Lower Extremity Motor Function Research Articles

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.

Longitudinal Changes in Temporospatial Gait Characteristics during the First Year Post-Stroke.

Given the paucity of longitudinal data in gait recovery after stroke, we compared temporospatial gait characteristics of stroke patients during subacute (<2 months post-onset, T0) and at approximately 6 and 12 months post-onset (T1 and T2, respectively) and explored the relationship between gait characteristics at T0 and the changes in gait speed from T0 to T1. Forty-six participants were assessed at T0 and a subsample of twenty-four participants were assessed at T2. Outcome measures included Fugl-Meyer lower-extremity motor score, 14 temporospatial gait parameters, and symmetry indices of 5 step parameters. Except for step width, all temporospatial parameters improved from T0 to T1 (p ≤ 0.0001). Additionally, significant improvements in symmetry were found for the initial double-support time and single-support time (p ≤ 0.0001). As a group, no significant differences were found between T1 and T2 in any of the temporospatial measures. However, the individual analysis revealed that 42% (10/24) of the subsample showed a significant increase in gait speed (Welch’s t-test, p ≤ 0.002). Yet, only 5/24 (21%) of the participants improved speed from T1 to T2 according to speed-based minimum detectable change criteria. The increase in gait speed from T0 to T1 was negatively correlated with gait speed and stride length and positively correlated with the symmetry indices of stance and single-support times at T0 (p ≤ 0.002). Temporospatial gait parameters and stance time symmetry improved over the first 6 months after stroke with an apparent plateau thereafter. A greater increase in gait speed during the first 6 months post-stroke is associated with initially slower walking, shorter stride length, and more pronounced asymmetry in stance and single-support times. The improvement in lower-extremity motor function and bilateral improvements in step parameters collectively suggest that gait changes over the first 6 months after stroke are likely due to a combination of neurological recovery, compensatory strategies, and physical therapy received during that time.

Saddle block anesthetic technique for benign outpatient anorectal surgery

BackgroundCurrent American Society of Colorectal Surgery Clinical Practice Guidelines for Ambulatory Anorectal Surgery endorse use of monitored anesthesia care, general anesthesia, or spinal anesthesia based on physician and patient preference. Although several studies support the use of monitored anesthesia care over general anesthesia, the literature regarding spinal anesthesia is limited and heterogenous due to small sample sizes and disparate spinal anesthesia techniques. Saddle block anesthesia is a form of spinal anesthesia that localizes to the lowermost sacral spinal segments allowing for preservation of lower extremity motor function and faster recovery. We accrued one of the largest reported cohort of anorectal procedures using saddle block anesthesia, as such, we sought to evaluate our institutional 12-year experience. MethodsPatients who underwent a benign anorectal procedure at our outpatient surgery center between July 2008−2020 were retrospectively reviewed. Demographics, surgical factors, perioperative times, and adverse events were collected from the electronic medical records. Saddle block anesthesia was generally performed in the preoperative area using a spinal needle (25–27 gauge) and a single injection technique of a 1:1 ratio local anesthetic mixed with 10% dextrose solution. Between 2.5–5 mg of hyperbaric anesthetic was injected intrathecally in the sitting position and the patient remained upright for 3–10 minutes. This technique of saddle block anesthesia provides analgesia for approximately 1–3 hours. ResultsIn the study, 859 saddle block anesthesia patients were identified, with a mean age of 44.6 years and American Society of Anesthesia score of 1.9; 609 (70.9%) were male. Surgical indications included lesion removal (27.1%), anal fistula (25.8%), hemorrhoidectomy (24.7%), pilonidal disease (6.3%), anal fissure (5.8%), and a combination of prior (10.2%). Prone jackknife positioning was used in 91.6% of procedures. Saddle block anesthesia most often was performed with bupivacaine (48.9%) or ropivacaine (41.7%). The median procedural saddle block anesthesia time was 11 minutes, surgery time was 17 minutes, anesthesia time was 42 minutes, and recovery time was 91 minutes. Patients spent a median of 3 hours and 53 minutes in the facility. Adverse events included urinary retention (1.9%), conversion to general anesthesia (1.8%), spinal headache (1.5%), hemodynamic instability (0.9%), and injection site reaction (0.3%). ConclusionDemonstrated using the largest known cohort of anorectal patients with saddle block anesthesia, saddle block anesthesia provides an effective method of analgesia to avoid general anesthesia with a low rate of adverse events.

