clinical review

Stroke: activities of Daily living

indexing Metadata/Description
    Title/condition: Stroke: Activities of Daily Living Synonyms: Cerebrovascular accident (CVA), cerebral infarct Anatomical location/body part affected: Brain, cerebral cortex/contralateral side of body is primarily affected (hemiplegia) Description Sensorimotor impairments (paralysis, weakness, sensory loss) and functional disability in activities of daily living (ADLs) resulting from corticospinal transsynaptic degeneration Types of cerebrovascular accidents Ischemic cerebrovascular accident, related to atherothrombotic disease, embolism, or venous sinus thrombosis(1) Hemorrhagic cerebrovascular accidents, including:(1)  Hypertensive hemorrhage  Subarachnoid hemorrhage  Vascular malformations  Atherosclerotic aneurysms  Mycotic aneurysms Cryptogenic cerebrovascular accident (CVA) is defined as a CVA of unknown cause(2) ICD-9 codes 438.30 monoplegia of upper limb (438.31 affecting dominant side, 438.32 affecting nondominant side) 438.40 monoplegia of lower limb (438.41 affecting dominant side, 438.42 affecting nondominant side) 438.6 alterations of sensations ICD-10 codes I69.4 sequelae of stroke, not specified as hemorrhage or infarction Reimbursement: Reimbursement for therapy will depend on insurance contract coverage; no special agencies or specific issues regarding reimbursement have been identified for stroke rehabilitation Presentation/signs and symptoms(3) Predominately unilateral paresis, poor coordination, and spasticity Impaired ROM of affected limb Sensory deficits (numbness, position sense) Post-stroke pain (commonly involving the shoulder/arm in upper limb monoplegia) Functional disability requiring increased dependence in: Basic ADLs activities that involve motor skills in personal care (transfers, sitting, dressing, toileting, reaching, holding, feeding, etc.) Instrumental ADLs activities that involve process skills (preparing a meal, light housework, taking medications as prescribed, shopping, using a telephone, etc.) and enable independence Compensatory postures and movements in ADLs (e.g., one-handed techniques) Reduced self-esteem and quality of life Depressive affect

 

author
Rudy Dressendorfer, PT, PhD, FACSM

Reviewers
Amy Lombara, PT, BS Cinahl Information Systems Glendale, California Rehabilitation Operations Council Glendale Adventist Medical Center Glendale, California

causes & Risk Factors

 Causes Ischemic CVA (cerebral anoxia resulting from vascular ischemia) Thrombus blood clot formed in a cerebral artery (main cause is atherosclerosis) Cardioembolic occlusion of a cerebral artery by clot/embolus formed elsewhere Arteriolar disease occlusion of small brain arteries resulting in lacunar stroke Systemic underperfusion due to cardiac failure Intracerebral hemorrhage physical deformation of brain tissue caused by hematoma ~20% of cerebral infarcts are of the hemorrhagic type(1)

Editor
Sharon Richman, MSPT Cinahl Information Systems

March 27, 2009

Published by Cinahl Information Systems. Copyright2009, Cinahl Information Systems. All rights reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206

Pathogenesis Acute anoxia in and/or below the sensorimotor cortex triggers a cascade of events leading to brain infarction Monoparesis/hemiparesis results from transsynaptic degeneration in the affected cortical and/or subcortical (white matter) areas that represent the contralateral upper extremity Improved paretic movements found in chronic (>1 year) stroke are associated with neural activation in the ipsilateral motor cortex, suggesting that some central motor learning may transfer to the unaffected hemisphere(4) Cortical reorganization, i.e., neuroplasticity, provides a rational basis for stroke rehabilitation strategies that restrict use of the lessaffected ipsilateral limb, such as constraint-induced movement therapy(5) Reorganization of white matter in the affected hemisphere may also contribute to motor recovery(6) Impairment of basic ADLs and cognitive function has been correlated with the degree of white matter lesions found on neuroimaging(7) Severe white matter lesions are associated with poor scores in instrumental ADLs,(7, 8) perhaps because executive processing skills and planning cognition are impaired Side of the lesion does not appear to determine ADL skills after a stroke(9) Risk factors for stroke Age stroke risk doubles for each decade after age 55(3) Increased age is associated with a decline in ADL ability after stroke(9) Gender (male > female)(3) Race (African American 2x > White > Asian)(3) Family history of stroke(3) Hypertension(3) Heart disease(3) Diabetes(3) Cigarette smoking(3) Carotid stenosis(3) Alcohol/cocaine abuse(3) Hypercoagulable states (polycythemia, sickle-cell anemia, cancer)(3) Hyperlipidemia(3) Post transient ischemic attack (TIA)(1) Arteritis, vasculitis, and head/neck trauma(1) CVA secondary to embolism risk factors include atrial fibrillation, myocardial infarction, valvulitis, endocarditis, mitral stenosis, mitral regurgitation, mitral valve prolapse(1)

