Wolf Motor Function Test Performance Time Research Articles

Translation and Initial Validation of the Chinese Version of the Action Research Arm Test in People with Stroke

Purpose This study aimed to translate the English version of the Action Research Arm Test (ARAT) into Chinese and to evaluate the initial validation of the Chinese version (C-ARAT) in patients with a first stroke. Methods An expert group translated the original ARAT from English into Chinese using a forward-backward procedure. Forty-four patients (36 men and 8 women) aged 22–80 years with a first stroke were enrolled in this study. The participants were evaluated using 3 stroke-specific outcome measures: C-ARAT, the upper extremity section of the Fugl–Meyer assessment (UE-FMA), and the Wolf Motor Function Test (WMFT). Internal consistency was analysed using Cronbach's α coefficients and item-scale correlations. Concurrent validity was determined using Spearman's rank correlation coefficients. Floor and ceiling effects were considered to be present when more than 20% of patients fell outside the preliminarily set lower or upper boundary, respectively. Results The C-ARAT items yielded excellent internal consistency, with a Cronbach's α of 0.98 (p < 0.001) and item-total correlations ranging from 0.727 to 0.948 (p < 0.001). The C-ARAT exhibited good-to-excellent correlations with the UE-FMA and WMFT functional ability (WMFT-FA) scores, with respective ρ values of 0.824 and 0.852 (p < 0.001), and an excellent negative correlation with the WMFT performance time (WMFT-time), with a ρ value of -0.940 (p < 0.001). The C-ARAT subscales generally exhibited good-to-excellent correlations with stroke-specific assessments, with ρ values ranging from 0.773 to 0.927 (p < 0.001). However, the gross subscale exhibited moderate-to-good correlations with the UE-FMA and WMFT-FA scores, with respective ρ values of 0.665 and 0.720 (p < 0.001). No significant floor effect was observed, and a significant ceiling effect was observed only on the WMFT-time. Conclusions The C-ARAT demonstrated excellent internal consistency and good-to-excellent concurrent validity. This test could be used to evaluate upper extremity function in stroke patients without cognitive impairment.

Adapted Tai Chi Enhances Upper Limb Motor Control in Chronic Stroke Patients: A Pilot Study

Background: Tai Chi has been reported as beneficial for improving balance post stroke, yet no study examined the use of Tai Chi for upper limb rehabilitation. The objective of this study was to evaluate the efficacy and acceptability of Tai Chi for upper limb rehabilitation post stroke. Methods: Twelve chronic stroke survivors with a persistent paretic upper limb underwent 60-min adapted Tai Chi sessions twice a week for eight weeks and a 4-week follow-up. A 10-min Tai Chi home program was recommended for the days without sessions. Session attendance and duration of self-practice at home were recorded. Motor function of the paretic arm (Fugl-Meyer Assessment upper-limb section (FMA-UL)), Wolf Motor Function Test (WMFT) and paretic arm use in daily life(Motor Activity Log (MAL)) were measured at baseline, post-treatment and follow-up. A feedback questionnaire was used to evaluate participants’ perception of the use of Tai Chi at follow-up. Results: Eleven participants completed the 8-week study. Participants with varying profiles including severely impaired upper limb, poor balance, shoulder pain, and severe spasticity, were able to practice an adapted version of Tai Chi. They attended all 16 sessions and practiced Tai Chi at home more than recommended (a total of 16.51 ± 9.21 hours). Participants demonstrated significant improvement over time in the FMA-UL (p=0.009), WMFT functional scale (p=0.003), WMFT performance time (p=0.048) and MAL Amount of Use scale (p=0.02). Moreover, participants confirmed the usefulness and ease of practicing the adapted Tai Chi. Conclusion: Tai Chi was acceptable and found to be effective for upper limb rehabilitation post stroke after adaptation of movements. Further large-scale randomized trials evaluating Tai Chi for upper limb rehabilitation are warranted.

