急性脑卒中患者独立步行能力的预测

目的　预测急性脑卒中患者独立步行能力的恢复。方法　采用以神经发育疗法和运动疗法为主的综合康复治疗技术 ,并配合传统的按摩疗法和功能性电刺激 ,以及躯干控制试验、站立平衡检测、功能独立性评定量表中的步行能力检测和巴氏指数的残疾程度评定 ,对急性脑卒中患者进行临床观察和研究。结果　急性脑卒中患者的躯干控制能力、站立平衡功能与独立步行能力的恢复呈高度正相关 (rs 分别为 0 .764和 0 .82 6)。康复组的独立步行能力恢复率为 72 .63 % ,与对照组 ( 14 .94% )相比差异有显著性 (P<0 .0 0 1)。经综合康复治疗 ,中度功能残疾和轻度功能残疾者中有 77.3 6%和 85 .72 %恢复独立步行 ,明显优于重度功能残疾者 ( 2 8.5 7% ) ,P <0 .0 0 1。结论　早期进行康复治疗 ,加强躯干控制能力和站立平衡功能训练 ,可以促进急性脑卒中患者独立步行能力的恢复 ,轻度和中度功能残者的独立步行能力恢复较好。     

Functional recovery of gait and joint kinematics after right hemispheric stroke

OBJECTIVE: To gain insight into the relation between changes in gait patterns over time and functional recovery of walking ability in stroke patients. DESIGN: Cohort study. SETTING: Inpatient rehabilitation center of a university hospital in the Netherlands. PARTICIPANTS: Thirteen stroke patients admitted, or awaiting admission, for inpatient rehabilitation 3 weeks poststroke, and 16 healthy control subjects. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: At 3, 6, 12, 24, and 48 weeks poststroke, functional recovery of walking ability was assessed with the Rivermead Mobility Index (RMI) and the Functional Ambulation Categories (FAC). When possible, kinematics of the knee, hip, and pelvis were assessed through gait analysis in an 8 x 4 m gait laboratory. Minimal scores of 8 on the RMI and 4 on the FAC were necessary before patients were classified as functionally recovered. RESULTS: Patients whose joint kinematics during ambulation had recovered to within the range of the control group showed functional recovery of walking ability. However, some patients whose kinematics had developed toward an abnormal pattern also showed functional recovery. CONCLUSIONS: Recovery of joint kinematics toward a normal pattern is not required for functional recovery of walking ability. Early recognition of compensatory walking patterns that facilitate functional recovery may have implications for rehabilitation programs.     

Criterion validity of the StepWatch Activity Monitor as a measure of walking activity in patients after stroke

Mudge S, Stott NS, Walt SE. Criterion validity of the StepWatch Activity Monitor as a measure of walking activity in patients after stroke.

Objectives

To test the validity of the StepWatch Activity Monitor (SAM) in subjects with stroke against 2 criterion standards, 3-dimensional gait analysis (3-DGA) and footswitches in a variety of indoor and outdoor walking conditions, including different speeds and different terrains, and to test the accuracy of the SAM when worn on the paretic limb.

Design

Criterion standard validation study.

Setting

Gait laboratory and outside course.

Participants

Twenty-five participants with physical disability after stroke.

Interventions

Not applicable.

Main Outcome Measures

The total step count measured simultaneously by SAM and either 3-DGA or footswitches for both paretic and nonparetic limbs.

Results

The total step count measured by the SAM and 3-DGA was highly correlated (nonparetic limb, r=.959; paretic limb, r=.896). The 95% limits of agreement (LOA) (derived from Bland-Altman analysis) between the SAM and 3-DGA were within ±10 steps for SAMs worn on either the nonparetic or paretic limb. The total step count measured simultaneously by the SAM and footswitches was also highly correlated for each limb (nonparetic, r=.999; paretic, r=.963). The 95% LOA between the SAM and footswitches were ±9 steps on the nonparetic limb but higher at ±57 steps on the paretic limb. Further analysis showed that the measurement differences occurred during the outdoor component of the combined walk. The 95% LOA between footswitches on both limbs were not more than ±9 steps for walking, suggesting that the error was accounted for by the SAM on the paretic limb, which both over- and underread the total step count in the outdoor walking conditions.

Conclusions

Criterion validity of the SAM to measure steps in both clinical and natural environments has been established when used on the nonparetic limb. However, more errors are apparent when the SAM is worn on the paretic limb while walking over a variety of outdoor terrains. Validation is recommended before use in patients with neurologic conditions affecting bilateral legs because there may be more error, particularly in outdoor activities.     