contraindications/Precautions
          Pediatric patients < 18 years of age Brain trauma Signs of acute illness: fever, chills, night sweats, nausea, vomiting, diarrhea Radicular neck/upper extremity pain Unexplained weight loss Comorbidity that may restrict vigorous exercise Non-finalized litigation regarding work disability Deep vein thrombosis (DVT) is a contraindication to exercising the involved limb Avoid pulling on hemiplegic arm See specific Contraindications/precautions to examination and Contraindications/precautions under Assessment/Plan of Care

Examination
 Contraindications/precautions to examination Notify referring physician on positive findings for conditions that may require a special prescription, including the following: Post-stroke shoulder pain that increases with movement; causes may include:  Adhesive capsulitis  Subacromial impingement  Rotator cuff pathology  Glenohumeral subluxation or acromioclavicular separation Brachial plexus/peripheral nerve traction injury Impaired joint mobility of the elbow (heterotropic ossification), wrist, or hand Upper motorneuron disease (Hoffmans sign) Complex regional pain syndrome, reflex sympathetic dystrophy Severe cachectic appearance History (Depending on the individuals stage of recovery at time of evaluation, the history section may vary slightly) History of present condition

 Mechanism of injury(1)
 CVA secondary to thrombosis

Onset progression of symptoms over hours to days Medical history often significant for TIA Time of presentation often occurs during the night while the individual is sleeping; typically the patient awakes with a slight
neurological deficit that gradually progresses
 CVA secondary to embolism

