Robotic Modified Constraint -Induced Therapy in Patients With Spastic Hemiplegic Stroke Post Botulinum Toxin A Injection

The upper-extremity (UE) subscale of the FMA will be used to assess neuromusculoskeletal and movement related functions. It consists of 33 upper extremity items for the reflexes and movement of shoulder, elbow, forearm, wrist, hand, and coordination/speed. They are scored on a 3-point ordinal scale (0-cannot perform, 1-performs partially, 2-performs fully)(Fugl Meyer et al., 1975). Higher score indicates better motor function of UE, and the maximum score is 66. Satisfactory psychometric properties of the FMA have been demonstrated(Platz et al., 2005)

Spasticity of skeletal muscle in upper extremity will be evaluated by using the MAS scale (Bohannon & Smith, 1987).It uses a 6-point scale to score the average resistance to passive movement for each join with higher score indicating higher spasticity. The MAS has shown good reliability and validity (Pandyan et al., 1999).

The amount of the impaired arm movement will be assessed by the activity monitors (i.e. accelerometers)(Schasfort, Busmann, Martens, & Stam, 2006; Uswatte, Giuliani, et al., 2006; Uswatte et al., 2000). Accelerometers, objectively recording the amount of activity in free-living conditions and estimating energy expenditure, have been applied to measure the amount of affected arm use over time. In addition, accelerometers were also used to provide a measure of sleep latency and efficiency in this project. The participants were required to comply with wearing the accelerometer on each arm for 3 consecutive days. The accelerometers used in this project will be wireless plastic units about the size and weight of a large wrist watch. The participants will wear them proximal to the wrist on terrycloth bands. The compliance of wearing accelerometers was approximately 76% of waking time (Schasfort et al., 2006).

The WMFT is a quantitative measure of upper extremity motor ability through timed and functional tasks (Uswatte, Taub, Stuss, Winocur, & Robertson, 1999). The WMFT includes 17 tasks (15 function-based and 2 strength-based). Performances were timed and rated by using a 6-point ordinal scale. The WMFT has good interrater reliability and criterion validity in patients with UE hemiparesis (D. M. Morris, Uswatte, Crago, Cook, & Taub, 2001) .

The MAL is a semi-structured interview to rate how well [quality of movement scale (QOM)] and how much [amount of use scale (AOU)] they use their affected upper extremity in 30 daily activities using a 6-point scale (Uswatte, Taub, Morris, Light, & Thompson, 2006). Higher scores represent better performance. The MAL has established reliability, validity, and responsiveness in patients with stroke (Uswatte, Taub, et al., 2006; Uswatte et al., 2005; Van der Lee, Beckerman, Knol, De Vet, & Bouter, 2004) . The MAL will be used to measure daily use of the affected upper limb in daily life in this project.

The NEADL is a measure of the requirement for help in performing instrumental activities of daily living (IADL) for patients with stroke(Nouri & Lincoln, 1987). The NEADL has 22 items divided into 4 areas of daily life: mobility, kitchen, domestic, and leisure activities. Participants need to choose the level of the independence (not at all, with help, on your own with difficulty, on your own). The reliability, validity, and responsiveness of the NEADL have well-established in patients with stroke.(Gladman, Lincoln, & Adams, 1993; Gompertz, Pound, & Ebrahim, 1994; Nouri & Lincoln, 1987).

The GAS is a useful measure of participants' individual goals that could be achieved in the course of intervention(Turner-Stokes, 2009). In the first session, the therapist will discuss with the participants and their families to define the goals. Each goal will be rated on a 5-point scale ranging from -2 to +2 in the last session. The higher score represents better performance. The GAS enables the data to be placed on a quantitative measurement scale and can be helpful for qualitative interpretation (Turner-Stokes, 2009). Evidence of validity and responsiveness for the GAS was reported in previous studies(Rockwood, Stolee, & FoxP, 1993).