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148

Attempting to Improve Function and Quality of Life Using the FTM Protocol:
Case Report
Andrew J. Butler, PT, PhD;1,4,5 Sarah Blanton, DPT, NCS;1 Veronica T. Rowe, MS, OTL/R;1
Steven L. Wolf, PT, PhD, FAPTA1,2,3,5

ABSTRACT
Background and Purpose: The Functional Tone Management
(FTM) arm training program® uses repetitive task practice,
stretching, and electrical stimulation as patients with moderate
upper extremity hemiparesis wear a dynamic hand orthosis to retrain
grasp and release of objects. The case study quantitatively evaluates
the extent to which FTM training improved function and quality of
life in a patient who met criteria for which the device was intended.
Case Description: The participant, a 44-year-old male in the
chronic stage of stroke recovery with moderate right upper extremity
motor impairment, was trained for 10 days over a 2-week period
by a licensed clinician with extensive experience in FTM training
methods. Measurements were taken over 3 baseline visits, then
immediately preintervention, postintervention, and at a 3-month
follow-up. The outcome measures, following the International
Classification of Functioning, Disability, and Health (ICF) Model,
included the: Fugl-Meyer assessment (FMA) (upper extremity
portion), UE range of motion (ROM), Modified Ashworth scale,
Wolf Motor Function Test (WMFT), and the Motor Activity Log
(MAL). Health related quality of life was measured using the Stroke
Impact Scale (SIS). Outcomes: The participant showed limited
gains in upper extremity function immediately postintervention.
Increases in AROM occurred in forearm supination and wrist
flexion and extension, but no improvements were noted in finger
ROM. A slight decrease in tone was found in forearm pronators (1
to 0) and wrist flexors (1+ to 1). WMFT values for the more affected
upper extremity did not change immediately after training, but a
17% reduction in time occurred at follow-up, with improvements,
most notably in the tasks of lifting a pencil and lifting a paper clip.
No changes occurred in UE-FMA scores immediately following the
intervention, however, a 17% improvement was measured at followup. A slight improvement in MAL scores was noted but not to a
level of independent functional use of the impaired upper extremity.
SIS scores improved in the domains of strength, communication,
mobility, social participation, hand recovery, and overall physical
component, while decreases were seen in the ADL/IADL, hand
function, emotion, and cognitive domains. Discussion: The case
study indicates that for this patient with chronic, moderate upper
extremity impairment following stroke, a 2-week FTM training
regimen resulted in modest changes occurring as a decrease in
impairment, with functional improvement and improved quality

of life. Further investigation of the innovative training program
should be undertaken before the efficacy of its use can be ascertained
amongst patients with limitations comparable to the participant.
Key Words: brain, rehabilitation, evaluation, cerebrovascular accident,
motor activity, physical therapy, International Classification of
Functioning, Disability, and Health
INTRODUCTION
Considerable effort has been directed toward the development
and testing of innovative approaches to reduce impairments and
improve functional ability in patients with stroke.1-3 Although
evidence continues to mount regarding the effectiveness of intensive
repetitive practice,4,5, techniques such as constraint-induced therapy
(CIT) may not benefit all individuals with Upper Extremity (UE)
hemiparesis. To date, only one case study6 has specifically examined
intensive task-oriented training for an individual with greater
impairment than typically seen in patients receiving CIT (ie, 10°
of wrist extension, at least 10° of metacarpophalangeal (MP) and
interphalangeal (IP) extension of 2 digits and the thumb.7,8 The
intensive protocol failed to show improvement in functional use of
the more affected limb.
Few treatment options are available for stroke survivors whose
hand cannot be effectively incorporated into a rehabilitation
regimen. The Functional Tone Management (FTM) arm training
program (Saebo, Inc, Charlotte, NC http://www.saebo.com/
home.html) promises a treatment alternative for such patients
with moderate to severe upper extremity (UE) impairment. The
program combines the use of a dynamic hand orthosis, called
the SaeboFlexTM (Figure.1) with a high repetition, task specific
training program for the hand and arm (www.saebo.com). The
SaeboFlexTM is specifically designed to position a nonfunctional
hand at optimal biomechanical advantage so that grasp and release
activities are possible. Positioning is accomplished by means of a
fixed wrist extension angle and a variable strength finger and thumb
spring system that maintains digit extension. In a process called
‘agonist retraining,’ the wearer uses the resistance of the finger and
thumb spring system to voluntarily activate and relax the finger
flexors, resulting in an assisted, functional grasp and release. Many
repetitions of grasp and release are then performed in an effort to
improve the volitional motor control of the finger flexors.9

