Fugl-Meyer Research Articles

Clinical Criteria to Perform the Step through Step Gait with a Cane in Chronic Stroke Patients

PURPOSE: The purpose of this study was to propose clinical criteria to differentiate patients who are able to perform the step-through-step gait pattern in chronic stroke patients. METHODS: Sixty patients with chronic stroke patients participated this study. To differentiate patients who could perform the step-through-step gait pattern, age, gender, and causes of stroke were noted, a Chedoke-McMaster (CM) damage list, Fugl-Meyer (FM) assessment scales and the Berg Balance Scale (BBS) were determined. A 10 meter gait test and Timed Up and Go (TUG) test were conducted to determine the differences in gait speed and dynamic balance between patients walking with or without canes in the step-through-step gait pattern group. RESULTS: There was no significant statistical difference in age, gender, and stroke type between all subjects. There were significant differences in the CM scale for postural and lower extremities, and FM scale for lower extremities and BBS. The dynamic balance ability and gait speed showed significant differences between the subjects in the step-through-step gait pattern with or without a cane during gait. CONCLUSION: CM and FM scales for the lower extremities and postural control, as well as BBS scales, can be used as criteria to differentiate patients who are able to perform the step-through-step gait pattern. These results can also be used to provide beneficial information to patients that are walking with canes.

Recovery of Paretic Lower Extremity Loading Ability and Physical Function in the First Six Months After Stroke

ObjectivesTo evaluate poststroke recovery of paretic lower extremity loading, walking ability, and self-reported physical function; and to identify subject characteristics associated with recovery. DesignInception cohort study, with testing at monthly intervals from 1 to 6 months poststroke. SettingMedical center and research laboratory. ParticipantsVolunteer 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. InterventionsNot applicable. Main Outcome MeasuresOutcomes were loading of the paretic lower extremity when standing up from a chair, self-selected gait speed (GS), and Physical Functioning Index. ResultsData 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. ConclusionsIndividuals 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.

The value of fMRI for predicting the clinical outcome of passive movement of a hemiplegic upper limb after stroke

Objective To study the potential of functional MRI (fMRI) during passive finger extension (FE) for predicting the motor function recovery of hemiplegic stroke survivors.Methods Nineteen survivors of a 1st cerebral infarction in the non-M1 cortex with complete paralysis on one side were selected for study.Within 1 week after the stroke,fMRI was performed while one of the patient's paralyzed fingers was passively flexed and extended.fMRI signals were acquired from the sensorimotor cortex (SMC),the supplementary motor area (SMA) and the premotor area (PM).Fugl-Meyer (FM) scores of arm motor function were recorded one week,one month and three months after the stroke.Results The early fMRI results were used to classify cortex activation performances as type Ⅰ (activation mainly on the affected side,but SMC and SMA activated bilaterally),type Ⅱ (activation of the SMC and SMA only on the affected side) or type Ⅲ (only activation of the SMC on the affected side).At one week after stroke the average FM scores of the three groups were not significantly different.At one month the three average FM scores were 47.1 ± 5.5 points,36 ±6.7 points and 11.2 ± 3.1 points,for groups Ⅰ,Ⅱ and Ⅲ respectively,each significantly different from the others.At three months the average FM ratings of groups Ⅰ (61.1 ± 3.8 points) and Ⅱ (59 ± 5.2 points) were not significantly different,but both were significantly higher than the average score of group Ⅲ (10.8 ± 5.6 points).Conclusion The early stage fMRI characteristics of hemiplegic patients can be used for predicting motor outcomes. Key words: Stroke; Functional magnetic resonance imaging; Passive movement

A novel five-category multimodal T1-weighted and T2-weighted magnetic resonance imaging-based stratification system for the selection of spinal arachnoid cyst treatment: a 15-year experience of 81 cases

