Stroke Impact Scale Scores Research Articles

The Correlation between Depression, Balance, and Physical Functioning Post Stroke

Depression, imbalance, and physical disability are among the serious stroke sequels. The objective of this study was to examine the correlation between depression, balance, and self-reported physical performance in patients post stroke. The Arabic versions of the Beck Depression Inventory (BDI), Dynamic Gait Index (A-DGI), and physical Stroke Impact Scale-16 version 3 were administered to a convenience sample of patients post stroke. The correlation between the mentioned measures was calculated using the Pearson coefficient. Additionally, the Kruskal-Wallis test was used to find out if the distribution of measurement scores differs among BDI levels of depression intensity or among Orpington Prognostic Scale (OPS) levels of stroke severity. Sixty-one patients with stroke (mean age [standard deviation] = 64 [12] years, 39 male) were recruited. Significant moderate correlations were found between BDI and A-DGI, BDI and Stroke Impact Scale (SIS), and A-DGI and physical SIS. Additionally, the distribution of the A-DGI and the physical SIS scores showed significant differences among BDI levels of depression intensity. Moreover, the distribution of the BDI, A-DGI, and physical SIS scores showed significant differences among OPS levels of stroke severity. Depressive symptoms were found frequent among people post stroke and were associated with balance and self-reported physical performance.

The post-stroke depression and its impact on functioning in young and adult stroke patients of a rehabilitation unit

Background: Stroke is a leading cause of disability and a major public health problem.Aims: To determine frequency and degree of post-stroke depression (PSD) and its impact on functioning in young and adult stroke patients in a rehabilitation unit.Method: The study included 72 stroke patients (aged 29–59 years) who were attending rehabilitation. The patients were assessed for depressive symptoms by Beck Depression Inventory (BDI), and their functioning by using the Stroke Impact Scale (SIS) and the Barthel Index of Activities of Daily Living (ADL).Results: Forty-eight patients had different degrees of depression: borderline clinical depression (13.8%), moderate depression (34.7%), severe depression (15.2%) or extreme depression (2.9%). There were no significant differences of BDI scores in 30–39, 40–49 and 50–59 years groups. Statistically significant correlations were between BDI score and SIS score, between BDI score and ADL index, and between SIS score and ADL index in men, women and total study patients.Conclusions: More than half of the PSD patients had a moderate degree of depression. Significant correlations were noticed between depressive symptoms and functional status evaluated both by an instrument of assessing stroke impact upon general health and an instrument for assessing the everyday activities.

Potential predictors for health-related quality of life in stroke patients undergoing inpatient rehabilitation.

BackgroundImproving HRQOL is the desired outcome for patients with stroke undergoing inpatient rehabilitation services. This study aimed to comprehensively identify the potential health-related quality of life (HRQOL) predictors in patients with stroke undergoing inpatient rehabilitation within the first year after stroke; thus far, such an investigation has not been conducted.MethodsWe enrolled 119 patients (88 males, 31 females) with stroke, and examined 12 potential predictors: age, sex, stroke type, stroke side, duration after onset, cognition (Mini-Mental State Examination; MMSE), depression (Beck Depression Inventory-II), stroke severity (National Institutes of Health Stroke Scale; NIHSS), upper- and lower-extremity motor function scores of the Fugl–Meyer Assessment (FMA) scale, balance (Berg Balance Scale; BBS), and functional status (Functional Independence Measure). HRQOL was measured using Stroke Impact Scale (SIS) 3.0.ResultsNIHSS score predicted the strength domain and total SIS score (41.5 % and 41.7 % of the variances, respectively). BBS score was a major predictor of mobility and participation/role domains (48.6 % and 10 % of the variances, respectively). MMSE score predicted the memory and communication domains (22.5 % and 36.3 % of the variances, respectively). Upper extremity score of the FMA scale predicted the daily living/instrumental activities of daily life and hand function domains (40.3 % and 20.6 % of the variances, respectively). Stroke side predicted the emotion domain (11.6 % of the variance).ConclusionsNIHSS, MMSE, BBS, FMA, and stroke side predicted most HRQOL domains. These findings suggest that different factors predicted various HRQOL domains in patients with stroke.