Departments of Rehabilitation Medicine, 2Medicine, 3Cell Biology, and 4Psychology, Emory University School of Medicine and 5Atlanta
VAMC Rehabilitation Research and Development Center5 Atlanta, GA (andrew.butler@emory.edu)
1

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The FTM arm training program, developed in 2001 evolved
from research documenting that insufficient agonist recruitment
(ie, those muscles primarily responsible for movement about
a joint) contributes significantly to movement limitations in
the neurologically impaired arm10,11 as well as evidence that UE
function can be improved through numerous repetitions, task
training programs for motor relearning.4,12 The SaeboFlexTM
incorporates functional use of the hand into the FTM training
approach, thus providing an alternative to therapies based on a
proximal to distal recovery paradigm.13 The FTM arm training
program includes (1) highly repetitive SaeboFlex -assisted grasp
and release combined with target driven arm movement patterns
designed to address the patient’s movement impairments, (2)
SaeboGlideTM that facilitates active and active-assisted range of
motion exercises for unilateral shoulder and elbow movement, and
(3) functional electrical stimulation (FES) to improve movement
in wrist and finger extensors. According to the company, these
elements are presumed to incorporate specific aspects of evidence
based practice in neurological rehabilitation. Specifically, intensive,
high repetition arm training has been shown to increase cortical
activation in areas of the somatosensory and pre-motor cortex.14
The activation has been correlated with improved UE motor
function.15,16 Also, repetitive, passive-active movement training has
been shown to improve upper limb motor function and ability in
patients with chronic stroke with all degrees of UE paresis.17 Finally,
the use of electrical stimulation has also been shown to improve
voluntary motor control of the hemiplegic wrist and forearm.18,19
The expectation of Saebo Inc. is that the orthosis will allow patients
to immediately begin using their hand to perform functional
exercises; thus allowing unilateral intensive arm training to occur.
According to the Saebo Company website, the FTM arm
training program is currently being used by over 450 therapists
across the United States and in 4 countries, yet there is little
evidence supporting the effectiveness. In a preliminary study20
involving 10 patients with severe chronic stroke, small gains were
seen in reaching and grasping, although these improvements were
“minimally reflected in the outcome measures chosen” (pg. 14).
One published abstract,21 evaluating 13 chronic stroke survivors,
indicated that increased range of motion, reduced tone and increased
function occurred using the SaeboFlexTM orthosis. Neither of
these studies used blind evaluators, or disability and health-related
quality of life (HRQOL) outcome measures in their assessment of
the technique. Consequently, there is a need to objectively assess
the value of the FTM program in assisting patients with upper
extremity impairment following stroke.
We describe a 2-week FTM UE training program comprised of
repetitive task practice using the Saebo customized dynamic wrist
orthosis, functional electrical stimulation (FES), and stretching
with anticipation that the program may lead to increased UE
range of motion, improved function, and improved quality of
life in a patient with moderate UE impairment following stroke.
Unique to the case study, we use an unbiased evaluator naive to
the intervention to administer an array of outcome measures that
follow the International Classification of Functioning, Disability and
Health 22(ICF) Model of Functioning and Disability.