Onset very fast (seconds) Medical history significant for TIA is uncommon Time of presentation individual is typically awake and active 10% of the cases are associated with seizures  CVA secondary to hypertensive hemorrhage Onset sudden Risk factors are akin to those for a CVA caused by a thrombosis Time of presentation usually during periods of activity Course of treatment  Medical management: Was thrombolytic intervention tried in the acute stage? Was a fall-related fracture treated operatively?  Medications for this condition: Determine what medications were prescribed and whether these are currently being taken. Baclofen, botulinum toxin, or dantrolene is commonly used to control hypertonicity. Is the patient medicated for post-stroke depression, seizures, pain, or hypercoaguability?  Diagnostic tests completed: Document the results of any plain radiographs, imaging studies, or other diagnostic testing The process of diagnosing a CVA may include (but not limited to) CT scans, MRI, blood tests, ECG, echocardiography, and ultrasound(1)  Home remedies/alternative therapies: Document any treatment at home or alternative therapies (e.g., massage, acupuncture) and whether or not they helped. Does the patient use a shoulder sling?  Previous therapy: Has patient had occupational or physical therapy for this or related conditions. If so, what specific treatments were helpful or not helpful? Aggravating/easing factors: Document factors that aggravate symptoms such as pain or hypertonicity during ADLs and factors that improve them Body chart: Use body chart to document location and nature of symptoms Nature of symptoms: Ask the patient to describe symptoms (e.g., pain, tingling, numbness, stiffness, edema, spasticity) and where these symptoms are located Rating of symptoms: Use a visual analog scale (VAS) or 0-10 scale to assess symptoms at their best, at their worst, and at the moment (specifically address if pain is present now and how much) Pattern of symptoms: Document changes in symptoms throughout the day and night, if any (AM, mid-day, PM, night); also document changes in symptoms due to weather or other external variables Sleep disturbance: If present, document the usual number of wakings/night Other symptoms: Document other symptoms patient may be experiencing that could exacerbate an already impaired ability to complete ADLs and/or indicate need for medical consultation (e.g., severe headaches, night sweats, new edema, rash) Barriers to learning  Are there any barriers to learning? Yes No  If Yes, describe (e.g., cognitive impairment, speech deficit, speaks foreign language) Past medical history  Previous history: Document any prior transient ischemic attack, stroke, angina, myocardial infarction, sleep apnea, or history of asthma attacks  Comorbid diagnoses: Ask patient about coexisting problems, including diabetes, cancer, heart disease, pregnancy, psychiatric disorders, musculoskeletal disorders, chronic lung disease, etc.  Medications previously prescribed: Obtain a comprehensive list of medications prescribed and/or being taken for other problems (including over-the-counter drugs)  Other symptoms: Ask about other symptoms that have affected the patients mobility in ADLs Social/occupational history Patients goals: Document what specific ADL skills the patient hopes therapy will improve Vocation/avocation and associated repetitive behaviors: Is the patient currently on work disability? Did the patient participate in vigorous recreational activities or sports? Functional limitations/assistance with ADLs/adaptive equipment: Does the patient use a wheelchair, ambulatory assistive device, knee brace, AFO, shoulder sling, or arm/wrist brace? Living environment: Identify barriers to independence in the home and whether any modifications are necessary (stairs, number of floors in home, lack of caregivers) Relevant tests and measures: (While tests and measures are listed in alphabetical order, sequencing should be appropriate to

patient medical condition, functional status, and setting.) Tests and measures commonly used by neurological specialist physical therapists when examining patients with stroke have been reported(10) Activities of daily living: Assess level of assistance, equipment used, and quality of movement with feeding, grooming, bathing, dressing, toileting, toilet transfers, tub/shower transfers. If appropriate (e.g., if performing a home evaluation), assess ability to manage household, including shopping, light cleaning, meal preparation, yard work, heavy cleaning, bed making, and money management Assistive and adaptive devices: Assess need for wheelchair, ambulatory assistive device, splint, or brace, if applicable, and fit if currently used Balance: Assess balance in sitting and standing. May use the Berg Balance Scale, the Functional Reach Test, or the Postural Assessment Scale for Stroke(11) Circulation: Assure that peripheral pulses are present in the affected limb and compare Cranial nerve integrity: Assess for deficits in cranial nerve function Olfaction (CN I): Can the patient smell coffee or soap with each nostril? Vision (CN II): Can the patient see an eye chart equally with each eye? Extraocular movements (CN III, IV, VI): Can the patient look in all directions, keeping the head still, without experiencing any double vision? Facial sensation (CN V): Can the patient feel a cotton wisp equally on each side of the face? Facial expression (CN VII): Assess for asymmetry in facial contour and wrinkles when patient is asked to smile, puff out cheeks, clench eyes tight Articulation (CN V, VII, IX, X, XII): Is the patients speech slurred, quiet, breathy, nasal, low or high pitched? Tongue protrusion (CN XII): Can the patient stick tongue straight out and move it equally from side to side? Functional mobility: Assess sitting and standing endurance. Assess ability to perform transfers and bed mobility. Assess upper extremity function in bed mobility, transfers, reaching, grasping, and holding. Assess lower extremity function in bed mobility, transfers, gait, thresholds, and stairs. Possible assessment tools include:(11) The Barthel Index superior reliability and validity, but limited at the upper functional levels The Motor Assessment Scale (MAS) good reliability and easy to use; primarily an assessment of mobility The Functional Independence Measure (FIM) good to superior reliability; evaluates function (including ADLs) and communication/ cognition The Rivermead Mobility Index evaluates functional mobility; quick The Assessment of Motor and Process Skills (AMPS) evaluates instrumental ADLs Gait/locomotion: Assess ability to walk and gait pattern, with assistance or assistive ambulatory device, if indicated. Tests to consider include the Functional Ambulation Profile and the Timed Up & Go Test(11) Joint integrity and mobility: Assess joint mobility in cases with impaired upper extremity and/or lower extremity function Motor function (motor control/tone/learning): Assess upper extremity grasp and release, and coordination (opposition, finger to nose, and diadochokinesis). Clinicians may consider using the Fugl-Meyer Assessment as it is reported to have good validity and reliability.(11) Modified Ashworth Scale for spasticity may be used during muscle tone assessment Muscle strength: Manually assess functional upper extremity strength (shoulder, elbow, wrist, and handgrip), trunk strength, and functional lower extremity strength (hip, knee, and ankle) Observation/inspection/palpation Inspect the limbs for signs of injury, inflammation, or DVT Inspect the skin for breakdown Palpate for dependent edema or muscle contractures Pain/tenderness: Assess with VAS Perception: Assess visual field, visual attention, right/left discrimination, body awareness, depth perception, motor planning, spatial relations, and figure ground discrimination Posture: Assess for asymmetric posture in sitting and standing Range of motion: Assess functional ROM of the extremities and spine Reflex testing: Test reflexes bilaterally and compare Sensory and peripheral nerve integrity testing: Assess for sensory changes (proprioception, kinesthesia, deep pressure, light touch, thermal) in affected limbs

