title: Effect of constraint-induced movement therapy on upper extremity function 3 to 9 months after stroke: the EXCITE randomized clinical trial. Repetitive bilateral arm training and motor cortex activation in chronic stroke: a randomized controlled trial. Balance training following stroke: effects of task-oriented exercises with and without altered sensory input Little therapy, little physical activity: rehabilitation within the first 14 days of organized stroke unit care. Inactive and Alone: Physical Activity Within the First 14 Days of Acute Stroke Unit Care Short-Term Effects of Practice With Trunk Restraint on Reaching Movements in Patients With Chronic Stroke: A Controlled Trial Team functioning and patient outcomes in stroke rehabilitation. Effects of Task Goal and Personal Preference on Seated Reaching Kinematics After Stroke A task-orientated intervention enhances walking distance and speed in the first year post stroke: a randomized controlled trial Task-Specific Training With Trunk Restraint on Arm Recovery in Stroke: Randomized Control Trial Systematic reviews of the effectiveness of quality improvement strategies and programmes The effect of a task-oriented walking intervention on improving balance self-efficacy poststroke: a randomized, controlled trial. Modified Constraint-Induced Therapy in Patients With Chronic Stroke Exhibiting Minimal Movement Ability in the Affected Arm Motor and Functional Recovery After Stroke: A Comparison of 4 European Rehabilitation Centers Exercise leads to faster postural reflexes, improved balance and mobility, and fewer falls in older persons with chronic stroke. Use of Time by Stroke Patients: A Comparison of Four European Rehabilitation Centers Mental Practice in Chronic Stroke: Results of a Randomized, Placebo-Controlled Trial Additional task-related practice improves mobility and upper limb function early after stroke: a randomised controlled trial. Contribution of the shaping and restraint components of Constraint-Induced Movement therapy to treatment outcome. Task-related training improves performance of seated reaching tasks after stroke. A randomized controlled trial. Task-related circuit training improves performance of locomotor tasks in chronic stroke: a randomized, controlled pilot trial. A randomized controlled comparison of upper-extremity rehabilitation strategies in acute stroke: A pilot study of immediate and long-term outcomes. The Delphi list: a criteria list for quality assessment of randomized clinical trials for conducting systematic reviews developed by Delphi consensus. The effectiveness of body weight-supported gait training and floor walking in patients with chronic stroke. Training symmetry of weight distribution after stroke: a randomized controlled pilot study comparing task-related reach, Bo bath and feedback training approaches The Role of Technology in Task-Oriented Training in Persons with Subacute Stroke: A Randomized Controlled Trial The influence of early cycling training on balance in stroke patients at the subacute stage. Results of a preliminary trial Effects of passive-active movement training on upper limb motor function and cortical activation in chronic patients with stroke: a pilot study. A randomized controlled trial of modified constraint-induced movement therapy for elderly stroke survivors: changes in motor impairment, daily functioning, and quality of life. Neurodevelopmental treatment after stroke: a comparative study Walking training of patients with hemiparesis at an early stage after stroke: a comparison of walking training on a treadmill with body weight support and walking training on the ground Rehabilitation of reaching after stroke: task-related training versus progressive resistive exercise. Lateral weight transference exercises following acute stroke: a preliminary study of clinical effectiveness A community-based fitness and mobility exercise program for older adults with chronic stroke: a randomized, controlled trial. Symmetrical body-weight distribution training in stroke patients and its effect on fall prevention. Gait outcome following outpatient physiotherapy based on the Bobath concept in people post stroke Effects of a range-of-motion exercise programme. Stroke patients and long-term training: is it worthwhile? A randomized comparison of two different training strategies after rehabilitation Effects of perceptual learning exercises on standing balance using a hardness discrimination task in hemiplegic patients following stroke: a randomized controlled pilot trial The effect of early aerobic training on independence six months post stroke A community-based upper-extremity group exercise program improves motor function and performance of functional activities in chronic stroke: a randomized controlled trial. Sitting training early after stroke improves sitting ability and quality and carries over to standing up but not to walking: a randomised trial. The effect of independent practice of motor tasks by stroke patients: a pilot randomized controlled trial Task-oriented progressive resistance strength training improves muscle strength and functional performance in individuals with stroke
abstract: CONTEXT Single-site studies suggest that a 2-week program of constraint-induced movement therapy ( CIMT ) for patients more than 1 year after stroke who maintain some h and and wrist movement can improve upper extremity function that persists for at least 1 year . OBJECTIVE To compare the effects of a 2-week multisite program of CIMT vs usual and customary care on improvement in upper extremity function among patients who had a first stroke within the previous 3 to 9 months . DESIGN AND SETTING The Extremity Constraint Induced Therapy Evaluation ( EXCITE ) trial , a prospect i ve , single-blind , r and omized , multisite clinical trial conducted at 7 US academic institutions between January 2001 and January 2003 . PARTICIPANTS Two hundred twenty-two individuals with predominantly ischemic stroke . INTERVENTIONS Participants were assigned to receive either CIMT ( n = 106 ; wearing a restraining mitt on the less-affected h and while engaging in repetitive task practice and behavioral shaping with the hemiplegic h and ) or usual and customary care ( n = 116 ; ranging from no treatment after concluding formal rehabilitation to pharmacologic or physiotherapeutic interventions ) ; patients were stratified by sex , prestroke dominant side , side of stroke , and level of paretic arm function . MAIN OUTCOME MEASURES The Wolf Motor Function Test ( WMFT ) , a measure of laboratory time and strength-based ability and quality of movement ( functional ability ) , and the Motor Activity Log ( MAL ) , a measure of how well and how often 30 common daily activities are performed . RESULTS From baseline to 12 months , the CIMT group showed greater improvements than the control group in both the WMFT Performance Time ( decrease in mean time from 19.3 seconds to 9.3 seconds [ 52 % reduction ] vs from 24.0 seconds to 17.7 seconds [ 26 % reduction ] ; between-group difference , 34 % [ 95 % confidence interval { CI } , 12%-51 % ] ; P<.001 ) and in the MAL Amount of Use ( on a 0 - 5 scale , increase from 1.21 to 2.13 vs from 1.15 to 1.65 ; between-group difference , 0.43 [ 95 % CI , 0.05 - 0.80 ] ; P<.001 ) and MAL Quality of Movement ( on a 0 - 5 scale , increase from 1.26 to 2.23 vs 1.18 to 1.66 ; between-group difference , 0.48 [ 95 % CI , 0.13 - 0.84 ] ; P<.001 ) . The CIMT group achieved a decrease of 19.5 in self-perceived h and function difficulty ( Stroke Impact Scale h and domain ) vs a decrease of 10.1 for the control group ( between-group difference , 9.42 [ 95 % CI , 0.27 - 18.57 ] ; P=.05 ) . CONCLUSION Among patients who had a stroke within the previous 3 to 9 months , CIMT produced statistically significant and clinical ly relevant improvements in arm motor function that persisted for at least 1 year . Trial Registration clinical trials.gov Identifier : NCT00057018 CONTEXT Reorganization in central motor networks occurs during early recovery from hemiparetic stroke . In chronic stroke survivors , specific rehabilitation therapy can improve upper extremity function . OBJECTIVE To test the hypothesis that in patients who have chronic motor impairment following stroke , specific rehabilitation therapy that improves arm function is associated with reorganization of cortical networks . DESIGN , SETTING , AND PATIENTS A r and omized controlled clinical trial conducted in a US ambulatory rehabilitation program with 21 patients ( median [ IQR ] , 50.3 [ 34.8 - 77.3 ] months after unilateral stroke ) . Data were collected between 2001 and 2004 . INTERVENTIONS Patients were r and omly assigned to bilateral arm training with rhythmic auditory cueing ( BATRAC ) ( n = 9 ) or st and ardized dose-matched therapeutic exercises ( DMTE ) ( n = 12 ) . Both were conducted for 1 hour , 3 times a week , for 6 weeks . MAIN OUTCOME MEASURES Within 2 weeks before and after the intervention , brain activation during elbow movement assessed by functional magnetic resonance imaging ( fMRI ) and functional outcome assessed using arm function scores . RESULTS Patients in the BATRAC group but not in the DMTE group increased hemispheric activation during paretic arm movement ( P = .03 ) . Changes in activation were observed in the contralesional cerebrum and ipsilesional cerebellum ( P = .009 ) . BATRAC was associated with significant increases in activation in pre central ( P<.001 ) and post central gyri ( P = .03 ) and the cerebellum ( P<.001 ) , although 3 BATRAC patients showed no fMRI changes . Considering all patients , there were no differences in functional outcome between groups . When only BATRAC patients with fMRI response were included ( n = 6 ) , BATRAC improved arm function more than DMTE did ( P = .02 ) . CONCLUSIONS These preliminary findings suggest that BATRAC induces reorganization in contralesional motor networks and provide biological plausibility for repetitive bilateral training as a potential therapy for upper extremity rehabilitation in hemiparetic stroke The purpose of this study was to compare the effects of a task-oriented exercise program with and without altered sensory input on postural stability in subjects with stroke . Sixteen hemiparetic subjects , at least 6 months post-stroke , were r and omly assigned to the experimental or control group , and participated in an 8-week task-oriented exercise program focusing on balance and mobility exercises . Exercises were performed under normal conditions by the control group , and under conditions of vision and surface manipulation by the experimental group . Pre- and post-test assessment s involved the measurement of the center of pressure ( COP ) displacement