Byl 2003

Methods	Randomized controlled cross‐over trial
Participants	Country: USA Setting: unclear 21 post‐stroke patients Mean time post stroke: 5.1 years Mean age: 63 years (SD 9.4 with a range of 42 to 79 years) 12 males and 6 females completed the study Inclusion criteria: stroke (either right or left hemisphere) at least 6 months in duration, able to walk 100 feet with or without a cane, partially opened and closed the hand, partially elevated the shoulder and elbow against gravity (45 to 60 degrees), can speak conversational English Exclusion criteria: tramatic brain injury, degenerative neuromuscular disease, or serious musculoskelatal injury
Interventions	Based on principles of neural adaptation Group A: 4 weeks sensory discrimination retraining then 4 weeks fine motor retraining Group B: 4 weeks fine motor retraining and then 4 weeks sensory discrimination retraining Each session 90 minsutes (also combination of guided mental imagery for 15 to 20 minutes and glove use on least affected limb 7 hours per day, home program)
Outcomes	Outcome measures: baseline, 4 and 8 weeks, and then 3 months post treatment Sensory discrimination (kinesthesia, graphesthesia, stereognosis) Fine motor control (digital reaction time, performance time on Purdue Peg Board) Upper extremity strength and range of motion Functional independence (Wolf motor Function Test, Califormia Functional Evaluation, gait speed)
Notes
Risk of bias
Bias	Authors' judgement	Support for judgement
Adequate sequence generation?	Unclear risk	Quote: "Subjects were randomly assigned" Comments: no specifics of sequence generation provided
Allocation concealment?	Unclear risk	Quote: "Subjects were randomly assigned" Comments: no mention of allocation concealment
Blinding? All outcomes	Low risk	Quote: "The evaluators were blinded to group assignment and a different evaluator readministered the tests at each assessment period. This controlled for the bias of retesting by the same evaluator" Comment: authors further state that "Where possible parallel test forms were administered at the beginning and the end of the study to minimize the bias of patient learning with retesting." Unlikely that therapist or participant blinding occurred
Incomplete outcome data addressed? All outcomes	Unclear risk	Quote: "Twenty‐one subjects were admitted to the study. Three subjects (1 from group A and 2 from Group B) were dropped from the study due to unrelated medical or personal problems." Comment: data for all measures and 18 remaining patients are presented in Tables 5 and 6 of the published study for outcomes at 4 and 8 weeks 3‐month follow‐up consisted of only 10 participants (first 10 admitted to the study) Although data for the 10 are reported in table 6, no statement as to why all 18 did not complete 3‐month follow‐up (or which patients were not included in this long‐term follow‐up)
Free of selective reporting?	Low risk	All planned outcomes were commented on in the Results section
Free of other bias?	Unclear risk	Comment: this was a cross‐over design with potential carry‐over effects across treatments (over 8 week period) Figure 4 in the published study indicates that group B made significant gains in both fine motor and sensory discrim during second 4 weeks of treatment No control group for comparison Authors appropriately report other study limitations in Discussion section