2012

431903

CRE26810.1177/0269215511431903Huseyinsinoglu et al.Clinical Rehabilitation

Article

CLINICAL REHABILITATION
Clinical Rehabilitation 26(8) 705715 The Author(s) 2012 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0269215511431903 cre.sagepub.com

Bobath Concept versus constraint-induced movement therapy to improve arm functional recovery in stroke patients: a randomized controlled trial
Burcu Ersoz Huseyinsinoglu1, Arzu Razak Ozdincler2 and Yakup Krespi1

Abstract Objective: To compare the effects of the Bobath Concept and constraint-induced movement therapy on arm functional recovery among stroke patients with a high level of function on the affected side. Design: A single-blinded, randomized controlled trial. Setting: Outpatient physiotherapy department of a stroke unit. Subjects: A total of 24 patients were randomized to constraint-induced movement therapy or Bobath Concept group. Intervention: The Bobath Concept group was treated for 1 hour whereas the constraint-induced movement therapy group received training for 3 hours per day during 10 consecutive weekdays. Main measures: Main measures were the Motor Activity Log-28, the Wolf Motor Function Test, the Motor Evaluation Scale for Arm in Stroke Patients and the Functional Independence Measure. Results: The two groups were found to be homogeneous based on demographic variables and baseline measurements. Significant improvements were seen after treatment only in the Amount of use and Quality of movement subscales of the Motor Activity Log-28 in the constraint-induced movement therapy group over the the Bobath Concept group (P=0.003; P= 0.01 respectively). There were no significant differences in Wolf Motor Function Test Functional ability (P=0.137) and Performance time (P= 0.922), Motor Evaluation Scale for Arm in Stroke Patients (P= 0.947) and Functional Independence Measure scores (P=0.259) between the two intervention groups. Conclusions: Constraint-induced movement therapy and the Bobath Concept have similar efficiencies in improving functional ability, speed and quality of movement in the paretic arm among stroke patients with a high level of function. Constraint-induced movement therapy seems to be slightly more efficient than the Bobath Concept in improving the amount and quality of affected arm use.

1Stroke

Unit, Florence Nightingale Hospital, Istanbul, Turkey University School of Physical Therapy and Rehabilitation, Istanbul, Turkey
2Istanbul

Corresponding author: Burcu Ersoz Huseyinsinoglu, Florence Nightingale Hastanesi, Inme Merkezi, Abide-i Hurriyet Cad. No: 164 Sisli Istanbul, Turkey Email: fztersoz@gmail.com

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Clinical Rehabilitation 26(8)

Keywords Bobath Concept, constraint-induced movement therapy, rehabilitation, stroke recovery, arm
Received: 21 July 2011; accepted: 6 November 2011

Introduction
After stroke, around 7080% of patients suffer from arm motor dysfunction of various degrees.1 Even mild impairment of arm function after stroke results in significant limitations in daily function and has been demonstrated to negatively impact quality of life.2,3 The Bobath Concept is currently defined as a problem-solving approach which places particular emphasis on the control of selective movement and the integration of postural control and task performance for the production of coordinated movement.4 The developments in the Bobath Concept have not yet been studied in trials of arm rehabilitation in stroke patients. More seriously, clinical studies in which intervention procedures have been used may not have reflected current Bobath Concept practice.4,5 Constraint-induced movement therapy is a repetitive, task-oriented training of the impaired arm for several hours a day. It also involves behavioural methods designed to transfer gains made in therapy sessions and constraining the patient to use the affected arm by using a protective mitt on the unaffected arm.6 Although the effectiveness of constraint-induced movement therapy has been shown in several studies, it is has been criticized because of difficulties in its application, its cost and the prolonged duration of treatment needed.7,8 There is still no consensus on the most effective intervention and treatment dose based on functional level of arm after stroke as trials differ in their methodological qualities.9 The questions that need to be answered in stroke rehabilitation, and more specifically in arm rehabilitation, are at what intensity, and which treatment is more beneficial for which patient? The answers to those questions would help to develop evidence-based physiotherapy concepts to improve arm and hand function after stroke.10,11

At present there is still no evidence to confirm whether the Bobath Concept is more or less effective than constraint-induced movement therapy. Therefore this study aimed to compare the effects of Bobath Concept and constraint-induced movement therapy on arm functional recovery among stroke patients who had high-level function in the affected side.