assessment/Plan of care
 Precautions/recommendations Avoid aggressive stretching in favor of gentle movement therapy techniques (pain-free range) Evidence is lacking to support the used of thermal modalities (cold or heat) for treating pain or hypertonicity in chronic stroke Discourage routine use of shoulder sling to avoid contractures and flexor synergy pattern Cryotherapy contraindications include:(12) Raynauds syndrome Medical instability Cryoglobulinemia

 Cold urticaria Paroxysmal cold hemoglobinuria Avoid applying cold over superficial nerves, areas of diminished sensation or with poor circulation, or slow-healing wounds Cryotherapy precautions include:(12) Use caution with patients who are hypertensive as cold can cause a transient increase in blood pressure; discontinue treatment if there
is an elevation in blood pressure

Use caution with patients who are hypersensitive to cold Avoid aggressive treatment with cold modalities over an acute wound Use of cryotherapy with patients who have an aversion to cold may be counterproductive if being used to promote muscle relaxation
and decrease pain

Superficial heat is contraindicated with:(12) Decreased circulation Decreased sensation Acute/subacute traumatic and inflammatory conditions Skin infections Impaired cognition or language barrier Malignant tumors Tendency for hemorrhage or edema Heat rubs Electrotherapy contraindications/precautions include (in some cases, when approved by the treating physician, electrotherapy may
be used under some of the circumstances listed below when benefits outweigh the perceived risk):(12) Stimulation through or across the chest Cardiac pacemakers Implanted stimulators Over carotid sinuses Uncontrolled hypertension/hypotension Peripheral vascular disease Thrombophlebitis Pregnancy Over pharyngeal area Diminished sensation Acute inflammation Seizure history Confused patients Immature patients Obesity Osteoporosis Used in close proximity to diathermy treatment Diagnosis/need for treatment: Stroke with residual paresis/paralysis, restricted mobility, pain, and impaired ability in ADLs Rule out Traumatic brain injury TIA if < 24 hours(1) Reversible ischemic neurological deficit (RIND) if > 24 hours but < 3 weeks(1) Tumor(1) Brain abscess(1) Cerebritis(1) Subdural hematoma(1) Epidural hematoma(1) Focal seizure activity(1) Myasthenia gravis(1) DVT Upper extremity conditions that may impair ADLs (e.g., adhesive capsulitis, shoulder joint subluxation, brachial plexus injury, complex regional pain, heterotropic ossification at elbow) Prognosis The majority of individuals post CVA (particularly lacunar infarcts) get better; however, they have a higher mortality rate than that seen in the general population(1) During the acute stage of CVA the rate of mortality is up to 25% Post CVA the rate of mortality is 31% at 1 year, and even greater in the elderly The number one cause of death in patients who have suffered a CVA is a recurrent CVA

