Skip to main page content

• HOME
• Current
• Past issues
• Contact us
• Subscribe
• Sign up for e-Alerts
• Help

PHYS THER
Vol. 89, No. 9, September 2009, pp. 995-997
DOI: 10.2522/ptj.2009.89.9.995

This Article Extract Full Text (PDF) Submit a response Alert me when this article is cited Alert me when Rapid Responses are posted Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Hammer, A. M. Articles by Lindmark, B. Search for Related Content PubMed Articles by Hammer, A. M. Articles by Lindmark, B. Related Collections Adaptive/Assistive Devices Therapeutic Exercise Hemiplegia/Paraplegia/Quadriplegia Motor Control and Motor Learning Stroke (Neurology) Stroke (Geriatrics) Social Bookmarking                      What's this?

Letters and Responses

Author Response

We thank Wolf¹ for his interest in our work recently published in PTJ.² We also thank the editor for giving us an opportunity to respond to Wolf's comments.

The issue of labeling an intervention is challenging. The reason for our choice of the term "forced use" is here explained. When our present study was initiated, constraint-induced movement therapy (CIMT) was presented only in the classic version,³ apart from forced use described earlier.^4,5 As the idea of our study was to add the sling to the ongoing rehabilitation, we did not think this would qualify the use of the term "CIMT" because the interventions were not intensified or focused exclusively on the upper limb. Other published studies in this area have used terms such as "modified CIMT,"^6–8 "distributed CIMT,"⁹ "shorter CIMT,"¹⁰ or "shortened CIMT,"¹¹ always completely focusing the training on the upper limb. Therefore, we believe "forced use" was a more appropriate label of our intervention.

The motor impairment of the people in our study was, to some extent, moderate. However, participants recruited for the EXCITE trial were both higher functioning and lower functioning, based on amount of wrist and digit extension at inclusion.^12,13 Our patients were all in the higher-functioning state, fulfilling such inclusion criteria. The Fugl-Meyer test scores presented by Wolf et al¹³ represent the total means for all patients in the EXCITE trial (42.5 and 41.1), but the mean Fugl-Meyer test score of the patients in the higher-functioning state was 44.9.¹⁴ The Motor Activity Log (MAL) scores presented in Figure 2 in the article by Wolf et al¹³ show that there was close to a 1-point difference at each time point between the lower-functioning and higher-functioning subgroups. Regarding our sample, the mean scores of the scales used (see Tab. 2 in our article²) were within the upper third of these scales’ range of scores. Nevertheless, the results of the 16-hole peg test and the Grippit ratio certainly represent a substantial deficit of motor function.

We recently reported on outcome on daily hand use,¹⁵ and the MAL scores showed an obviously reduced level of performance in daily life, with a baseline mean score 1 week before intervention of 1.3 on this 0 to 5 scale. Thus, we would say the level of hand use in our patients was similar to that of the higher-functioning subgroup in the EXCITE study.¹³ Individually, only 3 of the 30 participants in our study had a baseline MAL score higher than 2.5. We would suggest that this finding demonstrates that high scores on a motor scale do not tell the whole truth. Patients have much more difficulty making use of their hand in daily functioning, which is captured by a measure of daily hand use. This may be explained by the several extended difficulties encountered when performing a "real-life" task compared with a relatively simple standard test. Additionally, our sample performed a first preintervention test 1 week before the intervention not only of the MAL¹⁵ but also of the results for the other measures shown in the Table, indicating a slightly lower motor function than we reported immediately prior to the intervention.²

View this table: [in this window] [in a new window]

Table. Outcome Measures at the First Preintervention Test Occasiona

The field of stroke rehabilitation research is immense, and findings are gradually accumulating. To agree with Wolf, we are hopeful for the future with an extended base of knowledge concerning patient-related benefits of rehabilitation—no matter what ingredients of training contribute.

Ann M. Hammer and Birgitta Lindmark

A.M. Hammer, PT, MSc, is Doctoral Student, Department of Rehabilitation Medicine, Örebro University Hospital, and School of Health and Medical Sciences, Örebro University, S-701 85 Örebro, Sweden.
B. Lindmark, PhD, is Professor Emeritus, Section of Physiotherapy, Department of Neuroscience, Uppsala University, Uppsala, Sweden.