Methods
This single-blind, randomized clinical trial included stroke patients with a high level of function in the paretic arm. Arm function level was determined according to the active motion of distal joints and patients had to demonstrate active wrist extension of at least 20 degrees and 10 degrees of active extension of the metacarpophalangeal joints and each interphalangeal joint of all digits.12 Subjects were recruited from the outpatient clinic of the Stroke Unit of the Florence Nightingale Hospital. Twentyfour patients were eligible based on the following inclusion criteria: (1) a history of first-time stroke (324 months post stroke); (2) patients between 18 and 80 years of age; (3) active range of motion of at least 45 degrees of shoulder flexion, abduction or scaption, 20 degrees of elbow extension, 20 degrees of wrist extension from full flexion position, and 10 degrees of active extension of metacarpophalangeal joints and each interphalangeal joint of all digits;12 (4) ability to maintain standing balance for two minutes with arm support if necessary;12 (5) adequate vision and hearing to understand the test and therapy sessions; (6) adequate communication skills; (7) no serious cognitive disorders (score 24 on the Mini Mental State Exam);12 (8) exhibit no excessive pain that would interfere with the ability to participate in the treatment; (9) show no excessive spasticity in any joint of the affected arm (score 2 on the

Huseyinsinoglu et al. Modified Ashworth Scale in any joint); (10) considerable non-use of the affected upper limb (Amount of use and Quality of movement score <2.5 on Motor Activity Log-28);12 and (11) weakness of the affected arm. Subjects who met the inclusion criteria were randomly assigned to either constraint-induced movement therapy or Bobath Concept intervention group by using a randomization function of Microsoft Office Excel software. Blocked randomization was used. Treatment and random number columns were created and each part of the treatment column was (pre-assigned as B and C subjects, respectively) given a random number between 0 and 1 by the Microsoft Excel software random number generator. The sort and filter menu was used to sort the random number row from smallest to largest so that treatment groups were randomly ordered. Prestratification was applied to the subjects based on whether they had received injections of botulinum toxin-A within past three months. Before and after the interventions, measurements were obtained by a rater blinded to the group assignment. The blinded rater was trained to administer these tests before the beginning of the study. Both interventions were performed by a single physical therapist (BEH) according to the patients allocation. Before the study, BEH completed a course on constraint-induced movement therapy at Alabama University. She has five years experience in the use of constraint-induced movement therapy. She also received a basic course in Bobath Concept arranged by the International Bobath Instructors Training Association (IBITA). The study was approved by the local ethics committee and conducted in accordance with institutional guidelines, and all patients provided signed informed consent prior to study entry. Both interventions and assessments were applied to the participants in the physiotherapy department of the stroke unit at the hospital. During the constraint-induced movement therapy intervention, the participants less-affected hand was placed in a protective safety mitt for a total of 90% of their waking hours for a period of 12 consecutive days. Behavioural techniques (behavioural contract, caregiver contract, home practice, home diary, home

