What is the functional outcome for the upper limb after stroke?

Reliability and validity of Six-Spot Step Test (SSST) in stroke survivors

BACKGROUND

The Six-Spot Step Test (SSST) was originally developed to assess walking ability while challenging balance during walking in patients with multiple sclerosis. It provides more comprehensive information on ambulatory abilities than several existing measures such as the Timed Up & Go test (TUG test), the Functional Gait Assessment, and the Dynamic Gait Index. To assess the advanced balance control ability of stroke survivors, we modified the SSST to serve this purpose.

AIM

The aim of this study was to expand the current understanding of the psychometric properties of the SSST using healthy older adults and stroke survivors.

DESIGN

This study adopted an experimental design.

SETTING

University-affiliated neurorehabilitation laboratory.

POPULATION

A total of 50 study participants, including 25 chronic stroke survivors and 25 healthy older adults, were recruited from the community.

METHODS

The SSST was administered to the stroke survivors twice (day 1 & 2) with a 1-week interval. The Fugl-Meyer assessment for the lower extremities (FMA-LE), the Berg Balance scale (BBS), the limit of stability (LOS) test, the Timed Up & Go test (TUG test), and the Chinese version of the Community Integration Measures (CIM-C) were assessed on day 1 by random order. The healthy control group was assessed with the Six-Spot Step Test only on day 1.

RESULTS

The SSST showed excellent inter-rater, intra-rater, and test-retest reliability (intraclass correlation coefficient>0.95, p<0.001). Significant correlations were found between SSST performance and the FMA-LE results (r=0.517, p<0.05), BBS scores (q r =-0.531, p<0.05), and TUG test scores (r =0.828, p<0.001). The MDC in the mean SSST time for the affected leg and the unaffected leg in stroke survivors was 6.05s. The cutoff time was 10.11s (sensitivity, 80%; specificity, 92%) when kicking obstacles with the affected leg and 10.18s (sensitivity, 80%; specificity, 92%) when kicking obstacles with the unaffected leg.

CONCLUSIONS

The SSST was a reliable test and showed a significant correlation with FMA-LE scores, BBS scores, and TUG test times in stroke survivors.

CLINICAL REHABILITATION IMPACT

The SSST can be used to assess the advanced balance control of stroke survivors.

Physiotherapy based on problem-solving in upper limb function and neuroplasticity in chronic stroke patients: A case series

RATIONALE, AIMS, AND OBJECTIVES

Upper limb recovery is one of the main concerns of stroke neurorehabilitation. Neuroplasticity might underlie such recovery, particularly in the chronic phase. The purpose of this study was to assess the effect of physiotherapy based on problem-solving in recovering arm function in chronic stroke patients and explore its neuroplastic changes.

METHODS

A small sample research design with a n of 3 using a pre-post test design was carried out. Neuroplasticity and function were assessed by using functional magnetic resonance imaging (during motor imagery and performance), action research arm test, motor assessment scale, and Fugl-Meyer assessment scale, at 3 sequential time periods: baseline(m0-before a 4-week period without physiotherapy), pre-treatment(m1), and post-treatment(m2). Minimal clinical important differences and a recovery score were assessed. Assessors were blinded to moment assignment. Patients¹ underwent physiotherapy sessions, 50 minutes, 5 days/week for 4 weeks. Four control subjects served as a reference for functional magnetic resonance imaging changes.

RESULTS

All patients recovered more than 20% after intervention. Stroke patients had similar increased areas as healthy subjects during motor execution but not during imagination at baseline. Consequently, all patients increased activity in the contralateral precentral area after intervention.

CONCLUSIONS

This study indicates that 4 weeks of physiotherapy promoted the recovery of arm function and neuroplasticity in all chronic stroke patients. Future research is recommended to determine the efficacy of this therapy.

Prediction of Walking and Arm Recovery after Stroke: A Critical Review

Clinicians often base their predictions of walking and arm recovery on multiple predictors. Multivariate prediction models may assist clinicians to make accurate predictions. Several reviews have been published on the prediction of motor recovery after stroke, but none have critically appraised development and validation studies of models for predicting walking and arm recovery. In this review, we highlight some common methodological limitations of models that have been developed and validated. Notable models include the proportional recovery model and the PREP algorithm. We also identify five other models based on clinical predictors that might be ready for further validation. It has been suggested that neurophysiological and neuroimaging data may be used to predict arm recovery. Current evidence suggests, but does not show conclusively, that the addition of neurophysiological and neuroimaging data to models containing clinical predictors yields clinically important increases in predictive accuracy.