Address all correspondence to Ms Hammer at: ann.hammer{at}orebroll.se

 
This letter was posted as a Rapid Response on July 28, 2009, at www.ptjournal.org.

References

1. Wolf SL. Letter to the editor on "Effects of forced use on arm function in the subacute phase after stroke: a randomized, clinical pilot study." Phys Ther. 2009;89:526–539.[Abstract/Free Full Text]
2. Hammer AM, Lindmark B. Effects of forced use on arm function in the subacute phase after stroke: a randomized, clinical pilot study. Phys Ther. 2009;89:526–539.[Abstract/Free Full Text]
3. Taub E, Miller NE, Novack TA, et al. Technique to improve chronic motor deficit after stroke. Arch Phys Med Rehabil. 1993;74:347–354.[Web of Science][Medline]
4. Ostendorf CG, Wolf SL. Effect of forced use of the upper extremity of a hemiplegic patient on changes in function: a single-case design. Phys Ther. 1981;61:1022–1028.[Abstract/Free Full Text]
5. Wolf SL, Lecraw DE, Barton LA, Jann BB. Forced use of hemiplegic upper extremities to reverse the effect of learned nonuse among chronic stroke and head-injured patients. Exp Neurol. 1989;104:125–132.[CrossRef][Web of Science][Medline]
6. Atteya AA. Effects of modified constraint induced therapy on upper limb function in subacute patients. Neuroscience. 2004;9:24–29.
7. Wu CY, Lin KC, Chen HC, et al. Effects of modified constraint-induced movement therapy on movement kinematics and daily function in patients with stroke: a kinematic study of motor control mechanisms. Neurorehabil Neural Repair. 2007;21:460–466.[Abstract/Free Full Text]
8. Page SJ, Levine P, Leonard A, et al. Modified constraint-induced therapy in chronic stroke: results of a single-blinded randomized controlled trial. Phys Ther. 2008;88:333–340.[Abstract/Free Full Text]
9. Dettmers C, Teske U, Hamzei F, et al. Distributed form of constraint-induced movement therapy improves functional outcome and quality of life after stroke. Arch Phys Med Rehabil. 2005;86:204–209.[CrossRef][Web of Science][Medline]
10. Sterr A, Elbert T, Berthold I, et al. Longer versus shorter daily constraint-induced movement therapy of chronic hemiparesis: an exploratory study. Arch Phys Med Rehabil. 2002;83:1374–1377.[CrossRef][Web of Science][Medline]
11. Brogardh C, Vestling M, Sjolund BH. Shortened constraint-induced movement therapy in subacute stroke-no effect of using a restraint: a randomized controlled study with independent observers. J Rehabil Med. 2009;41:231–236.[CrossRef][Web of Science][Medline]
12. Winstein CJ, Miller JP, Blanton S, et al. Methods for a multisite randomized trial to investigate the effect of constraint-induced movement therapy in improving upper extremity function among adults recovering from a cerebrovascular stroke. Neurorehabil Neural Repair. 2003;17:137–152.[Abstract/Free Full Text]
13. Wolf SL, Winstein CJ, Miller JP, et al. Effect of constraint-induced movement therapy on upper extremity function 3 to 9 months after stroke: the EXCITE randomized clinical trial. JAMA. 2006;296:2095–2104.[Abstract/Free Full Text]
14. Wolf SL, Thompson PA, Morris DM, et al. The EXCITE trial: attributes of the Wolf Motor Function Test in patients with subacute stroke. Neurorehabil Neural Repair. 2005;19:194–205.[Abstract/Free Full Text]
15. Hammer AM, Lindmark B. Is forced use of the paretic upper limb beneficial? A randomized pilot study during subacute post-stroke recovery. Clin Rehabil. 2009;23:424–433.[Abstract/Free Full Text]

CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    Technorati    What's this?

This Article Extract Full Text (PDF) Submit a response Alert me when this article is cited Alert me when Rapid Responses are posted Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Hammer, A. M. Articles by Lindmark, B. Search for Related Content PubMed Articles by Hammer, A. M. Articles by Lindmark, B. Related Collections Adaptive/Assistive Devices Therapeutic Exercise Hemiplegia/Paraplegia/Quadriplegia Motor Control and Motor Learning Stroke (Neurology) Stroke (Geriatrics) Social Bookmarking                      What's this?