Deficits in motor coordination of the paretic lower limb limit the ability to immediately increase walking speed in individuals with chronic stroke

ObjectiveTo explore the relationships between clinical measures and the ability to increase walking speed in ambulatory people with chronic stroke and to identify which measures would best predict walking speed reserve.MethodsAn exploratory, cross-sectional study was conducted with 114 individuals with chronic stroke. The outcome of interest was walking speed reserve, defined as the difference between individuals’ comfortable and maximal walking speeds. Predictors were characteristics of the participants (age, sex, time since stroke, relative lower-limb dominance) and motor impairments (tonus, strength, and motor coordination).ResultsThe characteristics of the participants did not significantly correlate with walking speed reserve. All measures of motor impairments, i.e., tonus, strength, and motor coordination, were significantly correlated with walking speed reserve (p < 0.01), but only motor coordination was kept in the regression model. Motor coordination alone explained 35% (F = 61.5; p < 0.001) of the variance in walking speed reserve.ConclusionsThe level of motor coordination of the paretic lower limb is associated with the walking speed reserve of individuals with stroke. Interventions aimed at improving motor coordination may have the potential to improve everyday situations that require immediate increases in walking speed.     

The therapeutic effect of functional and transcutaneous electric stimulation on improving gait speed in stroke patients: a meta-analysis

OBJECTIVE: To determine the effect of previous treatments of functional electric stimulation (FES) and transcutaneous electric stimulation (TENS) on improving gait speed in subjects poststroke. DATA SOURCES: Relevant articles were obtained through a search of English-language articles cited in Medline, EMBASE, CINHAL, and PubMed databases from January 1966 to May 2005. STUDY SELECTION: Prospective clinical studies were included if electric stimulation was used to treat subjects poststroke and gait speed was used as an outcome measure. Excluded studies examined subjects with a variety of neurologic conditions, used implantable electrodes, or combined electric stimulation with treadmill training. A paired consensus between authors produced 8 articles. DATA EXTRACTION: Two investigators extracted data independently. The methodologic quality of the studies was assessed with the Downs and Black checklist. DATA SYNTHESIS: A fixed-effects model produced a mean difference (.18; 95% confidence interval, .08-.28) that was significant (z=3.65, P<.01), indicating the effectiveness of FES treatment at increasing gait speed in subjects poststroke. The effect sizes of the studies ranged from -.11 to 1.43 for FES and .19 to .42 for TENS. The type of FES and TENS devices, location of electrodes, amount of exposure, and subjects' stages of recovery varied between the studies. CONCLUSIONS: FES is effective at improving gait speed in subjects poststroke. Future research should examine the effectiveness of practical and readily available FES units to improve function in subjects in the subacute stages of recovery from a stroke. These studies should attempt to use a randomized controlled design with blinding and standardized outcome measures.     

Dual-task exercise improves walking ability in chronic stroke: a randomized controlled trial

Yang YR, Wang RY, Chen YC, Kao MJ. Dual-task exercise improves walking ability in chronic stroke: a randomized controlled trial.

Objective

To examine the effectiveness of a dual-task-based exercise program on walking ability in subjects with chronic stroke.

Design

Single-blind randomized controlled trial.

Setting

General community.

Participants

Twenty-five subjects with chronic stroke who were at least limited community ambulatory subjects (a minimum gait velocity, 58cm/s).

Interventions

Participants were randomized into a control group (n=12) or experimental group (n=13). Subjects in the control group did not receive any rehabilitation training. Subjects in the experimental group underwent a 4-week ball exercise program.

Main Outcome Measures

Gait performance was measured under single task (preferred walking) and tray-carrying task. Gait parameters of interest were walking speed, cadence, stride time, stride length, and temporal symmetry index.

Results

The experimental group showed significant improvement in all selected gait measures except for temporal symmetry index under both task conditions. In the control group, there were no significant changes over the 4-week period for all selected measures. There was a significant difference between groups for all selected gait variables except for temporal symmetry index under both task conditions.

Conclusions

The dual-task-based exercise program is feasible and beneficial for improving walking ability in subjects with chronic stroke.     

Walking speed best explains perceived locomotion ability in ambulatory people with chronic stroke,assessed by the ABILOCO questionnaire

BackgroundThe identification of the predictors of locomotion ability could help professionals select variables to be considered during clinical evaluations and interventions.ObjectiveTo investigate which impairment measures would best predict locomotion ability in people with chronic stroke.MethodsIndividuals (n = 115) with a chronic stroke were assessed. Predictors were characteristics of the participants (i.e. age, sex, and time since stroke), motor impairments (i.e. muscle tonus, strength, and motor coordination), and activity limitation (i.e. walking speed). The outcome of interest was the ABILOCO scores, a self-reported questionnaire for the assessment of locomotion ability, designed specifically for individuals who have suffered a stroke.ResultsAge, sex, and time since stroke did not significantly correlate with the ABILOCO scores (−0.07 < ρ < 0.05; 0.48 < p < 0.99). Measures of motor impairments and walking speed were significantly correlated with the ABILOCO scores (−0.25 < r < 0.57; p < 0.001), but only walking speed and strength were kept in the regression model. Walking speed alone explained 35% (F = 55.5; p < 0.001) of the variance in self-reported locomotion ability. When strength was included in the model, the explained variance increased to 37% (F = 31.4; p < 0.001).ConclusionsWalking speed and lower limb strength best predicted locomotion ability as perceived by individuals who have suffered a stroke.     