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CASE DESCRIPTION
History
The participant was a 44-year-old right handed male diagnosed
with a left middle cerebral artery (MCA) infarct one year earlier
with consequent moderate right hemiparesis (UE impairment
greater than lower extremity) and expressive aphasia. His magnetic
resonance (MR) images revealed a large (>5.0 cm) ischemic infarct
involving predominantly the left insula, extending slightly into the
external capsule, caudate, and external medullary lamina of globus
pallidus. Although his past medical history included a myocardial
infarction and coronary bypass surgery 10 years prior to his stroke
he had no hospitalization or major medical treatment until the
initial post-stroke hospitalization. He underwent 7 weeks of
inpatient rehabilitation, followed by intensive outpatient treatment
for aphasia and outpatient occupational and physical therapy.
At the conclusion of his therapy (3 months prior to entering the
study), he was independent in all activities of daily living and
community ambulation without an assistive device. He was taking
the following medications: Coumadin®, Prinivil® and Zocor®, but
was not receiving any pharmacologic treatment for spasticity. He
had no other recent cardiac related complications or complaints
and presented with adequate endurance to ambulate community
distances and drive independently.
Screening and Rationale for Participant Selection
The participant was selected with the intent to gain knowledge
about the utility of the device in a comprehensively documented
manner while using the protocol established by the company.
There was no expectation regarding the resulting magnitude
of improvement. The local ethics committee approved the
experimental procedures. Information concerning the participant’s
hospitalization, inpatient rehabilitation, and outpatient therapy was
obtained in compliance with the Health Information Portability and
Accountability Act (HIPPA). Prior to receiving the intervention,
details of the study were explained and signed informed consent
was obtained. General criteria for use of the SaeboFlexTM orthosis
included: (1) at least 10° of active range of motion (AROM) of
shoulder flexion/abduction, 10° of elbow flexion/extension and at
least 20° of volitional finger flexion when the hand was positioned
with wrist and fingers extended. He scored 24 or greater on
the Folstein Mini-Mental State Examination;23 communicated
accurately for training and evaluation procedures; was independent
in transfers, self-care needs, and standing for 2 minutes without an
assistive device and; was not receiving other rehabilitation therapy.
He exhibited a predominant flexor synergy in his right UE through
approximately 120° of range against gravity at the shoulder and
elbow, 20° against gravity at the wrist, and no finger extension.
Light touch and proprioception were intact.
The FTM orthosis was designed for patients without
volitional wrist/finger extension, so we specifically did not choose
a participant with full AROM of the wrist and finger extensors.
The participant was also chosen for this case study because he
was extremely motivated, had reliable family support, no recent
medical complications, and had UE active range of motion that
fit within the typical characteristics of patients who are considered
appropriate for the FTM protocol (ie, a patient whose movement

Vol. 30 • No. 3 • 2006

Journal of Neurologic Physical Therapy

characteristics did not qualify for CIT). It was felt that his available
active movement in the shoulder, elbow, and wrist were good
indicators of his potential ability to incorporate his arm in a taskoriented intensive repetitive practice protocol, but his limited finger
active range of motion prevented independent use of the hand in
functional tasks. Prior to the intervention, he expressed specific
functional goals of being able to eat, write, and play drums with
his more affected limb. Unexpectedly, 2 months following the
intervention, he underwent cardiac pacemaker implant surgery. The
potential effect of the surgery is addressed further in the discussion.
Examination
All examinations were conducted by the same clinician, not
associated with Saebo Inc. at a site independent from the Saebo
training site. The study design was intended to reduce the likelihood
of inherent bias or potential conflict of interest between evaluator
and interventionalist.
Tests and measures
The collection of outcome measures was assembled to evaluate
potential full-spectrum (body structure/function, activities, and
participation) effects of the FTM UE intervention, following the
International Classification of Functioning, Disability and Health
22
(ICF) Model of Functioning and Disability. Consequently, we
believed that the collection would address not only the functionallybased goals of the manufacturer to improve hand grasp and release,
but also would consider the broader effect of the intervention on
disability and social participation.
Structure/Function: UE impairment and function were measured
using the Fugl-Meyer UE assessment evaluation (FMA),24,25 physical
assessment evaluations of UE active/passive range of motion, the
modified Ashworth scale for muscle tone,26 and the Wolf Motor
Function Test (WMFT).27,28 Excellent intra-rater, inter-rater
reliability25,29 and construct validity30,31 have been demonstrated for
the FMA. The WMFT has been shown to have good clinometric
properties in the stroke population27,28 and correlates well with the
FMA. The inter-rater and intra-rater reliability of the modified
Ashworth scale in assessing spasticity remains uncertain.32 Bakheit
et al33 suggest that the scale does not reliably distinguish between
the multiple components of hypertonia (spasticity, thixotropy, and
changes in the viscoelastic properties of muscles). Important to
note, the scale measures passive resistance to movement and does
not give information about movement restrictions during active
functional use of the limb.
Activities and Participation: The Motor Activity Log (MAL)34,35
a self-report interview, was used to measure UE disability in 30
activities of daily living. High construct validity and reliability has
been demonstrated using a 14-item version of the instrument in
chronic stroke patients35 and a 28-item version in subacute stroke
patients.35
HRQOL was measured using the Stroke Impact Scale (SIS)
Version 3.0 (Version 3.0; Rehabilitation Outcomes Center,
Gainesville, Fla).36 Reliability and validity have been established in
the stroke population, and the SIS is sensitive to change in function
across domains.36
The FTM arm training protocol is an intense intervention;

