Admission motor impairment as a predictor of physical disability after stroke rehabilitation

Factors Influencing Real-World Use of the More-Affected Upper Limb After Stroke: A Scoping Review

IMPORTANCE

Current interventions are limited in improving use of the more-affected upper limb in real-world daily occupations and functional independence poststroke. A comprehensive understanding of the factors influencing real-world upper limb use is required to develop interventions to improve functional independence poststroke.

OBJECTIVE

To systematically review the factors that influence real-world use of the more-affected upper limb poststroke.

DATA SOURCES

We searched MEDLINE, Embase, PsycINFO, and the Physiotherapy Evidence Database for English-language articles from 2012 to 2023.

STUDY SELECTION AND DATA COLLECTION

Of 774 studies, we included 33 studies that had participants at least age 18 yr who exhibited upper limb impairments poststroke, objectively measured real-world upper limb use using a movement sensor, and measured factors affecting upper limb use. Two reviewers independently screened the abstracts.

FINDINGS

The results were categorized by International Classification of Functioning, Disability and Health domains. Prominent factors were upper limb impairment; motor ability; functional independence; task type; hand dominance; stroke-related factors, including time since stroke; and perception of use of the more-affected upper limb.

CONCLUSIONS AND RELEVANCE

Existing interventions primarily focus on upper limb impairments and motor ability. Our findings suggest that interventions should also incorporate other factors: task type (unilateral vs. bilateral), hand dominance, self-efficacy, and perception of more-affected limb use as active ingredients in improving real-world use of the more-affected upper limb poststroke. We also provide recommendations to use behavioral activation theory in designing an occupation-focused intervention to augment self-efficacy and confidence in use of the more-affected upper limb in daily occupations. Plain-Language Summary: In order to develop interventions to improve functional independence poststroke, occupational therapy practitioners must have a comprehensive understanding of the factors that influence real-world more-affected upper limb use. The study findings provide a set of distinct factors that practitioners can target separately or in combination to improve real-world use of the more-affected upper limb poststroke.

[Factors Modulating Motor Function Changes in Stroke Patients During Inpatient Neurological Rehabilitation]

PURPOSE

To identify factors that have an impact on the degree of functional improvements in stroke patients during inpatient neurological rehabilitation.

METHODS

Retrospective analysis of 398 stroke patients who participated in an inpatient Phase C rehabilitation (Barthel index between 30 and 70 points). We correlated changes in 3 physiotherapeutic assessments (transfer from sitting to standing; transfer from bed to (wheel)chair; climbing stairs) and 3 occupational therapeutic assessments (eating/drinking; dressing of the upper part of the body; object manipulation) with the factors age, gender, Barthel-Index at admission, time since stroke, length of stay in inpatient rehab, number and extent of therapies and ischemic versus hemorrhagic stroke. In addition, a stepwise regression analysis was performed.

RESULTS

The patient group showed significant improvements in all assessments. Length of stay in inpatient rehab and number/extent of therapies correlated with improvements of transfer from sitting to standing, transfer from bed to (wheel)chair, climbing stairs, and dressing of the upper part of the body. Number/extent of therapies also correlated with eating/drinking. Barthel-Index at admission was negatively correlated with transfer from sitting to standing, transfer from bed to (wheel)chair, and dressing of the upper part of the body. No correlation between changes of motor functions and age or gender or type of stroke (ischemic versus hemorrhagic) was found. Patients<3 months after stroke showed stronger improvements of transfer from sitting to standing, transfer from bed to (wheel)chair, climbing stairs, dressing of the upper part of the body, and object manipulation than patients>6 months after stroke. However, patients<3 months after stroke also stayed 10 days longer in inpatient rehab. The stepwise regression analysis identified the number of physiotherapies and Barthel-Index at admission as the most important factors for changes in transfer from sitting to standing and transfer from bed to (wheel)chair, number of physiotherapies and time since stroke for climbing stairs, number of occupational therapies for eating/drinking, number of occupational therapies and time since stroke for dressing the upper part of the body and number of occupational therapies and length of inpatient rehab for object manipulation.

CONCLUSION

In stroke patients, a higher number of therapies is associated with greater improvements of motor functions. Age, gender and type of stroke have no relevant impact on changes of motor functions during inpatient rehabilitation.

Prediction of hospitalization time and independence level with functional outcomes for patients with acute stroke: a retrospective study

OBJECTIVES

The objective of this study was to develop predictive models for estimating the length of stay (LOS) with standardized clinical outcome measures (Functional Independence Measure, Trunk Impairment Scale, Postural Assessment Scale for Stroke Patients, Fugl Meyer Assessment Scale, and Functional Ambulation Category) during acute care setting.

METHODS

One hundred sixty-nine patients were included in the retrospective study. Predictors chosen for the LOS included scores of functional outcome measures at admission. We used Spearman's rank correlation coefficients to calculate correlations among clinical outcome measures and LOS, stepwise multiple regression analysis to develop a predictive model, and receiver operating characteristics curve to analyze the predictive value of explanatory factors obtained from the previous model for discharge Functional Independence Measure score.

RESULTS

The predictive equation explained 81% of the variance in LOS. The most important predictors were trunk impairment, motor function of the upper extremity, walking ability, and independence level at admission. The receiver operating characteristic curve was obtained with a cut-off score of 13 points for the Trunk Impairment Scale, 47 points for Fugl Meyer Assessment-Upper Extremity, and 2 points for Functional Ambulation Category, demonstrating the highest percentage of the accurately predicted ability of independence level at discharge.

DISCUSSION

The models presented in this study could help clinicians and researchers to predict the LOS and discharge independence level of clinical outcomes for patients with acute stroke enrolled in an acute care setting.

Assessment of Lower Limb Motor Function, Ambulation, and Balance After Stroke

Restoration of ambulation is important for stroke patients. Valid and reliable methods are required for the assessment of lower limb functional status. We reviewed the psychometric properties of methods employed to assess lower extremity motor function, ambulation, and balance, with a focus on stroke patients. We define "motor function" as the ability to produce bodily movements when the brain, motor neurons, and muscles interact. "Ambulation" is defined as the ability to walk with or without a personal assistive device, and "balance" as the ability to maintain stability (without falling) during various physical activities. The Motricity Index and Fugl-Meyer Assessment of Lower Extremities assess the motor function of the lower limbs. The Functional Ambulation Category, 10-m Walk Test, and 6-minute Walk Test assess ambulation. The Berg Balance Scale, Timed Up and Go Test, Functional Reach Test, and Trunk Impairment Scale explore balance. All these tests exhibit high-level validity and have good inter-rater and test-retest reliabilities. However, only 3 methods have been formally translated into Korean. The methods discussed here can be used for standardized assessment, personalized goal setting, rehabilitation planning, and estimation of therapeutic efficacy.

Does severity of motor impairment affect reactive adaptation and fall-risk in chronic stroke survivors?

Background

A single-session of slip-perturbation training has shown to induce long-term fall risk reduction in older adults. Considering the spectrum of motor impairments and deficits in reactive balance after a cortical stroke, we aimed to determine if chronic stroke survivors could acquire and retain reactive adaptations to large slip-like perturbations and if these adaptations were dependent on severity of motor impairment.

