Effects of Forced Use Combined with Scheduled Home Exercise Program on Upper Extremity Functioning in Individuals with Hemiparesis Haeyean Park

Transcription

1 Effects of Forced Use Combined with Scheduled Home Exercise Program on Upper Extremity Functioning in Individuals with Hemiparesis Haeyean Park The Graduate School Yonsei University Department of Rehabilitation Therapy

2 Effects of Forced Use Combined with Scheduled Home Exercise Program on Upper Extremity Functioning in Individuals with Hemiparesis A Dissertation Submitted to the Department of Rehabilitation Therapy and the Graduate School of Yonsei University in partial fulfillment of the requirements for the degree of Doctor of Philosophy Haeyean Park June 2011

3 This certifies that the dissertation of Haeyean Park is approved. Thesis Supervisor: Minye Jung Eunyoung Yoo Soo Hyun Park Ji-Hyuk Park Daehyuk Kang The Graduate School Yonsei University June 2011

4 Acknowledgements I would like to dedicate my accomplishment to Dr. Bo-in Chung, my mentor, for her insight, guidance and love while the graduate school days. She has shown me a good example of a scholar and constantly offered me warm assistance. I sincerely appreciate the prudent advice and encouragement provided by Dr. Min-ye Jung, whose advice helped expand my knowledge and perspective for occupational therapy. I would like to thank Dr. Eun-young Yoo who gave me sincere and valuable advice to improve the quality of my academic requirements and dissertation. Also, I would like to thank Dr. Soo Hyun Park who stimulated the awareness in me to write with passion and to think creatively during my writing. I extend my gratitude to Dr. Ji-hyuk Park who made me think intuitionally and gave me warm encouragement. I would also like to express my appreciation to Dr. Dae-hyuk Kang whose academic advice and knowledge brought me opportunities to grow academically. Thank you to all my colleagues, especially Duck-yon Cho, Han-sol Kim, Hyunkyung Jo, Ji-eun Yoo, Heung-seok Park, Yoon-jeong Lim, No-yoel Yang, In-gyu Yoo, Jin-soo Kim, Joo-hyun Lee. I am grateful for what I met them and worked with them who were like family. In addition, I also want to give thanks to Min-hee Kim, Wonhwee Lee, Sung-min Ha, Su-jung Kim, Kyeu-nam Park, Sung-dae Jung, and Do-hun Jung for their big assistance and encouragement.

5 I wish to convey my gratitude to Jung-ran Kim, Jong-hoon Lee, Young-jin Jung, Sun-young Cho, Cheol-ha Baek, lovely baby Jun-su Lee who always standed by me in joy and sorrow. In addition, I would like to convey my wholehearted thanks to my dear friends Mi-yeon Jung, Min-young Jun, Eun-woo Kim, as well as my undergraduate students. Finally, most importantly my family whom I can never thank enough for their endless support. Thanks to my father, mother, aunt, uncle, cousin sister, her husband, and my first nephew Kyung-hun Kim. They gave me many valuable opportunities in my life and have constantly encouraged me with their abiding love. I promise them that I will make great efforts to achieve my dreams. Thank you.

6 Table of Contents List of Figures iii List of Tables iv Abstract v Introduction 1 Methods 9 1. Participants 9 2. Instruments Instruments for participant selection Mini Mental State Exam-Korean (MMSE-K) Upper extremity function measure Box and Block Test (BBT) Wolf Motor Function Test (WMFT) Activities of daily living function measure Motor Activity Log (MAL) Rate of performance of ADL tasks Psychosocial functioning measure Rosenberg Self-Esteem Scale (RSE) Psychosocial Well-Being Index-Short Form (PWI-SF) Design 15 - i -

7 4. Procedure Baseline period data collection Intervention period Forced use Scheduled home exercise program Intervention period data collection Data Analysis 29 Results Upper extremity function Box and Block Test (BBT) Wolf Motor Function Test (WMFT) Activities of daily living function Rate of performance of ADL tasks Motor Activity Log (MAL) Psychosocial status Rosenberg Self-Esteem Scale (RSE) Psychosocial Well-Being Index-Short Form (PWI-SF) 43 Discussion 44 Conclusion 52 References 54 Abstract in Korean 67 - ii -

8 List of Figures Figure 1. Trial design 17 Figure 2. Mitten 19 Figure 3. Participant 1 s tasks for improving arm functioning and ADL 21 Figure 4. Participant 2 s tasks for improving arm functioning and ADL 22 Figure 5. Participant 3 s tasks for improving arm functioning and ADL 23 Figure 6. Implementation rate of scheduled exercise tasks 28 Figure 7. Results of Box and Block Test (BBT) for upper extremity function during baseline and intervention periods 32 Figure 8. Results of Wolf Motor Function Test (WMFT) for upper extremity function: Functional ability and performance time for periods A, B, A, C, and at 1-month follow-up 34 Figure 9. Rate of performance of ADL tasks during baseline and intervention periods 38 Figure 10. Results of Self Esteem Scale (SES) at pre-intervention and post-intervention 42 Figure 11. Results of Psychosocial Well-Being Index-Short Form (PWI-SF) at pre-intervention and post-intervention 43 - iii -