707 skill assignment) designed to transfer gains from the treatment setting to daily life were applied. Shaping and task activities were provided during the individualized therapy sessions. Activities were selected by considering specific joint movements that exhibited the most pronounced deficits and the joint movements that physical therapists believed had the greatest potential for improvement. Since high-functioning patients were included, 3-hour daily therapy sessions were conducted and the treatment lasted for 10 consecutive weekdays. The Bobath Concept group also received individualized therapy sessions. Appropriate, relevant and patient-centred goals were set up before the therapy sessions. The physical therapist analysed the movement and task performance related to the rehabilitation goal to identify activity limitations and problems of movement dysfunction. Therapy sessions were planned according to those identified limitations for each patient. The emphasis was on control of muscle tone, quality of movement, external support, weight- bearing and stability of trunk during arm activity in functional situations with various positions (lying, sitting and standing both with and without objects and during unilateral or bilateral tasks). Depending on the Bobath Concepts discourse each patient trained about normal stimuli, correct positioning of arm and was given home exercises to continue the therapy 24 hours a day. Caregivers were also trained on the home exercise programme. The therapy session in the clinic lasted for 1 hour daily and the intervention lasted for 10 consecutive weekdays.

Primary outcome measure

Wolf Motor Function Test. Wolf Motor Function Test was designed to assess the motor ability of patients with arm motor deficits. The Wolf Motor Function Test has an established reliability and validity in stroke populations. The original version of the test was developed by Wolf et al.13 In our trial we used a modified Wolf Motor Function Test from the University of Alabama at Birmingham14 and the assessments were performed in accordance with the recommendations of education CD prepared by Alabama University Constraint Induced Movement Therapy Research

708 Group. The test contains 17 tasks; 15 of them are timed tasks and two of them are strength tasks. Only timed tasks were rated in this trial.

Clinical Rehabilitation 26(8) USA). The characteristics of the study groups were summarized with descriptive statistics. Differences in baseline characteristics between the two randomized groups were analysed by chi-square test and MannWhitney U-test. Wilcoxon signed-rank test was used to determine the difference within each group before and after the treatment. Differences in intervention efficiency between the groups were compared using the MannWhitney U-test. The effect size r was calculated for each variable to index magnitude of group differences in performance; a large effect is represented by an r of at least 0.50, a moderate effect by an r of 0.30, and a small effect by an r of 0.10.21 Linear regression analysis was performed to determine if there was any effect of dominant-side paresis on Motor Activity Log-28 Amount of use and Quality of movement scores after the interventions. The level of statistical significance was set at 0.05.

Secondary outcomes measures

Motor Activity Log-28. The Motor Activity Log-28 is a structured interview, which examines 28 activities of daily living. In the test, patients are asked to rate how much (Amount of use scale) and how well (Quality of movement scale) they can use their affected arm using a 6-point ordinal scale. This scale has been found to have good internal consistency, inter-rater reliability and construct validity.15 Huseyinsinoglu et al established the reliability and validity of Turkish Version of Motor Activity Log28 and this version was used in our study.16 Motor Evaluation Scale for Arm in Stroke Patients (MESUPES). Motor Evaluation Scale for Arm in Stroke Patients is a unique scale that takes the quality of upper limb movement into account during the evaluation of arm performance after stroke. It has two parts: MESUPES-Arm and MESUPES-Hand. Inter-rater reliability, internal construct validity and unidimensionality of the scale were established in stroke patients.17 In our study before initial of the interventions we adapted the Motor Evaluation Scale for Arm in Stroke Patients into Turkish with respect to steps of the guidelines about crosscultural adaptation18 and used the Turkish adapted form of the scale in the evaluation process. Functional Independence Measure (FIM). The Functional Independence Measure assesses the level of independence during activities of daily living. It has good inter-rater reliability and validity.19 The Turkish adapted version of the Functional Independence Measure was applied to the participants in the present study.20 The self-care subscale and total scores were calculated to assess the efficiency of the treatments.

