Limb In Stroke Patients Research Articles

Mirror Therapy in Complex Regional Pain Syndrome Type 1 of the Upper Limb in Stroke Patients

Background. Complex regional pain syndrome type 1 (CRPSt1) of the upper limb is a painful and debilitating condition, frequent after stroke, and interferes with the rehabilitative process and outcome. However, treatments used for CRPSt1 of the upper limb are limited. Objective. This randomized controlled study was conducted to compare the effectiveness on pain and upper limb function of mirror therapy on CRPSt1 of upper limb in patients with acute stroke. Methods. Of 208 patients with first episode of unilateral stroke admitted to the authors’ rehabilitation center, 48 patients with CRPSt1 of the affected upper limb were enrolled in a randomized controlled study, with a 6-month follow-up, and assigned to either a mirror therapy group or placebo control group. The primary end points were a reduction in the visual analogue scale score of pain at rest, on movement, and brush-induced tactile allodynia. The secondary end points were improvement in motor function as assessed by the Wolf Motor Function Test and Motor Activity Log. Results. The mean scores of both the primary and secondary end points significantly improved in the mirror group (P < .001). No statistically significant improvement was observed in any of the control group values (P > .001). Moreover, statistically significant differences after treatment (P < .001) and at the 6-month follow-up were found between the 2 groups. Conclusions. The results indicate that mirror therapy effectively reduces pain and enhances upper limb motor function in stroke patients with upper limb CRPSt1.

Actigraphic Measurement of Motor Deficits in Acute Ischemic Stroke

Background: This study aimed to investigate the use of actigraphy (accelerometry) to measure disuse of the impaired arm in acute stroke patients. We correlated the National Institute of Health Stroke Scale (NIHSS) and the Fugl-Meyer Assessment arm section (FMA) findings with actigraphic data as a measure of validity. Methods: Thirty-nine acute ischemic stroke patients were included within 1 week after stroke onset. At inclusion, motor deficits were assessed by the NIHSS, FMA and 48-hour actigraphic recordings of both wrists were performed. Results: Moderate but highly significant correlations (Spearman’s rho) between actigraphic recordings and total NIHSS (ratio r = –0.59 and activity of impaired arm r = –0.75; p < 0.001) and FMA (ratio r = 0.54 and activity of impaired arm r = 0.69; p < 0.001) scores were found. Based on actigraphic motor activity scores, ROC curves were calculated following dichotomization of the population based on NIHSS = 7 and FMA = 45, showing good sensitivity and specificity, with negative predictive value of 100% and positive predictive value of 91% for the ratio variable. Conclusions: Moderate but highly significant correlations were found between actigraphy and the stroke scales NIHSS and FMA. Actigraphy was able to reliably discriminate less impaired from more impaired stroke patients with excellent sensitivity and specificity values. Actigraphy is a simple, valid, objective and reliable clinical research tool that can be used to determine motor impairment of the upper limb in stroke patients.

Effects of Task Instructions and Target Location on Reaching Kinematics in People With and Without Cerebrovascular Accident: A Study of the Less-Affected Limb

We investigated how verbal instructions and target location interacted to influence reaching movement of the less-affected limb in participants with and without unilateral cerebrovascular accidents (CVAs). Using a counterbalanced repeated-measures design, 26 people with CVA and 24 age-matched healthy people performed the reaching tasks under 4 conditions formed by the crossing of verbal instructions (speed and accuracy emphasis) and target locations (ipsilateral and contralateral to the performing hand). In the control groups, speeded instructions and ipsilateral reaches elicited significantly more preprogrammed movements than did accuracy instruction and contralateral reaches, respectively. Similar patterns of performance in response to task constraints were found in the CVA groups except for movement initiation in the right CVA group. Instruction and locations interacted to constrain reaching movements in both control and CVA groups. The combination of speeded instruction and ipsilateral reach may optimize movement performance of the less-affected limb in stroke patients.