Methods

Twenty-six chronic stroke participants were categorized into high and low-functioning groups based on their Chedoke-McMaster-Assessment scores. All participants received a pre-training, slip-like stance perturbation at level-III (highest intensity/acceleration) followed by 11 perturbations at a lower intensity (level-II). If in early phase, participants experienced > 3/5 falls, they were trained at a still lower intensity (level-I). Post-training, immediate scaling and short-term retention at 3 weeks post-training was examined. Perturbation outcome and post-slip center-of-mass (COM) stability was analyzed.

Results

On the pre-training trial, 60% of high and 100% of low-functioning participants fell. High-functioning group tolerated and adapted at training-intensity level-II but low-functioning group were trained at level-I (all had > 3 falls on level-II). At respective training intensities, both groups significantly lowered fall incidence from 1st through 11th trials, with improved post-slip stability and anterior shift in COM position, resulting from increased compensatory step length. Both groups demonstrated immediate scaling and short-term retention of the acquired stability control.

Conclusion

Chronic stroke survivors are able to acquire and retain adaptive reactive balance skills to reduce fall risk. Although similar adaptation was demonstrated by both groups, the low-functioning group might require greater dosage with gradual increment in training intensity.

Manual function of the unaffected upper extremity can affect functional outcome after stroke

Traditionally, motor deficits of ipsilesional side, generally considered as the unaffected side, have been investigated less and the influence of the impairment is unknown. To evaluate the association between the manual function test (MFT) of nonparetic limb and poststroke functional outcome. We conducted a retrospective analysis of 71 hemiplegic patients with stroke. MFT on both sides was routinely measured at admission and 1 month later after admission by an experienced occupational therapist. The parameters of functional outcome after stroke were measured with the total score of functional independence measure (FIM) and the self-care subscore of FIM. Age, initial cognitive function, and MFT of the affected hand and unaffected hand were each significant factors for independently predicting short-term functional outcome after stroke. Linear regression analysis showed that initial MFT score of unaffected side is a significant predictor for 1 month follow-up subscore FIM (P<0.0001) and total FIM score (P<0.0001). Our findings suggests that initial MFT score of the nonparetic side has a significant correlation with functional outcome. Therefore, it is important to conduct MFT on the nonparetic side as well as the paretic side. Furthermore, it is necessary to undergo rehabilitation therapy on the nonparetic side.

The Onset and Frequency of Spasticity After First Ever Stroke

BACKGROUND

Spasticity is one of the most important causes of disability after stroke. In spite of high incidence of spasticity, little is known about the relationship between the occurrence and the development of spasticity. This study aimed to determine risk-factors of post stroke spasticity.

METHODS

This was an observational study of 149 persons with first ever stroke. The following parameters were assessed: Stroke severity, Spasticity, Disability and Joint contracture.

RESULTS

Prevalence of spasticity was between 17-25% during the first 3 months after stroke. The onset of spasticity was 13.79% and 4.16% at 1 and 3 months after stroke respectively. The prevalence of spasticity in the upper extremity was significantly more than lower extremity at 1 month. Spasticity was significantly more severe in the upper extremity than lower extremity. In patients with hemorrhagic stroke Odds ratios of spasticity was 2.5 times more than persons with ischemic stroke (P = 0.0210. The Odds ratios of severe spasticity at 1 and 3 months were 1.66 and 1.75 times more than the first week (P = 0.024, P = 0.042 respectively).

CONCLUSIONS

Post stroke spasticity is more common in persons with hemorrhagic stroke, severe paresis and lower functional abilities. The most incidence of spasticity happens in the first month after stroke.

Efficacy of Task-Specific Training on Physical Activity Levels of People With Stroke: Protocol for a Randomized Controlled Trial

BACKGROUND

The majority of people after stroke demonstrate mobility limitations, which may reduce their physical activity levels. Task-specific training has been shown to be an effective intervention to improve mobility in individuals with stroke, however, little is known about the impact of this intervention on levels of physical activity.

OBJECTIVES

The main objective is to investigate the efficacy of task-specific training, focused on both upper and lower limbs, in improving physical activity levels and mobility in individuals with stroke. The secondary objective is to investigate the effects of the training on muscle strength, exercise capacity, and quality of life.

DESIGN

This is a randomized controlled trial.

SETTING

The setting is public health centers.

PARTICIPANTS

Community-dwelling people with chronic stroke.

INTERVENTIONS

Participants will be randomized to either an experimental or control group, who will receive group interventions 3 times per week over 12 weeks. The experimental group will undertake task-specific training, while the control group will undertake global stretching, memory exercises, and health education sessions.

MEASUREMENTS

Primary outcomes include measures of physical activity levels and mobility, whereas secondary outcomes are muscle strength, exercise capacity, and quality of life. The outcomes will be measured at baseline, postintervention, and at the 4- and 12-week follow-ups.

CONCLUSIONS

The findings of this trial have the potential to provide important insights regarding the effects of task-specific training, focused on both upper and lower limbs, in preventing secondary poststroke complications and improving the participants' general health through changes in physical activity levels.

Field Validation of the Los Angeles Motor Scale as a Tool for Paramedic Assessment of Stroke Severity

Background and Purpose—

The Los Angeles Motor Scale (LAMS) is a 3-item, 0- to 10-point motor stroke-deficit scale developed for prehospital use. We assessed the convergent, divergent, and predictive validity of the LAMS when performed by paramedics in the field at multiple sites in a large and diverse geographic region.

Methods—

We analyzed early assessment and outcome data prospectively gathered in the FAST-MAG trial (Field Administration of Stroke Therapy–Magnesium phase 3) among patients with acute cerebrovascular disease (cerebral ischemia and intracranial hemorrhage) within 2 hours of onset, transported by 315 ambulances to 60 receiving hospitals.

Results—

Among 1632 acute cerebrovascular disease patients (age 70±13 years, male 57.5%), time from onset to prehospital LAMS was median 30 minutes (interquartile range 20–50), onset to early postarrival (EPA) LAMS was 145 minutes (interquartile range 119–180), and onset to EPA National Institutes of Health Stroke Scale was 150 minutes (interquartile range 120–180). Between the prehospital and EPA assessments, LAMS scores were stable in 40.5%, improved in 37.6%, and worsened in 21.9%. In tests of convergent validity, against the EPA National Institutes of Health Stroke Scale, correlations were r =0.49 for the prehospital LAMS and r =0.89 for the EPA LAMS. Prehospital LAMS scores did diverge from the prehospital Glasgow Coma Scale, r =−0.22. Predictive accuracy (adjusted C statistics) for nondisabled 3-month outcome was as follows: prehospital LAMS, 0.76 (95% confidence interval 0.74–0.78); EPA LAMS, 0.85 (95% confidence interval 0.83–0.87); and EPA National Institutes of Health Stroke Scale, 0.87 (95% confidence interval 0.85–0.88).

Conclusions—

In this multicenter, prospective, prehospital study, the LAMS showed good to excellent convergent, divergent, and predictive validity, further establishing it as a validated instrument to characterize stroke severity in the field.

Tele-rehabilitation service delivery journey from prototype to robust in-home use

PURPOSE

The purpose of this study is to present a retrospective study on clients with Acquired Brain Injury (ABI) enrolled in a tele-motion-rehabilitation service program for two or more months.