BackgroundIdiopathic spinal arachnoid cysts are rare cystic masses of the spinal canal generally classified as intra- or extradural, based on anatomical presentation. However, this system may not effectively indicate treatment.ObjectiveTo investigate the incidence, resection modality, and prognosis of spinal arachnoid cyst in a 15-year case series.Patients and methodsA retrospective study was conducted in 81 spinal arachnoid cyst patients (male:female 34:47, mean age 36.5 years, age range 6–66 years) classified using a novel five-category T1-weighted and T2-weighted magnetic resonance imaging (MRI) classification system (intramedullary, subdural extramedullary, subdural/epidural, intraspinal epidural, or intraspinal/extraspinal). Conservative treatment failed in all patients. They underwent spinal surgery between January 1995 and December 2010 and were followed up for 69 (range 3–187) months. Performance outcomes were assessed using the Fugl-Meyer (FM) scale 90 days after operation. Recurrences and deaths were recorded.ResultsSubdural/epidural and intraspinal epidural cysts accounted for 66.7% (54 of 81) of patients, but exhibited relatively lower rates of postsurgical improvement using FM, with only66.7% (36 of 54) of patients showing improvements. Excellent outcomes using the FM scale were reached in 100% (eight of eight) of intramedullary, intraspinal/extraspinal, and subdural extramedullary cyst patients, 86.7% (13 of 15) of subdural extramedullary cyst patients, and 66.7% (36 of 54) of epidural intraspinal cyst patients.ConclusionThe proposed five-category multimodal MRI-based stratification system for spinal arachnoid cyst patients may more effectively allow clinicians to select the appropriate surgical intervention, and may help to predict outcomes.

Abstract 148: Cortical Connectivity is a Powerful Predictor of Motor Recovery in Chronic Stroke

Introduction: Refinement of biomarkers and predictors of treatment response could greatly benefit restorative stroke therapeutics. The current study examined the performance of established biomarker/predictor measures in patients undergoing 4 weeks of therapy, and also examined performance of dense array EEG (d-EEG) measures of cortical connectivity. Methods: Twelve adults (mean age=54.0 ± 16.6 years) with chronic stroke and hemiparesis (Fugl-Meyer (FM) score=39 ± 12, range 23-56, max 66) underwent a baseline 3 minute resting dEEG recording (256 leads) as well as a 3T MRI scan, then received 4 weeks of telerehabilitation therapy. For dEEG measurement of cortical connectivity, mean coherence was derived for the high beta (20-30 Hz) frequency band, then partial least squares (PLS) regression was used to relate resting-state mean beta coherence to: (1) baseline impairment (FM score), and (2) improvement (change in FM across 4 weeks of therapy). Infarct volume and % corticospinal tract (CST) injury, measured on MRI scans, were also analyzed. Results: Arm motor status improved across the 4 weeks of therapy (FM change=4.5 ± 2.6, p=0.0001). Regarding biomarkers, CST injury correlated with baseline FM (R2=0.52, p=0.008), but infarct volume and age did not (p>0.05). Resting-state dEEG beta coherence correlated with baseline FM (R2=0.95); adding infarct volume and CST injury to the dEEG findings did not improve predictive strength. Regarding predictors, infarct volume, CST injury, age, and baseline FM each did not predict change in FM across the 4 wk of therapy (p>0.05). However, resting-state beta coherence, using a leave-one-out and predict validation procedure on the pre-therapy dEEG, predicted change in FM score with R2=0.74; adding infarct volume, CST injury, and baseline FM to the dEEG findings again did not improve prediction. Conclusions: The dEEG measures of cortical connectivity were strong correlates of baseline status and excellent predictors of behavioral improvement across 4 weeks of therapy. These dEEG measures compared favorably with established behavioral, demographic, and radiological measures. Resting state dEEG is a rapid, simple, safe method for studying brain function that performs excellently as a biomarker and as a predictor.

