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Clinical Rehabilitation
http://cre.sagepub.com/content/26/8/705
The online version of this article can be found at:
DOI: 10.1177/0269215511431903
2012 26: 705 originally published online 18 January 2012Clin Rehabil
Burcu Ersoz Huseyinsinoglu, Arzu Razak Ozdincler and Yakup Krespi
recovery in stroke patients: a randomized controlled trial
Bobath Concept versus constraint-induced movement therapy to improve arm functional
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Clinical Rehabilitation
26(8) 705 –715
© The Author(s) 2012
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DOI: 10.1177/0269215511431903
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CLINICAL
REHABILITATION
431903CRE26810.1177/0269215511431903Huseyinsinoglu et al.Clinical Rehabilitation
2012
1Stroke Unit, Florence Nightingale Hospital, Istanbul, Turkey
2Istanbul University School of Physical Therapy and
Rehabilitation, Istanbul, Turkey
Bobath Concept versus
constraint-induced movement
therapy to improve arm
functional recovery in stroke
patients: a randomized
controlled trial
Burcu Ersoz Huseyinsinoglu1, Arzu Razak Ozdincler2
and Yakup Krespi1
Abstract
Objective: To compare the effects of the Bobath Concept and constraint-induced movement therapy on
arm functional recovery among stroke patients with a high level of function on the affected side.
Design: A single-blinded, randomized controlled trial.
Setting: Outpatient physiotherapy department of a stroke unit.
Subjects: A total of 24 patients were randomized to constraint-induced movement therapy or Bobath
Concept group.
Intervention: The Bobath Concept group was treated for 1 hour whereas the constraint-induced
movement therapy group received training for 3 hours per day during 10 consecutive weekdays.
Main measures: Main measures were the Motor Activity Log-28, the Wolf Motor Function Test, the
Motor Evaluation Scale for Arm in Stroke Patients and the Functional Independence Measure.
Results: The two groups were found to be homogeneous based on demographic variables and baseline
measurements. Significant improvements were seen after treatment only in the ‘Amount of use’ and
‘Quality of movement’ subscales of the Motor Activity Log-28 in the constraint-induced movement
therapy group over the the Bobath Concept group (P = 0.003; P = 0.01 respectively). There were no
significant differences in Wolf Motor Function Test ‘Functional ability’ (P = 0.137) and ‘Performance time’
(P = 0.922), Motor Evaluation Scale for Arm in Stroke Patients (P = 0.947) and Functional Independence
Measure scores (P = 0.259) between the two intervention groups.
Conclusions: Constraint-induced movement therapy and the Bobath Concept have similar efficiencies
in improving functional ability, speed and quality of movement in the paretic arm among stroke patients
with a high level of function. Constraint-induced movement therapy seems to be slightly more efficient
than the Bobath Concept in improving the amount and quality of affected arm use.
Article
Corresponding author:
Burcu Ersoz Huseyinsinoglu, Florence Nightingale Hastanesi, Inme
Merkezi, Abide-i Hurriyet Cad. No: 164 Sisli Istanbul, Turkey
Email: fztersoz@gmail.com
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706 Clinical Rehabilitation 26(8)
Keywords
Bobath Concept, constraint-induced movement therapy, rehabilitation, stroke recovery, arm
Received: 21 July 2011; accepted: 6 November 2011
Introduction
After stroke, around 70–80% of patients suffer from
arm motor dysfunction of various degrees.1 Even
mild impairment of arm function after stroke results
in significant limitations in daily function and has
been demonstrated to negatively impact quality of
life.2,3
The Bobath Concept is currently defined as a
problem-solving approach which places particular
emphasis on the control of selective movement and
the integration of postural control and task perfor-
mance for the production of coordinated move-
ment.4 The developments in the Bobath Concept
have not yet been studied in trials of arm rehabilita-
tion in stroke patients. More seriously, clinical stud-
ies in which intervention procedures have been used
may not have reflected current Bobath Concept
practice.4,5
Constraint-induced movement therapy is a repet-
itive, task-oriented training of the impaired arm for
several hours a day. It also involves behavioural
methods designed to transfer gains made in therapy
sessions and constraining the patient to use the
affected arm by using a protective mitt on the unaf-
fected arm.6 Although the effectiveness of con-
straint-induced movement therapy has been shown
in several studies, it is has been criticized because of
difficulties in its application, its cost and the pro-
longed duration of treatment needed.7,8
There is still no consensus on the most effective
intervention and treatment dose based on functional
level of arm after stroke as trials differ in their meth-
odological qualities.9 The questions that need to be
answered in stroke rehabilitation, and more specifi-
cally in arm rehabilitation, are ‘at what intensity,
and which treatment is more beneficial for which
patient’? The answers to those questions would help
to develop evidence-based physiotherapy concepts
to improve arm and hand function after stroke.10,11
At present there is still no evidence to confirm
whether the Bobath Concept is more or less effec-
tive than constraint-induced movement therapy.
