Community walking can be assessed using a 10-metre timed walk test.

BACKGROUND: A decline in mobility is a common feature of multiple sclerosis (MS). Community walking scales are used to categorize patients in their ability to move independently. The first purpose of this study was to determine which specific gait speed corresponded with the categories of the Modified Functional Walking Categories (MFWC). The second purpose was to determine the Minimally Important Change (MIC) in absolute gait speed using the MFWC and Expanded Disability Status Scale (EDSS) as external criteria. METHOD: MS patients were measured six times in 6 years. Gait velocity was measured with the 10-metre timed walk test (10-m TWT), the severity of MS was determined with the EDSS, and community walking was assessed with the MFWC. For each category of the MFWC, Receiver Operating Characteristic (ROC) curves were used to find the best possible cut-off point on the 10-m TWT. The MIC in absolute gait speed was determined using a change of one category on the MFWC or one point on the EDSS. RESULTS: A strong relationship was found between gait speed and the MFWC; all areas under the ROC curves (AUCs) were between 0.74 and 0.86. The MIC in absolute gait speed could not be determined, because the AUCs were below the threshold of 0.70 and changes in gait speed were small. CONCLUSIONS: Gait speed is related to community walking, but an MIC in absolute gait speed could not be determined using a minimally important change on the MFWC or the EDSS as external criteria.

Utilization of health care by patients with multiple sclerosis is based on professional and patient-defined health needs.

OBJECTIVE: This cross-sectional study investigates healthcare utilization, and determines which predisposing, enabling, and health factors are associated with healthcare utilization among 121 patients with multiple sclerosis (MS). METHODS: Data on patient-related predisposing, enabling, and health factors were collected by means of written questionnaires and a home visit from a well-trained physiotherapist. RESULTS: Of the 121 patients with MS (mean age 43 years, mean score on the Expanded Disability Status Scale 3.5, disease duration 6 years), 16% were hospitalized in the previous year; 62% consulted their general practitioner, and 69% consulted their neurologist in the previous 6 months. Other medical specialists were consulted in the 6-month period by 50% of the study population. In a 4-week period preceding the home visit, 41% of the patients were treated by an allied healthcare professional. Multivariate logistic regression analyses showed that consulting the general practitioner, the neurologist, other medical specialists, and allied healthcare professionals, and the use of equipment/aids by MS patients is primarily related to their health, either as perceived by the patients themselves or defined by the professional. CONCLUSIONS: MS patients in the Netherlands make appropriate use of healthcare facilities, because their utilization can predominantly be explained by health-related factors, and not by predisposing or enabling factors.

Diagnosis and treatment of depression following acquired brain injury: a comparison of practice in the UK and the Netherlands.

OBJECTIVE: To describe and compare current practice in diagnosis and treatment of depression following acquired brain injury in two countries (UK and the Netherlands) which have different sets of guidelines. SETTING AND DESIGN: A cross-sectional survey of reported practice among rehabilitation physician members of the British and Dutch specialist societies. METHODS: A 12-item postal questionnaire was sent to 496 rehabilitation physicians with two reminders: N=353 (71%) responded, 146 of whom did not manage people with acquired brain injury, leaving 207 questionnaires for analysis (Netherlands N=121, UK N=86). Descriptive summary statistics were compiled. Categorical and dichotomous data were compared between the groups using chi-squared tests. RESULTS: Sixty-seven (78%) of British respondents served a predominantly younger adult (65 years) population, compared with only 27 (22%) of the Dutch, who mainly treated patients of all ages. In line with their respective guidelines, more British respondents reported that they screened all acquired brain injury patients for depression (68/86 (79%) British versus 71/121 (59%) Dutch, P<0.01), and used formal measures (37/68 (54%) versus 14/69 (20%), P<0.001). They also took a more active role in treatment of depression: only 1 (1%) never used antidepressants, compared with 22 (18%) of Dutch respondents (P<0.001). On the other hand, where antidepressants were prescribed, the Dutch respondents were more likely than the British to follow-up their patients (93/98 (95%) versus 67/84 (80%), P<0.01). CONCLUSIONS: The survey demonstrates a broadly similar approach, but highlights some significant variance in practice between the two countries which may stem from differences in population and service provision as well as their respective guidelines.

The usefulness of evaluative outcome measures in patients with multiple sclerosis.