during double-legged stance and sit-to-st and under four sensory conditions : ( 1 ) eyes open , normal surface ; ( 2 ) eyes open , soft surface ; ( 3 ) eyes closed , normal surface ; and ( 4 ) eyes closed , soft surface , as well as the 10-m walking test . Results showed significant improvements ( P<0.05 ) in COP displacement under sensory conditions ( 1 ) and ( 2 ) for the experimental group only , and limited changes for the sit-to-st and in both groups after training . Significant improvements ( P<0.05 ) were also found in both groups for the walking test . It is concluded that a task-oriented exercise program , assisted by sensory manipulation , is more effective at improving the st and ing balance of stroke subjects than a conventional task-oriented program . Die vorliegende Studie vergleicht die Wirkung eines anforderungsspezifischen Übungsprogramms mit und ohne Sinnesreizänderung auf die posturale Stabilität von Schlaganfallpatienten . Insgesamt 16 Hemiparetiker wurden mindestens sechs Monate nach dem Schlaganfall r and omisiert der Versuchs- oder der Kontrollgruppe zugeordnet , innerhalb derer sie acht Wochen an einem anforderungsspezifischen Programm mit speziellen Gleichgewichts- und Mobilitätsübungen teilnahmen . Die Kontrollgruppe führte die Übungen unter normalen Bedingungen durch , die Versuchsgruppe dagegen unter Manipulation der Aspekte Sicht und Gehflächen . Bei den Bewertungen vor und nach dem Test wurde die Verlagerung des Druckmittelpunkts ( COP ) während der zweibeinigen Haltung und der Aufstehübung anh and von vier Sinneszuständen gemessen : ( 1 ) offene Augen , normale Fläche , ( 2 ) offene Augen , weiche Fläche , ( 3 ) geschlossene Augen , normale Fläche und ( 4 ) geschlossene Augen , weiche Fläche sowie anh and des 10 m Gehtests . Die Ergebnisse wiesen nur bei der Versuchsgruppe bei der COP-Verlagerung unter den Sinneszuständen ( 1 ) und ( 2 ) beachtliche Verbesserungen ( P<0,05 ) auf und bei beiden Gruppen in beschränktem Maß Veränderungen bei der Aufstehübung . Bei beiden Gruppen wurden auch signifikante Verbesserungen ( P<0,05 ) beim Gehtest beobachtet . Daraus schließt sich , dass ein anforderungsspezifisches Übungsprogramm mit begleitender Sinnesmanipulation das Gleichgewicht von Schlaganfallpatienten bei aufrechter Körperhaltung effektiver verbessert als ein herkömmliches anforderungsspezifisches Programm . El propósito de este estudio fue comparar los efectos de un programa de ejercicios dirigidos , con estimulación sensorial alterada o sin ella , sobre la estabilidad postural de sujetos con accidente vascular cerebral . Dieciséis sujetos hemiparéticos que habían sufrido un accidente vascular cerebral hacía al menos 6 meses , fueron distribuidos al azar en dos grupos : uno experimental y uno control . Los mismos participaron durante 8 semanas en un programa de ejercicios dirigidos , el cual se centraba en ejercicios de balance y de movilidad . El grupo control realizó los ejercicios en condiciones normales , mientras que el grupo experimental los realizó en condiciones en que la visión y las superficies fueron alteradas . En las evaluaciones realizadas antes y después de los ejercicios se midió la desviación del centro de presión ( CP ) durante la postura de pie utiliz and o ambas piernas , así como en la postura sentada , listo para ponerse de pie , bajo cuatro condiciones sensoriales deferentes : 1 ) ojos abiertos , superficie normal ;  2  ) ojos abiertos , superficie bl and a ;  3  ) ojos cerrados , superficie normal ;  y  4 ) ojos cerrados , superficie bl and a. Se realizó además la prueba de la marcha de los 10 m. Los result ados mostraron mejoras significativas ( P<0,05 ) en la desviación del CP en ambos grupos durante la prueba de la marcha . Se concluyó que un programa de ejercicios dirigidos , en los que se utilicen manipulaciones sensoriales , es más efectivo que un programa convencional de ejercicios dirigidos para mejorar el balance durante la postura de pie en sujetos con accidente vascular cerebral . Le but de cette étude était de comparer les effets d'un programme d'exercices fonctionnels assistés ou non de stimulations sensorielles sur la stabilité posturale de sujets atteints d'un accident vasculaire cérébral ( AVC ) . Seize sujets hémiparétiques atteints d'un AVC depuis au moins 6 mois et répartis de façon aléatoire au sein du groupe expérimental et du groupe témoin ont participé à un programme d'exercices fonctionnels de huit semaines portant sur des exercices d'équilibre et de mobilité . Les exercices étaient exécutés en situation normale par le groupe témoin et en situation de manipulation de la vision et de la surface de support par le groupe expérimental . Les évaluations pré et post exercices ont été effectuées à l'aide de la mesure du déplacement du centre de pression ( CP ) lors du maintien de la position debout en appui bipodal et du transfert assis-debout selon les quatre conditions sensorielles suivantes : yeux ouverts , surface normale ( 1 ) ; yeux ouverts , surface moelleuse ( 2 ) ; yeux fermés , surface normale ( 3 ) ; yeux fermés , surface moelleuse ( 4 ) . Le test de marche de 10 mètres a aussi été inclus dans l'évaluation . Les résultats ont démontré une amélioration significative ( P<0.05 ) du déplacement du CP dans les conditions 1 et 2 pour le groupe expérimental seulement ainsi que des changements limités pour le transfert assis-debout chez les deux groupes de sujets à la suite de l'entraînement . Une amélioration significative ( P<0.05 ) a été observée au niveau du test de marche chez les deux groupes de sujets . Cette étude a démontré qu'un programme d'exercices fonctionnels assistés de stimulations sensorielles est plus efficace pour l'amélioration du maintien de l'équilibre en position debout chez les sujets atteints d'un AVC qu'un programme d'exercices fonctionnels conventionnnel OBJECTIVE To examine rehabilitation interventions and result ing physical activity patterns of patients managed in acute stroke units to help inform development of a r and omized controlled trial of very early rehabilitation . DESIGN An open observational study of patient activity and therapist report of patient interventions . A survey of stroke unit re sources . METHODS Patients less than 14 days post-stroke from 5 metropolitan stroke units were observed over 2 consecutive weekdays at 10-minute intervals between 08.00 h and 17.00 h. Physical activity , location and person(s ) present were ascertained at each observation . Therapists completed treatment records . Senior staff completed stroke unit surveys . RESULTS Patients after stroke ( n=58 ) were with therapists 5.2 % of the observed day . Few patients ( 17.1 % ) received  daily therapy  by more than one therapist . When patients received therapy , average session times were 24 minutes of physiotherapy , 23 minutes of occupational therapy and 33 minutes of speech pathology .  The more time that family members were present , the longer the treatment time . Four to 11 min of upper-limb therapy was provided . Muscle weakness and left hemiparesis were associated with less upper-limb activity . CONCLUSION These acute stroke care units were re source d according to recommended staff-patient ratios . Patients received little therapy and had low levels of physical activity Background and Purpose — One way that stroke units may improve outcome is by reducing complications of immobility through early mobilization ; however , this intervention needs testing . The purpose of this study was to determine the physical activity patterns of stroke patients managed within acute stroke units as a first step in developing an early mobilization protocol . Methods — We recruited 64 patients within 14 days after stroke from 5 metropolitan stroke units and observed them for 2 consecutive days at 10-minute intervals between the hours of 8 am and 5 pm . At each observation , we ascertained physical activity , location , and other person(s ) present . Therapists recorded therapy details . Results — The 58 patients who completed the study had a mean age of 71.3 years . Stroke severity ranged from mild ( National Institutes of Health Stroke Scale score , 1 ) to severe ( score , 27 ) , and mean time after stroke at observation was 5.6 days ( range , 0 to 13 days ) . Only 9 patients were restricted to bed . During the therapeutic day , patients spent > 50 % resting in bed , 28 % sitting out of bed , and only 13 % engaged in activities with the potential to prevent complications and improve recovery of mobility . Patients were alone > 60 % of the time . Conclusions — This is the first multicenter study of physical activity early after stroke . We believe the next step is to conduct a r and omized controlled trial to evaluate the effect of increased levels of  physical activity  early after stroke compared with current st and ards of care Background and Purpose — In prehension tasks with objects placed within arm ’s reach , patients with hemiparesis caused by stroke use excessive trunk movement to compensate for arm motor impairments . Compensatory trunk movements may improve motor function in the short term but may limit arm recovery in the long term . Previous studies showed that restriction of trunk movements during reach-to-grasp movements results in immediate increases in active arm joint ranges and improvement in interjoint coordination . To evaluate the potential of this technique as a therapeutic intervention , we compared the effects of short-term reach-to-grasp training ( 60-trial training session ) with and without physical trunk restraint on arm movement patterns in patients with chronic hemiparesis . Methods — A total of 28 patients with hemiparesis were assigned to 2 groups : 1 group practice d reach-to-grasp movements during which compensatory movement of the trunk was prevented by a harness ( trunk restraint ) , and the second group practice d the same task while verbally instructed not to move the trunk ( control ) .  Kinematics of reaching and grasping an object placed within arm ’s length were recorded before , immediately after , and 24 hours after training . Results — The trunk restraint group used more elbow extension , less anterior trunk displacement , and had better interjoint coordination than the control group after training , and range of motion was maintained 24 hours later in only the trunk restraint group . Conclusions — Restriction of compensatory trunk movements during practice may lead to greater improvements in reach-to-grasp movements in patients with chronic stroke than practice alone , and longer-term effects of this intervention should be evaluated OBJECTIVE To evaluate the relationship between rehabilitation team functioning and stroke patient outcomes .  