The National Institutes of Health Stroke Scale Lacks Validity in Chronic Hemiparetic Stroke

The National Institutes of Health Stroke Scale (NIHSS) is purported to be associated with long-term outcomes. This study determined the concurrent validity of the NIHSS with the Stroke Impact Scale (SIS), a previously validated measure of health status in chronic stroke survivors. The NIHSS and the SIS were administered to 147 subjects before participation in a multicenter, randomized, controlled trial. A Spearman's rho was used to determine correlations between NIHSS total score and (1) SIS physical dimension scores, (2) SIS overall perception of recovery scores, and (3) the SIS activities and independent activities of daily living (ADL/IADL) scores. SIS score variation and medians between subjects who scored a zero versus a nonzero on the NIHSS was also assessed. There was no association between total NIHSS scores and SIS physical dimension scores, SIS overall perception of recovery scores, and SIS ADL/IADL scores (P = -.036, P = .782; P = -.039, P = .640; P = -.054, P = .520; respectively). Lastly, significant variation and similar median scores on the SIS were found between those scoring a zero on the NIHSS versus those who did not score a zero. The NIHSS has no association with health status in chronic stroke and lacks association with measures of impairment and functional limitation. From these findings, we conclude that the NIHSS has poor validity to discern long-term poststroke outcomes and is not associated with health status. Because of possible limitation in the NIHSS's ability to accurately determine outcomes in this population, we recommend restriction of its use to the acute stage of recovery.

Use Fugl-Meyer assessment to determine appropriate and effective rehabilitation interventions for patients with stroke

hyperglycemia on functional outcomes in patients undergoing stroke rehabilitation remains to be determined. Purpose: The purpose of this study was to investigate the relationship between hyperglycemia and clinical outcomes in patients with subacute stroke. Methods: Twenty patients with subacute stroke were recruited. All participants received 20 sessions of robotassisted therapy and customary rehabilitation. Clinical outcomes, including modified Rankin Scale (mRS), FuglMeyer Assessment (FMA), and Stroke Impact Scale (SIS), were assessed before and after treatment. Blood biomarkers, including the glycosylated hemoglobin (HbA1c) and fasting blood glucose, were also assessed. Paired sample t test was used to examine the intervention effects, while the Pearson correlation coefficient (r) was used to determine the relationships between the clinical outcomes and the blood biomarkers. Results: After treatment, the participants demonstrated a decrease in mRS scores, and an improvement in FMA, FIM, and SIS scores (P< 0.01). However, no significant changes were found in the blood glucose and HbA1c concentrations. Baseline mild hyperglycemia (fasting glucose ≥120mg/dL) correlated significantly with post-treatment mRS scores (r= 0.50; P= 0.024) and approached significant correlation with FIM (r=−0.42; P= 0.066). After rehabilitation, significant correlation was found between mRS and glucose (r= 0.59) and HbA1c (r= 0.47). Conclusion(s): Persistent mild hyperglycemia could be a biomarker of rehabilitation effects for patients with subacute stroke. Lowering blood glucose and HbA1c were associated with improved clinical outcomes. Implications: This study suggests that glycemic status is associatedwith functional outcomes in patientswith subacute stroke. Clinicians may also consider glycemic status when designing personalized therapy.

Abstract 2: Structural Integrity of the Corpus Callosum Correlates with Sensorimotor Impairment after Stroke

Introduction: Responsiveness to motor rehabilitation varies greatly after stroke. Improved knowledge of the brain correlates of motor function are needed to assist in the development of more effective and personalized rehabilitation protocols. Changes in the integrity of the ipsilesional corticospinal tract after stroke have been well documented, but less is known about changes in the corpus callosum (CC). The purpose of this study was to determine if structural integrity of the motor and sensory portions of the CC change after stroke and whether any such changes are related to clinical measures of sensorimotor impairment and function. Methods: Fifty-five individuals with chronic stroke (age 60.5±13.2; days post-stroke 351.9±560; UE Fugl-Meyer (FM) motor score 38.5±14.6, no lesion in the CC) and 16 age-matched controls underwent diffusion tensor imaging (DTI) and behavioral assessments. Mean fractional anisotropy (FA) values for the motor and sensory regions of the CC were extracted and examined in relation to motor system behavioral measures including the UEFM, Box &amp; Blocks (BB), Nottingham sensory score, and Stroke Impact Scale (SIS) hand subsection. Results: Participants with stroke had significantly lower FA values compared to controls in both the motor and sensory CC regions ( p &lt;0.02) despite their strokes sparing the CC. In the CC motor region, FA was related to UEFM, BB, and SIS scores, such that higher structural integrity correlated with better motor status ( ρ &gt;0.30, p &lt;0.03 across comparisons). In the CC sensory region, FA was related to UEFM and SIS scores ( ρ &gt;0.31, p &lt;0.02) as well as Nottingham sensory scores (ρ=0.33, p&lt;0.05). CC motor and sensory FA did not correlate with FA in the ipsilesional peduncle ( ρ &lt;0.12, p &gt;0.40), suggesting that the magnitude of change in each region of the motor system was distinct. Conclusions: Decreased structural connectivity between the sensorimotor regions of the two hemispheres is related to motor impairment in chronic stroke in a manner that is distinct from corticospinal tract injury. Interventions that target the communication between hemispheres during motor rehabilitation may be warranted.