To select the most useful evaluative outcome measures for early multiple sclerosis, we included 156 recently diagnosed patients in a 3-year follow-up study, and assessed them on 23 outcome measures in the domains of disease-specific outcomes, physical functioning, mental health, social functioning and general health. A global rating scale (GRS) and the Expanded Disability Status Scale (EDSS) were used as external criteria to determine the minimally important change (MIC) for each outcome measure. Subsequently, we determined whether the outcome measures could detect their MIC reliably. From these, per domain the outcome measure that was found to be most sensitive to changes (responsive) was identified. At group level, 11 outcomes of the domains of physical functioning, mental health, social functioning and general health could reliably detect the MIC. Of these 11, the most responsive measures per domain were the Medical Outcome Study 36 Short Form sub-scale physical functioning (SF36pf), the Disability and Impact Profile (DIP) sub-scale psychological, the Rehabilitation Activities Profile sub-scale occupation (RAPocc) and the SF36 sub-scale health, respectively. Overall, the most responsive measures were the SF36pf and the RAPocc. In individual patients, none of the measures could reliably detect the MIC. In sum, in the early stages of multiple sclerosis the most useful evaluative outcome measures for research are the SF36pf (physical functioning) and the RAPocc (social functioning).

The initial course of daily functioning in multiple sclerosis: a three-year follow-up study.

We studied the initial course of daily functioning in multiple sclerosis (MS). A cohort of 156 recently diagnosed patients was prospectively followed for three years (five measurements). Domains of interest were neurological deficits, physical functioning, mental health, social functioning and general health. An a priori distinction was made between a relapse onset group (n = 128) and a non-relapse onset group (n =28). At baseline, neurological deficits are relatively minor for most patients, 26.3% have aberrant physical functioning scores, 38.5% have aberrant social functioning scores, 9% have aberrant mental health scores and 25% have aberrant general health scores. The neurological deficits and physical functioning deteriorated significantly over time. This deterioration was more pronounced and clinically relevant in the non-relapse onset group only. Mental health showed a significant, but not clinically relevant deterioration over time. Social functioning and general health showed non-significant effects for time. It is concluded that in the initial stage of MS, when neurological deficits are relatively minor and mental health is relatively unaffected, patients in both groups experience limitations in daily functioning. Patients in the non-relapse onset group have progressive neurological symptoms that are accompanied by progressive limitations in physical functioning, but not by progressive limitations in the other domains.

Work ability of Dutch employees with rheumatoid arthritis.

OBJECTIVES: To (i) examine the association between fatigue, psychosocial work characteristics (job control, support, participation in decision making, psychological job demands), and physical work requirements on the one hand and work ability of employees with rheumatoid arthritis (RA) on the other, and (ii) determine the advice that health care professionals give to employees with RA on how to maintain their work ability. METHODS: Data were gathered from 78 employees with early RA (response = 99%) by telephone interviews and self-report questionnaires. RESULTS: Fatigue, lack of autonomy, low coworker/supervisor support, low participation in decision making, and high physical work requirements (i.e. using manual force) predicted low work ability. High psychological job demands, however, did not predict low work ability. The rheumatologist, occupational physician, occupational therapist, physiotherapist, and psychologist gave advice on how to cope with RA at work to 36, 30, 27, 26, and 17% of the employees, respectively. Advice was directed mainly at factors intrinsic to the employee. Employees expressed a positive attitude towards this advice. CONCLUSIONS: Fatigue, lack of support, lack of autonomy, lack of participation in decision making, and using manual force at work (e.g. pushing and pulling) threaten the work ability of employees with RA. According to the employees with RA, involvement of health care professionals from different disciplines and the implementation of organizational and technical interventions would help them to tackle these threats.

Predictive factors of work disability in rheumatoid arthritis: a systematic literature review.