Recovery of the upper limb post ischaemic stroke and the predictive value of the Orpington Prognostic Score

Objective: To document upper limb recovery in stroke patients and investigate whether the Orpington Prognostic Score (OPS) performed within 48 hours of admission to hospital post ischaemic stroke was a predictor of upper limb function at six months and two years.

Design: Inception cohort design.

Setting: Teaching Hospital.

Subjects: One hundred and fourteen patients hospitalized with acute ischaemic stroke were stratified into three groups based on their OPS within 48 hours of admission post stroke and underwent further assessments at two weeks, six months and two years after stroke onset.

Main measures: Rivermead Arm Score (RAS), Nine Hole Peg Test (NHPT) and grip strength (GS).

Results: Patients with a good OPS and intermediate OPS showed significant recovery in all outcome measures for up to six months post stroke ( p < 0.05), while those with a poor OPS at 48 hours showed no significant improvement ( p < 0.05). The OPS score at 48 hours was the most highly correlated variable with upper limb outcome at six months (r = -0.728) and at two years (r = -0.712) compared with other variables such as age, class of stroke, sensation, grip strength and RAS.

Conclusion: Stroke patients demonstrate differential upper limb recovery patterns which need to be taken in consideration when designing studies that investigate efficacy of rehabilitation, and the OPS is highly correlated with upper limb recovery at six months and two years.

Older adults experience difficulty completing the lines and dots tasks of the Motor Assessment Scale

BACKGROUND

The advanced hand activities item of the Motor Assessment Scale (Upper Limb items, UL-MAS) includes the 'lines' and 'dots' tasks, which require skilful pencil use. Prior Rasch analysis studies identify these two tasks as the most difficult to achieve for stroke survivors compared with the other advanced hand activities. Yet it is unknown if healthy, older adults can perform these two tasks.

OBJECTIVES

To describe the performance of older adults' without stroke on the 'lines' and 'dots' tasks, relationship between age and task performance, and relationship between writing speed and performance on the 'lines' task.

METHODS

Cross-sectional study design. A sample of healthy older Australians (n = 120) aged between 60 and 99 years completed the UL-MAS 'lines' and 'dots' tasks and wrote two sentences using pencil.

RESULTS

Fifty-four participants (45%) failed the UL-MAS 'lines' task. Differences in line drawing performance across age groups were statistically significant (chi-square = 9.02, df = 3, p = .03). Eleven participants (9%) failed the 'dots' task, mostly from the 90 to 99 year age group. Participants who passed the 'lines' task wrote sentences faster than participants who failed (p<.001).

CONCLUSION

Older adults may not pass the UL-MAS 'lines' and 'dots' tasks due to age and individual skill level.

Games for Rehabilitation: Wii-based Movement Therapy Improves Poststroke Movement Ability

Stroke is the leading cause of adult-acquired motor disability. The greatest impediments to poststroke rehabilitation are access and patient compliance. Wii-based Movement Therapy was developed as an alternative to conventional and virtual reality therapies to overcome issues of rehabilitation access, cost, and patient compliance. Its success is evident by high levels of re-engagement in the community post-therapy.

The effect of olfactory stimuli on the balance ability of stroke patients

[Purpose] The present study attempted to identify the effect of olfactory stimulation on the balance ability of stroke patients. [Subjects] Thirty-three (33 males) stroke patients participated in the study. The stroke patients were divided into three groups: a black pepper oil (BPO) group (n=11), lavender oil (LVO) group (n=11), and distilled water (DW) group (n=11). [Methods] Two sessions (control trial/stimulus trial) of Romberg's test (eyes open 1 min/eyes closed 1 min) were conducted on a force platform to measure the data for the COP (center of pressure). Olfactory stimulation was provided at as a stimulus. [Results] With the eyes open, a statistically significant difference was found in average anterior posterior displacement (Ymean) and average medial lateral displacement (Xmean) among the three groups when comparing the groups before and after stimulation. The comparison between the eyes open and eyes closed conditions in each group showed a significant difference in the area of the 95% confidence ellipse (area) and Xmean of the BPO group and in the area of the LVO group (area, Xmean). [Conclusion] The findings indicate that the interaction of brain areas activated by the olfactory stimulation exerts an influence on the balance ability of stroke patients.