9 List of Tables Table 1. Demographic characteristics 10 Table 2. Scheduled home exercise program for Participant 1 24 Table 3. Scheduled home exercise program for Participant 2 25 Table 4. Scheduled home exercise program for Participant 3 26 Table 5. Comparison of mean number of wood blocks moved between baseline and intervention periods 31 Table 6. WMFT scores for functional ability at periods A, B, A, C, and 1-month follow-up 35 Table 7. WMFT performance time in seconds at periods A, B, A, C, and 1-month follow-up 36 Table 8. Comparison of rate of performance of ADL tasks 37 Table 9. Scores on MAL Amount of Use (AOU) subscales at A, B, A, C, and 1-month follow-up 40 Table 10. Scores on MAL Quality of Movement (QOM) subscales at A, B, A, C, and 1-month follow-up 41 - iv -

10 ABSTRACT Effects of Forced Use Combined with Scheduled Home Exercise Program on Upper Extremity Functioning in Individuals with Hemiparesis Haeyean Park Dept. of Rehabilitation Therapy (Occupational Therapy Major) The Graduate School Yonsei University The aims of this study were to 1) investigate the effects of forced use combined with scheduled home exercise program compared to forced use only on increasing upper extremity functioning, 2) examine whether increased upper extremity functioning generalized to activities of daily living (ADL) functioning, and 3) explore participants psychosocial functioning in three individuals with hemiparesis. A single-subject A-B-A -C research design was employed in this study. The intervention consisted of two conditions: forced use only (intervention period B), and - v -

11 forced use in addtion to individualized scheduled home exercise program (intervention period C). During the B and C intervention periods, participants had their unaffected arm immobilized by wearing mittens for 5 hours a day such that they were not able to manipulate objects using the unaffected hand. During the C intervention period, scheduled exercise programs were conducted across 14 sessions along with forced use according to a fixed schedule. A total of 10 tasks consisting of 5 tasks for improving arm functioning and 5 tasks of activities of daily living (ADL) were adopted, which differed across the three participants based on the level of functioning in their affected hand. During the entire 38 sessions, participants were assessed based on the BBT and rate of performance of ADL tasks at fixed hours each day. The participants were assessed using WMFT and MAL at the following 5 times: end of the first baseline period A, end of the first intervention period B, end of the second baseline period A, end of the second intervention period C, and at a 1 month follow-up session. In order to examine the psychosocial status of the participants, SES and PWI-SF were measured at the end of the first baseline period A and following the second intervention period C. The average of each participant s upper extremity and ADL functioning scores were analyzed through visual analysis using graphs. Also, the obtained results pre- and post-intervention were compared by statistical analysis. The results were as follows: 1) Forced use combined with individualized scheduled home exercise program compared to forced use only allowed individuals with chronic stroke to take part in - vi -

12 exercise programs on their own within their home setting, ultimately improving their upper extremity functioning with minimal therapist intervention. 2) The program s emphasis and promotion of performance in ADL tasks have the advantage of keeping participants focused and motivated so that a number of exercises can be maintained throughout the intervention. 3) Finally, when comparing psychosocial functioning at pre-intervention with post-intervention functioning, Participant 2 s self-esteem declined and stress level remained unchanged. On the other hand, self-esteem increased and perceived stress declined for Participants 1 and 3. The results of the present study suggest that forced use combined with individualized scheduled home exercise program compared to forced use only is beneficial in improving upper extremity functioning and ADL performance following stroke in the home setting. The inherent structure of this study intervention lends itself to a client-centered approach. As such, forced use combined with scheduled home exercise program has the potential to be a cost- and resource-efficient method for intensifying rehabilitation. Key Words: Stroke, Forced use, Home exercise program, Activity of daily living, Upper extremity functioning, Psychosocial functioning. - vii -

13 Introduction Cerebrovascular accident (CVA) is the second leading cause of death in Korea after cancer, with an average prevalence rate of 3.3 for every 100 persons (Ministry of Health & Welfare, 2009). Hemiparesis is the most substantial impairment associated with stroke (Duncan, Goldstein, Matchar, Divine, & Feussner, 1992; Gillot, Holder-Walls, Kurtz, & Varley, 2003). It has been estimated that 85% of stroke survivors experience primary motor deficit in the hand and approximately 55% to 75% of individuals experience persistent problems three to six months post stroke onset (Olsen, 1990). Impairment of upper limb functioning is the most common motor deficit. It has a significant impact on functional and social independence and such difficulties represent a major public health problem (Sterr & Freivogel, 2003). The loss of upper extremity functioning is a primary problem in managing everyday occupations of daily living (Broeren, Rydmark, & Sunnerhagen, 2004). The dominant focus for individuals with hemiparesis is their impairment, and the likelihood of difficulty in performing everyday activities may cause psychosocial repercussions such as frustration and ultimately affect self-esteem in the long run (Gordon, Charles, & Wolf, 2005). Low self-esteem in turn can significantly affect functional independence in a vicious cycle (Chang & Mackenzie, 1998). Following stroke, many individuals with arm paresis regain strength in the paretic upper limb, but often fail to accomplish independent daily functional tasks (Pierce et al., 2003). Taub and colleagues (Taub, - 1 -