Efficacy and safety of non-immersive virtual reality exercising in stroke rehabilitation (EVREST): a randomised, multicentre, single-blind, controlled trial

Non-immersive virtual reality is an emerging strategy to enhance motor performance for stroke rehabilitation. There has been rapid adoption of non-immersive virtual reality as a rehabilitation strategy despite the limited evidence about its safety and effectiveness. Our aim was to compare the safety and efficacy of virtual reality with recreational therapy on motor recovery in patients after an acute ischaemic stroke. In this randomised, controlled, single-blind, parallel-group trial we enrolled adults (aged 18-85 years) who had a first-ever ischaemic stroke and a motor deficit of the upper extremity score of 3 or more (measured with the Chedoke-McMaster scale) within 3 months of randomisation from 14 in-patient stroke rehabilitation units from four countries (Canada [11], Argentina [1], Peru [1], and Thailand [1]). Participants were randomly allocated (1:1) by a computer-generated assignment at enrolment to receive a programme of structured, task-oriented, upper extremity sessions (ten sessions, 60 min each) of either non-immersive virtual reality using the Nintendo Wii gaming system (VRWii) or simple recreational activities (playing cards, bingo, Jenga, or ball game) as add-on therapies to conventional rehabilitation over a 2 week period. All investigators assessing outcomes were masked to treatment assignment. The primary outcome was upper extremity motor performance measured by total time to complete the Wolf Motor Function Test (WMFT) at the end of the 2 week intervention period, analysed in the intention-to-treat population. This trial is registered with ClinicalTrials.gov, number NTC01406912. The study was done between May 12, 2012, and Oct 1, 2015. We randomly assigned 141 patients: 71 received VRWii therapy and 70 received recreational activity. 121 (86%) patients (59 in the VRWii group and 62 in the recreational activity group) completed the final assessment and were included in the primary analysis. Each group improved WMFT performance time relative to baseline (decrease in median time from 43·7 s [IQR 26·1-68·0] to 29·7 s [21·4-45·2], 32·0% reduction for VRWii vs 38·0 s [IQR 28·0-64·1] to 27·1 s [21·2-45·5], 28·7% reduction for recreational activity). Mean time of conventional rehabilitation during the trial was similar between groups (VRWii, 373 min [SD 322] vs recreational activity, 397 min [345]; p=0·70) as was the total duration of study intervention (VRWii, 528 min [SD 155] vs recreational activity, 541 min [142]; p=0·60). Multivariable analysis adjusted for baseline WMFT score, age, sex, baseline Chedoke-McMaster, and stroke severity revealed no significant difference between groups in the primary outcome (adjusted mean estimate of difference in WMFT: 4·1 s, 95% CI -14·4 to 22·6). There were three serious adverse events during the trial, all deemed to be unrelated to the interventions (seizure after discharge and intracerebral haemorrhage in the recreational activity group and heart attack in the VRWii group). Overall incidences of adverse events and serious adverse events were similar between treatment groups. In patients who had a stroke within the 3 months before enrolment and had mild-to-moderate upper extremity motor impairment, non-immersive virtual reality as an add-on therapy to conventional rehabilitation was not superior to a recreational activity intervention in improving motor function, as measured by WMFT. Our study suggests that the type of task used in motor rehabilitation post-stroke might be less relevant, as long as it is intensive enough and task-specific. Simple, low-cost, and widely available recreational activities might be as effective as innovative non-immersive virtual reality technologies. Heart and Stroke Foundation of Canada and Ontario Ministry of Health.

Baseline Severity of Upper Limb Hemiparesis Influences the Outcome of Low-Frequency rTMS Combined With Intensive Occupational Therapy in Patients Who Have Had a Stroke

