Title: Evidence on Upper Extremity Rehabilitation using Task-Oriented Approach on Patients with hronic !

troke
Appraisers: "arvey # $omingo
Appraisal Date: April %&'(
Review Date: April %&')
Clinical Scenario:
*a+ority o, the patients who come ,or rehabilitation at the linic ,or Therapy !ervices-Adult and Adolescent section .T!-AA/
are with neurologic lesions0 speci,ically stroke# *ost o, them0 aged (&-1& years old have chronic cases with 2(-'& years status
post their lesion but still have not recovered ,unctionally# *any o, the patients served at the clinic are already community
ambulators but now complains more o, di,,iculty in per,orming upper extremity ,unctions0 as in bimanual tasks like eating0
dressing0 preparing ,ood0 washing the dishes and doing the laundry# Their complaints are primarily linked but not limited to the
persistence o, synergistic patterns and spasticity limiting their upper extremity ,unction#
3ith learning o, motor combinations outside these synergistic patterns0 their in,luence to control motor acts decreases
.4runnstrom0 '5)& as cited by O6!ullivan0 %&&)/# Relearning motor skills in relation to improving ,unction there,ore is the
rehabilitative ,ocus o, physical therapists to address activity limitations o, patients with neurologic lesions a,,ected by persistence
o, pathologic synergies#
The Task-oriented approach addresses motor control problems at three levels7 Impairment, Strategy and Function. 8t real world
environments0 and provides intervention based on the a,orementioned three levels# *otor learning approaches such as this take
on the principle o, the plasticity o, the brain wherein reorgani9ation is possible depending on the amount o, ,eedback given to the
brain# 4rain reorgani9ation however is better maximi9ed during acute stages o, brain lesions
"owever patients who su,,ered stroke being catered at T!-AA are already in their chronic stages and have unlearned many
motor skills and have adapted their movements to dominating synergies# The therapist there,ore would like to know i, task-
oriented approach will be e,,ective in improving upper extremity ,unction o, patients with chronic stroke#
Clinical Question:
Patient: Patient with chronic stroke
Intervention: Task-oriented upper limb rehabilitation
Comparison intervention: N/A
Outcomes: 8mprove upper limb ,unction
Is task-oriented rehabilitation effective in improving upper limb function of patients ith chronic stroke!
Clinical Bottom Line:

There is high evidence suggesting that task-oriented upper limb rehabilitation is not e,,ective in improving upper extremity
,unction on patients with chronic stroke#
4ased on both articles appraised0 ,unctional arm training ."iggins et al#0 %&&1/ and rhythmic precision grip task-oriented
rehabilitation .$ispa et al#0 %&':/ ,or chronic patients with stroke are not e,,ective in improving arm ,unction# ;o statistical nor
clinical signi,icant di,,erences were noted ,or both treatments# The therapist there,ore recommends to de,er managing the
patients with chronic stroke using task-oriented rehabilitation# "owever it must be noted that ,uture evidences especially those o,
higher <uality types and increased sample si9e may change the recommendation#
1
Search Histor
Data!ases:
The ,ollowing databases were used ,or the evidence search7
'# Pub*ed
%# Physiotherapy Evidence $atabase .PE$ro/
:# ochrane $atabase
4. "igh3ire
The selection o, these databases has been agreed upon based on their credibility as established by ,re<uent citations in
systematic reviews and meta-analyses# The group also considered the accessibility o, these databases that o,,er ,ree usage and
,ree ,ull text o, most articles# =urthermore0 these databases contain relevant articles that relate to the clinical <uestion and the
physical therapy practice in general#
Search Terms
hronic
!troke0 ardiovascular disease0 >$0 ardiovascular accident0 >A
Task oriented approach0 task oriented training
Upper extremity0 bimanual
=unction0 activities
Inclusion Criteria:
