Although there were no significant between-group differences regarding shoulder pain, worrisome observations were that in the experimental group some participants reported that they considered the intervention to be very arduous, pain and spasticity medication were prescribed more frequently, and protocol compliance was lower. Combined with the finding that shoulder pain was more likely to occur in participants in the experimental group than in the control group (relative risk 1.44), these findings may indicate

that for some participants the experimental procedure was not well tolerated. During the eight weeks of intervention Ku-0059436 in vivo our participants showed increased Leeds Adult/Arm Spasticity Impact Scale sum scores and Fugl-Meyer Assessment arm motor scores – changes that were probably not clinically relevant and caused by a mix of spontaneous post-stroke recovery of function, learned capacity to use compensatory movement strategies

of the nonaffected arm and/or increased Abiraterone mouse involvement of the carer. Overall, the prevalence of elbow flexor hypertonia and spasticity jointly increased up to 55% at the end of the treatment period, roughly corresponding to three months post-stroke for our participants. These results are in concordance with previous work (de Jong et al 2011, van Kuijk et al 2007, Urban et al 2010). The unexpected high prevalence of hypertonia and spasticity (62%) and a decreasing prevalence of shoulder subluxation (31%) at follow-up in our sample may be explained by the fact that patients with relatively poor arm motor control have a higher risk of developing hypertonia (de Jong et al 2011). Although we performed an intention-to-treat analysis (ie, using any available data from all randomised subjects), we did not use forward imputation of missing data representing a clinical variable (eg, shoulder passive range of motion) that is worsening over time (de Jong et al 2007), as this might increase the chance of a Type I error. However, for completeness, this stricter intention-to-treat analysis using the data of all randomised subjects (n = 48) was performed. This analysis was inhibitors similar in outcome

to the original analysis but revealed an additional time effect of wrist extension with flexed fingers. A per found protocol analysis would also have resulted in similar results because no patients crossed over to the other group. We also refrained from performing a sensitivity analysis based on compliance because meaningful conclusions could not be drawn from the resulting limited sample sizes. We furthermore acknowledge that the Leeds Adult/Arm Spasticity Impact Scale lacks psychometric evaluation and our method to standardise the Tardieu Scale’s stretch velocity (V3) using a metronome was not validated and tested for reliability. Therefore, our data regarding basic arm activities, hypertonia, and spasticity should be interpreted with caution.