BACKGROUND: Work disability-a common outcome of rheumatoid arthritis (RA)-is a societal (for example, financial costs) and individual problem (for example, loss of status, income, social support, and distraction from pain and distress). Until now, factors that predict work disability in RA have not been systematically reviewed. OBJECTIVE: To determine predictive factors of work disability in RA as reported in the literature. METHODS: A systematic literature search in Cinahl (1988-2004), Embase (1988-2004), and Medline (1989-2004) was followed by the application of two sets of criteria related to: (a) methodological quality, and (b) measurement of the predictive factor. Based on the quality and the consistency of the findings, a rating system was used to assess the level of evidence for each predictive factor. RESULTS: Nineteen publications (17 cohorts) were identified, of which 13 met the general methodological quality criteria. Results provided strong evidence that physical job demands, low functional capacity, old age, and low education predict work disability in RA. Remarkably, biomedical variables did not consistently predict work disability. Moreover, owing to the lack of high quality studies no evidence was found for personal factors such as coping style, and work environmental factors such as work autonomy, support, work adjustments that are presumed crucial in the work disablement process. CONCLUSIONS: The results indicate that work disability in RA is a biopsychosocially determined misfit between individual capability and work demands.

Electrical stimulation of the upper limb in stroke: stimulation of the extensors of the hand vs. alternate stimulation of flexors and extensors.

OBJECTIVE: To investigate whether there is a difference in functional improvement in the affected arm of chronic stroke patients when comparing two methods of electrical stimulation. DESIGN: Explanatory trial in which 30 chronic stroke patients with impaired arm function were randomly allocated to either alternating electrical stimulation of the extensor and flexor muscles of the hand (group A) or electrical stimulation of the extensors only (group B). Primary outcome measure was the Action Research Arm test to assess arm function. Grip strength, Motricity Index, Ashworth Scale, and range of motion of the wrist were secondary outcome measures. RESULTS: Improvement on the Action Research Arm test was 1.0 point in group A and 3.3 points in group B; the difference in functional gain was 2.3 points (95% confidence interval, -1.06 to 5.60). The success rate (i.e., percentage of patients with a clinically relevant improvement of >5.7 points on the Action Research Arm test) was 27% in group B (four patients) and 8% in group A (one patient). The differences in functional gain and success rate were not statistically significant, neither were the differences between the two groups on the secondary outcome measures. CONCLUSION: The difference between the two stimulation strategies was not statistically significant.

Epidural metastatic spinal cord compression: functional outcome and survival after inpatient rehabilitation.

STUDY DESIGN: Retrospective descriptive study. OBJECTIVES: (1). To obtain an overall appraisal of patients with epidural metastatic spinal cord compression (SCC) admitted to nine Dutch spinal cord units (SCUs) between 01-01-1990 and 01-01-2000. (2). To identify factors that predict survival >1 year after in-patient rehabilitation of patients with epidural metastatic SCC. SETTING: Dutch SCUs. Rehabilitation Center Amsterdam, Amsterdam. Rehabilitation Center Heliomare, Wijk aan Zee. Rehabilitation Center De Hoogstraat, Utrecht. Rehabilitation Center Rijndam, Rotterdam. Rehabilitation Center Sophia Stichting, Den Haag. Rehabilitation Center Beatrixoord, Haren. Rehabilitation Center Het Roessingh, Enschede. Rehabilitation Center Sint Maartenskliniek, Nijmegen. Rehabilitation Center SRL Hoensbroeck, Hoensbroek. METHODS: (1). Clinical records were reviewed and demographic, clinical and functional data were collected according to a protocol. The date of admittance to the SCU, rehabilitation goals, date of discharge and date of death were recorded. (2). The odds ratio (OR) was calculated for all determinants on admittance to the SCU in order to find indicators that predict survival >1 year after discharge from the SCU. An OR >or=2 was considered to be clinically significant. RESULTS: In total, 131 patients with epidural metastatic SCC were admitted. In all, 117 clinical records were retrieved and 97 clinical records provided complete data. The average age on admittance was 58 years. Among the patients 53% were male. The average Barthel score on admittance was 7.2/20 points. The average length of stay in the SCU was 104 days (3-336). Overall, 66% of the patients were discharged. The average Barthel score on discharge was 12.0 points. The average survival after discharge was 808 (0-3669) days. During their stay on the SCU, seven patients died. At 1 year after discharge, 52% of the patients were still alive. These patients suffered less complications, had been admitted less often to a hospital during rehabilitation, had made better functional progress and had been discharged home more often. A survival >1 year after discharge is related to ASIA D (OR 4.3), MRC 4 and 5 (OR 5.4), tumour in remission (OR 3.8) and independence or partial independence on the Barthel items: dressing (OR 4.3) and making transfers (OR 5.0). CONCLUSIONS: Patients with epidural metastatic SCC may benefit from in-patient rehabilitation.