A Randomized Controlled Trial of the Effect of Repetitive Transcranial Magnetic Stimulation of the Motor Cortex on Lower Extremity Spasticity in Hereditary Spastic Paraplegia.

Hereditary spastic paraplegia refers to a group of conditions characterized by a slow progression of spasticity in lower limbs resulting in gait abnormalities. Current treatment options have proven to be insufficient in terms of symptom alleviation. In this study, we tested the effectiveness of repetitive transcranial magnetic stimulation (rTMS) on lower limb spasticity in patients with hereditary spastic paraplegia. Eight patients were randomly assigned to receive either five sessions of active 5 Hz-rTMS ( n = 4) or sham rTMS ( n = 4). The primary outcome was a change in spasticity assessed by the modified Ashworth scale. Secondary outcomes were change in 10 m walking test, Fugl-Meyer assessment of lower extremity motor function, and quality-of-life short-form survey scores. Assessment of the outcomes was done before, upon completion, and 1 month after the intervention. We analyzed the data using repeated-measure analysis of variance. Mean age of the participants was 38.5 (SD = 5.4) years, and 50% were women. Compared with sham rTMS, real rTMS was effective in decreasing modified Ashworth scale (rTMS × time: F [df = 2] = 7.44; P = 0.008). Real rTMS group had lower modified Ashworth scale scores at the end of rTMS sessions (estimate = -0.938; SE = 0.295; P = 0.019) and at the end of follow-up (estimate = -0.688; SE = 0.277; P = 0.048) compared with the sham rTMS group. Real and sham rTMS groups were not different in the secondary outcomes. Repetitive transcranial magnetic stimulation is an effective method in reducing lower limb spasticity of patients with hereditary spastic paraplegia.

Calculating Ex-ante Utilities From the Modified Japanese Orthopedic Association Score: A Prerequisite for Quantifying the Value of Care for Cervical Myelopathy.

General population utility valuation study. The aim of this study was to develop a technique for calculating utilities from the modified Japanese Orthopedic Association (mJOA) Score. The ability to calculate quality-adjusted life-years (QALYs) for degenerative cervical myelopathy (DCM) would enhance treatment decision making and facilitate economic analysis. QALYs are calculated using utilities. We recruited a sample of 760 adults from a market research panel. Using an online discrete choice experiment, participants rated eight choice sets based on mJOA health states. A multiattribute utility function was estimated using a mixed multinomial-logit regression model. The sample was partitioned into a training set used for model fitting and validation set used for model evaluation. The regression model demonstrated good predictive performance on the validation set with an area under the curve of 0.81 (95% confidence interval: 0.80-0.82)). The regression model was used to develop a utility scoring rubric for the mJOA. Regression results revealed that participants did not regard all mJOA domains as equally important. The rank order of importance was (in decreasing order): lower extremity motor function, upper extremity motor function, sphincter dysfunction, upper extremity sensation. This study provides a simple technique for converting the mJOA score to utilities and quantify the importance of mJOA domains. The ability to evaluate QALYs for DCM will facilitate economic analysis and patient counseling. Clinicians should heed these findings and offer treatments that maximize function in the attributes viewed most important by patients.Level of Evidence: 3.

Application of Intelligent Exercise Training Equipment in Clinical Nursing of Neurology Department.

To investigate the effect of intelligent exercise training equipment on lower limb function and standing stability of stroke patients with hemiplegia in clinical nursing of neurology department. Forty-eight stroke patients with a course of 1 to 3 months were randomly divided into treatment group and control group, with 24 cases in each group. The control group was treated with conventional rehabilitation training, and the treatment group was treated with intelligent training system, twice a day, 20 min each time. Lower extremity motor function (using the FMA-L scale) and walking function (using the functional walking scale FAC) were assessed before treatment and 4 weeks after treatment. The results showed that there was no statistical difference between the control group and the treatment group in the t-test of lower limb motor function scores before rehabilitation treatment (P > 0.05). After treatment, the lower extremity motor function scores of the two groups were tested by group design T-test, and the results showed that there was a significant difference between the two groups (P < 0.05); The effect of the treatment group was significantly better than that of the control group (P < 0.05). Intelligent exercise training equipment combined with routine rehabilitation therapy in clinical nursing of neurology department could improve the lower extremity motor function and walking ability of patients with convalescence stroke hemiplegia, and the effect was better than that of routine rehabilitation therapy alone.