14 Goldberg, & Taub, 1975) referred to this phenomenon as learned nonuse, and reported that the longer the time reinforcing the nonuse of the affected hand, the slower the recovery of function. Another study reported that individuals with hemiparesis tended not to use their affected hand rather than optimizing its potential use (Andrews & Steward, 1979). Taub and colleagues (Taub et al., 1993) developed an intervention that facilitated motor ability and functional use of the affected hand named the Constraint Induced Movement Therapy (CIMT). CIMT protocol includes constraining the unaffected hand for 90% of waking hours for two weeks while conducting forced use of the affected hand with repetitive task-oriented therapy for 6 hours each day during this period (Taub, Uswatte, & Pidikiti, 1999). The types of restraint include a sling, a sling combined with a resting hand splint, a half glove, and a mitt. Although the type of restraint does not affect treatment outcome, the use of a mitt rather than a sling is frequently employed in the clinical setting for safety reasons (Winstein et al., 2003). For example, the mitt allows the affected individual to be able to use the unaffected hand for protective extension in cases of falls or loss of balance (Winstein et al., 2003). In research regarding the effects of CIMT, CIMT group who wore an instrumented protective safety mitt on the unaffected hand while engaging in repetitive task practice showed a significant improvement in arm motor functioning that persisted for at least 1 year compared to the control group (Wolf et al., 2006). Other studies showed that individuals with hemiparesis significantly improved their quality of movement and showed increased use of the affected hand in different - 2 -

15 everyday situations after receiving CIMT (Kunkel et al., 1999; Miltner, Bauder, Sommer, Dettmers, & Taub, 1999; Morris, Crago, DeLuca, Pidikiti, & Taub, 1997; Taub et al., 1993). Thus, numerous studies suggested that CIMT is an effective intervention that increase arm use and functioning (Blanton, Wilsey, & Wolf, 2008; Dettmers et al., 2005; Taub & Uswatte, 2006; Yen, Wang, Chen, & Hong, 2005). However, the clinical utility of CIMT has not been widely accepted by clinicians because of its intensive treatment schedule (Pierce et al., 2003). As a result, modified CIMT (mcimt) protocol has been developed that can employ various types of restraint and different frequency and intensity of intervention. Page and colleagues (Page, Sisto, Levine, & McGrath, 2004) combined structured 30-minute functional practice sessions with restriction of the unaffected hand using a cotton hemi-sling 5 days per week for 5 hours each day during a 10-week period. Another study (Lin et al., 2007) provided individualized 2-hour therapy sessions per week for a 3-week period, restraining the unaffected hand and wrist using a mitt every day for 6 hours. These studies identified that mcimt is effective in increasing use of the affected hand and improving function in individuals with stroke. In summary, several studies on individuals with stroke have shown that both CIMT and mcimt can improve the function of the affected hand during performance of daily activities such as picking up a cup, grasping a spoon, or holding a book (Bonifer, Anderson, & Arciniegas, 2005; Miltner et al., 1999; Page, Levine, & Leonard, 2005). Nevertheless, both CIMT and mcimt have a number of common underlying problems. Individuals often hesitate to take part in such therapy due to the intensity - 3 -

16 of the massed training and the required restraining (Page, Levine, Sisto, Bond, & Johnston, 2002). It has been proposed that the nature of the treatment can make individuals feel additional frustration, resulting in increased family burden and safety concerns (Gordon et al., 2005). Treatment providers also report that both CIMT and mcimt create additional stress and increases the chance of safety accidents (e.g., risk of falls). Applying both intensive training and constraint in CIMT poses the question regarding which of the two components most influences functional improvement. To address this question, an alternative to the CIMT can be applied using the constraint component alone (Siegert, Lord, & Porter, 2004; van der Lee, 2001). This is termed forced use. In other words, although restraint is prescribed for both forced use and CIMT, forced use protocol involves voluntary unstructured practice whenever an activity is conducted while restraining the affected hand (Charles & Gordon, 2005). Forced use can be most appropriate for chronic stroke patients (van der Lee et al., 1999; Wolf, Lecraw, Barton, & Jann, 1989) because it does not involve structured practice such as shaping and repetitive task practice, and does not require particular attention to task participation time. In addition, individuals can choose to engage in particular tasks based on their capabilities. Accordingly, the dropout rate of individuals receiving CIMT (Dickson, 2002; Kim et al., 2008) is likely to be much higher than for those receiving forced use (Hammer & Lindmark, 2009; van der Lee et al., 1999). Also, the mechanism of recovery for intensive CIMT has been hypothesized to be due to plastic changes in the central nervous system (Liepert, - 4 -

17 Bauder, Miltner, Taub, & Weiller, 2000). Also, Liepert and colleagues (Liepert, Uhde, Gräf, Leidner, & Weiller, 2001) demonstrated that the motor output map in the affected hemisphere was significantly enlarged after forced use, and such increase in motor cortex excitability was accompanied by a significant improvement in dexterity. These results led to hypotheses regarding central nervous system (CNS) plasticity and the role of forced use therapy in cortical reorganization. Forced use has the potential to be a cost- and resource-efficient method for intensifying rehabilitation (Ploughman & Corbett, 2004). In a preliminary study of 9 individuals, participants took part in 1 week of daily conventional physiotherapy such as gait performance training, balance training, and activities of daily living training, which are routinely applied for individuals with stroke. Forced use was applied during the second week which consisted of immobilization of the unaffected hand with a splint. The combination of forced use and conventional physiotherapy enhanced motor performance compared to conventional physiotherapy alone (Liepert, Uhde, Gräf, Leidner, & Weiller, 2001). Several studies have shown significant results in favor of the efficacy of forced use compared to CIMT. For example, in a study investigating the effectiveness of forced use, a group of 33 individuals with chronic hemiparesis had their unaffected hand immobilized by a resting splint and closed arm sling for 6 hours a day for 5 days a week across a 2-week period. The results showed a lasting effect on the dexterity of the affected hand and on the amount of use of the affected hand in activities of - 5 -

