Standardizing the intensity of upper limb treatment in rehabilitation medicine

Objective: To describe a treatment protocol for the upper limb that standardizes intensity of therapy input regardless of the severity of presentation. Design: The protocol is described (Part 1) and feasibility and effect explored (Part 2). Subjects: Participants (n=11) had a single ischaemic stroke in the middle cerebral artery territory more than one year previously, and had residual weakness of the hand with some extension present at the wrist and the ability to grasp. Interventions: Following two baseline assessments, participants attended therapy for 1 hour a day for 10 consecutive working days. Treatment consisted of a combination of strength and functional task training. Outcomes were measured immediately after training, at one month and three months. Outcome measures: Intensity was measured with Borg Rating of Perceived Exertion. Secondary outcome measures included Action Research Arm Test (ARAT), nine-hole peg test, and Goal Attainment Scale. Results: Borg scores indicated that the level of intensity was appropriate and similar across all participants despite individual differences in the severity of their initial presentation (median (interquartile range) 14 (13-15)). The mean ARAT score significantly increased by 6.8 points (chi(2)(3) = 15.618, P < 0.001), and was maintained at three-month follow-up (z = -2.384, P = 0.016). The nine-hole peg test also showed a main effect of time and 88% of goals set were achieved. Conclusions: The physiotherapy protocol standardized intensity of treatment by grading exercise and task-related practice according to the person's residual ability, rather than simply standardizing treatment times. It was feasible and well tolerated in this group.