150

consequently, self-report pain and fatigue levels were monitored
daily throughout the course of training by therapists at the training
facility. Pain and fatigue levels were evaluated at the end of each
afternoon session using a Likert scale of 0-10 (0 = no pain/not at all
fatigued to 10 = unbearable pain/absolutely exhausted).
Six evaluations occurred over 7 months, with the evaluator naive
to the specific date and time of intervention delivery. Three baseline
(BSL) measurements were taken, BSL1, BSL2 (2 weeks after
BSL1), and BSL3 (1 month after BSL1). Approximately 1 month
later, the participant underwent an additional set of evaluations,
immediately prior to intervention (PreT), immediately after the
2-week intervention (PostT), and 3 months later, (Post 3T). The
final evaluation, Post 3T, occurred 7 months after initial assessment,
BSL1 (Table 1). Due to the time-frame of the questions, the SIS
questionnaire was given only at the following evaluation times:
BSL 1, BSL3, PreT, and Post3T. The evaluator had been previously
standardized on the WMFT and MAL testing procedures through
her involvement in the EXCITE national clinical trial. 38
Intervention
The FTM arm training program applied by occupational
therapists at the Saebo, Inc. training facility occurred 6 hours a day,
5 days a week for 2 consecutive weeks. The intensive protocol was
based on the CI therapy protocol standards.37,38 The duration of arm
training sessions with the SaeboFlexTM was based on recommended
wearing limits for the SaeboFlexTM orthosis to prevent possible skin
or soft tissue irritation and clinical experience suggesting that most
patients are fatigued to the point of decreased performance beyond
that duration. The 10 day intervention consisted of the following
daily schedule: (1) four 45 minute sessions of intensive repetitive
practice using a dynamic wrist orthosis to assist in wrist and finger
extension during functional tasks; (2) two 20 minute sessions of
FES focusing on wrist and finger extensor musculature and (3) two
25 minute sessions of UE stretching.
Specific procedural intervention
The dynamic orthosis consists of a wrap around forearm
support attached to a dorsal hand platform that supports 2 spring
attachments (Figure 1). Individual finger sleeves are attached to
springs by high tensile polymer line to provide assistance with finger
extension. Spring tensile strength was adjusted for the appropriate
amount of finger extension assistance needed to initiate opening of
the hand. Each 45 minute repetitive practice session included one or
more of the 4 following components: (1) individual muscle group
strengthening (ie, biceps during task of bringing hand to mouth);
(2) multiple muscle group strengthening (ie, pectoralis major/triceps
during a complex reach and retrieve task); and (3) hand exercises
with the orthosis and (4) hand exercises without orthosis. The first
of these daily four 45 minute repetitive practice sessions focused on
unidirectional reaching tasks, while the remaining 3 sessions were
primarily multidirectional in nature. A unidirectional task refers
simply to reaching and grasping a ball in a container, then transport
and release of the ball into an adjacent container. A multidirectional
task increased the demand of the reach and/or transport phase of the
activity by directing the patient to reach through strategically placed
hoops before and after grasping the ball to increase the complexity

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Figure 1. The Saeboflex® dynamic UE orthosis worn by the
patient during training. The photograph is reprinted with
permission from SAEBO, Inc.
of shoulder movements. Typically the patient stood during these
repetitive practice sessions using the orthosis.
Each functional task involved progressively challenging grasp
and release activities, modified to elicit increased movement at
certain joints; with consideration for movement limitations of the
participant. Frequent feedback regarding knowledge of performance
was given throughout each activity, including verbal instruction to
facilitate grasp and release. Active problem solving was facilitated
through alteration of the practice environment to increase task
complexity.
Unilateral SaeboGlideTM exercises for the shoulder and elbow
(a gliding sleeve/pole mechanism that facilitates glenohumeral
proximal activity) were included to provide assisted AROM exercises
and stretching to maximize the intensity of arm training exercise.3,39
Between intervals of arm training with the SaeboFlex, FES was
applied to the wrist and finger extensors. The wrist was positioned
in flexion40 to allow for decreased resistance from the finger flexors
and then wrist and finger extension was elicited using the BMR
NeuroTech♦ electrical stimulation unit (BMR NeuroTech, Inc.
Phoenix, Ariz). Parameters were set for single channel bi-phasic
current delivered at intensity sufficient to produce muscle tetany.
Current frequency was 35Hz, pulse width 275 µs and duration set
at 8 seconds on 16 seconds off.
Following completion of the 2 weeks of treatment, the participant
was instructed to work actively in the orthosis for 45 minutes per day,
stretch with the Unilateral SaeboGlideTM daily for 20 minutes and
use FES daily for 20 minutes. The patients self report home diary
indicated that he was compliant with these guidelines 5 days a week
for approximately 9 weeks, at which time he entered the hospital
for cardiac pacemaker implant surgery. After the hospitalization,
he reported that he did not use the FTM or perform other aspects
of the home exercise program for the remainder of the follow-up
period.