Comparison of three tools to measure improvements in upper-limb function with poststroke therapy

BACKGROUND

Functional ability is regularly monitored poststroke to assess improvement and the efficacy of clinical trials. The balance between implementation times and sensitivity has led to multidomain tools that aim to assess upper-limb function comprehensively.

OBJECTIVE

This study implemented 3 common multidomain tools to investigate their suitability across a broad spectrum of movement ability after stroke.

METHODS

Forty-nine hemiparetic patients (18 females), aged 22 to 83 years and 24.7 ± 39.2 months poststroke, were assessed before and after a 14-day upper-limb rehabilitation program of Wii-based Movement Therapy. Assessments included the upper-limb motor subscale of the Fugl-Meyer Assessment (F-M), the Wolf Motor Function Test (WMFT), and the Motor Assessment Scale (MAS) upper-limb sections 6 to 8. The MAS was analyzed both with and without the hierarchical system. Patients were stratified with low, moderate, or high motor-function.

RESULTS

Upper-limb function improved significantly for the pooled cohort for all assessments (P < .001), although ceiling effects were evident for the F-M, floor effects for the WMFT, and both floor and ceiling effects for MAS. When analyzed by stratified subgroup these improvements were significant for all groups with the F-M, for the moderate and high motor-function groups with both the WMFT and the MAS scored without hierarchical system, but only for the high motor-function group with the hierarchically scored MAS.

CONCLUSION

These results suggest that no single test is suitable for measuring function and improvement across the spectrum of poststroke upper-limb dysfunction and that assessment tool selection should be based on the level of residual motor-function of individual patients.

Age-dependent reorganization of peri-infarct "premotor" cortex with task-specific rehabilitative training in mice

BACKGROUND

The incidence of stroke in adulthood increases with advancing age, but there is little understanding of how poststroke treatment should be tailored by age.

OBJECTIVE

The goal of this study was to determine if age and task specificity of rehabilitative training affect behavioral improvement and motor cortical organization after stroke.

METHODS

Young and aged mice were trained to proficiency on the Pasta Matrix Reaching Task prior to lesion induction in primary motor cortex with endothelin-1. After a short recovery period, mice received 9 weeks of rehabilitative training on either the previously learned task (Pasta Matrix Reaching), a different reaching task (Tray Reaching), or no training. To determine the extent of relearning, mice were tested once weekly on the Pasta Matrix Reaching Task. Mice then underwent intracortical microstimulation mapping to resolve the remaining forelimb movement representations in perilesion motor cortex.

RESULTS

Although aged mice had significantly larger lesions compared with young mice, Pasta Matrix Reaching served as effective rehabilitative training for both age-groups. Young animals also showed improvement after Tray Reaching. Behavioral improvement in young mice was associated with an expansion of the rostral forelimb area ("premotor" cortex), but we failed to see reorganization in the aged brain, despite similar behavioral improvements.

CONCLUSIONS

Our results indicate that reorganization of motor cortex may be limited by either aging or greater tissue damage, but the capacity to improve motor function via task-specific rehabilitative training continues to be well maintained in aged animals.

Rasch-based scoring offered more precision in differentiating patient groups in measuring upper limb function

OBJECTIVE

To compare the discriminatory ability of Rasch-based and summative scoring in the context of assessing upper limb function of patients with stroke.

STUDY DESIGN AND SETTING

Data were from a cohort study of 497 adults with stroke undergoing physiotherapy. Upper limb function was assessed at admission and discharge using the upper limb subscale of the Motor Assessment Scale (UL-MAS). Rasch analysis was used to transform raw UL-MAS scores into interval measures. A relative precision (RP) index was used to differentiate patients by discharge destination.