DESIGN Prospect i ve observational study . SETTING Veterans Administration ( VA ) inpatient and subacute rehabilitation units . PARTICIPANTS Forty-six VA rehabilitation teams , including 530 rehabilitation team members from 6 disciplines ( medicine , nursing , social work , physical therapy , occupational therapy , speech language pathology ) and 1688 stroke patients treated by the teams . INTERVENTIONS Not applicable . MAIN OUTCOME MEASURES Ten scales assessing team member perceptions of team functioning ( communication , perceived effectiveness , physician involvement , physician support , teamness , utility of quality information , innovation , interprofessional relationships , order and organization , task orientation ) and 3 primary patient outcome variables-functional improvement , discharge home , and length of rehabilitation stay ( LOS ) . RESULTS Three of the 10 measures of team functioning were significantly associated with patient functional improvement ( P < .05 ) : task orientation , order and organization , and utility of quality information . One measure of team functioning-effectiveness-was significantly associated with LOS ( P < .05 ) . None of the team variables predicted discharge destination . Aspects of team functioning that were important to outcomes differed depending on the outcome of interests . Efforts directed toward improving team activities and relationships , including collaborative planning and problem solving and the use of feedback information , may enhance rehabilitation treatment effectiveness . CONCLUSIONS Characteristics of team functioning predict selected rehabilitation outcomes Background and Purpose — Current theories of motor control in rehabilitation focus on how the nervous system responds to many types of external and internal constraints to execute motor behavior to accomplish a task . However , the dynamic interplay between these 2 constraints remains unclear . This study examined the impact of some aspects of internal and external constraints on motor performance in persons with stroke . Methods — Twenty-seven persons with stroke used the uninvolved arms  to perform an upper-extremity reaching task under 4 experimental conditions , formed by the crossing of functional goals and personal preferences . For the higher level of a functional goal , subjects took a drink from a can of beverage . For the lower level of a functional goal , subjects brought the can to the mouth without drinking . The level of personal preferences was determined , by interview , by the degree of predilection for particular beverages . Results — Significant and large effects of functional goals and personal preference were found in the variables of movement time and reaction time . However , the data trend of the 4 testing conditions varied according to presence of visuospatial neglect and side of lesion . Conclusions — Offering choices for the treatment activities and incorporating functional goals to therapeutic tasks might enhance response rate or movement efficiency , depending on the side of the lesion and presence of visuospatial neglect . The findings suggest that the consideration of the neglect phenomenon is a necessity when rehabilitative treatment planning incorporates constraint factors Objective : To evaluate the efficacy of a task-orientated intervention in enhancing competence in walking in people with stroke . Design : Two-centre observer-blinded stratified block-r and omized controlled trial . Setting : General community . Subjects : Between May 2000 and February 2003 , 91 individuals with a residual walking deficit within one year of a first or recurrent stroke consented to participate . Interventions : The experimental intervention comprised 10 functional tasks design ed to strengthen the lower extremities and enhance walking balance , speed and distance . The control intervention involved the practice of upper extremity activities . Subjects in both groups attended sessions three times a week for six weeks . Main measures : Six-minute walk test ( SMWT ) , 5-m walk ( comfortable and maximum pace ) , Berg Balance Scale , timed ‘ up and go ’ . Results : At baseline , subjects in the experimental ( n = 44 ) and control ( n = 47 ) groups walked an average distance of 209 m ( SD = 126 ) and 204 m ( SD = 131 ) , respectively , on the SMWT . Mean improvements of 40 m ( SD = 72 ) , and 5 m ( SD = 66 ) were observed following the experimental and control interventions , respectively . The between-group difference was 35 m ( 95 % confidence interval ( CI ) 7 , 64 ) . Significant between-group effects of 0.21 m/s ( 95 % CI 0.12 , 0.30 ) and of 0.11 m/s ( 95 % CI 0.03 , 0.19 ) in maximum and comfortable walking speed , respectively , were observed . People with a mild , moderate or severe walking deficit at baseline improved an average of 36 ( SD = 96 ) , 55 ( SD = 56 ) and 18 m ( SD = 23 ) , respectively , in SMWT performance following the experimental intervention . Conclusions : Study findings support the efficacy of a task-orientated intervention in enhancing walking distance and speed in the first year post stroke , particularly in people with moderate walking deficits Background and Purpose — Task-specific training improves functional outcomes after stroke . However , gains may be accompanied by increases in movements compensating for motor impairments . We hypothesized that restriction of compensatory trunk movements may encourage recovery of premorbid movement patterns leading to better functional outcomes . The goal was to determine whether task-specific training with trunk-restraint ( TR ) produces greater improvements in arm impairment and function than training without TR in patients with chronic hemiparesis . Methods — Double-blind r and omized control trial of a therapist-supervised home program ( 3 times per week , 5 weeks ) in 30 patients with chronic hemiparesis stratified by arm impairment level ( Fugl-Meyer ) was performed . Intervention group ( TR group ) received progressive object-related reach-to-grasp training with prevention of trunk movements . Control group ( C ) practice d tasks without TR . Main outcome measures were upper limb impairment ( Fugl-Meyer Arm Section ) and function ( TEMPA ) and movement kinematics ( trunk displacement , elbow extension ; Optotrak , 10 trials ) of a reach-to-grasp movement . Evaluations were repeated before , immediately after , and 1 month postintervention by blind evaluators . Results — TR training led to greater improvements in impairment and function compared with C. Improvements were accompanied by increased active joint range and were greater in initially more severe patients . In these patients , TR decreased trunk movement and increased elbow extension , whereas C had opposite effects ( increased compensatory movements ) . In TR , changes in arm function were correlated with changes in arm and trunk kinematics . Conclusions — Treatment should be tailored to arm impairment severity with particular attention to controlling excessive trunk movements if the goal is to improve arm movement quality and function Systematic review s provide the best evidence on the effectiveness of healthcare interventions including quality improvement strategies . The methods of systematic review of individual patient r and omised trials of healthcare interventions are well developed . We discuss method ological and practice issues that need to be considered when undertaking systematic review s of quality improvement strategies including developing a review protocol , identifying and screening evidence sources , quality assessment and data abstract ion , analytical methods , reporting systematic review s , and appraising systematic review s. This paper builds on our experiences within the Cochrane Effective Practice and Organisation of Care ( EPOC ) review group OBJECTIVES To evaluate the efficacy of a task-oriented walking intervention in improving balance self-efficacy in persons with stroke and to determine whether effects were task-specific , influenced by baseline level of self-efficacy and associated with changes in walking and balance capacity . DESIGN Secondary analysis of a two-center , observer-blinded , r and omized , controlled trial . SETTING General community . PARTICIPANTS Ninety-one individuals with a residual walking deficit within 1 year of a first or recurrent stroke . INTERVENTION Task-oriented interventions targeting walking or upper extremity ( UE ) function were provided three times a week for 6 weeks . MEASUREMENTS Activities-specific Balance Confidence Scale , Six-Minute Walk Test , 5-m walk , Berg Balance Scale , and Timed " Up and Go " administered at baseline and postintervention . RESULTS The walking intervention was associated with a significantly greater average proportional change in balance self-efficacy than the UE intervention . Treatment effects were largest in persons with low self-efficacy at baseline and for activities relating to tasks practice d. In the walking group , change in balance self-efficacy correlated with change in functional walking capacity ( correlation coefficient=0.45 , 95 % confidence interval=0.16 - 0.68 ) . Results of multivariable modeling suggested effect modification by the baseline level of depressive symptoms and a prognostic influence of age , sex , comorbidity , time poststroke , and functional mobility on change in self-efficacy . CONCLUSION Task-oriented walking retraining enhances balance self-efficacy in community-dwelling individuals with chronic stroke . Benefits may be partially the result of improvement in walking capacity . The influence of baseline level of self-efficacy , depressive symptoms , and prognostic variables on treatment effects are of clinical importance and must be verified in future studies Background and Purpose The purpose of this study was to determine the efficacy of a reimbursable , outpatient modified constraint-induced therapy ( mCIT ) protocol administered to subjects with chronic stroke who initially exhibited minimal movement ability in their affected wrists and fingers . Subjects The subjects were 4 individuals who had experienced a stroke more than 1 year prior to study entry ( mean age [±SD]=60.25±1.98 years , mean time since stroke=37.5±23.2 months ) . Method A multiple-baseline , preintervention-postintervention , single-blinded case series design was used . The intervention consisted of structured , ½-hour therapy sessions emphasizing affected arm use in valued activities , occurring 3 times per week for 10 weeks . Subjects ’ less affected arms also were restrained 5 days per week for 5 hours per day during the same 10-week period . The main outcome measures were the Action Research Arm Test ( ARAT ) , the Motor Activity Log ( MAL ) , and