 

 Two-thirds of individuals die within 12 years of their initial CVA Long-term mortality rates are higher in men An individuals functional level at 6 months post ischemic stroke predicts his/her survival(13) Based on the collective results of 3 prospective cohort studies 7,710 individuals were evaluated at 6 months post CVA onset and followed for up to 19 years Median survival
 Based on all 3 cohorts:

9.7 years in 2,525 individuals independent in daily living 6 years in 3,436 individuals dependent in daily living
 Based on 2 of the cohorts: (modified Rankin scale was used)

  

> 15 years in 311 individuals with a Rankin score of 0 11.7 years in 540 individuals with a Rankin score of 1 8.4 years in 576 individuals with a Rankin score of 2 6 years in 433 individuals with a Rankin score of 3 3.7 years in 189 individuals with a Rankin score of 4 2.5 years in 136 individuals with a Rankin score of 5 Predictors of poor motor recovery and ability in ADLs Prolonged flaccidity period Severe arm weakness in acute stage Weak or no handgrip strength at 4 weeks after stroke Severe proximal spasticity Severely impaired cognition Poor sitting balance Bladder dysfunction, including impaired awareness of bladder needs The Hemispheric Stroke Scale score during inpatient rehabilitation was a valid predictor of ADL outcome at 6 months after discharge(14) Predictors of long-term participation in ADLs include age, comorbidity, cognitive affect, upper extremity ability, and lower extremity coordination(15) Clinical instruments predict functional outcome after stroke with better accuracy than lesion size and location.(16) For example, sitting balance (trunk control test), motor functioning (Motricity Index), and ADL assessment (Barthel Index) in the second week after stroke predicted independency in ADLs at 1 year, while MRI imaging did not have added predictive value(17) Referral to other disciplines: Physician for management of heart disease, hypertension, diabetes, hypercoagulable state, hyperlipidemia; nurse for smoking cessation program; occupational therapist for limitations with personal ADLs; speech therapist; social service Other considerations: Stroke rehabilitation practice has generally focused on the first 6 months. Current evidence suggests that positive functional outcomes may diminish with intervention after 1 year or more(18) Treatment interventions A common goal of rehabilitation team services after stroke is to achieve functional outcomes that reduce disability in ADLs. Focused functional tasks in occupational therapy are clearly effective for improving ability in personal ADLs after stroke.(19) However, it was concluded in a recent systematic review that the exact nature of the occupational therapy intervention to achieve maximum benefit in personal ADLs after stroke has yet to be defined.(20) In multidisciplinary therapy-based teamwork to improve ADLs, physical therapists may assess and treat deficits in sitting, standing, or gait that underlie disability in personal care.(21, 22) Functional training in physical therapy may also independently enhance ability in ADLs. For example, the addition of repetitive locomotor training to standard physical therapy resulted not only in better gait ability, it also improved competence in basic ADLs in a randomized controlled trial(23) Conventional physical therapy for stroke rehabilitation includes positioning, ROM, strengthening, functional mobilization, gait training, compensatory techniques and aerobic exercise (e.g., arm cranking, treadmill walking, or stationary recumbent cycling). Several treatment approaches for regaining motor control, such as proprioceptive neuromuscular facilitation, Bobath neurodevelopmental technique, Brunstrom movement therapy, and Rood sensorimotor technique, are also commonly used. In addition, the physical therapist may implement motor learning/relearning techniques employing task-specific practice with feedback. No single approach has been shown to be more effective than others for recovery of postural control and lower limb function following stroke; using a mix of components taken from different approaches deserves consideration(24) Moderately strong evidence supports the effectiveness of constraint-induced movement therapy (CIMT) for improving upper extremity function in daily activities after stroke (see Clinical Review Stroke: Upper Extremity; Accession Number: 5000008656). In one study, the CIMT group that wore a mitt on the less-affected hand while the more-affected UE received intensive training 2 hours/day, 5 days/week for 3 weeks improved planning and movement control strategies in reaching and bimanual tasks, as well as functional independence measures vs. the control group(25) Repetitive task-related training shows promise for improving function in daily living, but the available evidence is insufficient to determine its effectiveness compared to other interventions.(26) For example, task-oriented intervention did not improve manual dexterity (Box and Block Test) of the affected arm in chronic stroke.(27) However, further research is indicated because this type of training is an attainable home-based intervention Increased intensity of exercise has slight but beneficial impact on ADL(28)