Abstract T P122: Dose-Response Relationships in Brain and Behavioral Measures with Stroke Rehabilitation Using a Brain-Computer Interface

Introduction: Brain-computer interface (BCI) is an emerging technology for stroke rehabilitation, but little is known about how the administration of these therapies affects brain and behavior. We examine relationships between BCI therapy dose, intensity, and frequency with changes in laterality index (LI), Action Research Arm Test (ARAT), and Stroke Impact Scale (SIS). Methods: We collected ARAT and SIS scores as well as anatomical and functional MRI of 16 stroke patients with upper extremity motor impairment before, during, and after therapy using a BCI system with tongue and functional electrical stimulation. We acquired fMRI during finger tapping of each hand and computed LI with 3 mask sets at 2 thresholds. Changes from baseline LI and behavioral scores were assessed for correlation with cumulative therapy sessions, cumulative BCI runs, and overall runs/session using Spearman analysis and generalized estimating equations (GEE). Changes from baseline were also compared between subjects with different therapy frequencies. Results: Increased sessions correlated with changes in impaired finger tapping LI in 2 of 6 mask-threshold combinations (p&lt;0.05) and trended to significance (0.05≤p&lt;0.1) in 2 additional mask-threshold combinations. The relationship between cumulative runs and changes in impaired finger tapping LI also trended to significance (0.05≤p&lt;0.1) in 2 mask-threshold combinations. Changes in SIS Strength correlated (p&lt;0.05) with cumulative runs and with runs/session. All 8 of these relationships identified with Spearman analysis were significant with analysis using GEE (p &lt; 0.05). No relationships were observed between therapy dose or intensity and ARAT scores or unimpaired hand measures. No differences were observed between subjects with higher and lower therapy frequency. Conclusions: Patterns of brain activation shift toward contralesional hemisphere with additional therapy sessions and additional BCI runs. Increased BCI therapy intensity also correlates with increased self-reported strength. When using BCI in stroke rehabilitation, therapy frequency may be less important than dose and intensity, and neuroimaging and self-report measures may be more sensitive to differences in therapy administration.

Patient-reported measures provide unique insights into motor function after stroke.

Patient-reported outcome measures have been found useful in many disciplines but have received limited evaluation after stroke. The current study investigated the relationship that patient-reported measures have with standard impairment and disability scales after stroke. Patients with motor deficits after stroke were scored on standard assessments including the National Institutes of Health Stroke Scale, modified Rankin Scale, and Fugl-Meyer motor scale, and on 2 patient-reported measures, the hand function domain of the Stroke Impact Scale, which documents difficulty of hand motor usage, and the amount of use portion of the Motor Activity Log, which records amount of arm motor usage. The 43 participants had mild disability (median modified Rankin Scale=2), moderate motor deficits (Fugl-Meyer motor scale=46 ± 22), and mild cognitive/language deficits. The 2 patient-reported outcome measures, Stroke Impact Scale and Motor Activity Log, were sensitive to the presence of arm motor deficits. Of 21 patients classified as having minimal or no impairment or disability by the National Institutes of Health Stroke Scale or modified Rankin Scale (score of 0-1), 15 (71%) reported difficulty with hand movements by the Stroke Impact Scale score or reduced arm use by the Motor Activity Log score. Furthermore, of 14 patients with a normal examination, 10 (71%) reported difficulty with hand movements or reduction in arm use. Patient-reported measures were a unique source of insight into clinical status in the current population. Motor deficits were revealed in a majority of patients classified by standard scales as having minimal or no disability, and in a majority of patients classified as having no deficits.