18 daily living (ADL) (van der Lee et al., 1999). A study on 30 individuals with firstonset stroke who wore a mitten on the unaffected hand also demonstrated the effectiveness of forced use. The protocol was progressive, beginning with 1 hour of wearing a day and gradually increasing to 6 hours a day at 2 weeks. The participants receiving forced use therapy experienced more recovery of the hand and postural control than did control participants who received conventional therapy only, and they also achieved independence in ADL (Ploughman & Corbett, 2004). The results of these studies suggested that forced use has positive effects on upper extremity functioning, especially with respect to dexterity, amount of use, in addition to quality of use in ADL performance in individuals with chronic hemiparesis. Recent studies have focused on the use of forced use in the individual s home environment (Pierce et al., 2003). Generally, individuals who are experiencing cardiovascular accident (CVA) induced hemiparesis not only tend to spend most of their time alone, but also exercise infrequently outside the outpatient clinic setting (Bernhardt, Chan, Nicola, & Collier, 2007). In addition, outpatient therapy may have its own drawbacks. For example, transportation may be unavailable and/or tiring, scheduling appointments may be difficult, learning primarily takes place outside the client s own environment, and the therapist cannot always readily involve the client s family (Turton & Fraser, 1990). Home therapy presumably solves such problems, and its greatest contribution is that individuals can develop their ability to carry out daily activities if they receive therapy services at home (Outpatient Service Trialists, 2003). Relatedly, family plays a central role in home programs for - 6 -

19 individuals with hemiparesis (Visser-Meily et al., 2006). Indeed, a recent study showed that extensive home program of wearing a constraint that fosters exploration of the home environment for individuals with functionally impaired weak upper extremity frequently requires emotional as well as physical assistance from family members (Monaghan, Channell, McDowell, & Sharma, 2005). Forced use home program involves a restraint that results in unstructured practice whenever an activity is performed requiring the use of the affected hand (Charles & Gordon, 2005). Despite improving upper limb functioning during such a home program, it has been noted that individuals frequently report difficulty in adhering to a practice schedule that requires a restraining device at home and in voluntary use of the affected hand (Blanton & Wolf, 1999). Page and colleagues (Page, Sisto, Johnston, & Levine, 2002) suggested that more focused practice of specific activities at home while wearing the restraining mitt may be effective in improving program adherence. Pierce and colleagues (Pierce et al., 2003) argued that when individuals who are more likely to adhere to a home program of forced use protocols can be identified with the development of methods to maximize home practice, forced use protocols can be successful. Other methods to improve adherence to wearing a mitt have been proposed. For example, several studies used a home diary, behavioral contract, caregiver contract, and daily schedule to increase adherence (Morris et al., 1997; Morris & Taub, 2001; Taub et al., 1993; Taub et al., 1999). In the same manner, homework-based self-administered programs that were designed to encourage the use of the affected hand in ADL helped individuals to adhere to the - 7 -

20 predetermined treatment program and it was reported to be more meaningful to participants compared to a traditional intensive training program (Harris, Eng, Miller, & Dawson, 2009). Thus, well-organized and specific schedule that clearly defines the specific time of practice, tasks, content, and sequence apparently increases participants sense of responsibility and consistency by providing them with a clear plan from which they can organize assigned tasks or schedule over time (McClannahan & Krantz, 1999). Previous studies have demonstrated the effectiveness of forced use on upper limb functioning and ADL performance, and they proposed the need for additional research on the effects of home therapy, schedule adherence, and voluntary use of the affected hand. Also, although past research had emphasized the effects of psychosocial well-being and stress, they did not evaluate such factors specifically. Thus, the purposes of this study were 1) to examine the effects of forced use combined with scheduled home exercise program compared to forced use only on increasing upper extremity functioning in individuals with hemiparesis, 2) to explore whether increased upper extremity functioning generalized to activities of daily living (ADL) functioning, and 3) to investigate individuals psychosocial functioning

21 Methods 1. Participants Inquiry was made with the Wonju Christian Hospital and Wonju Community Center for Individuals with Disabilities for potential participants who may satisfy the study s inclusion criteria. The inclusion criteria were as follows: (1) a minimum of 6 months post single unilateral stroke with demonstration of current neurological stability; (2) no significant cognitive deficits as indicated by a score of 25 or higher on the Korean Mini Mental State Examination (MMSE-K) (Kwon & Park, 1989); (3) the ability to actively extend at least 10 at the affected metacarpophalangeal and interphalangeal joints, and 20 at the affected wrist joint; and (4) no balance problems that may compromise the participant s safety. Two males and one female diagnosed with stroke volunteered to participate in the present study. The participants mean age was 34.7 (SD = 15.9) and their dominant hand were all right-sided. Two participants were diagnosed with right-side hemiparetic stroke and one participant reported left-side hemiparetic stroke. Each participant s Brunnstrom s hand function recovery stage was Stage 4 or higher. They had no significant cognitive deficits. The purpose, nature, and requirements of the intervention were explained to each participant prior to beginning the study. All participants signed written - 9 -

22 informed consent. The intervention sessions were conducted in their home setting. Demographic characteristics of the participants are provided in Table 1. Table 1. Demographic characteristics Participant Gender Age Affected hand Dominant hand Time since stroke onset (mos) Hand function recovery stage a MMSE- K b 1 F 39 Rt Rt 12 Stage 4 27/30 2 M 48 Lt Rt 60 Stage 5 28/30 3 M 17 Rt Rt 8 Stage 4 27/30 Note. a : Brunnstrom's hand function recovery stage b : Mini Mental State Examination-Korean