Therefore this study aimed to compare the effects of
Bobath Concept and constraint-induced movement
therapy on arm functional recovery among stroke
patients who had high-level function in the affected
side.
Methods
This single-blind, randomized clinical trial included
stroke patients with a high level of function in the
paretic arm. Arm function level was determined
according to the active motion of distal joints and
patients had to demonstrate active wrist extension
of at least 20 degrees and 10 degrees of active exten-
sion of the metacarpophalangeal joints and each
interphalangeal joint of all digits.12 Subjects were
recruited from the outpatient clinic of the Stroke
Unit of the Florence Nightingale Hospital. Twenty-
four patients were eligible based on the following
inclusion criteria: (1) a history of first-time stroke
(3–24 months post stroke); (2) patients between 18
and 80 years of age; (3) active range of motion of at
least 45 degrees of shoulder flexion, abduction or
scaption, 20 degrees of elbow extension, 20 degrees
of wrist extension from full flexion position, and 10
degrees of active extension of metacarpophalangeal
joints and each interphalangeal joint of all digits;12
(4) ability to maintain standing balance for two min-
utes with arm support if necessary;12 (5) adequate
vision and hearing to understand the test and ther-
apy sessions; (6) adequate communication skills;
(7) no serious cognitive disorders (score ≥24 on the
Mini Mental State Exam);12 (8) exhibit no excessive
pain that would interfere with the ability to partici-
pate in the treatment; (9) show no excessive spastic-
ity in any joint of the affected arm (score ≤2 on the
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Huseyinsinoglu et al. 707
Modified Ashworth Scale in any joint); (10) consid-
erable non-use of the affected upper limb (Amount
of use and Quality of movement score <2.5 on
Motor Activity Log-28);12 and (11) weakness of the
affected arm.
Subjects who met the inclusion criteria were ran-
domly assigned to either constraint-induced move-
ment therapy or Bobath Concept intervention group
by using a randomization function of Microsoft
Office Excel software. Blocked randomization was
used. Treatment and random number columns were
created and each part of the treatment column was
(pre-assigned as B and C subjects, respectively)
given a random number between 0 and 1 by the
Microsoft Excel software random number genera-
tor. The sort and filter menu was used to sort the
random number row from smallest to largest so that
treatment groups were randomly ordered. Pre-
stratification was applied to the subjects based on
whether they had received injections of botulinum
toxin-A within past three months.
Before and after the interventions, measurements
were obtained by a rater blinded to the group assign-
ment. The blinded rater was trained to administer
these tests before the beginning of the study. Both
interventions were performed by a single physical
therapist (BEH) according to the patient’s alloca-
tion. Before the study, BEH completed a course on
constraint-induced movement therapy at Alabama
University. She has five years’ experience in the use
of constraint-induced movement therapy. She also
received a basic course in Bobath Concept arranged
by the International Bobath Instructors Training
Association (IBITA).