Abstract WP321: Somatosensory Stimulation Combined with Moderate Intensity Therapeutic Exercise Significantly Improves Motor Function in Chronic Stroke Survivors

Background: Somatosensory stimulation using electrical microcurrents (MSOMA) has proven efficacious for treatment of pain and tissue healing however little is known about its use to augment hemiparetic muscle response to therapeutic exercise. The study aimed to investigate functional upper limb control in chronic stroke survivors in response to a standardized combination of MSOMA and moderate intensity therapeutic exercise. Methods: 18 chronic stroke survivors (M/F = 12 / 6), age 59.68 +/- 18.67 years were assigned to two treatment groups with (n= 10), and without MSOMA (n = 8) in a university outpatient physical therapy clinic. Chronicity of impairment was 3.75 +/- 2.23 years. All groups participated in therapeutic exercise using “forced-use” of impaired limbs including total body reciprocal training and robot-assisted limb activities for 12 weeks. The MSOMA group received electrotherapy during clinic sessions and used the units during a standardized Home Exercise Program prescribed for both treatment groups. All patients were assessed at Baseline, 6-weeks and 12-weeks. Variables: Outcomes included Motor Activity Log-28 (MAL), Stroke Impact Scale (SIS), Box &amp; Blocks Test (BBT), grip strength (GRIP) and surface EMG activity in both upper extremities during a “Push Task” simulating the sit-to-stand transfer. EMG outcomes included mean muscle activity (MMA), and relative intra- and inter-limb muscle activity. Data Analysis: Statistical data analysis included descriptive statistics and repeated measures ANCOVA with Eta-squared values (η2). Games-Howell Post Hoc analysis with a Bonferroni correction was used at an alpha level of 0.05. Results: Results indicate a significant group difference with a low to moderate effect size for BBT (p = 0.086, η2 = 0.041), GRIP (p = 0.010, η2 = 0.384) and MMA values at 12-weeks with a significant Group x Time interaction effect for MAL (p = 0.040, η2 = 0.238) and SIS scores (p = 0.027, η2 = 0.344). Conclusions: Results indicate that standardized MSOMA combined with moderate intensity therapeutic exercise is tolerated well by chronic stroke survivors and can significantly improve fine and gross motor function in impaired upper limbs. Further investigation is warranted to explore dosage-specific responses in patients.

Abstract 122: AMES Treatment of Severe Hand Impairment Following Stroke

The objective of this study was to determine whether AMES (Assisted Movement with Enhanced Sensation), a novel therapeutic intervention that addresses impairments, rather than function, can reduce impairment and restore lost function in persons with a severely disabled hand. Forty-three participants with stroke (&gt;1 yr post-injury) were provided with thirty 30-min AMES treatments over 10 weeks. Of these participants, 24 had no baseline active extension of any finger of the affected hand. Participants were randomized to 1 of 2 treatment groups differentiated by the kind of biofeedback (active torque or EMG) associated with the AMES intervention. During treatment, a robotic device cyclically opened and closed the hand (5 deg/s, ±15 deg) while the participant assisted this movement using visual biofeedback, and while vibration (60 pulses/s, 2 mm) was applied to the lengthening muscles. Participants were evaluated twice, before and after the treatment period, with the Fugl-Meyer Assessment (FMA-UE), Stroke Impact Scale (SIS), and Box-and-Block Test. In addition, during each treatment session, the AMES robot tested each participant’s strength of thumb-and-finger flexion and extension. Both torque and EMG were recorded during this Strength Test in participants assigned to the EMG-biofeedback group. The results showed overall a significant increase in the FMA-UE score (t-test, p&lt;0.001), SIS score (t-test, p&lt;0.05), and Box-and-Block Test score (Wilcoxon, p&lt;0.005), without any difference between the 2 treatment groups. Four of the 24 initially plegic participants recovered the ability to move one or more blocks; however, all participants showing improvement in the Box-and-Block Test had a baseline FMA score of ≥17. Analysis of EMG during the hand-opening part of the Strength Test showed that AMES treatment of the EMG-biofeedback group significantly increased the amplitude of extensor activity (t-test, p&lt;0.001) and decreased flexor co-contraction (t-test, p&lt;0.05). We conclude that AMES coupled with either type of biofeedback may be effective at reducing impairment and increasing function in the severely impaired hand following stroke.

Abstract NS18: The Impact of Subtle but Significant Executive Function Deficits in Persons with Very Mild Ischemic Stroke

