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Stroke and Constraint-Induced Movement Therapy

Permanent Link: http://ufdc.ufl.edu/UFE0021618/00001

Material Information

Title: Stroke and Constraint-Induced Movement Therapy Use of Eshkol-Wachman Movement Notation to Examine Quality of Movement
Physical Description: 1 online resource (132 p.)
Language: english
Creator: Chiu, Yi-Po
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2007

Subjects

Subjects / Keywords: component, constraint, eshkol, essential, evaluation, generalized, induced, motor, movement, notation, program, quality, stroke, therapy, wachman
Rehabilitation Science -- Dissertations, Academic -- UF
Genre: Rehabilitation Science thesis, Ph.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: Quality of movement is an important indicator of post-stroke recovery, but has often been ignored by rehabilitation professionals. In addition, limited measures of movement quality are available in clinical and research settings. Constraint-Induced Movement Therapy (CIMT) has been a beneficial stroke intervention during the past two decades, but its effects on quality of movement has not been explored. In this study, the author developed an evaluation form, the Essential-Movement Component Evaluation (EMCE) form, based on a combined application of the Generalized Motor Program and Eshkol-Wachman Movement Notation (EWMN), measuring quality of movement that investigates invariant features for a reaching-grasping-lifting-placing task. For Experiment I, the results showed the EMCE form based on the EWMN method had excellent intra- and inter-rater reliability with high intraclass correlation coefficients and low standard error of measurement, when three raters graded 20 participants. With a short training and practice session, the raters, even novice investigators, can reliably document movement quality using the EMCE form. For Experiment II, the one-way analysis of variance (ANOVA) results demonstrated that people with stroke had less normal movement components and more compensatory movements than normal participants. Among people with stroke, the low-functioning group (n= 20; upper-extremity Fugl-Meyer motor scores ? 33) utilized less essential movement components than the high-functioning group (n= 20; upper-extremity Fugl-Meyer motor scores > 33). Both stroke groups significantly adopted more compensatory movement than the normal group (n= 10), but no difference was found between the two stroke groups. Underutilized essential-movement components and dominance of compensatory movement can provide rehabilitation professional useful information on developing tailored therapeutic programs to restore disrupted movement patterns post-stroke. For Experiment III, after 2-week CIMT, the two-group x two-time ANOVA results showed the low-functioning group (n= 30) significantly regained more essential movement components than the high-functioning group (n= 30). There was no statistically significant treatment effect on compensatory movement. In order to improve movement quality post-stroke, the goals of CIMT training, therefore, need to be expanded to increase the function of underused essential-movement components, re-establish normal movement sequences, and prevent compensatory movements.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Yi-Po Chiu.
Thesis: Thesis (Ph.D.)--University of Florida, 2007.
Local: Adviser: Light, Kathy E.
Electronic Access: RESTRICTED TO UF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE UNTIL 2008-12-31

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2007
System ID: UFE0021618:00001

Permanent Link: http://ufdc.ufl.edu/UFE0021618/00001

Material Information

Title: Stroke and Constraint-Induced Movement Therapy Use of Eshkol-Wachman Movement Notation to Examine Quality of Movement
Physical Description: 1 online resource (132 p.)
Language: english
Creator: Chiu, Yi-Po
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2007

Subjects

Subjects / Keywords: component, constraint, eshkol, essential, evaluation, generalized, induced, motor, movement, notation, program, quality, stroke, therapy, wachman
Rehabilitation Science -- Dissertations, Academic -- UF
Genre: Rehabilitation Science thesis, Ph.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: Quality of movement is an important indicator of post-stroke recovery, but has often been ignored by rehabilitation professionals. In addition, limited measures of movement quality are available in clinical and research settings. Constraint-Induced Movement Therapy (CIMT) has been a beneficial stroke intervention during the past two decades, but its effects on quality of movement has not been explored. In this study, the author developed an evaluation form, the Essential-Movement Component Evaluation (EMCE) form, based on a combined application of the Generalized Motor Program and Eshkol-Wachman Movement Notation (EWMN), measuring quality of movement that investigates invariant features for a reaching-grasping-lifting-placing task. For Experiment I, the results showed the EMCE form based on the EWMN method had excellent intra- and inter-rater reliability with high intraclass correlation coefficients and low standard error of measurement, when three raters graded 20 participants. With a short training and practice session, the raters, even novice investigators, can reliably document movement quality using the EMCE form. For Experiment II, the one-way analysis of variance (ANOVA) results demonstrated that people with stroke had less normal movement components and more compensatory movements than normal participants. Among people with stroke, the low-functioning group (n= 20; upper-extremity Fugl-Meyer motor scores ? 33) utilized less essential movement components than the high-functioning group (n= 20; upper-extremity Fugl-Meyer motor scores > 33). Both stroke groups significantly adopted more compensatory movement than the normal group (n= 10), but no difference was found between the two stroke groups. Underutilized essential-movement components and dominance of compensatory movement can provide rehabilitation professional useful information on developing tailored therapeutic programs to restore disrupted movement patterns post-stroke. For Experiment III, after 2-week CIMT, the two-group x two-time ANOVA results showed the low-functioning group (n= 30) significantly regained more essential movement components than the high-functioning group (n= 30). There was no statistically significant treatment effect on compensatory movement. In order to improve movement quality post-stroke, the goals of CIMT training, therefore, need to be expanded to increase the function of underused essential-movement components, re-establish normal movement sequences, and prevent compensatory movements.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Yi-Po Chiu.
Thesis: Thesis (Ph.D.)--University of Florida, 2007.
Local: Adviser: Light, Kathy E.
Electronic Access: RESTRICTED TO UF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE UNTIL 2008-12-31

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2007
System ID: UFE0021618:00001


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1 STROKE AND CONSTRAINT-INDUCED MOVEMENT THERAPY: USE OF ESHKOLWACHMAN MOVEMENT NOTATION TO EXAMINE QUALITY OF MOVEMENT By YI-PO CHIU A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2007

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2 2007 Yi-Po Chiu

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3 To my family, mentors, and friends.

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4 ACKNOWLEDGMENTS When I look back over the past five years, I am extremely amazed and grateful that on the road of pursuing my doctoral degree at University of Florida, there have been so many people that have supported and encouraged me. The care and love that I have received from the following people have not only helped me to reac h my goals, but have also made me a better person. First, I acknowledge my family. My pa rents have financially and spiritually supported my graduate studies from day one. Although th e whole study process took much longer than they expected, my family, including my two sisters, their husbands and my cutest nephew Sean, have strong faith in me. Second, I would like to express my greatest gratitude to my mentors. Dr. Kathye Light is an extraordinary mentor for my master and docto ral study at the University of Florida. During my eight years at UF, she has always supported my research direction.. I truly admire her knowledge and understanding of cultural differences She has shown me how to become a great mentor, educator and scientist for my future caree r in rehabilitation science. I will always miss our beneficial discussions about science and life. Dr. Philip Teitelbaum and Osnat Teitelbaum have been two important persons in my doctoral study. Dr. Teitelbaum is the most knowledgeable and distinguished scholar I have ever met. Because of their kindness and acceptance, I am able to experience the pow erfulness of the Eshkol-Wachman Movement Notation. Their unconditional support and teachi ng have deeply touched my heart. I am thankful they dont treat education as a trading business, or else I could never repay them for their numerous time spent on me. They also shared with me their invaluable Jewish culture during several holiday events. The honor is always mine to study with them. Dr. Craig Velozo has been a role model to me. He has taught me how cautiously we should deal with scientific data. Our previous collaboration with Rasch has shown me the essence of teamwork. His

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5 constructive suggestions and feedback always help me to better myself. Dr. Andrea Behrman has been supportive during my study. I thank her for her continuing support a nd guidance. Without the support and assistance from my fellow graduate students, colleagues and friends, I would not be able to smoothly finish my study. I would like to thank the people in the stroke laboratories, including Stacy, Sandy, Dr. Lorie Richards, Matt, Tara, Vicky, Fran, Sarah, and all volunteers for their assistance in my study. Stacy has been helping me with my writing since day one of my study. I tr uly appreciate how she treats me as her family. The most precious thing is that she opens her arms and heart to a foreigner like me. The two-week stay at her and Candys home at Columbia, SC meant so much to me, not only giving me a homey environment but also a booster shot on my di ssertation writing. Being able to visit Stacys family during the vacation of Independence Day in the past also tremendously alleviated my homesickness. Sandy is my wonderfu l American mother. I truly a ppreciate her care, assistance, encouragement and kindness. I also acknowledg e the following people. They have been my wonderful friends that have assi sted me in many different ways. They are Robert, Shin-Yi, PeyShan, Tiffany, Tseng-Tien, Rick and Stephanie, Zoe and Kang-Ue i, Kai-Jen and Tzu-Yi, Kevin and Caley, Andrea, Illy, Ruuds family, Stacy s family, Matts family and Sandys family. Robert has been a supportive friend for the past two years. He has shown me different aspects of life, such as humanity, politics, history and natu re. I have learned a lot from him. Shin-Yi and Pey-Shan have been my loyal statistics consulta nts for my study. Tiffany is my wonderful gal and best jogging partner. I miss the time we spent together. Rick and Stephanie allowed me to help in their kitchen, so I was ab le to experience the reality of restaurant business. Kevin and Caley, Zoe and Kang-Uei, and Kai-Jen and Tzu-Yi are the three couples of friends that have been provided valuable supports and assistance. When I feel stressfu l and need a place to retreat,

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6 the doors of their homes are always open for me. I really appreciate their wonderful friendship and hospitality. The last but not the least ap preciation is given to my two cats: Latte and Mimosa. Because of their company, my time at Gainesville can be more joyful.

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7 TABLE OF CONTENTS page ACKNOWLEDGMENTS...............................................................................................................4 LIST OF TABLES................................................................................................................. ........10 LIST OF FIGURES.......................................................................................................................11 ABSTRACT...................................................................................................................................12 CHAP TER 1 INTRODUCTION..................................................................................................................14 Background and Significance.................................................................................................14 Movement Disorders in Stroke........................................................................................ 14 Current Methodology of Movement Analysis................................................................. 17 Quality of Movement in Constr ain t-Induced Movement Therapy.................................. 21 Definition of Quality of Movement Used for People Post-Stroke.................................. 23 Generalized Motor Program Theory: The Research Framework.................................... 25 A Comprehensive Approach of Move m ent Analysis: Using Eshkol-Wachman Movement Notation..................................................................................................... 26 Research Aims and Hypotheses.............................................................................................. 29 Experiment I................................................................................................................... .30 Experiment II.................................................................................................................. .30 Experiment III................................................................................................................. 31 Summary.................................................................................................................................32 2 DEVELOPMENT AND RELIABILITY OF THE ESSENTIAL MOVEMENT COMPONE NT EVALUATION FORM USI NG ESHKOL-WACHMAN MOVEMENT NOTATION............................................................................................................................35 Introduction................................................................................................................... ..........35 Methods..................................................................................................................................37 Development of The Essential-Moveme nt Component Evaluation Form Using EWMN......................................................................................................................... 37 Lift Basket task..................................................................................................... 38 Eshkol-Wachman Movement Notation.................................................................... 39 Participants...............................................................................................................40 Essential-Movement Com ponent Evaluation form ..................................................40 Intra-Rater and Inter-Rater Re liability of The EMCE For m...........................................42 Participants...............................................................................................................42 Procedure..................................................................................................................44 Data Analysis..........................................................................................................................45 Results.....................................................................................................................................47 Intra-Rater Reliability...................................................................................................... 47

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8 Inter-Rater Reliability...................................................................................................... 47 Discussion...............................................................................................................................48 Rater Reliability of The EMCE Form.............................................................................48 Limitations.................................................................................................................... ...50 Conclusions.............................................................................................................................51 3 ASSESSING MOVEMENT QUALITY AFTER STROKE.................................................. 59 Introduction................................................................................................................... ..........59 Method....................................................................................................................................61 Participants......................................................................................................................61 Procedure.........................................................................................................................63 Data Analysis..........................................................................................................................66 Results.....................................................................................................................................66 Discussion...............................................................................................................................67 Conclusions.............................................................................................................................70 4 EFFECTS OF CONSTRAINT-INDUCED M OVEMENT THERAPY ON QUALITY OF MOVEMENT POST-STROKE....................................................................................... 74 Introduction................................................................................................................... ..........74 Methods..................................................................................................................................75 Participants......................................................................................................................75 Procedure.........................................................................................................................77 Lift Basket task..................................................................................................... 78 Essential-Movement Com ponent Evaluation form ..................................................79 Data Analysis...................................................................................................................80 Results.....................................................................................................................................81 Discussion...............................................................................................................................82 Essential-Movement Component....................................................................................82 Compensatory Movement............................................................................................... 84 Limitation..................................................................................................................... ...87 Conclusions.............................................................................................................................88 5 GENERAL SUMMARY AN D CONCLUSIONS .................................................................94 Overview....................................................................................................................... ..........94 Experiment I Summary........................................................................................................... 94 Experiment II Summary......................................................................................................... 96 Experiment III Summary...................................................................................................... 100 General Conclusions............................................................................................................ .103 APPENDIX A PILOT DATA.......................................................................................................................106 Pilot Study 1.................................................................................................................. .......106 Purpose..........................................................................................................................106

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9 Aim:...............................................................................................................................106 Participants....................................................................................................................106 Method/Data Analysis...................................................................................................106 Results and Conclusion................................................................................................. 107 Pilot Study 2.................................................................................................................. .......107 Purpose..........................................................................................................................107 Participants....................................................................................................................107 Method/Data Analysis...................................................................................................107 Results and Conclusion................................................................................................. 108 Pilot Study 3.................................................................................................................. .......109 Purpose..........................................................................................................................109 Participants....................................................................................................................109 Method/Data Analysis...................................................................................................109 Results and Conclusion................................................................................................. 109 B ESSENTIAL-MOVEMENT COMPONENT EVELUATION FORM................................ 114 C FUGL-MEYER ASSESSMENT..........................................................................................115 LIST OF REFERENCES.............................................................................................................120 BIOGRAPHICAL SKETCH.......................................................................................................132

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10 LIST OF TABLES Table page 1-1 Atypical synergy movement pattern s of extremities observed in people with stroke....... 33 1-2 Wolf Motor Function Test: Functional Ability Scale ........................................................33 2-1 Functional Ability Scale................................................................................................... .53 2-2 Demographic information of raters.................................................................................... 53 2-3 Demographic information of participants.......................................................................... 53 2-4 Intra-rater reliability (ICC) for indivi dual essential-m ovement component and total score of essential-movement component...........................................................................53 2-5 Intra-rater reliability (ICC) for m agnitude of esse ntial-movement components............... 54 2-6 Inter-rater reliability for individual and total score of essential-move ment component... 54 2-7 Inter-rater reliability (I CC) for m agnitude of four e ssential-movement components........ 54 2-8 Standard error of measurement (SEM) and m inimally detectable change (MDC)........... 54 3-1 Demographic information of subjects................................................................................ 71 3-2 One-way ANOVA results for total score of essential-m ovement component and compensatory movement, and movement ma gnitude of four movement components..... 71 3-3 Percentage of observed essentialm ovement components and compensatory movements of Lift Basket task in contro l, highand low-functioning stroke groups....... 72 4-1 Demographic information of participants.......................................................................... 89 4-2 Repeated measure ANOVA results for composite scores of essential-movement com ponent and compensatory movement and movement magnitude of three movement components...................................................................................................... 89 4-3 Percentage of observed essentialm ovement components and compensatory movements of Lift Basket task in hi ghand low-functioning stroke groups..................... 90 4-4 Corresponding compensatory movement of the Lift Basket task observed in individuals with stroke. ...................................................................................................... 90 A-1 Demographic information of contro l group participants of Pilot Study 1 ....................... 111 A-2 Results of Pilot Study 3....................................................................................................111

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11 LIST OF FIGURES Figure page 1-1 Two fundamental planes of EW sphere............................................................................. 34 1-2 The 26 positions on SoR when one unit of movement is 45 ............................................34 2-1 Lift Basket task..................................................................................................................55 2-2 Fundamental planes of EWMN sphere..............................................................................56 2-3 Positions on SoR................................................................................................................56 2-4 Example of original EWMN page for the L ift Basket task in WMFT........................... 57 2-5 Essential-Movement Component Evaluation form based on EW MN............................... 58 3-1 Set-up for the Lift Basket task........................................................................................... 73 4-1 Starting and ending positions of the L ift Basket task........................................................91 4-3 Mean composite scores of essential-move ment component for high-functioning and low-functioning stroke groups before and after receiving CIMT...................................... 93 A-1 EWMN page for the Lift Basket task in WMFT (example)......................................... 112 A-2 Essential-Movement Components Ev aluation Form (Prototype: without compensatory movement)................................................................................................ 113 B-1 EMCE form (with compensatory movement).................................................................. 114

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12 Abstract of Dissertation Pres ented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy STROKE AND CONSTRAINT-INDUCED MOVEMENT THERAPY: USE OF ESHKOLWACHMAN MOVEMENT NOTATION TO EXAMINE QUALITY OF MOVEMENT By Yi-Po Chiu December 2007 Chair: Kathye E. Light Major: Rehabilitation Science Quality of movement is an important indicato r of post-stroke recovery, but has often been ignored by rehabilitation professionals. In addi tion, limited measures of movement quality are available in clinical and research settings. Constraint-Induced Movement Therapy (CIMT) has been a beneficial stroke intervention during the past two decades, but its effects on quality of movement has not been explored. In this study, the author de veloped an evaluation form, the Essential-Movement Component Evaluation (EMCE) form, based on a combined application of the Generalized Motor Program and Eshkol-Wach man Movement Notation (EWMN), measuring quality of movement that investigates invarian t features for a reaching-grasping-lifting-placing task. For Experiment I, the results showed the EMCE form based on the EWMN method had excellent intraand inter-rater reliability with high intraclass correlation coefficients and low standard error of measurement, when three raters graded 20 participants. With a short training and practice session, the raters, even novice inve stigators, can reliably document movement quality using the EMCE form. For Experiment II, the one-way analysis of variance (ANOVA) results demonstrated that people with stroke had less normal movement components and more compensatory movements than normal partic ipants. Among people with stroke, the low-

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13 functioning group (n= 20; upper-extremity Fugl-Meyer motor scores 33) utilized less essential movement components than the high-functioning group (n= 20; upper-extremity Fugl-Meyer motor scores > 33). Both stroke groups significantly adopted more compensatory movement than the normal group (n= 10), but no differen ce was found between the two stroke groups. Underutilized essential-movement components a nd dominance of compensatory movement can provide rehabilitation professional useful information on developing tailored therapeutic programs to restore disrupted movement patterns post-stroke. For Experiment III, after 2-week CIMT, the two-group x two-time ANOVA results showed the low-functioning group (n= 30) significantly regained more essential movement components than the high-functioning group (n= 30). There was no statistically significant treatm ent effect on compensatory movement. In order to improve movement quality post-stroke, the goals of CIMT training, therefore, need to be expanded to increase the function of underused essential-movement components, re-establish normal movement sequences, and prevent compensatory movements.