 Based on a systematic review of trials of low to moderate quality Review analyzed 20 randomized trials with a total of 2,686 individuals post CVA Small but statistically significant results were obtained in the meta-analysis of 17 trials that examined the impact of augmented
exercise intensity during the initial 6 months post CVA

Statistically significant changes were not observed in 3 trials that examined increased exercise intensity in the chronic phase of stroke
recovery

Cumulative meta-analysis indicates that a minimum of 16 hours of extra treatment time during the initial 6 months is required to
achieve significant improvements in ADLs

For therapy specifically related to gait, see Clinical Review Stroke: Gait Training; Accession Number: 5000008657
Expected Progression
Allow several weeks for pain/ edema management

Problem
Pain and dependent edema

Goal
Resolution of pain and edema

Intervention
Therapeutic modalities Massage for dependent edema Physical agents and mechanical modalities Cryotherapeutic agents, arm elevation; trials of compression glove and pneumatic compression for edema

Home Program
Apply cold pack and mechanical modalities, as tolerated, to reduce pain

Contractures, decreased ROM

Resolution of contractures and improved ROM of extremities

Therapeutic modalities Manual joint mobilizations and stretching of tight tissues Active-assisted, active ROM exercises. Movement therapy techniques

Allow up to 12 weeks to achieve goals

ROM exercises in high functioning patients. Daily repetition of exercises

Cardiovascular deconditioning

Improve aerobic fitness

Therapeutic exercise Recumbent cycling, treadmill walking (if safely tolerated), and aquatic therapy as indicated and appropriate Therapeutic exercise Strengthening exercises. Movement therapy techniques Functional training Educate the patient on onehanded techniques in daily activities(29) Prescription, application of devices and equipment Numerous devices for improving basic and instrumental ADLs(29) Educate patient that routine use of shoulder sling is not indicated Discontinue shoulder sling except when ambulating

Allow up to 12 weeks to achieve goals

Provide patients parent/ caregiver with written instructions regarding activities that can be safely performed at home Strengthening exercises in high functioning patients. Daily repetition of exercises Patient/caregiver education on practicing tasks; provide patients parent/caregiver with written instructions regarding exercises and functional activities that can be performed at home. Patient/caregiver education on use of adaptive devices

Atrophy, weakness, and impaired motor control

Improve activation and strength of affected muscles

Allow up to 12 weeks to achieve goals

Dependence in ADLs

Greater independence in ADLs with the use of adaptive techniques and devices

Allow up to 12 weeks to achieve functional goals

Poor posture in ADLs

Improved posture during ADLs

Therapeutic exercise Positioning/postural exercises Functional postural control tasks

Allow up to 12 weeks to achieve functional goals

Patient/caregiver education on practicing tasks; provide patients parent/caregiver with written instructions regarding exercises and functional activities that can be performed at home

Favorable Outcomes/Outcome Measures

 Outcomes Reduced or resolved pain Resolved contractures and improved ROM Improved aerobic fitness Improved strength Improved motor control in ADLs Improved posture during ADLs Outcome measures Action Research Arm (ARA) Test(30) Functional Reach Test or The Postural Assessment Scale for Stroke(11) Barthel Index(11, 31) Motor Assessment Scale (MAS)(11) Functional Independence Measure (FIM)(11, 32) Rivermead Mobility Index(11) Assessment of Motor and Process Skills (AMPS)(11) Functional Ambulation Profile and the Timed Up & Go Test(11) Fugl-Meyer Assessment(11, 33) Modified Ashworth Scale for spasticity

