 ; 95 % confidence interval [ CI ] , 0.63 to 0.86 ) to 94 % ( PPV , 0.83 ; 95 % CI , 0.76 to 0.91 ) at 6 months . No change in probabilities of prediction dexterity was found after 4 weeks . CONCLUSIONS Based on the Fugl-Meyer scores of the flaccid arm , optimal prediction of arm function outcome at 6 months can be made within 4 weeks after onset . Lack of voluntary motor control of the leg in the first week with no emergence of arm synergies at 4 weeks is associated with poor outcome at 6 months I used leg and arm paresis to predict outcome measured as extremity function in a prospect i ve study of 75 consecutive hemiplegic patients admitted to an inpatient stroke rehabilitation unit . In each patient , extremity paresis was quantified according to the five-point scoring system advised by the Medical Research Council , upper extremity function was quantified using the Barthel Index subscore for feeding and dressing the upper body , and lower extremity function was quantified according to a five-point scoring of the ability to walk . Improvement was recorded for upper extremity function in 52 % of the patients and for lower extremity function in 89 % . Best extremity function was reached a mean + /- SEM of 9 + /- 3 and 10 + /- 4 weeks after stroke for the upper and lower extremities , respectively . In patients experiencing complete recovery , this occurred a mean + /- SEM of 7 + /- 2 weeks ( for both upper and lower extremities ) after the stroke . Only 8 - 11 % of the patients with paresis scores of less than or equal to 2 regained independent extremity function after rehabilitation . Half of the patients with paresis scores of greater than or equal to 3 regained independent extremity function after rehabilitation , while the other half were able to perform extremity function with only minimal assistance . As predictors of extremity function , the Barthel Index subscore was slightly better ( r = 0.64 ) than paresis score ( r = 0.58 ) . However , because evaluation of extremity paresis is easy , it appears to be useful as a preliminary predictor of outcome following stroke Background . Motor recovery after stroke is predicted only moderately by clinical variables , implying that there is still a substantial amount of unexplained , biologically meaningful variability in recovery . Regression diagnostics can indicate whether this is associated simply with Gaussian error or instead with multiple sub population s that vary in their relationships to the clinical variables . Objective . To perform regression diagnostics on a linear model for recovery versus clinical predictors . Methods . Forty-one patients with ischemic stroke were studied . Impairment was assessed using the upper extremity Fugl-Meyer Motor Score . Motor recovery was defined as the change in the upper extremity Fugl-Meyer Motor Score from 24 to 72 hours after stroke to 3 or 6 months later . The clinical predictors in the model were age , gender , infa rct location ( subcortical vs cortical ) , diffusion weighted imaging infa rct volume , time to re assessment , and acute upper extremity Fugl-Meyer Motor Score . Regression diagnostics included a Kolmogorov-Smirnov test for Gaussian errors and a test for outliers using Studentized deleted residuals . Results . In the r and om sample , clinical variables explained only 47 % of the variance in recovery . Among the patients with the most severe initial impairment , there was a set of regression outliers who recovered very poorly . With the outliers removed , explained variance in recovery increased to 89 % , and recovery was well approximated by a proportional relationship with initial impairment ( recovery ≅ 0.70 × initial impairment ) . Conclusions . Clinical variables only moderately predict motor recovery . Regression diagnostics demonstrated the existence of a sub population of outliers with severe initial impairment who show little recovery . When these outliers were removed , clinical variables were good predictors of recovery among the remaining patients , showing a tight proportional relationship to initial impairment OBJECTIVE Focal transcranial magnetic stimulation was used to test prospect ively corticospinal excitability changes and reorganization of first dorsal interosseous ( FDI ) motor cortical representation in 31 patients who experienced a first ischemic stroke in the middle cerebral artery territory . All had severe h and palsy at onset . METHODS Patients were assessed clinical ly with the Medical Research Council , Rankin , the National Institutes of Health stroke scales and Barthel Index at days 1 , 8 , 30 , 90 , 180 and 360 after stroke . The following parameters of FDI  motor evoked potential ( MEPS ) to focal transcranial magnetic stimulation were measured at the same delays : motor threshold , MEP amplitude , excitable cortical area , hot spot and center of gravity of FDI motor maps on affected and unaffected hemispheres . Correlations were sought between clinical and electrophysiological parameters . RESULTS In patients whose affected motor cortex remained excitable at day 1 , motor thresholds were not significantly different between sides and were similar to those of controls . Persistence of MEP on the affected side at day 1 was a strong predictor of good recovery . If present at day 1 , MEPs recorded in affected