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14 CHAPTER 1 INTRODUCTION Background and Significance Stroke is the leading cau se of long-te rm disability in the United States.1, 2 Of those individuals who sustain a stroke, 66% lose long-term functional ability in their affected arm.3-5 About 700,000 Americans experience a first or recurrent stroke each year,6 resulting in annual direct and indirect costs that are expe cted to reach $62.7 billion nationwide in 2007.2 Persons who sustain a stroke often re quire an enormous amount of medical care involving acute, rehabilitative, and other maintenance types of trea tment. Furthermore, 84% of those who return to their homes following treatm ent are unable to resume work.7 Strokes not only affect the person who has had the stroke, but also those who live and work with the i ndividual. Changes in role function, self-perception, qua lity of life, as well as basic capabilities are apparent after stroke. In light of the fore going statistics, the widespread oc currence of upper-extremity paresis following stroke presents an important ch allenge for rehabilitation research. In this chapter, the author reviews the releva nt literature of importa nt topics in stroke relevant to this dissertation. The topics include common movement disorders post-stroke, current methodology of movement analysis, quality of movement in Constraint-Induced Movement Therapy (CIMT), the Generalized Motor Program theory (GMP), and the EshkolWachman Movement Notation (EWMN). Movement Disorders in Stroke The m ost common impairments contributing to movement dysfunction after stroke are muscle weakness,8-11 abnormal muscle tone,9, 11 atypical movement synergy,9, 12, 13, and impaired inter-joint coordination. 14-17

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15 Muscle weakness Muscle weakness is one of the ne gative signs of CNS injury after an individual suffers a stroke.18 Eighty to ninety percent of people with stroke demonstrate weakness of muscles.11, 19 Possible factors contributing to muscle weakness post-stroke include alterations in the physiology of motor units, notably changes in firing rates and muscle-fiber atrophy.8 Overall, muscle weakness may develop after stroke as a result of deconditioning. In particular, muscle weakness related to stroke paresis may affect one half of the body, including the trunk and the extremities.9 In the trunk, muscle weakness can interfere with postural control, balance, and the ability to perform movement sequences.20, 21 Weakness in the extremities can impede functional use in activit ies, such as weight bearing and activities of daily living.9, 21 Abnormal muscle tone. After stroke, alterations in muscle tone are observed.9, 21 Muscle tone changes may be leading to flaccidity or spas ticity. Flaccidity or complete loss of muscle tone is usually present immediatel y after the stroke. Duration of flaccidity is generally shortlived, lasting hours, days, or weeks. Prolonged muscular flaccidity post-stroke, however, is regarded as a negative indi cator for functional prognosis.22 Spasticity emerges in about 90% of stroke cases and can occur in all muscles.23 Lance offered a definition of spasticity that has been generally accepte d by physiologists: Spasticity is a motor disorder characterized by a velocity-depende nt increase in tonic st retch reflexes (muscle tone) with exaggerated tendon jerks, resulting from hyperexcitability of the stretch reflex, as one component of the upper-motor neuron syndrome11, 24 In other words, spasticity is a state of hypereflexia after suffering upper-motor neuron lesions.25, 26 The existence of spasticity, which arises from injury to corticospinal pathways and occurs as part of an upper-motoneuron syndrome usually includes other componen ts, resulting in the

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16 term, spasticity syndromes.23 Clinically, spasticity syndromes18, 23, 27-30 contain increased resistance to passive movement, clasp-knife re sponse, ankle clonus, flexor/extensor spasms, and excessive muscle cocontraction. The effects of spasticity include restricted voluntary movement and static posturing of the limbs.31 Individuals with persiste nt spasticity post-stroke tend to have less functional recovery32-34 and spend longer time in rehabilitation18 than the persons without spasticity. Atypical or pathological movement synergy. Synergy is defined as the action of muscles working together in a fixed spatial a nd temporal relationship producing a coordinated and functional movement.35 Injury to the central-nervous sy stem, such as stroke may affect synergistic organization of movement. Following stroke, movements are often limite d to patterns of stereotyped atypical or pathological movement synergy. There are two distinct atypical synergy patterns for each extremity: flexion synergy and extension synergy (Table 1-1).12, 36 Performing a dynamic activity, such as reaching for an object and walking may elicit thes e pathological synergy patterns. Muscles involved in pathological synergy patterns are of ten so closely connected that selective movements outside the synergistic patt erns become impossible. For instance, bending the elbow to touch the chin may result in shou lder flexion, abduction, an d external rotation. According to Brunnstroms clin ical observation, however, rec overy of stroke may follow a stereotyped sequence, which includes six stages.12 As recovery progresses, the atypical movement synergies begin to dissipate and lose their dominance over actio ns after individuals have learned more voluntary move ment. Active selective control of the affected body parts then become achievable.9, 12, 13 For example, an individual with a stroke moves the arm from 0 to 90 of shoulder flexion when keeping the elbow straight and the forearm fully pronated. An

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17 indication of synergy-free movement is that the el bow and forearm shall be able to maintain their required positions while the arm is m oving to 90 of shoulder flexion. Impaired inter-joint coordination. Inter-limb incoordination is a major impairment of motor control following a stroke. Coordination is defined as ability to control ones movement properly,37 a behavior of two or more degrees of freedom in rela tion to each other to produce skilled activity,38 and accurate timing of activity onset in different muscles.39 The common manifestations of impaired inter-limb coordination reported in previous studies of individuals with stroke incl ude incorrect timing of muscle activation,14, 21, 40, 41 slowness of movement,15, 42-44 segmented movement,15, 42, 43 variable arm movement,42, 44 larger movement errors,42 and recruitment of extr a degrees of freedom (i.e. compensatory movements from other body parts).15, 42, 43, 45 Current Methodology of Movement Analysis Scientists, clinicians, and engineers have developed various m ethods and equipment to study movement deficits and functional recovery post-stroke. In this section, the relevant literature concerning contemporary methodology of movement analysis used for stroke research will be reviewed. The advantages and disadvantag es of these methodologies will be discussed. The methodology for investigating m ovement deficits after stroke can be divided into two main categories: qualitative and quantitative methods.46 Qualitative methods. These are defined as nonnumeric ev aluations of motion using visual observation and video analysis. Observation. Therapists typically use observati on to evaluate moveme nt of stroke patients in clinical rehabilitation settings.12, 13, 21 Common parameters of observation include atypical synergy patterns, postural symmetry, stat ic/dynamic balance, and gait patterns.36 For instance, post-stroke atypical synergy is an abnormal stereotyped movement pattern. There are two major

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18 types of pathological synergy patterns in the extremities (Table 1-1): flexion synergy and extension synergy.47 Brunnstrom12 suggested that the recovery of motor function after stroke follows characteristic stages. In the later stag es, patients are able to make movements out of synergy.12 Out of synergy indicates increased sel ective/voluntary contro l of the paretic body. Clinicians document the progress of synergy move ment patterns as an indicator of improvement. Video/photographic analysis. Video or photographic analys is is a common research method of motion analysis used in rehabilitation clinics and research facilities After videotaping or taking pictures of patients movements, therapists or researchers can further evaluate quality of movement. Reflective markers on specific an atomical landmarks, for instance joint and bone prominences, can assist the observation of body parts and positions. Recently, Bukowski48 developed a movement analysis procedure, analyzing the range-of-motion and the muscles involved in daily activities. Th e procedure requires participants to expose the region of interest and to repeatedly perform an activity to dete rmine appropriate body land marks. After placing body markers on each subject, evaluators can m easure range-of-motion and infer involved muscles from changes of joint position in video clips. Bukowskis method finely integrates kinesiology with representative ac tivities of daily life, but the procedure of analysis can be timeconsuming. In addition, requiring repetitive performance and physical exposure may cause inconvenience and subject fatigue, thus hindering clini cal feasibility. Quantitative methods These are defined as numeric eval uations of motion, based on data collected during the performance46, such as biomechanics an d motor function scales. Biomechanical analysis. Biomechanists appl y the theory of mechanics and physics to a biological system to analyze the movement of an organism and the effect of forces on the organism.46 Biomechanical analysis includes two ma in aspects: kinematics and kinetics.

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19 Kinematics is a study that focuses on movement char acteristics and spatial /temporal perspectives of movement without considering the forces involved in the m ovement. A kinematic analysis involves describing a movement in terms of its position, velocity, and acceleration. Kinetics is concerned with forces acting on a system. The common research parameters in biomechanics can include speed, direction, force, moment, and torque.46 Biomechanical methods are heavily dependent on data collection us ing laboratory equipment. Elect ro-goniometers, accelerometers, and imaging techniques are frequent ly used for kinematic analysis.49 Kinetic analysis necessitates use of force tr ansducers and force plates.49 Furthermore, processing the collected data often requires sophisticated algorithms, mechanical models, or computer software. Motor function scales. In order to quantify human moveme nt, numerous motor function scales have been developed, for example, the Fu nctional Ability Scale(FAS) in the Wolf Motor Function Test (WMFT),50 the Quality of Movement Scale in the Motor Activity Log,1 Chedoke Arm and Hand Activity Inventory,51-53 and the Reaching Performance Scale.54 Motor function scales are designed using ordina l rating categories, which assign scores from low to high with specific descriptions to indicat e increase or decrease of moto r function. For instance, the Functional Ability Scale in the Wolf Motor Functi on Test is a 6-point scale ranging from 0 (Does not attempt with the involved arm) to 5 (Does attempt with the involved arm and the movement appears to be normal). Ordinal motor function s cales are used extensivel y in studies of stroke intervention effectiveness.54-58 Qualitative methods have some advantages ove r quantitative methods for describing poststroke movement. Qualitative methods are more flexible, feasible, convenient and less costly than quantitative methods.59 The limitations of qualitative me thods, however, include lack of precision, reliability, and validity.60, 61 Moreover, subjective, narrative information from

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20 qualitative analysis is typically obtained under le ss controlled, and less structured conditions than those for quantitative analysis.62 Many of the conventional qualit y of movement measurements focus on a specific aspect of impairment rather th an the wide range of issues which arise from compromised movement. For instance, both Brunns troms notion of hemiplegic limb synergies12 and Bobaths concept of abnormal movement patterns combined with abnormal postural tone13 have a tendency to emphasize specific movement impairment. Their specification of movement impairment mainly targets the affected limbs, without considering associated compensatory movements of the body. There is, therefore, a need for further research to develop a more comprehensive and clinically feas ible measurement method to syst ematically analyze quality of movement. Quantitative methods, such as biomechanics for example, can have greater accuracy, but their cost and time consuming nature make these methods only feasible in a laboratory environment. The sophisticated systems of movement analysis can be used to identify parameters of normal movement, and are sometime s used in research. The required equipment, however, is expensive, needs considerable expe rtise for its operation, and the volume of data produced can often be overwhelming.63 The derivatives from advanced calculations of biomechanical parameters can actually generate great confusion and difficulty for clinicians without providing sufficient direct informati on about the movement. Most of the stroke intervention studies focus mainly on aspects of movement deficits as measured by movement speed and accuracy. 1, 50, 64-71 These aspects do not give insigh t into the intera ction of body parts that produce them. Motor function scales are feasible and helpful for healthcare providers, but a statistically significant change of averaged scor es can merely indicate an incremental change along that scale72 and provide limited information about improvement in function and quality of

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21 movement. For example, evaluators are una ble to explain what the actual movement improvement is when there is a statistically sign ificant change in averag ed FAS score of WMFT from 2.5 to 3.6. Developing a measurement template to meas ure quality of movement, therefore, is beneficial to our understanding of post-stroke movement after interv ention. In the next section, this need in stroke assessment is further illu strated by using examples from Constraint-Induced Movement Therapy (CIMT) research. CIMT ha s been acknowledged as an effective stroke intervention during the last two decades. Quality of Movement in Constr aint-Induced Movement Therapy During the past two decades, Constrai nt-Induced Movem ent Therapy (CIMT)1, 67, 68 has been developed by Taub, Wolf and others. CIMT is mainly used in the post-stroke population. The hypothesis of CIMT is that re straint of the less-affected uppe r-extremity will force the moreaffected extremity to overcome the phenomenon of learned nonuse.66, 67 Based on animal studies in which primates received surgical deafferentation of one upper-extremity, learned nonuse was defined as an adverse learning cycl e caused by unsuccessful motor attempts with the deafferented arm that resulted in pa in, failure or uncoordinated movements.1 The ultimate goals of CIMT are to break the adverse learne d nonuse cycle and to impr ove functional use of the affected upper-extremity. Constraint-Induced Movement Therapy has two main components: 1) restraint of the lessaffected upper-extremity for 90% of waking hour s to force the use of the affected upperextremity, and 2) extensive practi ce with the affected upper-extremity. To date, the effectiveness of CIMT intervention and its promising results have been widely discussed in the literature.1, 50, 64-70 No studies, however, directly address the impact of CIMT on quality of movement.

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22 Assessment of quality of movement: Wolf Motor Function Test The Wolf Motor Function Test (WMFT)50 is one of the primary outcome meas urements reported in CIMT studies. Originally, the 15 timed tasks of the WMFT are arranged in an order based upon biomechanical complexity and progress from proximal to distal joint involvement. A recent pilot study of the WMFT using Rasch measurement, conducted by Wen and Velozo (unpublished) in 2003, however, has shown a different order of task diffi culty. This indicates that Wolfs conceptual task complexity is not reflected in participants responses For example, the last task, Lift Basket, which was supposed to be the most difficult task of WMFT became the second difficult task. The WMFT quantifies upper-extremity movement ability through timed singleor multiple-joint motions and functional tasks. The results of the WMFT are reported on two forms: average time and average functional-ability scores (Table 12). Researchers report CIMT as effective and clinically meaningful when individuals poststroke significantly decrease average time or increase average functional-ability scores.50, 64, 65, 67, 68, 71-74 Decreased time to perform a task tends to indicate improved efficiency of movement according to CIMT literature.1, 50, 64-71 Recent biomechanical studies of reaching/gras ping movement in stroke populations,42, 43, 45, 75 however, raise some controversial questions : Is a faster movement a better movement? Do patients with stroke recover their pre-str oke movement after CIMT? Do patients with stroke adopt compensatory strategies to perform tasks more efficiently after CIMT? In the study by Cirstea, Ptito and Levin, decreased movement time after tr aining in moderate-to-severe hemiparesis may be ascribed to adopting compensatory movement s as the optimal solution to improve movementoutcome measurements.75 There is, however, minimal information available regarding using compensatory strategies to improve performance during CIMT.

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23 Moreover, regarding improved functional-activity scores of the WMFT after CIMT, averaged ordinal-scale scores of the 15 tasks provide very limited information about actual improvement of movement.76 If the scores change from ratin g category 2 to 4 after CIMT, does it mean the improvement is doubled? What are the factors that contribute to the improvement of scores? Interpreting scores changing from 2 to 4 as a 100% functional improvement would be erroneous. Inappropriately interpreting results from the ordinal motor-func tion scales may cause potential distortion or bias of inference. Bonifer et al.72 suggested that future CIMT studies should evaluate the relationships between ch anges on standardized assessments of motor function and improvements in everyday function. In the present research, the questions rais ed above about CIMT intervention regarding quality of movement were inve stigated by analyzing a complex movement selected from the WMFT. Quality of movement is clearly defined and the results are clea rly presented. Definition of Quality of Movement Used for People Post-Stroke Both rehabilitation professionals and individu als post-stroke want to wor k towards and accomplish well-controlled, normal looking move ments. Studying quality of movement, therefore, is important to clinicians and rese archers. Quality of m ovement, however, has not been systemically measured, and in fact, the definition of quality of movement continues to be controversial. The common indicators of quality of movement in the literature include: coordination of inter-limb movements, movement time, linear displacement, linear velocity, linear acceleration, angular displacement, angular velocity, angular acceleration, force, and moment of force. 17, 44, 45, 75, 77 In addition, some researchers consider that efficiency of movement is a representati on of quality of movement.78 An efficient movement with high movement quality is the one that fulfills a specific purpose with movement economy at the required speed and with the least energy expenditure.79-81 The description of quality of

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24 movement, therefore, appears to differ widely among professionals. In Pomeroys study, ten experienced physical therapists were asked to gr ade the quality of moveme nts of people with and without stroke, based on their pe rformance of six standardized functional tasks, using a 100-mm visual-analogue scale. Their intriguing results suggested that substantial disagreement existed among therapists in grading movement quality. In contrast, no signi ficant discrepancy was found between the grading scores of the same therapist at two separate viewing times. The meaning of movement quality, therefore, may be consistent within an individual therapist but discrepant between therapists. Definition of qualit y of movement. Prior to investigating post -stroke movement quality, establishing a reference point fo r quality is necessary. Genera lly speaking, the consensus of rehabilitation professionals in regard to this reference point is normal movement.82 Normal movement is the movement observed in people with no previous neurological disorders that may affect movement execution.83 Moreover, normal movement has been a basis for treating neurologically-injured individuals.13, 14, 47 Assessing impairment a nd designing its appropriate intervention, therefore, depends on a thor ough understanding of normal movement. In the current research, this author defines quality of movement as movement component and strategy. Through direct observation coupled with the use of a coherent movement analysis system, clinicians and researchers can then id entify the movement composition (i.e. movement components) and sequence. When therapists re cognize specific aspects of a particular skill and movement sequence of a task,84 the information will assist clinic ians and researchers in assessing progress of recovery and deve loping rehabilitation programs. After defining quality of movement, the followi ng sections focus on 1) the essentials of normal human movement based on the Generali zed Motor Program theory, which was the

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25 central framework of this research, and 2) the Eshkol-Wachman Movement Notation (EWMN), an assessment tool used in this research to develop a movement quality analysis form. Generalized Motor Program Theory: The Research Framework In order to study quality of m ovement in normal people and people with stroke, the GMP theory was employed throughout this research. The cl arity of this theory allows us to establish the essentials of human movement. The GMP theory,38, 85 a theory that provides an expl anation for the motor control and motor learning of both rapid and slow movement s, was proposed by Schmidt in 1975. Since then the GMP theory has been extensively discussed in the studies of cognitive psychology, neuroscience, motor development, physic al therapy, and occupational therapy.86 The GMP theory was proposed as a theoretical structure to explain various responses of a movement that share invariant features, such as the sequencing of submovements, relative timing, and relative forces. Actions controlled by the same GMP diff er from each other in the assignment of variant movement parameters, for instance absolute time, absolute force, and selection of effectors.38, 85, 86 In light of the GMP theory, invariant subm ovements in a fixed movement sequence can be identified when different individua ls execute the same activity. For instance, the reach/g rasp action is a task frequently investigated in studies of upperextremity motor function. The essential invariant f eatures have been extensively discussed. In order to accomplish the reach/grasp action, an individual has to execute a sequence of submovements. These include eye/head movement that responds to the location of a targeted object, hand reaching out, hand opening, and grasping. These submovements are invariant among different individuals. According to GMP theory, what makes movement look different is how fast or how forcibly people move.

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26 Another classic example of the GMP theory demonstrated by Lashley is handwriting.38, 87 Two right-handed, blindfolded indi viduals were asked to write the words motor equivalence with their right hand (the dominant hand), their left hand (the non-dominant hand) and their teeth. The results showed that even when writing with di fferent effectors or in different speed and size, certain aspects of the written words appeared to be invariant, for instance, the shapes of the letters. The invariant features of the GMP theory, ther efore, can serve as a research framework in studying quality of movement. Wh en the invariant features of movement in people without stroke can be distinguished, healthcare providers will be able to clearly and effectively pinpoint the impairment of motor control in people with stroke. A Comprehensive Approach of Movement An alysis: Using Eshkol-Wachman Movement Notation Understanding the fundam ental deficits of move ment in individuals post stroke is crucial for the development of effective rehabilitative in terventions. In the present research, the author examined post-stroke movement deficit using a comprehensive approach that contained two modes of assessment. First, the author considered the whole body as one functional unit. Therefore, by using whole-body movement analysis, affected and less affected body parts will be considered at the same time. Knowing the limitations of upper-extre mity function in an impaired limb is central but knowing the influence of the less-affected body parts is also benefici al to understand the interactions between different body parts. Secon d, the author analyzed post-stroke movement as a multifaceted process, which took into account th e sequence of submovements. Examination of a movement included a beginning, middle, and end poi nt in its discrete pa rts and overall sum.

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27 This approach provided further insight about the conditions and challe nges facing patients poststroke when executing an activity. As of today few systematic methods of whole-body motion analysis are available for clinicians or researchers in stroke rehabilita tion. Existing systems may be able to define, describe, and distinguish the different types of movement, but these st andardized methodologies apply to only the body segment most affected by th e stroke. In addition, th ese analyses are most often end-point measurements. When studyi ng movement deficits following stroke, biomechanical researchers mainly give atten tion to partial views of a movement, without considering involvement of other body parts.17, 43, 45, 75, 77, 88, 89 A nalyzing movements for the changing interrelationship of whole-body parts, he nce, can yield an in creased understanding of human movement. A comprehensiv e view of movement could help identification of the often dysfunctional movement parameters seen post-stroke. In order to implement this comprehensive approach, the author chose the EWMN90-92 method as the evaluation tool. Eshkol-Wachman Movement Notation (EWMN). EWMN90-92 is a movement language developed in Israel by professors Noa Eshkol and Avraham Wachman. In the literature of human and animal behavior, EWMN has been show n to effectively describe various aspects of movement, such as time, speed, direction, magnitude, limb position, inter-limb spatial relations/coordination, sequence and trajectory.93-97 Although EWMN is not currently a widely known or accepted method to analyze movement in stroke rehabilita tion, some research scientists have pointed out the benefits of utilizing this useful tool. Teitelbaum94, 97 and Whishaw93, 96 have utilized EWMN in their researc h, with the understanding that observing and noting movement as a multifaceted sequence can bri ng forth helpful insights about brain function and recovery.