METHODS

Data from 82 clients (46 males; 74 with ABI), aged 22-85 years, are reported. The Kinect-based CogniMotion System (ReAbility Online, Gertner Institute, Tel Hashomer, Israel) provided services that included 30-min biweekly sessions. Participants were evaluated prior to and 2 months following the commencement of service with clinical assessments that measured movements and function of the weaker upper extremity and cognitive abilities.

RESULTS

Clients enrolled in the service had intact or mild cognitive impairment, mild-moderate motor impairment but little use of their weak upper extremity for daily activities. They were satisfied with the service and reported high levels of system usability. Post-intervention clinical assessments were performed on about half of the participants after 2 months; significant improvements in active movements of the weak upper extremity, shoulder flexion range of motion and in the Trail Making Test were found (p < 0.05).

CONCLUSIONS

The service appears to be feasible for people with ABI and effective in important clinical outcomes related to improvements in upper extremity function. Implications for Rehabilitation Tele-rehabilitation provided with Microsoft Kinect 3D sensor virtual reality tracking system is feasible for people with Acquired Brain Injury. People with Acquired Brain Injury in the chronic stage were satisfied with the tele-rehabilitation service and perceived it as beneficial to improve their motor and cognitive abilities The CogniMotion System service appears to be effective in important clinical outcomes related to improvements in upper extremity function.

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.

Longitudinal robustness of variables predicting independent gait following severe middle cerebral artery stroke: a prospective cohort study

Objective: To determine within the first 10 weeks post onset the most robust variables in the prediction of recovery of independent gait at six months post stroke.

Design: A prospective cohort study.

Subjects: One hundred and one first ever ischaemic middle cerebral artery stroke patients. None of these patients were able to walk at onset and all suffered from a marked hemiplegia.

Setting: Twenty-four determinants, possibly related to recovery of gait at six months, were measured within 14 days following stroke onset. Based on Functional Ambulation Categories (FAC) independent gait was classified into present (FAC ≥ 4) or absent (FAC < 4). Bivariate logistic regression analysis was used to select determinants. Only significant determinants during the entire 10-week period were used for further weekly multivariate logistic prediction modelling of independent gait at six months post stroke.

Results: After six months post onset 62% ( N = 63) regained independent gait. Age, Barthel Index, Trunk Control Test, Motricity Index of arm and leg, Brunnstrom Fugl-Meyer stage of leg motor recovery, and type of intervention were significant determinants in bivariate analysis, but age of patient and Barthel Index were the most robust determinants in the final prediction model. Weekly re-evaluation produced sensitivity values between 89% and 96% and specificity values between 53% and 62%.

Conclusion: In initially non-ambulatory stroke patients age and Barthel Index were the most robust variables during the first 10-week poststroke period in the prediction of independent walking at six months. However, prediction of non-ambulation at six months proved to be less accurate.

An Evaluation of the Extended Barthel Index with Acute Ischemic Stroke Patients

Objective. To evaluate the Extended Barthel Index with acute ischemic stroke patients. Methods. This prospective 1- to 6-week poststroke follow-up study was carried out using 33 newly diagnosed acute ischemic stroke patients who were admitted to the University Medical Centre Ljubljana, Department of Neurology. Measures used were Barthel Index (BI), Extended Barthel Index (EBI), Fugl Meyer Motor Impairment Scale, 1-5 Self-assessment scale, Rivermead Behavioural Memory Test. Results. The EBI is a reliable scale in terms of internal consistency. The cognitive part is less reliable than the physical part of the EBI. It is a 3-dimensional scale as calculated by factor analysis (factor 1 with eigenvalue 8.2, factor 2 with eigenvalue 2.7 and factor 3 with eigenvalue 0.9). Criterion validity to the BI and and the Fugl-Meyer Motor Impairment scale was supported (P = 0.1-0.001). External validity to the Self-Assessment scale was also supported (P < 0.001). It is more sensitive to the changes in functional status that occur in the 1st 6 weeks poststroke than the original BI, although the ceiling effect was not really explained in this follow-up period. Conclusion. The EBI is a valid, reliable, 2- to 3-dimensional outcome measure of disability/activity for stroke patients. To some extent, it also reveals the level of patients’ perception of their functional status.

A virtual shopping task for the assessment of executive functions: Validity for people with stroke

The importance of assessing executive functions (EF) using ecologically valid assessments has been discussed extensively. Due to the difficulty of carrying out such assessments in real-world settings on a regular basis, virtual reality has been proposed as a technique to provide complex functional tasks under a variety of differing conditions while measuring various aspects of performance and controlling for stimuli. The main goal of this study was to examine the discriminant, construct-convergent and ecological validity of the Adapted Four-Item Shopping Task, an assessment of the Instrumental Activity of Daily Living (IADL) of shopping. Nineteen people with stroke, aged 50-85 years, and 20 age- and gender-matched healthy participants performed the shopping task in both the SeeMe Virtual Interactive Shopping environment and a real shopping environment (the hospital cafeteria) in a counterbalanced order. The shopping task outcomes were compared to clinical measures of EF. The findings provided good initial support for the validity of the Adapted Four-Item Shopping Task as an IADL assessment that requires the use of EF for people with stroke. Further studies should examine this task with a larger sample of people with stroke as well as with other populations who have deficits in EF.

Effects of horse-riding exercise on balance, gait, and activities of daily living in stroke patients

[Purpose] This study aimed to investigate the effects of horse-riding exercise on balance, gait, and activities of daily living (ADLs) in stroke patients. [Subjects] Among 20 participants with stroke, 10 were randomly assigned to the experimental group, and 10 were randomly assigned to the control group. The experimental group participated in horse-riding exercise for 30 minutes per day, 5 days a week for 6 weeks. Balance was tested with the Berg Balance Scale (BBS). Gait was measured using the 10-Meter Walk Test (10MWT). ADLs were tested with the Modified Barthel Index (MBI). Differences between pre- and post-experiment values within the two groups were compared using paired t-tests. Between-group differences were compared using independent t-tests. [Results] The experimental group showed significant improvements in balance, gait, and ADLs following horse-riding exercise. Additionally, the experimental group showed significant differences in balance, gait, and ADLs compared with in the control group. [Conclusion] These results support that horse-riding exercise enhances balance, gait, and ADLs in stroke patients. This study supports the need for further research on horse-riding exercise programs.

Neuromuscular Electrical Stimulation for Motor Restoration in Hemiparesis

This article assesses the clinical efficacy of established neuromuscular electrical stimulation (NMES) technologies for motor restoration in hemiparesis and provides an overview of evolving technologies. Transcutaneous NMES facilitates motor recovery. However, its impact on physical disability remains uncertain. Transcutaneous NMES also decreases shoulder subluxation, but its effect on shoulder pain remains uncertain. Clinically deployable upper extremity neuroprosthesis systems will not be available until sometime in the distant future. However, there is stronger evidence for the clinical utility of lower extremity neuroprosthesis systems. Evolving technology utilizes semi-implanted or fully implanted systems with more sophisticated control paradigms. Initial experiences with these systems are reviewed and directions for future research are discussed in this article.

Real-world affected upper limb activity in chronic stroke: an examination of potential modifying factors

BACKGROUND

Despite improvement in motor function after intervention, adults with chronic stroke experience disability in everyday activity. Factors other than motor function may influence affected upper limb (UL) activity.

