Post-stroke Hemiplegia Research Articles

The subjective visual vertical in patients with pusher behaviour: A pilot study with a psychophysical approach

Pusher behaviour (PB) reflects some misrepresentation of verticality. However, its neural mechanisms are still unclear. The aim of this pilot study is to assess the perception of the subjective visual vertical in patients with PB using an orientation discrimination task relying on a psychophysical forced-choice procedure. A sample of eight patients with post-stroke hemiplegia, three of whom with (PB+ group) and five without (PB– group) a clear PB, and 10 matched healthy subjects, was selected. All participants were assessed with an orientation discrimination task based on the objective Two-Alternatives Forced Choice (2AFC) procedure, in which observers are forced to report whether an oriented stimulus that was tilted off-vertical by a varying amount (but never vertical) was tilted clockwise or counterclockwise from vertical. Participants' ability in detecting the visual vertical was estimated by calculation of bias and threshold, which represent deviations of the subjective vertical from the physical vertical and the sensitivity to orientation offsets away from vertical, respectively. While there were no significant differences between groups in terms of bias, statistical analysis showed a significantly higher threshold in the PB+ group compared to both PB– and control groups. Results suggest that vertical misrepresentation might be due to the presence, in patients with PB, of a lower signal-to-noise ratio in coding systems. Implications for clinical practice are discussed.

Interaction of electrical stimulation and voluntary hand movement in SII and the cerebellum during simulated therapeutic functional electrical stimulation in healthy adults

The therapeutic application of functional electrical stimulation (FES) has shown promising clinical results in the rehabilitation of post-stroke hemiplegia. It appears that the effect is optimal when the patterned electrical stimulation is used in close synchrony with voluntary movement, although the neural mechanisms that underlie the clinical successes reported with therapeutic FES are unknown. One possibility is that therapeutic FES takes advantage of the sensory consequences of an internal model. Here, we investigate fMRI cortical activity when FES is combined with voluntary effort (FESVOL) and we compare this activity to that produced when FES and voluntary activity (VOL) are performed alone. FESVOL revealed greater cerebellar activity compared with FES alone and reduced activity bilaterally in secondary somatosensory areas (SII) compared with VOL alone. Reduced activity was also observed for FESVOL compared with FES alone in the angular gyrus, middle frontal gyrus and inferior frontal gyrus. These findings indicate that during the VOL condition the cerebellum predicts the sensory consequences of the movement and this reduces the subsequent activation in SII. The decreased SII activity may reflect a better match between the internal model and the actual sensory feedback. The greater cerebellar activity coupled with reduced angular gyrus activity in FESVOL compared with FES suggests that the cortex may interpret sensory information during the FES condition as an error-like signal due to the lack of a voluntary component in the movement.

Family rehabilitation enhances functional recovery of patients with post-stroke hemiplegia

Two hundred and forty patients with post-stroke hemiplegia, discharged from October 2009 to January 2010, were randomly divided into two groups. One hundred twenty patients received home-based rehabilitation training, another 120 patients received conventional treatment and non-specific home rehabilitation. Brunnstrom rating and Barthel index ( BI) evaluation of motor function and activities of daily living (ADL) were performed in both groups before and after training program; Hamilton anxiety scale (HAMA) , Hospital Anxiety and Depression Scale (HAD) Assessment of anxiety and depression were also performed. Results showed that the lower limb function and ADL ability in home rehabilitation group were significantly increased, the anxiety and depression were significantly improved after home rehabilitation training ( P 0. 05 ). Key words: Rehabilitation nursing; Cerebrovascular accident

Reliability and Validity of Ultrasonographic Measurements of Acromion-Greater Tuberosity Distance in Poststroke Hemiplegia