Satisfactory cross cultural equivalence of the Dutch WOMAC in patients with hip osteoarthritis waiting for arthroplasty.

BACKGROUND: Cross cultural validity is of vital importance for international comparisons. OBJECTIVE: To investigate the validity of international Dutch-English comparisons when using the Dutch translation of the Western Ontario and McMaster Universities osteoarthritis index (WOMAC). PATIENTS AND METHODS: The dimensionality, reliability, construct validity, and cross cultural equivalence of the Dutch WOMAC in Dutch and Canadian patients waiting for primary total hip arthroplasty was investigated. Unidimensionality and cross cultural equivalence was quantified by principal component and Rasch analysis. Intratest reliability was quantified with Cronbach's alpha, and test-retest reliability with the intraclass correlation coefficient. Construct validity was quantified by correlating sum scores of the Dutch WOMAC, Arthritis Impact Measurement Scales (Dutch AIMS2), Health Assessment Questionnaire (Dutch HAQ), and Harris Hip Score (Dutch HHS). RESULTS: The WOMAC was completed by 180 Dutch and 244 English speaking Canadian patients. Unidimensionality of the Dutch WOMAC was confirmed by principal component and Rasch analysis (good fit for 20/22 items). The intratest reliability of the Dutch WOMAC for pain and physical functioning was 0.88 and 0.96, whereas the test-retest reliability was 0.77 and 0.92, respectively. Dutch WOMAC pain sum score correlated 0.69 with Dutch HAQ pain, and 0.39 with Dutch HHS pain. Dutch WOMAC physical functioning sum score correlated 0.46 with Dutch AIMS2 mobility, 0.62 with Dutch AIMS2 walking and bending, 0.67 with Dutch HAQ disability, and 0.49 with Dutch HHS function. Differential item functioning (DIF) was shown for 6/22 Dutch items. CONCLUSIONS: The Dutch WOMAC permits valid international Dutch-English comparisons after correction for DIF.

Pyridostigmine in postpolio syndrome: no decline in fatigue and limited functional improvement.

OBJECTIVES: To investigate the effect of pyridostigmine on fatigue, physical performance, and muscle function in subjects with postpoliomyelitis syndrome. METHODS: 67 subjects with increased fatigue and new weakness in one quadriceps muscle showing neuromuscular transmission defects, were included in a randomised, double blind, placebo controlled trial of 60 mg pyridostigmine four times a day for 14 weeks. Primary outcome was fatigue (on the "energy" category of the Nottingham health profile). Secondary outcomes included two minute walking distance and quadriceps strength and jitter. Motor unit size of the quadriceps was studied as a potential effect modifier. The primary data analysis compared the changes from baseline in the outcomes in the last week of treatment between groups. RESULTS: 31 subjects treated with pyridostigmine and 31 subjects treated with placebo completed the trial. No significant effect of pyridostigmine was found on fatigue. The walking distance improved more in the pyridostigmine group than in the placebo group (by 7.2 m (6.0%); p<0.01). Subgroup analysis showed that a significant improvement in walking performance was only found in subjects with normal sized motor units. Quadriceps strength improved more in the pyridostigmine group than in the placebo group (by 6.7 Nm (7.2%); p = 0.15). No effect of pyridostigmine was found on jitter. CONCLUSIONS: Pyridostigmine in the prescribed dose did not reduce fatigue in subjects with postpoliomyelitis syndrome. However, it may have a limited beneficial effect on physical performance, especially in subjects with neuromuscular transmission defects in normal sized motor units.

Perceived health in a population based sample of victims of the 1956 polio epidemic in the Netherlands.

OBJECTIVE: To investigate perceived health and its relation to residual paresis from polio, late onset neuromuscular symptoms following poliomyelitis (LSP), and sex, in a population based sample of polio survivors. METHODS: 350 subjects traced from the notification records of the Dutch 1956 polio epidemic received a mailed questionnaire on residual polio paresis and new neuromuscular symptoms. Perceived health was measured using the Nottingham health profile. Respondents with new muscle weakness and new neuromuscular symptoms were considered as cases with LSP. RESULTS: Health problems were perceived by 151 of the 260 respondents. Respondents with residual paresis had significantly more health problems than clinically recovered respondents for the Nottingham health profile category of physical mobility. The perceived health of respondents with LSP (45.5%) was significantly worse than that of respondents without LSP for all the health profile categories. Among the respondents with LSP, health status did not differ between those with residual paresis and those who had recovered, except for physical mobility. Female respondents with LSP reported worse health status than male respondents with regard to physical mobility and social isolation. CONCLUSIONS: In this population based sample, health problems were frequently reported. They were mainly related to late onset neuromuscular symptoms following poliomyelitis, which were perceived by a substantial proportion of all polio survivors-not only subjects with polio residuals but also individuals who (subjectively) had recovered from polio.