The study was approved by the local ethics com-
mittee and conducted in accordance with institu-
tional guidelines, and all patients provided signed
informed consent prior to study entry.
Both interventions and assessments were applied
to the participants in the physiotherapy department
of the stroke unit at the hospital. During the con-
straint-induced movement therapy intervention, the
participant’s less-affected hand was placed in a pro-
tective safety mitt for a total of 90% of their waking
hours for a period of 12 consecutive days.
Behavioural techniques (behavioural contract, care-
giver contract, home practice, home diary, home
skill assignment) designed to transfer gains from
the treatment setting to daily life were applied.
Shaping and task activities were provided during
the individualized therapy sessions. Activities were
selected by considering specific joint movements
that exhibited the most pronounced deficits and the
joint movements that physical therapists believed
had the greatest potential for improvement. Since
high-functioning patients were included, 3-hour
daily therapy sessions were conducted and the treat-
ment lasted for 10 consecutive weekdays.
The Bobath Concept group also received indi-
vidualized therapy sessions. Appropriate, relevant
and patient-centred goals were set up before the
therapy sessions. The physical therapist analysed
the movement and task performance related to the
rehabilitation goal to identify activity limitations
and problems of movement dysfunction. Therapy
sessions were planned according to those identified
limitations for each patient. The emphasis was on
control of muscle tone, quality of movement, exter-
nal support, weight- bearing and stability of trunk
during arm activity in functional situations with
various positions (lying, sitting and standing both
with and without objects and during unilateral or
bilateral tasks). Depending on the Bobath Concept’s
discourse each patient trained about normal stimuli,
correct positioning of arm and was given home
exercises to continue the therapy 24 hours a day.
Caregivers were also trained on the home exercise
programme. The therapy session in the clinic lasted
for 1 hour daily and the intervention lasted for 10
consecutive weekdays.
Primary outcome measure
Wolf Motor Function Test. Wolf Motor Function Test
was designed to assess the motor ability of patients
with arm motor deficits. The Wolf Motor Function
Test has an established reliability and validity in
stroke populations. The original version of the test
was developed by Wolf et al.13 In our trial we used a
modified Wolf Motor Function Test from the Univer-
sity of Alabama at Birmingham14 and the assessments
were performed in accordance with the recommenda-
tions of education CD prepared by Alabama Univer-
sity Constraint Induced Movement Therapy Research
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708 Clinical Rehabilitation 26(8)
Group. The test contains 17 tasks; 15 of them are
timed tasks and two of them are strength tasks. Only
timed tasks were rated in this trial.
Secondary outcomes measures
Motor Activity Log-28. The Motor Activity Log-28 is a
structured interview, which examines 28 activities
of daily living. In the test, patients are asked to rate
how much (Amount of use scale) and how well
(Quality of movement scale) they can use their
affected arm using a 6-point ordinal scale. This
scale has been found to have good internal consis-
tency, inter-rater reliability and construct validity.15
Huseyinsinoglu et al established the reliability and
validity of Turkish Version of Motor Activity Log-
28 and this version was used in our study.16
Motor Evaluation Scale for Arm in Stroke Patients
(MESUPES). Motor Evaluation Scale for Arm in
Stroke Patients is a unique scale that takes the qual-
ity of upper limb movement into account during the
evaluation of arm performance after stroke. It has
two parts: MESUPES-Arm and MESUPES-Hand.
Inter-rater reliability, internal construct validity and
unidimensionality of the scale were established in
stroke patients.17 In our study before initial of the
interventions we adapted the Motor Evaluation
Scale for Arm in Stroke Patients into Turkish with
respect to steps of the guidelines about cross-
cultural adaptation18 and used the Turkish adapted
form of the scale in the evaluation process.