To clarify whether the efficacy of combined low-frequency repetitive transcranial magnetic stimulation (rTMS) and intensive occupational therapy (OT) depends on baseline severity of upper limb hemiparesis after stroke. Retrospective comparative study. Department of Rehabilitation Medicine at a university hospital. Fifty-two patients who had sustained a stroke and had upper limb hemiparesis (age: 57 ± 13 years; time after onset: 50 ± 33 months). Based on the Brunnstrom stage for hand-fingers at admission, patients were divided into a Stage 3 group (n = 13), a Stage 4 group (n = 20), and a Stage 5 group (n = 19). During a 15-day hospitalization, each patient underwent 22 sessions of 20-minute low-frequency rTMS that was applied to the non-lesional hemisphere and 120 minutes of intensive OT (one-on-one training and self-training). Motor function of the affected upper limb was evaluated with the Fugl-Meyer Assessment and the Wolf Motor Function Test (WMFT) on the days of admission and discharge. WMFT performance time data were log-transformed. The Fugl-Meyer Assessment score increased significantly in all patients (from 40.2 ± 12.2 to 43.4 ± 11.8 points, P < .001), but the score increase was significantly larger in the Stage 4 group than in the other two groups (2.1 ± 2.3 points in the Stage 3 group, 5.1 ± 2.9 points in the Stage 4 group, and 2.3 ± 1.8 points in the Stage 5 group, all P < .05). Similarly, the WMFT performance time decreased significantly in all patients (from 3.27 ± 0.90 to 2.96 ± 1.10, P < .001), but the difference in the extent of the decrease was significant between Stage 3 and Stage 4 groups and between Stage 3 and Stage 5 groups (0.04 ± 0.07 in the Stage 3 group, 0.41 ± 0.29 in the Stage 4 group, and 0.35 ± 0.31 in the Stage 5 group, all P < .01). Our 15-day protocol of low-frequency rTMS and intensive OT is potentially promising in improving motor function of the affected upper limb. The extent of motor improvement by the intervention seemed to be influenced by the severity of upper limb hemiparesis at study entry.

Minimal Detectable Change Scores for the Wolf Motor Function Test

Background. The Wolf Motor Function Test (WMFT) is an impairment-based test whose psychometrics have been examined by previous reliability and validity studies. Standards for evaluating whether a given change is meaningful, however, have not yet been addressed. Objectives. To determine the standard error of measurement (SEM) and minimal detectable change (MDC) for the WMFT. Methods. Data were collected from 6 university laboratories that participated in the EXCITE national clinical trial and included 96 individuals with sub-acute stroke (3—9 months). Measurements were made by blinded evaluators who were trained and standardized to administer the WMFT, which was completed on 2 occasions 2 weeks apart. No intervention was given between testing sessions. Results. The WMFT Performance Time score has a SEM of 0.2 seconds and a MDC95 of 0.7 seconds. The individual task timed items MDC 95 ranged from 1.0 second (turn key in lock) to 3.4 seconds (reach and retrieve) with individual task items demonstrating notablly higher variability than the average WMFT Performance Time. The average WMFT Functional Ability Scale SEM and MDC95 is 0.1 points. Conclusions. When assessing the effect of a therapeutic intervention, if an individual experiences an amount of change equal to or greater than the MDC, then one may be 95% confident that this margin of change is truly larger than measurement error and not a chance result. Thus, the determination of SEM and MDC in outcome assessments allows researchers and clinicians to distinguish which results are actual differences versus which results are simply changes resulting from error or chance.

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

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

The Effects of Constraint-Induced Therapy on Kinematic Outcomes and Compensatory Movement Patterns: An Exploratory Study

Massie C, Malcolm MP, Greene D, Thaut M. The effects of constraint-induced therapy on kinematic outcomes and compensatory movement patterns: an exploratory study. Objective To determine changes in kinematic variables and compensatory movement patterns of survivors of stroke completing constraint-induced therapy (CIT). Design Pre-post, case series. Setting Clinical rehabilitation research laboratory. Participants Men (n=7) and women (n=3) with unilateral stroke occurring at least 9 months prior to study entry with moderate, stable motor deficits. Intervention Participants completed 10 consecutive weekdays of CIT for 6 hours a day comprised of trainer-supervised, functionally based activities using massed practice. Main Outcome Measures Kinematic measures included movement time, average velocity, trajectory stability, shoulder abduction, and segmental contribution. Functional measures included Wolf Motor Function Test (WMFT) performance time and functional ability scores and Motor Activity Log (MAL) “how-well” scores. All measures were administered before and after the 2-week CIT intervention. Results Movement time, average velocity, and trajectory stability significantly improved after CIT. Participants used more shoulder flexion to reach after CIT, but also demonstrated increased compensatory shoulder abduction. Functional scores also significantly improved, including WMFT performance time and functional ability and MAL scores. There was no change in trunk movement or amount of elbow extension. Conclusions CIT improved motor capacities in the hemiparetic arm as reflected in the functional outcomes and in some kinematic measures. Participants' reliance on common compensatory movements was not beneficially affected by CIT. The results of this study demonstrate that while functional capacity and some movement strategies in the hemiparetic arm improve after CIT, participants may not overcome their reliance on common compensatory movement patterns. Based on these findings, this study suggests that CIT may encourage subjects to generate movement through compensatory and/or synergy-dominated movement rather than promote the normalization of motor control. This outcome highlights the need to develop CIT further as an intervention that improves functional capacity and more normative movement strategies.