Ipsi-lesional motor deficits in hemiparetic patients with stroke

Previous studies have proven that motor deficits are expressed in the ipsi-lesional limbs of the injured hemisphere in a variety of motor tasks. However, it still remained controversial for the distinct characteristics of the motor deficits according to the dysfunction of each hemisphere related to motor control. We evaluated the performance of the ipsi-lesional limb in stroke patients and age-sex matched normal controls. Kinematic components such as the temporal variation and accuracy index were analyzed. Our findings revealed that both groups with right or left hemisphere damage showed poor accuracy in terms of complex visuomotor function. Overall, patients with left hemisphere damage exhibited temporal inconstancies in simple repetitive movement. Accordingly, the non-dominant hemisphere plays a primary role in the function of complex visuospatial accuracy, whereas the dominant hemisphere is mainly involved in the motor control of bilateral upper limbs as well as the performance of complex tasks. Therefore, we assumed that such deficits may be caused by damage of the lateralized hemispheric function, depending on the property of the performed task and hemispheric asymmetry. The manifest understanding of the ipsi-lesional motor abnormalities provides clinicians with useful neurophysiologic information, and with the necessity of careful evaluation and therapeutic intervention on the ipsi-lesional upper limb, often clinically assumed as "the non-affected side".

Ipsilesional motor deficits following stroke reflect hemispheric specializations for movement control

Recent reports of functional impairment in the 'unaffected' limb of stroke patients have suggested that these deficits vary with the side of lesion. This not only supports the idea that the ipsilateral hemisphere contributes to arm movements, but also implies that such contributions are lateralized. We have previously suggested that the left and right hemispheres are specialized for controlling different features of movement. In reaching movements, the non-dominant arm appears better adapted for achieving accurate final positions and the dominant arm for specifying initial trajectory features, such as movement direction and peak acceleration. The purpose of this study was to determine whether different features of control could characterize ipsilesional motor deficits following stroke. Healthy control subjects and patients with either left- or right-hemisphere damage performed targeted single-joint elbow movements of different amplitudes in their ipsilateral hemispace. We predicted that left-hemisphere damage would produce deficits in specification of initial trajectory features, while right-hemisphere damage would produce deficits in final position accuracy. Consistent with our predictions, patients with left, but not right, hemisphere damage showed reduced modulation of acceleration amplitude. However, patients with right, but not left, hemisphere damage showed significantly larger errors in final position, which corresponded to reduced modulation of acceleration duration. Neither patient group differed from controls in terms of movement speed. Instead, the mechanisms by which speed was specified, through modulation of acceleration amplitude and modulation of acceleration duration, appeared to be differentially affected by left- and right-hemisphere damage. These findings support the idea that each hemisphere contributes differentially to the control of initial trajectory and final position, and that ipsilesional deficits following stroke reflect this lateralization in control.

A NOVEL SELF-ASSISTED REHABILITATION SYSTEM FOR THE UPPER LIMBS BASED ON VIRTUAL REALITY

We propose a novel self-assisted rehabilitation system for the upper limbs of stroke patients. The system mainly includes two haptic devices (PHANTOM Omni), an advanced inertial sensor (MTx) and a computer. The inertial sensor is used to get the real-time orientation of one of the manipulator's hands, and the haptic devices are used to get the real-time positions of the manipulator's two hands and generate the appropriate forces that act on the two hands. We have built a virtual force model to get the accurate magnitude and orientation of the forces. With the change of the position and orientation of the manipulator's hands, the magnitude and orientation of the forces will change accordingly. The manipulator operates the styluses of the two haptic devices to control the position and orientation of the virtual object m, so that it can track the virtual object m′, which moves and rotates randomly in 4 degree-of-freedoms (DOF). It is expected to improve the agility and strength of manipulator's hands in this way. Furthermore, one hand can be used to assist the other one in the rehabilitation, so the self-assistance character is included in the system. The advantages of high safety, compaction and self-assistance will make the system suitable for home rehabilitation.