Maintenance or Prevention
  Maintain the highest achievable ROM, strength, and function of the affected limbs Reduce modifiable stroke risk factors

Patient Education
 American Stroke Association - http://www.strokeassociation.org

coding Matrix
References in this Clinical Review are rated using the following codes, listed in order of strength: M Published meta-analysis SR Published systematic or integrative literature review RCT Published research (randomized controlled trial) R Published research (not randomized controlled trial) C Case histories, case studies G Published guidelines RV Published review of the literature RU Published research utilization report QI Published quality improvement report L Legislation PGR Published government report PFR Published funded report PP Policies, procedures, protocols X Practice exemplars, stories, opinions GI General or background information/texts/reports U Unpublished research, reviews, poster presentations or other such materials CP Conference proceedings, abstracts, presentations

References
1. DynaMed Editorial Team. Stroke (acute management). DynaMed website. http://www.ebscohost.com/dynamed. Updated March 18, 2009. Accessed March 23, 2009. (RV) 2. Guercini F, Acciarresi M, Agnelli G, Paciaroni M. Cryptogenic stroke: time to determine aetiology. J Thromb Haemost. 2008; 6(4): 549554. (RV) 3. Zorowitz R, Baerga E, Cuccurullo S. Stroke. In: Cuccurullo SJ, ed. Physical Medicine and Rehabilitation Board Review. New York: Demos Medical Publishing, 2004:1-46. (GI) 4. Luft AR, Waller S, Forrester L, et al. Lesion location alters brain activation in chronically impaired stroke survivors. Neuroimage. 2004;21(3):924-935. (R) 5. Sunderland A, Tuke A. Neuroplasticity, learning and recovery after stroke: a critical evaluation of constraint-induced therapy. Neuropsychol Rehabil. 2005;15(2):81-96. (RV) 6. Zhang L, Butler AJ, Sun CK, Sahgal V, Wittenberg GF, Yue GH. Fractal dimension assessment of brain white matter structural complexity post stroke in relation to upper extremity motor function. Brain Res. 2008;1228: 229-240. (R) 7. Pohjasvaara TI, Jokinen H, Ylikoske R, et al. White matter lesions are related to impaired instrumental activities of living poststroke. J Stroke Cerebrovasc Dis. 2007;16(6):251-258. (R) 8. Steffens DC, Bosworth HB, Provenzale JM, MacFall JR. Subcortical white matter and functional impairment in geriatric depression. Depress Anxiety. 2002;15(1):23-28. (R) 9. Rexroth P, Fisher AG, Merritt BK, Gliner J. ADL differences in individuals with unilateral hemispheric stroke. Can J Occup Ther. 2005;72(4):212-221. (R) 10. Andrews AW, Folger SE, Norbet SE, Swift LC. Tests and measures used by specialist physical therapists when examining patients with stroke. J Neurol Phys Ther. 2008;32(3):122-128. (R)