Results
A total of 83 post-stroke patients were admitted to the physiotherapy department of the stroke unit from July 2008 to April 2010 and 24 subjects were eligible for the study. Reasons for exclusion are shown in Figure 1. Two dropped out of the constraint-induced movement therapy group during the intervention period; both were personal choice. Twenty-two participants completed the two-week treatment. The characteristics of the patients in the two study groups are shown in Table 1. There were no statistically significant differences between the groups with regard to demographic and clinical features. Groups did not also differ with regard to the location of the lesion (having either hemispheric or brainstem lesion). There were nine (81.9%) participants with hemispheric lesions in the constraintinduced movement therapy group and all patients in the Bobath Concept group had hemispheric lesions (P>0.05). Both constraint-induced movement therapy and Bobath Concept groups showed statistically significant improvements on all measurements (Motor Activity Log-28, Wolf Motor Function Test, Motor

Statistical analysis
All data analyses were computed with SPSS for Windows version 11.5 (SPSS Inc., Chicago, IL,

Huseyinsinoglu et al.

709

Assessed for eligibility (n=83) Excluded (n=59) Unable to attain high function (n=32) MAL-28 score >2.5 (n=6) No weakness in affected arm (n=13) Mini Mental State Exam score <24 (n=3) Not in 324 months after stroke (n=3) Refused to participate (n=2) Included in study and randomized (n=24)

Bobath Concept group (n=11)

Constraint-induced movement therapy group (n=13)

Received intervention (n=11) Drop-out (n=0)

Received intervention (n=13) Drop-out (n=2); personal choice

Analysed (n=11)

Analysed (n=11)

Figure 1. Study diagram.

Evaluation Scale for Arm in Stroke Patients and Functional Independence Measure) from baseline to post-treatment assessments (Table 2). At posttreatment assessment, the constraint-induced movement therapy group had significantly better Amount of use scale and Quality of movement scale scores (P = 0.003, P = 0.01 respectively). According to the Wolf Motor Function Test and the Motor Evaluation Scale for Arm in Stroke Patients, there was no statistically significant difference between the constraintinduced movement therapy and Bobath Concept groups after treatment (P > 0.05). In addition, both Functional Independence Measure total score and Functional Independence Measure self-care score

after treatment were not significantly different between the two groups (P > 0.05) (Table 2). Since the constraint-induced movement therapy group showed significant improvements only in quality and amount of impaired arm use compared to the Bobath Concept group and considering that dominantside paresis was slightly but not significantly more frequent in the constraint-induced movement therapy group, we investigated whether there was an effect of dominant-side paresis. However, there was no effect of dominant-side paresis on improvement of Motor Activity Log-28 Amount of use (95% CI, 1.130.62, P = 0.551) and Motor Activity Log-28 Quality of movement (95% CI, 1.010.68, P = 0.685).

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Table 1. Demographic and clinical characteristics of the study groups Characteristic Age, years (meanSD) Time since stroke, months (meanSD) Level of education in years (meanSD) Sex, M/F (n) Received physiotherapy previously, n (%) Living at home with family or caregiver, n (%) Received botolunim toxin-A injection within past 3 months, n (%) Lesion type, n (%) Ischaemic Haemorrhagic Paresis on dominant side, n (%) Sensation loss, n (%) Pain, n (%) Speech disorder, n (%) Functional evaluationa MAL-28 AOU MAL-28 QOM MESUPES WMFT FA WMFT PT (s) FIM self-care FIM total
aResults

Clinical Rehabilitation 26(8)

CIMT group (n=11) 49.1 13.7 10.66.1 9.84.2 7/4 11 (100%) 11 (100%) 3/8

BC group (n=11) 48.215.4 13.16.3 9.75.1 5/6 11 (100%) 11 (100%) 4/7

P for difference 0.948 0.322 1.000 0.392 1.000 1.000 0.647

7 (63.6%) 4 (36.4%) 7 (63.6%) 3 (27.3%) 1 (9.1%) 1 (9.1%) 0.9 (0.6) 0.79 (0.58) 43 (7.42) 3.2 (0.9) 25.6 (19) 30.1 (8.75) 111.3 (12.5)