Neuromuscular electric stimulation effect on lower-extremity motor recovery and gait kinematics of patients with stroke: a randomized controlled trial

OBJECTIVE: To evaluate the effects of neuromuscular electric stimulation (NMES) of the tibialis anterior muscle on motor recovery and gait kinematics of patients with stroke. DESIGN: Randomized, controlled, assessor-blinded trial. SETTING: Rehabilitation ward and gait laboratory of a university hospital. PARTICIPANTS: A total of 25 consecutive inpatients with stroke (mean age, 55y), all within 6 months poststroke and without volitional ankle dorsiflexion. INTERVENTION: Both the NMES group (n=12) and the control group (n=13) participated in a conventional stroke rehabilitation program, 5 days a week for 4 weeks. The NMES group also received 10 minutes of NMES to the tibialis anterior muscle of the paretic limb. MAIN OUTCOME MEASURES: Brunnstrom stages of motor recovery and kinematic characteristics of gait. RESULTS: Brunnstrom stages improved significantly in both groups (P<.05). In total, 58% of the NMES group and 61% of the control group gained voluntary ankle dorsiflexion. Between-group difference of percentage change was not significant (P>.05). Gait kinematics was improved in both groups, but the difference between groups was not significant. CONCLUSIONS: NMES of the tibialis anterior muscle combined with a conventional stroke rehabilitation program was not superior to a conventional stroke rehabilitation program alone, in terms of lower-extremity motor recovery and gait kinematics.     

早期康复治疗对脑卒中偏瘫患者肢体功能及日常生活能力的影响

目的探讨早期康复治疗对急性脑卒中偏瘫患者上下肢功能恢复及日常生活能力的影响。方法选择急性脑卒中偏瘫患者76例,随机分为康复组和对照组(每组38例)。用前瞻性研究方法对两组进行比较分析。康复组在临床药物治疗的同时进行正规的康复训练,对照组给予临床药物治疗及未经指导的自我锻炼。分别于入选治疗前24h及治疗后6~8周进行测评。运动功能采用Fugl-M eyer运动功能积分法(FMA)测评,日常生活能力用Barthel指数评分。结果经6~8周治疗后,Barthel指数及FMA评分均有一定程度的改善,但康复组明显优于对照组(P<0.01)。康复组治疗后FMA的提高程度上下肢差异无统计学意义。结论急性脑卒中偏瘫患者进行早期康复治疗能明显改善肢体运动功能、提高日常生活能力。     

早期康复治疗对脑血管意外患者下肢运动功能及独立行走的影响

目的比较不同时间介入康复治疗对脑血管意外患者下肢运动功能及步行功能的影响。方法脑血管意外患者40例,发病后≤1个月进行康复治疗的20例为早期治疗组;>1个月的20例为对照组,均以物理治疗为主,结合中医传统疗法,治疗30 d后比较治疗前后患者的Brunnstrom分级及行走能力。结果治疗30 d后与治疗前比较,对照组患者Brunnstrom运动分级无明显提高,χ2=3.6,P>0.05。治疗组患者Brunnstrom运动分级明显提高,χ2=17.36,P<0.05。治疗组与对照组对比对照组3种分类,χ2=6.88,P<0.05。治疗组独立步行率80%,与对照组40%比较,χ2=6.67,P<0.01。早期治疗组Brunnstrom运动分级及行走能力均较对照组均有显著提高。结论脑血管意外患者早期进行康复治疗对下肢运动功能及步行功能恢复效果好。     

Outcome measures to assess walking ability following stroke: a systematic review of the literature

Objectives

The recovery of independent walking is an important goal in stroke rehabilitation. The objective of this systematic review was to identify all outcome measures used in the stroke research literature that included an evaluation of walking ability and evaluate the concepts contained in these measures with reference to the International Classification of Functioning, Disability and Health (ICF) framework.

Data sources

Searches were conducted of MEDLINE, CINAHL, EMBASE and PsycINFO databases for the time period January 1990-December 2005 using appropriate keywords.

Review methods

Studies were selected for further analysis if they used one or more standardized outcome measure incorporating an aspect of walking defined by the ICF. The outcome measure had to have published psychometric properties and specifically measure walking rather than mobility. The content of each outcome measure was classified with reference to the ICF subcategories for walking. The number of times each outcome measure was used was calculated.