Multimodal assessment of interhemispheric cortical interactions and differential behavioral relevance in upper and lower extremity motor function in chronic stroke

Multimodal assessment of interhemispheric cortical interactions and differential behavioral relevance in upper and lower extremity motor function in chronic stroke

Efficacy of an exoskeleton-based physical therapy program for non-ambulatory patients during subacute stroke rehabilitation: a randomized controlled trial

BackgroundIndividuals requiring greater physical assistance to practice walking complete fewer steps in physical therapy during subacute stroke rehabilitation. Powered exoskeletons have been developed to allow repetitious overground gait training for individuals with lower limb weakness. The objective of this study was to determine the efficacy of exoskeleton-based physical therapy training during subacute rehabilitation for walking recovery in non-ambulatory patients with stroke.MethodsAn assessor-blinded randomized controlled trial was conducted at 3 inpatient rehabilitation hospitals. Patients with subacute stroke (< 3 months) who were unable to walk without substantial assistance (Functional Ambulation Category rating of 0 or 1) were randomly assigned to receive exoskeleton-based or standard physical therapy during rehabilitation, until discharge or a maximum of 8 weeks. The experimental protocol replaced 75% of standard physical therapy sessions with individualized exoskeleton-based sessions to increase standing and stepping repetition, with the possibility of weaning off the device. The primary outcome was walking ability, measured using the Functional Ambulation Category. Secondary outcomes were gait speed, distance walked on the 6-Minute Walk Test, days to achieve unassisted gait, lower extremity motor function (Fugl-Meyer Assessment), Berg Balance Scale, Patient Health Questionnaire, Montreal Cognitive Assessment, and 36-Item Short Form Survey, measured post-intervention and after 6 months.ResultsThirty-six patients with stroke (mean 39 days post-stroke) were randomized (Exoskeleton = 19, Usual Care = 17). On intention-to-treat analysis, no significant between-group differences were found in the primary or secondary outcomes at post-intervention or after 6 months. Five participants randomized to the Exoskeleton group did not receive the protocol as planned and thus exploratory as-treated and per-protocol analyses were undertaken. The as-treated analysis found that those adhering to exoskeleton-based physical therapy regained independent walking earlier (p = 0.03) and had greater gait speed (p = 0.04) and 6MWT (p = 0.03) at 6 months; however, these differences were not significant in the per-protocol analysis. No serious adverse events were reported.ConclusionsThis study found that exoskeleton-based physical therapy does not result in greater improvements in walking independence than standard care but can be safely administered at no detriment to patient outcomes.Clinical Trial Registration The Exoskeleton for post-Stroke Recovery of Ambulation (ExStRA) trial was registered at ClinicalTrials.gov (NCT02995265, first registered: December 16, 2016)

Selective Motor Control is a Clinical Correlate of Brain Motor Tract Impairment in Children with Spastic Bilateral Cerebral Palsy.

Selective voluntary motor control is an important factor influencing gross motor function, interjoint coordination, and the outcome of hamstring-lengthening surgery in spastic cerebral palsy. Using DTI, we investigated whether selective voluntary motor control would show strong correlations with WM motor tract microstructure and whether selective voluntary motor control is more sensitive to global WM impairment than gross motor function. Children with spastic bilateral cerebral palsy born preterm and typically developing children were recruited. The Selective Control Assessment of the Lower Extremity (SCALE) and Gross Motor Function Measure (GMFM) were assessed in participants with cerebral palsy. Participants underwent brain MR imaging to collect DWI data. Tract-Based Spatial Statistics was used to analyze the WM for between-group differences and correlations with SCALE and GMFM. ROI analyses compared motor regions. Twelve children with cerebral palsy (mean age, 11.5 years) and 12 typically developing children (mean age, 10.3 years) participated. Altered DTI outcomes were found throughout the whole brain for the cerebral palsy group. SCALE, developed to evaluate selective voluntary motor control in cerebral palsy, showed significant positive correlations with fractional anisotropy in more WM voxels throughout the whole brain and for motor regions, including the corticospinal tract and corpus callosum, compared with GMFM. A significant negative correlation between radial diffusivity and SCALE, but not GMFM, was found within the corpus callosum. SCALE was a more sensitive clinical correlate of motor and whole-brain WM tract impairment in children with spastic bilateral cerebral palsy, suggesting greater anisotropy and myelination in these regions for those with higher selective voluntary motor control.