11. Umphred DA. Neurological Rehabilitation. 5th ed. St Louis: Mosby Elsevier; 2007. (GI) 12. Michlovitz SL, Nolan TP. Modalities for Therapeutic Intervention. 4th ed. Philadelphia: F.A. Davis Company; 2005. (GI) 13. Slot KB, Berge E, Dorman P, et al. Impact of functional status at six months on long term survival in patients with ischaemic stroke: prospective cohort studies. BMJ. 2008;336(7640):376-379. (R) 14. Frank B, Schlote A, Hasenbein, Wallesch CW. Prognosis and prognostic factors in ADL-dependent stroke patients during their first inpatient rehabilitation a prospective multicentre study. Disabil Rehabil. 2006;28(21):1311-1318. (R) 15. Desrosiers J, Noreau L, Rochette A, Bourbonnais D, Bravo G, Bourget A. Predictors of long-term participation after stroke. Disabil Rehabil. 2006;28(4):221-230. (R) 16. Hatakenaka M, Miyai I, Sakoda S, Yanagihara T. Proximal paresis of the upper extremity in patients with stroke. Neurology. 2007;69(4):348-355. (R) 17. Schiemanck SK, Kwakkel G, Post MW, Kappelle LJ, Prevo AJ. Predicting long-term independency in activities of daily living after middle cerebral artery stroke: does information from MRI have added predictive value compared with clinical information? Stroke. 2006;37(4):1050-1054. (R) 18. Aziz NA, Leonardi-Bee J, Phillips M, Gladman JR, Legg L, Walker MF. Therapy-based rehabilitation services for patients living at home more than one year after stroke. Cochrane Database Syst Rev. 2008;(2):CD005952. doi:10.1002/14651858. CD005952. (SR) 19. Legg L, Drummond A, Leonardi-Bee J, et al. Occupational therapy for patients with problems in personal activities of daily living after stroke: systematic review of randomized trials. BMJ. 2007; 335(7626):922. (SR) 20. Legg L, Drummond A, Langhorne P. Occupational therapy for patients with problems in activities of daily living after stroke. Cochrane Database Syst Rev. 2006;(4):CD003585. doi: 10.1002/14651858.CD003585. Updated January 21, 2009. (SR) 21. Tempest S, McIntyre A. Using ICF to clarify team roles and demonstrate clinical reasoning in stroke rehabilitation. Disabil Rehabil. 2006;28(10):663-667. (RV) 22. Outpatient Service Trialists. Therapy-based rehabilitation services for stroke patients at home. Cochrane Database Syst Rev. 2003;(1):CD002925. doi: 10.1002/14651858. CD002925. Updated January 21, 2009. (SR) 23. Pohl M, Werner C, Holzgraefe M, et al. Repetitive locomotor training and physiotherapy improve walking ability and basic activities of daily living after stroke: a single-blind, randomized multicentre trial (DEutsche GAngtrainerStudie, DEGAS). Clin Rehabil. 2007;21(1):17-27. (RCT) 24. Pollock A, Baer G, Langhorne P, Pomeroy V. Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke: a systematic review. Clin Rehabil. 2007;21(5):395-410. (SR) 25. Wu CY, Lin KC, Chen HC, Chen IH, Hong WH. Effects of modified constraint-induced movement therapy on movement kinematics and daily function in patients with stroke: a kinematic study of motor control mechanisms. Neurorehabil Neural Repair. 2007;21(5):460-466. (RCT) 26. French B, Leathley M, Sutton C, et al. A systematic review of repetitive function task practice with modeling of resource use, costs and effectiveness. Health Technol Assess. 2008;12(30):1-140. (SR) 27. Higgins J, Salbach NM, Wood-Dauphinee S, Richards CL, Cote R, Mayo NE. The effect of a task-oriented intervention on arm function in people with stroke: a randomized controlled trial. Clin Rehabil. 2006;20(4):296-310. (RCT) 28. Kwakkel G, van Peppen R, Wagenaar RC, et al. Effects of augmented exercise therapy time after stroke: a meta-analysis. Stroke. 2004;35(11):2529-2539. (M) 29. Ryan PA, Sullivan JW. Activities of daily living adaptations: managing the environment with one-handed techniques. In: Gillen G, Burkhardt A, eds., Stroke Rehabilitation: A Function-Based Approach. St. Louis: Mosby;2004:614-632. (GI) 30. Van de Winckel A, Feys H, Lincoln N, De Weerdt W. Assessment of arm function in stroke patients: Rivermead Motor Assessment revised with Rasch analysis. Clin Rehabil. 2007;21(5):471-479. (R) 31. Collin C, Wade DT, Davies S, Home V. The Barthel ADL Index: a reliability study. Int Disabil Stud. 1988;10(2):61-63. (R) 32. Smith P, Hamilton BB, Granger CV. Functional Independence Measure Decision Tree: The FONE FIM. Buffalo, NY: State University of New York Research Foundation, 1990. (G) 33. Gladstone DJ, Danells CJ, Black SE. The Fugl-Meyer assessment of motor recovery after stroke: a critical review of its measurement properties. Neurorehabil Neural Repair. 2002;16(3):232-240. (RV)