the Fugl-Meyer Assessment of Motor Recovery ( FM ) . Results The subjects exhibited improvements in use of the more affected arm ( + 1.9 , + 1.8 , + 1.7 , and + 2.3 for subjects 1 through 4 , respectively ) and in quality of movement ( + 1.5 , + 2.1 , + 1.63 , and + 1.9 for subjects 1 through 4 , respectively ) , as measured by the MAL . They also exhibited reduced impairment , as measured by the FM ( + 5.0 , + 6.5 , + 5.5 , and + 5.0 for subjects 1 through 4 , respectively ) , and increased fine motor skill movement , as measured by the ARAT ( + 7.5 , + 7.0 , + 7.0 , and + 5.5 for subjects 1 through 4 , respectively ) . Discussion and Conclusion The findings demonstrated that mCIT participation was efficacious because it led to increased use of the affected arm and of function and to increased ability to perform valued activities . The subjects reported some new ability to perform some valued activities . These outcomes are significant because few therapies are believed to effectively increase use of the affected arm and function in this population Background and Purpose — Outcome after first stroke varies significantly across Europe . This study was design ed to compare motor and functional recovery after stroke between four European rehabilitation centers . Methods — Consecutive stroke patients ( 532 patients ) were recruited . They were assessed on admission and at 2 , 4 , and 6 months after stroke with the Barthel Index , Rivermead Motor Assessment of Gross Function , Rivermead Motor Assessment of Leg/Trunk , Rivermead Motor Assessment of Arm , and Nottingham Extended Activities of Daily Living  ( except on admission ) . Data were analyzed using r and om effects ordinal logistic models adjusting for case-mix and multiple testing . Results — Patients in the UK center were more likely to stay in lower Rivermead Motor Assessment of Gross Function classes compared with patients in the German center ( & Dgr;OR , 2.4 ; 95 % CI , 1.3 to 4.3 ) . In the Swiss center , patients were less likely to stay in lower Nottingham Extended Activities of Daily Living classes compared with patients in the UK center ( & Dgr;OR , 0.7 ; 95 % CI , 0.5 to 0.9 ) . The latter were less likely to stay in lower Barthel Index classes compared with the patients in the German center ( & Dgr;OR , 0.6 ; 95%CI , 0.4 to 0.8 ) . Recovery patterns of Rivermead Motor Assessment of Leg/Trunk and Rivermead Motor Assessment of Arm were not significantly different between centers . Conclusions — Gross motor and functional recovery were better in the German and Swiss centers compared with the UK center , respectively . Personal self-care recovery was better in the UK compared with the German center . Previous studies in the same centers indicated that German and Swiss patients received more therapy per day . This was not the result of more staff but of a more efficient use of human re sources . This study indicates potential for improving rehabilitation outcomes in the UK and Belgian centers OBJECTIVES To determine the effect of two different community-based group exercise programs on functional balance , mobility , postural reflexes , and falls in older adults with chronic stroke . DESIGN A r and omized , clinical trial . SETTING Community center . PARTICIPANTS Sixty-one community-dwelling older adults with chronic stroke . INTERVENTION Participants were r and omly assigned to an agility ( n=30 ) or stretching/weight-shifting ( n=31 ) exercise group . Both groups exercised three times a week for 10 weeks . MEASUREMENTS Participants were assessed before , immediately after , and 1 month after the intervention for Berg Balance , Timed Up and Go , step reaction time , Activities-specific Balance Confidence , and Nottingham Health Profile . Testing of st and ing postural reflexes and induced falls evoked by a translating platform was also performed . In addition , falls in the community were tracked for 1 year from the start of the interventions . RESULTS Although exercise led to improvements in all clinical outcome measures for both groups , the agility group demonstrated greater improvement in step reaction time and paretic rectus femoris postural reflex onset latency than the stretching/weight-shifting group . In addition , the agility group experienced fewer induced falls on the platform . CONCLUSION Group exercise programs that include agility or stretching/weight shifting exercises improve postural reflexes , functional balance , and mobility and may lead to a reduction of falls in older adults with stroke Background and Purpose — Differences exist between European countries in the proportion of patients who die or become dependent after stroke . The aim of the present study was to identify differences in the use of time  by stroke patients in 4 rehabilitation centers in 4 European countries . Methods — In each of the 4 centers , 60 r and omly selected stroke patients were observed at 10-minute intervals using behavioral mapping . Observations took place on 30 weekdays selected at r and om , on equal numbers of morning , afternoon , and evening sessions . A logistic generalized estimating equation model with correction for differences in case mix and multiple testing was used for the analysis . Results — Overall time available from different professions was the highest in the United Kingdom , but patients in the United Kingdom spent on average only 1 hour per day in therapy . This was significantly less than patients in Belgium and Germany , who spent ≈2 hours , and patients in Switzerl and who spent ≈3 hours per day in therapy . In all centers , patients spent less than half their time in interactions and > 72 % of the time in nontherapeutic activities . Conclusions — Important differences in the use of time were established , which appeared dependent on management decisions rather than the number of staff available . Patients in the Swiss and German centers spent more time in therapy , possibly because of the structured organization of rehabilitation . Further studies will verify whether this has an effect on outcome Background and Purpose — Mental practice ( MP ) of a particular motor skill has repeatedly been shown to activate the same musculature and neural areas as physical practice of the skill . Pilot study results suggest that a rehabilitation program incorporating MP of valued motor skills in chronic stroke patients provides sufficient repetitive practice to increase affected arm use and function . This Phase 2 study compared efficacy of a rehabilitation program incorporating MP of specific arm movements to a placebo condition using r and omized controlled methods and an appropriate sample size . Method — Thirty-two chronic stroke patients ( mean=3.6 years ) with moderate motor deficits received 30-minute therapy sessions occurring 2 days/week for 6 weeks , and emphasizing activities of daily living . Subjects r and omly assigned to the experimental condition also received 30-minute MP sessions provided directly after therapy requiring daily MP of the activities of daily living ; subjects assigned to the control group received the same amount of therapist interaction as the experimental group , and a sham intervention directly after therapy , consisting of relaxation . Outcomes were evaluated by a blinded rater using the Action Research Arm test and the upper extremity section of the Fugl-Meyer Assessment . Results — No pre-existing group differences were found on any demographic variable or movement scale . Subjects receiving MP showed significant reductions in affected arm impairment and significant increases in daily arm function ( both at the P<0.0001 level ) . Only patients in the group receiving MP exhibited new ability to perform valued activities . Conclusions — The results support the efficacy of programs incorporating mental practice for rehabilitating affected arm motor function in patients with chronic stroke . These changes are clinical ly significant The purpose of this study was to investigate whether additional practice of either upper limb or mobility tasks improved functional outcome during inpatient stroke rehabilitation . This prospect i ve , r and omised , single blind clinical trial recruited 30 stroke subjects into either an Upper Limb or a Mobility Group . All subjects received their usual rehabilitation and an additional session of task-related practice using a circuit class format . Independent assessors , blinded to group allocation , tested all subjects . Outcome measures used were three items of the Jebsen Taylor H and Function Test ( JTHFT ) , two  arm items  of the Motor Assessment Scale ( MAS ) , and three mobility measures , the Timed Up and Go Test ( TUGT ) , Step Test , and Six Minute Walk Test ( 6MWT ) . Both groups improved significantly between pre- and post-tests on all of the mobility measures , however only the Upper Limb Group made a significant improvement on the JTHFT and MAS upper arm items . Following four weeks training , the Mobility Group had better locomotor ability than the Upper Limb Group ( between-group differences in the 6MWT of 116.4 m , 95 % CI 31.4 to 201.3 m , Step Test 2.6 repetitions , 95 % CI -1.0 to 6.2 repetitions , and TUGT -7.6 sec , 95 % CI -15.5 to 0.2 sec ) . The JTHFT dexterity scores in the Upper Limb Group were 6.5 sec ( 95 % CI -7.4 to 20.4 sec ) faster than the Mobility Group . Our findings support the use of additional task-related practice during inpatient stroke rehabilitation . The circuit class format was a practical and effective means to provide supervised additional practice that led to significant and meaningful functional gains Two important components of Constraint-Induced Movement therapy are thought to be intense training of the more-impaired arm and physical restraint of the less-impaired arm . This preliminary study examined the effects of type of training ( task- practice , shaping ) and restraint ( sling , half-glove , no restraint ) on treatment outcomes . Seventeen individuals at least 1-year post-stroke with mild/moderate upper extremity motor deficit were consecutively assigned to Sling and Task- practice , Sling and Shaping , Half-glove and Shaping , and Shaping Only groups . Task- practice involved repetitive more-impaired arm training on functional tasks for 6 hr/day for 10 consecutive weekdays . Shaping differed from task- practice in that task dem and s were progressively increased and immediate performance feedback was provided frequently and systematic ally . " Sling " groups placed the less-impaired arm in a resting h and -splint/sling assembly for most waking hours over the 2-week intervention , while the " Half-glove " group wore a modified gardening glove as a reminder not to use the more affected arm in the life situation . There were no between-group differences in outcome at post-treatment , although two-years afterwards Sling & Task- practice and Half-glove & Shaping participants showed larger and smaller retention of gains , respectively , than those in the Sling & Shaping group . Thus , long-term outcomes may have been affected by type of more-impaired arm motor training and less-impaired arm restraint . These variables , however , were confounded with between-group differences in training intensity , limiting confidence in this conclusion BACKGROUND AND PURPOSE After stroke , the ability to balance in sitting is critical to independence . Although impairments in sitting balance are common , little is known about the effectiveness of rehabilitation strategies design ed to improve it . The purpose of this r and omized placebo-controlled study was to evaluate the effect of a 2-week task-related training program aim ed at increasing distance reached and the contribution of the affected lower leg to support and balance . METHODS Twenty subjects at least 1 year after stroke were r and omized into an experimental or control group . The experimental group participated in a st and ardized training program involving practice of reaching beyond arm 's length . The control group received sham training involving completion of cognitive-manipulative tasks within arm 's length .  