RESULTS

The analysis confirmed the unidimensional structure of UL-MAS at both admission and discharge and demonstrated the adequate fit of the items. The RP index favored the Rasch-based scoring over the summative scoring in differentiating between the two patient groups, with significant gains in precision at admission (15%) and discharge (11%). When examining patients in the upper or lower quartile of UL-MAS, the gains in precision were statistically significant in favor of the Rasch-based scoring, with 20% precision at admission and 19% precision at discharge.

CONCLUSION

Rasch-based scoring was more precise in differentiating patient groups by discharge destination than the summative scoring used to measure upper limb function, especially at the extreme range of the scale.

The impact of mental practice on stroke patients' postural balance

INTRODUCTION

The most common problem in stroke patients is reduced balance and derangements of postural control that lead to increase the chance of falling and instability during walking. Since physical practice improves balance and postural control, it is assumed also that the application of mental practice would be useful in enhancing such balance. Mental practice is defined as the cognitive rehearsal of a physical skill in the absence of overt physical movements. Factors such as similar time between actual execution and mental performance of a task, the increase of regional cerebral blood flow and also the vegetative activation, all suggest that mental practice imitates physical performance of a task. Thus, the main purpose of this study was to investigate the effect of such mental practice on postural balance among stroke survivors.

METHOD AND MATERIALS

This study was implemented as an experimental (interventional), case-control, double blind and randomized trial design. A total of 30 subjects (16 males and 14 females) with necessary arousal, attention and memory functions as their major components of mental practice, participated. Subjects' mean ages were 48.1 ± 10.5 years. They were divided randomly in two control and experimental groups. Timed Get up and Go (TUG) test was used to evaluate the balance of all participants. They were assessed before-after treatment and two weeks post-treatment as research's follow up. The two groups received the same method of occupational therapy services, but the experimental group in addition to aforementioned occupational therapy, was requested to participate in mental practice sessions.

RESULTS

Mental practice had a significant effect on postural balance in stroke survivors (P=<0.001).

CONCLUSION

Mental practice may improve postural balance in stroke patients and can be considered for them as a beneficial rehabilitative technique.

SALGOT--Stroke Arm Longitudinal study at the University of Gothenburg, prospective cohort study protocol

Background

Recovery patterns of upper extremity motor function have been described in several longitudinal studies, but most of these studies have had selected samples, short follow up times or insufficient outcomes on motor function. The general understanding is that improvements in upper extremity occur mainly during the first month after the stroke incident and little if any, significant recovery can be gained after 3-6 months. The purpose of this study is to describe the recovery of upper extremity function longitudinally in a non-selected sample initially admitted to a stroke unit with first ever stroke, living in Gothenburg urban area.

Methods/Design

A sample of 120 participants with a first-ever stroke and impaired upper extremity function will be consecutively included from an acute stroke unit and followed longitudinally for one year. Assessments are performed at eight occasions: at day 3 and 10, week 3, 4 and 6, month 3, 6 and 12 after onset of stroke. The primary clinical outcome measures are Action Research Arm Test and Fugl-Meyer Assessment for Upper Extremity. As additional measures, two new computer based objective methods with kinematic analysis of arm movements are used. The ABILHAND questionnaire of manual ability, Stroke Impact Scale, grip strength, spasticity, pain, passive range of motion and cognitive function will be assessed as well. At one year follow up, two patient reported outcomes, Impact on Participation and Autonomy and EuroQol Quality of Life Scale, will be added to cover the status of participation and aspects of health related quality of life.

Discussion

This study comprises a non-selected population with first ever stroke and impaired arm function. Measurements are performed both using traditional clinical assessments as well as computer based measurement systems providing objective kinematic data. The ICF classification of functioning, disability and health is used as framework for the selection of assessment measures. The study design with several repeated measurements on motor function will give us more confident information about the recovery patterns after stroke. This knowledge is essential both for optimizing rehabilitation planning as well as providing important information to the patient about the recovery perspectives.

Trial registration

ClinicalTrials.gov: NCT01115348

Mental practice for treating upper extremity deficits in individuals with hemiparesis after stroke

BACKGROUND

Activity limitations of the upper extremity are a common finding for individuals living with stroke. Mental practice (MP) is a training method that uses cognitive rehearsal of activities to improve performance of those activities.