Background: Executive functions (EF) are essential for independence and engagement in complex activities. Neuropsychological and functional evaluations of stroke outcome may be insensitive to subtle EF deficits present in mild stroke (mCVA) despite low NIHSS scores and excellent outcome based on the Barthel Index (BI&gt;95) and Modified Rankin Scale (MRS&lt; 1). We evaluated EF deficits in 25 individuals with first mCVA (admission NIHSS &lt; 5) and 21 matched controls on the Multiple Errands Test-Revised (MET-R). Methods: Inclusion criteria: age &gt; 18 years, first clinical stroke, functional independence (pre-stroke BI &gt;95 and MRS &lt; 1) and community residence at admission and 6 month follow-up. Demographic and clinical information were obtained at acute admission to acute neurology stroke service. Stroke was confirmed by a neurologist and acute imaging reviewed to score stroke lesions and location and white matter disease. Six month follow-up included a neuropsychological test battery, self-reported outcomes by the Stroke Impact Scale (SIS) and Reintegration to Normal Living Scale (RNLI) and the MET-R, a performance test previously used with TBI. The MET-R is a timed test which requires following standard instructions and rules while performing multiple tasks in a real-world environment. Results: Sample mean age was 60 ± 10.8 years; 65% female and 30 % Black, with no significant demographic differences between groups. The mCVA group reported SIS Global Recovery Scores of 68 ± 21.6, Participation Scores of 73.8 ±24.1 and Memory Scores of 77.2 ± 17.5. Differences between controls and the mCVA group were significant for MET-R sub-scores including: Tasks Completed (p&lt;0.0001), Rules Broken (p&lt;0.001), and Performance Efficiency (p &lt;0.002). Poor performance on the MET-R was associated with lower SIS scores and lower life satisfaction and measured by the RNLI. Conclusion: Persons with Persons with mCVA lacking obvious cognitive or motor impairments may be discharged home without rehabilitation or support because currently available measures are inadequate to identify the presence of EF deficits. Subjective complaints of difficulty with cognitively demand activities at follow-up should be evaluated. Rehabilitation can effectively address these deficits.

Portable Neurorobotics for the Severely Affected Arm in Chronic Stroke

Few motor therapies increase active movement in the severely impaired arm of individuals with chronic stroke. Existing robotic devices to address this need are large and expensive. This case study describes the application and reports outcomes associated with a repetitive task-specific training (RTP) program incorporating a portable robotic device. We assessed outcomes related to affected arm impairment, ability to perform valued activities, satisfaction with movement performance, and quality of life in a participant with chronic stroke exhibiting severe arm hemiparesis. The participant was a 53-year-old man, 30 months after hemorrhagic stroke. At the time of enrollment, he exhibited some active shoulder and elbow flexion, but no active elbow extension, and no active movement at any joint below the elbow. The participant engaged in RTP incorporating a portable, electromyography-triggered neurorobotic device in 1-hour sessions, 3 days/week for 8 weeks using the affected arm. The upper extremity section of the Fugl-Meyer Impairment scale (FM), the Canadian Occupational Performance Measure (COPM), and the Stroke Impact Scale (SIS) were administered before and after training. After intervention, the subject exhibited reduced affected arm impairment (+2 points on the FM), increased ability to perform valued activities, increased satisfaction with performance of these activities (indicated by score increases of +2 and +1.8 points on the COPM Performance and Satisfaction scales, respectively), improved strength, performance of activities of daily living, hand function, participation, and physical function (as indicated by increases in respective SIS scores). The RTP incorporating the neurorobotic device appears promising. To our knowledge, this is the first study documenting a portable robotic-based RTP strategy in a person exhibiting this severity of hemiparesis.

Balance, Balance Confidence, and Health-Related Quality of Life in Persons With Chronic Stroke After Body Weight–Supported Treadmill Training

Combs SA, Dugan EL, Passmore M, Riesner C, Whipker D, Yingling E, Curtis AB. Balance, balance confidence, and health-related quality of life in persons with chronic stroke after body weight–supported treadmill training. Objectives To examine changes in balance, balance confidence, and health-related quality of life immediately and 6 months after body weight–supported treadmill training (BWSTT) for persons with chronic stroke (primary objective) and to determine whether changes in gait speed after BWSTT were associated with changes in these dimensions of health (secondary objective). Design Prospective pre-/posttest pilot study with 6 months retention. Setting University research laboratory settings. Participants A convenience sample of participants (N=19; at least 6mo poststroke; able to ambulate 0.4–0.8m/s) were recruited. Intervention BWSTT was provided for 24 sessions over 8 weeks with 20 minutes of total walking each session. Main Outcome Measures Berg Balance Scale (BBS), Activities-Specific Balance Confidence (ABC) Scale, Stroke Impact Scale (SIS), comfortable 10-m walk test (CWT), and fast 10-m walk test (FWT). Proportions of participants who achieved minimal detectable changes (MDCs) were examined for all measures. Results Statistically significant improvements were found from pre- to posttest for BBS, ABC, SIS mobility, SIS stroke recovery, and CWT scores ( P<.05) and from pretest to retention on BBS, ABC, CWT, and FWT scores ( P<.05). For most participants, improvements did not exceed MDCs. Changes in gait speed and BBS, ABC, and SIS scores were not associated. Conclusions The findings of this study suggest that effects of BWSTT may transfer beyond gait to positively influence balance, balance confidence, and health-related quality of life. However, for most participants, BWSTT was not sufficient to induce improvements in balance and balance confidence beyond measurement error or long-term retention of enhanced perceptions of quality of life.

