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A Systematic Review of Voluntary Arm Recovery in Hemiparetic Stroke: Critical Predictors for Meaningful Outcomes Using the International Classification of Functioning, Disability, and Health

Chen, Shu-Ya PT, MS; Winstein, Carolee J. PT, PhD, FAPTA

Journal of Neurologic Physical Therapy: March 2009 - Volume 33 - Issue 1 - pp 2-13
doi: 10.1097/NPT.0b013e318198a010

Background and Purpose: Stroke is the leading cause of long term disability in the United States. Most poststroke individuals experience difficulty in moving the contralesional limbs to perform daily activities. Studies were systematically reviewed to identify the best predictors of arm-specific motor recovery and further analyzed using the International Classification of Functioning, Disability, and Health to distinguish outcome measures that best reflected participation in life situations.

Methods: We used PubMed, CINAHL, the Cochrane Library, and EMBASE with the keywords stroke, upper extremity, recovery of function, and predictor. Inclusion and exclusion criteria were developed and applied to further refine the search. Finally, methodological quality was assessed.

Results: Fifty-six studies published between 1979 and 2008 met the criteria. There was a 317% increase in the frequency of articles on predictors of arm recovery over a nearly 30-year period. Thirty-six percent were of high methodological quality (score, ≥10 of 15). Early neurophysiologic and sensorimotor measures were the best predictors at follow-up of arm-specific outcomes. There was no outcome measure classified at the International Classification of Functioning, Disability, and Health participation level. Only one study provided information about an outcome-related minimal clinically important difference.

Discussion and Conclusions: Initial measures of the integrity of neural connectivity and voluntary motor behavior were the best predictors of arm-specific functional recovery. The paucity of valid and reliable instruments to capture the more distal outcomes associated with activities and participation has likely limited the breadth of available evidence in this field. This suggests an urgent need for the development of direct measures of arm use in real-life environments.

Division of Biokinesiology and Physical Therapy, School of Dentistry, University of Southern California, Los Angeles, California.

Address correspondence to: Carolee Winstein, E-mail:

© 2009 Neurology Section, APTA