FDI were significantly smaller than of the opposite side or in normals and progressively recovered up to day 360 . In these patients , area of excitable cortex remained stable throughout the entire study . At day 1 , amplitudes of MEPs obtained in unaffected FDI were significantly larger than later . Between days 1 and 360 , we observed a significant displacement of center of gravity of motor maps towards more frontal regions on the affected side while no change was noted on the unaffected side . CONCLUSIONS Our data confirm the early prognosis value of transcranial magnetic stimulation in stroke . They indicate that the brain insult induces a transient hyperexcitability of the unaffected motor cortex . The evolution of FDI motor maps along the course of recovery mostly reflect corticospinal excitability changes but might also reveal some degree of brain plasticity . Most modifications observed occurred within 3 months of stroke onset OBJECTIVE To examine the relationship between individual strength parameters and functional motor ability over time during rehabilitation in stroke patients . DESIGN A multiple-baseline experiment with assessment at inclusion and after 3 and 6 weeks . SETTING Secondary -care rehabilitation center . PARTICIPANTS A convenience sample of 16 subacute stroke patients . INTERVENTIONS Not applicable . MAIN OUTCOME MEASURES Maximal voluntary force and rate of rise of tension of h and grip , wrist extension , and elbow flexion and extension were recorded at all 3 times . At the same time , functional motor assessment s were evaluated by the  Action Research Arm Test ( ARAT ) , Box and Block test , and Rivermead Test . RESULTS We found no correlation between maximal voluntary force increases of various muscle contractions measurements . Neither the increase of grip strength nor that of wrist extension force correlated with improvement in ARAT score . Yet the improvement in the rate of rise of tension of h and grip ( Spearman rho=.91 ) and of wrist extension ( Spearman rho=.73 ) correlated with the improvement of the ARAT score and explained 77 % of the variance of the ARAT . CONCLUSIONS The change in the rate of rise of tension of the h and grip has a better predictive value for the functional recovery compared to the change in maximal voluntary force in patients with moderate arm and h and weakness after stroke . The rate of rise of tension of h and grip seems an adequate quantifiable parameter to detect small improvements during functional recovery BACKGROUND TMS ( transcranial magnetic stimulation ) and DTT ( diffusion tensor tractography ) have different advantages in evaluating stroke patients . TMS has good clinical accessibility and economical benefit . On the contrary , DTT has a unique advantage to visualize neural tracts three-dimensionally although it requires an expensive and large MRI machine . Many studies have demonstrated that TMS and DTT have predictive values for motor outcome in stroke patients . However , there has been no study on the comparison of these two evaluation tools . In the current study , we compared the abilities of TMS and DTT to predict upper motor outcome in patients with ICH ( intracerebral hemorrhage ) . METHODS Fifty-three consecutive patients with severe motor weakness  were evaluated by TMS and DTT at the early stage ( 7 - 28 days ) of ICH . Modified Brunnstrom classification ( MBC ) and the motricity index of upper extremity ( UMI ) were evaluated at onset and 6 months after onset . RESULTS Patients with the presence of a motor evoked potential ( MEP ) in TMS or a preserved corticospinal tract ( CST ) in DTT showed better motor outcomes than those without ( p=0.000 ) . TMS showed higher positive predictive value than DTT . In contrast , DTT showed higher negative predictive value than TMS . CONCLUSIONS TMS and DTT had different advantages in predicting motor outcome , and this result could be a reference to predict final neurological deficit at the early stage of ICH OBJECTIVE To investigate the predictive value of paired transcranial magnetic stimulation ( TMS ) at rest in stroke patients in comparison with the predictive value derived from data obtained by single TMS during facilitation . METHODS Fifty-six patients with a single ischemic lesion and no electromyographic responses from single TMS in the resting affected h and muscles participated in the study . TMS assessment was performed 32 days post-stroke . It consisted of a single stimulation at maximal output during facilitation ( controlateral h and grip and elbow flexion ) and a paired-pulse stimulation at rest with two stimuli at maximal output at interstimulus intervals ranging from 15 to 100 ms . Two blind clinical assessment s using the ' motricity index ' were carried out 26 and 76 days post-stroke . RESULTS Thirty-seven percent of patients were responsive to single TMS during facilitation , had better clinical scores at both evaluations and better clinical recovery . Fifty-four percent of patients responded to paired TMS , had better clinical scores at the second evaluation and better clinical recovery . All patients who responded to the single stimulation paradigm also responded to the paired one . CONCLUSIONS A positive correlation was found between the responsiveness to both the TMS paradigms ( facilitation procedure and paired stimulation ) and clinical recovery . This underlines the importance of facilitation during single TMS in stroke patients and suggests that paired TMS at rest might supplement this procedure in stroke studies OBJECTIVE To determine the prognostic value of clinical assessment and motor evoked potentials for upper limb strength and functional recovery after acute stroke , and to establish the possible use of motor evoked potentials in rehabilitation . DESIGN A prospect i ve study . SUBJECTS Fifty-two patients with hemiparesis were enrolled one month post-stroke ; 38 patients concluded the study at 12 months . METHODS Motor evoked potentials were recorded at baseline and after one month .  