Effectiveness of Motor Imagery Training for Lower Extremity Motor Function in Patients With Stroke: A Systematic Review and Meta-Analysis

<h3>Objective(s)</h3> Motor imagery training (MIT) is considered an emerging and non-invasive rehabilitation technique that patients could easily master to improve functional outcomes. To evaluate the effectiveness of MIT combined with conventional rehabilitation therapy (CRT) in treatment of lower extremity motor functions (LEMFs) in patients with stroke. <h3>Data Sources</h3> PubMed, Embase, Cochrane Library, Web of Science, ClinicalTrials, Chinese Biomedical Literatures database, Chinese National Knowledge Infrastructure, Wan-Fang Database, and Chinese Scientific Journals Database were researched from the earliest records to December 1, 2020. <h3>Study Selection</h3> Randomized controlled trials (RCTs) that compared MIT associated with CRT versus a control CRT in patients with lower extremity motor dysfunction after stroke, were selected. Among the 781 records screened, 15 trials, in which motor imagination questionnaires clearly performed, were included with 761 eligible patients. <h3>Data Extraction</h3> Pooled outcome data were completed by two researchers independently. Primary evaluation index was the Fugl-Meyer assessment scale-Lower extremity (FMA-LE). The second evaluation indices were Functional Ambulation Category (FAC) and Berg Balance Scale (BBS). Meanwhile, the methodological quality of included studies was conducted via the Physiotherapy Evidence Database scale and the Cochrane risk of bias criteria tools. <h3>Data Synthesis</h3> Meta-analysis showed that there existed statistically significant improvements in FMA-LE (WMD=3.65, 95%CI=2.52, 4.78, P < 0.00001), FAC (WMD=0.80, 95% CI=0.22, 1.38, P=0.006) and BBS (WMD=6.15, 95% CI=2.98, 9.32, P=0.0001) in the MIT associated with CRT group versus the control group after an intervention of more than 3 weeks. <h3>Conclusions</h3> MIT associated with CRT had better effectiveness in LEMFs than CRT alone. <h3>Author(s) Disclosures</h3> None.

Impact of different bilateral knee extension strengths on lower extremity performance.

Despite the impact of leg muscle strength on lower extremity motor performance—including walking and sit-to-stand transfer—it remains difficult to predict the relationship between bilateral leg muscle strength and lower extremity performance. Therefore, this study was designed to predict lower extremity function through the differential modeling of logarithmic and linear regression, based on knee extension strength.The study included 121 individuals living in the same community. The bilateral strengths of the knee extensors were measured using a handheld dynamometer, and the Timed Up & Go test (TUG) performance time and 5-m minimum walking times were assessed to predict lower extremity motor functions. Bilateral normalized knee extension muscle strengths and lower extremity motor function scores, including walking or TUG performance times, were assessed on the logarithmic and linear models. The Akaike information criterion (AIC) was used to evaluate the coefficient compatibility between the logarithmic regression model and the linear regression model.The AIC value for the linear model was lower than that for the logarithmic model regarding the walking time. For walking time estimation in the linear model, the coefficient value of knee extension strength was larger on the strong than on the weak side; however, the AIC value for the logarithmic model was lower than that for the linear model regarding TUG performance time. In the logarithmic model's TUG performance time estimation, the coefficient value of knee extension strength was larger on the weak than on the strong side.In conclusion, our study demonstrated different models reflecting the relationship between both legs’ strengths and lower extremity performance, including the walking and TUG performance times.

The Scoli-RISK 1 results of lower extremity motor function 5 years after complex adult spinal deformity surgery.