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28 EWMN is a simple geometrical model, which is compatible with the structure and function of the human body in motion. In EWMN, each limb is reduced to its longitudinal axis, an imaginary straight line of unchanging length. A limb doesnt refer to merely arms and legs, but to any part of the body, which lies between two joints or is a mobile extremity attached to a joint. Thus, the head, neck, trunk, pelvis and the fingers each consider as a limb. The movements of a single axis of constant length, which is free to move about its fixed end, are always enclosed by a sphere. Therefore, when a limb moves, it follows curved paths on the surface of such a sphere. In order to define such data, coordinates are ascribed to the sphere in a way analogous to latitude and longitude of the geographic globe. The horizontal plane (Figure 11A) of the sphere is parallel to the ground. One direction on this plane is chosen as a starting position/direction for all measurements. When the measuring unit is 45 degrees, eight positions/directions are obtained. Vertical pl anes (Figure 1-1B) are perpendicular to, and intersect with these horizontal directions. The inte rsections of horizontal and vertical planes are defined as positions on the EW sphere. The EW sphere is referred to as the System of Reference (SoR).90-92 When one unit of movement is 45 degrees, 26 positions are defined on the SoR.(Figure 1-2) In EWMN, all movements ar e reduced to three types: plane, conical and rotatory movements according to the angular rela tionship between the axis of movement and the initial position of the limb.90, 92 The advantages of using the EWMN method include: 1. EWMN can systematically record a nd measure whole body movements, without depending on expensive equipment and compli cated computer software analyses. The equipment needed for EWMN analysis are a vide o camera, TV monitor, VCR, or DVD recorder and DVD player.

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29 2. EWMN can directly investig ate the prime mover of any movement. In any movement the limbs of the body are characte rized as either active or b eing carried. In EWMN, the movements of passively carried limbs (light limb) are influe nced by the actual active moving limbs (heavy limb). The spatial changes of th e light limb are simply secondary products of the heavy limbs movement. Researchers often pa y attention to the light limb although the heavy limb is doing the movement. For instance, when an individual with stroke reaches for a target on the table, the major research interest is often ab out whether the hand can touch the target as fast as possible. Which body part actually moves (h eavy limb) seems less important than completion of the task. The patient can just use the trunk (h eavy limb) to carry the hand (light limb) to the target and still succeed in the task. Examini ng the movements of the heavy limb can readily show actual body parts that are re cruited for execution of an ac tivity. The movement of the heavy limb (prime mover), therefore, wa s the focus of this investigation. 3. In EWMN the exact sequence of human mo vement pattern can be analyzed by frameby-frame analysis. The essential components of a movement can th en be readily determined. Although EWMN has been shown to be an e ffective and efficient method to study human movement, its reliability has not been quantitat ively determined. In order to justify the reproducibility and dependability of the EWMN method in the field of movement analysis, the tests of its intra-rater and inter-rater reliability are required. Research Aims and Hypotheses The overall aim s of this research were: 1) to determine, for the first time, the reliability of a movement analysis chart using the EWMN90-92 method, 2) to investigate invariant features of a reaching-grasping-lifting-placing task for those with and without stroke, 3) to examine the change in movement quality of a reaching-grasping-lifting-placing task following CIMT intervention in terms of inva riant features, including moveme nt sequences, components and

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30 strategies, and 4) to systematically characteri ze the compensatory movements observed in people with stroke while performing a reach ing-grasping-lifting-placing task. Experiment I General a im 1. Development of a movement analysis form using the Eshkol-Wachman Movement Notation method and establishment of its reliability Specific aim 1. To develop a movement analysis form, the Essential-Movement Component Evaluation (EMCE) form, to measure m ovement quality of the Lift Basket task Specific aim 2. To establish, for the first time, intra-rater and inter-rater reliability of the EWMN method when using the EMCE Form. (see Appendix B) Hypothesis 1. All the three raters in the intra-rater reliability test will show an excellent intraclass correlation coefficient (ICC) value, which exceeds .75,98-100 between two separate testing times. Hypothesis 2. The result of the inter-rater reliab ility test will show an excellent ICC value, which exceeds .75,98-100 among the three raters. Experiment II General a im 2. Comparison of movement between pe rsons with and without stroke in terms of movement components, sequence and strategy Specific aim 3. To determine the differences between the control and two stroke groups in terms of the score of essential-movement components and movement sequence identified by the EMCE form in a reaching-grasping-lifting-placi ng task. The essential-movement components identified in persons without stroke are the te n consecutive actions required for accomplishing the Lift Basket task. (See Appe ndix A: Pilot Study 2 for the deta ils of how the ten essentialmovement components were identified.)

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31 Hypothesis 3. Ten essential-movement components of the Lift Basket task in the WMFT 1, 50, 64, 65, 101 that were previously identified by EWMN will appear among all control group participants, but will be observed le ss in participants with stroke. Hypothesis 4. For participants with stroke, th e high-functioning group will preserve greater scores of essential-movement components than the low-functi oning group in the Lift Basket task. Hypothesis 5. The control group participants will in itiate the Lift Ba sket task with proximal body parts progressing to distal body parts; whereas, participants post-stroke will initiate the task with proximal body parts and only recruit proximal body parts to complete the task. Experiment III General a im 3. Determination of quality of moveme nt changes after th e intervention of Constraint-Induced Movement Therapy Specific aim 4. To examine the Lift Basket task after CIMT in terms of essentialmovement components, movement sequence, and strategy. Hypothesis 6. During the pre-test evaluation the high-functioning stroke group will preserve more essential-movement component s of the Lift Basket task than the lowfunctioning stroke group. Hypothesis 7. After receiving the 2-week CIMT in tervention, both the high-functioning and low-functioning stroke groups will show signif icant improvement in the scores of essentialmovement components. Hypothesis 8. After receiving the 2-week CIMT in tervention, the low-functioning stroke group will show more movement improvement in te rms of total scores of essential-movement components, as compared with the high-functioning stroke group.

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32 General aim 4. Characterization of compensatory m ovement in persons with stroke Specific aim 5. To systematically categorize compen satory movements observed from the Lift Basket task in people with stroke. Hypothesis 9. After 2-week CIMT intervention, the stroke groups will have less compensatory movement as compared with pretest while performing the Lift Basket task. (See Appendix B. EMCE form for explanation of compensatory movement.) Summary The rationale of CIMT suggests that the l earned nonuse developed in people with stroke may be reversed by stressing the interaction between the affected and less affected upperextremity. Constraint on usi ng the less affected upper-extrem ity may force the use of the affected upper-extremity and promote its function. The manner in which CIMT examines quality of movement, however, has yet to cons ider movement sequence, movement strategy and whole-body movement analysis. Instead, the outcome measures us ed reveal limited information about post-stroke movement, opting to measure qua lity of movement in terms of how patients score on a 6-point ordinal scale of th e Wolf Motor Function Test (WMFT).102 In the current research, therefor e, the author sought to have a more inclusive understanding of a complex movement in the WMFT through analyses of invariant movement features as defined in the GMP theory. In addition, the author took a comprehensive approach using EWMN that emphasized the whole-body movement analysis and whole procedure of movement to investigate the changes of movement qua lity after the CIMT intervention.

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33 Table 1-1. Atypical synergy movement patterns of extremities observed in people with stroke Flexion Synergy Extension Synergy Scapular retraction/elevation or hyperextension Scapular protraction Shoulder abduction, external rotation Shoulder adduction, internal rotation Elbow flexion Elbow extension Forearm supination Forearm pronation Upper extremity Wrist & finger flexion Wrist & finger flexion Hip flexion, abduction, external rotation Hip extension, adduction, internal rotation Knee flexion Knee extension Ankle dorsiflexion Ankle plantarflexion, inversion Lower extremity Toe dorsiflexion Toe plantarflexion Table 1-2. Wolf Motor Function Te st: Functional Ability Scale Rating Description 0 Does not attempt with involved arm. 1 Involved arm does not participate functionally; however, attempt is made to use the arm. In unilateral tasks the uninvolved extremity may be used to move the involved extremity. 2 Does, but requires assistance of uninvolved extremity for minor readjustments or change of position, or requires more than two attempts to complete, or accomplishes very slowly. In bilateral tasks the involved extremity may serve only as a helper or stabilizer. 3 Does, but movement is influenced to some degree by synergy or is performed slowly and/or with effort. 4 Does; movement is close to normal*, but slightly sl ower; may lack precision, fine coordination or fluidity. 5 Does; movement appears to be normal*. = for the determination of normal the uninvolved limb ca n be utilized as an available index for comparison, with pre-morbid limb dominance taken into consideration.

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34 Figure 1-1. Two fundamental planes of EW sphere Figure 1-2. The 26 positions on SoR when one unit of movement is 45 A. Horizontal Plane B. Vertical Plane

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35 CHAPTER 2 DEVELOPMENT AND RELIABILITY OF THE ESSENTIAL MOVEMENT COMPONENT EVAL UATION FORM USING ESHKOL-WACHMAN MOVEMENT NOTATION Introduction Movem ent quality is an importa nt aspect in our daily life.103 Physical education teachers use quality of movement to evaluate student perf ormance. Athletes rely on the analysis of movement quality to improve their technique and pursue perfect performance. Dancers strive for a smooth and coordinated movement based on th e qualitative performance. So do people following a stroke. After our cl ients can perform certain representative functional activities, such as walking and reaching, improvement in qua lity of these movements becomes their next ultimate goal. A movement with poor quality may impede the use of the affected extremities, and may adversely affect self image a nd further hamper social participation.104 Quality of movement, nevertheless, is an aspect that has not been extensively explored in stroke rehabilitation. Possible reasons for ignoring movement quality assessment can be the current emphasis on a functional treatment approach,17, 75, 88, 105 lack of agreement on the definition of movement quality,63 and the lack of measurements av ailable to describe changes of movement quality.106, 107 Currently, therapists and resear chers may pay more attention to successful and fast performance of a task ra ther than to how the movement is executed.108 In addition, a functional treatment approach can le ad to greater improvement in quantitative measures than a traditional neuromuscular approach, which emphasizes normality of movement.109 Clinicians and researchers seem to have an implicit knowledge about quality of movement.63 Generally speaking, the consensus of rehabi litation professionals in regard to this reference point is normal movement.82 Normal movement is the movement observed in people with no previous neur ological disorders that ma y affect movement execution.83

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36 Moreover, normal movement has been a basis for treating neurologically -injured individuals.13, 14, 47 In order to investigate post-stroke quality of movement, the invariant features of the Generalized Motor Program (GMP) theory can se rve as the research framework in this study since the clarity of this theory allows us to establish the essentials of human movement. The GMP theory,38, 85 a theory that provides an explanation for the motor control and motor learning of both rapid and slow movements, was proposed by Schmidt in 1975. Since then the GMP theory has been extensively discussed in the studies of cognitive psychology, neuroscience, motor development, physical therapy, and occupational therapy.86 The GMP theory was proposed as a theoretical struct ure to explain various responses of a movement that share invariant features, such as the sequencing of s ubmovements, relative timing, and relative forces. Actions controlled by the same GMP differ from each other in the assignment of variant movement parameters, for instance absolute time, absolute force, and selection of effectors.38, 85, 86 Invariant submovements, in a fixed movement sequence, can be identified when different individuals execute the same activity. Accordin g to the GMP theory, quality of movement in this study is defined as specific aspects of movement, including movement components, sequence, and strategy.84 A movement of good quality is one that approximates normal movement.82, 83 Studying invariant features (i.e. moveme nt component, sequence and strategy) of post-stroke movements can provi de important information rega rding the impact of stroke on motor programming. Biomechanical methods may be useful to explore quality of movement, but the requirement of expensive equipment and complicated computer software an alyses can make this application very difficult in c linical settings. Developing a c linically feasible and reliable

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37 method to measure quality of m ovement would, therefore, provide a means for clinicians to report valuable information. In this study, the Eshkol-Wachman Movement Notation (EWMN) was introduced to provide an effective and economical method. EWMN90-92 is a movement language developed in Israel by professors Noa Eshkol and Avraham Wachman. In the literature of human and animal behavior, EWMN has been shown to effectively describe various aspects of movement, such as time, speed, directi on, magnitude, limb position, inter-limb spatial relations/coordination, sequence and trajectory.93-97 EWMN was the assessment tool used in this study to develop an evaluation form ba sed on a combined application of GMP38, 85 and EWMN,90-92 measuring quality of moveme nt that investigates invariant features for a reachinggrasping-lifting-placing task.. The aims of this study were to 1) develop the Essential-Movement Component Evaluation (EMCE) form for a reaching-grasping-lifting-placing task in WMFT using the EWMN method, and 2) to determine the intraand inter-rater reliability of the EM CE form for a reachinggrasping-lifting-placing task. Methods Development of The Essential-Movement Co mponent Evaluation F orm Using EWMN The movement task selected for this study wa s the Lift Basket task of the WMFT. The WMFT is a standardized test and one of the primary outcomes in the CIMT studies.1, 50, 57, 58, 64, 67, 68, 74, 101 The WMFT consists of a series of 15 timed tasks and two st rength tasks that are performed in either a sitting or standing posit ion. The 15 tasks are arranged in order of biomechanical complexity according to the joints involved and the level of difficulty. The tasks progress from proximal to distal joint involvement and from gross to fine motor skills.50 A recent pilot study of the WMFT using Rasch measurement, conducted by Wen and Velozo (unpublished) in 2003, however, has shown a differen t order of task difficulty. This indicates

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38 that Wolfs conceptual task complexity is not reflected in participants responses. For example, the last task, Lift Basket, which was supposed to be the most difficult task of WMFT became the second difficult task. The WMFT quantifies up per-extremity movement ability through timed singleor multiple-joint motions and functional tasks.50 The last task in the WMFT, Lift Basket, is regarded as a complex task that demands efforts from multiple body systems, such as muscle strength, dynamic/standing balance, and inter-limb coordination. As compar ed with a simple activity, such as reaching for an object on a table, Lift Basket is a representa tive activity with greater difficulty in our daily life. This task requires involvement from the whole body. Studyi ng this task, therefore, can show how one body part interacts with others du ring movement. Moreover, the Lif t Basket task is an out of synergy movement that can target the limitati on people with stroke have when performing a reaching and lifting task.88 Lift Basket task The set-up o f the Lift Basket task included a ba sket, a desk (29 high) located in front of the participant and a bedside table (44 high) located on the particip ants side to be tested. (see Figure 2-1) The bedside table extended along th e width of the desk. The basket was placed on the desk and lined up with the center of the participants body. A three-pound weight was placed in the basket. Participants were tested in a standing position while facing the desk. The set-up of the Lift Basket task is illustrated with it s starting position (Figure 2-1A) and ending position (Figure 2-1B). The task description was Patie nt attempts to pick up basket by grasping handle (from underneath the handle) and placing the basket on far edge of the rolling bedside table. All participants were asked to Pick up the ba sket with your hand and place the basket on the rolling table. The far edge of the basket should go past the far edge of th e bedside table. Try not to move your feet while you do this ta sk. Do this as quickly as you can.102 The subjects

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39 movement progression was videotaped from a front view. Participants video tapes were then converted to DVD in digital format using a Pa nasonic DVD recorder (model DMR-E95HS) for further analyses of EWMN. Eshkol-Wachman Movement Notation EW MN90-92 is a movement language developed in Israel by professors Noa Eshkol and Avraham Wachman. In the literatu re of human and animal behavi or, EWMN has been shown to effectively describe various aspects of moveme nt, such as time, speed, direction, magnitude, limb position, inter-limb spatial relations/c oordination, sequence and trajectory.93-97 Although EWMN is not currently a widely known or acce pted method to analyze movement in stroke rehabilitation, some research scient ists have pointed out the benefits of utilizing this useful tool. Teitelbaum94, 97 and Whishaw93, 96 have utilized EWMN in their research, with the understanding that observing and noting movement as a multifaceted sequence can bring forth helpful insights about brain function and recovery. EWMN is a simple geometrical model, which is compatible with the structure and function of the human body in motion. In EWMN, each limb is reduced to its longitudinal axis, an imaginary straight line of unchanging length. A limb doesnt refer to merely arms and legs, but to any part of the body, which lies between two joints or is a mobile extremity attached to a joint. Thus, the head, neck, trunk, pelvis and the fingers each consider as a limb. The movements of a single axis of constant length, which is free to move about its fixed end, are always enclosed by a sphere. Therefore, when a limb moves, it follows curved paths on the surface of such a sphere. In order to define such data, coordinates are ascribed to the sphere in a way analogous to latitude and longitude of the geographic globe. The horizontal plane (Figure 22A) of the sphere is parallel to the ground. One direction on this plane is chosen as a starting position/direction for all measurements. When the measuring unit is 45 degrees, eight

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40 positions/directions are obtained. Vertical pl anes (Figure 2-2B) are perpendicular to, and intersect with these horizontal directions. The inte rsections of horizontal and vertical planes are defined as positions on the EW sphere. The EW sphere is referred to as the System of Reference (SoR).90-92 When one unit of movement is 45 degrees, 26 positions are defined on the SoR.(Figure 2-3) In EWMN, all movements ar e reduced to three types: plane, conical and rotatory movements according to the angular rela tionship between the axis of movement and the initial position of the limb.90, 92 EWMN can provide a system atic and whole-body movement analysis to determine movement components, sequence and strategy. Participants Sixteen participants were included to de velop the EssentialMovem ent Component Evaluation Form, including 8 participants without stroke (age range: 50~79 y/o; mean age: 70 y/o; 4M/4F) and 8 participants with stroke (a ge range 37~84 y/o; mean age: 64.8 y/o; 5M/3F). All participants were randomly selected from four CIMT studies that were conducted at the Department of Physical Therapy, University of Florida and the Brain Rehabilitation Research Center, Malcom Randall Veteran Affairs Medical Center, Gainesvi lle, Florida. Participants video tapes of the Lift Basket task were fi rst converted to DVD in digital format using a Panasonic DVD recorder (model DMR-E95HS). Essential-Movement Comp onent Evaluation form In the laboratory, the author, a physical th erapist with threeyear EW MN training experience, played video clips frame-by-frame (30 frames/second) using a Pioneer DVD player (model DVD-V7400) to write the movement using EWMN. On an example of original EWMN page (Figure 2-4), each column on the table re presented a time point during the task and each row indicated a body part.