23 2. Instruments 2.1 Instruments for participant selection Mini Mental State Examination-Korean (MMSE-K) The MMSE-K (Kwon & Park, 1989) is the Korean standardized version of the MMSE (Folstein, Folstein, & McHugh, 1975), a widely used screening measure of cognitive function in Korea. MMSE-K assesses a number of cognitive domains, including orientation, memory, language, attention/concentration, and visuospatial construction. This 12-item tool takes approximately 10 minutes to administer, with a total score ranging from 0 to 30. Inter-rater reliability of MMSE-K was excellent (r=.999) (Kwon & Park, 1989). A total score of 25 points or higher indicates no cognitive impairment (Kwon & Park, 1989). The MMSE-K was used as the reference criterion of cognitive impairment and conducted by the principal investigator. 2.2 Upper extremity function measure Box and Block Test (BBT) The Box and Block Test (BBT) was developed by Ayres and Buhler in 1957 and it was modified by Fuchs and Buhler (As cited in Cromwell, 1976). BBT measures unilateral gross manual dexterity and manipulation skills for activities of daily living (ADL). A wooden box 53.7 cm x 25.4 cm x 8.5 in dimension is divided by a

24 cm partition placed at the center and individuals are scored based on the number of blocks transferred from one compartment to the other in 60 seconds (Mathiowetz, Volland, Kashman, & Weber, 1985). Test-retest (r=.93 for left; r=.97 for right) and inter-rater reliability (r=.99 for left; r=1.00 for right) of the BBT was excellent (Cromwell, 1976). The BBT was conducted by the principal investigator and the scores of the affected hand were included in this study Wolf Motor Function Test (WMFT) The Wolf Motor Function Test (WMFT) was developed by Wolf and colleagues (Wolf, Lecraw, Barton, & Jann, 1989) to evaluate upper extremity movement ability for individuals post stroke and traumatic brain injury. The original version of the test consisted of 21 simple tasks, but the most recent version includes 17 tasks (Morris, Uswatte, Crago, Cook, & Taub, 2001). The tasks are arranged in order of complexity progressing from proximal to distal joint involvement. The WMFT examines hand movement and movement speed in the affected hand, and requires a few tools and minimal training for test administration (Wolf et al., 2001). Because two tasks are simple measures of strength (Morris et al., 2001), the present study used the remaining 15 tasks which measure functional ability and performance time. Inter-rater reliability of the WMFT was.97 (Wolf et al., 2001). The WMFT was administered by the principal investigator and the scores for the affected hand were included in this study

25 2.3 Activities of daily living function measure Motor Activity Log (MAL) The Motor Activity Log (MAL) was developed by Taub and colleagues (Taub et al., 1993) to measure the actual use of the affected hand during activities of daily living (ADL). The activities in the original version of the MAL consisted of 14 functional tasks (Taub et al., 1993), but possible 30 functional tasks have been reported in other studies (Blanton & Wolf, 1999; van der Lee, Beckerman, Knol, De Vet, & Bouter, 2004). The MAL is conducted using a structured interview. participants are asked about their quality of movement (QOM) on a 6-point scale (0 = inability to use the affected hand for this activity to 5 = ability to use the affected hand for this activity just as well as before the stroke) and amount of use (AOU) on a 6-point scale (0 = never use the affected hand for this activity to 5 = always use the affected hand for this activity) (Rowland & Gustafsson, 2008). Sum scores are calculated for the AOU and QOM separately and each score is divided by the number of specified tasks that the participant actually performed, resulting in a mean score per item (van der Lee et al., 1999). Test-retest reliability of MAL was high (r= ) (Uswatte, Taub, Morris, Light, & Thompson, 2006). The MAL was conducted by the principal investigator and the scores for the affected hand were included in this study

26 2.3.2 Rate of performance of ADL tasks ADL tasks for calculating the rate of performance of ADL tasks consisted 30 ADL items of the Motor Activity Log (MAL). The researcher questioned how many tasks were performed from the list of 30 tasks each day. Rate of performance of ADL tasks was calculated by the principal investigator and only the scores for the affected hand were included in this study. The rate of performance of ADL tasks was calculated using the following formula: number of performed ADL tasks 30 X Psychosocial functioning measure Rosenberg Self-Esteem Scale (RSE) The Rosenberg Self-Esteem Scale (RSE) was developed by Rosenberg (Rosenberg, 1965) to measure self-esteem. RSE is composed of 10 questions scored on a 4-point scale, ranging from strongly agree to strongly disagree. The scale is scored by summing the individual items after reverse scoring the negatively worded items. Higher scores indicate higher degree of self-esteem. Inter-rater reliability of the RSE was.92 and test-retest reliability was.85 (Rosenberg, 1979). The RSE was administered by the principal investigator

27 2.4.2 Psychosocial Well-Being Index-Short Form (PWI-SF) Psychosocial Well-Being (PWI) was developed by Chang (1993) based on the General Health Questionnaire-60 (GH-60) (Goldberg, 1969), which is composed of 45 questions scored on a 4-point scale and measures the degree of psychosocial stress. Due to the criticism that the PWI is abstract and demonstrates low response rate secondary to its long nature, Chang and colleagues (Chang, Cha, Won, & Koh, 2001) developed the 18-item Psychosocial Well-Being Index Short Form (PWI-SF), a selfadministered instrument scored on a 4-point scale. Total score is obtained by summing the points for each item. Total score over 27 indicates a high-risk stress group, score between 9 and 26 potential stress group, and a score below 8 indicates healthy group. Inter-rater reliability of the PWI-SF was high (r=.87) (Chang et al., 2001). The PWI-SF was conducted by the principal investigator. 3. Design This study used a single-subject A-B-A -C research design which is a withdrawal design that requires the removal of the independent variable. Such a design allows one to conclude with more confidence that changes in the dependent variable are related to the presence or absence of the independent variable (Backman, Harris, Chisholm, & Monette, 1997). In this study, A and A, or the baseline periods, consisted of 5 sessions each, while B and C periods, the actual intervention periods,