Therapeutic electrical stimulation to improve motor control and functional abilities of the upper extremity after stroke: a systematic review.

BACKGROUND: Therapeutic electrical stimulation (TES) is a therapeutic strategy aimed at improving impairments of the upper extremity in stroke. OBJECTIVE: Assessment of the available evidence on the effect of TES of the affected upper extremity in improving motor control and functional abilities after stroke. METHODS: A systematic literature search was performed to identify randomized controlled trials (RCTs) that have studied the effect of TES on motor control and functional abilities. The methodological quality of the studies was assessed systematically by two raters. The reported outcomes were examined to evaluate the effect of TES and to identify a possible relationship with patient characteristics, method of stimulation and methodological quality. When possible, effect sizes were calculated (Hedges' g). RESULTS: Six RCTs were included. The methodological scores ranged from 7 to 16 (maximum 19). All studies assessed the effect on motor control, and four reported a positive effect. Effect sizes calculated in three studies ranged from 0.55 to 1.46. Only two studies assessed the effect on functional ability, one reported a positive effect. Subgroup analyses in two studies suggest a better response to stimulation in less severely affected patients. Apart from this, no relationship between effect and patient characteristics, method of stimulation or methodological quality could be detected. CONCLUSIONS: The present review suggests a positive effect of electrical stimulation on motor control. No conclusions can be drawn with regard to the effect on functional abilities.

Functional recovery after cardiac rehabilitation.

OBJECTIVE: To study the effect of a cardiac rehabilitation programme based on the guidelines of the Dutch Heart Association (DHA). DESIGN: Randomized controlled trial with a waiting list control group. SETTING: Outpatient clinic of Rehabilitation Centre Amsterdam. SUBJECTS: Forty patients with a first myocardial infarction. INTERVENTIONS: Immediately after randomization the experimental group started the rehabilitation programme; the waiting list control group started after six weeks. No other type of treatment was given during the waiting period. MAIN OUTCOME MEASURES: Physical recovery, tested by means of an exercise test on a bicycle ergometer, and feelings of well-being (MPVH-W), handicap (MPVH-H) and distress (MPVH-D), tested using a Dutch questionnaire: the Medische Psychologische Vragenlijst voor Hartpatiënten, MPVH (medical psychological questionnaire for cardiac patients). RESULTS: The adjusted treatment effects of the cardiac rehabilitation programme were 4.72% on the exercise test, 3.43 points on MPVH-W, -1.93 points on MPVH-H, and 0.12 points on MPVH-D. These effects were not statistically significant. CONCLUSION: Changes after a cardiac rehabilitation programme are relatively small, but are found in both the physical and the psychosocial domain.

Submaximal exercise capacity and maximal power output in polio subjects.

OBJECTIVES: To compare the submaximal exercise capacity of polio subjects with postpoliomyelitis syndrome (PPS) and without (non-PPS) with that of healthy control subjects, to investigate the relationship of this capacity with maximal short-term power and quadriceps strength, and to evaluate movement economy. DESIGN: Cross-sectional survey. SETTING: University hospital. PARTICIPANTS: Forty-three polio subjects (25 PPS, 18 non-PPS) and 12 control subjects. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Power output, oxygen uptake, and heart rate were measured in an incremental submaximal cycle ergometry test. Maximal short-term power was measured in 5-second all-out efforts. Knee extensor strength was measured on a chair dynamometer. RESULTS: The mean submaximal power +/- standard deviation at 80% of heart rate reserve of 83.8 +/- 29.9 watts in the polio subjects was significantly less than the mean submaximal power of 142.1 +/- 30.4 watts in the control group. However, expressed as a percentage of the maximal short-term power, submaximal power did not differ between the groups. Strength and maximal short-term power correlated significantly (p < .005) with submaximal power (r = .64 and .76, respectively). The oxygen uptake was higher than theoretically expected for the given submaximal power output in polio subjects, and appeared to increase with increasing asymmetry in strength and power between legs. No differences were found between PPS and non-PPS subjects. CONCLUSION: The submaximal work capacity of polio subjects was severely reduced, mainly in association with the reduced muscle capacity. And, because of a reduced movement economy, their energy cost was elevated. Although muscle loads in activities such as walking and climbing stairs differ from cycling, they also may require elevated relative levels of effort, predisposing subjects to premature fatigue in sustained activity.