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41 After comparing the pages of participants, ten movement components and five compensatory movements were identified. In accordance with the theory of GMP, the ten essential movement components were the invariant sequencing movement components observed in all participants wit hout stroke. These ten movement components that reflected the invariant features of GMP were named essen tial-movement components. For instance, the first pair of red circles (i.e. the second column eye contact with the basket handle) was observed before the second pair of circle s (i.e. the third columninitia tive synergy). Compensatory movements were found in the participants with stroke. Based on these findings, the author created the Essential Movement Component Evaluation (EMCE) form based upon EWMN for Lift Basket task.(Figure 2-5) The ten essential-movement components of Lift Basket task included 1) eye contact with basket handles, 2) initiative synergy: coupled but opposite move ments of the arm and forearm (i.e. simultaneous shoulder extension and elbow flexion on the sagittal plane), 3) upper-arm movement with forearm fixation: maintaining constant height of the forearm in space while the upper arm moves forward toward the basket, 4) contralateral weight shifting, 5) grasping preparation: opening the hand, 6) grasping, 7) shift of eye c ontact to the high tabletop, 8) diagonal shift of upper arm (i.e. shoulder flexion a nd abduction), 9) ipsilate ral weight shifting, 10) placing the basket (i.e. elbow ex tension). The compensatory movements include 1) upper-arm abduction, 2) trunk side-bending, 3) trunk forward rotation, 4) tr unk backward rotation, and 5) non-standard grasping. The detailed definition of the ten essential-movement components and compensatory movement can be found in the EMCE form (Figure 2-5). The grading system of the EMCE form ha s two parts: existence of the movement component and magnitude of the movement co mponent. The essential-movement components

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42 are first graded by whether a movement componen t is observed (0= No; 1= Yes). The range of the essential-movement component composite sc ore is 0 to 10. Three essential-movement components are further graded by how much range-of-motion is observed (0= no movement observed; 1= 0 movement < 30; 2= 30 movement < 60; 3= 30 movement < 60). The three essential-movement components are upper-ar m movement with forearm fixation, diagonal shifting of upper arm (including hori zontal and vertical shifting), and forearm movement to place the basket. These essential components we re chosen since their range-of-motion can be visually measured. The compensatory moveme nt is graded by whether a compensatory movement is observed. (0= No; 1= Yes) The ra nge of compensatory movement composite score is 0 to 5. The EMCE form was used in the following experiment to determine its intraand interrater reliability. Intra-Rater and Inter-Rater Reliability of The EMCE Form Participants Raters. A convenience sam ple of thr ee doctoral students (age range = 28 ~ 33 years; mean age = 31.3 years; standard deviation of age = 2.89 years; 2 men and 1 woman) from various departments of University of Flor ida volunteered to participate in th is study as raters. Descriptive information regarding the raters is provided. (T able 2-2) These thre e graduate students are currently enrolled in the Department of Physical Thera py, Occupational Therapy and Material Science respectively. Re cruiting three raters with different background represents a variety of experience levels. Subjects. Twenty participants were randomly select ed from four CIMT studies that were conducted at the Department of Physical Th erapy, University of Florida and the Brain Rehabilitation Research Center, Malcom Randall Veteran Affairs Medical Center, Gainesville, Florida. The main participant characteristics ar e presented, including age, gender, side of stroke

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43 and time since stroke.(Table 2-3) Three groups of participants were includ ed in this experiment: participants without stro ke (normal group; n= 4), high-functioni ng participants with stroke (n= 8), and low-functioning participants with stroke (n= 8). The participants with stroke were divided into two groups using their upper-extremity Fugl-Meyer motor scores: high-functioning (s cores > 33) and low-functioning group (scores 33). The Fugl-Meyer Assessment110 (see Appendix C) is regarded as an objective and quantifiable assessment of motor impairment The Fugl-Meyer Assessment is also a standardized assessment to measure recovery after stroke. The upper-extremity Fugl-Meyer motor component (total score = 66 ) assesses the ability to move in /out of synergy, reflexes, wrist stability, grasping ability and c oordination. In stroke rehabil itation research, the Fugl-Meyer Assessment is frequently used as a pr imary outcome measure of impairment,74, 111 and has been shown to be predictive of dependency, f unctional level and recovery after stroke.58, 112-114 The inclusion criterion for the control gr oup was that they had no prior history of neurological disorders. All pa rticipants with stroke in this experiment met the following inclusion criteria: 1) the diagnosis of at least one stroke, but no t more than three strokes on the same side of the brain, 2) stroke at least three months prior to study par ticipation, 3) ability to follow simple instructions, 4) a score of 20 or higher on the Mini Mental-State Exam,115 5) the ability to sit independently wit hout back or arm support for two mi nutes, 6) the ability to stand with support of a straight cane, quad cane or he mi-walker for two minutes 7) the ability to actively participate for six hours of therapy without long rests or nap periods, 8) passive rangeof-motion of all upper-extremity motions of at le ast half the normal range, 9) traditional CIMT minimal motor criteria.1, 67, 116-118 Minimal motor criteria were defined as active movement of the wrist through at least 20 degrees of extens ion from a relaxed flexed position, and active

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44 movement of at least three finge rs (the thumb and two fingers) 20 degrees of extension at the metacarpal-phalangeal and proximal interphalangeal joints. Exclusion criteria for both stroke groups incl uded 1) any health problems that put the individual at significant risk of harm during the study, 2) any ot her neurological conditions such as multiple sclerosis or Parkinsons disease, 3) taking drugs for spasticity, 4) pain that is scored greater than 5/10 on the McGill Pain Scale119. Furthermore, the partic ipants were excluded if they could not independently reach the handle of the basket for the Lift Basket task of the WMFT in a standing position with or without sup port of a straight cane, quad cane or hemiwalker within two minutes. Procedure All data u sed in this experiment were retr ospectively retrieved fr om four previously completed studies. All participants signed a consent form that was pre-approved by the Institutional Review Board of University of Fl orida for permission to be videotaped and have their videotapes analyzed for movement control. The participants without stroke were recruited from the local community and only received one test, the Wolf Motor Function Test (WMFT),1, 50, 64, 65, 101 which is a standardized evaluation in traditional CIMT.1, 65 The participants with stroke received a series of pre-test evaluations that included the WMFT.1, 50, 64, 65, 101 To examine inter-rater and intra-rater reliabili ty, all three raters were provided with the EMCE Form of EWMN and written instructions for administering the evaluation. The raters were then given a one-hour trai ning session by the primary investig ator to review the movement components, grading criteria, and instructions for administering the evaluation. Applied examples of grading were also provided using sa mple video clips of Lift Basket task, along with feedback and discussion regarding the choice of the appropriate rati ngs. After training, the raters were instructed not to discuss the grading crite ria or the evaluation with other raters. A DVD

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45 disc that contained the twenty participants video clips was then given to each rater. In the laboratory, the raters played vide o clips frame-by-frame (30 frames/second) at separate times to grade participants movement, using a Pioneer DVD player (model DVD-V7400). To investigate intra-rater re liability, one week after this viewing session, the same raters were asked to grade the same participants movement. A one-week time period was chosen to minimize the possibility of recall. The order of appearance of each participants video clip was randomly altered by the primary investigator for the second viewing of the DVD. The same guidelin es used in the first viewing session were followed in the second viewing session. In additio n, raters were blind to the groups to which the participants were assigned, his or her first viewing results, and ot her raters results. The above precautions were taken in order to minimize possi ble rater bias caused by raters memory of the results of the first viewing session.62 Data Analysis For the reliability tests in this study, three statistical met hods were chosen, including the intraclass correlation coefficient (ICC),98-100 standard error of measurement (SEM),120, 121 and minimal detectable change (MDC).122, 123 ICC is a reliability index that measures the strength of reliability.62 ICC ranges from 0 to 1. SEM is a co mmon method that measures the consistency or stability of repeat ed responses over time.62 A measure with stable responses can separate out errors due to the rater or instrument. SEM can re flect the range of scores that can be expected on retesting or the extent of expect ed error in different raters scor es. MDC is an index to measure how much change of specific score is necessa ry to be confident that true change has occurred.124 A small MDC indicates that the changes measured by an instrument are not caused by error.

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46 The scores graded by the raters using the EMCE form included number of essentialmovement components (essential-movement co mponent composite score) and movement magnitude of the three movement components. For statistical evaluation of inter-rater and intrarater reliability, ICC(2,1)98-100 was used to determine the reliability of 1) the essential-movement component composite scores, 2) movement ma gnitude of three movement components (upperarm movement with forearm fixation, horizontal and vertical shifting movement of upper arm, and placing basket), and 3) i ndividual essential-movement co mponents. The standards of interpreting magnitude of the ICC we re based on Fleiss categories: .40= poor, .40-.75= fair to good, >.75= excellent.100, 125 SEM and MDC was calculated for the total sc ore of essential-movement components for inter-rater and intra-rater reliability. The SEM is expressed in the units of the measure and is estimated as follows: ICC SD 1 where SD is the standard de viation of the pooled measures of the scores. The MDC was calcu lated using the following formula: 2 96.1 SEM MDC,126 where 1.96 reflects the 95% confidence intervals and 2accounts for the additional uncertainty introduced by measur ements obtained at two different time points. SEM estimates how repeated measures of a person on the same instrument tend to be distributed around his or her true score. SEM is di rectly related to the reli ability of a test. The larger the SEM, the lower the reli ability of the test and the less precision there is in the measures taken and scores obtained. MDC reflects the sm allest detectable difference that can be considered actual change that exceeds measuremen t error. A change in an observed value that is less than the MDC would be considered in distinguishable from measurement error.

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47 Results Intra-Rater Reliability The ICC values of three raters for grading the individual essentialmovement components and essential-movement component composite scor es were reported.(Table 2-4) Intra-rater reliability of essential-movement components scores were reported by an overall ICC of .93, which ranged from .89 to .97. In terms of intra-reliability for the ten indi vidual essential-moveme nt component items, the overall ICC values ranged from .46 to .96. Most of ICC values for the three individual raters were above .75 (excellent), except for Rater 3s item 3 (.59; upper-arm movement with forearm fixation), 6 (.55; eye contact with high table) and 8 (.70; placing basket), Rater 1s item 10 (.45; contralateral weight shifting), and Rater 2s item 6 (.65) and 9 (.57; ipsilateral weight shifting). ICC results for movement magnitude of three essential-movement components were presented.(Table 2-5) Overall ICC values were ranged from .73 to .91. The ranges of ICC item values for individual raters were .65 .96 (Rater 1), .75 .95 (Rater 2), and .75 .86 (Rater 3). Inter-Rater Reliability The ICC (2,1) values of overall three raters for individual and total scores of essentialmove ment components were reported.(Table 2-6) Inter-rater reliability of the total score of essential-movement components wa s reported by an overall ICC of .95. In terms of reliability, for the ten individual essential-movement co mponent items, the overall ICC values ranged from .37 to 1. Most of ICC values were above .75, except for item 1 (.56; eye contact with basket handles), 6 (.59) and 9 (.37; ipsilateral weight shifting). ICC results for the magnitudes of four essential-movement components were presented.(Table 2-7) Most of the component s had an ICC value higher than .75, except for

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48 upper-arm movement with forear m fixation (.74; item 3) and horizontal shifti ng of upper arm (.40; item 7). The standard error of measurement (SEM), 95% confidence interval (CI) of SEM, and minimal detectable change (MDC) for inter-rater and intra-rater reliability of EMCE form were presented.(Table 2-8) Discussion No effective assessm ents that measure quali ty of movement are available in stroke rehabilitation. Stroke interven tion studies focus typically on asp ects of movement deficits as measured by movement speed and accuracy.1, 50, 64-71 These measures do not give insight into the interaction of body parts that produce them. Motor function scales may be feasible and convenient for healthcare providers Nevertheless, a statistically significant change of averaged scores can merely indicate an in cremental movement along that scale72 and provide limited information about improvement in function and qu ality of movement. In addition, these methods emphasize specification of movement impairment mainly for the affected limbs without considering associated compensatory movement s from the rest of body. There is a need, therefore, to develop a comprehensive and relia ble measure to analyze movement quality in a whole-body manner. Rater Reliability of The EMCE Form The results of this study indica ted that the movement components of the Lift Basket task analyzed can be assessed reliably with a minima l degree of error, with the exception of those movement components that requir e identifying movement compensa tion. The ICCs for intraand inter-rater reliability were excellent (.89-.97 and .90-.95, resp ectively), suggesting excellent agreement both within and between raters. The SEM for inter-rater reliability was 0.52 and intra-rater reliabili ty ranged from 0.15 to 0.47. This represented an error of measurement

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49 ranging from 0.15 to 0.52. A smaller SEM relates to higher reliability of th e test and therefore, more precision there is in the m easure taken and scores obtained. The high ICCs and subsequent low SEMs demo nstrate that novice investigators, even those without formal rehabilitation or moveme nt training, can reliably document movement using the established ECME form and a short training and practice se ssion. While most of the 10 component movements demonstrated excellent intr a-rater reliability, an analysis of individual items demonstrated that the fixation item (uppe r-arm movement with forearm fixation), had a lower ICC value (.72), although still good.98-100 The recognition of compensatory movement patterns, such as using forward trunk rotation to compensate for lack of upper arm and forearm movement, may be a skill that requires more advanced training. Physical and occupational therapists should have the skills to identify thes e compensatory movements. The PT (Rater 1) and OT (Rater 2) participated in the reliability study had higher overall ICCs (.91 and .97) than the non-rehabilitation professional (Rater 3) ( .89), although the non-professional still had an overall excellent ICC. This trend held true fo r the total ICCs and SEMs. These results suggest EMCE is an effective measure with excellent rater reliability. Eval uators with little training or knowledge of movement analysis can still reliab ly use a well-established EMCE template to assess quality of movement. The SEM represents the standard deviation of measurement errors and reflects the extent of expected error in repeated measurements or different raters scores.120, 121 The SEM is expressed in the units of the m easure, therefore allowing an erro r distribution to be established around the measurement calculated. Measurement e rrors are assumed to be normally distributed; therefore, there is a 95% probability that an i ndividuals true value would be within 2 SEMs of the original measurement. For example, the 95% SEM for inter-rater reliability was .02, so

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50 for a measured score of 4, we would be 95% co nfident that the true measurement would be between 2.98 and 5.02. The ICC provides information on the relative reliability of a measure by assessing the degree of associ ation between repeated measur ements, while the SEM provides information on the absolute reliability of a meas ure by assessing the extent to which a score may vary with repeated measurements based on measurement error.121 Another way measurement error was assess ed in this study was by determining the minimal detectable change (MDC). The MDC takes into account multiple measures/variances across different testing times while the SEM is a reflection of error associated with measurements obtained during one time period.122, 123 The MDC reflects the smallest detectable difference that can be considered actual change that exceeds measurement error. A change in an observed value that is less than the MDC would be considered indistinguishable from measurement error. The MDC was calculated using the following formula: 2 96.1 SEM MDC, where 1.96 reflects the 95% CI and 2 accounts for the additional uncertainty introduced by measurem ents obtained at two different time points.126 The MDC for intra-rater reliability is an important in dicator, since in Experiment II the author will document changes from preto post-CIMT. The MDC for the total score of the essentialmovement components was 0.90; this means a pa rticipant must exceed a change of .90 to identify the change as true and not due to measur ement error. Therefore, if a person scores a 4 on the pre-test and a 5 on the post-test, we can be sure the change is real and not due to measurement error. Limitations Two lim itations of the current study need to be addressed. While exce llent reliability was demonstrated, establishing validity of the measure is difficult. To address this limitation, an

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51 attempt was made to demonstrate validity in Experiment II by comparing the movements of a person with stroke to normal movements in individuals without stroke, where normal movement is considered the gold standard for validity purposes. Nevertheless, determination of the validity of the current template in this study may be accomplished by future collaboration with adequate biomechanical methods. Second, although utilization of th e EMCE form showed excellent inter-rater and intrarater reliability, even for a nonrehabilitation professional, the generalization of the EMCE method for functional activities of daily life can be limited. Future study is necessary to develop the EMCE form s for other representative daily activities,127 such as walking, eating and ascending/desc ending stairs. Researchers w ith appropriate training in EWMN could develop EMCE forms for other key movements to effectively measure quality of movement. Conclusions Quality of movement is an important indicato r of post-stroke recovery, but has often been ignored by rehabilitation professionals. In order to investigate post-stroke quality of movement, the invariant features of the Generalized Motor Program (GMP) theory can serve as the research framework in this study since the cl arity of this theory allows us to establish the essentials of human movement. Biomechanical methods may be useful to explore quality of movement, but the requirement of expensive equipment and complicated computer software analyses can make their application very difficult in clinical settings. The Eshkol-Wachman Movement Notation (EWMN), therefore, was introduced to provide an effective and economical method. In this study, the author developed an evaluation form based on a combined application of the GMP38, 85 and EWMN,90-92 measuring quality of movement that investigates invariant features for a reaching-grasping-lifting-placing task.

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52 Overall an excellent ICC value was establ ished for this new outcome measure (the Essential-Movement Component Evaluation form) that provides a systematic whole-body movement analysis in a feasible manner. The co mbination of invariant f eatures of the GMP and EWMN method to study quality of movement in people with stroke is effective and reliable. This measurement template does more than traditional assessments by evaluating the contributions of the whole body to the activity, thus pr oviding an additional means to assess quality of movement. Novice investigators, even those without form al rehabilitation or movement training, can reliably document moveme nt using the established ECME form with minimal training and practice.

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53 Table 2-1. Functional Ability Scale Rating Description 0 Does not attempt with involved arm. 1 Involved arm does not participate functionally; however, attempt is made to use the arm. In unilateral tasks the uninvolved extremity may be used to move the involved extremity. 2 Does, but requires assistance of uninvolved extremity for minor readjustments or change of position, or requires more than two attempts to complete, or accomplishes very slowly. In bilateral tasks the involved extremity may serve only as a helper or stabilizer. 3 Does, but movement is influenced to some degree by synergy or is performed slowly and/or with effort. 4 Does; movement is close to normal*, but slightly sl ower; may lack precision, fine coordination or fluidity. 5 Does; movement appears to be normal*. = for the determination of normal the uninvolved limb ca n be utilized as an available index for comparison, with pre-morbid limb dominance taken into consideration. Table 2-2. Demographic information of raters Rater 1 Rater 2 Rater 3 Gender Male Female Male Age 33 33 28 Department Physical Therapy Occupationa l Therapy Material Science & Engineering Therapist Degree Physical Therapist Occupational Therapist None Table 2-3. Demographic information of participants Normal group High-functioning stroke group Low-functioning stroke group (n = 4) (n = 8) (n = 8) Range 23 78 37 78 37 86 Age (year) Mean SD 55.8 25.9 64.5 14.1 68 16.1 Gender (Male/Female) 1/3 6/2 7/1 Affected side (R/L) **** 4/4 3/5 Range **** 34 59 18 33 Upper Extremity Fugl-Myer scores (maximum: 66) Mean SD **** 44.1 8.3 29 5.1 Range 1.06 1.19 3.21 21.08 17.14 86.37 Averaged Wolf Motor Function Test time (second) Mean SD 1.13 0.06 8.36 6.34 55.28 24.29 Table 2-4. Intra-rater reliability (ICC) for individual essentia l-movement component and total score of essential-movement component Essential Movement Component Item 1 2 3 4 5 6 7 8 9 10 Total Rater 1 0.79 0.75 0.77 0.95 0.94 0.90 1 0.77 0.92 0.45 0.91 Rater 2 1 0.94 0.83 1 0.94 0.65 1 0.82 0.57 1 0.97 Rater 3 1 0.86 0.59 0.82 0.86 0.55 0.88 0.70 0.88 0.93 0.89 Overall 0.79 0.87 0.72 0.93 0.92 0.46 0.96 0.77 0.46 0.79 0.93

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54 Table 2-5. Intra-rater reliability (ICC) for magnitude of essential-movement components. (UA = upper arm) Magnitute of Movement UA with Fixation Horizontal Shifting Vertical Shifting Placing Basket Rater 1 .65 .72 .70 .96 Rater 2 .87 .85 .75 .95 Rater 3 .75 .86 .76 .82 Overall .73 .81 .75 .91 Table 2-6. Inter-rater reliability for individual and total score of essential-movement component; data were reported by ICC (2,1). Essential Movement Component 1 2 3 4 5 6 7 8 9 10 Total .56 .79 .78 .98 .87 .59 1 .86 .37 .75 .95 Table 2-7. Inter-rater reliability (ICC) for magnitude of four essential-movement components Magnitude of Movement UA with Fixation Horizontal Shifti ng Vertical Shifting Placing Basket .74 .40 .75 .92 Table 2-8. Standard error of measurement (SEM ), 95% confidence interv al (CI) of SEM, and minimally detectable change (MDC) SEM 95% SEM MDC Inter-rater 0.52 .02 1.43 Rater 1 0.47 .92 1.29 Rater 2 0.36 .71 0.99 Rater 3 0.15 .29 0.41 Intra-rater Average 0.33 .64 0.90

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55 Figure 2-1. Lift Basket task A. Starting position B. Ending position

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56 Figure 2-2. Fundamental planes of EWMN sphere Figure 2-3. Positions on SoR when one unit of movement is 45 A. Horizontal Plane B. Vertical Plane

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57 Figure 2-4. Example of origin al EWMN page for the Lif t Basket task in WMFT Abbreviations: LH, left hand; LLA, left lower arm; LUA, lower upper arm; LSh, left shoulder; RH, right hand; RLA, right lower arm; RUA, right upper arm; RSh, right shoulder; Plv, pelvis; BKH, basket handle; BKB, basket bottom; TabH, high tabletop; Wt, weight shifting. Note: Red circles represent the movement components identified across normal participants.