Effect of recover and treat in early days on the paralysis of limbs in stroke patients

目的 探讨运动疗法为主的康复治疗对脑卒中恢复期肢体功能恢复的影响.方法采用以运动疗法为主配合中频治疗、作业治疗、电针、心理疏导对94例脑卒中患者瘫痪肢体进行康复治疗.结果 94例患者的瘫痪肢体的功能有不程度的恢复,应用Brunnstrom偏瘫肢体功能评定法评定,发病后≤1个月的恢复较理想,与发病后1～3个月和3～6个月的进行肢体功能恢复比较,差异有显著意义(P＜0.01和P＜0.05).结论早期康复治疗对脑卒中患者肢体功能的恢复效果显著。

Effects of mental practice on affected limb use and function in chronic stroke

Page SJ, Levine P, Leonard AC. Effects of mental practice on affected limb use and function in chronic stroke. ObjectiveTo determine the efficacy of a mental practice (MP) protocol in increasing the function and use of the more affected limb in stroke patients. DesignRandomized, controlled, multiple baseline, pre-post, case series. SettingOutpatient rehabilitation hospital. ParticipantsEleven patients who had a stroke more than 1 year before study entry (9 men; mean age, 62.3±5.1y; range, 53–71y; mean time since stroke, 23.8mo; range, 15–48mo; 10 strokes exhibiting upper-limb hemiparesis on the dominant side) and who exhibited affected arm hemiparesis and nonuse. InterventionAll patients received 30-minute therapy sessions 2 days a week for 6 weeks. The sessions emphasized activities of daily living (ADLs): 6 subjects randomly assigned to the MP condition concurrently received sessions requiring daily MP of the ADLs; 5 subjects (control group) received an intervention consisting of relaxation techniques. Main outcome measuresThe Motor Activity Log and Action Research Arm (ARA) test. ResultsAffected limb use as rated by MP patients and their caregivers increased (1.55, 1.66, respectively), as did patient and caregiver ratings of quality of movement (2.33, 2.15, respectively) and ARA scores (10.7). In contrast, the controls showed nominal increases in the amount they used their affected limb and in limb function. A Wilcoxon test on the ARA scores revealed significantly (P=.004) greater changes in the MP group’s scores. ConclusionsParticipation in an MP protocol may increase a stroke patient’s use of his/her more affected limb. Data further support that the protocol resulted in correlative, MP-induced, motor function improvements. The mechanisms whereby MP increases affected arm use are unknown. Perhaps using the more affected limb becomes more salient through MP, or perhaps motor schema are altered during MP to integrate limb use.

EVALUATION OF SKILLED LEG MOVEMENTS IN PATIENTS WITH STROKE USING A COMPUTERIZED MOTOR-SKILL ANALYZER FOR THE LOWER LIMB

The utility of a new computerized motor-skill analyzer for the lower limb was studied in healthy subjects and patients with stroke. The computerized motor-skill analyzer for the lower limb evaluated accuracy in a figure-tracking task with the foot. The intraclass correlation coefficients of measurements in subjects were .61 to .89 (p < .01). The trajectory errors of the unaffected lower limb in stroke patients were negatively correlated with physical ability. Trajectory errors of the patients were significantly larger than those of the healthy subjects. These results suggest that the computerized motor-skill analyzer is useful for quantitatively evaluating motor-skills of the lower limb.