The study designs must be a !ystematic Review0 *eta-analysis0 Randomi9ed clinical trials and?or ontrolled clinical
trials#
Patients involved had chronic stroke0 which means they had the condition ,or at least 1 months .O6!ullivan0 %&&)/
Patients involved are adults ranging ,rom (&-1& years old
Published within the last '& years
Published in English and studies that have English translations
"#clusion Criteria:
Patients have other musculoskeletal conditions that a,,ect gait#
Used other physical agents ,or treatment#
Please re,er to page 1 .Appendix A0 !earch "istory =lowchart/ ,or details o, the search process#
2
Summar o$ Stu%ies
Stu%
&etho%olo'
(Dispa) et al*) +,-./ The e,,ect o, repetitive rhythmic precision grip task-oriented
rehabilitation in chronic stroke patients7 A pilot study
(Hi''ins) et al*) +,,0/ The e,,ect o, a task-oriented intervention on arm ,unction in
people with stroke7 A randomi9ed control trial
Desi'n Randomi9ed controlled trial Randomi9ed control trial
Inclusion Criteria
Patients had to have stroke .evidenced by *R8/ ,or a minimum o, 1 months
"ad to be able to li,t and hold an ob+ect o, %@&g between thumb and index
,inger ,or a ,ew seconds
3ith a *ini *ental !tate Evaluation score o, above %1?:&
linical diagnosis o, a ,irst or recurrent stroke
Residual walking de,icit
3ith at least '( out o, %( score on telephone version o, *ini-*ental !tate
Examination
Ability to walk '&m independently with or without supervision?aid
!u,,icient language ability to ,ollow instructions
Aiving in the community
$ischarged ,rom physical rehabilitation
Aess than ' year post-stroke at time o, recruitment
Sample
Ten .'&/ chronic hemiparetic patients .mean age 11 B ''#' years0 nine men and one
woman/ divided into the groups A and 4 with nC@ each group#
Total o, 5' sub+ects recruited ,rom 5 hospitals and % rehabilitation centers divided into
% treatment groups7
a/ Arm group .nC()0 mean age ): B D years0 1(E males0 )DE post-stroke at
'-( years/
b/ 3alking group .nC((0 mean age )' B '% years0 @5E males0 15E post-
stroke at '-( years/
Intervention
The trial is a cross-over design with therapy sessions that occurred at '-hour0 : times
a week ,or D weeks# =our weeks each were allocated ,or the unilateral movement
therapy and bilateral movement therapy# =or the entire period o, the program0 ongoing
treatments were kept unchanged#
A# 4ilateral movement therapy
- ) bilateral grip-li,t task-oriented exercises with auditory cueing .(
simultaneous bilateral tasks0 : alternated bilateral movement tasks/
4# Unilateral movement therapy
- !ame exercises described in the bilateral movement protocols with same
rhythm and task di,,iculty level adapted#
!ub+ects in both groups participated in 'D practice sessions .5& min each/ : times a
week ,or 1 weeks#
A# Arm intervention
- =unctional training regarding daily activities that were di,,icult to per,orm and
that they wanted to improve# Tasks and di,,iculty levels were modi,ied
accordingly and as needed# >ibration and passive range o, movements
were given to those who did not have su,,icient movement in their paretic
arms#
4# 3alking interventions
- '& ,unctional tasks designed to strengthen lower extremities and enhance0
walking balance0 speed and distance covered
3
Stu%
&etho%olo'
(Dispa) et al*) +,-./ The e,,ect o, repetitive rhythmic precision grip task-oriented
rehabilitation in chronic stroke patients7 A pilot study
(Hi''ins) et al*) +,,0/ The e,,ect o, a task-oriented intervention on arm ,unction in
people with stroke7 A randomi9ed control trial
Outcome
&easures
A# 4ody structures and ,unctions
'# Using a manipulandum with three strain gauges to allow ,orce perpendicular
to each contact sur,ace be measured in addition to the total tangential ,orce
applied on the ob+ect#
%# Purdue pegboard test to evaluate digital dexterity
4# Activity and participation
'# A48A"A;$ <uestionnaire to assess manual ability or capacity to manage
daily activities re<uiring use o, upper limbs
%# !AT8!-!troke <uestionnaire to measure activities and participation in actual