Abstract T MP40: A Home-Based Telerehabilitation System for Patients With Stroke

Evidence suggests that greater duration and intensity of rehabilitation therapy improves outcomes for patients with stroke. Delivery of care is often limited, however, e.g., due to systems of care delivery, cost, rural location, or difficulty travelling. The current study addressed this unmet need by examining the feasibility of a home-based telerehabilitation system. Entry criteria included age >18 yrs, 12-26 wk post stroke, and arm motor deficits (Fugl-Meyer (FM) score 22-55) that were stable. Each subject received 28 d of daily home-based telerehabilitation using a fixed system that we delivered/assembled. Each day consisted of 1 structured hour (testing, BP check, individualized exercises and games, and stroke prevention education) plus up to 1 hour of free play on dozens of games. Each week, subjects had a 1 videoconference with a licensed therapist and 1 with a research assistant; subjects could also phone the lab for technical support if needed. Enrollees were 54±17 yr (mean±SD), 6M/6F, with baseline FM=39±12 (range 23-55). Compliance was excellent, with subjects engaging in therapy 329 of 336 (97.9%) assigned days. Arm motor status improved (FM change 4.8±3.8 points from baseline to 1 mo post-therapy, p=0.0015). Although scores on tests of computer literacy declined with age (r = -0.90 to -0.92, p<0.0001), as expected, the arm motor gains derived from use of this system did not vary with age. The stroke education module was associated with significant gains in stroke prevention knowledge. BP was recorded by the patient, and results automatically transmitted to lab, on 97.9% of assigned days. Therapist videoconferences detected PHQ-2 scores consistent with depression in 3/12 patients. Therapists were able to review patient performances and upload revised therapy settings to the patient’s home system without difficulty at any time of day. Results of this pilot study support the utility of a home-based system to effectively deliver telerehabilitation, improve patient education, screen for complications of stroke, and as well as to provide a means for patient interaction with medical personnel. The use of a computer-based interface offers many opportunities to monitor and improve the health of patients after stroke.

Abstract T MP44: Different Predictors of Treatment Gains in Lacunar and Non-lacunar Stroke

Introduction: Numerous predictors of treatment-induced behavioral gains after stroke have been identified. However, only a few types of predictors have generally been examined at a time. The current study examined multiple categories of established predictors in parallel among patients enrolled in a motor therapy study, hypothesizing that brain injury and function are of greatest predictive value. Furthermore, given that clinical relationships often differ according to stroke pathophysiology, the hypothesis was also tested that predictors of treatment gains vary according to stroke subtype. METHODS: Patients with age>18 yr, stable arm paresis, and stroke 11-26 wks prior were enrolled in a study (NCT01244243) that provided 3 weeks of standardized robotic arm therapy. The primary outcome measure was change in Fugl-Meyer (FM) and Action Research Arm Test (ARAT) scores. A total of 6 categories of baseline assessments were evaluated as potential predictors of treatment gains: [1] demographics/history, [2] behavior, [3] genetics, [4] neurophysiology (TMS), [5] brain injury (3T MRI), and [6] brain function (3T fMRI). For each category, the strongest bivariate predictor of gains (when significant) was advanced into a multivariate model. RESULTS: At baseline, the 29 patients had substantial motor deficits (FM=36±15), medium-sized infarcts (33±48cc; 8 lacunar, 21 non-lacunar), and were 4.3 months post-stroke. Patients improved significantly (p<0.0005) on the FM (3.7±3.5) and ARAT (4.1±6.3) scores. In non-lacunar stroke, extent of corticospinal tract injury and baseline behavior survived as predictors of treatment gains in the multivariate model (r=0.60, p=0.02). In lacunar stroke, the model found that extent of activation within ipsilesional primary motor cortex was the sole predictor of gains (r=0.79, p=0.02). CONCLUSIONS: Measures of brain injury, brain function, and behavior are the strongest predictors of arm motor gains among patients in the early phase of chronic stroke. Different factors predict gains across stroke subtypes. Current results may be useful for patient selection in a clinical trial setting, where effective stratification can reduce variance and increase study power.

Stroke Survivors Scoring Zero on the NIH Stroke Scale Score Still Exhibit Significant Motor Impairment and Functional Limitation.

Objective. To determine the National Institutes of Health Stroke Scale's (NIHSS's) association with upper extremity (UE) impairment and functional outcomes. Design. Secondary, retrospective analysis of randomized controlled trial data. Setting. Not applicable. Participants. 146 subjects with stable, chronic stroke-induced hemiparesis. Intervention. The NIHSS, the UE Fugl-Meyer (FM), and the Arm Motor Ability Test (AMAT) were administered prior to their participation in a multicenter randomized controlled trial. Main Outcome Measures. The NIHSS, FM, and AMAT. Results. The association between the NIHSS and UE impairment was statistically significant (P = −0.204; p = 0.014) but explained less than 4% of the variance among UE FM scores. The association between NIHSS total score and function as measured by the AMAT was not statistically significant (P = −0.141; p = 0.089). Subjects scoring a “zero” on the NIHSS exhibited discernible UE motor deficits and varied scores on the UE FM and AMAT. Conclusion. While being used in stroke trials, the NIHSS may have limited ability to discriminate between treatment responses, even when only a relatively narrow array of impairment levels exists among patients. Given these findings, NIHSS use should be restricted to acute stroke studies and clinical settings with the goal of reporting stroke severity.