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58 Figure 2-5. Essential-Move ment Component Evaluation form based on EWMN Movement Grading I. Nominal Data (eye contact, initiative synergy, weight shifting, grasping preparation, grasping and compensatory movement) 0 = no movement observed 1 = movement observed II. Ordinal Data (movement of upper arm with fixation of forearm, di agonal shifting, and placing basket) 0 = no movement observed 1 = less than 30 of movement as compared with the previous limb position 2 = 30 movement < 60 3 = 60 movement < 90 Movement Component eye contactbasket handle initiative synergy UA m't with forearm (f) Upper arm abduction trunk side-bending trunk flexion/rotation grasping preparation grasping Non-standard grasping eye contactside table diagonal H/V shifting placing basket trunk extension/rotation trunk side-bending weight shiftingipsilateral weight shiftingcontralateral Essential-Movement Component Definition 1. Eye contact: eye contact with the targets (handles of basket or side tabletop) 2. Initiative synergy: forearm and upper arm simult aneously initiate the task in opposite directions 3. Movement of upper arm with fixation of forearm: forearm height in space is fixed while approaching the basket; amount of upper arm movement is graded 4. weight shifting: whole body shifts to the ipsilateral or contralateral side 5. Grasping preparation: hand opens bef ore grasping handles of basket 6. Grasping: fingers approximate each other after han d contacts with the handles of the basket from underneath the handles 7. Diagonal shifting: 1) release baske t from contact with front table, then transport basket to side table 2) this movement comprises two su b-components: horizontal shift and vertical shift 8. Placing basket: basket is brought to top of side table **Compensatory movement (shaded cells): 1) having extr a trunk or upper arm use, which assists or replaces prime movers or 2) not grasping the basket handles from underneath the handles Movement Rating Scale of Lifting Ba sket in Wolf Motor Function Test Date: ______________ Participant: ____________ Rater:

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59 CHAPTER 3 ASSESSING MOVEMENT QUALITY AFTER STROKE Introduction Hum an movements reflect an individuals pers onality, styles and cu lture. Movement is used to manipulate our external environment and an expression of self emotion.128 There is a natural quality to our movement. When movement capability is altered by a stroke, clients not only lose motor function, but also th eir natural quality of movement.42, 45, 105, 107 Rehabilitation therapists have always been concerned with attempting to recover movement quality. By applying various strategies, therapists aim to en able the recovery proc ess and facilitate the movement restoration. For example, neuromuscula r facilitation approaches were developed with treatment oriented to improving movement patterns toward normality of movement.13, 129 In this day of insurance driven medicine, the concern of cost containment often causes therapists to alter their expecta tions for clients to that of simply reaching task accomplishment goals within a limited pe riod of time, regardless of movement quality. Instead of focusing on true recovery and normal movement restoration, co mpensatory strategies have played a dominant role in current rehabilitation intervention. Quality of movement, nevertheless, does matter in our daily life.103 Dancers strive for a smooth and coordinated move. Athletes pursue perfect performance. So do people following a str oke. After our clients can perform certain representative functional activi ties, such as walking and reaching, improvement in quality of these movements becomes their next ultimate goa l. A movement with poor quality may impede their use of the affected extremities, especially in the public, and may further hamper social participation.104 Clinicians and researchers have develope d several instruments to measure movement quality after stroke, but their attempts often focus on general functional ability of specific

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60 affected body parts rather than quality of movement in a whol e-body view. Examples of these measurements include the Functional Activity Sc ale (FAS) in the Wolf Motor Function Test (WMFT),50, 102 the Quality of Movement Scale (QoM) in the Motor Activity Log,1 the Motor Evaluation Scale for Upper Extremity in Stroke Patients (MESUPES),106 and movement pattern analyses.13, 107 Ordinal motor function s cales, such as FAS and QoM, are used extensively in studies of stroke inte rvention effectiveness.54-58 Motor function scales are feasible and helpful for healthcare providers, but a st atistically significant change of averaged scores can merely indicate an incremental change along that scale72 and provide limited information about improvement in function and quality of movement. MESUPES is a scale of movement quality that encompasses eight arm function items with six rating categories and nine hand function items with three rating categories.106 The grading system does not have a uniform definition across the items. In addition, the composite scor e generated may simply indicate the level of assistance required while performing the tasks, rather than quality of the movement. Two examples of movement pattern analysis include Bobaths test for quality of movement patterns13 and Cirsteas biomechanical m ovement variable analysis.17, 42, 75, 107 The tasks used by Bobath mainly examine the ability of active selective control of the affected body parts and are not directly related to functional movement. As fo r Cirsteas biomechanical method, the derivatives from advanced calculations of biomechanical pa rameters can actually generate great confusion and difficulty for clinicians without providi ng sufficient direct information about the movement.130, 131 Developing a clinically feasible a nd reliable method to measure post-stroke movement quality, therefore, becomes necessary for advancing evaluation skills of clinicians to determine effectiveness of stroke interventions.

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61 Recently, Chiu has developed an evaluation te mplate, the Essential-Movement Component Evaluation (EMCE) form to m easure quality of movement.132 The development of EMCE was based on a combined application of the Generalized Motor Program (GMP) theory38, 85 and the Eshkol-Wachman Movement Notation (EWMN) method.90-92 The EMCE form had an excellent overall intra-rater [ICC(2,1)= .93; 95% CI= .88-.96; p< 0.001 ] and inter-rater reliability [ICC(2,1)= .95; 95% CI= .89-.98; p < 0.001].132 In addition, the EMCE form had a small standard error of measurement (SEM= .33) a nd minimally detectable change (MDC= .9).132 The high ICCs and subsequent low SEMs indicated that novice investigator s, even those without formal rehabilitation training, can reliably doc ument movement using the established ECME form and a short training and practice session. Evaluators with little training or knowledge of movement analysis can still relia bly use a well-established EMCE template to assess quality of movement in terms of movement components, sequence and strategy. The effectiveness, reliable, economical, and user-friendly features of EMCE have made its future use feasible in clinical and research settings. The objective of this research was to present a method of measuring movement quality a nd to explore if this method can distinguish problematic movement patterns obs erved in people with stroke. Method Participants Fifty participants were random ly selected from four CIMT studies that were conducted at the Department of Physical Therapy, University of Florida and the Brain Rehabilitation Research Center, Malcom Randall Veteran Affairs Medical Center, Gainesvi lle, Florida. Participant characteristics were presented, including age, gende r, side of stroke and time since stroke.(Table 3-1) Three groups were included in this experi ment: participants withou t stroke (normal group;

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62 n= 10), high-functioning participan ts with stroke (n= 20) and lo w-functioning participants with stroke (n= 20). The participants with stroke were divided into two groups using their upper-extremity Fugl-Meyer motor scores: high-functioning (s cores > 33) and low-functioning group (scores 33). The Fugl-Meyer Assessment110 (see Appendix C) is regarded as an objective and quantifiable assessment of motor impairment The Fugl-Meyer Assessment is also a standardized assessment to measure recovery after stroke. The upper-extremity Fugl-Meyer motor component (total score = 66 ) assesses the ability to move in /out of synergy, reflexes, wrist stability, grasping ability, and c oordination. In stroke rehabilit ation research, the Fugl-Meyer Assessment is frequently used as a pr imary outcome measure of impairment,74, 111 and has been shown to be predictive of dependency, f unctional level and recovery after stroke.58, 112-114 The inclusion criterion for the control gr oup was that they had no prior history of neurological disorders. All pa rticipants with stroke in this experiment met the following inclusion criteria: 1) the diagnosis of at least one stroke, but no t more than three strokes on the same side of the brain, 2) stroke at least three months prior to study par ticipation, 3) ability to follow simple instructions, 4) a score of 20 or higher on the Mini Mental-State Exam,115 5) the ability to sit independently wit hout back or arm support for two mi nutes, 6) the ability to stand with support of a straight cane, quad cane or he mi-walker for two minutes 7) the ability to actively participate for six hours of therapy without long rests or nap periods, 8) passive rangeof-motion of all upper-extremity motions of at le ast half the normal range, 9) traditional CIMT minimal motor criteria.1, 67, 116-118 Minimal motor criteria were defined as active movement of the wrist through at least 20 degrees of extens ion from a relaxed flexed position, and active

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63 movement of at least three finge rs (the thumb and two fingers) 20 degrees of extension at the metacarpal-phalangeal and proximal interphalangeal joints. Exclusion criteria for both stroke groups incl uded 1) any health problems that put the individual at significant risk of harm during the study, 2) any ot her neurological conditions such as multiple sclerosis or Parkinsons disease, 3) taking drugs for spasticity, 4) pain that is scored greater than 5/10 on the McGill Pain Scale119. Furthermore, the partic ipants were excluded if they could not independently reach the handle of the basket for the Lift Basket task of the WMFT in a standing position with or without sup port of a straight cane, quad cane or hemiwalker within two minutes. Procedure All data u sed in this experiment were retr ospectively retrieved fr om four previously completed studies. All participants signed a consent form that was pre-approved by the Institutional Review Board of Univ ersity of Florida for permission to be tested and to have their videotapes analyzed for movement control. The participants without stro ke were recruited from the local community and only received one test, the Wolf Motor Function Test (WMFT),1, 50, 64, 65, 101 which is a standardized evalua tion tool in traditional CIMT.1, 65 The participants with stroke first received a series of pre-te st evaluations that included the WMFT.1, 50, 64, 65, 101 The movement task selected for this study wa s the Lift Basket task of the WMFT. The WMFT is a standardized test and one of the primary outcomes in the CIMT studies.1, 50, 57, 58, 64, 67, 68, 74, 101 The WMFT consists of a series of 15 timed tasks and two st rength tasks that are performed in either a sitting or standing posit ion. The 15 tasks are arranged in order of biomechanical complexity according to the joints involved and the level of difficulty. The tasks progress from proximal to distal joint involvement and from gross to fine motor skills.50 A recent pilot study of Rasch measurement condu cted by Wen and Velozo (unpublished) in 2003,

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64 however, has shown a different order of task diffi culty. This indicates that Wolfs conceptual task complexity is not reflected in participants responses For example, the last task, Lift Basket, which was supposed to be the most difficult task of WMFT became the second difficult task. The WMFT quantifies upper-extremity movement ability through timed singleor multiple-joint motions and functional tasks.50 The last task in the WMFT, Lift Basket, is regarded as a complex task that demands efforts from multiple body systems, such as muscle strength, dynamic/standing balance, and inter-limb coordination. The Rasch pilot study of Wen and Velozo (unpublished) demonstrated the Lift Basket task to be the second most difficult task of the WMFT in terms of item difficulty analysis. As compared with a simple activity, such as reaching for an object on a table, Lift Basket is a representative activity with greater difficulty in our daily life. This task requires involvement from the whole body. Studyi ng this task, therefore, can show how one body part interacts with others du ring movement. Moreover, the Lif t Basket task is an out of synergy movement that can target the limitati ons people with stroke have when performing a reaching and lifting task.88 Lift Basket task. The set-up of the Lift Basket ta sk included a basket, a desk (29 high) located in front of the participant and a be dside table (44 high) located on the participants side to be tested. (see Figure 3-1A and 3-1B) The bedside table extende d along the width of the desk. The basket was placed on the desk and lined up with the center of the participants body. A three-pound weight was placed in the basket. Participants ar e tested in a standing position while facing the desk. The set-up of the Lift Ba sket task is illustrated with its starting position (Figure 3-1A) and ending position (Figure 3-1B). Th e task description was Patient attempts to pick up basket by grasping handle (from underneat h the handle) and placing the basket on far

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65 edge of the rolling bedside table. All participan ts were asked to Pick up the basket with your hand and place the basket on the rolling table. Th e far edge of the basket should go past the far edge of the bedside table. Try not to move your feet while you do this task. Do this as quickly as you can.102 The subjects movement progression wa s videotaped from a front view. Participants video tapes were then converted to DVD in digital format using a Panasonic DVD recorder (model DMR-E95HS) for further analyses of EWMN. In this study, the motion videos of the Lift Basket task of WMFT pre-test were randomly selected from the three groups. The fifty videos tape s were converted to DVD in digital format using a Panasonic DVD recorder (model DMR-E95H S) for further analyses of EWMN. In the laboratory, a physical therapist w ith three-year EWMN training experience played video clips frame-by-frame (30 frames/second) to grade participants movement using a Pioneer DVD player (model DVD-V7400). The EMCE form (see Appendix B) was used to analyze participants movement quality in terms of movement component, sequence, and strategy. The essential-movement components were first graded by whether a movement component was observed (0= No; 1= Yes). The range of es sential-movement component composite score is 0 to 10. Three essential-movement component s were further graded by how much range-ofmotion is observed (0= no movement observed; 1= 0 movement < 30; 2= 30 movement < 60; 3= 30 movement < 60). The three essential-movement components were upper-arm movement with forearm fixation, diagonal sh ifting of upper arm (including horizontal and vertical shifting), and forearm m ovement to place the basket. These essential components were chosen since their range-of-motion can be visual ly measured. The compensatory movement was graded by whether a compensatory movement is observed. (0= No; 1= Yes) The range of compensatory movement composite score is 0 to 5.

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66 Data Analysis One-way analysis of varian ce (ANOVA) was used to dete rmine if there were any statistically significant differe nces in essential-movement component composite scores, compensatory movement composite scores a nd movement magnitude of three essentialmovement components between three groups (nor mal, high-functioning and low-functioning). The significant level was set at .05. In a ddition, the Scheffe post-hoc multiple comparison analysis was used to determine pair-wise si gnificance. The prevalence for each essentialmovement component and compensatory movement was reported in percentage. Results The one-way ANOVA r esults are pr esented. (Table 3-2) All p values of the dependent variables were less than .001, including the essential-movement component total score, the compensatory movement total score, and the movement magnitude of the three essentialmovement components. Most of the Scheffe post-hoc multiple comparison analyses were statistically significant, excep t for upper-arm diagonal shifti ng (high-functioning vs. normal), total score of compensatory movement (highfunctioning vs. low-functioning), and upper-arm movement with forearm fixation (high-functioning vs. low-functioning). Percentages of observed movement component and compensato ry movement from the three groups were reported. (Table 3-3) The percentage of ever y essential-movement components observed from the three groups decreased as impairment leve l increased, except for the contralateral weight shifting which was the same for three groups. Pe rcentages of observed compensatory movement increased as impairment level increased. A sm all percentage of compensatory movement was noticed in the normal group as well.

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67 Discussion The results from the ANOVAs showed there were statistically significant differences between the means of the groups for total score of essential-movement components, the total score of compensatory movements, and the movement magnitude of the three essentialmovement components. In accordance with the hypothesis, the results suggested that the EMCE form for the Lift Basket task was able to eff ectively distinguish the di fferences between normal individuals and the two different stroke groups. As for the pos t-hoc analyses, no significant differences were found in the movement magnit ude of the upper-arm horizontal and vertical shifting between the high-functioning and norma l group. These non-significant results suggest that in the high-functioning stroke group the mo vement of the upper-arm was not significantly different during this lifting component than the normal group. No significant differences were noted, however, between the highand low-functioning group s in the total score of compensatory movements or in the magnitude of upper-arm movement with forearm fixation. Unlike the lifting component, dur ing the early phase of reaching (i.e. upper-arm movement with fixation) the high-functioning gr oup was not statistically differe nt than that of the lowfunctioning group. A possible expl anation can be that the highfunctioning stroke group adopted compensatory movement during reaching even when their function was improved. The compensatory movements observed included mo vement initiation with upper-arm abduction, trunk side-bending, and trunk forwar d rotation. Adopting these compensatory movements in the high-functioning stroke group can be an indication of the habitual movement strategy that followed the previous atypical synergy while th eir upper extremity function was still limited. The percentage of every essential-movement component in the two stroke groups was observed less as impairment level increased, exce pt for contralateral weight shifting which was the same for both the high and low functioning gr oups. People with stroke have the tendency to

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68 bear their weight on the less aff ected side, but have difficulty in shifting the weight to the affected side.44, 133 The inability to shift body weight from one side to another may cause decreased ability to engage in dynamic ac tivities, such as reaching or walking.134 The most impaired essential-movement components f ound in the low-functioning stroke group included initiative synergy (preparation for reaching), fo rearm fixation (aiming), grasp preparation (hand opening), grasp, eye contact to hi gh table (estimation for height of lifting), upper-arm diagonal shifting (upper-arm strength), and placing basket (el bow extension). The initiative synergy is an essential-movement component that acted as a preparatory step of reaching. Instead of moving the upper arm directly to the ta rget, the forearm and upper arm simultaneously initiated the task in opposite directions (i.e. a c ouple movement of shoulder exte nsion and elbow flexion on the sagittal plane). Then the forearm and upper arm move forward toward the basket handle. This short time delay caused by the in itiative synergy provides the forearm an opportunity to prepare its appropriate position for later reaching. Forearm fixation is an aiming movement that keeps the forearm in a fixed height until the hand reaches to the target. According to the GMP theory, actions controlled by the same GMP share the same invariant features, such as the sequencing of s ubmovements, relative timing and relative forces. Movements governed by the same GMP differ from each other in the assignment of variant movement parameters, for instance absolute time, absolute force, and selection of effectors.38, 85, 86 In line with the GMP theory, invariant subm ovements in a fixed movement sequence can be identified when different indivi duals execute the same activity. In this experiment, decreased use of essential-movement component with th e increase of compensatory movements was found as impairment level increased. These result s indicated that the motor programming may be altered in people with stroke. Having less esse ntial-movement components forced individuals

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69 with stroke to adopt more compensatory m ovements. Underutilized essential-movement components in stroke groups provide clinicians a useful direction of treatment. Instead of simply emphasizing repetition and speed, an effective training program may also focus on restoring underutilized essential-movement com ponents in a sequencing manner. Compensatory movements were found in all th ree groups, but the prevalence increased as impairment levels increased from normal, to high-functioning, to low-functioning. Possible reasons for the normal group adopting compensa tory movements were inaccurate basket placement, short body structure, or muscle weak ness. When these conditions exist, the upper arm and trunk may need to compensate for the disc repancy in the position of the basket. For the low-functioning stroke group, however, compensato ry movements were often substituted for essential-movement components, which may indicat e the inability to recr uit certain body parts17, 42, 45, 75, 89, 135, 136 or muscle weakness.8, 10, 11, 18, 19 Additionally, the prox imal body parts, which include upper arm and trunk, often dominated th e movement or incorrectly initiated the movement, for example, the movement was initiated by trunk side-bending or upper arm abduction. For the high-functioning group, whil e the essential-movement components were observed, compensatory movements still appeared, but functioned as assistance for the essentialmovement components. Whether compensatory movement is a necessary post-stroke adaptation, which should not be corrected remains controversial.137-139 Some recent studies, however, have shown that emphasis on training certain underutilized movement components during reaching, such as elbow and shoulder range-of-motion can significantly improve movement quality.107, 140 On the other hand, restraint of the trunk to prevent its compensatory contribution toward a reaching or pointing task, while training, can actua lly induce more upper extremity movement89, 135, 136, 141

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70 Trunk restraint allows patients with stroke to make use of arm joint ranges that are present but not normally recruited during unrestrained arm -reaching tasks. Thus, the underlying "normal" patterns of movement coordinati on may not be entirely lost af ter a stroke and underutilized essential-movement compone nt may be restorable.135 In order to improve quality of movement, therefore, restoration of underu sed essential-movement component and reduction or inhibition of compensatory movements may be two pr iority goals for treatment. Limitations. Improper experiment set-up for vide otaping was noticed during reviewing movement clips. Different locations where the ba sket was placed or diffe rent starting position of the task may induce unnecessary compensatory movements that were observed in normal individuals. The EMCE has shown to be a reliabl e research template to investigate quality of movement, but the generalization of the results from this expe riment can be limited due to specificity of task nature. Future development of EMCE for other repres entative activities of daily life is necessary to improve external validity. Conclusions The EMCE for m for the Lift Basket task was ab le to effectively distinguish the differences between normal individuals and the two different stroke groups. Stat istically significant differences in quality of movement were f ound between normal individuals and people with stroke. The percentage of e ssential-movement component observed from the two stroke groups decreased as impairment level increased. Compensatory movements were found in all three groups, but prevalence increased as impairmen t level increased from normal, to highfunctioning, to low-functioning. Underutilized movement components and dominance of compensatory movements can provide rehabili tation professional useful information on developing tailored therapeutic programs to restore disrupted movement patterns in the stroke population.