Kumar P, Bradley M, Gray S, Swinkels A. Reliability and validity of ultrasonographic measurements of acromion-greater tuberosity distance in poststroke hemiplegia. Objectives The primary aim of this study was to assess the intrarater reliability of ultrasonographic measurements of acromion-greater tuberosity (AGT) distance in patients with stroke using portable ultrasound. A secondary aim was to determine the discriminant validity of the ultrasonographic technique by comparison of AGT distance measurements of stroke-affected and unaffected shoulders. Design Test–retest design. Setting Two local National Health Service hospitals in the South West of England. Participants Patients with first-time stroke (N=26; 16 men, 10 women; mean age ± SD, 71±10y) with 1-sided weakness who gave informed consent were recruited. Interventions Not applicable. Main Outcome Measures Portable diagnostic ultrasound was used to record measurements on day 1 and again within a fortnight. Bedside measurements were undertaken by a single physical therapist with patients seated upright in a standard hospital chair. Intraclass correlation coefficients (ICCs) and standard errors of measurement were used to assess reliability. Minimum detectable change (MDC90) scores were used to estimate the magnitude of change that is likely to exceed measurement error. Repeated-measures analysis of variance (ANOVA) was used to assess discriminant validity. Results Mean ± SD AGT distances on the stroke-affected side and unaffected side were 2.3±0.6cm and 1.9±0.3cm, respectively. ICC for within-day reliability was .98 for the affected shoulder and .95 for the unaffected shoulder. Corresponding values for between-day reliability were .94 and .76. The standard error of measurement for both affected and unaffected shoulders was less than 0.2cm. Within-day MDC90 for the affected shoulder and the unaffected shoulder was ±0.2cm and ±0.1cm, respectively. Repeated-measures ANOVA showed a significant difference between mean AGT distance for the affected and unaffected shoulders. Conclusions Ultrasonographic measurement of AGT distance demonstrates both intrarater reliability and discriminant validity and has the potential to assess shoulder subluxation in patients with stroke. Research into interrater reliability and concurrent validity of ultrasonographic measurements of AGT distance in patients with stroke is required.

Inter-rater reliability of the Modified Ashworth Scale and modified Modified Ashworth Scale in assessing poststroke elbow flexor spasticity

The Modified Ashworth Scale (MAS) is commonly used in clinical practice for grading spasticity. However, it was modified recently by omitting grade '1+' of the MAS and redefining grade '2'. The aim of this study was to investigate the inter-rater reliability of MAS and modified MAS (MMAS) for the assessment of poststroke elbow flexor spasticity. Sixty-four patients with poststroke hemiplegia were enrolled. The mean age and time since the stroke were 60.5 ± 11.9 years and 15.7 ± 10.2 weeks, respectively. The patients were tested by two raters having equal experience in applying MAS. They were not subjected to any training for administering MMAS. After performing no more than two test movements, the raters graded the resistance felt, according to the MAS and MMAS, respectively based on same stretch. The degree of agreement was analyzed using the weighted kappa (kw) statistic. Inter-rater agreements were very good for both MAS and MMAS, with weighted kappa values of 0.868 and 0.892, respectively. The highest agreements were observed for grade '0' in applying MAS and for grade '2' in applying MMAS; on the other hand, the lowest agreements were observed for grade '2' in applying MAS and for grade '3' in applying MMAS. According to our results, MAS and MMAS have very good inter-rater reliability for assessment of poststroke elbow flexor spasticity. Neither of the scales is superior to each other when using them to grade spasticity in patients with hemiplegia for this muscle group.

Home based therapy can be of, at least, short term value

Home based therapy can be of, at least, short term value

Testimony on the sexuality of post-stroke hemiplegic patients

Summary The medical treatment of patients with post-stroke hemiplegia is well documented. Eighty percent of patients are still able to walk after the stroke, but in more than 50% of cases, the patients experience sexual difficulties. We therefore decided to investigate the semiology of the sexual difficulties experienced by these patients using questionnaires and interviews. Methodology and population The patients (11 males and five females), were questioned between November 2008 and June 2009. The mean age was 48 (18–66 years). For 10 subjects, the stroke was still recent (less than 1 year), and older in six cases (between 2 and 11 years). The topography of the lesions was in the MCA in eight cases, frontal in five cases and parietooccipital in the remaining three cases. Finally, the brain lesion was predominantly to the right (13 cases). We successively assessed the patients’ autonomy (Barthel Index), their mood (Beck Score, 1996) and the quality of their sex life (Hudson questionnaire) ( Hudson et al., 1981 ). Results Nearly 40% of subjects responded to our questionnaires; 11 males and five females. Heavy medications intake was not related with sexual impairment. Besides, the sample was considered too weak to find a correlation between the quality of the sexuality and the indication of independence. We did not either find correlation between depressive state, laterality of the cerebral lesion and the quality of the sexuality. Discussion The aetiology of the post-stroke sexual dysfunctions described was both varied and polymorphic. The extent of brain damage and the level of involvement of the sensory and motor system or the genital and sphincter region were significant negative factors but it is important not to underestimate the role of the patient's psychological state subsequent to the stroke, the effect of medication or the modification to the patient's body-image and the impact of the representations of sexuality of the disabled person in the onset of these disorders. Conclusion The effect of medication, depression, or the existence of damage to the right cortical region do not seem to be correlated to the onset of sexual dysfunctions. However, the level of functional independence would appear to be a decisive factor in the onset of sexual dysfunction.