Action Observation Therapy in the Subacute Phase Promotes Dexterity Recovery in Right-Hemisphere Stroke Patients

The clinical impact of action observation (AO) on upper limb functional recovery in subacute stroke patients is recent evidence. We sought to test the hypothesis that training everyday life activities through AO coupled with task execution might activate the left hemisphere different from the right one. Sixty-seven first-ever ischemic stroke subjects were randomly assigned to receive upper limb training coupled with AO tasks or standard rehabilitation. The groups were matched by age and gender, Bamford category, and interval from stroke and lesion side. Fugl-Meyer (FM) and Box and Block Test (BBT) were used to measure hand function recovery at the end (T1) and 4-5 months after the treatment (T2). At T1, FM was increased by 31% (±26%), of maximum achievable recovery, whereas BBT was increased by 17% (±18%); at T2, FM had reached 43% (±45%) of maximum recovery, while BBT had reached 25% (±22%). Combining the effects of treatment to those of lesion side revealed significantly higher gains, in both FM and BBT scores, in left hemiparetic subjects when exposed to AO as compared to standard rehabilitation alone (P < .01). The findings lead to recommend the use of AO in addition to motor training in left hemiparetic patients.

The effect of random or sequential presentation of targets during robot-assisted therapy on children

Robot assisted upper extremity therapy has been shown to be effective in adult stroke patients and in children with cerebral palsy (CP) and other acquired brain injuries (ABI). The patient's active involvement is a factor in its efficacy. However, this demands focused attention during training sessions, which can be a challenge for children. To compare results of training requiring two different levels of focused attention. Differences in short term performance and retention of gains as a function of training protocol as measured by the Fugl-Meyer (FM) were predicted. Thirty-one children with CP or ABI were randomly divided into two groups. All received 16 one hour sessions of robot-assisted therapy (twice a week for 8 weeks) where they moved a robot handle to direct a cursor on the screen toward designated targets. One group had targets presented sequentially in clockwise fashion, the other presented in random order. Thus, one group could anticipate the position of each target, the other could not. Both groups showed significant functional improvement after therapy, but no significant difference between groups was observed. Assist-as-needed robotic training is effective in children with CP or ABI with small non-significant differences attributed to attentional demand.

Factors affecting falls in community-dwelling individuals with stroke in Singapore after hospital discharge

This study aimed to investigate the factors affecting the incidence of falls among individuals with stroke living in the community one year after discharge from a rehabilitation hospital in Singapore. A cross-sectional telephone survey of individuals with stroke living in the community was carried out one year after discharge. The interview covered aspects such as incidence and circumstances of fall, use of walking aids, and presence of environmental obstacles. Each participant's case record was retrospectively reviewed using discharge Fugl-Meyer (FM) assessment of the upper and lower limbs, functional independence measure (FIM) and Berg Balance Scale (BBS). A total of 126 individuals with stroke were interviewed. Overall, 24% fell in the year following their discharge. Factors associated with falls were longer length of hospital stay, lower BBS and lower-limb FM scores, and lower discharge FIM scores for the Bladder and Bowel Management, Transfer, Mobility, Communication, and Social Cognition domains (p < 0.05). The fallers were more likely to use walking aids, and required help with basic activities of daily living after discharge (p < 0.05). Multivariate logistic regression analysis revealed that only the Transfer domain was an independent factor for falls. Discharge FIM outcomes, especially for the Transfer domain, can be used to identify communitydwelling individuals with stroke who have a high fall risk after discharge. Identification of such individuals will enable early fall prevention management, which will in turn minimise fall events in the community.

Effect of Functional Electrical Stimulation with Mirror Therapy on Upper Extremity Motor Function in Poststroke Patients