Quality-of-Life Change Associated With Robotic-Assisted Therapy to Improve Hand Motor Function in Patients With Subacute Stroke: A Randomized Clinical Trial

At 6 months poststroke, most patients cannot incorporate their affected hand into daily activities, which in turn is likely to reduce their perceived quality of life. This preliminary study explored change in patient-reported, health-related quality of life associated with robotic-assisted therapy combined with reduced therapist-supervised training. A single-blind, multi-site, randomized clinical trial was conducted. Seventeen individuals who were 3 to 9 months poststroke participated. Sixty hours of therapist-supervised repetitive task practice (RTP) was compared with 30 hours of RTP combined with 30 hours of robotic-assisted therapy. Participants completed the Stroke Impact Scale (SIS) at baseline, immediately postintervention, and 2 months postintervention. Change in SIS score domains was assessed in a mixed model analysis. The combined therapy group had a greater increase in rating of mood from preintervention to postintervention, and the RTP-only group had a greater increase in rating of social participation from preintervention to follow-up. Both groups had statistically significant improvement in activities of daily living and instrumental activities of daily living scores from preintervention to postintervention. Both groups reported significant improvement in hand function postintervention and at follow-up, and the magnitude of these changes suggested clinical significance. The combined therapy group had significant improvements in stroke recovery rating postintervention and at follow-up, which appeared clinically significant; this also was true for stroke recovery rating from preintervention to follow-up in the RTP-only group. LIMITATIONS OUTCOMES: of 30 hours of RTP in the absence of robotic-assisted therapy remain unknown. Robotic-assisted therapy may be an effective alternative or adjunct to the delivery of intensive task practice interventions to enhance hand function recovery in patients with stroke.

Adaptive physical activity improves mobility function and quality of life in chronic hemiparesis

This study investigated the effects of an adaptive physical activity (APA) program on mobility function and quality of life (QOL) in chronic stroke patients. Twenty subjects with chronic hemiparesis completed a 2-month, combined group, class-home exercise regimen that emphasized mobility training. APA improved Berg Balance Scale scores (35 +/- 2 vs 45 +/- 2, p = 0.001), 6-minute walk distances (114 +/- 15 vs 142 +/- 7 m, p < 0.001), and Short Physical Performance Battery scores (3.2 +/- 0.4 vs 5.2 +/- 0.6, p < 0.001). Barthel Index scores increased (75 +/- 4 vs 84 +/- 4, p < 0.001), but Lawton scores were unchanged. Geriatric Depression Scale (p < 0.01) and Stroke Impact Scale (SIS), Mobility, Participation, and Recovery improved with APA (p < 0.03). APA has the potential to improve gait, balance, and basic but not instrumental activities of daily living profiles in individuals with chronic stroke. Improved depression and SIS scores suggest APA improves stroke-specific outcomes related to QOL.

Functional Capacity and Health-Related Quality of Life in Individuals Post Stroke

Background: In individuals post stroke, cardiovascular and functional capacity is frequently reduced independent of severity. The psychological consequences of this reduction have only been briefly investigated. This study investigated the relationship between functional capacity and health-related quality of life (HRQoL) in individuals post stroke. Method: Thirty subjects with a mild stroke were tested 60 ± 27 months (mean ± SD) post stroke. Functional capacity was quantified with the 6-minute walk test (6MWT) and perceived HRQoL was evaluated by using the Stroke Impact Scale (SIS) version 3.0 questionnaire. Results: The 6MWT distance walked was 353 ± 137 m, that is, 63% of the distance predicted for healthy adults. HRQoL was reduced with the lowest SIS scores in the domains of strength, hand function, and participation domains and the highest scores in the domains of mobility, communication, activities of daily living/instrumental activities of daily living (ADL/IADL), and memory. The SIS domains of hand function, strength, mobility, ADL/IADL, and participation were all positively correlated with 6MWT distance, with the strongest correlation for the latter four domains. Conclusion: Reductions in both functional capacity and HRQoL were documented. Functional capacity was positively correlated with six of the HRQoL domains and was strongest with the SIS domains most related to demands made on the individual throughout the day.