environment experienced by patients a,ter chronic stroke
A# *easures o, arm activity limitation .capacity/
'# 4ox and 4lock Test ,or gross manual dexterity
%# ;ine-"ole Peg Test ,or ,ine manual dexterity
:# TE*PA .Test dFGvaluation des membres supGrieurs des personnes HgGes/
,or activity per,ormance o, the arms on individuals over the age o, 1&
4# *easures o, arm impairment
'# Irip strength using Jamar dynamometer
%# Upper extremity subscale o, !TREA* .!troke Rehabilitation Assessment o,
*ovement/ to measure voluntary movement o, the arm
# 8ndices o, arm activity limitation .capacity/
'# 4arhtel 8ndex .,eeding0 personal hygiene0 bathing0 dressing only/
%# Older Americans Resources and !ervices !cale K 8nstrumental Activities o,
$aily Aiving .meal preparation and housework only/
:# *edical Outcomes !tudy :1-8tem short ,orm Luestionnaire M!=-:1N .grocery
carrying and bathing?dressing only/
(# Ieriatric $epression !cale to measure depressive symptoms
Results1
Outcomes
The two-way R*-A;O>A applied to the results o, the paretic hand at the :
assessment periods did not detect di,,erence between two movement therapy groups
."O&#'(( in all instances/#
;o signi,icant changes ,or the body structures and ,unctions Mgrip-li,t parameters
."O&#'5: in all instances/0 digital dexterity ."C&#'5:/N0 manual ability ."C&#&)%/ or
patient satis,action with activities and participation in daily li,e ."C&#%1'/#
;o statistically signi,icant di,,erences and clinically signi,icant improvements on both
groups in all outcome measures7 4ox and 4lock Test .P
%
C:0 d,C&#50 PC&#D'D/0 ;ine-
hole peg test0 TE*PA0 grip strength .meanC&#@kg arm group more than mobility
group/0 !TREA* .meanC: points increase on both groups/0 and on all indices o, arm
activity limitation
"vi%ence Level %A .Please re,er to page ) K Appendix 0 Table o, Evidence Aevels/ %A .Please re,er to page ) K Appendix 0 Table o, Evidence Aevels/
4
Comments12otes:
"iggins et al# .%&&1/ provided a hypothesis that walking intervention may also increase arm ,unction based on the
premise o, using the hands ,or ambulation such as in holding onto handrails#
The studies are randomi9ed controlled trials and are o, strong design0 given an intervention clinical <uestion# The
studies are o, high <uality based on the scores using the Physiotherapy Evidence $atabase .PE$ro/ rating scale .see
page )0 Appendix 40 ritical Appraisal/# $espite the good <uality o, the article obtained0 no meta-analyses or
systematic review were ac<uired# There,ore0 ,urther studies o, stronger design may in,luence the result o, the study#
$espite the studies6 strong design and high <uality0 they also has some limitations# $ispa et al# .%&':/0 being a pilot
study has a small sample si9e0 a,,ecting the applicability o, the results in other populations# 4oth studies did not have
participant and therapist blinding0 a,,ecting the reliability and validity o, their results# !peci,ically ,or the study o, "iggins
et al# .%&&1/0 some o, their dropouts were caused by participants6 wanting to undergo walking intervention instead o,
the arm intervention#
;o study reported on the cost-e,,ectiveness o, the interventions#
Citations:
Article#
$ispa0 $#0 Ae+eune0 T#0 Q Thonnard0 JA# .%&':/# The e,,ect o, repetitive rhythmic precision grip task-oriented rehabilitation in
chronic stroke patients7 A pilot study# International $ournal of %ehabilitation %esearch. &'.'/7D'-D)# doi7
'&#'&5)?*RR#&b&':e:%D:@ac,d@
"iggins0 J#0 !albach0 ;#0 3ood-$auphinee0 !#0 Richards0 #0 ote0 R#0 Q *ayo0 ;# .%&&1/# The e,,ect o, a task-oriented
intervention on arm ,unction in people with stroke7 A randomi9ed controlled trial# (linical %ehabilitiation )**'R %&7 %51-
:'&# doi7 '&#''5'?&%15%'@@&@cr5(:oa
%eferences#
incinnati hildren6s "ospital *edical enter# .*ay )0 %&&5a/# +able of evidence levels# ,evels of individual studies by domain,
study design, - .uality. Retrieved ,rom http7??groups?ce?;ewE4?E4=iles?TableEvidenceAevels#pd,
incinnati hildrenFs "ospital *edical enter .*ay )0 %&&5b/# /rading a body of evidence to anser a clinical .uestion.