Ultrasonographic Findings in Hemiplegic Knees of Stroke Patients

Clinical and radiologic asymmetric arthritic differences between paralyzed and nonparalyzed limbs of stroke patients have been reported. Arthritic pathology aggravates motor dysfunction and compromises rehabilitation. Musculoskeletal ultrasonography plays an important role in showing soft tissue and the articular cartilage of the knee. Fifty-nine patients with either ischemic or hemorrhagic stroke-induced right or left hemiplegia were recruited to evaluate soft-tissue and intra-articular cartilage changes in hemiplegic knees of stroke patients using ultrasonography. An additional 15 subjects (30 knees) without knee disease or a history of knee trauma or surgery were used as controls. There were significant differences in suprapatellar effusion and patellar tendinitis between hemiplegic and nonhemiplegic knees. Suprapatellar effusion and pes anserinus tendinitis were correlated with Brunnstrom stage. The length of time since stroke onset was not significantly correlated with positive ultrasonographic findings in hemiplegic knees. In conclusion, ultrasonography is useful for detecting periarticular soft-tissue changes and intra-articular lesions in hemiplegic knees of stroke patients.

RETRACTED: Amelioration by mecobalamin of subclinical carpal tunnel syndrome involving unaffected limbs in stroke patients

Our previous study showed that overuse of the nonparetic hand and wrist of the nonparetic side following stroke result in significantly more abnormal on the nonparetic side than on the hemiparetic side in terms of electrophysiologic indices of median nerve function. The purpose of this study was to evaluate the effects of the orally administered mecobalamin, an analogue of vitamin B12, for carpal tunnel syndrome (CTS) in the nonparetic side in patients following stroke. In a randomized open label and prospective study of stroke patients, 67 received of 1500 μg mecobalamin daily for 2 years, and the remaining 68 (untreated group) did not. At baseline, sensory nerve conduction velocity, motor nerve conduction velocity, sensory nerve action potentials (SNAP) at the wrist, palm-to-wrist distal sensory latency, palm-to-wrist SNAP, motor nerve conduction velocity compound motor action potentials, and distal motor latency of median nerve were significantly more abnormal on the nonparetic side than on the hemiparetic side or in controls. Before the treatment 21 patients (31%) of untreated and 20 patients (30%) of treated group met electrophysiologic criteria for CTS. Sensory impairment of the nonparetic side had lessened in the treated group. After 2 years, all electrophysiologic indices of nonparetic side were significantly improved in the treated group compared with those in the untreated group. The improvement from baseline of electrophysiologic parameters in sensory nerve in the treated group was greater than the improvement measured in motor nerve. There were no side effects. Oral mecobalamin treatment is a safe and potentially beneficial therapy for CTS in stroke patients.

Meta-Analysis Examining the Effectiveness of Electrical Stimulation in Improving Functional Use of the Upper Limb in Stroke Patients

Cerebrovascular accidents (CVA) are the leading cause of long-term disability. About 600,000 Americans will have a stroke this year (American Heart Association, 2002). It is estimated that between 29% and 75% of those who suffer from strokes will be affected by upper extremity impairments, including shoulder subluxation, pain, flaccidity, and decreased upper extremity limb function (Wang, Chan, & Tsai, 2000).This meta-analysis examines the effectiveness of electrical stimulation on treating the upper extremities of patients who suffer cerebro-vascular accidents (strokes). Illustrating the efficacy of electrical stimulation on stroke patients may help to influence occupational therapists use of this adjunctive treatment method.

Meta-Analysis Examining the Effectiveness of Electrical Stimulation in Improving Functional Use of the Upper Limb in Stroke Patients

Cerebrovascular accidents (CVA) are the leading cause of long-term disability. About 600,000 Americans will have a stroke this year (American Heart Association, 2002). It is estimated that between 29% and 75% of those who suffer from strokes will be affected by upper extremity impairments, including shoulder subluxation, pain, flaccidity, and decreased upper extremity limb function (Wang, Chan, & Tsai, 2000).This meta-analysis examines the effectiveness of electrical stimulation on treating the upper extremities of patients who suffer cerebro-vascular accidents (strokes). Illustrating the efficacy of electrical stimulation on stroke patients may help to influence occupational therapists use of this adjunctive treatment method.