Improvements in Speed-Based Gait Classifications Are Meaningful

Gait velocity is a powerful indicator of function and prognosis after stroke. Gait velocity can be stratified into clinically meaningful functional ambulation classes, such as household ambulation (<0.4 m/s), limited community ambulation (0.4 to 0.8 m/s), and full community ambulation (>0.8 m/s). The purpose of the current study was to determine whether changes in velocity-based community ambulation classification were related to clinically meaningful changes in stroke-related function and quality of life. In subacute stroke survivors with mild to moderate deficits who participated in a randomized clinical trial of stroke rehabilitation and had a baseline gait velocity of 0.8 m/s or less, we assessed the effect of success versus failure to achieve a transition to the next class on function and quality of life according to domains of the Stroke Impact Scale (SIS). Of 64 eligible participants, 19 were initially household ambulators, and 12 of them (68%) transitioned to limited community ambulation, whereas of 45 initially limited community ambulators, 17 (38%) became full community ambulators. Function and quality-of-life SIS scores after treatment were significantly higher among survivors who achieved a favorable transition compared with those who did not. Among household ambulators, those who transitioned to limited or full community ambulation had significantly better SIS scores in mobility (P=0.0299) and participation (P=0.0277). Among limited community ambulators, those who achieved the transition to full community ambulatory status had significantly better scores in SIS participation (P=0.0085). A gait velocity gain that results in a transition to a higher class of ambulation results in better function and quality of life, especially for household ambulators. Household ambulators possibly had more severe stroke deficits, reducing the risk of "ceiling" effects in SIS-measured activities of daily living and instrumental activities of daily living. Outcome assessment based on transitions within a mobility classification scheme that is rooted in gait velocity yields potentially meaningful indicators of clinical benefit. Outcomes should be selected that are clinically meaningful for all levels of severity.

Combined Functional Task Practice and Dynamic High Intensity Resistance Training Promotes Recovery of Upper-extremity Motor Function in Post-stroke Hemiparesis

Weakness is a significant impairment in persons with post-stroke hemiparesis, yet traditional clinical perspectives caution against strengthening in neurological populations. Significant correlations between weakness and functional movement have been demonstrated, however, a clear relationship between increased strength and functional improvement has been elusive. This case study describes a combined program of dynamic, high-intensity resistance training and functional task practice for the upper-extremity in adult hemiparesis. The patient was a 65-year-old, right hand dominant woman who presented to the Neural Control of Movement Laboratory at the Palo Alto VA Rehabilitation Research and Development Center 16 weeks following clipping of an unruptured aneurysm with consequent dense right hemiparesis. She received 7 weeks of acute rehabilitation according to CARF guidelines (ie, at least 3 hours of two or more disciplines, 6 days per week). Her baseline research evaluation revealed significant upperextremity deficits at the ICF body structure/function level including: weakness, shoulder pain, mild resistance to passive movement, and need for moderate to maximal assistance in many activities of daily living including bathing and dressing. The Stroke Impact Scale score reporting her perspective indicated she had recovered from her stroke only 50%. The hybrid resistance training-functional task practice intervention, detailed in this report, was delivered 3 times per week for 6 weeks with each session lasting 75:00. The subject revealed marked improvements in isometric and dynamic force production in 5 key upper-extremity actions: elbow flexion, elbow extension, shoulder flexion, shoulder abduction, and shoulder external rotation. Strength gains were accompanied by increased EMG activation immediately postintervention and by a combination of increased activation and apparent hypertrophic effects at 6 month follow up. Marked improvements were noted in all clinical and functional measures and in an elbow trajectorytracking task which served as a surrogate measure of motor control. Improvements in strength and positive outcome effects at the physiological, clinical, and functional levels were observed in this subject following the experimental hybrid upper-extremity rehabilitation intervention described. Importantly, no deleterious effects were observed including exacerbation of spasticity or musculoskeletal compromise. Observations of improved EMG activation in this case study suggest that improvements in motor activation underlie these strength gains and can likely be attributed to working at a high intensity level.