Neurologic complications after complex adult spinal deformity (ASD) surgery are important, yet outcomes are heterogeneously reported, and long-term follow-up of actual lower extremity motor function is unknown. To prospectively evaluate lower extremity motor function scores (LEMS) before and at 5years after surgical correction of complex ASD. Retrospective analysis of a prospective, multicenter, international observational study. The Scoli-RISK-1 study enrolled 272 ASD patients undergoing surgery from 15 centers around the world. Inclusion criteria were Cobb angle of > 80°, corrective osteotomy for congenital or revision deformity and/or 3-column osteotomy. Among patients with 5-year follow-up, comparisons of LEMS to baseline and within each follow-up period were made via documented neurologic exams on each patient. Seventy-seven (28.3%) patients had 5-year follow-up. Among these 77 patients with 5-year follow-up, rates of postoperative LEMS deterioration were: 14.3% hospital discharge, 10.7% at 6 weeks, 6.5% at 6months, 9.5% at 2years and 9.3% at 5years postoperative. During the 2-5year window, while mean LEMS did not change significantly (-0.5, p = 0.442), eight (11.1%) patients deteriorated (of which 3 were ≥ 4 motor points), and six (8.3%) patients improved (of which 2 were ≥ 4 points). Of the 14 neurologic complications, four (28.6%) were surgery-related, three of which required reoperation. While mean LEMS were not impacted in patients with a major surgery-related complication, mean LEMS were significantly lower in patients with neurologic surgery-related complications at discharge (p = 0.041) and 6 months (p = 0.008) between the two groups as well as the change from baseline to 5years (p = 0.041). In 77 patients undergoing complex ASD surgery with 5-year follow-up, while mean LEMS did not change from 2 to 5years, subtle neurologic changes occurred in approximately 1 in 5 patients (11.1% deteriorated; 8.3% improved). Major surgery-related complication did not result in decreased LEMS; however, those with neurologic surgery-related complications continued to have decreased lower extremity motor function at 5years postoperative. These results underscore the importance of long-term follow-up to 5years, using individual motor scores rather than group averages, and comparing outcomes to both baseline and last follow-up.

Lateral Corticospinal Tract and Dorsal Column Damage: Predictive Relationships With Motor and Sensory Scores at Discharge From Acute Rehabilitation After Spinal Cord Injury

ObjectiveTo determine if lateral corticospinal tract (LCST) integrity demonstrates a significant predictive relationship with future ipsilateral lower extremity motor function (LEMS) and if dorsal column (DC) integrity demonstrates a significant predictive relationship with future light touch (LT) sensory function post spinal cord injury (SCI) at time of discharge from inpatient rehabilitation. DesignRetrospective analyses of imaging and clinical outcomes. SettingUniversity and academic hospital. ParticipantsA total of 151 participants (N=151) with SCI. InterventionsInpatient rehabilitation. Main Outcome MeasuresLEMS and LT scores at discharge from inpatient rehabilitation. ResultsIn 151 participants, right LCST spared tissue demonstrated a significant predictive relationship with right LEMS percentage recovered (β=0.56; 95% confidence interval [CI], 0.37-0.73; R=0.43; P<.001). Left LCST spared tissue demonstrated a significant predictive relationship with left LEMS percentage recovered (β=0.66; 95% CI, 0.50-0.82; R=0.51; P<.001). DC spared tissue demonstrated a significant predictive relationship with LT percentage recovered (β=0.69; 95% CI, 0.52-0.87; R=0.55; P<.001). When subgrouping the participants into motor complete vs incomplete SCI, motor relationships were no longer significant, but the sensory relationship remained significant. Those who had no voluntary motor function but recovered some also had significantly greater LCST spared tissue than those who did not recover motor function. ConclusionsLCST demonstrated significant moderate predictive relationships with lower extremity motor function at the time of discharge from inpatient rehabilitation, in an ipsilesional manner. DC integrity demonstrated a significant moderate predictive relationship with recovered function of LT. With further development, these neuroimaging methods might be used to predict potential deficits after SCI and to provide corresponding targeted interventions.

Effectiveness of a Long-Term, Home-Based Aerobic Exercise Intervention on Slowing the Progression of Parkinson Disease: Design of the Cyclical Lower Extremity Exercise for Parkinson Disease II (CYCLE-II) Study.