Responsiveness and Validity of 3 Outcome Measures of Motor Function After Stroke Rehabilitation

To the Editor: With interest we read the recently published letter of Dr Sivan, “Interpreting Effect Size to Estimate Responsiveness of Outcome Measures,”1 as a response to a paper by Hsieh et al2 in which they provided indices of the magnitude of treatment-related intraindividual change assessed with the Fugl-Meyer Assessment (FMA), Action Research Arm Test (ARAT), and Wolf Motor Function Test performance time (WMFT-TIME) and functional ability scores (WMFT-FAS). As an effect size index, Hsieh et al used the method of the so-called standardized response mean (SRM) by which mean change in scores over time is divided by the SD of these change scores (see Formula A). ![Formula][1] As Sivan argued in his letter,1 the interpretation of the magnitude of intraindividual change estimated with a SRM may lead to overestimation or underestimation of treatment-related effects when the widely used thresholds of Cohen3 … [1]: /embed/graphic-1.gif

Interpreting the Randomized Clinical Trial of Constraint-Induced Movement Therapy

JAMA Effect of Constraint-Induced Movement Therapy on Upper Extremity Function 3 to 9 Months After Stroke: The EXCITE Randomized Clinical Trial Steven L. Wolf, PhD, PT; Carolee J. Winstein, PhD, PT; J. Philip Miller, AB; Edward Taub, PhD; Gitendra Uswatte, PhD; David Morris, PhD, PT; Carol Giuliani, PhD, PT; Kathye E. Light, PhD, PT; Deborah Nichols-Larsen, PhD, PT; for the EXCITE Investigators 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 hand 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 prospective, single-blind, randomized, 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 hand while engaging in repetitive task practice and behavioral shaping with the hemiplegic hand) 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 P Conclusion: Among patients who had a stroke within the previous 3 to 9 months, CIMT produced statistically significant and clinically relevant improvements in arm motor function that persisted for at least 1 year. Trial Registration: clinicaltrials.gov Identifier:NCT00057018

Constraint-induced movement therapy improves upper extremity motor function after stroke

What is the effect of constraint-induced movement therapy (CIMT) on upper limb function in patients 3 to 9 months after stroke? Randomised controlled trial with concealed allocation and assessor blinding. Seven universities in the USA, recruiting participants from 247 medical facilities. 222 adults 3 to 9 months after their first ischaemic or haemorrhagic stroke with at least 10° of active extension at the wrist and at the thumb and two fingers. Participants also had to demonstrate adequate balance, transfer, sit-to-stand, and standing ability while wearing the mitt used to apply CIMT. One hundred and six patients were randomised to CIMT and 116 to usual care. CIMT involved wearing a restraining mitt on the less-affected hand for 90% of their waking hours over a 2-week period. On weekdays during this period, repetitive task practice and behavioural shaping with the hemiplegic hand were performed for up to 6 hours per day, with 30 minutes of additional practice of the tasks at home. Usual care ranged from no treatment after concluding formal rehabilitation to the application of orthotics or occupational/physical therapy on a domiciliary or outpatient basis. The primary outcomes were the Wolf Motor Function Test (WMFT), which includes measures of speed and strength of upper extremity motor function, and the Motor Activity Log (MAL), an interview-derived measure on a 0–5 scale of the amount and quality of performance of 30 common daily activities. The Stroke Impact Scale (SIS) health status interview was a secondary outcome measure. All outcomes were measured after treatment and at 4, 8, and 12 months post-treatment. From baseline to 12 months, the CIMT group showed greater improvements than the usual care group in: the WMFT Performance Time by 34% (95% confidence interval (CI) 12 to 51); the MAL Amount of Use by 0.43 (95% CI 0.05 to 0.80); and the MAL Quality of Movement by 0.48 (95% CI 0.13 to 0.84). The CIMT group also had a significantly greater decrease in self-perceived hand function difficulty on the SIS hand domain, by 9% (95% CI 0.3 to 19). Among patients who have had a stroke in the past 3 to 9 months, CIMT produces improvements in arm motor function that persist for at least one year.