Functional Independence Measure (FIM). The Func-
tional Independence Measure assesses the level of
independence during activities of daily living. It has
good inter-rater reliability and validity.19 The Turk-
ish adapted version of the Functional Independence
Measure was applied to the participants in the pres-
ent study.20 The self-care subscale and total scores
were calculated to assess the efficiency of the
treatments.
Statistical analysis
All data analyses were computed with SPSS for
Windows version 11.5 (SPSS Inc., Chicago, IL,
USA). The characteristics of the study groups were
summarized with descriptive statistics. Differences
in baseline characteristics between the two random-
ized groups were analysed by chi-square test and
Mann–Whitney U-test. Wilcoxon signed-rank test
was used to determine the difference within each
group before and after the treatment. Differences in
intervention efficiency between the groups were
compared using the Mann–Whitney U-test. The
effect size r was calculated for each variable to
index magnitude of group differences in perfor-
mance; a large effect is represented by an r of at
least 0.50, a moderate effect by an r of 0.30, and a
small effect by an r of 0.10.21 Linear regression
analysis was performed to determine if there was
any effect of dominant-side paresis on Motor
Activity Log-28 Amount of use and Quality of
movement scores after the interventions. The level
of statistical significance was set at 0.05.
Results
A total of 83 post-stroke patients were admitted to
the physiotherapy department of the stroke unit
from July 2008 to April 2010 and 24 subjects were
eligible for the study. Reasons for exclusion are
shown in Figure 1. Two dropped out of the con-
straint-induced movement therapy group during the
intervention period; both were personal choice.
Twenty-two participants completed the two-week
treatment.
The characteristics of the patients in the two
study groups are shown in Table 1. There were no
statistically significant differences between the
groups with regard to demographic and clinical fea-
tures. Groups did not also differ with regard to the
location of the lesion (having either hemispheric or
brainstem lesion). There were nine (81.9%) partici-
pants with hemispheric lesions in the constraint-
induced movement therapy group and all patients in
the Bobath Concept group had hemispheric lesions
(P > 0.05).
Both constraint-induced movement therapy and
Bobath Concept groups showed statistically signifi-
cant improvements on all measurements (Motor
Activity Log-28, Wolf Motor Function Test, Motor
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Huseyinsinoglu et al. 709
Evaluation Scale for Arm in Stroke Patients and
Functional Independence Measure) from baseline to
post-treatment assessments (Table 2). At post-
treatment assessment, the constraint-induced move-
ment therapy group had significantly better Amount
of use scale and Quality of movement scale scores
(P = 0.003, P = 0.01 respectively). According to the
Wolf Motor Function Test and the Motor Evaluation
Scale for Arm in Stroke Patients, there was no statis-
tically significant difference between the constraint-
induced movement therapy and Bobath Concept
groups after treatment (P > 0.05). In addition, both
Functional Independence Measure total score and
Functional Independence Measure self-care score
after treatment were not significantly different
between the two groups (P > 0.05) (Table 2).
Since the constraint-induced movement therapy
group showed significant improvements only in qual-
ity and amount of impaired arm use compared to the
Bobath Concept group and considering that dominant-
side paresis was slightly but not significantly more
frequent in the constraint-induced movement therapy
group, we investigated whether there was an effect of
dominant-side paresis. However, there was no effect
of dominant-side paresis on improvement of Motor
Activity Log-28 Amount of use (95% CI, –1.13–0.62,
P = 0.551) and Motor Activity Log-28 Quality of
movement (95% CI, –1.01–0.68, P = 0.685).
Assessed for eligibility
(n=83)
Excluded (n=59)
Unable to attain high function (n=32)
MAL-28 score >2.5 (n=6)
No weakness in affected arm (n=13)
Mini Mental State Exam score <24 (n=3)
Not in 3–24 months after stroke (n=3)
Refused to participate (n=2)
Included in study and randomized
(n=24)
Bobath Concept group
(n=11)
Constraint-induced
movement therapy group
(n=13)
Received intervention (n=11)
Drop-out (n=0)
Received intervention (n=13)
Drop-out (n=2); personal
choice
Analysed
(n=11)
Analysed
(n=11)
Figure 1. Study diagram.