Influence of Probe Reaction Time during Rhythmic Stabilization on Standing Stability of Patients with Post-Stroke Hemiplegia

[Purpose] The purpose of this study was to examine the influence of the probe reaction time (P-RT) during rhythmic stabilization (RS) on standing stability of patients with post-stroke hemiplegia. [Subjects] The subjects were 29 patients with post-stroke hemiplegia (males, mean age 56.2 ± 11.9 years), who had been receiving treatment at the Jilin Rehabilitation Medical Center in China. They were divided into two groups: the cerebral hemorrhage (CH) group and the cerebral infarction (CI) group. [Methods] We evaluated the simple reaction time (SRT), the P-RT during RS, the maximal resistance force of RS (Max. RF), the resistance force of RS during P-RT (RF during P-RT), and the timed up-and-go test (TUG). [Results] P-RT was significantly longer than SRT, and RF during P-RT was less than the Max. RF in both groups. P-RT of CH patients was significantly longer than that of CI patients. There were significant correlations between P-RT and SRT, P-RT and RF during P-RT, and Max. RF and RF during P-RT in both groups. [Conclusion] The results suggest that attention decreased more during the dual task in the CH group than in the CI group. Not only trunk muscle force but also attention maybe factors influencing the standing stability of patients with post-stroke hemiplegia.

Chronological Changes in Astrocytes Induced by Chronic Electrical Sensorimotor Cortex Stimulation in Rats

Motor cortex stimulation (MCS) is a treatment option for various disorders such as medically refractory pain, poststroke hemiplegia, and movement disorders. However, the exact mechanisms underlying its effects remain unknown. In this study, the effects of long-term chronic MCS were investigated by observing changes in astrocytes. A quadripolar stimulation electrode was implanted on the dura over the sensorimotor cortex of adult rats, and the cortex was continuously stimulated for 3 hours, 1 week, 4 weeks, and 8 weeks. Immunohistochemical staining of microglia (ionized calcium-binding adaptor molecule 1 [Iba1] staining) and astrocytes (glial fibrillary acidic protein [GFAP] staining), and neuronal degeneration histochemistry (Fluoro-Jade B staining) were carried out to investigate the morphological changes following long-term chronic MCS. Iba1 staining and Fluoro-Jade B staining showed no evidence of Iba1-positive microglial changes or neurodegeneration. Following continuous MCS, GFAP-positive astrocytes were enlarged and their number increased in the cortex and the thalamus of the stimulated hemisphere. These findings indicate that chronic electrical stimulation can continuously activate astrocytes and result in morphological and quantitative changes. These changes may be involved in the mechanisms underlying the neuroplasticity effect induced by MCS.

A Patient with Post-stroke Right Hemiplegia Showed Improved Finger Dexterity after Physical Therapy for the Trunk and Scapular Region of the Affected Side: Examination of the Effects of Physical Therapy using Surface Electromyography

A Patient with Post-stroke Right Hemiplegia Showed Improved Finger Dexterity after Physical Therapy for the Trunk and Scapular Region of the Affected Side: Examination of the Effects of Physical Therapy using Surface Electromyography

Effects of 3-month Combined Functional Training at an Adult Day-care Facility on Lower Extremity Muscle Strength and Gait Performance in Community-dwelling People with Chronic Hemiplegia

[Purpose] The purpose of this study was to examine the effects of low-frequency combined functional training over a 3-month period on lower extremity muscle strength and gait performance in community-dwelling people with chronic post-stroke hemiplegia. [Subjects] The subjects were 23 individuals with chronic post-stroke hemiplegia, utilizing the services of an adult day-care facility. [Methods] All subjects performed functional training programs consisting of stretching, strengthening, postural balance training, and gait training once or twice a week for 3 months. Leg muscle strength measured using a leg press machine at one repetition maximum (1RM), comfortable gait speed (CGS), maximal gait speed (MGS), and the difference between MGS and CGS (ΔGS) were assessed before and after intervention. [Results] Comparison of each outcome before and after intervention revealed significant increases in 1RM, CGS, MGS, and ΔGS. The change rate of ΔGS was correlated only with that of MGS. [Conclusion] Three-month combined functional training was effective at enhancing lower extremity muscle strength and gait performance, and ΔGS was increased by enhancement of MGS in community-dwelling people with chronic post-stroke hemiplegia.