10 (90.9%) 1 (9.1%) 3 (27.3%) 2 (18.2%) 1 (9.1%) 0 0.63 (0.65) 0.63 (0.66) 38 (12.2) 2.9 (0.9) 31.5 (23.7) 31 (6.9) 112 (13.4)

0.311 0.087 1.000 1.000 1.000 0.212 0.358 0.340 0.373 0.768 0.717 0.792

of functional evaluation are expressed in mean scores (SD). CIMT, constraint-induced movement therapy; BC, Bobath Concept; MAL-28 AOU, Motor Activity Log-28 Amount of use; MAL-28 QOM, Motor Activity Log-28 Quality of movement; MESUPES, Motor Evaluation Scale for Upper Extremity in Stroke Patients; WMFT FA, Wolf Motor Function Test Functional Ability; WMFT PT, Wolf Motor Function Test Performance Time; FIM, Functional Independence Measure.

Discussion
Our study revealed that the Bobath Concept and constraint-induced movement therapy approaches resulted in similar degrees of functional ability, performance time, quality of movement and independence level in activities of daily living in stroke patients with a high level of function in the affected arm. However, the two treatment groups differed with regard to purely subjective criteria (i.e. Motor Activity Log-28 Amount of use scale and Quality of movement scale). Significant improvements were seen after treatment in the amount and quality of affected arm use in constraint-induced movement therapy group over the Bobath Concept group.

In our study, results from the Motor Activity Log28 were consistent with many studies in the literature which compare the effect of constraint-induced movement therapy versus different control groups in stroke patients.7 The EXCITE trial, the first randomized multicentre trial of constraint-induced movement therapy, concluded that administration of constraint-induced movement therapy resulted in statistically relevant improvements in amount and quality of paretic arm use compared with usual and customary care in stroke patients who experienced a first stroke between three and nine months prior.12 Taub et al demonstrated in a placebo-controlled trial that chronic stroke patients showed very large improvements in constraint-induced movement

Huseyinsinoglu et al.
Table 2. Comparison of the two treatment groups for functional outcome measures Outcome measures CIMT group (n=11) After treatment MeanSD Median (Minmax) 3,20.57 3.2 (2.14) 30.56 3 (1.93.9) 4.030.78 4.2 (2.45) 15.213.7 7.8 (4.246) 48.77.1 51 (3756) 356.6 36 (1942) 116.311.1 119 (87126) BC group (n=11) After treatment MeanSD P-value* Median (Minmax) 1.781.08 1.6 (0.253.32) 1.781.09 1.73 (0.253.40) 3.31.1 3 (25) 20.518 17.4 (3.6065) 43.411.5 42 (2658) 35.15.2 36 (2442) 115.710.9 119 (87126) 0.003 0.003

711

P-value Effect size, r

MAL-28 AOU MAL-28 QOM WMFT FA WMFT PT(s) MESUPES FIM self-care FIM total

Baseline MeanSD Median (Minmax) 0.90.6 0.9 (0.22) 0.790.58 0.75 (0.22) 3.270.96 3.1 (24.8) 25.619 22.8 (660) 437.4 44 (3353) 30.18.75 28 (1540) 112.212.5 110 (86124)

Baseline P-value* MeanSD Median (Minmax) 0.003 0.630.65 0.46 (0.032.2) 0.630.66 0.46 (0.032.3) 2.90.9 2.6 (24.8) 31.523.7 30.8 (584) 3812.2 41 (1754) 31.96.9 33 (1840) 11213.4 117 (77124)

0.64 0.53 0.31 0.02 0.01 0.24 0.20

0.003

0.003

0.01

0.003

0.008

0.137

0.003

0.003

0.922

0.003

0.003

0.947

0.003

0.005

0.259

0.003

0.005

0.336

*P for baseline versus after treatment. P for CIMT versus BC. CIMT, constraint-induced movement therapy; BC, Bobath Concept; MAL-28 AOU, Motor Activity Log-28 Amount of use; MAL-28 QOM, Motor Activity Log-28 Quality of movement; MESUPES, Motor Evaluation Scale for Upper Extremity in Stroke Patients; WMFT FA, Wolf Motor Function Test Functional Ability; WMFT PT, Wolf Motor Function Test Performance Time; FIM, Functional Independence Measure.