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710 Clinical Rehabilitation 26(8)
Discussion
Our study revealed that the Bobath Concept and
constraint-induced movement therapy approaches
resulted in similar degrees of functional ability, per-
formance time, quality of movement and indepen-
dence level in activities of daily living in stroke
patients with a high level of function in the affected
arm. However, the two treatment groups differed
with regard to purely subjective criteria (i.e. Motor
Activity Log-28 Amount of use scale and Quality of
movement scale). Significant improvements were
seen after treatment in the amount and quality of
affected arm use in constraint-induced movement
therapy group over the Bobath Concept group.
In our study, results from the Motor Activity Log-
28 were consistent with many studies in the litera-
ture which compare the effect of constraint-induced
movement therapy versus different control groups in
stroke patients.7 The EXCITE trial, the first random-
ized multicentre trial of constraint-induced move-
ment therapy, concluded that administration of
constraint-induced movement therapy resulted in
statistically relevant improvements in amount and
quality of paretic arm use compared with usual and
customary care in stroke patients who experienced a
first stroke between three and nine months prior.12
Taub et al demonstrated in a placebo-controlled trial
that chronic stroke patients showed very large
improvements in constraint-induced movement
Table 1. Demographic and clinical characteristics of the study groups
Characteristic CIMT group (n = 11) BC group (n = 11) P for difference
Age, years (mean ± SD) 49.1 ± 13.7 48.2 ± 15.4 0.948
Time since stroke, months (mean ± SD) 10.6 ± 6.1 13.1 ± 6.3 0.322
Level of education in years (mean ± SD) 9.8 ± 4.2 9.7 ± 5.1 1.000
Sex, M/F (n) 7/4 5/6 0.392
Received physiotherapy previously, n (%) 11 (100%) 11 (100%) 1.000
Living at home with family or caregiver, n (%) 11 (100%) 11 (100%) 1.000
Received botolunim toxin-A injection within
past 3 months, n (%)
3/8 4/7 0.647
Lesion type, n (%)
Ischaemic 7 (63.6%) 10 (90.9%) 0.311
Haemorrhagic 4 (36.4%) 1 (9.1%)
Paresis on dominant side, n (%) 7 (63.6%) 3 (27.3%) 0.087
Sensation loss, n (%) 3 (27.3%) 2 (18.2%) 1.000
Pain, n (%) 1 (9.1%) 1 (9.1%) 1.000
Speech disorder, n (%) 1 (9.1%) 0 1.000
Functional evaluationa
MAL-28 AOU 0.9 (0.6) 0.63 (0.65) 0.212
MAL-28 QOM 0.79 (0.58) 0.63 (0.66) 0.358
MESUPES 43 (7.42) 38 (12.2) 0.340
WMFT FA 3.2 (0.9) 2.9 (0.9) 0.373
WMFT PT (s) 25.6 (19) 31.5 (23.7) 0.768
FIM self-care 30.1 (8.75) 31 (6.9) 0.717
FIM total 111.3 (12.5) 112 (13.4) 0.792
aResults of functional evaluation are expressed in mean scores (SD).
CIMT, constraint-induced movement therapy; BC, Bobath Concept; MAL-28 AOU, Motor Activity Log-28 Amount of use; MAL-28
QOM, Motor Activity Log-28 Quality of movement; MESUPES, Motor Evaluation Scale for Upper Extremity in Stroke Patients;
WMFT FA, Wolf Motor Function Test Functional Ability; WMFT PT, Wolf Motor Function Test Performance Time; FIM, Functional
Independence Measure.