Evaluation of a dynamic ankle foot orthosis in hemiplegic gait: A case report

This investigation utilized a single case design to evaluate the effects of a dynamic AFO on ambulation in post stroke hemiplegia. A single patient with stroke related hemiplegia using a dynamic AFO underwent gait analysis while walking on level ground. Outcome measures included temporal-spatial gait parameters and bilateral kinematic joint angles at the ankle, knee, and hip with and without AFO. Walking speed, stride length, step length and cadence increased with the dynamic AFO. Step width and double support decreased, while single support remained unchanged on the affected limb with the dynamic AFO. With the dynamic AFO there was increased hip flexion at foot strike and toe-off, increased hip sagittal plane angular velocity during swing, and decreased abduction. The dynamic AFO had a positive effect on the participant's overall gait which included improved temporal-spatial parameters and gait velocity which is likely due to a decrease in the overall energy cost of walking. Kinematic angles at the hip were most notably affected by brace utilization and this effect should be more fully explored. Further research with a larger sample utilizing dynamic AFOs is indicated to explore the generalizability of these findings and to determine the potential utility of these braces as an alternative to the traditionally prescribed solid AFO.

Changes of electroencephalogram in post-stroke hemiplegia patients treated with electroacupuncture at the nerve trunk

Objective To observe the short-term effects of electroacupuncture at different acupoints on patients with hemiplegia after cerebral infarction.

The Effects of Tuning an Ankle-Foot Orthosis Footwear Combination on Kinematics and Kinetics of the Knee Joint of an Adult with Hemiplegia

The effects of tuning the AFO footwear combination (AFOFC) for an adult with post-stroke hemiplegia were investigated. Gait analysis and tuning were carried out using a Vicon 3D motion analysis system and two force plates. Tuning of the AFOFC was accomplished by gradually modifying its design over a number of gait trials, to achieve optimal (i.e., as close as possible to normal, within the capability of the patient) knee kinematics and alignment of the Ground Reaction Force vector (GRF) relative to the knee joint. Heel wedges and a stiff rocker were used to tune mid-stance and terminal stance, respectively. Temporal-spatial parameters and selected kinetic and kinematic variables were compared between the non-tuned AFOFC, the tuned AFOFC immediately after tuning, and the tuned AFOFC after three months. There were several changes after three months compared to the non-tuned AFOFC, including improvement in stride length and a reduction in knee hyperextension. A subjective reduction in knee pain and improvement in function were also reported. The feasibility and the lack of objective evidence of tuning AFOFCs as a part of a clinical service need to be addressed in future research.

A neurophysiological and clinical study of Brunnstrom recovery stages in the upper limb following stroke

Primary objective: To determine the extent to which the Brunnstrom recovery stages of upper limb in hemiparetic stroke patients are correlated to neurophysiological measures and the spasticity measure of Modified Modified Ashworth Scale (MMAS).Research design: A concurrent criterion-related validity study.Interventions: Not applicable.Methods and procedures: Thirty patients (15 men and 15 women; mean ± SD = 58.8 ± 11.5 years) with upper limb spasticity after stroke were recruited. Wrist flexor spasticity was rated using the MMAS. The neurophysiological measures were Hslp/Mslp ratio, Hmax/Mmax ratio and Hslp.Main outcomes and results: There was a significant moderate correlation between the Brunnstrom recovery stages and the neurophysiological measures. The Brunnstrom recovery stages were highly correlated to the MMAS scores (r = −0.81, p < 0.0001).Conclusions: The Brunnstrom recovery stages are moderately correlated with neurophysiological measures and highly correlated with the MMAS regarding the evaluation of motor recovery in stroke patients. The Brunnstrom recovery stages can be used as a valid test for the assessment of patients with post-stroke hemiplegia.

Addition of an Anabolic Steroid to Strength Training Promotes Muscle Strength in the Nonparetic Lower Limb of Poststroke Hemiplegia Patients

ABSTRACTIn this prospective observer-blinded open-label nonrandomized controlled trial, 25 inpatients with hemiplegia 1–8 months after stroke were assigned to an anabolic androgenic steroid (AAS; n = 14) or a control (n = 11) group: The former received 100 mg metenolone enanthate by intramuscular injection once a week for 6 weeks along with rehabilitation therapy including muscle strength training of the nonparetic lower limb, which consisted of 100 repetitions of isokinetic reciprocal knee extension/flexion (60°/s) on a dynamometer once a day for 5 days a week over 6 weeks, and the latter received rehabilitation therapy alone. The maximal peak torque of the nonparetic lower limb, including the isokinetic (60°/s, 120°/s, and 180°/s), isotonic, and isometric muscle strength of knee extension/flexion, measured every 2 weeks, was compared with the baseline values. Significant increases in peak torque were seen at 2 weeks in 9 of the 10 conditions and at 6 weeks in 8 of the 10 conditions tested for the AAS group but in only 1 and 5 conditions for the control group, respectively. While no contraindications for AAS were encountered, the combination of AAS and muscle strength training tended to have a positive effect on muscle strength after stroke.