Performance of reaching in sitting was measured before and after training using electromyography , videotaping , and two force plates . Variables tested were movement time , distance reached , vertical ground reaction forces through the feet , and muscle activity . Subjects were also tested on sit-to-st and , walking , and cognitive tasks .  Nineteen subjects completed the study . RESULTS After training , experimental subjects were able to reach faster and further , increase load through the affected foot , and increase activation of affected leg muscles compared with the control group ( P < .01 ) . The experimental group also improved in sit-to-st and . The control group did not improve in reaching or sit-to-st and . Neither group improved in walking . CONCLUSIONS This study provides strong evidence of the efficacy of task-related motor training in improving the ability to balance during seated reaching activities after stroke OBJECTIVE To evaluate the immediate and retention effects of a 4-week training program on the performance of locomotor-related tasks in chronic stroke . DESIGN R and omized , controlled pilot study with 2-month follow-up . SETTING Rehabilitation center . SUBJECTS A convenience sample consisting of 12 chronic stroke subjects was used . Subjects were r and omly assigned to the experimental or the control group . Three subjects withdrew from the study . INTERVENTION Both experimental and control groups participated in exercise classes three times a week for 4 weeks . The exercise class for the experimental group focused on strengthening the affected lower limb and practicing functional tasks involving the lower limbs , while the control group practice d upper-limb tasks . MAIN OUTCOME MEASURES Lower-limb function was evaluated by measuring walking speed and endurance , peak vertical ground reaction force through the affected foot during sit-to-st and , and the step test . RESULTS The experimental group demonstrated significant immediate and retained ( 2-month follow-up ) improvement ( p < or = .05 ) compared with the control group in walking speed and endurance , force production through the affected leg during sit-to-st and , and the number of repetitions of the step test . CONCLUSION The pilot study provides evidence for the efficacy of a task-related circuit class at improving locomotor function in chronic stroke OBJECTIVE To evaluate the immediate and long-term effects of 2 upper-extremity rehabilitation approaches for stroke compared with st and ard care in participants stratified by stroke severity . DESIGN Nonblinded , r and omized controlled trial ( baseline , postintervention , 9mo ) design . SETTING Inpatient rehabilitation hospital and outpatient clinic . PARTICIPANTS Sixty-four patients with recent stroke admitted for inpatient rehabilitation were r and omized within severity strata ( Orpington Prognostic Scale ) into 1 of 3 intervention groups . Forty-four patients completed the 9-month follow-up . INTERVENTIONS St and ard care ( SC ) , functional task practice ( FT ) , and strength training ( ST ) . The FT and ST groups received 20 additional hours of upper-extremity therapy beyond st and ard care distributed over a 4- to 6-week period . MAIN OUTCOME MEASURES Performance measures of impairment ( Fugl-Meyer Assessment ) , strength ( isometric torque ) , and function ( Functional Test of the Hemiparetic Upper Extremity [ FTHUE ] ) . RESULTS Compared with SC participants , those in the FT and ST groups had significantly greater increases in Fugl-Meyer motor scores ( P=.04 ) and isometric torque ( P=.02 ) posttreatment . Treatment benefit was primarily in the less severe participants , where improvement in FT and ST group Fugl-Meyer motor scores more than doubled that of the SC group . Similar results were found for the FTHEU and isometric torque . During the long term , at 9 months , the less severe FT group continued to make gains in isometric muscle torque , significantly exceeding those of the ST group ( P<.05 ) . CONCLUSIONS Task specificity and stroke severity are important factors for rehabilitation of arm use in acute stroke . Twenty hours of upper extremity-specific therapy over 4 to 6 weeks significantly affected functional outcomes . The immediate benefits of a functional task approach were similar to those of a resistance-strength approach , however , the former was more beneficial in the long-term Most systematic review s rely substantially on the assessment of the method ological quality of the individual trials . The aim of this study was to obtain consensus among experts about a set of generic core items for quality assessment of r and omized clinical trials ( RCTs ) . The invited participants were experts in the field of quality assessment of RCTs . The initial item pool contained all items from existing criteria lists . Subsequently , we reduced the number of items by using the Delphi consensus technique . Each Delphi round comprised a question naire , an analysis , and a feedback report . The feedback report included staff team decisions made on the basis of the analysis and their justification . A total of 33 international experts agreed to participate , of whom 21 completed all question naires . The initial item pool of 206 items was reduced to 9 items in three Delphi rounds . The final criteria list ( the Delphi list ) was satisfactory to all participants . It is a starting point on the way to a minimum reference st and ard for RCTs on many different research topics . This list is not intended to replace , but rather to be used alongside , existing criteria lists OBJECTIVE To compare body weight-supported exercise on a gait trainer with walking exercise overground . DESIGN R and omized controlled trial . SETTING Rehabilitation hospital . PARTICIPANTS Forty-five ambulatory patients with chronic stroke . INTERVENTIONS Patients were r and omized to 3 groups : ( 1 ) gait trainer exercise with functional electric stimulation ( GTstim ) , ( 2 ) gait trainer exercise without stimulation ( GT ) , and ( 3 ) walking overground ( WALK ) . All patients practice d gait for 15 sessions during 3 weeks ( each session , 20 min ) , and they received additional physiotherapy 55 minutes daily . MAIN OUTCOME MEASURES Ten-meter walk test ( 10MWT ) , six-minute walk test ( 6MWT ) , lower-limb spasticity and muscle force , postural sway tests , Modified Motor Assessment Scale ( MMAS ) , and FIM instrument scores were recorded before , during , and after the rehabilitation and at 6 months follow-up . RESULTS The mean walking distance using the gait trainer was 6900+/-1200 m in the GTstim group and 6500+/-1700 m in GT group . In the WALK group , the distance was 4800+/-2800 m , which was less than the walking distance obtained in the GTstim group ( P=.027 ) . The body-weight support was individually reduced from 30 % to 9 % of the body weight over the course of the program . In the pooled 45 patients , the 10MWT ( P<.001 ) , 6MWT ( P<.001 ) , MMAS ( P<.001 ) , dynamic balance test time ( P<.001 ) , and test trip ( P=.005 ) scores improved ; however , no differences were found between the groups . CONCLUSIONS Both the body weight-supported training and walking exercise training programs result ed in faster gait after the intensive rehabilitation program . Patients ' motor performance remained improved at the follow-up Objective : To determine ( 1 ) the most effective of three treatment approaches to retrain seated weight distribution long-term after stroke and ( 2 ) whether improvements could be generalized to weight distribution in st and ing . Setting : Inpatient rehabilitation unit . Design : Forty asymmetrical acute stroke subjects were r and omly allocated to one of four groups in this pilot study . Changes in weight distribution were compared between the 10 subjects of each of three treatment groups ( task-specific reach , Bobath , or Balance Performance Monitor [ BPM ] feedback training ) and a no specific treatment control group . One week of measurement only was followed by two weeks of daily training sessions with the treatment to which the subject was r and omly allocated . Measurements were performed using the BPM daily before treatment sessions , two weeks after cessation of treatment and 12 weeks post study . Weight distribution was calculated in terms of mean balance ( percentage of total body weight ) or the mean of 300 balance points over a 30-s data run . Results : In the short term , the Bobath approach was the most effective treatment for retraining sitting symmetry after stroke ( p = 0.004 ) . Training with the BPM and no training were also significant ( p = 0.038 and p = 0.035 respectively ) and task-specific reach training failed to reach significance ( p = 0.26 ) . At 12 weeks post study 83 % of the BPM training group , 38 % of the task-specific reach group , 29 % of the Bobath group and 0 % of the untrained group were found to be distributing their weight to both sides . Some generalization of symmetry training in sitting to st and ing was noted in the BPM training group which appeared to persist long term . Conclusions : Results should be treated with caution due to the small group sizes . However , these preliminary endings suggest that it might be possible to restore postural symmetry in sitting in the early stages of rehabilitation with therapy that focuses on creating an awareness of