Motor recovery of the upper extremity in stroke patients is an important goal of rehabilitation. In particular, motor recovery can be accelerated when physical and cognitive interventions are combined. Thus, the aim of this study was to investigate the effects of functional electrical stimulation (FES) with mirror therapy (MT) on motor function of upper extremity in stroke patients. Twenty-seven stroke patients were recruited, and the 23 subjects who met the inclusion criteria were randomly allocated into 2 groups: the experimental group (n = 12) and the control group (n = 11). Both groups received conventional rehabilitation training for 60 minutes/day and 5 days/week for 4 weeks. In addition, members of the experimental group received FES with MT and members of the control group received FES without MT for 30 minutes/day and 5 days/week for 4 weeks. Immediately before and after intervention, motor recovery was measured using the Fugl-Meyer (FM) assessment, Brunnstrom's motor recovery stage (BMRS), the Manual Function Test (MFT), and the Box and Block Test (BBT). Significant upper extremity motor improvements were observed in the experimental and control groups according to the FM, BMRS, MFT, and BBT (P < .05). In particular, FM subscores for wrist, hand, and co-ordination and MFT subscores for hand function were more significantly improved in the experimental group (P < .05). Motor functions of the upper extremity were improved by FES with MT versus controls. The study shows that FES with MT during poststroke rehabilitation may effectively improve motor functions of the upper extremity.

S4-2. The evaluation of brain function with neuro-rehabilitation modalities in stroke patients

The relation was investigated between functional improvement of hemiparetic arm and change of cortical perfusion (BCP) during voluntary muscle contraction (VOL), EMG-controlled FES (EMG-FES) and simple electrical muscle stimulation (ES) before and after EMG-FES therapy in chronic stroke patients. Sixteen chronic stroke patients with moderate residual hemiparesis underwent 5 months of task-orientated EMG-FES therapy of the paretic arm once or twice a week. Before and after treatment, arm function was clinically evaluated and BCP during VOL, ES and EMG-FES were assessed using multi-channel near-infrared spectroscopy. BCP in the ipsilesional sensory-motor cortex (SMC) was greater during EMG-FES than during VOL or ES; therefore, EMG-FES caused a shift in the dominant BCP from the contralesional to ipsilesional SMC. After EMG-FES therapy, Fugl-Meyer (FM) score and maximal grip strength (GS) were improved significantly even with variability within individual patients. Clinical improvement accompanied an increase in ipsilesional SMC activation during VOL and EMG-FES condition. The EMG-FES may have more influence on ipsilesional BCP than VOL or ES alone. The sensory motor integration during EMG-FES therapy might facilitate BCP of the ipsilesional SMC and influence on brain reorganization, which result in functional improvement of hemiparetic upper extremity.

Response to Letter Regarding Article, “Patient-Reported Measures Provide Unique Insights Into Motor Function After Stroke”

We thank Drs Stinear and Byblow for their kind words. These authors identified a compelling message regarding patient stratification from Figure 2 of our prior report: specific ranges of upper extremity (UE) Fugl–Meyer (FM) scores correspond to distinct UE functional states (see below). This approach provides a Rosetta Stone, whereby examination assessments are expressed in terms that are clinically meaningful and elegantly simple. Drs Stinear and Byblow consider use of this approach in the setting of clinical care delivery, but its value might also extend to clinical trial design, including end points. In some studies, a continuous variable used to measure behavior is collapsed into a categorical variable. Although doing so can decrease statistical power1 and reduce granularity of the measure, this approach can be advantageous in certain settings, 2 of which are considered below: (1) when the levels of the categorical variable are defined in a manner that has strong clinical validity, and (2) when …

The effects of electromyography-controlled functional electrical stimulation on upper extremity function and cortical perfusion in stroke patients

ObjectiveThe relation was investigated between hemiparetic arm function improvement and brain cortical perfusion (BCP) change during voluntary muscle contraction (VOL), EMG-controlled FES (EMG-FES) and simple electrical muscle stimulation (ES) before and after EMG-FES therapy in chronic stroke patients. MethodsSixteen chronic stroke patients with moderate residual hemiparesis underwent 5months of task-orientated EMG-FES therapy of the paretic arm once or twice a week. Before and after treatment, arm function was clinically evaluated and BCP during VOL, ES and EMG-FES were assessed using multi-channel near-infrared spectroscopy. ResultsBCP in the ipsilesional sensory-motor cortex (SMC) was greater during EMG-FES than during VOL or ES; therefore, EMG-FES caused a shift in the dominant BCP from the contralesional to ipsilesional SMC. After EMG-FES therapy, arm function improved in most patients, with some individual variability, and there was significant improvement in Fugl–Meyer (FM) score and maximal grip strength (GS). Clinical improvement was accompanied by an increase in ipsilesional SMC activation during VOL and EMG-FES condition. ConclusionThe EMG-FES may have more influence on ipsilesional BCP than VOL or ES alone. SignificanceThe sensory motor integration during EMG-FES therapy might facilitate BCP of the ipsilesional SMC and result in functional improvement of hemiparetic upper extremity.