28 each lasted for 14 sessions. During the baseline periods (A and A ), data were collected while neither forced use nor scheduled home exercise program were provided. The intervention consisted of two conditions: forced use only (intervention period B), and forced use in addition to an individualized scheduled home exercise program (intervention period C) (Figure 1). During the entire 38 sessions that composed the baseline and intervention periods, participants were assessed based on the BBT and rate of performance of ADL tasks at fixed hours each day. Researcher visited the participants homes in 30-minute intervals. The participants were assessed using WMFT and MAL at the following 5 times: end of the first baseline period A, end of the first intervention period B, end of the second baseline period A, end of the second intervention period C, and at a 1 month followup session. In order to examine the psychosocial status of the participants, SES and PWI-SF were measured at the end of the first baseline period A and following the second intervention period C

29 A B A' C Baseline observation period Intervention period Baseline observation period Intervention period No intervention Forced use No intervention Forced use + Scheduled home exercise program Daily test (5sessions) Daily test (14sessions) Daily test (5sessions) Daily test (14sessions) After 1 month 1 st test 2 nd test 3 rd test 4 th test 5 th test (Follow up test) Figure 1. Trial design

30 4. Procedure 4.1 Baseline period data collection Participants were assessed using the BBT and rate of performance of ADL tasks before receiving intervention during the five baseline sessions at fixed hours each day. The primary investigator, a licensed occupational therapist, visited each participant at scheduled times and conducted the BBT and calculated the rate of performance of ADL tasks, which took 10 to 15 minutes for each participant. 4.2 Intervention period Forced use During the B and C intervention periods, the participants had their unaffected hand immobilized by wearing a mitten for five hours a day, which prevented them to grasp and manipulate objects using their unaffected hand (Figure 2). Their unaffected hands were restrained during the intervention periods for 5 hours, from 10:00 a.m. to 12:30 p.m. and from 2:30 p.m. to 5:00 p.m. excluding lunch time. Researcher telephoned each participant to remind them of the starting and ending times of the forced use periods. Throughout the early part of the intervention, the researcher encouraged the participants to wear the mitten on their unaffected hand and perform ADL tasks with their affected hand except during activities that may threaten their safety and balance. Through their caregiver s help, the researcher checked whether

31 each participant had worn the mitten as instructed. The rate of mitten use for all participants was 100 percent during intervention periods B and C. Figure 2. Mitten

32 4.2.2 Scheduled home exercise program During intervention period C, the exercise programs were conducted 14 times along with forced use according to a fixed schedule. A total of 10 tasks consisting of 5 tasks for improving arm functioning and 5 tasks of activities of daily living (ADL) were adopted, which differed across the three participants based on the level of functioning in their affected hand (Figures 3, 4, 5). The researcher selected the tasks for improving arm functioning based on each participant s performance with the goal of improving their shoulder, elbow, hand, and finger functioning. The participants conducted each task for 10 minutes on average to check whether the task was genuinely implemented. In particular, each ADL task was determined based on information gathered during interviews with the participants and their caregiver, with the goal of selecting tasks that were deemed essential in minimizing the need for assistance. Based on their hand grip function, an equipment to be used when performing the particular ADL tasks was made from a hook and a strap and was built and placed in a fixed location. The researcher gave each participant a timetable that included the detailed times, tasks, and sequences to be used (Tables 2, 3, 4). The participants were also requested to complete a record of the tasks conducted, and the researcher visited each participant s home during the study period to verify whether the task had been actually implemented

33 Tasks for activities of daily living Tasks for improving arm functioning Cleaning up the kitchen Saving coins Removing dust Stamping Vacuuming the room Moving wood block Wiping with a cloth Picking up with tweezers Mopping the floor Stacking cones Figure 3. Participant 1 s tasks for improving arm functioning and ADL

34 Tasks for activities of daily living Tasks for improving arm functioning Vacuuming the room Stacking flat ring Mopping the floor Moving wood block Washing the window Moving beans with tweezers Wiping with a cloth Saving coin Removing dust Rolling and inserting pegs Figure 4. Participant 2 s tasks for improving arm functioning and ADL

35 Tasks for activities of daily living Tasks for improving arm functioning Vacuuming the room Stamping Mopping the floor Moving wood block Watering plants Passing rings along the arch Brushing away dust Stacking blocks Removing dust Drawing lines Figure 5. Participant 3 s tasks for improving arm functioning and ADL

36 Table 2. Scheduled home exercise program for Participant 1 Time Task Sequence 10:00~10:30 Cleaning up the kitchen b Arranging 20 or more items to their right places in the kitchen 10:30~11:00 Moving wood blocks a Moving 64 wooden blocks attached to a velcro board from one place to another 11:00~11:30 Stamping a Stamping along 5 lines drawn on a paper that was attached to a wall 11:30~12:00 Vacuuming the room b Taking out the vacuum from the storage place, inserting the power line into the electric socket, vacuuming the room, and putting it back in its place 12:00~12:30 Mopping the floor b the kitchen and living room, and putting it back in Taking out the mop from the bathroom, mopping its place 14:30~15:00 Wiping with a cloth b furniture (table, chair, shelf, desk, bookshelf), and Taking out a cloth from the storage place, wiping putting it back in its place 15:00~15:30 Removing dust b Cleaning the dust on bed cover, blanket, and pillow using a dust roller 15:30~16:00 Stacking cones a Moving 20 stacking cones from Board A to Board B 16:00~16:30 Picking up with tweezers a Picking up 50 different sized tweezers and vertically inserting them in a wood board 16:30~17:00 Saving coins a Saving 50 coins arranged on a 30cm X 50cm styrofoam plate in a piggy bank Note. a : Task to improve arm functioning b : Task to improve ADL