%etrieved from http7??www#cincinnatichildrens#org?assets?&?)D?'&1)?%)&5?%)))?%)5:?5%&&?bd1,(eea-D%@c-(5c:-a&e@-
:e11c@(dc&11#pd,
OF!ullivan0 !# 4#0 Q !chmit90 T# J# .Eds#/# .%&&)/# "hysical rehabilitation 01th ed.2# Philadelphia7 =#A# $avis ompany#
Physiotherapy Evidence $atabase# .'555/# "34ro scale. Retrieved ,rom http7??www#pedro#org#au?wp-
content?uploads?PE$roSscale#pd,
5
Appen%i# A* Search Results
Pub*ed
Tields Title Abstract Obtained
Task oriented %:(D - - -
Utask orientedU A;$ stroke '%: - - -
Utask orientedU A;$ stroke A;$ chronic :@ @ % %
PE$ro
Tields Title Abstract Obtained
Task oriented @) - - -
task oriented A;$ stroke :) - - -
task oriented A;$ stroke A;$ chronic '% @ % %V
5same articles retrieved as in "ub6ed
"igh3ire
Tields Title Abstract Obtained
Task oriented D@& - - -
task oriented A;$ stroke @' - - -
task oriented A;$ stroke A;$ chronic %( % ' 'V
5same article retrieved as in "ub6ed
ochrane
Tields Title Abstract Obtained
Task oriented %(: - - -
task oriented A;$ stroke @D - - -
task oriented A;$ stroke A;$ chronic '1 ( % %V
5same articles retrieved as in "ub6ed
6
Appen%i# B* Critical Appraisal
PH3SIOTH"RAP3 "4ID"2C" DATABAS" (P"Dro/ SCAL"
Ran%omi5e% Clinical Trials
Authors .Tear/
PE$ro !cale riteria
Luality
'V % : ( @ 1 ) D 5 '& ''
Total
.n?'&/
$ispa0 $#0 Ae+eune0 T#0 Q Thonnard0
JA# .%&':/
)?'& "igh
"iggins0 J#0 !albach0 ;#0 3ood-
$auphinee0 !#0 Richards0 #0 ote0 R#0
Q *ayo0 ;# .%&&1/
D?'& "igh
VAn additional criterion that relates to the external validity .or WgeneralisabilityX or WapplicabilityX o, the trial/ has been retained so
that the $elphi list is complete0 but this criterion will not be used to calculate the PE$ro score reported on the PE$ro web site#
P"Dro Scale Criteria
-* "li'i!ilit criteria were speci$ie% - This criterion is satis,ied i, the report describes the source o, sub+ects and a list o,
criteria used to determine who would be eligible to participate in the study#
+* Su!6ects were ran%oml allocate% to 'roups (in a crossover stu%) su!6ects were ran%oml allocate% an or%er
in which treatments were receive%/ - A study is considered to have used random allocation i, the report states that
allocation was random# The precise method o, randomi9ation need not be speci,ied# Procedures such as coin-tossing
and dice-rolling should be considered random# Luasi-randomi9ation allocation procedures such as allocation by
hospital record number or birth date0 or alternation0 do not satis,y this criterion#
.* Allocation was conceale% - oncealed allocation means that the person who determined i, a sub+ect was eligible ,or
inclusion in the trial was unaware0 when this decision was made0 o, which group the sub+ect would be allocated to# A
point is awarded ,or this criterion0 even i, it is not stated that allocation was concealed0 when the report states that
allocation was by sealed opa<ue envelopes or that allocation involved contacting the holder o, the allocation schedule
who was Wo,,-siteX#
7* The 'roups were similar at !aseline re'ar%in' the most important pro'nostic in%icators - At a minimum0 in
studies o, therapeutic interventions0 the report must describe at least one measure o, the severity o, the condition
being treated and at least one .di,,erent/ key outcome measure at baseline# The rater must be satis,ied that the groups6
outcomes would not be expected to di,,er0 on the basis o, baseline di,,erences in prognostic variables alone0 by a
clinically signi,icant amount# This criterion is satis,ied even i, only baseline data o, study completers are presented#
8* There was !lin%in' o$ all su!6ects
0* There was !lin%in' o$ all therapists who a%ministere% the therap
9* There was !lin%in' o$ all assessors who measure% at least one :e outcome
;* &easures o$ at least one :e outcome were o!taine% $rom more than ;8< o$ the su!6ects initiall allocate% to
