***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    ***EXAMPLES*** 
    Input: Background and Purpose — The Motor Activity Log ( MAL ) is a semistructured interview for hemiparetic stroke patients to assess the use of their paretic arm and h and ( amount of use [ AOU ] ) and quality of movement [ QOM ] ) during activities of daily living . Scores range from 0 to 5 . The following clinimetric properties of the MAL were quantified : internal consistency ( Cronbach α ) , test – retest agreement ( Bl and and Altman method ) , cross-sectional construct validity ( correlation between AOU and QOM and with the Action Research Arm [ ARA ] test ) , longitudinal construct validity ( correlation of change on the MAL during the intervention with a global change rating [ GCR ] and with change on the ARA ) , and responsiveness ( effect size ) . Methods — Two baseline measurements 2 weeks apart and 1 follow-up measurement immediately after 2 weeks of intensive exercise therapy either with or without immobilization of the unimpaired arm ( forced use ) were performed in 56 chronic stroke patients . Results — Internal consistency was high ( AOU : α=0.88 ; QOM : α=0.91 ) . The limits of agreement were −0.70 to 0.85 and −0.61 to 0.71 for AOU and QOM , respectively . The correlation with the ARA score ( Spearman ρ ) was 0.63 ( AOU and QOM ) . However , the improvement on the MAL during the intervention was only weakly related to the GCR and to the improvement on the ARA , Spearman ρ was between 0.16 and 0.22 . The responsiveness ratio was 1.9 ( AOU ) and 2.0 ( QOM ) . Conclusion — The MAL is internally consistent and relatively stable in chronic stroke patients not undergoing an intervention . The cross-sectional construct validity of the MAL is reasonable , but the results raise doubt about its longitudinal construct validity Objective : To compare the measurement properties of the Modified Health Assessment Question naire [ MHAQ ] , the SF-36 ® Health Survey 10 item Physical Functioning scale [ PF10 ] , and scores from an item response theory ( IRT ) based scale combining the two measures . Study Design : Rheumatoid arthritis ( RA ) patients ( n = 339 ) enrolled in a multi-center , r and omized , double-blind , placebo-controlled trial completed the MHAQ and the SF-36 pre- and post-treatment . Psychometric analyses used confirmatory factor analysis and IRT models . Analyses of variance were used to assess sensitivity to changes in disease severity ( defined by the American College of Rheumatism ( ACR ) ) using change scores in MHAQ , PF10 , and IRT scales . Analyses of covariance were used to assess treatment responsiveness . Results : For the entire score range , the 95 % confidence interval around individual patient scores was smaller for the combined ( total ) IRT based scale than for other measures . The MHAQ and PF10 were about 70 % and 50 % as efficient as the total IRT score of physical functioning in discriminating among ACR groups , respectively . The MHAQ and PF10 were also less efficient than the total IRT score in discriminating among treatment groups . Conclusions : Combining scales from the two short forms yields a more powerful tool with greater sensitivity to treatment response OBJECTIVES After stroke , abnormal arm posture due to spasticity in a functionally useless arm may interfere with self care tasks . In these patients botulinum toxin treatment presents an opportunity to reduce disability . The purpose was to investigate whether reduction in spasticity after botulinum toxin treatment translates into reduction in disability and carer burden . METHODS Forty patients with stroke with spasticity in a functionally useless arm ( median duration 3.1 years ) were r and omised to receive  intramuscular botulinum toxin type A ( BT-A ; Dysport ) ( n=20 ) or placebo ( n=20 ) in a total dose of 1000 MU divided between elbow , wrist , and finger flexors . Spasticity ( using the modified Ashworth scale ) , muscle power , joint movement , and pain were assessed . Disability and carer burden were measured using an eight item and a four item scale respectively . Two baseline and three post-treatment assessment s ( weeks 2 , 6 , and 12 ) were made . Concurrent treatments as far as possible remained unchanged and not optimised . RESULTS Disability improved at week 6 with BT-A compared with placebo . This effect , present at week 2 , wore off by week 12 . Reduction in carer burden was seen at week 6 with BT-A and continued for at least 12 weeks . Forearm flexor spasticity was reduced with BT-A up to 12 weeks after treatment . Although significant improvement in elbow flexor spasticity was seen at week 2 with BT-A compared with placebo , this effect was not evident at weeks 6 and 12 . Arm pain was not improved after BT-A. Grip strength was reduced with BT-A. No serious BT-A related adverse effects were reported . CONCLUSION BT-A is useful for treating patients with stroke who have self care difficulties due to arm spasticity . The decision to treat should also include relief of carer burden . As muscle weakness may occur , its potential impact on functional activities must be assessed before intervention OBJECTIVE To compare the clinical effectiveness and cost-effectiveness of treating upper limb spasticity due to stroke with botulinum toxin type A plus an upper limb therapy programme with the upper limb therapy programme alone . DESIGN A multicentre open-label parallel-group r and omised controlled trial and economic evaluation . SETTING Twelve stroke services in the north of Engl and , UK . PARTICIPANTS Three hundred and thirty-three adults with upper limb spasticity at the shoulder , elbow , wrist or h and and reduced upper limb function due to stroke more than 1 month previously . INTERVENTIONS The intervention group received botulinum toxin type A injection(s ) plus a 4-week programme of upper limb therapy . The control group received the upper limb therapy programme alone . Participants were clinical ly reassessed at 3 , 6 and 9 months to determine the need for repeat botulinum toxin type A injection(s ) and /or therapy . MAIN OUTCOME MEASURES The primary outcome was upper limb function 1 month after study entry measured by the Action Research Arm Test ( ARAT ) . A successful outcome was defined as : ( 1 ) a change of three or more points on the ARAT scale for a participant whose baseline ARAT score was between 0 