OBJECTIVES

To determine if MP improves the outcome of upper extremity rehabilitation for individuals living with the effects of stroke.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (November 2010), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, November 2009), PubMed (1965 to November 2009), EMBASE (1980 to November 2009), CINAHL (1982 to November 2009), PsycINFO (1872 to November 2009), Scopus (1996 to November 2009), Web of Science (1955 to November 2009), the Physiotherapy Evidence Database (PEDro), CIRRIE, REHABDATA, ongoing trials registers, and also handsearched relevant journals and searched reference lists.

SELECTION CRITERIA

Randomised controlled trials involving adults with stroke who had deficits in upper extremity function.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion. We considered the primary outcome to be the ability of the arm to be used for appropriate tasks (i.e. arm function).

MAIN RESULTS

We included six studies involving 119 participants. We combined studies that evaluated MP in addition to another treatment versus the other treatment alone. Mental practice in combination with other treatment appears more effective in improving upper extremity function than the other treatment alone (Z = 3.48, P = 0.0005; standardised mean difference (SMD) 1.37; 95% confidence interval (CI) 0.60 to 2.15). We attempted subgroup analyses, based on time since stroke and dosage of MP; however, numbers in each group were small. We evaluated the quality of the evidence with the PEDro scale, ranging from 6 to 9 out of 10; we determined the GRADE score to be moderate.

AUTHORS' CONCLUSIONS

There is limited evidence to suggest that MP in combination with other rehabilitation treatment appears to be beneficial in improving upper extremity function after stroke, as compared with other rehabilitation treatment without MP. Evidence regarding improvement in motor recovery and quality of movement is less clear. There is no clear pattern regarding the ideal dosage of MP required to improve outcomes. Further studies are required to evaluate the effect of MP on time post stroke, volume of MP that is required to affect the outcomes and whether improvement is maintained long-term. Numerous large ongoing studies will soon improve the evidence base.

The test-retest reliability and responsiveness to change for the Hand Function Survey during stroke rehabilitation

BACKGROUND/AIM

The Hand Function Survey (HFS) is a questionnaire designed to measure self-reported ability to use the affected hand during 13 everyday tasks in people with stroke. The HFS appears practical for clinical use and has established psychometric properties. This study aimed to investigate test-retest reliability and responsiveness to change for the HFS during stroke rehabilitation.

METHODS

Twenty-two people with a first episode stroke, and without severe cognitive and language difficulties, participated. Participants were assessed on three occasions: baseline, 48 hours later and at follow-up (four to six weeks later) using two tests of upper extremity function, the HFS and the Action Research Arm Test (ARAT). Test-retest reliability of the HFS between baseline and 48 hours was examined using tests of agreement (Lin's Concordance and Cohen's Kappa). Responsive to change for the HFS was investigated by comparing the difference between baseline and follow-up scores. The level of agreement between the change observed for the ARAT and HFS was analysed.

RESULTS

Strong agreement (Rho_c = 0.99; Κ(w) =0.97) was observed between the test-retest HFS scores. Significant improvement between baseline and follow-up occurred for both the HFS and ARAT. A moderate agreement was found between change observed for the HFS and ARAT (Rho_c=0.62; Κ(w) =0.65).

CONCLUSION

The HFS was found to be a reliable and responsive self-report test of hand function during stroke rehabilitation. The HFS could be used in conjunction with other clinical tests of hand function during the rehabilitation of people with stroke without severe cognitive and language difficulties.

Development and Trial of an Upper Limb Assessment Tool for the Acute Neurological Patient

Background:

Within acute neurosciences, occupational therapy upper limb assessment facilitates acute rehabilitation, prevention of secondary complications, and discharge planning.

Purpose:

The purpose of this preliminary study was to investigate best practice upper limb assessment of the acute neurological patient.

Procedures:

An occupational therapy internal audit identified the need for an acute-specific upper limb assessment. Although a comprehensive literature review failed to identify a suitable pre-existing assessment, two standardised assessments formed the basis of a composite assessment tool.

Findings:

Positive clinician feedback to the trial of the composite assessment indicated its potential clinical utility.

Conclusion:

Further modification and acute-care trials are recommended to ascertain if the establishment of psychometric properties is warranted.