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Huseyinsinoglu et al. 711
therapy group relative to the general fitness control
group.22 In another study Lin et al found that a con-
straint-induced movement therapy group exhibited
significantly better performance in Motor Activity
Log than the dose-matched control intervention.23
It is of note to emphasize that the Motor Activity
Log-28 was originally developed for the assessment
of the improvement in patients under constraint-
induced movement therapy, which may partly
explain Motor Activity Log-28 results in favour of
this treatment modality. On the other hand, placing
the unaffected hand in a protective safety mitt for a
total of 90% of waking hours during the constraint-
induced movement therapy intervention may lead
the patients to perceive that they have made ‘more
use’ of the affected arm and this may have a positive
effect, especially on the results of the Amount of use
scale in the Motor Activity Log-28. Therefore
Table 2. Comparison of the two treatment groups for functional outcome measures
Outcome
measures CIMT group (n = 11) BC group (n = 11)
P-value†Effect
size, r
Baseline
Mean ± SD
After
treatment
Mean ± SD P-value*
Baseline
Mean ± SD
After
treatment
Mean ± SD P-value*
Median Median Median Median
(Min–max) (Min–max) (Min–max) (Min–max)
MAL-28 AOU 0.9 ± 0.6 3,2 ± 0.57 0.003 0.63 ± 0.65 1.78 ± 1.08 0.003 0.003 0.64
0.9 3.2 0.46 1.6
(0.2–2) (2.1–4) (0.03–2.2) (0.25–3.32)
MAL-28 QOM 0.79 ± 0.58 3 ± 0.56 0.003 0.63 ± 0.66 1.78 ± 1.09 0.003 0.01 0.53
0.75 3 0.46 1.73
(0.2–2) (1.9–3.9) (0.03–2.3) (0.25–3.40)
WMFT FA 3.27 ± 0.96 4.03 ± 0.78 0.003 2.9 ± 0.9 3.3 ± 1.1 0.008 0.137 0.31
3.1 4.2 2.6 3
(2–4.8) (2.4–5) (2–4.8) (2–5)
WMFT PT(s) 25.6 ± 19 15.2 ± 13.7 0.003 31.5 ± 23.7 20.5 ± 18 0.003 0.922 0.02
22.8 7.8 30.8 17.4
(6–60) (4.2–46) (5–84) (3.60–65)
MESUPES 43 ± 7.4 48.7 ± 7.1 0.003 38 ± 12.2 43.4 ± 11.5 0.003 0.947 0.01
44 51 41 42
(33–53) (37–56) (17–54) (26–58)
FIM self-care 30.1 ± 8.75 35 ± 6.6 0.003 31.9 ± 6.9 35.1 ± 5.2 0.005 0.259 0.24
28 36 33 36
(15–40) (19–42) (18–40) (24–42)
FIM total 112.2 ± 12.5 116.3 ± 11.1 0.003 112 ± 13.4 115.7 ± 10.9 0.005 0.336 0.20
110 119 117 119
(86–124) (87–126) (77–124) (87–126)
*P for baseline versus after treatment.
†P for CIMT versus BC.
CIMT, constraint-induced movement therapy; BC, Bobath Concept; MAL-28 AOU, Motor Activity Log-28 Amount of use; MAL-28
QOM, Motor Activity Log-28 Quality of movement; MESUPES, Motor Evaluation Scale for Upper Extremity in Stroke Patients;
WMFT FA, Wolf Motor Function Test Functional Ability; WMFT PT, Wolf Motor Function Test Performance Time; FIM, Functional
Independence Measure.