Attempting to Improve Function and Quality of Life Using the FTM Protocol

The Functional Tone Management (FTM) arm training program uses repetitive task practice, stretching, and electrical stimulation as patients with moderate upper extremity hemiparesis wear a dynamic hand orthosis to retrain grasp and release of objects. The case study quantitatively evaluates the extent to which FTM training improved function and quality of life in a patient who met criteria for which the device was intended. The participant, a 44-year-old male in the chronic stage of stroke recovery with moderate right upper extremity motor impairment, was trained for 10 days over a 2-week period by a licensed clinician with extensive experience in FTM training methods. Measurements were taken over 3 baseline visits, then immediately preintervention, postintervention, and at a 3-month follow-up. The outcome measures, following the International Classification of Functioning, Disability, and Health (ICF) Model, included the: Fugl-Meyer assessment (FMA) (upper extremity portion), UE range of motion (ROM), Modified Ashworth scale, Wolf Motor Function Test (WMFT), and the Motor Activity Log (MAL). Health related quality of life was measured using the Stroke Impact Scale (SIS). The participant showed limited gains in upper extremity function immediately postintervention. Increases in AROM occurred in forearm supination and wrist flexion and extension, but no improvements were noted in finger ROM. A slight decrease in tone was found in forearm pronators (1 to 0) and wrist flexors (1+ to 1). WMFT values for the more affected upper extremity did not change immediately after training, but a 17% reduction in time occurred at follow-up, with improvements, most notably in the tasks of lifting a pencil and lifting a paper clip. No changes occurred in UE-FMA scores immediately following the intervention, however, a 17% improvement was measured at followup. A slight improvement in MAL scores was noted but not to a level of independent functional use of the impaired upper extremity. SIS scores improved in the domains of strength, communication, mobility, social participation, hand recovery, and overall physical component, while decreases were seen in the ADL/IADL, hand function, emotion, and cognitive domains. The case study indicates that for this patient with chronic, moderate upper extremity impairment following stroke, a 2-week FTM training regimen resulted in modest changes occurring as a decrease in impairment, with functional improvement and improved quality of life. Further investigation of the innovative training program should be undertaken before the efficacy of its use can be ascertained amongst patients with limitations comparable to the participant.

Neurotransplantation for patients with subcortical motor stroke: a Phase 2 randomized trial

No definitive treatment exists to restore lost brain function following a stroke. Transplantation of cultured neuronal cells has been shown to be safe and effective in animal models of stroke and safe in a Phase 1 human trial. In the present study the authors tested the usefulness of human neuron transplantation followed by participation in a 2-month stroke rehabilitation program compared with rehabilitation alone in patients with substantial fixed motor deficits associated with a basal ganglia stroke. Human neuronal cells (LBS-Neurons; Layton BioScience, Inc.) were delivered frozen and then thawed and formulated on the morning of surgery. The entry criteria in this randomized, observer-blinded trial of 18 patients included age between 18 and 75 years, completed stroke duration of 1 to 6 years, presence of a fixed motor deficit that was stable for at least 2 months, and no contraindications to stereotactic surgery. Patients were randomized at two centers to receive either 5 or 10 million implanted cells in 25 sites (seven patients per group) followed by participation in a stroke rehabilitation program, or to serve as a nonsurgical control group (rehabilitation only; four patients). The surgical techniques used were the same at both centers. All patients underwent extensive pre- and postoperative motor testing and imaging. Patients received cyclosporine A for 1 week before and 6 months after surgery. The primary efficacy measure was a change in the European Stroke Scale (ESS) motor score at 6 months. Secondary outcomes included Fugl-Meyer, Action Research Arm Test, and Stroke Impact Scale scores, as well as the results of other motor tests. Nine strokes were ischemic in origin and nine were hemorrhagic. All 14 patients who underwent surgery (ages 40-70 years) underwent uncomplicated surgeries. Serial evaluations (maximum duration 24 months) demonstrated no cell-related adverse serological or imaging-defined effects. One patient suffered a single seizure, another had a syncopal event, and in another there was burr-hole drainage of an asymptomatic chronic subdural hematoma. Four of seven patients who received 5 million cells (mean improvement 6.9 points) and two of seven who received 10 million cells had improved ESS scores at 6 months; however, there was no significant change in the ESS motor score in patients who received cell implants (p = 0.756) compared with control or baseline values (p = 0.06). Compared with baseline, wrist movement and hand movement scores recorded on the Fugl-Meyer Stroke Assessment instrument were not improved (p = 0.06). The Action Research Arm Test gross hand-movement scores improved compared with control (p = 0.017) and baseline (p = 0.001) values. On the Stroke Impact Scale, the 6-month daily activities score changed compared with baseline (p = 0.045) but not control (p = 0.056) scores, and the Everyday Memory test score improved in comparison with baseline (p = 0.004) values. Human neuronal cells can be produced in culture and implanted stereotactically into the brains of patients with motor deficits due to stroke. Although a measurable improvement was noted in some patients and this translated into improved activities of daily living in some patients as well, this study did not find evidence of a significant benefit in motor function as determined by the primary outcome measure. This experimental trial indicates the safety and feasibility of neuron transplantation for patients with motor stroke.