Reliability, validity and factor structure of the upper limb subscale of the Motor Assessment Scale (UL-MAS) in adults following stroke

PURPOSE

The upper limb items of the Motor Assessment Scale (MAS) have been shown to be a sensitive, valid and reliable measure of upper limb function for adults following stroke, however the validity and reliability of summing these items into an independent subscale has not yet been evaluated. The stability, internal consistency and construct validity of the upper limb MAS subscale (UL-MAS) was assessed in this study.

METHOD

Twenty-seven inpatients following stroke (mean age = 67 years, range = 40 - 80) were sampled from an acute, inpatient rehabilitation setting. Patients were evaluated with 'Upper Arm Function', 'Hand Movements', and 'Advanced Hand Activities' items of the MAS by masked physiotherapists who had received standardized training in administration of the MAS.

RESULTS

All items were explained by one factor on confirmatory factor analysis and correlated significantly with one another and with the composite (summed total) score. Internal consistency analysis produced a Cronbach's alpha of 0.83 which did not benefit from removal of any items.

CONCLUSIONS

The acceptable internal consistency score obtained verifies the validity and reliability of using the UL-MAS as an independent scale. This study has also verified the construct validity of the UL-MAS subscale and provides a valuable extension of previous work, which together demonstrates the value of the UL-MAS as a responsive, valid and reliable measure of upper limb function in adults following stroke. The UL-MAS produced a single, composite score that could be interpreted as a total score for upper limb function in this population.

Clinical measures of handgrip limitation relate to impaired pinch grip force control after stroke

This study examined whether clinical measures of handgrip limitation relate to laboratory measures of grip force impairment during a pinch grip, lift, and hold task post-stroke. Handgrip ability in 45 people with stroke who had residual grip ability was examined relative to 45 age-matched healthy adults. The clinical tests included items from a) the Jebsen Taylor Hand Function Test; b) the Motor Assessment Scale; c) the Functional Independence Measure (FIM); and d) a custom-designed survey about hand-use in daily life. The laboratory test was summarized by principal components: 1) Pre-Lift Delay and 2) Grip Force Dyscontrol. For the stroke group, a moderate to strong correlation was found between Pre-Lift Delay and each clinical measure of handgrip limitation (rs=0.70-0.85) except the FIM (rs=0.38-0.49). In contrast, Grip Force Dyscontrol was not associated with handgrip limitation on any of the clinical tests (rs=-0.08 to 0.18).

Assessments of Upper Limb Ability following Stroke: A Review

The aim of this paper was to review the psychometric properties and clinical utility of assessments of upper limb ability following stroke. Upper limb ability was defined as the use of the arm in meaningful activity. The database searches identified 13 assessments of upper limb ability. The inclusion criteria were (a) an evaluation of upper limb ability post-stroke, (b) a quantitative assessment yielding a numerical score, (c) able to be administered by an occupational therapist and (d) published information building on the results of a review in 2001. The assessments included were reviewed with respect to the ability measured, equipment required, evidence of reliability and validity, and advantages and disadvantages of use.

Seven assessments satisfied the inclusion criteria. These assessments have undergone varying degrees of psychometric testing as outcome measures for upper limb recovery and all demonstrate at least adequate levels of reliability and validity. There is variation in the availability of instruction manuals and time commitments for test administration. All test items are generally available and inexpensive, enabling departments to set up the assessments with minimal financial outlay.

The assessments described are regularly used in research and all demonstrate psychometric properties that suggest that they could be incorporated into clinical practice. Occupational therapists are encouraged to consider how they may include these assessments into their own clinical practice. An important step in this process may be further research into the clinical utility of these assessments.

The sensitivity of three commonly used outcome measures to detect change amongst patients receiving inpatient rehabilitation following stroke

OBJECTIVE

To investigate the sensitivity of three commonly used functional outcome measures to detect change over time in subjects receiving inpatient rehabilitation post stroke.

DESIGN

Subjects were assessed within one week of admission and one week of discharge from an inpatient rehabilitation facility. Several parameters of sensitivity were calculated, including floor and ceiling effects, the percentage of subjects showing no change and the effect size of the change between admission and discharge.

SETTING

The medical rehabilitation ward of an inpatient rehabilitation facility.

SUBJECTS

Seventy-eight subjects receiving inpatient rehabilitation following a first or recurrent stroke.