Simultaneous development and implementation of the children's rehabilitation activities profile: a communication instrument for pediatric rehabilitation.

PURPOSE: To describe the methods used for the development and implementation of the Rehabilitation Activities Profile for Children (Children's RAP), an instrument to structure information for team conferences. METHODS: Our strategy consisted of nine steps: (1) survey in clinical practice; (2) literature search; (3) formation of a national study group; (4) development of specifications and a national draft; (5) development of local drafts; (6) integration of local drafts; (7) consultation of users and experts; (8) national conference; and (9) assessment of user experience. RESULTS: The final version of the Children's RAP consists of three sections: (1) basic information about the child and its proxies; (2) present situation and needs of the child and its proxies; and (3) conclusions of the team conference. User satisfaction ranged from adequate to good. The Children's RAP is currently used in 53% of the Dutch pediatric rehabilitation centres. CONCLUSION: The methods used guarantee an optimal involvement of users, experts and literature. With these methods it was possible to develop an instrument which is widely accepted and implemented in clinical practice.

Randomized trial of 4-aminopyridine in patients with chronic incomplete spinal cord injury.

OBJECTIVE: To test the efficacy of 4-aminopyridine (4-AP) on functional status, walking speed and vibration perception in patients with chronic, incomplete spinal cord injury. METHODS: Twenty SCI patients were randomized in a trial with a double-blind, crossover design to receive four weeks of orally administered 4-AP, followed by a two-week wash-out period and four weeks of placebo, or vice versa. The total daily dose of 4-AP during the four weeks of treatment was systematically increased to a maximum of 0.5 mg/kg body weight. Evaluation of (side-)effects took place at the beginning, after one week, and at the end of each four-week study period. RESULTS: No significant benefit was found on functional status (COOP-WONCA). A statistically significant treatment effect was found on the vibration perception threshold (VPT) in the left fingers, during the first study period. On average, patients receiving 4-AP treatment responded less favourably (mean increase in VPT of 0.29 (0.31) microm) than patients receiving placebo (mean decrease in VPT of 0.05 (0.35) microm) (p=0.04). Neither comfortable nor maximum walking speed altered significantly following 4-AP treatment. CONCLUSIONS: No statistically significant, functional benefit from 4-AP was found for patients in the present study. Furthermore, no support was found for the possibility that an a priory selection of responsive patients would have yielded more favourable results.

The responsiveness of the Action Research Arm test and the Fugl-Meyer Assessment scale in chronic stroke patients.

The responsiveness of the Action Research Arm (ARA) test and the upper extremity motor section of the Fugl-Meyer Assessment (FMA) scale were compared in a cohort of 22 chronic stroke patients undergoing intensive forced use treatment aimed at improvement of upper extremity function. The cohort consisted of 13 men and 9 women, median age 58.5 years, median time since stroke 3.6 years. Responsiveness was defined as the sensitivity of an instrument to real change. Two baseline measurements were performed with a 2-week interval before the intervention, and a follow-up measurement after 2 weeks of intensive forced use treatment. The limits of agreement, according to the Bland-Altman method, were computed as a measure of the test-retest reliability. Two different measures of responsiveness were compared: (i) the number of patients who improved more than the upper limit of agreement during the intervention; (ii) the responsiveness ratio. The limits of agreement, designating the interval comprising 95% of the differences between two measurements in a stable individual, were -5.7 to 6.2 and -5.0 to 6.6 for the ARA test and the FMA scale, respectively. The possible sum scores range from 0 to 57 (ARA) and from 0 to 66 (FMA). The number of patients who improved more than the upper limit were 12 (54.5%) and 2 (9.1%); and the responsiveness ratios were 2.03 and 0.41 for the ARA test and the FMA scale, respectively. These results strongly suggest that the ARA test is more responsive to improvement in upper extremity function than the FMA scale in chronic stroke patients undergoing forced use treatment.