body position This trial compares the effects of task-oriented physical therapy ( PT ) provided with and without the use of rehabilitation technology on locomotor recovery in 63 persons with subacute stroke . Participants in the experimental ( EXP ) group used a treadmill , a Kinetron isokinetic exerciser , and a limb-load monitor , whereas those in the control ( CTL ) group did not while engaging in PT 1 h per day , 5 days per week for 2 months . Locomotor recovery was assessed by clinical ( gait speed , Fugl Meyer motor leg and arm subscores , the Balance Scale , the Timed Up and Go , and the Barthel ambulation subscore ) and laboratory outcomes ( gait kinematics and kinetics ) pre- and posttherapy and 3 months later . Within groups , gait speed ( P < 0.01 ) and all secondary measures improved posttherapy ( P < 0.01 - 0.05 ) , and improvements in clinical measures were maintained at follow-up , but there was no difference between groups ( P > 0.05 ) . When the groups were pooled , the increase in gait speed was associated ( r = 0.52 , P = 0.003 ) with an increase in ankle power generation of the affected leg . The results demonstrate that the efficacy of the task-oriented approach is not dependent on rehabilitation technology Objective : To investigate the effect of early cycling training on balance and motor abilities of stroke patients in their subacute stage . Design : R and omized clinical trial . Setting : Inpatient rehabilitation . Subjects : Twenty-four patients who had had a first stroke were r and omly assigned to a cycling training group ( n = 10 ) or to a control ( n = 14 ) group . Intervention : All subjects received their usual rehabilitation programme ; the cycling training group received in addition a daily session of leg cycle ergometer , lasting three weeks . Both groups were followed for six weeks . Main outcome measurements : Balance was assessed using the Postural Assessment Scale for Stroke Patients ( PASS ) and the st and ing balance test . The motor function of the lower extremity was also assessed by the Fugl-Meyer Assessment ( FMA ) . Results : In the within-group comparison , both the exercise group and the control group had improved significantly ( P B=0.01 ) with time with respect to PASS total ( exercise group 18.79=2.8 to 31.19=2.2 , control group 18.19=3.2 to 26.49=3.8 ) and PASS subscores , as well as the FMA score ( exercise group 17.29=7.5 to 29.19=5.9 , control group 16.69=6.4 to 22.19=6.8 ) . In addition there was a significant group = time interaction effect , with exercise group patients demonstrating better performance in both the total PASS score and PASS subscores and FMA score relative to the control patients ( P B=0.01 ) . Conclusions : These preliminary findings suggest that stroke patients in the subacute stage can improve their motor and balance abilities after an early short duration of cycling training OBJECTIVE To explore how repetitive passive-active movement training effects upper limb motor function and cortical activation in patients with stroke . DESIGN Single-group treatment trial with baseline comparisons . PATIENTS Ten chronic patients with stroke with paresis of the upper limb . METHODS Assessment s were performed during a 4-week baseline period before and once after 4 weeks of training using the Motor Assessment Scale of the upper limb , Nine Hole Peg Test , goniometer for range of movement and the modified Ashworth scale for muscle tone . Two patients underwent functional magnetic resonance imaging pre- and post-training . The treatment consisted of daily sessions of repeated functional reaching and grasping movements guided passively and attempted actively during 4 weeks . RESULTS The group improved in range of motion and Motor Assessment Scale scores . Subjects reported improvements in a variety of daily tasks requiring the use of the affected upper limb . Increases in cortical activation in prefrontal and sensorimotor areas were observed in parallel with improvements of upper limb motor function in the 2 patients scanned . CONCLUSION The 4-week training programme improved h and motor function and ability . Cortical activation on functional magnetic resonance imaging changed in parallel suggesting reorganization of areas related to movements of the paretic limb OBJECTIVE To examine the benefits of modified constraint-induced movement therapy ( mCIMT ) on motor function , daily function , and health-related quality of life ( HRQOL ) in elderly stroke survivors . DESIGN Two-group r and omized controlled trial , with pretreatment and posttreatment measures . SETTING Rehabilitation clinics . PARTICIPANTS Twenty-six elderly stroke patients ( mean age , 72 y ) with 0.5 to 31 months postonset of a first-ever cerebrovascular accident . INTERVENTIONS Twenty-six patients received either mCIMT ( restraint of the unaffected limb combined with intensive training of the affected limb ) or traditional rehabilitation for a period of 3 weeks . MAIN OUTCOME MEASURES Outcome measures included the Fugl-Meyer Assessment ( FMA ) , FIM instrument , Motor Activity Log ( MAL ) , and Stroke Impact Scale ( SIS ) . The FMA evaluated the severity of motor impairment ; the FIM instrument and MAL reported daily function ; and the SIS detected HRQOL . RESULTS The mCIMT group exhibited significantly greater improvements in motor function , daily function , and the physical domain of HRQOL than the traditional rehabilitation group . Patients in the mCIMT group perceived significantly greater percent of recovery after treatment than patients in the traditional rehabilitation group . CONCLUSIONS These findings suggest mCIMT is a promising intervention for improving motor function , daily function , and physical aspects of HRQOL in elderly patients with stroke . The mCIMT was well tolerated by the elderly patients even though it is a rigorous training program Background : Neurodevelopmental treatment ( NDT ) is a rehabilitation approach increasingly used in the care of stroke patients , although no evidence has been provided for its efficacy . Objective : To investigate the effects of NDT on the functional status and quality of life ( QoL ) of patients with stroke during one year after stroke onset . Methods : 324 consecutive patients with stroke from 12 Dutch hospitals were included in a prospect i ve , non-r and omised , parallel group study . In the experimental group ( n = 223 ) , nurses and physiotherapists from six neurological wards used the NDT approach , while conventional treatment was used in six control wards ( n = 101 ) . Functional status was assessed by the Barthel index . Primary outcome was “ poor outcome ” , defined as Barthel index < 12 or death after one year . QoL was assessed with the 30 item version of the sickness impact profile ( SA-SIP30 ) and the visual analogue scale . Results : At 12 months , 59 patients ( 27 % ) in the NDT group and 24 ( 24 % ) in the non-NDT group had poor outcome ( corresponding adjusted odds ratio = 1.7 ( 95 % confidence interval , 0.8 to 3.5 ) ) . At discharge the adjusted odds ratio was 0.8 ( 0.4 to 1.5 ) and after six months it was 1.6 ( 0.8 to 3.2 ) . Adjusted mean differences in the two QoL measures showed no significant differences between the study groups at six or 12 months after stroke onset . Conclusions : The NDT approach was not found effective in the care of stroke patients in the hospital setting . Health care professionals need to reconsider the use of this approach Objective : To compare the effect of walking training on a treadmill with body weight support ( BWS ) and walking training on the ground at an early stage of rehabilitation in patients with hemiparesis after stroke . Design : R and omized controlled experimental study . Setting : Multicentre design ; three departments of rehabilitation medicine . Subjects : Seventy-three consecutive first stroke patients admitted to a rehabilitation clinic were r and omized into a treatment group and a control group . Interventions : The treatment group received walking training on a treadmill with BWS for 30 minutes , 5 days a week . The control group received walking training according to the Motor Relearning Programme ( MRP ) on the ground for 30 minutes 5 days a week , not including treadmill training . During the time in the rehabilitation department ( about two months ) , all patients in the study also received professional stroke rehabilitation besides the walking training in the two groups . Main outcome measures : Functional Independence Measure ( FIM ) , walking velocity for 10 m , Functional Ambulation Classification ( FAC ) , Fugl-Meyer Stroke Assessment and Berg 's Balance Scale . The assessment s were performed at admission , at discharge and at 10-month follow-up . Results : There were no statistically significant differences between the groups at discharge or at the 10-month follow-up with regard to FIM , walking velocity , FAC , Fugl-Meyer Stroke Assessment , and Berg 's Balance Scale . Patients in both groups improved in these variables from admission to the 10-month follow-up . Conclusions : Treadmill training with BWS at an early stage of rehabilitation after stroke is a comparable choice to walking training on the ground OBJECTIVE To evaluate the effectiveness of 2 rehabilitative approaches for improving paretic limb reaching by chronic stroke subjects . DESIGN Pre- and posttest reaching to targets ipsilateral , midline , and contralateral to the impaired side . SETTING Training in subjects ' homes ; testing in a laboratory setting . PARTICIPANTS Twelve poststroke volunteers were matched using the Motor Assessment Scale ( MAS ) and then were r and omly assigned to 1 of 2 training conditions . Subjects were subsequently categorized as at a high or low functional level , using the reaching pretest movement time scores . INTERVENTIONS Training ( trunk unrestrained ) using the paretic limb was 4 weeks ( 12 sessions ) . Task-related training ( TRT ) involved reaching to objects placed across the workspace . Progressive resistive exercise ( PRE ) involved whole-arm pulling against resistive therapeutic tubing in planes and distances similar to that in TRT . Main outcome measures Kinematic analysis of arm trajectory and trunk motion using the Peak Performance System , as well as scores on the MAS and the Rivermead Motor Assessment ( RMA ) . RESULTS For low-level groups , TRT result ed in increased substitutive trunk use at the target ipsilateral to the moving arm , and for midline and contralateral targets after PRE . Only low-level , TRT subjects straightened h and paths , which suggested better coordination of elbow-shoulder motion , and improved on the RMA . High-level subjects decreased trunk use at ipsilateral target after PRE , which was