MEASURES

Five-metre walk, comfortable pace (gait speed), the Berg Balance Scale and the Motor Assessment Scale.

RESULTS

Sixty-one subjects had complete admission and discharge data. Gait speed and the Berg Balance Scale were both sensitive to change and demonstrated large effect sizes. The Motor Assessment Scale item five also showed a large effect size and was able to detect change amongst lower functioning subjects. The other items of the Motor Assessment Scale were less useful, in particular, the effect sizes for upper extremity change scores were small (d=0.36-0.5) and the majority of subjects (44.3-63.9%) showed no change over time on these measures.

CONCLUSION

Gait speed, the Berg Balance Scale and the Motor Assessment Scale item five were sensitive to change over time in this sample.

Observation of arm behaviour in healthy elderly people: Implications for contracture prevention after stroke

The purpose of this study was to observe normal arm movement in healthy older adults to determine the duration, frequency, and purpose of arm elevation and external rotation to guide clinical practice in the prevention of contracture. An observational study was undertaken in the homes and local community of 21 older people mean age 73 (SD 7) years. Participants' arm movements were observed for a median time of 254 (IQR 85) min during the day. The duration (min/hr) and frequency (movements/hr) which the arm spent in positions of 45 degrees to 90 degrees elevation, > 90 degrees elevation, and external rotation, as well as the purpose (manipulating, holding, reaching, pulling/pushing, or gesturing) for which these positions were adopted, were recorded. Participants' arms spent little time (3.6 min/hr) at 45 to 90 degrees elevation and almost no time (0.6 min/hr) at > 90 degrees elevation or external rotation (0.6 min/hr). Participants' arms moved to > 90 degrees elevation 13 times/hr and into external rotation 18 times/hr. Participants moved momentarily to elevation > 45 degrees and external rotation in order to reach for objects, while holding objects was the primary reason for maintaining positions for > 2 s. It may be possible to minimise the incidence of shoulder contracture in those patients with stroke who have regained some shoulder muscle activity by placing at-risk muscles in lengthened positions while replicating these features of everyday activities.

Motor recovery after stroke: a systematic review of the literature

OBJECTIVE

To collect and integrate existing data concerning the occurrence, extent, time course, and prognostic determinants of motor recovery after stroke using a systematic methodologic approach.

DATA SOURCES

A computer-aided search in bibliographic databases was done of longitudinal cohort studies, original prognostic studies, and randomized controlled trials published in the period 1966 to November 2001, which was expanded by references from retrieved articles and narrative reviews.

STUDY SELECTION

After a preliminary screening, internal, external, and statistical validity was assessed by a priori methodologic criteria, with special emphasis on the internal validity.

DATA EXTRACTION

The studies finally selected were discussed, based on the quantitative analysis of the outcome measures and prognostic determinants. Meta-analysis was pursued, but was not possible because of substantial heterogeneity.

DATA SYNTHESIS

The search resulted in 174 potentially relevant studies, of which 80 passed the preliminary screening and were subjected to further methodologic assessment; 14 studies were finally selected. Approximately 65% of the hospitalized stroke survivors with initial motor deficits of the lower extremity showed some degree of motor recovery. In the case of paralysis, complete motor recovery occurred in less than 15% of the patients, both for the upper and lower extremities. Hospitalized patients with small lacunar strokes showed relatively good motor recovery. The recovery period in patients with severe stroke was twice as long as in patients with mild stroke. The initial grade of paresis was the most important predictor for motor recovery (odds ratios [OR], >4). Objective analysis of the motor pathways by motor-evoked potentials (MEPs) showed even higher ORs (ORs, >20).

CONCLUSIONS

Our knowledge of motor recovery after stroke in more accurate, quantitative, and qualitive terms is still limited. Nevertheless, our data synthesis and quantitative analysis comprises data from many methodologically robust studies, which may support the clinician in the management of stroke patients. With respect to early prognosis of motor recovery, our review confirms clinical experience that the initial grade of paresis (as measured on admission in the hospital) is the most important predictor, although the accuracy of prediction rapidly improves during the first few days after stroke. Initial paralysis implies the worst prognosis for subsequent motor recovery. Remarkably, the prognostic accuracy of MEPs appears much higher than that of clinical examination for different subgroups of patients.