therapy group relative to the general fitness control group.22 In another study Lin et al found that a constraint-induced movement therapy group exhibited significantly better performance in Motor Activity Log than the dose-matched control intervention.23 It is of note to emphasize that the Motor Activity Log-28 was originally developed for the assessment of the improvement in patients under constraintinduced movement therapy, which may partly

explain Motor Activity Log-28 results in favour of this treatment modality. On the other hand, placing the unaffected hand in a protective safety mitt for a total of 90% of waking hours during the constraintinduced movement therapy intervention may lead the patients to perceive that they have made more use of the affected arm and this may have a positive effect, especially on the results of the Amount of use scale in the Motor Activity Log-28. Therefore

712 long-term results are important to conclude whether this effect lasts when the safety mitt is removed during the daytime after treatment. As there are conflicting results about the long-term results of the Motor Activity Log-28 in the literature, the main goal of rehabilitation may be determined carefully for high-level arm post-stroke patients before admitting the patient to the constraint-induced movement therapy intervention.12,24,25 In our study, dominant-side paresis was more frequent in the constraint-induced movement therapy group, although this difference did not reach statistical significance (P = 0.087). It is plausible that patients with dominant-hand paresis may have more potential to use the affected arm effectively because they used to perform many activities with that dominant side before their stroke. However, further analysis showed that dominant-hand paresis has no effect on recovery as measured by the Motor Activity Log-28 Amount of use and Quality of movement scales. These results are consistent with other studies that examined the influence of hand dominance on response to constraint-induced movement therapy.26,27 The Wolf Motor Function Test, which measures arm motor function objectively, was the primary outcome of our trial. Similar to our findings, some studies that compared the effects of constraintinduced movement therapy using a control group could not find any statistically significant difference in motor dysfunction after treatment.28,29 On the other hand, several other studies that used conventional therapy or a general care control group showed significant improvements in the constraintinduced movement therapy group on Wolf Motor Function Test.12,22,23 Different results for motor dysfunction after treatment might be explained by the differences in treatment doses and the therapy content in the control groups compared with the constraint-induced movement therapy group. Increased duration of therapy and increased number of training hours have been suggested to improve the results of constraint-induced movement therapy.30 Although therapy duration is important, arm motor function recovery could not be explained based on therapeutic time alone. The results related to Wolf Motor Function Test in our

Clinical Rehabilitation 26(8) study support the concept that to achieve a better level of motor function in the arm, it is important to work on skill acquisition, movement quality and patient-specific activity, as well as repeated activities with longer duration therapy sessions.31 In this study, the Motor Evaluation Scale for Arm in Stroke Patients was used as an objective means to assess changes in the quality of arm movement. According to the Motor Evaluation Scale for Arm in Stroke Patients procedures, accuracy and amount of movement are measured by the physical therapist while the patient performs the activity. This is the main difference that discriminates the Motor Evaluation Scale for Arm in Stroke Patients from the Motor Activity Log-28 Quality of movement scale. The Quality of movement scale is more subjective than the Motor Evaluation Scale for Arm in Stroke Patients as it is a semi-structured interview scale. The patient answers the question about how well he or she uses the affected arm during each daily activity in the Motor Activity Log Quality of movement scale. In our trial different approaches of these measurements may cause the different results for quality of movement in the two intervention groups. While the constraint-induced movement therapy group had better performance on the Motor Activity Log-28 Quality of movement scale than the Bobath Concept group after treatments, no statistically significant difference in Motor Evaluation Scale for Arm in Stroke Patients was evident between the two intervention groups. On the other hand, the results for the Motor Evaluation Scale for Arm in Stroke Patients may show that although constraint-induced movement therapy emphasizes frequent repetition of the movement it may affect the quality of movement positively in stroke patients with a high-level arm. In this study, the difference between two groups in activities of daily living levels following treatment was not statistically significant. This finding is consistent with many studies that measured activities of daily living levels with Functional Independence Measure or other related scales after arm rehabilitation of stroke patients.23,32 Since activities of daily living measurements often reflect compensatory behaviour, arm recovery may not primarily be explained by those measurements. As we