OBJECTIVE

To characterize affected UL activity and examine potential modifying factors of affected UL activity in community-dwelling adults with chronic stroke.

METHODS

Forty-six adults with chronic stroke wore accelerometers on both ULs for 25 hours and provided information about potential modifying factors [time spent in sedentary activity, cognitive impairment, depressive symptomatology, number of comorbidities, motor dysfunction of the affected UL, age, activities of daily living (ADL) status, and living arrangement]. Accelerometry was used to quantify duration of affected and unaffected UL activity. The ratio of affected-to-unaffected UL activity was also calculated. Associations within and between accelerometry-derived variables and potential modifying factors were examined.

RESULTS

Mean hours of affected and unaffected UL activity were 5.0 ± 2.2 and 7.6 ± 2.1 hours respectively. The ratio of affected-to-unaffected UL activity was 0.64 ± 0.19, and hours of affected and unaffected UL activity were strongly correlated (r = 0.78). Increased severity of motor dysfunction and dependence in ADLs were associated with decreased affected UL activity. No other factors were associated with affected UL activity.

CONCLUSIONS

Severity of motor dysfunction and ADL status should be taken into consideration when setting goals for UL activity in people with chronic stroke. Given the strong, positive correlation between affected and unaffected UL activity, encouragement to increase activity of the unaffected UL may increase affected UL activity.

Psychometric Properties of the Lower Extremity Subscale of the Fugl-Myer Assessment for Community-dwelling Hemiplegic Stroke Patients

[Purpose] The purpose of this study was to investigate the psychometric properties of the lower extremity subscale of the Fugl-Meyer Assessment lower extremity (FMA-LE) for community-dwelling hemiplegic stroke patients. [Subjects] The participants were 140 community-dwelling hemiplegic stroke patients. [Methods] To determine the psychometric properties of the FMA-LE, we examined construct validity, response characteristics, item discrimination, and internal consistency. [Results] Factor analysis of the FMA-LE revealed that the first factor explained 61.73% of the variance and provided evidence of unidimensionality. The FMA-LE did not show ceiling or floor effects; Cronbach's α was 0.935 (95% CI: 0.919-0.950). [Conclusion] Because the FMA-LE seems to be both valid and reliable, we conclude that it is appropriate for the measurement of the lower extremity motor impairment of community-dwelling hemiplegic stroke patients.

Contralateral needling at unblocked collaterals for hemiplegia following acute ischemic stroke

Hemiplegia caused by stroke indicates dysfunction of the network between the brain and limbs, namely collateral shock in the brain. Contralateral needling is the insertion of needles into acupoints on the relative healthy side of the body to treat diseases such as apoplexy. However, there is little well-designed and controlled clinical evidence for this practice. This study investigated whether contralateral needling could treat hemiplegia after acute ischemic stroke in 106 randomly selected patients with acute ischemic stroke. These patients were randomly assigned to three groups: 45 in the contralateral needling group, receiving acupuncture on the unaffected limbs; 45 in the tional acupuncture group, receiving acupuncture on the hemiplegic limbs; and 16 in the control group, receiving routine treatments without acupuncture. Acupuncture at acupoints Chize (LU5) in the upper limb and Jianliao (TE14) in the lower limb was performed for 45 minutes daily for 30 consecutive days. The therapeutic effective rate, Neurological Deficit Score, Modified Barthel Index and Fugl-Meyer Assessment were evaluated. The therapeutic effective rate of contralateral needling was higher than that of conventional acupuncture (46.67% vs. 31.11%, P < 0.05). The neurological deficit score of contralateral needling was significantly decreased compared with conventional acupuncture (P < 0.01). The Modified Barthel Index and Fugl-Meyer Assessment score of contralateral needling increased more significantly than those of conventional acupuncture (both P < 0.01). The present findings suggest that contralateral needling unblocks collaterals and might be more effective than conventional acupuncture in the treatment of hemiplegia following acute ischemic stroke.

Recovery of paretic lower extremity loading ability and physical function in the first six months after stroke

OBJECTIVES

To evaluate poststroke recovery of paretic lower extremity loading, walking ability, and self-reported physical function; and to identify subject characteristics associated with recovery.

DESIGN

Inception cohort study, with testing at monthly intervals from 1 to 6 months poststroke.

SETTING

Medical center and research laboratory.

PARTICIPANTS

Volunteer sample of individuals with first-ever, unilateral, noncerebellar stroke (N=33). A total of 78 individuals underwent screening, and 45 were found to be eligible. Of these, 8 declined participation, 2 were excluded because of deteriorating cognitive status, and 2 were lost to follow-up. The remaining 33 individuals enrolled in the study, and 30 (91%) completed the study.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Outcomes were loading of the paretic lower extremity when standing up from a chair, self-selected gait speed (GS), and Physical Functioning Index.

RESULTS

Data analyses using linear mixed models indicated that subjects improved over time for all outcomes. Baseline Fugl-Meyer (FM) lower extremity motor scale score was a predictor of immediate poststroke performance for paretic lower extremity loading and self-selected GS, and a predictor of recovery rate for paretic lower extremity loading. Factors identified as having significant effects on performance at 6 months poststroke were baseline FM lower extremity motor scale score for paretic lower extremity loading and self-selected GS and baseline star cancellation score (from the Behavioral Inattention Test) for paretic lower extremity loading.

CONCLUSIONS

Individuals with better baseline paretic lower extremity motor function have better ability to load that extremity during functional activities and faster walking speeds, and these advantages are still present at 6 months poststroke. Individuals with severe visuospatial neglect demonstrate less ability to load the paretic leg during functional activities at 6 months poststroke.

A novel robot device in rehabilitation of post-stroke hemiplegic upper limbs

BACKGROUND AND AIMS

In this pilot study, we introduce the "NeReBot", a novel robotic device designed and programmed for clinical neurological applications. The aim of the study was to test whether additional sensorimotor training of paralyzed or paretic upper limbs, delivered by NeReBot, enhanced motor and functional outcome in stroke patients.

METHODS

Twenty patients with post-stroke hemiparesis or hemiplegia received standard poststroke multidisciplinary rehabilitation, and were randomly assigned either to exposure to the robotic device without training or to additional sensorimotor robotic training (about 4 h/week) for 4 weeks. Robot training consisted of peripheral manipulation of the shoulder and elbow of the impaired limb, correlated with visual stimuli.

RESULTS

At hospital discharge, impairment and disability had declined in all patients, but the group with robot training showed higher gains on motor impairment and functional recovery, which were maintained at the 3-month follow-up. No adverse events resulted from robot-assisted therapy.

CONCLUSIONS

According to our results, NeReBot therapy may efficaciously complement standard post-stroke multidisciplinary rehabilitation and offer novel therapeutic strategies for neurological rehabilitation.

Randomized Trial of Treadmill Training to Improve Walking in Community-Dwelling People after Stroke: The AMBULATE Trial

Background

Residual walking deficits are common in community-dwelling people after stroke.

Aims

The aim of this study was to determine if a four-month treadmill and overground walking program is more effective than a two-month program, compared with control, at improving walking in community-dwelling people with stroke who walk slowly.