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Outcomes
Values for changes in physical measures are represented in Table
1 across baseline visits and from PreT to Post 3T.
FMA motor and coordination score improved a total of 17%
from BSL 1 to Post 3T, with 9.5% of the change occurring across
the baseline period, no change occurring from PreT to PostT
and 6.5% of the change occurring from PreT to Post 3T. Range
of motion values were variable across evaluations, without clear
patterns of improvement. With the exception of the active forearm
supination and wrist extension, none of the PROM or AROM gains
after intervention were greater than the peak values observed for the
same motions measured during baseline visits. Shoulder flexion and
abduction were maintained at full range during the intervention,
but decreased by over 30% at follow-up. Wrist flexion and forearm
supination showed increases immediately after training and at
follow-up. Reduced tone was seen immediately after training in
forearm pronator muscles (eg, scores went from 1 to 0), but the
decrease was not evident at the 3-month follow-up. The slight tone
decrease observed in wrist flexors (score of 1+ to 1) was maintained
at follow-up. No change in the Modified Ashworth score was noted
in elbow flexor musculature.
The mean scores for the WMFT timed items (15 of 17 tasks)
were calculated for each visit (Figure 2). Tasks that could not be
completed within 120 seconds were coded as 121 and calculated as
such in the overall mean score. Little change occurred for the more
affected UE over baseline evaluations (Bsl 1= 52.43s; Bsl 2=53.16s
and Bsl 3 = 48.71s). There were no changes observed immediately
following training (PreT = 47.55s; PostT=47.65s), but there was a
decrease in average movement time at the 3 month follow-up after
training (Post 3T = 39.34s). Over the entire 7 month evaluation
period, a 25% decrease occurred from Bsl 1 to Post 3T, with 17% of
that change occurring from post 1T to 3T. A detailed examination
of individual tasks within the WMFT showed large improvements
(ie, decreased movement times) in ‘lift pencil’ and ‘lift paper clip’
tasks that persisted to the 3-month follow-up. The participant never
successfully completed the following fine motor tasks: lift a can,
stack 3 checkers, flip 3 cards, or turn a key in a lock.
The amount of use scores (AS) on the MAL were constant across
baseline visits and increased slightly after training (Figure 3). AS

Figure 2. Changes in mean WMFT times (ordinate) across visits
(abscissa). The less affected UE corresponds to the stippled line,
while the more affected arm corresponds to solid line. Refer to
narrative for a complete description of visits.

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Journal of Neurologic Physical Therapy

152

Table 1. Physical Measures Pre- and Post- FTM arm training intervention. Presented are active and passive range of motion
measurements, modified Ashworth scores, Fugl-Meyer UE motor assessment scores, and Stroke Impact Scale scores across visits.
Scores in parentheses indicate either maximum attainable score for each part of the FMA or minimum and maximum scores for the
SIS.
STRUCTURE/FUNCTION
Range of Motion Tasks-for the more affected arm

BSL1

BSL2

BSL3

PreT

PostT

Post3T

Shoulder Int. Rot.