37 Table 3. Scheduled home exercise program for Participant 2 Time Task Sequence 10:00~10:30 Vacuuming the room a inserting the power line into the electric socket, vacuuming the room, and putting it back in its place Taking out the vacuum from the storage place, 10:30~11:00 Mopping the floor a the kitchen and living room, and putting it back in Taking out the mop from the bathroom, mopping its place 11:00~11:30 Stacking flat rings b Stacking 50 flat rings on a wood bar 11:30~12:00 Moving wood blocks b Moving wood 64 blocks attached to a velcro board from one place to another 12:00~12:30 Rolling and inserting pegs b Rolling 16 pegs 180 degrees and putting them back in the same place 14:30~15:00 Saving coins b Saving 50 coins arranged on a coin tong in a piggy bank 15:00~15:30 Moving beans with tweezers b Moving 60 beans with tweezers from one place to another 15:30~16:00 Washing the window a Cleaning the window with cloth and window cleaning fluid 16:00~16:30 Wiping with a cloth a furniture (table, chair, shelf, desk, bookshelf), and Taking out a cloth from the storage place, wiping putting it back in its place 16:30~17:00 Removing dust a Cleaning the dust on bed cover, blanket, and pillow using a dust roller Note. a : Task to improve arm functioning b : Task to improve ADL

38 Table 4. Scheduled home exercise program for Participant 3 Time Task Sequence 10:00~10:30 Removing dust b Cleaning the dust on bed cover, blanket, and pillow using a dust roller 10:30~11:00 Watering plants b Watering plants with a watering pot 11:00~11:30 Stamping a Stamping along 5 lines drawn on a paper 11:30~12:00 Moving wood blocks a Moving 64 wood blocks attached to a velcro board from one place to another 12:00~12:30 Passing rings along the arch a Moving 20 rings from one end to another along an arch 14:30~15:00 Vacuuming the room b inserting the power line into the electric socket, Taking out the vacuum from the storage place, vacuuming the room, and putting it back in its place 15:00~15:30 Mopping the floor b the kitchen and living room, and putting it back in Taking out the mop from the bathroom, mopping its place 15:30~16:00 Brushing away dust b Cleaning dust on bookcase with brush 16:00~16:30 Stacking blocks a Stacking 30 blocks on a wood bar 16:30~17:00 Drawing lines a Drawing continuous 50 vertical and horizontal lines from one point to another Note. a : Task to improve arm functioning b : Task to improve ADL

39 To determine the implementation rate of scheduled exercise tasks, the researcher divided the number of scheduled exercise tasks completed per day by the total of 10 assigned tasks multiplied by 100. The implementation rates of scheduled exercise tasks for Participants 1, 2, and 3 were 85%, 70%, and 90%, respectively (Figure 6)

40 Figure 6. Implementation rate of scheduled exercise tasks

41 4.3 Intervention period data collection Data collection during intervention periods were the same as in the baseline period data collection. During each of the 14 sessions (B and C), participants were assessed based on the BBT score and rate of performance of ADL tasks at fixed hours each day as in the baseline period. 5. Data analysis Results were visually analyzed using graphs and by comparing the mean scores of all measures across the pre- and post-intervention period

42 Results 1. Upper extremity function 1.1 Box and Block Test (BBT) The rates of increase on motor functioning in the BBT for Participants 1, 2, and 3 were 99.0%, 22.1%, and 74.6%, respectively. Compared to the baseline period, the number of wood blocks that were moved during the period of intervention increased substantially (Table 5, Figure 7)

43 Table 5. Comparison of mean number of wood blocks moved between baseline and intervention periods A B A' C Rate of increase (%) Participant Participant Participant Note. A : Baseline observation period B : Intervention period (forced use) A' : Baseline observation period C : Intervention period (forced use + scheduled home exercise program) Rate of increase : Rate of increase from period A to period C, which was calculated using the following formula: mean number of wood blocks moved (C period A period) mean number of wood blocks moved (A period) X

44 Figure 7. Results of Box and Block Test (BBT) for upper extremity function during baseline and intervention periods

45 1.2 Wolf Motor Function Test (WMFT) Performance on the WMFT showed an improvement in the post-intervention period C compared to the baseline period A. The amount of time needed to complete the tasks also decreased (Figure 8)

46 Figure 8. Results of Wolf Motor Function Test (WMFT) for upper extremity function: Functional ability and performance time for periods A, B, A, C, and at 1-month follow-up

47 Specifically, all of the participants showed improvement in functional ability not only from the baseline period A to intervention period C, but also from the baseline period A to the 1-month follow-up period. Although the total score for Participants 1 and 2 slightly decreased following intervention C until the 1-month follow-up, Participant 3 continued to improve at 1-month follow-up (Table 6). Table 6. WMFT scores for functional ability at periods A, B, A, C, and 1-month follow-up A B A Participant Participant Participant C (Change in total score from A to C) 58 (+6) 74 (+12) 49 (+10) 1-month follow-up (Change in total score from A to 1-month follow-up) 56 (+4) 73 (+11) 50 (+11) Note. A : Baseline observation period B : Intervention period (forced use) A' : Baseline observation period C : Intervention period (forced use + scheduled home exercise program)