Upper limb muscular strength ( Medical Research Council Scale , MRC ) and functional tests ( Frenchay Arm Test , Barthel Index ) were used as dependent outcome variables 12 months later . Motor evoked potentials were classified as present or absent . Predictive values of motor evoked potentials and MRC were evaluated . RESULTS At 12 months , patients with baseline recordable motor evoked potentials showed a good functional recovery ( positive predictive value 94 % ) . The absence of motor evoked potentials did not exclude muscular strength recovery ( negative predictive value 95 % ) . Motor evoked potentials had a higher positive predictive value than MRC only in patients with MRC < 2 . CONCLUSION Motor evoked potentials could be a supportive tool to increase the prognostic accuracy of upper limb motor and functional outcome in hemiparetic patients , especially those with severe initial paresis ( MRC < 2 ) and /or with motor evoked potentials absent in the post-stroke acute phase In a retrospective survey , 487 research projects approved by the Central Oxford Research Ethics Committee between 1984 and 1987 , were studied for evidence of publication bias . As of May , 1990 , 285 of the studies had been analysed by the investigators , and 52 % of these had been published . Studies with statistically significant results were more likely to be published than those finding no difference between the study groups ( adjusted odds ratio [ OR ] 2.32 ; 95 % confidence interval [ Cl ] 1.25 - 4.28 ) . Studies with significant results were also more likely to lead to a greater number of publications and presentations and to be published in journals with a high citation impact factor . An increased likelihood of publication was also associated with a high rating by the investigator of the importance of the study results , and with increasing sample size . The tendency towards publication bias was greater with observational and laboratory-based experimental studies ( OR = 3.79 ; 95 % Cl = 1.47 - 9.76 ) than with r and omised clinical trials ( OR = 0.84 ; 95 % Cl = 0.34 - 2.09 ) . We have confirmed the presence of publication bias in a cohort of clinical research studies . These findings suggest that conclusions based only on a review of published data should be interpreted cautiously , especially for observational studies . Improved strategies are needed to identify the results of unpublished as well as published studies OBJECTIVE To assess the relative responsiveness of 2 commonly used upper-extremity motor scales , the Action Research Arm Test ( ARAT ) and the Fugl-Meyer Assessment ( FMA ) , in evaluating recovery of upper-extremity function after an acute stroke in patients undergoing inpatient rehabilitation . DESIGN Prospect i ve . SETTING An acute stroke rehabilitation unit . PARTICIPANTS One hundred four consecutive admissions ( 43 men , 61 women ; mean age + /- st and ard deviation , 72+/-13y ) to a rehabilitation unit 16+/-9 days after acute stroke . INTERVENTIONS Not applicable . MAIN OUTCOME MEASURES The following assessment s were completed within 72 hours of admission and 24 hours before discharge :  ARAT , upper-extremity motor domain of the FMA , National Institutes of Health Stroke Scale , FIM instrument total score , and FIM activities of daily living ( FIM-ADL ) subscore .  RESULTS The Spearman rank correlation statistic indicated that the 2 upper-limb motor scales ( ARAT , FMA ) correlated highly with one another , both on admission ( rho = .77 , P < .001 ) and on discharge ( rho = .87 , P < .001 ) . The mean change in score from admission to discharge was 10+/-15 for the ARAT and 10+/-13 for the FMA motor score . The responsiveness to change as measured by the st and ard response mean was .68 for the ARAT and .74 for the FMA motor score . The Spearman rank correlation of each upper-limb motor scale with the FIM-ADL at the time of admission was as follows : ARAT , rho equal to .32 ( P < .001 ) and FMA motor score , rho equal to .54 ( P < .001 ) . CONCLUSIONS Both the FMA motor score and the ARAT were equally sensitive to change during inpatient acute rehabilitation and could be routinely used to measure recovery of upper-extremity motor function
target: The most important predictive factors for upper limb recovery following stroke appears to the initial severity of motor impairment or function
background: Objective : To systematic ally review and summarize the current available literature on prognostic variables relating to upper limb recovery following stroke .
  To identify which , if any variables predict upper limb recovery following stroke .