not observed after TRT . No significant differences between training conditions were found for other kinematic variables . CONCLUSIONS Training benefits appear to depend on initial level of functioning . Although compensatory trunk use was evident , low-level subjects seemed to benefit most from TRT . High-level subjects , whose kinematics showed fairly normal movement organization , demonstrated less compensatory movement after PRE Objectives : To evaluate a training programme aim ed at improving lateral weight transference in patients following acute stroke to determine main treatment effects , if any , to inform the design of future studies . Design : A single-blind r and omized controlled trial . Setting : The Stroke Unit at The James Cook University Hospital , Middlesbrough , UK . Subjects : Thirty-five patients with an acute stroke . Interventions : All subjects received their usual care , including physiotherapy . The treatment group ( n / 17 ) received 12 additional therapy sessions ( over four weeks ) comprising exercises aim ed at improving lateral weight transference in sitting delivered by trained physiotherapy assistants . Main outcome measures : Measures of dynamic reaching , sitting and st and ing , and static st and ing balance were undertaken by a blind independent observer . Results : Specific measures of weight displacement in st and ing and reaching , and timed st and ing up and sitting down did not detect any differences over time regardless of group . Neither were there any significant changes over time , except for sway during static st and ing ( p B=0.01 ) and time to return to their original position during dynamic reaching ( p / 0.01 ) . Conclusions : A training programme aim ed at improving lateral weight transference did not appear to enhance the rehabilitation of acute stroke patients . Improvements observed in postural control in st and ing and sitting may be attributable to usual care or natural recovery OBJECTIVES To examine the effects of a community-based group exercise program for older individuals with chronic stroke . DESIGN Prospect i ve , single-blind , r and omized , controlled intervention trial . SETTING Intervention was community-based . Data collection was performed in a research laboratory located in a rehabilitation hospital . PARTICIPANTS Sixty-three older individuals ( aged > or = 50 ) with chronic stroke ( poststroke duration > or = 1 year ) who were living in the community . INTERVENTION Participants were r and omized into intervention group ( n=32 ) or control group ( n=31 ) . The intervention group underwent a fitness and mobility exercise ( FAME ) program design ed to improve cardiorespiratory fitness , mobility , leg muscle strength , balance , and hip bone mineral density ( BMD ) ( 1-hour sessions , three sessions/week , for 19 weeks ) . The control group underwent a seated upper extremity program . MEASUREMENTS Cardiorespiratory fitness ( maximal oxygen consumption ) , mobility ( 6-minute walk test ) , leg muscle strength ( isometric knee extension ) , balance ( Berg Balance Scale ) , activity and participation ( Physical Activity Scale for Individuals with Physical Disabilities ) , and femoral neck BMD ( using dual-energy x-ray absorptiometry ) . RESULTS The intervention group had significantly more gains in cardiorespiratory fitness , mobility , and paretic leg muscle strength than controls . Femoral neck BMD of the paretic leg was maintained in the intervention group , whereas a significant decline of the same occurred in controls . There was no significant time-by-group interaction for balance , activity and participation , nonparetic leg muscle strength , or nonparetic femoral neck BMD . CONCLUSION The FAME program is feasible and beneficial for improving some of the secondary complications result ing from physical inactivity in older adults living with stroke . It may serve as a good model of a community-based fitness program for preventing secondary diseases in older adults living with chronic conditions OBJECTIVE To determine the role of symmetrical body-weight distribution training in preventing falls among patients with hemiplegic stroke . DESIGN A prospect i ve study using a st and ing biofeedback trainer . SETTING Hospital-based rehabilitation units . PATIENTS Fifty-four patients with hemiplegic stroke ( 30 in the training group , 24 in the control group ) . INTERVENTIONS Conventional stroke rehabilitation program , plus symmetrical st and ing training and repetitive sit-to-st and training , with a st and ing biofeedback trainer . Training effect was evaluated by assessing the sit-to-st and performance and comparing the occurrence of falls in the 2 groups at a 6-month follow-up . MAIN OUTCOME MEASURES Occurrence of falls , sit-to-st and performance , including body-weight distribution , rate of rise in force , and sway in center of pressure ( COP ) . RESULTS Significant improvement in sit-to-st and performance was found in patients in the training group . Body weight was distributed more symmetrically in both legs , with less mediolateral sway in the COP when rising and sitting down . The mean difference in body-weight distribution between the left and right legs while subjects were rising from a chair significantly decreased , from 49.5 % + /- 18.9 % to 38.6 % + /- 15.8 % of body weight ( BW ) ( p < .005 ) . The rate of rise in force while rising from a chair significantly increased , from 28.3 % + /- 13.5%BW/s to 53.6 % + /- 20.5%BW/s ( p < .001 ) . At the 6-month follow-up , 10 of 24 patients ( 41.7 % ) in the control group had fallen , compared with only 5 of 30 patients ( 16.7 % ) in the training group ( p < .05 ) . CONCLUSIONS Symmetrical body-weight distribution training may improve sit-to-st and performance and , consequently , decrease the number of falls by stroke patients Purpose . The purpose of this study was to characterize the gait cycle of patients with hemiplegia before and after a period of outpatient physiotherapy based on the Bobath concept . Methods . Nine patients , at least 6 weeks post stroke and recently discharged from a stroke unit , were measured before and after a period of outpatient physiotherapy ( mean duration = 17.4 weeks ) . Therapy was documented using a treatment checklist for each patient . The primary outcome measures were a number of gait variables related to the therapists ' treatment hypothesis , recorded during the gait cycle using the CODA motion analysis system . Other secondary outcome measures were the Motor Assessment Scale , Modified Ashworth Scale , subtests of the Sodring Motor Evaluation Scale , the Step test , a 10-m walk test , the Barthel Index and the London H and icap Score . Results . Recovery of more normal gait patterns in the gait cycle ( using motion analysis ) did not occur . Significant changes in temporal parameters ( loading response , single support time ) for both legs , in one kinematic ( dorsiflexion during stance ) and one kinetic variable on the unaffected side ( hip flexor moment ) , and most of the clinical measures of impairment , activity and participation ( with the exception of the Modified Ashworth Scale and the 10-m walk ) were noted . Conclusions . Study findings did not support the hypothesis that the Bobath approach restored more normal movement patterns to the gait cycle . Further research is required to investigate the treatment techniques that are effective at improving walking ability in people after stroke AIM This paper reports an evaluation of a range-of-motion exercise programme aim ed at improving joint flexibility , activity function , perception of pain , and depressive symptoms in a sample of stroke survivors in long-term care facilities . BACKGROUND The benefits of physical rehabilitation for stroke survivors have been well established . There is , however , little empirical data on the effects of a simple nurse-led range-of-motion exercise programme in improving function for these people . METHOD A r and omized controlled trial was conducted in 1999 with 59 bedridden older stroke survivors in residential care . Participants were r and omly assigned to usual care or one of two intervention groups . The 4-week , twice-per-day , 6 days-per-week range-of-motion exercise protocol s were similar in both intervention groups , and consisted of full range-of-motion exercises of the upper and lower extremities . To test the effect of different degrees of staff involvement , in intervention group I , a Registered Nurse was present to supervise participants performing the exercises , while intervention group II involved a Registered Nurse physically assisting participants to achieve maximum range-of-motion within or beyond their present abilities . RESULTS Both intervention groups had statistically significant improvement in joint angles , activity function , perception of pain and depressive symptoms compared with the usual care group ( P < 0.05 ) . Post hoc comparison revealed that the joint angles in intervention group II were statistically significantly wider than in both the other groups ( P < 0.01 ) . CONCLUSIONS A simple nurse-led range-of-motion exercise programme can generate positive effects in enhancing physical and psychological function of bedridden older people with stroke . Further studies are needed to investigate the long-term effects of the programme in maximizing function , reducing care utilization and enhancing quality of life for this population Objective : To find out if there were any differences in improvement and maintenance of motor function , activity of daily living and grip strength between patients with first-ever stroke receiving two different strategies of physical exercise during the first year after stroke . Design : A longitudinal r and omized controlled stratified trial . Setting : Rehabilitation institutions , community , patients ' homes and nursing homes . Subjects : Seventy-five male and female first-time-ever stroke patients : 35 in an intensive exercise group and 40 in a regular exercise group . Intervention : The intensive exercise group received physiotherapy with focus on intensive exercises in four periods during the first year after stroke . The regular exercise group patients were followed up according to their subjective needs during the corresponding year . Main outcome measures : Motor Assessment Scale , Barthel Index of Activities of Daily Living , and grip strength . Results : Both groups improved significantly up to six months when function stabilized . The groups did not differ significantly on any test occasions . The difference of improvement from admission to discharge was significant in favour of the intensive exercise group , in the Motor Assessment Scale total score ( intensive