Perceived and actual arm performance in multiple sclerosis: relationship with clinical tests according to hand dominance

Background: The real-life relevance of frequently applied clinical arm tests is not well known in multiple sclerosis (MS). Objective: This study aimed to determine the relation between real-life arm performance and clinical tests in MS. Methods: Thirty wheelchair-bound MS patients and 30 healthy controls were included. Actual and perceived real-life arm performance was measured by using accelerometry and a self-reported measure (Motor Activity Log). Clinical tests on ‘body functions & structures’ (JAMAR handgrip strength, Motricity Index (MI), Fugl Meyer (FM)) and ‘activity’ level (Nine Hole Peg Test (NHPT), Action Research Arm test) of the International Classification of Functioning were conducted. Statistical analyses were performed separately for current dominant and non-dominant arm. Results: For all outcome measures, MS patients scored with both arms significantly lower than the control group. Higher correlations between actual arm performance and clinical tests were found for the non-dominant arm (0.63–0.80). The FM (55%) was a good predictor of actual arm performance, while the MI (46%) and NHPT (55%) were good predictors of perceived arm performance. Conclusions: Real-life arm performance is decreased in wheelchair-bound MS patients and can be best predicted by measures on ‘body functions & structures’ level and fine motor control. Hand dominance influenced the magnitude of relationships.

Randomized Controlled Trial of Surface Peroneal Nerve Stimulation for Motor Relearning in Lower Limb Hemiparesis

ObjectiveTo compare the motor relearning effect of a surface peroneal nerve stimulator (PNS) versus usual care on lower limb motor impairment, activity limitation, and quality of life among chronic stroke survivors. DesignSingle-blinded randomized controlled trial. SettingTeaching hospital of academic medical center. ParticipantsChronic stroke survivors (N=110; >12wk poststroke) with unilateral hemiparesis and dorsiflexion strength of ≤4/5 on the Medical Research Council scale. InterventionsSubjects were stratified by motor impairment level and then randomly assigned to ambulation training with either a surface PNS device or usual care (ankle-foot orthosis or no device) intervention. Subjects were treated for 12 weeks and followed up for 6 months posttreatment. Main Outcome MeasuresLower limb portion of the Fugl-Meyer (FM) Assessment (motor impairment), the modified Emory Functional Ambulation Profile (mEFAP) performed without a device (functional ambulation), and the Stroke Specific Quality of Life (SSQOL) scale. ResultsThere was no significant treatment group main effect or treatment group by time interaction effect on FM, mEFAP, or SSQOL raw scores (P>.05). The time effect was significant for the 3 raw scores (P<.05). However, when comparing average change scores from baseline (t1) to end of treatment (t2, 12wk), and at 12 weeks (t3) and 24 weeks (t4) after end of treatment, significant differences were noted only for the mEFAP and SSQOL scores. The change in the average scores for both mEFAP and SSQOL occurred between t1 and t2, followed by relative stability thereafter. ConclusionsThere was no evidence of a motor relearning effect on lower limb motor impairment in either the PNS or usual-care groups. However, both the PNS and usual-care groups demonstrated significant improvements in functional mobility and quality of life during the treatment period, which were maintained at 6-month follow-up.

Size Doesn't Matter: Cortical Stroke Lesion Volume Is Not Associated With Upper Extremity Motor Impairment and Function in Mild, Chronic Hemiparesis

ObjectivesTo determine (1) the relationship between lesion volume and upper extremity (UE) motor impairment using the UE section of the Fugl-Meyer (FM) assessment; and (2) the relationship between lesion volume and UE functional outcomes using the Arm Motor Ability Test (AMAT) Functional Ability (FA) and Time scales. DesignSecondary retrospective analysis of randomized controlled trial data. SettingOutpatient rehabilitation clinic. ParticipantsSubjects with chronic stroke (N=139, 83 men; mean age ± SD of all subjects, 56.7±11.2y; mean time ± SD since stroke onset, 59.6±65.6mo; 90 subjects with right hemiparesis) and stable, active, distal UE movement. InterventionData were collected related to subjects' lesion volume and UE movement before their participation in a multicenter, randomized controlled trial. Main Outcome MeasuresFM and AMAT. ResultsNeither age nor lesion volume was related to FM performance. The P value for the regression coefficient of lesion volume was .045 in the AMAT FA model and .016 in the AMAT Time model. Lesion volume accounted for only an additional 1.7% (AMAT FA) to 3.1% (AMAT Time) of the variability in motor function and was not clinically meaningful. ConclusionsData suggest no relationship between lesion volume and UE impairment, and a small, clinically insignificant relationship between lesion volume and UE motor function. Stroke causes metabolic changes in intact regions and diffuse structural loss in anatomically remote regions from the infarction. These other factors may account for variance in motor outcomes after stroke.