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71 Table 3-1. Demographic information of subjects Normal group High-functioning stroke group Low-functioning stroke group (n = 10) (n = 20) (n = 20) Range 23 79 28 82 37 84 Age (year) Mean SD 53.74 21.83 60.55 15.99 69.8 9.55 Gender (Male/Female) 3/7 13/7 12/8 Affected side (R/L) **** 11/9 8/12 Range **** 34 59 8 29 Upper Extremity Fugl-Myer scores (maximum: 66) Mean SD **** 45.05 7.69 24 5.0 Range 0.90 1.38 0.61 55.77 29.84 110.26 Averaged Wolf Motor Function Test time (second) Mean SD 1.11 0.16 15.48 16.16 76.83 20.97 Table 3-2. One-way ANOVA result s for total score of essential-movement component and compensatory movement, and movement ma gnitude of four movement components. ( = .05) ANOVA Scheffe post-hoc analysis F significance High vs. NormalHigh vs. Low Low vs. Normal Total Components 79.3 < 0.001* 0.001* < 0.001* < 0.001* Total Compensations 24.83 < 0.001* < 0.001* 0.08 < 0.001* Upper Arm Movement with fixation 22.19 < 0.001* < 0.001* 0.055 < 0.001* Upper Arm Horizontal Shifting 32.11 < 0.001* 0.088 < 0.001* < 0.001* Upper Arm Vertical Shifting 36.003 < 0.001* 0.177 < 0.001* < 0.001* Movement Magnitude Placing Basket 36.577 < 0.001* 0.001* < 0.001* < 0.001*

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72 Table 3-3. Percentage of observed essential-movement components and compensatory movements of Lift Basket task in contro l (normal), highand low-functioning stroke groups. Group ESSENTIAL MOVEMENT COMPONENTS Low High Normal eye contact to basket 90 100 100 initiative synergy 5 30 100 forearm fixation 5 35 100 grasp preparation 15 75 100 grasp 30 90 100 eye contact to table 35 95 100 upper arm diagonal shift 35 100 100 placing basket 5 60 100 weight shift ipsilateral 45 100 100 weight shift contralateral 100 100 100 total components 37 81 100 COMPENSATIONS trunk sidebending 85 75 20 trunk forward rotation 95 90 30 trunk backward rotation 80 80 10 non-standard grasping 61 10 0 upper arm abduction 70 55 10 total compensations 77 62 14

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73 Figure 3-1. Set-up for the Lift Basket task A. Starting position B. Ending position

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74 CHAPTER 4 EFFECTS OF CONSTRAINT-INDUCED M OVEMENT THERAPY ON QUALITY OF MOVEMENT POST-STROKE Introduction Constraint-Induced Movem ent Therapy (CIMT)1, 67, 68 has been a promising rehabilitation strategy during the past two decades. CIMT is mainly used in the post-stroke population The hypothesis of CIMT is that restraint of the less-affected upper-extremity will force the moreaffected extremity to overcome the phenomenon of learned nonuse.66, 67 Based on animal studies in which primates received surgical deafferentation of one upper-extremity, learned nonuse was defined as an adverse learning cycl e caused by unsuccessful motor attempts with the deafferented arm that resulted in pa in, failure or uncoordinated movements.1 The ultimate goals of CIMT are to break the adverse learne d nonuse cycle and to further improve functional use of the affected upper-extremity. While substantial research eviden ce supports benefits of CIMT,1, 67, 68, 71, 105, 114, 118, 142, 143 limited evidence is available regarding the unde rlying mechanisms that account for improved motor function.143 One of the most common reported outc omes is the Wolf Motor Function Test (WMFT).1, 50, 57, 67, 68, 102 Outcomes of WMFT have two parts: time to complete a task and score on an ordinal scale (Functional Ability Scale). Th e resultant data indicate changes in movement efficiency and use of affected extremity. This information, however, does not allow investigators to address direct changes in quality of movement. Is a fa ster movement a better movement? Do patients with stro ke recover their pre-stroke move ment after CIMT? Do patients with stroke adopt compensatory st rategies to perform tasks more efficiently after CIMT? In order to answer these questions, the au thor has developed th e Essential-Movement Component Evaluation (EMCE) form, a research temp late to evaluate quality of movement. The development of EMCE was based on a combined application of the Generalized Motor Program

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75 (GMP) theory38, 85 and the Eshkol-Wachman Move ment Notation (EWMN) method.90-92 EMCE can provide crucial information about compositio n of a movement (i.e. movement component, sequence and strategy) and infl uence of compensatory movement. In addition, EMCE was shown to have an excellent inte r-rater [ICC(2,1)= .95; 95% CI= .89-.98; p< 0.001] and intra-rater reliability [ICC(2,1)= .93; 95% CI= .88-.96; p< 0.001] according to our previous study.132 In addition, the EMCE form had a small standard error of measurement (SEM= .33) and minimally detectable change (MDC= .9).132 The high ICCs and subseque nt low SEMs indicated that novice investigators, even those without formal rehabilitation training, can reliably document movement using the established ECME form and a short training and practice session. Evaluators with little training or knowledge of movement analys is can still reliably use a wellestablished EMCE template to assess quality of movement in terms of movement components, sequence and strategy. The aims of this study we re 1) to determine the effects of CIMT on quality of movement measured by EMCE, and 2) to systematically categorize compensatory movement used in persons with stroke preand post-CIMT. Methods Participants Sixty participants were random ly selected from four CIMT studies that were conducted at the Department of Physical Therapy, University of Florida and the Brain Rehabilitation Research Center, Malcom Randall Vetera n Affairs Medical Center, Gain esville, Florida. Primary participant characteristics were presented, includi ng age, gender, side of stroke and time since stroke.(Table 4-1) Two groups of participan ts were included in this experiment: highfunctioning participants with stroke (n= 30), and low-functioning partic ipants with stroke (n= 30). The participants with stroke were divided into two groups using their upper-extremity Fugl-Meyer motor scores: high-functioning (s cores > 33) and low-functioning group (scores

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76 33). The Fugl-Meyer Assessment110 (see Appendix C) is regarded as an objective and quantifiable assessment of motor impairment The Fugl-Meyer Assessment is also a standardized assessment to measure recovery after stroke. The upper-extremity Fugl-Meyer motor component (total score = 66 ) assesses the ability to move in /out of synergy, reflexes, wrist stability, grasping ability and c oordination. In stroke rehabil itation research, the Fugl-Meyer Assessment is frequently used as a pr imary outcome measure of impairment,74, 111 and has been shown to be predictive of dependency, f unctional level and recovery after stroke.58, 112-114 All participants with stroke in this experiment met the following inclusion criteria: 1) the diagnosis of at least one stroke, but not more than three strokes on the same side of the brain, 2) stroke at least three months prior to study participation, 3) ability to follow simple instructions, 4) a score of 20 or higher on the Mini Mental-State Exam,115 5) the ability to sit independently without back or arm support for two minutes, 6) the ability to stand with support of a straight cane, quad cane or hemi-walker for two minutes, 7) the ability to actively participate for six hours of therapy without long rests or nap peri ods, 8) passive range-of-motion of all upperextremity motions of at least half the normal ra nge, 9) traditional CIMT minimal motor criteria.1, 67, 116-118 Minimal motor criteria were defined as ac tive movement of the wrist through at least 20 degrees of extension from a rela xed flexed position, and active move ment of at least three fingers (the thumb and two fingers) 20 degrees of extens ion at the metacarpal-phalangeal and proximal interphalangeal joints. Exclusion criteria for both stroke groups in clude 1) any health problems that put the individual at significant risk of harm during the study, 2) any ot her neurological conditions such as multiple sclerosis or Parkinsons disease, 3) taking drugs for spasticity, 4) pain that is scored greater than 5/10 on the McGill Pain Scale119. Furthermore, the partic ipants were excluded if

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77 they could not independently reach the handle of the basket for the Lift Basket task of the WMFT with or without support of a walking assi stive device within the two-minute time period. Procedure All data u sed in this experiment were retr ospectively retrieved fr om four previously completed studies. All participants signed a consent form that was pre-approved by the Institutional Review Board of University of Fl orida for permission to be videotaped and have their videotapes analyzed for movement control. The participants with stroke first received a series of pre-test evaluati ons that included the WMFT,1, 50, 64, 65, 101 which is a standardized evaluation in traditional CIMT.1, 65 After completing the pre-test evaluations, the pa rticipants with stroke received two weeks (ten consecutive weekdays) of CIMT. During the two-week inte rvention, the less-affected hand was immobilized in a padded mitt for 90% of the waking hours. The mitt was to be worn at all times except when performing a minimal amount of agreed upon activ ities (e.g. bathroom activities, naps, when the less-affected limb is us ed for an assistive device in walking, and other circumstances where safety may be compromise d). During the ten consecutive weekdays, the participants with stroke recei ved supervised task practice, using only their affected upperextremity for six hours a day. The tasks included items such as: meal preparation, eating, grooming, home maintenance, games and hobbies. The CIMT intervention emphasized substantial movement repetitions while performing functional activities of daily life. After the 2week treatment, the participants with stroke r eceived a series of posttest evaluations, which were the same as the pre-test evaluations. The movement task selected for this study wa s the Lift Basket task of the WMFT. The WMFT is a standardized test and one of the primary outcomes in the CIMT studies.1, 50, 57, 58, 64, 67, 68, 74, 101 The WMFT consists of a series of 15 timed tasks and two st rength tasks that are

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78 performed in either a sitting or standing posit ion. The 15 tasks are arranged in order of biomechanical complexity according to the joints involved and the level of difficulty. The tasks progress from proximal to distal joint involvement and from gross to fine motor skills.50 A recent pilot study of Rasch measurement condu cted by Wen and Velozo (unpublished) in 2003, however, has shown a different order of task diffi culty. This indicates that Wolfs conceptual task complexity is not reflected in participants responses For example, the last task, Lift Basket, which was supposed to be the most difficult task of WMFT became the second difficult task. The WMFT quantifies upper-extremity movement ability through timed singleor multiple-joint motions and functional tasks.50 The last task in the WMFT, Lift Basket, is regarded as a complex task that demands efforts from multiple body systems, such as muscle strength, dynamic/standing balance, and inter-limb coordination. The Rasch pilot study of Wen and Velozo (unpublished) demonstrated the Lift Basket task to be the second most difficult task of the WMFT in terms of item difficulty analysis. As compared with a simple activity, such as reaching for an object on a table, Lift Basket is a representative activity with greater difficulty in our daily life. This task requires involvement from the whole body. Studyi ng this task, therefore, can show how one body part interacts with others du ring movement. Moreover, the Lif t Basket task is an out of synergy movement that can target the limitati ons people with stroke have when performing a reaching and lifting task.88 Lift Basket task The set-up o f the Lift Basket task included a ba sket, a desk (29 high) located in front of the participant and a bedside tabl e (44 high) located on the part icipants side to be tested. (Figure 4-1A and 4-1B) The bedside table extend ed along the width of the desk. The basket was placed on the desk and lined up with the center of the participants body. A three-pound weight

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79 was placed in the basket. Participants were tested in a standing position while facing the desk. The set-up of the Lift Basket task is illustra ted with its starting position (Figure 4-1A) and ending position (Figure 4-1B). The task descripti on was Patient attempts to pick up basket by grasping handle (from underneath the handle) and placing the basket on far edge of the rolling bedside table. All participants were asked to Pick up the bask et with your hand and place the basket on the rolling table. The far edge of the basket should go past the far edge of the bedside table. Try not to move your feet while you do this task. Do this as quickly as you can.102 The subjects movement progression wa s videotaped from a front view. Participants video tapes were then converted to DVD in digital form at using a Panasonic DVD recorder (model DMRE95HS) for further analyses of the Eshkol -Wachman Movement Notation (EWMN). EWMN9092 is a movement language developed in Isr ael by professors Noa Eshkol and Avraham Wachman. In the literature of human and animal behavior, EWMN has been shown to effectively describe various aspects of moveme nt, such as time, speed, direction, magnitude, limb position, inter-limb spatial relations/c oordination, sequence and trajectory.93-97 Essential-Movement Comp onent Evaluation form The Essential-Movem ent Component Evaluati on (EMCE) Form (see Figure 4-2) was used to evaluate and document participants movement quality. The EMCE form of EWMN encompasses ten sequencing movement components identified from particip ants without stroke, and compensatory trunk movements identified fr om the participants with stroke. The ten essential-movement components of Lift Basket ta sk include 1) eye contact with basket handles, 2) initiative synergy: coupled but opposite movements of the arm and forearm, 3) forearm fixation: maintaining constant height of forear m in space while arm moves toward the basket, 4) contralateral weight shifting, 5) ha nd preparation for grasping, 6) gr asping, 7) shift of eye contact to side tabletop, 8) diagonal sh ift of upper arm, 9) ipsilate ral weight shifting, 10) forearm

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80 movement of placing the basket. The compensatory movements include 1) upper-arm abduction, 2) trunk side-bending, 3) trunk forward rotation, 4) trunk backward rotation, and 5) non-standard grasping. The detailed definition of the ten essential-movement components and compensatory movement can be found in Appendix A or the EMCE form (Figure 4-2). In this experiment, the one hundred and twen ty video clips were converted to DVD in digital format using a Panas onic DVD recorder (model DMR-E95HS) for further analyses of EWMN. In the laborato ry, a physical therapist with thr ee-year EWMN training experience played video clips frame-by-frame (30 frames/sec ond) to grade participants movement using a Pioneer DVD player (model DVD-V7400). The EM CE form based on EWMN was used to analyze participants movement quality in te rms of movement component, sequence, and strategy.132 The essential-movement components are fi rst graded by whether a movement component is observed (0= No; 1= Yes). The range of esse ntial-movement component composite score is 0 to 10. Three essential-movement components ar e further graded by how much range-of-motion is observed (0= no movement observed; 1= 0 movement < 30; 2= 30 movement < 60; 3= 30 movement < 60). The three essential-mo vement components are upper-arm movement with forearm fixation, diagonal shifting of upper arm (including horizontal and vertical shifting), and forearm movement to place the basket. Th e compensatory movement is graded by whether a compensatory movement is observed. (0= No; 1= Yes) The range of compensatory movement composite score is 0 to 5. Data Analysis A two-group (high-functioning and low-functi oning stroke groups) x two-tim e (pre-CIMT and post-CIMT) analysis of variance (ANOVA) with repeated measures were conducted to analyze the six dependent variab les in this study. The depend ent variables included essential-

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81 movement component composite scores and co mpensatory movement composite scores, and movement magnitude of the four movement compone nts. The significant le vel was set at .05. In addition, the use of t-test was to determine pai r-wise significance when the interaction (group x time) was statistically significant. The prevalence of each essential-movement component and compensatory movement was also reported in percentage. Results Results of the 2(group) x 2 (t esting tim es) ANOVAs with repeated measures conducted in this experiment are presented (T able 4-2). Statistically significant differences existed between pre-CIMT and post-CIMT in upper-arm move ment with forearm fixation and upper-arm horizontal shifting. Between the two stroke gro ups, statistically significant differences were found in compensatory composite scores and al l four movement magnitude variables. Results revealed a statistical ly significant group (high-func tioning, low-functioning) x time (pre-CIMT, post-CIMT) interaction for essen tial-movement component composite scores (F(1, 58) = 7.05, p < 0.01). Fig 4-3 was the interaction plot of two groups mean composite scores of essential-movement component. Specifically, es sential-movement component composite scores increased in the low functioning group fr om pre-CIMT to post-CIMT (t = -3.47, p < 0.01), but not in the high-functioning group (t = 0.28, p = 0.78). A statistically significant group effect was found, indicating the low-functi oning group adopted more compen satory movements than the high-functioning group. (F(1, 58) = 5.84, p < 0.05) Percentages of obs erved movement component and compensatory movement from the three gr oups were reported. (Table 4-3) For the percentage of compensatory movement, al though both groups showed increased use of compensatory movement after CIMT, the change s were not statistically significant.

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82 Discussion CIMT leads to im provement in upper-e xtremity motor f unction post-stroke.1, 67, 68, 71, 105, 114, 118, 142, 143 The underlying movement strategies th at account for the functional improvement from CIMT remain unknown.143 In a recent article, Wolf de fined clinically meaningful improvements of CIMT as a reduction in the num bers of the 15 timed WMFT tasks that could not be completed.109 His inference may be appropriate in terms of movement efficiency, but there was no indication how the individuals with stroke altered their movement quality. The Essential-Movement Component Evaluation (EMC E) is a reliable, effective and economical method to examine quality of movement in terms of movement components, sequence, and strategy.132 The goal of this experiment was to us e the EMCE method to study the effects of CIMT on the movement quality of a reaching-graspi ng-lifting-placing task (i.e. Lift Basket) in WMFT. Essential-Movement Component The statistically significant interaction betw een tim e and group for the essential-movement component composite scores indicates the impa ct of treatment depended on the groups. The interpretation of the main effects (group or time) was incomplete and misleading. Treatment effects of CIMT on the essential-movement comp onent, therefore, depended on the severity or level of the impairment. Post hoc analyses indicated that the composite scores were significantly increased after CIMT in the low-functioning group, but not in the high-functioning group. CIMT seemed to have more effect on re storing essential-movement components in the low-functioning group than in the high-functioni ng group. A possible explanation may be that the low-functioning group had fewer moveme nt components pre-CIMT than the highfunctioning group. In the low-functioning group six out of the ten essential-movement components were lower than 50 percent on the pr e-test. These underutili zed components in the

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83 low-functioning group included initiative syne rgy, forearm fixation, grasping preparation, grasping, upper-arm diagonal shif ting, and placing basket. The high-functioning group did not show statistically significant change in the esse ntial-movement component total score after the intervention. On the prevalen ce table (Table 4-3), two underutilized components were found: initiative synergy and forearm fixation. Re garding movement magnitude, two components (upper-arm movement forearm fixation and upper-arm horizontal shifting) showed statistically significant treatment effects. Those treatment effects indicate d that CIMT promoted range-ofmotion of shoulder flexion a nd horizontal abduction. The initiative synergy is an essential-movement component that acted as a preparatory step of reaching. Instead of moving the upper arm directly to the ta rget, the forearm and upper arm simultaneously initiate the task in opposite di rections (i.e. a couple movement of shoulder extension and elbow flexion on the sagittal pl ane). Then the forearm and upper arm move forward toward the basket handle. This shor t time delay caused by the initiative synergy provides the forearm an opportuni ty to prepare its appropriate position for later reaching. Forearm fixation is a subsequent aiming movement that keeps the forearm in a fixed height until the hand reaches to the target. Without this aiming movement, the process of reaching requires more adjustments and the movement becomes un smooth and segmental. Grasping preparation is a crucial component to have a successful grasp. An inappr opriate hand opening can impede formation of a secure grasp.45, 77, 144 Upper-arm diagonal shif ting (shoulder flexion and abduction) and placing basket (elbow extension) are two out of synergy movements. According to Brunnstrom, these movements are of ten difficult to regain for people post-stroke.12 Except for forearm fixation showing decreased use, after receiving CIMT, most of the underutilized components in the lo w-functioning group increased or maintained their pre-CIMT

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84 use,. In addition to forearm fixation, the hi gh-functioning group had more declining components than the low-functioning group, in cluding grasping preparation a nd grasping. The allowance of compensatory movement during CIMT training ma y have lead to the decline in essentialmovement components. The limitations in movement control may be different for highand low functioning groups. Forced use of the affected extremity possibly encouraged and elicited the exploration of underutilized e ssential-movement components in the low-functioning group. When having more pre-existing essential-move ment components, the same training, however, may encourage the use of compensatory movement in the high-functioning group in order to meet the speed command of the task. Compensatory Movement There was n o statistically significant treatmen t effect on the total compensatory movement score, indicating CIMT did not increase the us e of compensatory movements. A possible explanation was that increased use of certain compensatory movements was offset by decreased use of others, such as trunk side-bending and no n-standard grasping. In addition, a statistically significant group effect was found, indicati ng the low-functioning group adopted more compensatory movements than the high-functioning group. (F(1, 58) = 5.84, p < 0.05) Most of the compensatory movements were frequently observed in both groups preand post-CIMT. Initiative synergy was often substituted by the trunk side-bending to the contralateral side along with s houlder abduction. Instead of moving the upper arm forward with forearm fixation, the elbow joint was locked at 90 degree of flexion during the whole reaching part of the task. In order to reach for the basket, therefore, the trunk had to forward rotate so that the hand could perform the subsequent gras ping movement. Two non-standard grasping compensatory movements were observed: wrist a nd reversed maneuvers. In the wrist maneuver the hand went under and passed the basket handle, and then the wrist lifted the basket. The

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85 reversed maneuver was that the hand grasped the basket handle with th e thumb pointing toward the individual. The compensatory grasping mane uvers appeared to occur for individuals who could not perform grasping preparation (hand opening) and forearm supination. When the upper arm shifted diagonally to lift the basket, trunk ba ckward rotation often assisted the lifting. Elbow extension was necessary for placing the bask et onto the high table. Ipsilateral weight shifting, however, took the place of elbow movement, and the elbow often remained at 90 degree of flexion. Generally speaking, the low-func tioning group often substituted compensatory movements for the essential-movement components, which may indicate the inability to recruit certain body parts17, 42, 45, 75, 89, 135, 136 or muscle weakness.8, 10, 11, 18, 19 Additionally, the proximal body parts, which include the upper arm and trunk, often dominated the movement or incorrectly initiated the movement. Alt hough the high-functioning group used the essential-movement components, compensatory movements still appear ed, but functioned as assistance. A table is presented to summarize the aforementioned compensatory movements. (Table 4-4) CIMT is a rehabilitative approach based on the task -oriented model.25, 109 The task-oriented model assumes that control of movement is organized around goal-directed, functional behaviors rather than on musc les or movement patterns.145 The task-oriented model also encourages the individual to actively pa rticipate in solving motor challenges.146 In rehabilitation, practicing a motor task or activit y should be functionally based and practiced in a variety of contexts. Thus, the patient can develo p and implement the strategies learned for future tasks after discharge from therapy. The two training modes of CIMT are repetitive task practice and adaptive task practice.109 Repetitive task practice em phasizes continuous attempts to execute movements of a repeated nature, such as dusting, eating, or combing. The practice is designed to enhance problem-solving skills. Adaptiv e task practice uses the principles of operant