exercise group 7.5 ; regular exercise group 1.7 , P = 0.01 ) , and in the Barthel Index of Activities of Daily Living total score ( 17.4 versus 8.9 , P = 0.04 ) . Conclusion : Motor function , activities of daily living functions and grip strength improved initially and were maintained during the first year after stroke in all patients irrespective of exercise regime . This indicates the importance of motivation for regular exercise in the first year following stroke , achieved by regular check-ups Objective : To investigate the effect of perceptual learning exercises for hardness discrimination by the soles on st and ing balance in stroke patients with hemiplegia . Subjects : Twenty-eight subjects were r and omly assigned to an experimental or a control group and participated in a rehabilitation programme . Intervention : The experimental group received perceptual learning exercises on hardness discrimination using three different levels of hardness of a rubber sponge for 10 days . Main measures : Length , enveloped area and rectangular area of the parameter of postural sway were measured by a stabilometer on entry into the study and after 10 days . Results : Twenty-six subjects completed the study . Data indicate that more parameters indicating postural sway were significantly decreased in the experimental group than in the control group . Also , there was a significant difference between the groups in change scores ( pre-exercise minus postexercise ) of length and enveloped area . Conclusion : The plantar perception exercise used as a method in this study is considered to be effective as a supplemental exercise for st and ing balance . The possibility of clinical application using the hardness discrimination task with rubber as a balance exercise is therefore suggested Objective : To investigate whether early aerobic training has a beneficial effect on stroke patients '  independence in daily and social activities six months after the event . Design : R and omized clinical trial . Setting : Rehabilitation unit . Subjects : Ninety-two patients after a first stroke . Interventions : Forty-six patients participated in an eight-week programme of aerobic training , using a leg cycle ergometer . Main outcome measures : Frenchay Activities Index ( FAI ) measured twice , at entry to programme ( pre-event score ) and six months after the onset of the event . Results : Despite the significant improvement of study group patients ' functional abilities immediately after the intervention compared with controls , no significant difference was found in FAI mean score between groups six months post event . An interaction effect was noted between event severity , intervention and FAI total score . Mean FAI score declined significantly less in the less severely impaired study group patients . Conclusions : Early , moderately intense aerobic training has no direct impact on independence in daily and social activities as measured by FAI total score six months after a stroke OBJECTIVE To assess the effects of a community-based exercise program on motor recovery and functional abilities of the paretic upper extremity in persons with chronic stroke . DESIGN R and omized controlled trial . SETTING Rehabilitation research laboratory and a community hall . PARTICIPANTS A sample of 63 people ( > or = 50y ) with chronic deficits result ing from stroke ( onset > or = 1y ) . INTERVENTIONS The arm group underwent an exercise program design ed to improve upper-extremity function ( 1h/session , 3 sessions/wk for 19wk ) . The leg group underwent a lower-extremity exercise program . MAIN OUTCOME MEASURES The Wolf Motor Function Test ( WMFT ) , Fugl-Meyer Assessment ( FMA ) , h and -held dynamometry ( grip strength ) , and the Motor Activity Log . RESULTS Multivariate analysis showed a significant group by time interaction ( Wilks lambda=.726 , P=.017 ) , indicating that overall , the arm group had significantly more improvement than the leg group . Post hoc analysis demonstrated that gains in WMFT ( functional ability ) ( P=.001 ) and FMA ( P=.001 ) scores were significantly higher in the arm group . The amount of improvement was comparable to other novel treatment approaches such as constraint-induced movement therapy or robot-aided exercise training previously reported in chronic stroke . Participants with moderate arm impairment benefited more from the program . CONCLUSIONS The pilot study showed that a community-based exercise program can improve upper-extremity function in persons with chronic stroke . This outcome justifies a larger clinical trial to further assess efficacy and cost effectiveness QUESTION What is the effect of a sitting training protocol in people early after stroke on sitting ability and quality , and does it carry over to mobility ? DESIGN R and omised placebo-controlled trial with concealed allocation , assessor blinding and intention-to-treat analysis . PARTICIPANTS Twelve individuals who had a stroke less than three months previously and were able to sit unsupported . INTERVENTION The experimental group completed a 2-week sitting training protocol that involved practising reaching tasks beyond arm 's length . The control group completed a 2-week sham sitting training protocol that involved practising cognitive-manipulative tasks within arm 's length . OUTCOME MEASURES The primary outcome was sitting ability ( maximum reach distance ) . Secondary outcomes were sitting quality ( reach movement time and peak vertical force through affected foot during reaching ) and carry over to mobility ( peak vertical force through affected foot during st and ing up and walking speed during 10 m Walk Test ) . Outcome measures were taken before and after training and six months later . RESULTS After 2 weeks ' training , the experimental group had increased their maximum reach distance by 0.17 m ( 95 % CI 0.12 to 0.21 ) , decreased their movement time by 0.5 s ( 95 % CI -0.8 to -0.2 ) , increased their peak vertical force through the affected foot during reaching by 13 % of body weight ( 95 % CI 6 to 20 ) and increased their peak vertical force through the affected foot during st and ing up by 21 % of body weight ( 95 % CI 14 to 28 ) compared with the control group . After 6 months , significant between-group differences were maintained for maximum reach distance and peak vertical force through the affected foot during st and ing up . CONCLUSIONS The sitting training protocol was both feasible and effective in improving sitting and st and ing up early after stroke and somewhat effective six months later Objective : To investigate the effect of independent practice of sitting balance as an addition to st and ard physiotherapy treatment for patients with stroke . Design : R and omized controlled trial , using blocked r and omization procedure with 2:1 ratio . Subjects : In patients with diagnosis of stroke , having achieved one minute of independent sitting balance but not yet achieved 10 independent steps , and with no known previous disabilities , pathology or neurological de”cit affecting mobility prior to stroke . Intervention : A four-week regime of independent practice aim ed at improving aspects of balance , as an addition to st and ard physiotherapy treatment based on the Bobath Approach . Main outcome measure : Proportion of patients achieving ‘ normal ’ symmetry of weight distribution during sitting , st and ing , rising to st and , sitting down , and reaching . Results : Nineteen subjects were r and omized to the control group ; nine to the intervention group . There were no clinical ly signi”cant differences in measured outcome between the groups . Conclusions : The regime of independent practice had no measured bene”cial effect on the balance ability of patients with recently acquired stroke Objective : To examine the effectiveness of task-oriented progressive resistance strength training on lower extremity strength and functional performance in chronic stroke subjects . Design : Single-blind , r and omized controlled trial . Setting : Medical centre and district hospital . Subjects : Forty-eight subjects at least one year post stroke . Interventions : Participants r and omly allocated to two groups , control  ( n-/24 ) and experimental  ( n-/24 ) . Subjects in the control group did not receive any rehabilitation training . Subjects in the experimental group were put on a four-week task-oriented progressive resistance strength training . Main measures : Lower extremity muscle strength , gait velocity , cadence , stride length , six-minute walk test , step test , and timed up and go test . Results : Muscle strength significantly improved in the experimental group for strong side muscle groups ( ranged from 23.9 % to 36.5 % ) and paretic side muscle groups ( ranged from 10.1 % to 77.9 % ) . In the control group muscle strength changes ranged from 6.7 % gain to 11.2 % decline . The experimental group showed significant improvement in all selected measures of functional performance except for the step test . In the control group , the number of repetitions of the step test significantly decreased ( -20.3 % ) with no change in other functional tests . There was a significant difference between groups for muscle strength and all functional measures . The strength gain was significantly associated with gain in the functional tests . Conclusions : The task-oriented progressive resistance strength training programme could improve lower extremity muscle strength in individuals with chronic stroke and could carry over into improvement in functional abilities
target: RESULTS Studies of task-related training showed benefits for functional outcome compared with traditional therapies .
  Active use of task-oriented training with stroke survivors will lead to improvements in functional outcomes and overall health-related quality of life .
  CONCLUSION Generally , task-oriented rehabilitation proved to be more effective .
  Many interventions are feasible for nurses and can be performed in a ward or at home .
background: AIM This paper is a report of a review conducted to provide an overview of the evidence in the literature on task-oriented training of stroke survivors and its relevance in daily nursing practice .
  BACKGROUND Stroke is the second leading cause of death and one of the leading causes of adult disability in the Western world .
  The use of neurodevelopmental treatment in the daily nursing care of stroke survivors does not improve clinical outcomes .
  Nurses are therefore exploring other forms of rehabilitation intervention , including task-oriented rehabilitation .
  Despite the growing number of studies showing evidence on task-oriented interventions , recommendations for daily nursing practice are lacking .