Previous short duration studies have demonstrated that high-intensity aerobic exercise improves aspects of motor and non-motor function in people with Parkinson disease (PwPD); however, the effectiveness of a long-term exercise intervention on slowing disease progression is unknown. The primary aim of this study is to determine the disease-altering effects of high-intensity aerobic exercise, administered on an upright stationary cycle, on the progression of PD. A secondary aim is to develop a prognostic model for 12-month changes in the Movement Disorder Society Unified Parkinson's Disease Rating Scale III (MDS-UPDRS III) of PwPD undergoing an aerobic exercise intervention. This pragmatic, multisite, single-rater blinded, randomized controlled trial will recruit PwPD from 2 large, urban, academic medical centers. Participants (N = 250 PwPD) will be randomized to (1) home-based aerobic exercise or (2) usual and customary care. Those in the aerobic exercise arm will be asked to complete in-home aerobic exercise sessions at 60% to 80% of heart rate reserve 3 times per week for 12months utilizing a commercially available upright exercise cycle. The usual and customary care group will continue normal activity levels. Daily activity will be monitored for both groups throughout the 12-month study period. The primary outcome, both to assess disease-modifying response to aerobic exercise and for prognostic modeling in the aerobic exercise arm, is 12-month rate of change in the MDS-UPDRS III. Clinical and biomechanical measures will also be used to assess upper and lower extremity motor function as well as non-motor functions. Should long-term aerobic exercise demonstrate disease-modifying capability, this study will provide evidence that "Exercise is Medicine" for PwPD. Further, the derived prognostic model will inform a patient-specific exercise prescription for PwPD and expected effects on PD progression.

Effectiveness of additional C2 decompression of the cervical spinal canal after cervical laminoplasty: a retrospective cohort study

Purpose This study aimed to assess the effects of additional C2 decompression of the cervical spinal canal on the postoperative outcomes after cervical laminoplasty in patients with cervical stenosis caused by ossification of the posterior longitudinal ligament (OPLL). Materials and methods This retrospective cohort study included patients with cervical stenosis due to OPLL and treated between April 2014 and December 2015. The patients who underwent C2-7 (additional C2 decompression) and C3-7 posterior decompression were compared using the Japanese Orthopedic Association (JOA) scores, visual analog scale (VAS) scores, axial symptom scores, and intervals between the posterior margin of the vertebral body and the K-line. Results There were 36 and 24 patients in the additional C2 decompression and control groups, respectively. The JOA scores were higher in the additional C2 decompression group than the controls at 1 and 3 years (p < 0.05). Upper extremity motor function after the operation and at 1 and 3 years and lower extremity motor function after operation were improved in the additional C2 decompression group (all p < 0.05 vs. controls). VAS scores were lower in the additional C2 decompression group than controls at 1 year (p < 0.05). Axial symptom scores in the additional C2 decompression group were decreased postoperatively but increased at 1 and 3 years (p < 0.05 vs. controls). Finally, the posterior shift of the K-line in the additional C2 decompression group was significant (from 0.98 to 1.68 cm, p < 0.05). Conclusions Additional C2 decompression might improve the effectiveness of cervical laminoplasty in patients with cervical stenosis caused by OPLL.

Longitudinal motor function in proximal versus distal DMD pathogenic variants.

There is considerable heterogenicity in clinical outcomes in Duchenne muscular dystrophy (DMD). The aim of this study was to assess whether dystrophin gene (DMD) pathogenic variant location influences upper or lower extremity motor function outcomes in a large prospective cohort. We used longitudinal timed and quantitative motor function measurements obtained from 154 boys with DMD over a 10-y period by the Cooperative International Neuromuscular Research Group Duchenne Natural History Study (CINRG-DNHS) to understand how the trajectories of motor function differ based on proximal versus distal DMD pathogenic variants. Proximal variants were defined as located proximal to 5' DMD intron 44, and distal variants as those including nucleotides 3' DMD including intron 44. Distal DMD variants are predicted to alter the expression of short dystrophin isoforms (Dp140, Dp116, and Dp71). We compared various upper extremity and lower extremity motor function measures in these two groups, after adjusting for total lifetime corticosteroid use. The time to loss-of-ambulation and timed motor function measurements of both upper and lower limbs over a 10-y period were comparable between boys with proximal (n=53) and distal (n=101) DMD pathogenic variants. Age had a significant effect on several motor function outcomes. Boys younger than 7y of age (n=49) showed gain in function whereas boys 7y and older (n=71) declined, regardless of dystrophin pathogenic variant location. The longitudinal decline in upper and lower motor function is independent of proximal versus distal location of DMD pathogenic variants.