and 3 , ( 2 ) a change of six or more points on the ARAT scale for a participant whose baseline ARAT score was between 4 and 51 , or ( 3 ) a final ARAT score of 57 for a participant whose baseline ARAT score was 52 - 56 . Outcome assessment s were undertaken at 1 , 3 and 12 months by an assessor who was blinded to the study group allocation . Upper limb impairment and activity limitation were assessed by : Modified Ashworth Scale ; Motricity Index ; grip strength ; ARAT ; Nine-Hole Peg Test ; upper limb basic functional activity questions and the Barthel Activities of Daily Living ( ADL ) Index . Stroke-related quality of life/participation restriction was measured using the Stroke Impact Scale , European Quality of Life-5 Dimensions ( EQ-5D ) and the Oxford H and icap Scale . Upper limb pain was assessed using numerical rating scales . Participant-selected upper limb goal achievement ( 1 month only ) was measured using the Canadian Occupational Performance Measure . Adverse events were compared . Health-care and social services re source use was compared during the first 3 months postr and omisation . EQ-5D data were used to calculate the quality -adjusted life-years ( QALYs ) associated with intervention and control treatments , and the incremental cost per QALY gained of botulinum toxin type A plus therapy compared with therapy alone was estimated . The sensitivity of the base-case results to alternative assumptions was investigated , and cost-effectiveness acceptability curves , which summarise the evidence of botulinum toxin type A plus therapy being cost-effective for a range of societal willingness to pay for a QALY values , are presented . RESULTS R and omisation groups were well matched at baseline . There was no significant difference between the groups for the primary outcome of improved arm function at 1 month . This was achieved by 30/154 ( 19.5 % ) in the control group and 42/167 ( 25.1 % ) in the intervention group ( p = 0.232 ) . The relative risk of having a ' successful treatment ' in the intervention group compared with the control group was 1.3 [ 95 % confidence interval ( CI ) 0.9 to 2.0 ] . No significant differences in improved arm function were seen at 3 or 12 months . In terms of secondary outcomes , muscle tone/spasticity at the elbow was decreased in the intervention group compared with the control group at 1 month . The median change in the Modified Ashworth Scale was - 1 in the intervention group compared with zero in the control group ( p < 0.001 ) . No difference in spasticity was seen at 3 or 12 months . Participants treated with botulinum toxin type A showed improvement in upper limb muscle strength at 3 months . The mean change in strength from baseline ( upper limb component of the Motricity Index ) was 3.5 ( 95 % CI 0.1 to 6.8 ) points greater in the intervention group compared with the control group . No differences were seen at 1 or 12 months . Participants in the intervention group were more likely to be able to undertake specific basic functional activities , e.g. dress a sleeve , clean the palm and open the h and for cutting fingernails . At 1 month , 109/144 ( 75.7 % ) of the intervention group and 79/125 ( 63.2 % ) of the control group had improved by at least one point on a five-point Likert scale for at least one of these tasks ( p = 0.033 ) . At 3 months the corresponding proportions were 102/142 ( 71.8 % ) of the intervention group and 71/122 ( 58.2 % ) of the control group ( p = 0.027 ) . Improvement was sustained at 12 months for opening the h and for cleaning the palm and opening the h and for cutting the nails but not for other activities . Pain rating improved by two points on a 10-point severity rating scale in the intervention group compared with zero points in the control group ( p = 0.004 ) at 12 months , but no significant differences were seen at 1 or 3 months . There were a number of occasions when there were statistically significant differences in favour of the intervention group ; however , these differences were small and of uncertain clinical relevance . These differences were : 3 months - upper limb function ( change in ARAT score from baseline ) , pain ( EQ-5D ) and participation restriction ( Oxford H and icap Scale ) ; 12 months - anxiety/depression ( EQ-5D ) and participation restriction ( Oxford H and icap Scale ) . No differences in grip strength , dexterity or the Barthel ADL Index were found at any time point . There were no differences between the groups for achievement of patient-selected goals . There was a higher incidence of general malaise/flu-like/cold symptoms in participants treated with botulinum toxin type A with a relative risk of 7.6 ( 95 % CI 1.8 to 32.3 ) . Only one serious adverse event ( dysphagia ) was potentially related to botulinum toxin type A.  Time since stroke and severity of initial upper limb function were preplanned subgroup analyses . There was no significant difference in either subgroup for achievement of ARAT ' success ' following treatment with botulinum toxin type A. The base-case incremental cost-effectiveness ratio was 93,500 pounds per QALY gained and estimation of the cost-effectiveness acceptability curve for botulinum toxin type A plus the upper limb therapy programme indicated that there was only a 0.36 probability of it being cost-effective at a threshold ceiling ratio of 20,000 pounds per QALY . CONCLUSIONS The addition of botulinum toxin type A to an upper limb therapy programme to treat spasticity due to stroke did not enhance improvement in upper limb function when assessed by the prespecified primary outcome measure at 1 month . However , improvements were seen in muscle tone at 1 month , upper limb strength at 3 months , upper limb functional activities related to undertaking specific basic functional tasks at 1 , 3 and 12 months , and upper limb pain at 12 months . Botulinum toxin was well tolerated and side effects were minor . The addition of botulinum toxin type A to an upper limb therapy programme for the treatment of upper limb spasticity due to stroke was not estimated to be cost-effective at levels of willingness to pay for a QALY set by NHS decision-makers . TRIAL REGISTRATION IS RCT N78533119 ; EudraCT 2004 - 002427 - 40 ; CTA 17136/0230/001 
    Output:
    
The ArmA is design ed to measure passive and active function following focal interventions for the hemiparetic upper limb .