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712 Clinical Rehabilitation 26(8)
long-term results are important to conclude whether
this effect lasts when the safety mitt is removed dur-
ing the daytime after treatment. As there are con-
flicting results about the long-term results of the
Motor Activity Log-28 in the literature, the main
goal of rehabilitation may be determined carefully
for high-level arm post-stroke patients before admit-
ting the patient to the constraint-induced movement
therapy intervention.12,24,25
In our study, dominant-side paresis was more
frequent in the constraint-induced movement ther-
apy group, although this difference did not reach
statistical significance (P = 0.087). It is plausible
that patients with dominant-hand paresis may have
more potential to use the affected arm effectively
because they used to perform many activities with
that dominant side before their stroke. However,
further analysis showed that dominant-hand paresis
has no effect on recovery as measured by the Motor
Activity Log-28 Amount of use and Quality of
movement scales. These results are consistent with
other studies that examined the influence of hand
dominance on response to constraint-induced move-
ment therapy.26,27
The Wolf Motor Function Test, which measures
arm motor function objectively, was the primary
outcome of our trial. Similar to our findings, some
studies that compared the effects of constraint-
induced movement therapy using a control group
could not find any statistically significant difference
in motor dysfunction after treatment.28,29 On the
other hand, several other studies that used conven-
tional therapy or a general care control group
showed significant improvements in the constraint-
induced movement therapy group on Wolf Motor
Function Test.12,22,23 Different results for motor dys-
function after treatment might be explained by the
differences in treatment doses and the therapy con-
tent in the control groups compared with the con-
straint-induced movement therapy group.
Increased duration of therapy and increased
number of training hours have been suggested to
improve the results of constraint-induced move-
ment therapy.30 Although therapy duration is impor-
tant, arm motor function recovery could not be
explained based on therapeutic time alone. The
results related to Wolf Motor Function Test in our
study support the concept that to achieve a better
level of motor function in the arm, it is important to
work on skill acquisition, movement quality and
patient-specific activity, as well as repeated activi-
ties with longer duration therapy sessions.31
In this study, the Motor Evaluation Scale for Arm
in Stroke Patients was used as an objective means to
assess changes in the quality of arm movement.
According to the Motor Evaluation Scale for Arm in
Stroke Patients procedures, accuracy and amount of
movement are measured by the physical therapist
while the patient performs the activity. This is the
main difference that discriminates the Motor
Evaluation Scale for Arm in Stroke Patients from
the Motor Activity Log-28 Quality of movement
scale. The Quality of movement scale is more sub-
jective than the Motor Evaluation Scale for Arm in
Stroke Patients as it is a semi-structured interview
scale. The patient answers the question about how
well he or she uses the affected arm during each
daily activity in the Motor Activity Log Quality of
movement scale. In our trial different approaches of
these measurements may cause the different results
for quality of movement in the two intervention
groups. While the constraint-induced movement
therapy group had better performance on the Motor
Activity Log-28 Quality of movement scale than the
Bobath Concept group after treatments, no statisti-
cally significant difference in Motor Evaluation
Scale for Arm in Stroke Patients was evident
between the two intervention groups. On the other
hand, the results for the Motor Evaluation Scale for
Arm in Stroke Patients may show that although con-
straint-induced movement therapy emphasizes fre-
quent repetition of the movement it may affect the
quality of movement positively in stroke patients
with a high-level arm.
In this study, the difference between two groups
in activities of daily living levels following treat-
ment was not statistically significant. This finding is
consistent with many studies that measured activi-
ties of daily living levels with Functional
Independence Measure or other related scales after
arm rehabilitation of stroke patients.23,32 Since
activities of daily living measurements often reflect
compensatory behaviour, arm recovery may not pri-
marily be explained by those measurements. As we
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Huseyinsinoglu et al. 713
aimed to investigate the global effects of interven-
tions in activities of daily living level, in our trial we
also assessed the patients by using Functional
Independence Measure beside the motor function
tests.