Huseyinsinoglu et al. aimed to investigate the global effects of interventions in activities of daily living level, in our trial we also assessed the patients by using Functional Independence Measure beside the motor function tests. Up to this point we have generally discussed trials that compare the effects of constraint-induced movement therapy versus other interventions, in the form of conventional therapy, custom care or neurodevelopmental treatment (intensive bimanual training), since few trials have investigated the outcomes of Bobath Concept on arm recovery in stroke patients.5,33,34 It is suggested in a review about the effect of Bobath Concept on arm recovery that sensitive upper limb measures, trained Bobath therapists and homogenous samples should be used.5 In our trial the methodology was consistent with the suggestions of this review. Another trial looked at the effects of increased exercise therapy time for arm rehabilitation with either Bobath Concept or Arm BASIS training in stroke patients with severe arm paresis. Fugl-Meyer arm motor score was the main measurement and it was concluded that the increased exercise therapy time for Arm BASIS training enhanced selective motor control in severe arm paresis group after stroke.31 As our trial aimed to compare the efficiency of the Bobath Concept and constraint-induced movement therapy, the treatments were applied to the participants according to the original protocols without taking into account the time period. This meant that the constraintinduced movement therapy group had three times as much therapy time as the Bobath Concept group. Nevertheless, in our stroke group with a high level of function in the affected arm there was no significant difference between two groups in Wolf Motor Function Test after treatments. There is some strength in our study. This is the first randomized controlled trial to compare the effects of constraint-induced movement therapy and Bobath Concept in Turkish stroke patient population. Both interventions were performed by a certified physical therapist with ten years experience in stroke rehabilitation. Therefore the original procedure of constraint-induced movement therapy and current practice of Bobath Concept were applied to the participants. The blind rater was trained in the

713 procedures before the trial. With the aim of creating homogeneous treatment groups, pre-stratification was done with regard to botulinum toxin-A injections within the previous three months. In the present study, inclusion criteria regarding the phase of stroke was limited to patients with subacutechronic stroke to ignore the effects of spontaneous recovery on treatment approaches. The effect size of Wolf Motor Function Test Functional Ability which was obtained from this trial may be used as a reference to calculate power of a multicentre clinical trial if this outcome measurement is determined as a primary outcome. Several limitations of this trial are noteworthy. First, as this trial was a PhD thesis it was carried out in one centre and a single physical therapist gave both treatments. Because of difficulty in finding eligible patients who met all the inclusion criteria of the study in just one centre, we had a relatively small sample size. On the other hand, a single therapist could have been biased towards favouring one or other treatment, and this might have affected the outcome. A single physical therapist would also have much the same interpersonal relationship in both groups so this could be an advantage of our trial. Second, time since stroke (324 months) was too long and no other factors than botulinum toxinA treatment was taken into account for the prestratification of patients. If such a long time after stroke is defined as an inclusion criteria, factors such as prior rehabilitation duration, drug treatments, depression status and environmental variables such as living conditions and caregivers are all important factors affecting recovery and should be considered in multicentre trials. Nevertheless all our patients received physiotherapy previously, and were living at home with family or caregivers. Third it was not possible to evaluate fulfilment of the requirement to use a mitt on the unaffected side as well as to record their activities for 90% of waking hours, because most of the patients did not fill the home diary correctly. On the other hand, objective results about compliance with home exercise programmes was not determined in the two treatment group. Another limitation of our study was that intention-to-treat analysis was not employed. For this reason, we did not avoid the effect of drop-outs