'roups - This criterion is only satis,ied i, the report explicitly states both the number o, sub+ects initially allocated to
groups and the number o, sub+ects ,rom whom key outcome measures were obtained# 8n trials in which outcomes are
measured at several points in time0 a key outcome must have been measured in more than D@E o, sub+ects at one o,
those points in time#
=* All su!6ects $or whom outcome measures were availa!le receive% the treatment or control con%ition as
allocate% or) where this was not the case) %ata $or at least one :e outcome was anal5e% ! >intention to
treat? - An intention to treat analysis means that0 where sub+ects did not receive treatment .or the control condition/ as
allocated0 and where measures o, outcomes were available0 the analysis was per,ormed as i, sub+ects received the
treatment .or control condition/ they were allocated to# This criterion is satis,ied0 even i, there is no mention o, analysis
by intention to treat0 i, the report explicitly states that all sub+ects received treatment or control conditions as allocated#
7
-,* The results o$ !etween@'roup statistical comparisons are reporte% $or at least one :e outcome - A between-
group statistical comparison involves statistical comparison o, one group with another# $epending on the design o, the
study0 this may involve comparison o, two or more treatments0 or comparison o, treatment with a control condition# The
analysis may be a simple comparison o, outcomes measured a,ter the treatment was administered0 or a comparison o,
the change in one group with the change in another .when a ,actorial analysis o, variance has been used to analyse
the data0 the latter is o,ten reported as a group Y time interaction/# The comparison may be in the ,orm hypothesis
testing .which provides a WpX value0 describing the probability that the groups di,,ered only by chance/ or in the ,orm o,
an estimate .,or example0 the mean or median di,,erence0 or a di,,erence in proportions0 or number needed to treat0 or
a relative risk or ha9ard ratio/ and its con,idence interval#
--* The stu% provi%es !oth point measures an% measures o$ varia!ilit $or at least one :e outcome - A point
measure is a measure o, the si9e o, the treatment e,,ect# The treatment e,,ect may be described as a di,,erence in
group outcomes0 or as the outcome in .each o,/ all groups# *easures o, variability include standard deviations0
standard errors0 con,idence intervals0 inter<uartile ranges .or other <uantile ranges/0 and ranges# Point measures
and?or measures o, variability may be provided graphically .,or example0 !$s may be given as error bars in a =igure/
as long as it is clear what is being graphed .,or example0 as long as it is clear whether error bars represent !$s or
!Es/# 3here outcomes are categorical0 this criterion is considered to have been met i, the number o, sub+ects in each
category is given ,or each group#
=or criteria ( and )-''0 key outcomes are those outcomes which provide the primary measure o, the e,,ectiveness .or lack o,
e,,ectiveness/ o, the therapy# 8n most studies0 more than one variable is used as an outcome measure#
=or criteria @-)0 blinding means the person in <uestion .sub+ect0 therapist or assessor/ did not know which group the sub+ect had
been allocated to# 8n addition0 sub+ects and therapists are only considered to be WblindX i, it could be expected that they would
have been unable to distinguish between the treatments applied to di,,erent groups# 8n trials in which key outcomes are sel,-
reported .e#g#0 visual analogue scale0 pain diary/0 the assessor is considered to be blind i, the sub+ect was blind#
8
Appen%i# C* Ta!le o$ "vi%ence Levels
=rom incinnati hildrenFs "ospital *edical enter# .*ay )0 %&&5a/# Table o, evidence levels7 Aevels o, individual studies by
domain0 study design and <uality# Retrieved ,rom http7??groups?ce?;ewE4?E4=iles?TableEvidenceAevels#pd,
9