Results

Three hundred and fifty-seven studies met the selection criteria. Sixty-one different outcome measures were used a total of 848 times to measure walking ability. Six of the outcome measures reflected impairment and 52 reflected limitations of activity and participation. The other three outcome measures showed overlap between domains, reflecting aspects of both impairment and limitations in activity and participation. The three most frequently used measures (self-paced gait speed measured over a short distance, spatiotemporal parameters and fast gait speed) were used 350 times but only assessed one ICF subcategory. The Rivermead Mobility Index and the Adapted Patient Evaluation Conference System assessed the greatest number of ICF subcategories but were used only 19 times and once respectively.

Conclusions

The most frequently used outcome measures reflect only one aspect of walking ability: walking short distances. Mobility tasks related to function in the community, like walking long distances, around obstacles and over uneven ground, and moving around outside or in buildings other then the home are not well represented by outcome measures used in most studies.     

急性脑卒中偏瘫患者初诊时坐位姿势保持能力对判断功能预后的价值

目的　研究初诊时坐位姿势保持能力对急性脑卒中偏瘫患者功能预后的价值。方法　 86例急性脑卒中偏瘫患者根据初诊时坐位姿势保持能力的评价分为良好组和不良组 ,对两组患者出院时的步行能力、日常生活活动能力和住院时间进行评测。结果　初诊时坐位姿势保持能力良好组 ,站立训练开始的时间、步行训练开始的时间和住院时间明显比不良组短 (P <0 .0 0 1 ) ,说明良好组比不良组功能恢复快。出院时步行自立度和日常生活活动能力方面 ,良好组明显优于不良组 (P <0 .0 0 1 )。结论　初诊时坐位姿势保持能力与功能恢复密切相关 ,可作为功能预后的一个重要指标     

Immediate effects of neuromuscular joint-facilitation bridging exercises on walking ability and balance function in stroke patients

[Purpose] This study aimed to examine the immediate effects of a pelvic neuromuscular joint-facilitation intervention on the walking and balance ability of patients with hemiplegia caused by cerebrovascular accidents. [Participants and Methods] A total of 15 patients with hemiplegia caused by cerebrovascular accidents underwent a neuromuscular joint-facilitation lumbar-pattern intervention (intervention group), a bridge exercise (bridge intervention group), or a neuromuscular joint-facilitation bridge intervention (neuromuscular joint-facilitation bridge group). Each intervention was randomly administered at 7-day intervals. Measurement items included the timed up-and-go test, functional reach test, 10-m maximum walking speed test, and load in the standing position. Measurements were taken before and after the intervention in each group. [Results] The timed up-and-go test result was significantly shorter in the neuromuscular joint-facilitation intervention group. Timed up-and-go test results, functional reach, 10-m walking time, and standing load (non-paralyzed side) significantly improved in the neuromuscular joint-facilitation bridge group. [Conclusion] The neuromuscular joint-facilitation bridge intervention was immediately effective in patients with hemiplegia caused by cerebrovascular accidents and improved their walking and balance ability.     

Effect of sensory-amplitude electric stimulation on motor recovery and gait kinematics after stroke: a randomized controlled study

OBJECTIVE: To evaluate the effects of sensory-amplitude electric stimulation (SES) of the paretic leg on motor recovery and gait kinematics of patients with stroke. DESIGN: Randomized, controlled, double-blind study. SETTING: Rehabilitation ward and gait laboratory of a university hospital. PARTICIPANTS: A total of 30 consecutive inpatients with stroke (mean age, 63.2 y), all within 6 months poststroke and without volitional ankle dorsiflexion were studied. INTERVENTION: Both the SES group (n=15) and the placebo group (n=15) participated in a conventional stroke rehabilitation program 5 days a week for 4 weeks. The SES group also received 30 minutes of SES to the paretic leg without muscle contraction 5 days a week for 4 weeks. MAIN OUTCOME MEASURES: Brunnstrom stages of motor recovery and time-distance and kinematic characteristics of gait. RESULTS: Brunnstrom stages improved significantly in both groups (P<.05). In total, 58% of the SES group and 56% of the placebo group gained voluntary ankle dorsiflexion. The between-group difference of percentage change was not significant (P>.05). Gait kinematics was improved in both groups, but the between-group difference was not significant. CONCLUSIONS: In our patients with stroke, SES of the paretic leg was not superior to placebo in terms of lower-extremity motor recovery and gait kinematics.     

脑血管意外恢复期患者认知缺陷的测量和分析

作者根据脑血管意外(CVA)患者的特点和我国文化背景,专门设计了包括记忆力、注意力、定向力、语言能力和复杂作业操作能力等内容的认知功能测量表,并利用此表对30例CVA患者进行了初步认知测量阳分析。该表敏感度高,可重复使用,符合我国国情,患者容易接受。结果表明,中风后患者大多有不同程度的认知缺陷,如记忆力、注意力和复杂作业操作能力等。