Repetitive Transcranial Magnetic Stimulation With H-Coil Coupled With Cycling for Improving Lower Limb Motor Function After Stroke: An Exploratory Study

Repetitive transcranial magnetic stimulation (rTMS) has been recognized as a promising intervention for the treatment of post-stroke motor deficits. Here, we explore safety, feasibility, and potential effectiveness of high-frequency rTMS (HF-rTMS) delivered with the Hesed coil (H-coil) during active cycling on paretic lower extremity (LE) motor function in chronic stroke. Twelve subjects with a first-ever stroke were recruited in this double-blind, placebo controlled, crossover study. Eleven sessions of HF-rTMS (40 2s-trains of 20Hz at 90% resting leg motor threshold) were delivered over the LE motor areas using the H-coil during active cycling for three weeks. Each subject underwent both real and sham rTMS treatments separated by a four-week washout period, in a random sequence. Vital signs were recorded before and after each rTMS session. Any discomfort related to stimulation and side effects were recorded. LE function was also evaluated with Fugl-Meyer assessment (FMA-LE), spasticity was assessed with modified-Ashworth scale and measures of gait speed and endurance (10-meter and 6-min walk tests, respectively) were recorded. No participant reported serious adverse effects. During real rTMS, 4 of 12 subjects reported mild side effects including transitory dizziness and muscle twitches on shoulder, so that intensity of stimulation initially set at 90% of RMT was reduced to 80% of RMT on average in these four subjects. Only real treatment was associated with a significant and sustained improvement in FMA-LL (67% responders vs. 9% of the sham). Spasticity significantly ameliorated only after the real rTMS. Real treatment did not offer advantages on walking timed measures when compared with sham. This exploratory study suggests that bilateral HF-rTMS combined with cycling is safe and potentially effective in ameliorating paretic LE motor function and spasticity, rather than gait speed or endurance, in chronic stroke.

Effect of vitamin D supplementation on lower extremity motor function and ambulation in stroke patients

Background/aimThe aim of this study was to investigate the effect of vitamin D supplementation on ambulation and mobility in hospitalized patients undergoing stroke rehabilitation.Materials and methodsThis study was conducted retrospectively between September 2020 and October 2020 at Gazi University Faculty of Medicine Physical Medicine and Rehabilitation Department. Seventy-six patients who received inpatient stroke rehabilitation treatment between May 2018 and February 2020 were included in the study. The patients were divided into two groups as those who did and did not take vitamin D supplements. Lower extremity motor function and ambulation status were compared using Brunnstrom recovery stage (lower extremity) and functional ambulation classification (FAC) scores before and after rehabilitation.Results Thirty-nine patients received vitamin D treatment during the rehabilitation process and 37 patients did not. The two groups were similar in terms of age, sex, time since stroke, stroke type, comorbid diseases, nutritional status, rehabilitation duration, and FAC and Brunnstrom scores before rehabilitation (p > 0.05). At the end of rehabilitation, the changes in FAC and Brunnstrom scores were higher in patients receiving vitamin D supplementation (p = 0.005 and p = 0.018). The change in FAC and Brunnstrom scores in patients who were undergoing rehabilitation for the first time and/or in the first 3 months after stroke was higher in the group receiving vitamin D supplementation compared with the group not receiving vitamin D (p < 0.05). In patients who were not within the first 3 months after stroke, vitamin D treatment did not affect FAC and Brunnstrom scores.Conclusion Vitamin D supplementation may increase the success of rehabilitation therapy in patients during the first 3 months poststroke.