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86 or instrumental conditioning to repeatedly perfor m a defined task in a se ries of trials. During each trial, the task has a defined duration. The goal of adaptive task practice is either to increase the successful repetitions or to use less time to complete the ta sk. From the standpoint of the task-oriented model, both practice modes imply th at compensatory movement is acceptable and should be encouraged if function is improved.137, 147 The allowance of compensatory movement during CIMT training may be based on some controversial assumptions: 1) movement impairment is not reversible; 2) improvement on goal-directed functional tasks is more meaningful to patients recovery than improveme nt on movement quality; or 3) faster movement or more completions indicates bett er motor control or coordination. Recent studies suggest that impaired moveme nt components may be reversible and not normally just recruited post-stroke.89, 135, 136, 141 Trunk restraint to pr event its compensatory contribution toward a reaching or pointing task while training can induce more upper extremity movement. For instance, Mich aelsen, Dannenbaum and Levin, re ported that for the control group (no trunk restraint) afte r one-month of arm training, trunk compensatory movement increased, but for the experimental group d ecreased trunk movement and increased elbow extension were found.135 Trunk restraint allowed patients with stroke to make use of arm joint ranges that were present but not normally recrui ted during unrestrained arm-reaching tasks. Thus, the underlying "normal" patterns of movement coordination may not be entirely lost after stroke.135 Changing movement pattern, including rest oration of essential-movement component and inhibition of compensatory movement can be beneficial to improve quality of movement.138, 139 Whether functional recovery is simply goal attainment, or improved movement control while accomplishing the goal, still remains debatable.146 Task-oriented intervention, such as

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87 CIMT, focuses on task completion as fast or as many times as possi ble, without consideration of compensatory movements. Moving faster with gr eater numbers of repetitions appears to indicate improved function in the laborat ory, but when individuals retu rn to the community, the less coordinated or awkward movement may adversely a ffect self image, especially in the public. Allowance of compensatory movement can be detrim ental to the recovery process. For example, if a client with stroke can not walk, and they choose to use a powered wheelchair in order to compensate the impaired function and to attain th e goal of independent mobility. The ability of walking would never be restored. Quality of movement does matte r in our daily life.107, 140 After our clients can perform certain re presentative functional activities, such as walking and reaching, improvement in quality of these movements becomes their next ultimate goal. In this study, movement quality is defi ned as movement that approximates normal movement. Normal movement is that observed in people without disorders that affect movement execution.82, 83 In addition, normal movement encompasses movement components that are required for executing a movement (i.e. essentia l-movement component) in a sequencing manner without using compensatory movement. EMCE method can effectively pinpoint the missing essential-movement components and compensato ry movement. The beneficial information gathered from the EMCE form can assist clinic ians to design appropria te and tailored training programs for their clients if movement quality is a treatment goal. The goals of CIMT training can then be further clarified to improve the esse ntial-movement components, re-establishment of normal movement sequence, and preventi on of compensatory movement. Limitation Evaluation o f the Lift Basket task was unde r the condition that te sted participants maximal capacity. The participants were asked to execute the task as quickly as possible. Adoption of compensatory movement under this situation, however, may not indicate this

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88 strategy will be seen when participants performs the task at a self-paced comfortable speed. For future study, investigation of compensatory movement while pe rforming at a self-paced speed may be necessary. Conclusions A statistically significant interaction between time and group for essential-m ovement component composite scores was found, indicati ng treatment effects of CIMT on essentialmovement component depended on the severity le vel of impairment. The composite scores significantly increased only in the low-functioning group, but no significant changes were found in the high-functioning group. Although there was no statistically significan t treatment effect on compensatory movement scores, increased use of compensatory movement was found in both groups. In order to improve movement qual ity post-stroke, the goals of CIMT training, therefore, need to be expanded to increase the function of underused essential-movement components, re-establish normal movement sequences, and prevent compensatory movements.

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89 Table 4-1. Demographic information of participants High-functioning stroke group Lo w-functioning stroke group (n = 30) (n = 30) Mean SD 64 14.83 69.48 10.62 Age (year) Range 32 89 37 86 Gender (Male/Female) 18/12 22/8 Affected side (R/L) 17/13 12/18 Pre-CIMT [meanSD (range)] 46.6 7.54 (35-61) 26.2 5.82 (8-33) Upper Extremity Fugl-Myer scores (maximum: 66) Post-CIMT [meanSD (range)] 49.03 8.39 (33-63) 30.6 7.91 (10-47) Pre-CIMT [meanSD (range)] 16.38 18.88 (0.61-69.49) 65.99 26.39 (5.12-110.26) Averaged Wolf Motor Function Test time (second) Post-CIMT [meanSD (range)] 11.85 13.21 (0.66-42.42) 54.67 31.16 (2.99-110.01) Table 4-2. Repeated measure ANOVA results for composite scores of essential-movement component and compensatory movement and movement magnitude of three movement components. ( = .05) Parameters Time Group Time x Group Pillai's Trace F p -value F p -value F p -value Total Components 5.11 < 0.05* 40.88 < 0.001* 7.05 < 0.01* Total Compensations 2.61 0.11 5.84 < 0.05* 0.29 0.59 Upper Arm Movement with fixation8.42 < 0.01* 17.44 < 0.001* 3.74 0.06 Upper Arm Horizontal Shifting 7.8 < 0.01* 29.04 < 0.001* < 0.001 1 Upper Arm Vertical Shifting 1.08 0.3 24.77 < 0.001* 1.91 0.17 Movement Magnitude Placing Basket 1.12 0.29 26.85 < 0.001* 0.01 0.91

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90 Table 4-3. Percentage of observed essentia l-movement components and compensatory movements of Lift Basket task in hi ghand low-functioning stroke groups. Group Low-functioning High-functioning ESSENTIAL MOVEMENT COMPONENTS Pre-CIMT Post-CIMT Pre-CIMT Post-CIMT eye contact to basket 93 100 100 100 initiative synergy 7 13 30 37 forearm fixation 13 0 33 23 grasp preparation 20 20 73 63 grasp 40 67 90 73 eye contact to table 50 73 97 97 upper arm diagonal shift 47 70 97 97 placing basket 13 13 57 77 weight shift ipsilateral 50 60 93 97 weight shift contralateral 100 100 100 100 total components 43 52 77 76 COMPENSATIONS trunk sidebending 87 83 73 67 trunk forward rotation 93 97 93 87 trunk backward rotation 77 97 77 87 non-standard grasping 50 33 10 27 upper arm elevation 67 77 47 60 total compensations 75 77 60 65 Table 4-4. Corresponding compensatory movement of the Lift Basket task observed in individuals with stroke. Stages Movement Component Compensatory Movement Trunk side-bending Initiative synergy Shoulder abduction Elbow locked at 90 flexion Reaching Upper arm movement with forearm fixation Trunk forward rotation Grasping Grasping Wrist or reversed maneuver Lifting Upper arm diagonal shifti ng Trunk backward rotation Placing Placing basket Ipsilate ral weight shifting

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91 Figure 4-1. Starting and ending positions of the Lift Basket task A. Starting position B. Ending position

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92 Figure 4-2. Essential-Movement Component Evaluation Form Movement Rating Scale of Lifting Ba sket in Wolf Motor Function Test Date: ______________ Participant: ____________ R ate r : Movement Component eye contactbasket handle initiative synergy UA m't with forearm (f) Upper arm abduction trunk side-bending trunk flexion/rotation grasping preparation grasping Non-standard grasping eye contactside table diagonal H/V shifting placing basket trunk extension/rotation trunk side-bending weight shiftingipsilateral weight shiftingcontralateral Essential-Movement Component Definition 1. Eye contact: eye contact with the tar gets (handles of basket or side tabletop) 2. Initiative synergy: forearm and upper arm simult aneously initiate the task in opposite directions 3. Movement of upper arm with fixation of forearm: forearm height in space is fixed while approaching the basket; amount of upper arm movement is graded 4. Weight shifting: whole body shifts to the ipsilateral or contralateral side 5. Grasping preparation: hand opens bef ore grasping handles of basket 6. Grasping: fingers approximate each other after han d contacts with the handles of the basket from underneath the handles 7. Diagonal shifting: 1) release baske t from contact with front table, then transport basket to side table 2) this move ment comprises two sub-components: hor izontal shift and vertical shift 8. Placing basket: basket is brought to top of side table **Compensatory movement (shaded cells): 1) having extr a trunk or upper arm use, which assists or replaces prime movers or 2) not grasping the basket handles from underneath the handles Movement Grading I. Nominal Data (eye contact, initiative synergy, weight shifting, grasping preparation, grasping and compensatory movement) 0 = no movement observed 1 = movement observed II. Ordinal Data (movement of upper arm with fixation of forearm, di agonal shifting, and placing basket) 0 = no movement observed 1 = less than 30 of movement as compared with the previous limb position 2 = 30 movement < 60 3 = 60 movement < 90

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93 Essential Movement Component Composit Scores 0 2 4 6 8 10 Pre-CIMTPost-CIMTmean scores High-functioning Low-functionin g Figure 4-3. Mean composite scores of essentia l-movement component for high-functioning and low-functioning stroke groups be fore and after receiving CIMT.

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94 CHAPTER 5 GENERAL SUMMARY AND CONCLUSIONS Specific and detailed discussions have been prov ided in the p revious chapters regarding the three studies using the Essential-Movement Co mponent Evaluation (EMCE) form to examine quality of movement for CIMT intervention and stroke rehabi litation. The purpose of this chapter is to summarize and integrate th e major findings for each experiment. Overview Scientists and clinicians have developed num erous methods to measure movement impairment following stroke. Quality of moveme nt, however, has not been objectively measured in clinical or research settings. The Functiona l Ability Scale (FAS; see Table 2-1) is a measure of movement quality currently used in Constr aint-Induced Movement Th erapy research, but its outcomes provide limited information about func tional improvement and quality of movement.72 Three experiments were included in this disser tation. The first experi ment (Chapter 2) was to develop a clinically feasible template, EMCE to measure quality of movement post-stroke based on a combined application of the Generalized Motor Program (GMP) theory38, 85 and the Eshkol-Wachman Movement Notation (EWMN) method.90-92 In addition, th e interand intrarater reliability of the EMCE fo rm were established. The second e xperiment (Chapter 3) was to present a method of measuring movement quality (i .e. EMCE) and to explore if this method can distinguish problematic movement patterns observed in people with stroke. Finally, the third experiment (Chapter 4) was to use the EMCE to investigate the effect of CIMT on movement quality in terms of essential-movement components, sequence and strategy. Experiment I Summary The goals of this study were to develop a qua lity of m ovement evaluation form and to further determine the interand intra-rater reliab ility of this evaluation form. Using the EWMN

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95 method, ten movement components and five compensatory movements were identified and included on the EMCE form for the Lift Basket task of WMFT. The ten essential-movement components of the task include 1) eye contact with basket handles, 2) in itiative synergy: coupled but opposite movements of the arm and forearm (i.e. simultaneous shoulder extension and elbow flexion on the sagittal plane), 3) upper-arm movement with fo rearm fixation: maintaining constant height of the forearm in space while the upper arm moves forward toward the basket, 4) contralateral weight shifting, 5) grasping preparation: opening th e hand, 6) grasping, 7) shift of eye contact to the high tabletop, 8) diagonal shift of upper arm (i.e shoulder flexion and abduction), 9) ipsilateral weight shifting, 10) placing the basket (i.e. elbow extension). The compensatory movements include 1) upper-a rm abduction, 2) trunk side-bending, 3) trunk forward rotation, 4) trunk backward rota tion, and 5) non-standard grasping. The results of this study indica ted that the movement components of the Lift Basket task analyzed can be assessed reliably with a minimal degree of error. The ICCs for intraand interrater reliability were excellent (.89-.97 and .90-.95, re spectively), suggesting excellent agreement both within and between raters. The SEM for inter-rater reliability was 0.52 and intra-rater reliability ranged from 0.15 to 0.47. This repr esented an error of measurement ranging from 0.15 to 0.52. A smaller SEM relates to higher reliability of the test and therefore, more precision in the measure. The high ICCs and subsequent low SEMs demo nstrate that novice investigators, even those without formal rehabilitation or moveme nt training, can reliably document movement using the established ECME form and a short training and practice session. The SEM represents the standard deviation of measurem ent errors and reflects the extent of expected error in repeated measurements or different raters scores.120, 121 SEM is directly related to the reliability of a test.

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96 The larger the SEM, the lower the reliability of the test and the less precision there is in the measures taken and scores obtained. The MDC re flects the smallest detectable difference that can be considered actual chang e that exceeds measurement error. The MDC for the total score of the essential-movement components was 0.90; this means a participant must exceed a change of .90 in the essential-movement component total score to identify the change as true and not due to measurement error. Therefore, if a person sc ores a 4 on the pre-test and a 5 on the post-test, we can be sure the change is real and not due to measurement error. While most of the 10 component movements dem onstrated excellent in tra-reliability, an analysis of individual items de monstrated that the fixation item (upper-arm movement with forearm fixation), had a lower I CC value (.72), although still good.98-100 The recognition of compensatory movement patterns, such as using fo rward trunk rotation to co mpensate for lack of upper-arm and forearm movement, may be a skill that requires more advanced training. Physical and occupational therapists should have the skills to identify these compensatory movements. The PT (Rater 1) and OT (Rater 2) participated in the reliability study had higher overall ICCs (.91 and .97) than the non-rehabilitation pr ofessional (Rater 3) (.89), although the nonprofessional still had an overall ex cellent ICC. This trend held tr ue for the total ICCs and SEMs. These results suggest EMCE is an effective measur e with excellent rater reliability. Evaluators with little training or knowledge of movement analysis can stil l reliably use a well-established EMCE template to assess quality of movement. Experiment II Summary The goal of this study was to apply the EMCE form to a larger sample to examine the differences between people with and without stro ke in terms of quality of movement. The results from the ANOVAs showed there were statistically significant differences between the means of the groups for total score of essential-movement components, the total score of compensatory

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97 movements, and the movement magnitude of th e three essential-movement components. In accordance with the hypothesis, the results suggest ed that the EMCE form for the Lift Basket task was able to effectively distinguish the differences between normal individuals and the two different stroke groups. As for the post-hoc an alyses, no significant differences were found in the movement magnitude of the upper-arm horiz ontal and vertical sh ifting between the highfunctioning and normal group. Thes e non-significant results suggest that in the high-functioning stroke group the movement of the upper-arm wa s not significantly diffe rent during this lifting component than the normal group. No significant differences were noted, however, between the highand low-functioning groups in the total score of compensatory movements or in the magnitude of upper-arm movement with forearm fixation. Unlike the lifting component, during the early phase of reaching (i .e. upper-arm movement with fixation) the high-functioning group was not statistically different th an that of the low-functioning group. A possible explanation can be that the high-functioning stroke group adopted compensatory movement during reaching even when their function was improved. The compensa tory movements observed included movement initiation with upper-arm abduction, trunk side-b ending, and trunk forward rotation. Adopting these compensatory movements in the high-functioning stroke group can be an indication of the habitual movement strategy that followed the previous atypical synergy while their upper extremity function was still limited. The percentage of every essential-movement component in the two stroke groups was observed less as impairment level increased, exce pt for contralateral weight shifting which was the same for both the high and low functioning gr oups. People with stroke have the tendency to bear their weight on the less aff ected side, but have difficulty in shifting the weight to the affected side.44, 133 The inability to shift body weight from one side to another may cause

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98 decreased ability to engage in dynamic ac tivities, such as reaching or walking.134 The most impaired essential-movement components f ound in the low-functioning stroke group included initiative synergy (preparation for reaching), fo rearm fixation (aiming), grasp preparation (hand opening), grasp, eye contact to hi gh table (estimation for height of lifting), upper-arm diagonal shifting (upper-arm strength), and placing basket (el bow extension). The initiative synergy is an essential-movement component that acted as a preparatory step of reaching. Instead of moving the upper arm directly to the ta rget, the forearm and upper arm simultaneously initiated the task in opposite directions (i.e. a c ouple movement of shoulder exte nsion and elbow flexion on the sagittal plane). Then the forearm and upper arm move forward toward the basket handle. This short time delay caused by the in itiative synergy provides the forearm an opportunity to prepare its appropriate position for later reaching. Forearm fixation is an aiming movement that keeps the forearm in a fixed height until the hand reaches to the target. According to the GMP theory, actions controlled by the same GMP share the same invariant features, such as the sequencing of s ubmovements, relative timing and relative forces. Movements governed by the same GMP differ from each other in the assignment of variant movement parameters, for instance absolute time, absolute force, and selection of effectors.38, 85, 86 In line with the GMP theory, invariant subm ovements in a fixed movement sequence can be identified when different indivi duals execute the same activity. In this experiment, decreased use of essential-movement component with th e increase of compensatory movements was found as impairment level increased. These result s indicated that the motor programming may be altered in people with stroke. Having less esse ntial-movement components forced individuals with stroke to adopt more compensatory m ovements. Underutilized essential-movement components in stroke groups provide clinicians a useful direction of treatment. Instead of simply

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99 emphasizing repetition and speed, an effective training program may also focus on restoring underutilized essential-movement com ponents in a sequencing manner. Compensatory movements were found in all th ree groups, but the prevalence increased as impairment levels increased from normal, to high-functioning, to low-functioning. Possible reasons for the normal group adopting compensa tory movements were inaccurate basket placement, short body structure, or muscle weak ness. When these conditions exist, the upper arm and trunk may need to compensate for the disc repancy in the position of the basket. For the low-functioning stroke group, however, compensato ry movements were often substituted for essential-movement components, which may indicat e the inability to recr uit certain body parts17, 42, 45, 75, 89, 135, 136 or muscle weakness.8, 10, 11, 18, 19 Additionally, the prox imal body parts, which include upper arm and trunk, often dominated th e movement or incorrectly initiated the movement, for example, the movement was initiated by trunk side-bending or upper arm abduction. For the high-functioning group, whil e the essential-movement components were observed, compensatory movements still appeared, but functioned as assistance for the essentialmovement components. Whether compensatory movement is a necessary post-stroke adaptation, which should not be corrected remains controversial.137-139 Some recent studies, however, have shown that emphasis on training certain underutilized movement components during reaching, such as elbow and shoulder range-of-motion can significantly improve movement quality.107, 140 On the other hand, restraint of the trunk to prevent its compensatory contribution toward a reaching or pointing task, while training, can actua lly induce more upper extremity movement89, 135, 136, 141 Trunk restraint allows patients with stroke to make use of arm joint ranges that are present but not normally recruited during unrestrained arm -reaching tasks. Thus, the underlying "normal"

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100 patterns of movement coordinati on may not be entirely lost af ter a stroke and underutilized essential-movement compone nt may be restorable.135 In order to improve quality of movement, therefore, restoration of underu sed essential-movement component and reduction or inhibition of compensatory movements may be two pr iority goals for treatment. Experiment III Summary The goals of the third experim ent were to determine the effects of CIMT on quality of movement as measured by EMCE, and to system atically categorize compensatory movements used by persons with stroke preand post-CIMT. The results reve aled a statistically significant interaction between time and group for the esse ntial-movement component composite scores indicates the impact of treatment depended on the groups. The interpretation of the main effects (group or time) was incomplete and misleading. Treatment effects of CIMT on the essentialmovement component, therefore, depended on the severity or level of the impairment. Post hoc analyses indicated that the composite scores were significantly increased after CIMT in the lowfunctioning group, but not in the high-functioning group. CIMT seemed to have more effect on restoring essential-movement components in the low-functioning group than in the highfunctioning group. A possible e xplanation may be that the low-functioning group had fewer movement components pre-CIMT than the high-f unctioning group. In the low-functioning group six out of the ten essential-movement components were lower than 50 percent on the pre-test. These underutilized components in the low-f unctioning group included initiative synergy, forearm fixation, grasping preparation, gras ping, upper-arm diagonal shifting, and placing basket. The high-functioning group did not show statistically signi ficant change in the essentialmovement component total score af ter the intervention. On the prev alence table (Table 4-3), two underutilized components were found: initiative synergy and forearm fixation. Regarding movement magnitude, two components (upper-arm movement forearm fixation and upper-arm

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101 horizontal shifting) showed statistically significa nt treatment effects. Those treatment effects indicated that CIMT promoted range-of-motion of shoulder flexion and horizontal abduction. The initiative synergy is an essential-movement component that acted as a preparatory step of reaching. Instead of moving the upper arm directly to the ta rget, the forearm and upper arm simultaneously initiate the task in opposite di rections (i.e. a couple movement of shoulder extension and elbow flexion on the sagittal pl ane). Then the forearm and upper arm move forward toward the basket handle. This shor t time delay caused by the initiative synergy provides the forearm an opportuni ty to prepare its appropriate position for later reaching. Forearm fixation is a subsequent aiming movement that keeps the forearm in a fixed height until the hand reaches to the target. Without this aiming movement, the process of reaching requires more adjustments and the movement becomes un smooth and segmental. Grasping preparation is a crucial component to have a successful grasp. An inappr opriate hand opening can impede formation of a secure grasp.45, 77, 144 Upper-arm diagonal shif ting (shoulder flexion and abduction) and placing basket (elbow extension) are two out of synergy movements. According to Brunnstrom, these movements are of ten difficult to regain for people post-stroke.12 Except for forearm fixation showing decreased use, after receiving CIMT, most of the underutilized components in the lo w-functioning group increased or maintained their pre-CIMT use,. In addition to forearm fixation, the hi gh-functioning group had more declining components than the low-functioning group, in cluding grasping preparation a nd grasping. The allowance of compensatory movement during CIMT training ma y have lead to the decline in essentialmovement components. The limitations in movement control may be different for highand low functioning groups. Forced use of the affected extremity possibly encouraged and elicited the exploration of underutilized e ssential-movement components in the low-functioning group.