The Resonating Arm Exerciser: design and pilot testing of a mechanically passive rehabilitation device that mimics robotic active assistance

BackgroundRobotic arm therapy devices that incorporate actuated assistance can enhance arm recovery, motivate patients to practice, and allow therapists to deliver semi-autonomous training. However, because such devices are often complex and actively apply forces, they have not achieved widespread use in rehabilitation clinics or at home. This paper describes the design and pilot testing of a simple, mechanically passive device that provides robot-like assistance for active arm training using the principle of mechanical resonance.MethodsThe Resonating Arm Exerciser (RAE) consists of a lever that attaches to the push rim of a wheelchair, a forearm support, and an elastic band that stores energy. Patients push and pull on the lever to roll the wheelchair back and forth by about 20 cm around a neutral position. We performed two separate pilot studies of the device. In the first, we tested whether the predicted resonant properties of RAE amplified a user’s arm mobility by comparing his or her active range of motion (AROM) in the device achieved during a single, sustained push and pull to the AROM achieved during rocking. In a second pilot study designed to test the therapeutic potential of the device, eight participants with chronic stroke (35 ± 24 months since injury) and a mean, stable, initial upper extremity Fugl-Meyer (FM) score of 17 ± 8 / 66 exercised with RAE for eight 45 minute sessions over three weeks. The primary outcome measure was the average AROM measured with a tilt sensor during a one minute test, and the secondary outcome measures were the FM score and the visual analog scale for arm pain.ResultsIn the first pilot study, we found people with a severe motor impairment after stroke intuitively found the resonant frequency of the chair, and the mechanical resonance of RAE amplified their arm AROM by a factor of about 2. In the second pilot study, AROM increased by 66% ± 20% (p = 0.003). The mean FM score increase was 8.5 ± 4 pts (p = 0.009). Subjects did not report discomfort or an increase in arm pain with rocking. Improvements were sustained at three months.ConclusionsThese results demonstrate that a simple mechanical device that snaps onto a manual wheelchair can use resonance to assist arm training, and that such training shows potential for safely increasing arm movement ability for people with severe chronic hemiparetic stroke.

Efficacy and safety of short-term use of COX-2 inhibitors in patients after an acute stroke with musculoskeletal pain

Objective:Musculoskeletal pain commonly occurs in the elderly, many of whom are also prone to suffer from strokes. We studied whether short-term use (≤ 4 weeks) of cyclooxygenase-2 (COX-2) inhibitors for musculoskeletal pain in stroke patients helped them to participate in their therapies and was safe and efficacious.Materials and Methods:Three hundred and three patients admitted consecutively with first ischemic stroke were studied. Two cohorts were defined, based on whether patients with acute stroke had sufficient musculoskeletal pain that warranted oral COX-2 inhibitors (COX-2 group) or not (case-matched controls). Primary efficacy measures were change in Fugl-Meyer (F-M) pain score and change in total functional independence measure (TFIM) scores on discharge from hospital. Safety was judged by the incidence of vascular episodes during the study period.Results:From the original 303 patients, 64 patients in the COX-2 group were matched with 64 patients in the non-COX-2 group. The groups were matched for age (±5 years), gender, and admission TFIM score (± 5 points). Baseline characteristics between the 2 groups were similar. The primary and secondary outcome measures were similar between the 2 groups, except for ambulation endurance, which favored the non-COX-2 group (P < 0.03). Greater change in the pain score (less pain) was found in the COX-2 group; this effect was strongest in patients who were independent prior to their stroke (on post hoc analysis). There were too few adverse events in either group of any significance.Conclusions:The short-term use of COX-2 inhibitors reduced musculoskeletal pain in acute stroke patients, improved functional motor outcome, and were found to be safe.