Osteoporosis in hemiplegic stroke patients as studied with dual-energy x-ray absorptiometry

Objectives: To compare bone mineral densities (BMDs) of the affected and unaffected limbs in stroke patients at multiple sites; to study longitudinal changes during a 3-month rehabilitation program; and to relate BMDs to demographic, impairment, and disability variables. Design: Descriptive study. Setting: Tertiary rehabilitation center. Patients: One hundred four consecutive hemiplegic inpatients, 69 men, age 56.5 ± 13.2yrs, 47 with left-sided brain lesion. Median days from onset to admission and median length of stay days were 83 and 105.5, respectively. Main Outcome Measures: BMDs of proximal humerus, distal radius, femoral neck, and calcaneus bilaterally, and third lumbar vertebra, measured with dual-energy x-ray absorptiometry (DXA), were compared between affected and unaffected sides at admission and discharge. Results: Stroke Impairment Assessment Set (SIAS) motor scores, Functional Independence Measure (FIM) scores, grip strength, and awake/sleep heart rate counts (activity index) improved significantly at discharge. Affected/unaffected BMD ratios were 88.3% to 98.4% at admission and 79.6% to 98.8% at discharge, lowest for the humerus. Discharge/admission ratios were 89.1% to 97.8% for the affected and 97.4% to 100% for the unaffected side. All BMDs were intercorrelated (R = .438 to .873). They correlated significantly with age, body weight, grip strength, FIM scores, and activity index. Factors selected to explain BMD with multiple regression analysis differed according to the site and timing of the measurement. Conclusions: BMDs of the affected side were lower and most marked in the humerus. Longitudinally, not only the affected but the unaffected BMDs decreased. Age, sex, duration of stroke, anthropometric measurements, motor paralysis, muscle strength, and activity level contributed differently to bone loss according to the site and timing of the measurement.

RETRACTED: Accelerated bone remodeling in patients with poststroke hemiplegia

A significant bone-mass reduction occurs on the hemiplegic side of stroke patients because of disuse and vitamin D deficiency. This may explain why hip fractures in poststroke patients occur almost exclusively on the hemiplegic side. To further evaluate this osteopenia, bone mineral density (BMD) in both second metacarpals was assessed in 61 patients and 28 control subjects. Serum concentrations of intact parathyroid hormone (PTH), osteocalcin (OC), tartrate-resistant acid phosphatase (TRAP), 25-hydroxyvitamin D (25-OHD), and calcium also were determined. The patients' BMD values were higher on the hemiplegic side than on the nonhemiplegic side. BMD on the hemiplegic side correlated positively with serum concentrations of PTH, OC and TRAP, which exceeded those in control subjects. Serum 25-OHD was low in patients, correlating negatively with BMD on the hemiplegic side. Serum PTH correlate positively with the levels of OC and TRAP and negatively with 25-OHD concentrations. The results indicate that skeletal remodeling is accelerated in patients with hemiplegia, with resorption predominating. We concluded that vitamin D deficiency and compensatory secondary hyperparathyroidism stimulating skeletal turnover is an important cause of osteopenia in the hemiplegic limbs of stroke patients. This osteopenia might be corrected by administration of etidronate to inhibit osteoclastic bone resorption together with a vitamin D supplement.

Measurement of spasticity and associated reactions in stroke patients before and after physiotherapeutic intervention

The purpose of this study is to present two methods of measuring the related phenomena of spasticity and associated reactions (ARs) in the plegic upper limb of stroke patients before and after treatment according to the Bobath approach. Thirty-three hemiplegic patients participated in the study. Spasticity of the elbow flexors and extensors was measured in 13 patients using the passive mode of the KinCom isokinetic dynamometer. The AR in the elbow was measured using a goniometer in all patients while at rest and following an exertion. The isokinetic measurements revealed a highly significant relationship (p &lt;0.001) between spastic resistance and the test angular velocity for both flexors and extensors, but did not demonstrate an improvement following treatment. The ARs scores improved significantly following treatment. The merits and limitations of using isokinetic dynamometry and ARs for measuring spasticity are discussed.