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102 When having more pre-existing essential-move ment components, the same training, however, may encourage the use of compensatory movement in the high-functioning group in order to meet the speed command of the task. There was no statistically significant treatment effect on the total compensatory movement score, in dicating CIMT did not increase the use of compensatory movements. A possible expl anation was that increased use of certain compensatory movements was offset by decreased use of others, such as trunk side-bending and non-standard grasping. In addi tion, a statistically significant group effect was found, indicating the low-functioning group adopted more compen satory movements than the high-functioning group. Most of the compensatory movements were frequently observed in both groups preand post-CIMT. Initiative synergy was often substituted by the trunk side-bending to the contralateral side along with s houlder abduction. Instead of moving the upper arm forward with forearm fixation, the elbow joint was locked at 90 degree of flexion during the whole reaching part of the task. In order to reach for the basket, therefore, the trunk had to forward rotate so that the hand could perform the subsequent gras ping movement. Two non-standard grasping compensatory movements were observed: wrist a nd reversed maneuvers. In the wrist maneuver the hand went under and passed the basket handle, and then the wrist lifted the basket. The reversed maneuver was that the hand grasped the basket handle with th e thumb pointing toward the individual. The compensatory grasping mane uvers appeared to occur for individuals who could not perform grasping preparation (hand opening) and forearm supination. When the upper arm shifted diagonally to lift the basket, trunk ba ckward rotation often assisted the lifting. Elbow extension was necessary for placing the bask et onto the high table. Ipsilateral weight shifting, however, took the place of elbow movement, and the elbow often remained at 90 degree

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103 of flexion. Generally speaking, the low-func tioning group often substituted compensatory movements for the essential-movement components, which may indicate the inability to recruit certain body parts17, 42, 45, 75, 89, 135, 136 or muscle weakness.8, 10, 11, 18, 19 Additionally, the proximal body parts, which include the upper arm and trunk, often dominated the movement or incorrectly initiated the movement. Alt hough the high-functioning group used the essential-movement components, compensatory movements still appeared, but functioned as assistance. General Conclusions The EMCE m ethod can effectively pinpoint mi ssing essential-movement component and compensatory movement. With appropriate training of EWMN, researchers could develop EMCE forms to evaluate movement quality for representative activities of daily living. The beneficial information gathered from the EMCE form will assist clinicians to design appropriate and tailored training progra ms for their clients. CIMT is a rehabilitative approach based on the task -oriented model.25, 109 The task-oriented model assumes that control of movement is organized around goal-directed, functional behaviors rather than on musc les or movement patterns.145 The task-oriented model also encourages the individual to actively pa rticipate in solving motor challenges.146 In rehabilitation, practicing a motor task or activit y should be functionally based and practiced in a variety of contexts. Thus, the patient can develo p and implement the strategies learned for future tasks after discharge from therapy. The two training modes of CIMT are repetitive task practice and adaptive task practice.109 Repetitive task practice em phasizes continuous attempts to execute movements of a repeated nature, such as dusting, eating, or combing. The practice is designed to enhance problem-solving skills. Adaptiv e task practice uses the principles of operant or instrumental conditioning to repeatedly perfor m a defined task in a se ries of trials. During each trial, the task has a defined duration. The goal of adaptive task practice is either to increase

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104 the successful repetitions or to use less time to complete the ta sk. From the standpoint of the task-oriented model, both practice modes imply th at compensatory movement is acceptable and should be encouraged if function is improved.137, 147 According to the results of this study, the methodology of CIMT did not improve quality of movement in terms of compensatory movements (Table 4-3), which were not seen in people without neur ological disorders. Most of the compensatory movements, however, were fre quently observed in both groups preand postCIMT. Why do individuals with stroke choose comp ensatory movements in the Lift Basket task? A potential explanation can be the speed required to perform the task. The subjects were asked to execute the Lift Basket task as fast as possible, which test ed individuals maximal capacity. In order to reach for the target at the fastest speed, use of compensatory movements may be just a representation of the trade-o ff between speed and movement quality. This argument seems legitimate, but several recent studi es have reported that individuals post-stroke also use compensatory movements when reach ing at a self-paced or comfortable speed.45, 135, 148 Whether functional recovery is simply goal a ttainment or improved movement pattern in accomplishing the goal still remains debatable.146 Achieving good movement quality is an important goal for people recovering from a str oke. A movement of good quality is one that approximates normal movement.82, 83 Normal movement encompasses movement components that are required for executing a movement (i.e. essential-movement components) in a sequencing manner without using compensatory m ovements. The goals of CIMT training, therefore, need to be expanded to increase the function of underused essential-movement components, re-establish normal movement sequences, and prevent compensatory movements. In order to improve movement quality and motor relearning, the incorpor ation of appropriate

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105 guidance that emphasizes normal movement component, sequence, and strategy may be necessary for future CIMT.30, 38

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106 APPENDIX A PILOT DATA Pilot Study 1 Purpose The purpose of Pilot Study 1 was to conduct th e proposed project with a sm all number of participants to determine the f easibility of utilizing the planne d methodology in reliability tests for EWMN. Aim: To determine the feasibility of conducting the inter-rater reliab ility and intra-rater reliability for EWMN. Hypothesis 1. The preliminary result of intra-rater reliability test will show a high percentage of agreement, which will exceed 90 pe rcent, between two separate testing times. Hypothesis 2. The preliminary result of inter-rater reliability test will show a high percentage of agreement, which will exceed 90 percent, among three different raters. Participants Three participants without stroke were random ly selected from a control group for this study. All participants were vol untarily recruited from the local community. Their demographic information is listed (Table A-1). Method/Data Analysis Three participants video tapes of the Lift Basket task were first converted to DVD in digital format using a Panasoni c DVD recorder (model DMR-E95HS) In the laboratory, three raters with at least three-years EWMN traini ng experience, then played video clips frame-byframe (30 frames/second) to grade participants m ovement using EWMN at separate times, using a Pioneer DVD player (model DVD-V7400). One week after this view ing session, the same

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107 raters were asked to grade the same partic ipants movement. Percent of agreement was calculated for inter-rater and intra-rater reliability. Results and Conclusion For the intra-rater reliability test, the percenta ge of agreement was 98%. For the inter-rater reliability test, the percentage of agreement was 96%. Both intra-rater reliability and inter-rater reliability showed values higher than 90%. The re sults indicate that after adequate training in EWMN, raters can perform the evaluations reliably. Pilot Study 2 Purpose The purpose of Pilot Study 2 was to conduct th e proposed project with a sm all number of participants to determine f easibility of utilizing the planned methodology in determining invariant features of the Lift Ba sket task using the EWMN method. Participants Eight participants without stroke (age range : 50~79 y/o; mean age: 70 y/o; 4M/4F) were randomly selected from a control group for this study. All particip ants were voluntarily recruited from the local community. Method/Data Analysis Participants video tapes of the Lift Basket task were first convert ed to DVD in digital format using a Panasonic DVD recorder (model DM R-E95HS). In the la boratory, the author, a physical therapist with three-years EWMN trai ning experience, played video clips frame-byframe (30 frames/second) to grade participan ts movement using EWMN, using a Pioneer DVD player (model DVD-V7400). Figure A-1 was an example of original EWMN page. Each column on the table represented a time point during the task. For instance, the first pair of red

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108 circles (i.e. the second columneye contact with the basket handle) was observed before the second pair of circles (i.e. the th ird columninitiative synergy). Results and Conclusion Using EWMN, ten essential movement com ponents were identified in sequence from control group participants: 1. Eye contact with basket handles 2. Initiative synergy: coupled but oppos ite movements of the arm and forearm 3. Forearm fixation: maintaining constant height of forearm in space while arm moves toward the basket 4. Contralateral weight shifting 5. Hand preparation for grasping 6. Grasping 7. Shift of eye contact to side tabletop 8. Diagonal shift of arm 9. Ipsilateral weight shifting 10. Forearm movement of placing the basket. The ten essential-movement components indicate that all participants not suffering from stroke demonstrate these invarian t components in their movement control for the Lift Basket task. The study of essential-movement compone nt follows the theory of Generalized Motor Programs.38, 85 Normal movement strategy is recognized as recruiting first a proximal body part and then a distal one. According to th e above findings, an EssentialMovement Components Evaluation Form (EMCE) for the Lift Basket task in the WMFT was created (Figure A-2). Among the

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109 ten essential-movement components, initiativ e synergy and forearm fixation were two movements that have never been reported in the literature of reaching. Pilot Study 3 Purpose The two purposes of Pilot Study 3 were 1) to m odify the original Essential-Movement Components Evaluation Form (Table A-3) for use in participants with stroke, and 2) to show differences in essential-movement components among the three groups (control, low-functioning stroke pre-test and high-functioning stroke pre-test). Participants Six participants (two participants from each group) were randomly selected from the three groups for this study. Method/Data Analysis Participants video tapes of the Lift Basket task were first convert ed to DVD in digital format using a Panasonic DVD recorder (model DM R-E95HS). In the la boratory, the author, a physical therapist with three-years EWMN trai ning experience, played video clips frame-byframe (30 frames/second) to grade participan ts movement using EWMN, using a Pioneer DVD player (model DVD-V7400). The total essentialmovement component scores were calculated. Results and Conclusion After using EWMN in examining the moveme nts of the Lift Basket task in the participants with stroke, five compensatory movements were observed. The compensatory movement included upper-arm elevation, trunk side-bending, trunk forward rotation, trunk backward rotation, and non-standard grasping. Th e original EMCE form was modified as seen in Appendix B, which was used for this current project to record both essential-movement components and compensatory movements. The differences of essential-movement components

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110 among the three groups were shown.(Ta ble A-2) As severity of st roke increased, the numbers of essential-movement components decreased.(Ta ble A-4) The high-functioning stroke group preserved more essential-movement component s than the low-functioning stroke group. Compensatory movements were found (excessive trunk use and alternative grasping) in the participants with stroke. In conclusion, the findings of Pilot Study 3 suggest that 1) there were missing essential-movement components in partic ipants with stroke while performing the Lift Basket task; 2) the degree of missing essential-movement com ponents appeared proportional to the severity of stroke, and 3) compensatory movements were substituted for missing essentialmovement components of the Lift Basket task in participants with stroke. Completion of the pilot study demonstrated that developing the temp late and using it to assess movement during the Lift Basket task is feasible.

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111 Table A-1. Demographic information of c ontrol group participants of Pilot Study 1 Participants Age Gender Handedness #1 23 Female Right #2 79 Male Left #3 77 Male Right Table A-2. Results of Pilot Study 3. Control #1 Control #2 High-functioning #1High-functio ning #2 Low-functioning #1 Low-functioning #2 eye contactbasket handle initiative synergy UA m't with forearm (f) trunk side-bending trunk flexion/rotation grasping preparation grasping Non-standard grasping eye contactside table diagonal H/V shifting placing basket trunk extension/rotation trunk side-bending weight shiftingipsilateral weight shiftingcontralateral # of movement components 10 9 8 5 4 3

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112 Figure A-1. EWMN page for the Lift Basket task in WMFT (example) Abbreviations: LH, left hand; LLA, left lower arm; LUA, lower upper arm; LSh, left shoulder; RH, right hand; RLA, right lower arm; RUA, right upper arm; RSh, right shoulder; Plv, pelvis; BKH, basket handle; BKB, basket bottom; TabH, high tabletop; Wt, weight shifting. Note: Red circles represent the movement components identified across normal participants

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113 Figure A-2. Essential-Moveme nt Components Evaluation Fo rm (Prototype: without compensatory movement) Movement Rating Scale of Lifting Ba sket in Wolf Motor Function Test Date: ______________ Participant: ____________ Rater: ____________ Movement Component eye contactbasket handle initiative synergy UA m't with forearm (f) grasping preparation grasping eye contactside table diagonal H/V shifting placing basket weight shiftingipsilateral weight shiftingcontralateral Movement Component Definition 1. Eye contact: eye contact with the tar gets (handles of basket or side tabletop) 2. Initiative synergy: forearm and upper arm simult aneously initiate the task in opposite directions 2 Movement of upper arm with fixation of forearm: forearm height is fixed in space while approaching the basket; amount of upper arm movement is graded 3 weight shifting: whole body shifts to the ipsilateral or contralateral side 4 Grasping preparation: hand opens bef ore grasping handles of basket 5 Grasping: fingers approximate each other after han d contacts with the handles of the basket from underneath the handles 6 Diagonal shifting: 1) release basket from contact with front table, then transport basket to side table 2) this move ment comprises two sub-components: horizontal shift and vertical shift 7 Placin g basket: basket is b r ou g ht to to p of side table Movement Grading I. Nominal Data (shaded cells: eye contact, in itiative synergy, weight shifting, grasping preparation, grasping and compensatory movement) 0 = no movement observed 1 = movement observed II. Ordinal Data (movement of upper arm with fixation of forearm, di agonal shifting, and placing basket) 0 = no movement observed 1 = less than 30 of movement as compared with the previous limb position 2 = 30 movement < 60 3 = 60 movement < 90

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114 APPENDIX B ESSENTIAL-MOVEMENT COMPONENT EVELUATION FORM Figure B-1. EMCE for m (with compensatory movement) Movement Grading I. Nominal Data (eye contact, initiative synergy, weight shifting, grasping preparation, grasping and compensatory movement) 0 = no movement observed 1 = movement observed II. Ordinal Data (movement of upper arm with fixation of forearm, di agonal shifting, and placing basket) 0 = no movement observed 1 = less than 30 of movement as compared with the previous limb position 2 = 30 movement < 60 3 = 60 movement < 90 Movement Component eye contactbasket handle initiative synergy UA m't with forearm (f) Upper arm abduction trunk side-bending trunk flexion/rotation grasping preparation grasping Non-standard grasping eye contactside table diagonal H/V shifting placing basket trunk extension/rotation trunk side-bending weight shiftingipsilateral weight shiftingcontralateral Essential Movement Component Definition 1. Eye contact: eye contact with the tar gets (handles of basket or side tabletop) 2. Initiative synergy: forearm and upper arm simultaneously initiate the task in opposite directions 3. Movement of upper arm with fixation of forearm: fo rearm height in space is fixed while approaching the basket; amount of upper arm movement is graded 4. Weight shifting: whole body shifts to the ipsilateral or contralateral side 5. Grasping preparation: hand opens before grasping handles of basket 6. Grasping: fingers approximate each other after hand contacts with the handles of the basket from underneath the handles 7. Diagonal shifting: 1) release baske t from contact with front table, then transport basket to side table 2) this movement comprises two su b-components: horizontal shift and vertical shift 8. Placing basket: basket is brought to top of side table **Compensatory movement (shaded cells): 1) having extr a trunk or upper arm use, which assists or replaces prime movers or 2) not grasping the basket handles from underneath the handles Movement Rating Scale of Lifting Ba sket in Wolf Motor Function Test Date: ______________ Participant: ____________ Rater:

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115 APPENDIX C FUGL-MEYER ASSESSMENT

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120 LIST OF REFERENCES 1. Taub E, Miller NE, Novack TA, et al. Tec hnique to improve chronic motor deficit after stroke. Arch Phys Med Rehabil. Apr 1993;74(4):347-354. 2. Rosamond W, Flegal K, Friday G, et al. Heart disease and stroke statistics--2007 update: a report from the American Heart Associati on Statistics Committee and Stroke Statistics Subcommittee. Circulation. Feb 6 2007;115(5):e69-171. 3. Kwakkel G, Kollen B, Wagenaar R. Therapy impact on functional recovery in stroke rehabilitation: a critical review of the literature. Physiotherapy. 1999;85(7):377-391. 4. Sunderland A, Tinson D, Bradley L, Hewer RL. Arm function after stroke. An evaluation of grip strength as a measure of recovery and a prognostic indicator. J Neurol Neurosurg Psychiatry. Nov 1989;52(11):1267-1272. 5. Wade DT, Langton-Hewer R, Wood VA, Skilb eck CE, Ismail HM. The hemiplegic arm after stroke: measurement and recovery. J Neurol Neurosurg Psychiatry. Jun 1983;46(6):521-524. 6. American Heart Association. Heart disease and stroke statistics-2005 update. Dallas, TX: American Heart Association; 2004. 7. Ernst E. A review of stroke rehabilitation and physiotherapy. Stroke. Jul 1990;21(7):1081-1085. 8. Bourbonnais D, Vanden Noven S. Wea kness in patients with hemiparesis. Am J Occup Ther. May 1989;43(5):313-319. 9. Ryerson SD. Hemiplegia. In: Umphred D, ed. Neurological rehabilitation 4th ed. St. Louis, MO: Mosby; 2001:741-789. 10. Chae J, Yang G, Park BK, Labatia I. Musc le weakness and cocontraction in upper limb hemiparesis: relationship to motor impairment and physical disability. Neurorehabil Neural Repair. Sep 2002;16(3):241-248. 11. Sheean G. Neurophysiology of spasticity. In: Barnes M, Johnson, GR, ed. Upper motor neuron syndrome and spasticity New York, NY: Cambridge University Press; 2000:1278. 12. Brunnstrom S. Movement therapy in hemiplegia : a neurophysiological approach New York, NY: Harper & Row; 1970. 13. Bobath B. Adult hemiplgia: evaluation and treatment 3rd ed. Oxford: Heinemann Medical; 1990.

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132 BIOGRAPHICAL SKETCH I received m y Bachelor of Science in Phys ical Therapy from the National Cheng Kung University (NCKU), Tainan, Taiwan in 1995. Af ter fulfilling a 2-year mandatory military service, I returned to NCKU in 1997 and worked as a teaching assistant at the Department of Physical Therapy for 2 years. To accumulate cl inical experience, I also worked as a physical therapist in a variety of setti ngs, including outpatient and home ca re, on a part-time basis. Based on these valuable experiences, I no ticed therapeutic techniques th at physical therapists use can mostly rely on personal clinical observations. The lack of evid ence and support for neurological physical therapy led me to the University of Florida in 1999, where I pursued a Master Degree in Health Science and a Doctoral Degree in Rehabilita tion Science. I received my Master of Health Science in Physical Therapy at th e University of Florida in 2001. My main research concentration in the Re habilitation Science Do ctoral program was movement dysfunction and my mino r concentration was gerontology. I have been involved in numerous research projects, espe cially in stroke rehabilitation. Under the supervision of my mentor, Dr. Kathye E. Light, I have been workin g on a series of studies of Constraint-Induced Movement Therapy (CIMT) to improve upper-ex tremity function in st roke population. During the first half of my doctoral study, I used el ectromyography to study muscle activation patterns of upper extremity post-stroke. However, a ch ance of research collaboration with Dr. Philip Teitelbaum at the Department of Psychology determ ined the direction of my dissertation. My focus of the study was using the Eshkol-Wachman Movement Notation to develop a movement evaluation template for measuring qua lity of movement post-stroke.