20

70

70

40

70

50

Wrist Extension

70

70

70

45

50

70

Hand MCP Extension 5th

0

0

0

0

0

10

Wrist Flexion

0

0

90

30

45

50

Wrist Extension

38

35

25

40

40

45

Forearm Supination

0

30

0

10

20

40

Shoulder Flexion

115

120

180

180

180

115

Shoulder Abduction

90

85

180

180

180

95

Elbow Flexors

1+

1+

1+

1+

1+

1+

Forearm Pronators

1+

1+

1

1

0

1

Wrist Flexors

1+

1+

1

1+

1

1

42

41

46

46

46

49

31.25

**

31.25

43.75

**

62.5

a. Arm strength “How would your rate strength of your arm?” (0-5)

2

**

2

3

**

3

b. Grip strength “How would your rate strength of your grip?” (0-5)

2

**

2

3

**

4

75

**

78.57

75

**

67.86

Subscale 3: Emotion

41.67

**

61.11

52.78

**

44.44

Subscale 4: Communication

32.14

**

42.86

50

**

64.29

Subscale 5: ADL/IADL

50

**

52.50

77.50

**

67.50

Subscale 6: Mobility

55.56

**

61.11

63.89

**

66.67

5

**

5

10

**

5

Subscale 8: Social Participation

12.5

**

21.88

28.16

**

37.5

Overall physical component score (subscales 1, 5, 6, 7 combined)

35.45

37.47

48.78

30

15

PROM (degrees)

AROM (degrees)

Modified Ashworth Scale of Muscle Tone (0-4)

Fugl-Meyer
Motor and Coordination (0-66)

ACTIVITIES/PARTICIPATION
Stroke Impact Scale (0-100)
Subscale 1: Strength

Subscale 2: Memory and Thinking

Subscale 7: Hand function

Hand recovery from stroke (percentage of recovery 0-100)

30

**

** SIS data were not recorded at all evaluation sessions due to the time dependence of the interview.

50.42
**

40

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Journal of Neurologic Physical Therapy

scores did not go above one, demonstrating the person used their
more affected UE only occasionally or very rarely. A slight increase
was noted in the How Well (HW) scores, from a 0.98 (note: score
of 1 = the arm was used during the activity but was not helpful or
very poorly) at Pre1T to a 1.11 at PostT and continued to an average
of slightly above 2 at follow-up; indicating the more affected arm
was of some use during activities but needed some help from the
stronger arm or was moved very slowly or with difficulty.
The largest increases after FTM training in HRQOL (from PreT
to Post 3T) were seen in the domains of strength (combined upper
and lower extremity 43% change), communication (29% change),
social participation (33% change), and hand recovery from stroke
(33% change) (SIS, Table 1). The highest score in the hand function
domain was still very minimal (10 out of 100), and decreased after
training (5 out of 100). Emotion, memory and thinking, and ADL/
IADL scores all decreased after training.
Self-report pain and fatigue level scores ranged from 3.5 to 9 (10
representing “absolutely exhausted”) across the 2-week intervention,
with an average fatigue level of 7. The first 2 intervention days
fatigue levels were rated at less than moderate, but from day 3
through day 10 the patients fatigue level ranged from 7 to 9. There
was no mention of arm pain at any time point during the training.
Our volunteer did complain of back pain, especially during the first
4 days of the intervention (average 6.5 – moderate pain), but during
the second week of the intervention he had no complaints of pain.
DISCUSSION
To our knowledge this case is the first evaluation of the FTM
arm training program utilizing the Saeboflex® with a spectrum of
outcomes measures that span structure/function to participation in
activities of daily living. The results indicate that for a patient with
chronic, moderate upper extremity impairment following stroke,
2 weeks of FTM training regimen resulted in modest changes
occurring as a decrease in impairment, with functional improvement
and improved HRQOL. Changes in impairment in this individual
appear to be somewhat greater than those seen in a previous report20
showing minimal improvement and limited functional use of the

Figure 3. Changes in MAL scores (ordinate) for the more affected
arm for each visit (abscissa). The amount score (Amount)
corresponds to the stippled line, while the how well (How Well)
corresponds to the solid line.