48 Moreover, all of the participants mean completion time decreased not only from the baseline period A to intervention period C, but also from the baseline period A to the 1-month follow-up. Although the mean time for Participant 3 slightly increased following intervention C until the 1-month follow-up, mean completion times for Participants 1 and 2 decreased at 1-month follow-up (Table 7). Table 7. WMFT performance time in seconds at periods A, B, A, C, and 1-month follow-up A B A Participant Participant Participant C (Change in mean time from A to C) 3.5 (-4.0) 2.5 (-1.0) 24.2 (-11.4) 1-month follow-up (Change in mean time from A to 1-month follow-up) 4.1 (-3.4) 3.2 (-0.3) 21.7 (-13.9)

49 2. Activities of daily living function 2.1 Rate of performance of ADL tasks The rate of increase on rate of performance of ADL tasks for Participants 1, 2, and 3 were 57%, 113%, and 48.8%, respectively, which demonstrates a marked improvement from the baseline period (Table 8, Figure 9). Table 8. Comparison of rate of performance of ADL tasks A B A' C Rate of increase (%) Participant Participant Participant Note. A : Baseline observation period B : Intervention period (forced use) A' : Baseline observation period C : Intervention period (forced use + scheduled home exercise program) Rate of increase : Rate of increase from period A to period C, which was calculated using the following formula: rate of performance of ADL tasks (C period A period) rate of performance of ADL tasks (A period) X

50 Figure 9. Rate of performance of ADL tasks during baseline and intervention periods

51 2.2 Motor Activity Log (MAL) The results from the MAL indicated an improvement in use and quality of movement in the post-baseline period C compared to the baseline period A. Table 9 and 10 shows the mean score across the functional items on the 2 components of the MAL (AOU and QOM). The amount of use increased 0.60, 1.26 and 1.00 for Participants 1, 2, and 3 from baseline period A to intervention C, respectively. Such an increase declined at 1-month follow-up but remained higher than that at baseline for each participant (Table 9)

52 Table 9. Scores on MAL Amount of Use (AOU) subscales at A, B, A, C, and 1- month follow-up A B A Participant Participant Participant Note. a AOU : Amount Of Use b QOM : Quality Of Movement A : Baseline observation period C (Change in mean score from A to C) 1.97 (+0.60) 1.73 (+1.26) 2.20 (+1.00) 1-month follow-up (Change in mean score from A to 1-month follow-up) 1.53 (+0.16) 0.73 (+0.26) 1.63 (+0.43) B : Intervention period (forced use) A' : Baseline observation period C : Intervention period (forced use + scheduled home exercise program)

53 The quality of movement increased 1.00, 0.27 and 0.73 for Participants 1, 2, and 3 from baseline period A to intervention C, respectively. Similar to AOU, enhancement in QOM declined at 1-month follow-up for two participants (Participants 2 and 3) but still remained higher than that at baseline (Table 10). Table 10. Scores on MAL Quality of Movement (QOM) subscales at A, B, A, C, and 1-month follow-up A B A Participant Participant Participant Note. a AOU : Amount Of Use b QOM : Quality Of Movement A : Baseline observation period C (Change in mean scores from A to C) 2.47 (+1.00) 3.27 (+0.27) 2.73 (+0.73) 1-month follow-up (Change in mean scores from A to 1-month follow-up) 2.53 (+1.06) 3.13 (+0.13) 2.50 (+0.50) B : Intervention period (forced use) A' : Baseline observation period C : Intervention period (forced use + scheduled home exercise program)

54 3. Psychosocial status 3.1 Rosenberg Self-Esteem Scale (RSE) Although improvement in self-esteem was found for Participants 1 and 3 in the post-intervention period compared to the pre-intervention period, Participant 2 s selfesteem score declined (Figure 10). Figure 10. Results of Self Esteem Scale (SES) at pre-intervention and post-intervention

55 3.2 Psychosocial Well-Being Index-Short Form (PWI-SF) Although psychosocial stress declined for Participants 1 and 3 in the post- intervention period compared to the pre-intervention period, stress level for Participant 2 remained unchanged (Figure 11). Figure 11. Results of Psychosocial Well-Being Index-Short Form (PWI-SF) at preintervention and post-intervention

56 Discussion The primary purpose of this study was to examine the effects of forced use combined with scheduled home exercise program compared to forced use only on improving upper extremity functioning in individuals with hemiparesis using a singlesubject research design. The secondary purpose of this study was to investigate whether such a program requiring minimal therapist intervention had a positive effect on activities of daily living in persons with post-stroke hemiparesis. The tertiary purpose of this study was to explore whether individuals with stroke can take part in exercise programs on their own within a home setting and demonstrate improved psychosocial functioning. The results showed that all three participants improved their upper extremity functioning and activities of daily living when forced use combined with scheduled home exercise program was implemented more than forced use only. In addition, the results were maintained for one month after the intervention. Specifically, after forced use with scheduled home exercise program, the rate of increase in the mean number of wood blocks moved in the Box and Block Test by the affected hand for Participant 1 improved 34.0%, from 65.0% during intervention B to 99.0% after intervention C. Participant 2 showed a relatively lower rate of increase of 7.2% for the affected hand, from 14.9% to 22.1%, while Participant 3 showed an increase of 32.9%, from 41.7% to 74.6%. When compared with baseline A and intervention