Method

A three-arm randomized trial with concealed allocation, assessor blinding, and intention-to-treat analysis involving 102 people with stroke living in the community who walked slowly was undertaken. Experimental group 1 undertook 30 min of treadmill and overground walking thrice per week for four-months, experimental group 2 undertook training for two-months, while the control group had no intervention. The primary outcome was walking measured as the distance covered during the six-min walk test. Other outcomes were walking speed, step length and cadence, health status, community participation, self-efficacy and falls.

Results

By two-months, the experimental groups, who were both undergoing training, had improved their six-min walk distance compared with the control group. The four-month training group continued training beyond two-months and improved further so that by four months they walked 38 m (95% confidence interval 15–60) more than the control group and 29 m (95% confidence interval 4–53) more than the two-month training group. However, by 12 months, well after the cessation of training, both experimental groups had returned to near baseline levels, and there was no difference between the groups.

Conclusion

Four months of treadmill training results in better walking. However, these effects disappear once training ceases. Therefore, training should be ongoing.

Compelled Body Weight Shift Technique to Facilitate Rehabilitation of Individuals with Acute Stroke

BACKGROUND

The study evaluates the effectiveness of Compelled Body Weight Shift (CBWS) approach in the rehabilitation of individuals with stroke. CBWS involves a forced shift of body weight towards a person's affected side by means of a shoe insert that establishes a lift of the nonaffected lower extremity.

METHODS

Eleven patients with acute stroke were randomly assigned to experimental and control groups. The experimental group received a two-week conventional physical therapy combined with CBWS and the control group received only a two-week conventional therapy. Weight bearing, Gait velocity, Berg's Balance, and Fugl-Meyer's Scores were recorded before and after the intervention.

RESULTS

Weight bearing on the affected side increased in the experimental group and decreased in the control group. The increase in gait velocity with treatment was significant in both the groups (P < 0.05). However, experimental group (P = 0.01) demonstrated larger improvements in gait velocity compared to the control group (P = 0.002). Berg Balance and Fugl-Meyer scores increased for both the groups.

CONCLUSION

The implementation of a two-week intervention with CBWS resulted in the improvement in weight bearing and gait velocity of individuals with acute stroke. The present preliminary study suggests that CBWS technique could be implemented as an adjunct to conventional rehabilitation program for individuals with acute stroke.

Performance-based tests in subjects with stroke: outcome scores, reliability and measurement errors

OBJECTIVES

To assess the intra- and inter-rater reliabilities and measurement errors of seven widely applied performance-based tests for stroke subjects (comfortable/maximal gait speeds and both stair ascending/descending cadences, as well as the Timed 'Up and Go' test) and to verify whether the use of different types of outcome scores (one trial, the means of two and three trials, and the best and the worst values of the three trials) affected the score values, as well as their reliability and measurement errors.

DESIGN

Intra- and inter-rater reliability study.

SETTING

Research laboratory.

SUBJECTS

Sixteen stroke subjects with a mean age of 52 ± 17.9 years.

MAIN MEASURES

Seven performance-based tests, over two sessions, seven days apart, evaluated by two independent examiners. A third examiner recorded all data. One-way ANOVAs, intra-class correlation coefficients (ICCs) and percentages of the standard errors of measurement (SEM%) were used for analyses.

RESULTS

For all tests, similar results were found for all types of outcome scores (0.01 ≤ F ≤ 0.56; 0.34 ≤ p ≤ 0.99). For instance, at the comfortable gait speed, the means (SD) values for the first trial, the means of two and three trials and the best and worst of three trials were, respectively, 1.04 (0.25), 1.04(0.24), 1.05 (0.24), 1.10 (0.26), 1.02 (0.24) seconds. Significant and adequate values of intra- (0.75 ≤ ICC ≤ 0.96; p ≤ 0.002) and inter-rater (0.75 ≤ ICC ≤ 0.97; p ≤ 0.001) reliabilities were found for all tests and outcome scores. Measurement errors were considered low (5.01 ≤ SEM% ≤14.78) and were also similar between all outcome scores.

CONCLUSIONS

For the seven tests, only one trial was necessary to provide consistent and reliable results regarding the functional performances of stroke subjects.

Step Test scores are related to measures of activity and participation in the first 6 months after stroke

BACKGROUND

The Step Test (ST) is a measure of dynamic standing balance and paretic-lower-extremity motor control in patients with stroke. Little is known about the extent to which impairments assessed by the ST relate to activity and participation during stroke recovery.

OBJECTIVE

The purpose of this study was to determine relationships between ST scores and measures of activity and participation during the first 6 months after stroke.

DESIGN

This was a prospective cohort study.

METHODS

Thirty-three individuals (18 men, 15 women) with a diagnosis of a single, unilateral stroke participated in the study. Participants were tested one time per month from 1 to 6 months poststroke. The ST was considered an impairment-level measure. Self-selected gait speed and the Medical

OUTCOMES

Study 36-Item Short-Form Health Survey (SF-36) Physical Function Index (PFI) were used to assess physical function. Three domains (mobility, basic and instrumental activities of daily living, participation) of the Stroke Impact Scale were used to assess self-reported disability. Regression analyses were conducted to examine the bivariate associations between ST scores and each physical function and disability measure at each time point (1-6 months).

RESULTS

The ST scores were positively associated with both physical function measures. The associations were stronger for self-selected gait speeds (R(2)=.60-.79) than for the PFI scores (R(2)=.32-.60). During the first 6 months after stroke, each additional step with the paretic lower extremity on the ST corresponded to a 0.07-m/s to 0.09-m/s increase in gait speed, and each additional step with the nonparetic lower extremity was associated with a 0.07-m/s to 0.08-m/s gait speed increase. The impairment-disability associations were weaker than the impairment-physical function associations.

LIMITATIONS

Limitations of the study include a relatively small sample size and lack of examiner blinding with regard to participant characteristics.

CONCLUSIONS

Impairments in balance and paretic-lower-extremity motor control, as measured by the ST, relate to physical function and disability during the first 6 months following stroke.

Psychometric comparisons of 4 measures for assessing upper-extremity function in people with stroke

BACKGROUND

Functional limitation of the upper extremities is common in patients with stroke. An upper-extremity measure with sound psychometric properties is indispensable for clinical and research use.

OBJECTIVE

The purpose of this study was to compare the psychometric properties of 4 clinical measures for assessing upper-extremity motor function in people with stroke: the upper-extremity subscale of the Fugl-Meyer Motor Test (UE-FM), the upper-extremity subscale of the Stroke Rehabilitation Assessment of Movement, the Action Research Arm Test (ARAT), and the Wolf Motor Function Test.

DESIGN

This was a prospective, longitudinal study.

METHODS

Fifty-three people with stroke were evaluated with the 4 measures at 4 time points (14, 30, 90, and 180 days after stroke). Thirty-five participants completed all of the assessments. The ceiling and floor effects, validity (concurrent validity and predictive validity), and responsiveness of each measure were examined. Interrater reliability and test-retest reliability also were examined.