Vol. 30 • No. 3 • 2006

hand in 2 chronic stroke survivors at 3 months. One must consider
that changes in the current study may have become evident only
because of the application of an array of measures across multiple
domains. The potential for change is particularly relevant for this
participant because the extent of his UE impairment was such that
no other evidence-based treatment options were available.
Current recommendations from the Heart and Stroke Foundation
of Ontario 2001 Consensus Panel 4 for clients with mild to moderate
UE motor impairments (who demonstrate high motivation and
potential for functional gains) include the use of repetitive and
intense practice of novel tasks. These tasks should be designed to
challenge the stroke survivor, facilitating the progression of motor
skills acquisition to use the more-involved upper limb during
functional activities. Our patient exhibited potential for functional
gains, as he was a highly motivated, cognitively alert, middle-aged
man, living and driving independently in the community. The FTM
arm training paradigm, composed of a combination of evidencebased therapeutic approaches including repetitive and intense use of
novel tasks with elements of motor learning, may have resulted in
only modest improvements in impairments, function, and QOL in
our stroke survivor because of initial level of UE impairment.
Improving limb function among stroke survivors with moderately
to severely impaired upper extremities continues to be a challenge to
clinicians. In a study by Kwakkel and colleagues,41 62% of individuals
with a MCA stroke failed to achieve some dexterity at 6 months,
indicating that the prognosis for functional outcome in this patient
group is poor. Other studies have also reported poorer outcomes
associated with increased severity of impairment.42-44 Although
the participant in this case study could be described as moderately
impaired at baseline based upon his initial Fugl-Meyer Assessment
score, he did not have active finger extension and would not have
met the minimal motor criteria for a CI therapy intervention. The
impaired ability of the individual to initiate finger extension may
lend support for a key factor in the prognosis of functional hand
recovery. For example, Fritz, et al showed that finger extension was
the only significant predictor of outcomes using the WMFT (mean
score from timed tasks only) in patients receiving CI therapy.45
Indeed, the initial level of UE impairment after stroke appears to
be a moderating variable46 in recovery and the ability to initiate
distal active movement of the UE is emerging as a potent indicator
for potential reacquisition of meaningful function. The minimal
movement criteria (the ability to initiate wrist extension and finger
extension of at least 2 digits) for CI therapy was developed from
a series of electromyography (EMG) biofeedback studies in stroke
patients performed by Wolf and Binder-Macleod8 that indicated
voluntary movements of finger and wrist extension were a better
predictor of future acquisition of independent limb use than was
the ability to reduce the hyperactive responses from stretching UE
flexor muscle groups.47 The number of patients that actually achieve
this level of functional recovery in the upper limb is estimated to be
approximately 28% to 32% of the stroke population.48
While lack of finger and wrist extension may rightly be considered
an important prognostic indicator in stroke recovery, it is important
to recognize that traditional therapeutic approaches designed to
promote recovery have struggled to develop methods that allow

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Journal of Neurologic Physical Therapy

patients with moderate to severely impaired UEs to successfully
practice highly repetitive grasp and release activities. Importantly,
one of the signature elements of the FTM treatment paradigm is
the dynamic orthosis that is used to assist finger extension. The
device allows the impaired hand to engage in functional activities
during training and is expected to facilitate use of the limb during
functional tasks in an effort to carry-over into ‘real world’ activities
of daily living. Unfortunately, the patient did not report subjective
improvements in his goals of eating, writing, or playing the drums.
Despite an increase in functional activities reported by MAL scores
immediately after training and at follow-up, the actual changes in
movement were not manifest as independent use of the limb in
functional tasks. These outcomes are similar to the minimal MAL
changes that occurred in a patient with comparable motor deficits
who received 3 weeks of CI therapy.6 The only other brief mention
of a patient without active finger extension receiving a similar
intensive therapy was Taub and colleagues (1999) who describe a
client that had ‘almost no ability to move his fingers’ (pg. 245) as a
‘treatment failure.’49
While the patient simply may not have had the residual
neural substrate to improve despite a baseline FMA score of 42,
other possible factors affecting these results should be considered.
Active assistance with grasp and release (ie, finger extension) using
the dynamic orthosis may not be an effective means of fostering
engagement of the forearm and wrist musculature in the functional
training activities that do not use or require an orthosis. Additionally,
the activities associated with the repetitive task practice involved
manipulation of various sized foam balls (versus functional-used
based objects such as eating or writing utensils), which may not
have offered an adequate functional task practice environment to
enhance motor learning.
The patient’s greatest improvements in HRQOL were manifest
in the domains of strength, communication, mobility, social
participation, and perceived percentage hand recovery of the SIS.
Although percentage of hand recovery improved, in contrast the
highest score in the hand function domain was still very minimal
(10 out of 100), and decreased after training (5 out of 100). This
apparent improvement may be a reflection of the context of the
questions in each section. Although the participant felt his hand had
recovered 40% since he had his stroke, this percentage of recovery
was still not adequate to perform the primarily fine motor activities
described in the hand function domain.
Emotion, memory and thinking, and ADL/IADL scores all
decreased by the 3 month follow-up, domains that perhaps were
more sensitive to conditions associated with his cardiac surgery
at 2 months post training. A comprehensive instrument such as
the SIS is therefore helpful in illuminating the complexity of the
participant’s stroke recovery process.
Strengths and Limitation of the Case
A major strength of the case study was the use of multiple
outcome measures across domains of the ICF model to detect
change in a broad array of areas. These measurements were applied
by a standardized evaluator naive to the participant’s interventional
status and not associated with the individuals performing the
intervention, therefore reducing the likelihood of inherent bias or