A prospective randomized controlled study on the effect of balance training on lower limb movement and balance dysfunction in severe burn patients

Objective: To observe the rehabilitation effect of balance training on motor and balance function of lower extremities of deep burn patients. Methods: A prospective randomized controlled study was conducted. From January 2016 to January 2020, sixty-four patients with lower limb motor and balance dysfunction after deep burn were admitted to Tongren Hospital of Wuhan University＆Wuhan Third Hospital, the burn area was 30% to 70% Total Body Surface Area, and the burn depth of more than one hip, knee and ankle joint of both lower limbs and their periphery were deep second or third degree. According to the method of random number table, the patients were divided into routine training(RT) group and balance training(BT) group. There were 32 cases in each group, 22 males and 10 females in the RT group, aged 40.5 (35.5, 52.8) years old, and 24 males and 8 females in the BT group, aged 37.0 (30.0, 44.0) years old. Patients in group RT were conventionally conducted with knee joint stretch treatment, continuous passive motion treatment, lower limb muscle strength training and pressure therapy; while patients in group BT were conducted with balance training besides RT such as sitting balance, center of gravity transfer, pelvic stability, standing alternately on one leg and standing on balance pad. Patients in the 2 groups were treated for 4 months. Before treatment and after 4 months of treatment,Berg balance score, lower limb function score and balance activity self-confidence score were evaluated . The data were statistically analyzed with t test, Mann-Whitney U test, Wilcoxon signed rank test or χ² test. Results: (1) Before treatment, the difference value of Berg balance score of patients in group RT was (25±9), which was similar to (25±7) in group BT(t=-0.154,P>0.05). After 4 months of treatment, the difference value of Berg balance score of patients in group BT was (43±6), which was higher than (40±6) in group RT (t=2.028,P<0.05). The difference values of Berg balance scores of the patients in group RT and BT after 4 months of treatment were obviously higher than those before treatment(t=-15.189,-26.2,P<0.001). (2) Before treatment, the lower limb function score of patients in group RT was 25.0 (16.5,30.0), which was similar to 23.0(10.3,28.8) in group BT(Z=-1.575,P>0.05). After 4 months of treatment, the lower limb function score of patients in group BT was 55.0(35.0, 60.0) , which was significantly higher than 43.0 (36.0, 53.0) in group RT(Z=-2.744,P<0.01). The lower limb function scale of patients in group RT and BT after 4 months of treatment were obviously higher than those before treatment(Z=-4.943,-4.955,P<0.01). (3) Before treatment, the balance activity self-confidence scores of the two groups were similar(t=-0.966,P>0.05) . After 4 months of treatment , the balance activity self-confidence scores of patients in group ST was significantly higher than that in group RT (t=3.343,P<0.01). The balance activity self-confidence scores of patients in groups RT and BT after 4 months of treatment were obviously higher than those before treatment(t=-19.611,-34.300,P<0.001). Conclusions: The balance training can effectively promote the recovery of lower limb motor and balance function on the basis of conventional rehabilitation treatment for patients with lower limb motor and balance dysfunction after deep burns.

Early physical rehabilitation therapy between 24 and 48 h following acute ischemic stroke onset: a randomized controlled trial

Purpose Early mobilization is believed to be helpful for patients with acute ischemic stroke. This study aimed to compare the difference between starting rehabilitation between 24 and 48 h and 72 and 96 h following the onset of ischemic stroke. Materials and methods This was a single-center, single-blind, randomized controlled trial. The early rehabilitation (ER) group started exercising between 24 and 48 h after stroke onset, which the standard rehabilitation (SR) group started exercising between 72 and 96 h. The two groups received sitting, standing, and repetitive body strength training respectively. Results In this study, 110 patients were analyzed. Patients in the early rehabilitation group had more favorable outcomes (The modified Rankin scale score 0-2, ER group = 32 versus SR group = 20, adjusted odds ratio 2.27, 95% CI 1.05-4.87; p = 0.036) at 3-month follow-up. The simplified Fugl–Meyer assessment (FMA) scores for the lower extremity were influenced by the interaction effect (F = 7.24, p = 0.01). The post-hoc analysis revealed a difference in the lower extremity FMA score at one week after stroke (difference 2.30 (95% CI 0.65–3.96); p = 0.007). Conclusions Early physical rehabilitation training between 24 and 48 h may be beneficial and improve patients’ lower extremity function within the first week. Clinical Trial Registration Unique identifier NCT02718534 Implications for rehabilitation Acute ischemic stroke has a variety of symptoms, and acroparalysis is a major concern. Starting physical rehabilitation early can improve the prognosis of patients with ischemic stroke. Early rehabilitation is more conducive to the recovery of lower extremity motor function, but in the subsequent rehabilitation process, the upper extremity function should be paid more attention.