RESULTS

All measures, except for the UE-FM, had significant floor effects or ceiling effects at one or more time points. The Spearman rho correlation coefficient for each pair of the 4 measures was > or =.81, indicating high concurrent validity. The predictive validity of the 4 measures was satisfactory (Spearman rho, > or =.51). The responsiveness of the 4 measures at 14 to 180 days after stroke was moderate (.52 < or = effect size < or = .79). The 4 measures had good interrater reliability (intraclass correlation coefficient [ICC], > or =.92) and test-retest reliability (ICC, > or =.97). Only the minimal detectable changes of the UE-FM (8% of the highest possible score) and the ARAT (6%) were satisfactory.

LIMITATIONS

The sample size was too small to conduct data analysis according to type or severity of stroke. In addition, the timed component of the Wolf Motor Function Test was not used in this study.

CONCLUSIONS

All 4 measures showed sufficient validity, responsiveness, and reliability in participants with stroke. The UE-FM for assessing impairment and the ARAT for assessing disability had satisfactory minimal detectable changes, supporting their utility in clinical settings.

Mental imagery for relearning of people after brain injury

OBJECTIVE

This paper reported on the application of mental imagery to the relearning of daily task performance in people with brain injury.

METHOD

The changes in two subjects who had suffered from cerebral infarction shown throughout a 3-week mental imagery programme were described. The subjects' improvement in task performance and other clinical outcomes illustrated the programme's therapeutic effects on skill relearning, maintenance and generalization.

RESULTS

After completing the programme, the subjects showed improvements in performance at both the trained and untrained tasks. Feedback from the patients also suggested its ability to enhance their day-to-day functioning. Clinical assessment results indicated that the subjects experienced an increase in the attention and sequential processing functions but not in the motor and other cognitive functions.

CONCLUSION

Mental imagery appears to be effective at enhancing the task relearning of subjects after brain injury. The skills acquired under this treatment regime can be retained and then generalized to other tasks. Its therapeutic effect is probably mediated by the improved attention and planning and execution functions associated with the rehearsal. Further research should conduct clinical controlled trials to gather evidence on its efficacy at promoting functional regain in people suffering from neurological disorders.

Responsiveness and validity of three outcome measures of motor function after stroke rehabilitation

BACKGROUND AND PURPOSE

This study investigated and compared the responsiveness and validity of the Fugl-Meyer Assessment (FMA), the Action Research Arm Test (ARAT), and the Wolf Motor Function Test (WMFT) for patients after stroke rehabilitation.

METHODS

A total of 57 patients with stroke received 1 of 3 rehabilitation treatments for 3 weeks. At pretreatment and posttreatment, the 3 outcome measures, as well as the Functional Independence Measure (FIM) as the external criterion, were administered. The standardized response mean (SRM) and the Wilcoxon signed rank test were used to examine the responsiveness. Construct validity and predictive validity were examined by the Spearman correlation coefficient (rho).

RESULTS

The responsiveness of the FMA, ARAT, and WMFT functional ability scores was large (SRM=0.95-1.42), whereas the WMFT performance time score was small (SRM=0.38). The responsiveness of the FMA was significantly larger than those of the ARAT and the WMFT-TIME, but not the WMFT functional ability scores. With respect to construct validity, correlations between the FMA and other measures were relatively high (rho=0.42-0.76). The FMA and the WMFT performance time scores at pretreatment had moderate predictive validity with the FIM scores at posttreatment (rho=0.42-0.47). In addition, the ARAT and the WMFT functional ability scores revealed a low predictive validity with the FIM (rho=0.17-0.26).

CONCLUSIONS

The results support the FMA and the WMFT-FAS are suitable to detect changes over time for patients after stroke rehabilitation. While simultaneously considering the responsiveness and validity attributes, the FMA may be a relatively sound measure of motor function for stroke patients based on our results. Further research based on a larger sample is needed to replicate the findings.

Improving community ambulation after stroke: the AMBULATE Trial

Background

It has been reported that following rehabilitation, only 7% of stroke survivors are able to walk at a level commensurate with community participation. Previous research indicates that treadmill and overground walking training can improve walking capacity in people living in the community after stroke. The main objectives of the AMBULATE trial are to determine (i) whether a 4-month treadmill walking program is more effective than a 2-month program, compared to control, in improving walking capacity, health and community participation and (ii) the "threshold" walking speed that results in sufficient walking capacity that makes walking self-sustaining.

Methods/Design

A prospective randomised controlled trial of unsupported treadmill training with a 12 month follow-up with concealed allocation and blinded assessment will be conducted. 210 community-dwelling people after stroke who are able to walk independently but slowly will be recruited and randomly allocated to either a 4 month training group, 2 month training group or the control (no intervention) group. Intervention for the two training groups will occur 3 days per week for 30 minutes each session. Measurements of walking, health and community participation will be taken at baseline, 2 months, 4 months, 6 months and 12 months. This study has obtained ethical approval from the relevant Human Research Ethics Committees.

Discussion

By improving stroke survivors' walking ability, it is likely also to improve their general wellbeing by promoting better health and greater community participation. Furthermore, if stroke survivors can reach a point where their walking and community participation is self-sustaining, this will reduce the burden of care on family and friends as well as the economic burden on the health system. Given the major demographic shift in developed nations involving significant growth in the aged population, this research will make an important evidence-based contribution to the promotion of healthy ageing.

Trial registration

This trial is registered with the Australian New Zealand Clinical Trials Registry, (ACTRN012607000227493)

Affective temperament in stroke patients

OBJECTIVE

The aims of this study were to determine the dominant affective temperament changes in stroke survivors and whether temperament affects the disability.

METHODS

A total of 63 stroke patients were included in this study. Temperament Evaluation of Memphis, Pisa, Paris and San Diego Autoquestionnaire was used to determine the dominant affective temperament (depressive, hyperthymic, cyclothymic, irritable or anxious). The disability level was measured with the Barthel index (BI).

RESULTS

Depressive temperament (17.5%) and anxious temperament (12.7%) were the most common dominant affective temperaments. The frequencies of irritable, cyclothymic and hyperthymic temperaments were 4.8, 3.2 and 0%, respectively. The mean BI score was 78.1 ± 18.3 in patients with depressive temperament and 67.4 ± 28.4 in patients without depressive temperament (p = 0.403). The mean BI score was 78.1 ± 15.3 in patients with anxious temperament and 68.0 ± 28.3 in patients without anxious temperament (p = 0.541). Multiple linear regression analysis indicated that BI score was not associated with affective temperament changes.

CONCLUSION

The results of the current study suggest that depressive and anxious temperaments are the most common affective temperaments and that there appears to be no association between disability level and dominant affective temperament in stroke survivors.

Psychometric comparisons of 2 versions of the Fugl-Meyer Motor Scale and 2 versions of the Stroke Rehabilitation Assessment of Movement

OBJECTIVE

To provide empirical justification for selecting motor scales for stroke patients, the authors compared the psychometric properties (validity, responsiveness, test-retest reliability, and smallest real difference [SRD]) of the Fugl-Meyer Motor Scale (FM), the simplified FM (S-FM), the Stroke Rehabilitation Assessment of Movement instrument (STREAM), and the simplified STREAM (S-STREAM).

METHODS

For the validity and responsiveness study, 50 inpatients were assessed with the FM and the STREAM at admission and discharge to a rehabilitation department. The scores of the S-FM and the S-STREAM were retrieved from their corresponding scales. For the test-retest reliability study, a therapist administered both scales on a different sample of 60 chronic patients on 2 occasions.