Pusher現象を呈し、座位・立位保持および立ち上がり動作に転倒の危険性を認めた脳梗塞後左片麻痺患者の一症例

Pusher現象を呈し、座位・立位保持および立ち上がり動作に転倒の危険性を認めた脳梗塞後左片麻痺患者の一症例

Poster 396: Improvement in Gait of Persons with Post-stroke Spastic Hemiplegia after Intrathecal Baclofen (ITB) Therapy: A Long-term Follow-up Study

Poster 396: Improvement in Gait of Persons with Post-stroke Spastic Hemiplegia after Intrathecal Baclofen (ITB) Therapy: A Long-term Follow-up Study

Development of a Pedal Powered Wheelchair

A first student project to put pedals on a wheelchair for exercise and propulsion was unsuccessful. The need remained and in June of 2005 the “Eureka” event occurred. Seeing a five-year-old on her training-wheel-equipped bicycle suggested that a fifth wheel could be added in the center between the wheelchair's two large rear wheels, and a mast supported by the fifth wheel's axle could extend forward to support a front axle and pedal set. A chain drive completed the propulsion system. There are no pedal-powered wheelchairs currently on the market. Around 2001 a product (EZChair) without retractable pedals was on the market but withdrawn. A team at the University of Buffalo invented and patented a pedal-powered wheelchair in 1993 (US Patent 5,242,179), but it was not commercialized. Also, a Japanese company designed and built a series of fifth-wheel wheelchair designs. Between 2006 and late 2008 we built many prototypes incorporating geometries that permitted retracting the pedal. For compactness a “Pedalong” with three telescoping tubes was built but it proved impossible to secure tightly. In the next design twin telescoping tubes passing above and to the rear of the rear axle provided the desired extension. A clamp at the front of the outer tube provided tightness of the assembly. In the Northwestern research program (see below), there was some success, but awkwardness in operation prevented commercialization. In October 2008 a major design change from a fifth wheel in the center to a powering of the two standard rear wheels was begun. This required a new chain path geometry and addition of a differential to the drive train. With the new design user control, arm-powering and braking through the rear wheels is retained, and chair stability is improved. Twelve individuals with chronic post-stroke hemiplegia (&gt;6 months post-stroke event) participated in a study to examine the metabolic energy expended when participants performed a 6-minute walk test, a 6 minute leg-propelled wheelchair trial (using the Pedalong), and a 6 minute arm-propelled wheelchair trial. VO2, VCO2, and distance traveled were measured using a portable metablic cart system and wheel-based distance measurement system. The Pedalong and walking trials showed equivalent oxygen consumption levels, but manual pushing was, on average, significantly less. All three modes (walking, leg-propelled and arm-propelled) resulting in similar distances traveled within the 6 minute period. The leg-propelled trials generated the greatest amount of VCO2 during expiration compared with the other modes. This means that more of the available oxygen is being utilized (metabolized) during the leg-propelled mode and so, a greater number of calories were being burned during this 6-minute test.

Inter-rater reliability of the Modified Modified Ashworth Scale as a clinical tool in measurements of post-stroke elbow flexor spasticity

Patients with neurological conditions may be affected by spasticity. The Modified Modified Ashworth Scale (MMAS) is a clinical tool used to measure spasticity. The purpose of the present study was to investigate the inter-rater reliability of the MMAS during the assessment of elbow flexor spasticity in adult patients with post-stroke hemiplegia. Twenty-one adult patients with stroke (5 women, 16 men) with a median age of 60 years (interquartile range, 47-68) were tested. Elbow flexors on the affected side were examined. Inter-rater reliability for two inexperienced raters was very good. The weighted Kappa value was 0.81 (Standard Error = 0.097, 95% CI: 0.62-1.00, p = 0.0002). The weighted percentage agreement was 97.4%. The agreement between raters occurred mostly on score 1 (38.1%) followed by score 0 (23.8%). The MMAS yielded reliable measurements between raters when used on patients post-stroke with elbow flexor spasticity.