Up to this point we have generally discussed tri-
als that compare the effects of constraint-induced
movement therapy versus other interventions, in the
form of conventional therapy, custom care or neuro-
developmental treatment (intensive bimanual train-
ing), since few trials have investigated the outcomes
of Bobath Concept on arm recovery in stroke
patients.5,33,34 It is suggested in a review about the
effect of Bobath Concept on arm recovery that sen-
sitive upper limb measures, trained Bobath thera-
pists and homogenous samples should be used.5 In
our trial the methodology was consistent with the
suggestions of this review. Another trial looked at
the effects of increased exercise therapy time for
arm rehabilitation with either Bobath Concept or
Arm BASIS training in stroke patients with severe
arm paresis. Fugl-Meyer arm motor score was the
main measurement and it was concluded that the
increased exercise therapy time for Arm BASIS
training enhanced selective motor control in severe
arm paresis group after stroke.31 As our trial aimed
to compare the efficiency of the Bobath Concept
and constraint-induced movement therapy, the treat-
ments were applied to the participants according to
the original protocols without taking into account
the time period. This meant that the constraint-
induced movement therapy group had three times as
much therapy time as the Bobath Concept group.
Nevertheless, in our stroke group with a high level
of function in the affected arm there was no signifi-
cant difference between two groups in Wolf Motor
Function Test after treatments.
There is some strength in our study. This is the
first randomized controlled trial to compare the
effects of constraint-induced movement therapy and
Bobath Concept in Turkish stroke patient popula-
tion. Both interventions were performed by a certi-
fied physical therapist with ten years’ experience in
stroke rehabilitation. Therefore the original proce-
dure of constraint-induced movement therapy and
current practice of Bobath Concept were applied to
the participants. The blind rater was trained in the
procedures before the trial. With the aim of creating
homogeneous treatment groups, pre-stratification
was done with regard to botulinum toxin-A injec-
tions within the previous three months. In the pres-
ent study, inclusion criteria regarding the phase of
stroke was limited to patients with subacute–chronic
stroke to ignore the effects of spontaneous recovery
on treatment approaches. The effect size of Wolf
Motor Function Test Functional Ability which was
obtained from this trial may be used as a reference
to calculate power of a multicentre clinical trial if
this outcome measurement is determined as a pri-
mary outcome.
Several limitations of this trial are noteworthy.
First, as this trial was a PhD thesis it was carried out
in one centre and a single physical therapist gave
both treatments. Because of difficulty in finding eli-
gible patients who met all the inclusion criteria of
the study in just one centre, we had a relatively
small sample size. On the other hand, a single thera-
pist could have been biased towards favouring one
or other treatment, and this might have affected the
outcome. A single physical therapist would also
have much the same interpersonal relationship in
both groups so this could be an advantage of our
trial. Second, time since stroke (3–24 months) was
too long and no other factors than botulinum toxin-
A treatment was taken into account for the pre-
stratification of patients. If such a long time after
stroke is defined as an inclusion criteria, factors
such as prior rehabilitation duration, drug treat-
ments, depression status and environmental vari-
ables such as living conditions and caregivers are all
important factors affecting recovery and should be
considered in multicentre trials. Nevertheless all our
patients received physiotherapy previously, and
were living at home with family or caregivers. Third
it was not possible to evaluate fulfilment of the
requirement to use a mitt on the unaffected side as
well as to record their activities for 90% of waking
hours, because most of the patients did not fill the
home diary correctly. On the other hand, objective
results about compliance with home exercise pro-
grammes was not determined in the two treatment
group. Another limitation of our study was that
intention-to-treat analysis was not employed. For
this reason, we did not avoid the effect of drop-outs
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714 Clinical Rehabilitation 26(8)
in the constraint-induced movement therapy group.
Finally, three patients with Wolf Motor Function
Test pretreatment scores very close to the upper
limit potentially and causing bias were not excluded
from the study because they were reported to be suf-
fering from weakness of the affected arm.
Clinical messages
•Constraint-induced movement therapy and
the Bobath Concept have similar efficacy
in arm rehabilitation of stroke patients
with high-level arm function according to
objective criteria such as functional ability,
speed and quality of movement.
•Constraint-induced movement therapy is
more effective than the Bobath Concept in
improving the amount and quality of paretic
arm use with regard to a patient’s perception.
Funding
This research received no specific grant from any funding
agency in the public, commercial, or not-for-profit
sectors.
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