RESULTS

Only the S-STREAM had no notable floor or ceiling effects at admission and discharge. The 4 motor scales had good concurrent validity (rho >or= .91) and satisfactory predictive validity (rho = .72-.77). The scales showed responsiveness (effect size d >or= 0.34; standardized response mean >or= 0.95; P < .0001), with the S-STREAM most responsive. The test-retest agreements of the scales were excellent (intraclass correlation coefficients >or= .96). The SRD of the 4 scales was 10% of their corresponding highest score, indicating acceptable level of measurement error. The upper extremity and the lower extremity subscales of the 4 showed similar results.

CONCLUSIONS

The 4 motor scales showed acceptable levels of reliability, validity, and responsiveness in stroke patients. The S-STREAM is recommended because it is short, responsive to change, and able to discriminate patients with severe or mild stroke.

Supported treadmill training to establish walking in non-ambulatory patients early after stroke

BACKGROUND

It has been reported that only half of the non-ambulatory stroke patients admitted to inpatient rehabilitation in Australia learn to walk again 1. Treadmill walking with partial weight support via an overhead harness is a relatively new intervention that is designed to train walking. The main objective of this randomised controlled trail is to determine whether treadmill walking with partial weight support via an overhead harness is effective at establishing independent walking (i) more often, (ii) earlier and (iii) with a better quality of walking, than current physiotherapy intervention for non-ambulatory stroke patients.

METHODS

A prospective, randomised controlled trial of inpatient intervention with a 6 month follow-up with blinded assessment will be conducted. 130 stroke patients who are unable to walk independently early after stroke will be recruited and randomly allocated to a control group or an experimental group. The control group will undertake 30 min of routine assisted overground walking while the experimental group will undertake 30 min of treadmill walking with partial weight support via an overhead harness per day. The proportion of participants achieving independent walking, the quality of walking, and community participation will be measured. The study has obtained ethical approval from the Human Research Ethics Committees of each of the sites involved in the study.

DISCUSSION

Given that the Australian population is ageing and people after stroke can expect to live for longer, attainment of safe, independent walking is more likely to be associated with long-term health and well being. In its National Research Priorities, the Government has recognised that it will be important to promote healthy ageing and that this endeavour will be underpinned by research. The results of this study will clearly identify effective intervention to establish early quality walking, thereby promoting an increase in community participation in the longer term.

Is improvement in impaired cognition and depressive symptoms in post-stroke patients associated with recovery in activities of daily living?

BACKGROUND AND PURPOSE

Depression and cognitive impairment after stroke are associated with physical functional outcomes, but there are limited data on whether depressive symptoms and cognitive status and improvements independently influence functional status and recovery.

METHODS

In a 6-month prospective cohort study of 141 post-acute stroke patients, demographic and clinical data on admission, and neurological, cognitive, depressive symptoms and functional variables on admission and at 6 months after stroke were measured using the National Institute of Health Stroke Scale (NIHSS), Abbreviated Mental Test (AMT), Geriatric Depression Scale (GDS) and Barthel Index (BI).

RESULTS

On multivariate analysis, severe activities of daily living (ADL) dependence at 6 months was significantly less likely associated with higher baseline AMT score denoting better cognitive status (OR=0.68, 95% CI 0.48-0.97 per score point) and with greater AMT change score denoting greater cognitive improvement (OR=0.61, 95% CI 0.41-0.91 per change score point); it was also more likely with higher baseline NIHSS scores denoting severe neurological impairment, (OR=1.74, 95% CI 1.13-2.63 per point score), NIHSS change score [denoting lesser neurological improvement (OR = 1.83, 95% CI 1.13-2.93 per unit change score)], but was not associated with baseline or change scores of GDS. Greater magnitudes of functional recovery [BI change score (standardized beta)] were associated with better baseline depressive symptoms (-0.21) and improvement (-0.31), but not with cognitive status or improvement, in the presence of other significant variables, neurological status (-0.89) and improvement (-0.65), lower baseline physical functional status (-0.85) and younger age (-0.23).

CONCLUSIONS

These data suggest that improving depressive symptoms in stroke patients may accelerate functional recovery, but the level of physical functioning achieved post-stroke is determined by neurological and cognitive factors, consistent with the evidence that improvement of depressive symptoms through therapeutic intervention is limited by cognitive impairment.

Robotic-Assisted Rehabilitation of the Upper Limb After Acute Stroke

OBJECTIVE

To investigate whether early therapy with a novel robotic device can reduce motor impairment and enhance functional recovery of poststroke patients with hemiparetic and hemiplegic upper limb.

DESIGN

A single-blind randomized controlled trial, with an 8-month follow-up.

SETTING

Neurologic department and rehabilitation hospital.

PARTICIPANTS

Thirty-five patients with acute (< or =1 wk of onset), unilateral, ischemic embolic, or thrombotic stroke.

INTERVENTIONS

Patients of both groups received the same dose and length per day of standard poststroke multidisciplinary rehabilitation. Patients were randomly assigned to 2 groups. The experimental group (n=17) received additional early sensorimotor robotic training, 4 hours a week for 5 weeks; the control group (n=18) was exposed to the robotic device, 30 minutes a week, twice a week, but the exercises were performed with the unimpaired upper limb. Training by robot consisted of peripheral manipulation of the shoulder and elbow of the impaired limb, correlated with visual stimuli.

MAIN OUTCOME MEASURES

The Fugl-Meyer Assessment (FMA) of upper-extremity function (shoulder/elbow and coordination and wrist/hand subsections) to measure each trained limb segment; the Medical Research Council (MRC) score to measure the strength of muscle force during 3 actions: shoulder abduction (MRC deltoid), elbow flexion (MRC biceps), and wrist flexion (MRC wrist flexors); the FIM instrument and its motor component; and the Trunk Control Test (TCT) and Modified Ashworth Scale (MAS).

RESULTS

Compared with the patients in the control group, the experimental group showed significant gains in motor impairment and functional recovery of the upper limb after robot therapy, as measured by the MRC deltoid (P< or =.05) and biceps (P<.05) scores, the FMA for the proximal upper arm (P<.05), the FIM instrument (P<.05), and the FIM motor score (P<.01); these gains were also sustained at the 3- and 8-month follow-up. The FMA and MRC wrist flexor test findings did not differ statistically either at the end of training or at the follow-up sessions. We found no significant differences in MAS and TCT in either group in any of the evaluations. No adverse effects occurred and the robotic approach was very well accepted.

CONCLUSIONS

Patients who received robotic therapy in addition to conventional therapy showed greater reductions in motor impairment and improvements in functional abilities. Robotic therapy may therefore effectively complement standard rehabilitation from the start, by providing therapeutic support for patients with poststroke plegic and paretic upper limb.