154

potential conflicts of interest. Multiple baseline evaluations allowed a
comparison of the magnitude of change occurring over time without
intervention to change occurring as a result of the intervention.
The comparison of change values across measurements showed
the inherent variability of performance over time in a moderately
impaired stroke survivor while clarifying the actual improvements
that resulted from the intervention.
An important potential modifier that may have limited the
individual’s long term improvement was the fact that he underwent
cardiac pacemaker implant surgery 2 months following the 2week intensive training. While the surgery did not impair the
patient’s ability to move his arms (ie, pacemaker was implanted
subcutaneously inferior to the right clavicle), he was limited in his
more affected arm use for several weeks postsurgery. Although the
break in his home exercise program may have impaired his progress,
the patient stated that he continued to use his more affected limb
as much as possible. One must also consider the overall affect of
the participant’s co-morbidities on the outcomes. His history of
heart disease with a recent pacemaker implant indicates that he may
not have had the cardiovascular endurance to achieve maximal gains
offered by the intensive 2 week training paradigm. Indeed, lower
HRQOL scores in the physical domain of the SIS are correlated
with more co-morbidities in stroke survivors.50 Considering the
potentially profound effect of these confounding factors, the
participant nonetheless continued a trend toward improvement
in the subjective reports of strength, mobility, and overall physical
domains of the SIS and in the “How well” portion of the MAL at
the 3 month follow-up.
The results from the study raise many questions. For instance,
in those domains in which functional improvement occurred; what
aspect of the training paradigm was responsible for the functional
improvement? What are the distinct effects of the stretching,
FES, dynamic orthosis, and goal directed task practice? Who
is appropriate for FTM training? Would a patient with more
distal movement or less flexor tone gain greater benefit from the
intervention? Can patients with flaccid paresis and increased
flexor tone show improvements? What are the minimum neural
substrates required to achieve clinically meaningful improvements
in UE function through intense therapeutic intervention? Only
well-designed studies with a large and diverse number of patients
can address each of these questions adequately.
CONCLUSION
The case is one of the first to describe the use of the FTM
arm training paradigm in a patient with chronic stroke. These
outcomes suggest modest improvements in impairment, function,
and HRQOL are possible with the FTM arm training program. In
light of the intensity, cost and time demands of the intervention, the
further clinical use of the paradigm would require clinical support
from additional investigations. Our results demonstrate the need
for a systematic series of studies to objectively assess the value of
the FTM arm training program in assisting patients with moderate
to severe UE impairment following stroke to improve both their
impairment status and functional potential.

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Journal of Neurologic Physical Therapy

ACKNOWLEDGMENTS
For their assistance with data collection and help with figures, we
gratefully acknowledge the following individuals: Dara A. Weiner
BS, and Vanessa Cavalheiro OTR/L. We thank John F. Farrell,
OTR/L and Henry B. Hoffman, M.S., OTR/L from SAEBO, Inc.
who provided the intervention to our patient volunteer. Finally we
are grateful to our patient who volunteered many hours of his time
for the study. This work was supported in part by NIH R01 NS
40984 and RO1 HD 37606.
Role of the Sponsors: None of the funding agencies had any role
in the design and conduct of the study; the collection, management,
analysis, and interpretation of the data; or in the preparation of the
manuscript. Funds were allocated by SAEBO, Inc to Dr. Blanton
to observe patient training. The 2-week intervention was provided
gratis by SAEBO, Inc. to the participant. At the initiation of the
study Dr. Wolf was not associated with SAEBO Inc. He is currently
a paid member of their Scientific Advisory Board.
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