714 in the constraint-induced movement therapy group. Finally, three patients with Wolf Motor Function Test pretreatment scores very close to the upper limit potentially and causing bias were not excluded from the study because they were reported to be suffering from weakness of the affected arm. Clinical messages Constraint-induced movement therapy and the Bobath Concept have similar efficacy in arm rehabilitation of stroke patients with high-level arm function according to objective criteria such as functional ability, speed and quality of movement. Constraint-induced movement therapy is more effective than the Bobath Concept in improving the amount and quality of paretic arm use with regard to a patients perception. Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Clinical Rehabilitation 26(8)

8. Sterr A, Szameitat A, Shen S and Freivogel S. Application of the CIT concept in the clinical environment: hurdles, practicalities, and clinical benefits. Cogn Behav Neurol 2006; 19: 4854. 9. Young JA and Tolentino M. Neuroplasticity and its applications for rehabilitation. Am J Ther 2011; 18: 7080. 10. Liepert J. Evidence-based therapies for arm dysfunction. Curr Opin Neurol 2010; 23: 678682. 11. Kwakkel G, Van Peppen R, Wagenaar RC, et al. Effects of augmented exercise therapy time after stroke. A metaanalysis. Stroke 2004; 35: 25292536. 12. Wolf SL, Winstein CJ, Miller JP, et al. Effect of constraint induced movement therapy on arm function 3 to 9 months after stroke: The EXCITE randomized clinical trial. JAMA 2006; 296: 20952104. 13. Wolf SL, Catlin PA, Ellis M, Archer AL, Morgan B and Piacentino A. Assessing Wolf Motor Function Test as outcome measure for research in patients after stroke. Stroke 2001; 32: 16351639. 14. Morris DM, Uswatte G, Crago JE, Cook EW, III and Taub E. The reliability of the Wolf Motor Function Test for assessing arm function after stroke. Arch Phys Med Rehabil 2001; 82: 750755. 15. Uswatte G, Taub E, Morris D, Light K and Thompson PA. The motor activity log-28: Assessing daily use of the hemiparetic arm after stroke. Neurology 2006; 67: 11891194. 16. Huseyinsinoglu BE, Ozdincler AR, Oul OE and Krespi Y. Reliability and validity of Turkish version of Motor Activity Log-28.Turkish J Neurol 2011; 17:8389. 17. Van de Winckel A, Feys H, van der Knaap S, et al. Can quality of movement be measured? Rasch analysis and inter-rater reliability of the Motor Evaluation Scale for Arm in Stroke Patients (MESUPES). Clin Rehabil 2006; 20: 871884. 18. Beaton DE, Bombardier C, Guillemin F and Ferraz MB. Guidelines for the process of cross-cultural adaptation of self-report measures. Spine 2000; 25: 31863191. 19. Kidd D, Stewart G, Baldry J, et al. The functional inde pendence measure: A comparative validity and reliability study. Disabil Rehabil 1995; 17: 1014. 20. Kckdeveci AA, Yavuzer G, Elhan AH, Sonel B and Ten nant A. Adaptation of the Functional Independence Measure for use in Turkey. Clin Rehabil 2001; 15: 311319. 21. Cohen J (ed.) Statistical power analysis for the behavioral seciences, second edition. Hillsdale, NJ: Lawrence Erlbaum Associates, 1988. 22. Taub E, Uswatte G, King DK, Morris D, Crago JE and Chatterjee A. A placebo-controlled trial of constraint-induced movement therapy for arm after stroke. Stroke 2006; 37: 10451049. 23. Lin KC, Wu CY, Liu JS, Chen YT and Hsu CJ. Constraint induced therapy versus dose-matched control intervention to improve motor ability, basic/extended daily functions, and quality of life in stroke. Neurorehabil Neural Repair 2009; 23: 160165.

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