Kinesiological and kinematical analysis for stroke subjects with asymmetrical cycling movement patterns

This aim of this study is to provide quantitative analyses of asymmetrical movements between affected and unaffected limbs for hemiparetic subjects in a cycling ergometer. To acquire kinesiological and kinematical data, electromyography (EMG) of quadriceps muscles in the both legs as well as crank positions under three cycling workloads were recorded. The symmetry index (SI) was designed to measure the similarity between muscle activities recorded from affected and unaffected limbs. Using kinematical information of the crank position, the cycling unsmoothness (denoted as roughness index, RI) can be derived from the curvature of the instantaneous cycling speed. Thirteen hemiparetic subjects following a cerebrovascular accident (CVA) and eight able-bodied subjects participated in this study. With total symmetry at SI=1, the average SIs of hemiparetic subjects (0.66+/-0.18) were significantly lower (p<0.01) than those of normal subjects (0.91+/-0.08) but no significant difference found among three workloads. From the average RI, subjects with hemiparesis exhibited less smooth cycling movements compared to normal group (p<0.01). Non-parametric Friedman and Wilcoxon tests of RIs further indicated that the workload factors are significantly different only for hemiparetic group (p<0.01). No significant difference between lower workloads in RIs showed that the CVA subjects' sound side alone can execute most of the cycling load with minimal involvement of the affected side under lower workload condition. When cycling at a heavier load, however, it is essential to force the affected limb to assist in the pedaling, thus accomplishing an effective cycling exercise. By combining these two quantitative indices, we can observe the kinesiological measurement of the symmetry of EMG phasic activities from SI and the kinematical cycling smoothness in a coordinated movement from RI, which could provide a clinical guideline for cycling exercises for hemiparetic subjects.

Motor evoked potentials of the lower extremity in predicting motor recovery and ambulation after stroke: a cohort study 11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated

OBJECTIVE

To assess the prognostic value of motor evoked potentials (MEPs) in the lower extremity with respect to motor recovery and functional recovery in stroke patients.

DESIGN

Cohort study.

SETTING

The department of neurology at a university hospital.

PARTICIPANTS

Thirty-eight acute-stroke patients with complete paralysis (paralysis subgroup) or severe paresis (paresis subgroup) of the lower extremity. MEPs of the vastus medialis and the tibialis anterior muscles were recorded between days 3 and 10 after stroke onset.

INTERVENTIONS

Not applicable. Main outcome measures A separate proximal leg motor score (maximum, 16 points) and crural motor score (maximum, 2 points) were defined within the lower-limb subset of the original Fugl-Meyer Motor Assessment to evaluate the motor performance at regular intervals until 6 months after stroke. The transfer item of the Barthel Index and the Functional Ambulation Categories scores were used to assess transfer and walking ability.

RESULTS

For the paralysis subgroup (n=30), the follow-up was complete in 27 patients (2 patients died, 1 patient underwent above-knee amputation). At 26 weeks, 20 patients experienced proximal motor recovery (mean score +/- standard deviation, 11.70+/-4.48), and 12 of them also showed crural motor recovery (mean score, 1.40+/-.51). Nine patients (33%) could perform an independent transfer safely, and 7 (26%) had learned to walk independently. Analysis revealed significant relationships for tibialis anterior muscle MEPs and motor recovery of crural leg muscles (odds ratio [OR]=18.00; 95% confidence interval [CI], 1.31-894.40), but not for vastus medialis muscle MEPs and proximal motor recovery (OR=6.00; 95% CI,.53-303.00). We found no association between vastus medialis muscle MEPs and recovery of ambulation. However, tibialis anterior muscle MEPs seemed to provide a test with prognostic value for the ability to perform independent transfers (OR=17.50; 95% CI, 1.36-267.00), but not for walking (OR=5.25; 95% CI,.40-77.57). Patients in the paresis subgroup experienced more favorable motor and functional recovery than did those in the paralysis subgroup.

CONCLUSIONS

Tibialis anterior muscle MEPs registered in subacute phase after stroke may provide important prognostic information, both for motor recovery of the crural muscles and for the ability to perform independent transfers in patients with initial complete paralysis of the lower extremity. Vastus medialis muscle MEPs were not predictive for motor and functional recovery.

The Stroke Rehabilitation Assessment of Movement (STREAM): A Comparison With Other Measures Used to Evaluate Effects of Stroke and Rehabilitation

Background and Purpose. The Stroke Rehabilitation Assessment of Movement (STREAM) is a relatively new measure of voluntary movement and basic mobility. The main objectives of this study were: (1) to examine the relationship of the STREAM to other measures of impairment and disability and (2) to compare its usefulness for evaluating effects of stroke and rehabilitation and for assessing change over time with that of other measures of impairment and disability. Subjects and Methods. The performance of 63 patients with acute stroke on the STREAM and other measures of impairment and disability was evaluated during the first week after stroke and 4 weeks and 3 months later. Results. Scores on the STREAM were associated with scores on the Box and Block test, Balance Scale, Barthel Index, gait speed, and the Timed “Up & Go” Test (with Pearson correlation coefficients ranging from .57 to .80) and were associated with categories of the Barthel Index and Balance Scale. The STREAM's ability to predict discharge destination from the acute care hospital, as well as to predict gait speed and Barthel Index scores at 3 months poststroke, was comparable to that of other commonly used measures. Standardized response mean estimates provided supporting evidence for the ability of the STREAM to reflect change over time. Discussion and Conclusion. The results obtained with the STREAM, as compared with other measures of impairment and disability in people with stroke, suggest that it may be useful in clinical practice and research.

Validation of the Berg Balance Scale as a predictor of length of stay and discharge destination in stroke rehabilitation

OBJECTIVE

To validate the utility of the Berg Balance Scale (BBS) in predicting length of stay (LOS) and discharge destination for patients admitted to a stroke rehabilitation unit.

DESIGN

Prospective study.

SETTING

Provincial tertiary inpatient stroke unit for a primarily geriatric population.

PARTICIPANTS

A total of 313 of the 325 patients admitted consecutively between April 1998 and August 2000.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

LOS and discharge destination.

RESULTS

Admission BBS scores correlated negatively with LOS (r=-.53, controlling for age). Logistic regression confirmed that the following were independent predictors of being discharged home rather than to an institution (adjusted odds ratio, 95% confidence interval): admission BBS (1.09, 1.06-1.12) and the presence of family supports (15.0, 7.2-31.3). These results generally concur with previously published results, obtained at a different stroke rehabilitation setting.

CONCLUSIONS

This study validates the use of the BBS scores in assisting to estimate approximate LOS and eventual discharge destination. Age did not correlate significantly with the outcomes measured in this study, which was conducted in a geriatric population.

Does balance or motor impairment of limbs discriminate the ambulatory status of stroke survivors?

OBJECTIVE

This study was performed to determine if ambulatory function is governed by motor impairment of limbs or balance ability in subjects with hemiplegia caused by stroke.

DESIGN

Seven patients who walked with physical assistance (FIM 4) after stroke and 13 who walked independently with assistive devices (FIM 6) were compared with 13 healthy subjects. Motor impairment of limbs was evaluated with the Fugl-Meyer Assessment. The Berg Balance Scale and limit of stability test of the Smart Balance Master were used to evaluate balance ability.

RESULTS

The FIM 6 group and the controls were best differentiated by motor impairment of the paretic limbs and limit of stability in the backward direction. Motor impairment of the upper limb and limit of stability in direction toward the paretic side separated the FIM 4 from the FIM 6 group. Upper limb motor impairment and the Berg Balance Scale consistently separated the three subject groups.

CONCLUSIONS

Motor impairment in the paretic upper limb and balance dysfunction should be addressed in treatments working toward independent ambulation.