Clinical correlation between motor evoked potentials and gait recovery in poststroke patients

OBJECTIVE: To evaluate, in patients with a stroke in the area of the middle cerebral artery, whether transcranial magnetic stimulation values from the affected lower limb correlated with the degree of gait recovery. DESIGN: The prognostic evaluation in subjects with complete lower-limb palsy, inability to walk, and dependence in the activities of daily living, 1 month after vascular injury. SETTING: University-affiliated rehabilitation hospital. PARTICIPANTS: Twenty consecutive patients (12 women, 8 men) were enrolled 1 month poststroke (30+/-5 d); all patients concluded the rehabilitation program, which lasted 6 months. INTERVENTION: Barthel Index score, Hemiplegic Stroke Scale (HSS) score, and motor evoked potentials (MEPs) from the tibialis anterior muscle were performed 1, 4, and 7 months poststroke. The Wilcoxon signed-rank test, Mann-Whitney U test, and Spearman rank-order correlation coefficient were employed. MAIN OUTCOME MEASURES: The independence of gait defined as an HSS gait score of 3 or less (ability to walk without assistance apart from a stick or cane). RESULTS: Patients with no recordable MEPs 1 month poststroke never regained walking ability; patients with MEPs of 8% or more (13.11+/-5.95) regained independent gait at discharge. It was not possible to predict walking capacity in patients with MEPs less than 8% (4.0+/-1.41). Four months postinjury, walking capacity was achieved only by the patients with MEPs of 18% or more (23.1+/-6.2). CONCLUSIONS: In the postacute phase of stroke, the lower-limb MEP amplitudes could be a supportive tool for prognosis of lower-limb motor outcome.     

Postacute predictors of functional and cognitive progress in traumatic brain injury: somatosensory evoked potentials

OBJECTIVE: To investigate the prognostic value of electrophysiologic studies performed during the postacute phase after traumatic brain injury (TBI). DESIGN: A prospective comparative study in which 26 patients with TBI participated. Patients were grouped according to their admission short-latency somatosensory evoked potential (SEP) results. Nonparametric Kruskal-Wallis and Mann-Whitney U tests were applied to different SEP groups to determine the differences among them in specific functional and cognitive outcome measures. SETTING: An inpatient brain injury rehabilitation unit. PARTICIPANTS: Twenty-six patients with TBI who were admitted to the rehabilitation center at the postacute phase for a late inpatient rehabilitation program and 15 age-matched healthy subjects who served as a control group for the electrophysiologic comparison. MAIN OUTCOME MEASURES: Motricity Index, Barthel Index, Disability Rating Scale, Mini-Mental Status Exam, and Rancho Los Amigos Scale. RESULTS: Disability Rating Scale scores at discharge and rate of change of Barthel Index scores differed between median nerve SEP classification groups (p<.05 for both). Disability Rating Scale scores at admission (p<.05) and at discharge (p<.01), Barthel Index scores at discharge (p<.05), and rate of change of Barthel Index scores (p<.05) differed between tibial nerve SEP classification groups. There was a relation between Motricity Index side scores at discharge and the different body side SEP response groups (p<.0001). Cognitive results showed no relation to the SEP groups. CONCLUSIONS: Postacute SEP scores after a late admission to a rehabilitation center showed a relation to measures of functional and motor progress. Patients with better SEP responses were more likely to experience greater functional and motor improvement. Cognitive functions were not related to SEP results.     

老年与非老年初发脑卒中患者早期康复疗效对照研究

目的 探讨早期康复治疗对老年初发脑卒中患运动功能和生活自理能力的影响。方法 比较１０３例初发脑卒中患,老年组７６例,对照组（非老年组）２７例,康复治疗开始在发病７ｄ内５７例,８￣３０ｄ内２２例,３１￣９０ｄ内２２例,３１￣９０ｄ内２４例。治疗方法包括运动功能和生活处理能力训练两个方面,每周治疗５次,每次４５ｍｉｎ。治疗前后用Ｆｕｇｌ－Ｍｅｙｅｒ量表９ＦＭＡ）主宰运动功能,用Ｂａｒｔｈｅｌ指数（     

Predictors of a successful driver evaluation in stroke patients after discharge based on an acute rehabilitation hospital evaluation

OBJECTIVE: One of the most common concerns of a stroke patient is the ability to drive. We aimed to determine which neurologic impairments on an acute rehabilitation admission evaluation predict the likelihood of a successful driver evaluation after discharge. DESIGN: Prospective study in an acute stroke rehabilitation unit. RESULTS: A total of 45 stroke patients undertook a driver evaluation at our institution. The mean age +/- standard deviation was 71.0 +/- 9.8 yrs, Mini-Mental State Examination score was 22.7 +/- 8.1, upper limb and lower limb Motricity Index scores were 63.7 +/- 34.8 and 71.8 +/- 24.3, Limb Placement Task was 4.6 +/- 3.6 inches, and admission total FIM score was 68.5 +/- 18. The admission variables differed between those who failed (n = 10) vs. those who passed the in-clinic driver evaluation (n = 29, 75%): Mini-Mental State Examination (17.5 +/- 9.7 vs. 24.6 +/- 6.7, P = 0.004), and upper limb (82 +/- 23.7 vs. 57.4 +/- 36.1, P = 0.05) and lower limb (87.6 +/- 11.8 vs. 66.4 +/- 25.2, P = 0.01) Motricity Index scores. CONCLUSIONS: Patients who undertook and passed the in-clinic driver evaluation had, at admission, higher Mini-Mental State Examination and Motricity Index scores with normal visual field defects.     

Motor evoked potentials of the lower extremity in predicting motor recovery and ambulation after stroke: a cohort study

OBJECTIVE: To assess the prognostic value of motor evoked potentials (MEPs) in the lower extremity with respect to motor recovery and functional recovery in stroke patients. DESIGN: Cohort study. SETTING: The department of neurology at a university hospital. PARTICIPANTS: Thirty-eight acute-stroke patients with complete paralysis (paralysis subgroup) or severe paresis (paresis subgroup) of the lower extremity. MEPs of the vastus medialis and the tibialis anterior muscles were recorded between days 3 and 10 after stroke onset. INTERVENTIONS: Not applicable.Main outcome measures A separate proximal leg motor score (maximum, 16 points) and crural motor score (maximum, 2 points) were defined within the lower-limb subset of the original Fugl-Meyer Motor Assessment to evaluate the motor performance at regular intervals until 6 months after stroke. The transfer item of the Barthel Index and the Functional Ambulation Categories scores were used to assess transfer and walking ability. RESULTS: For the paralysis subgroup (n=30), the follow-up was complete in 27 patients (2 patients died, 1 patient underwent above-knee amputation). At 26 weeks, 20 patients experienced proximal motor recovery (mean score +/- standard deviation, 11.70+/-4.48), and 12 of them also showed crural motor recovery (mean score, 1.40+/-.51). Nine patients (33%) could perform an independent transfer safely, and 7 (26%) had learned to walk independently. Analysis revealed significant relationships for tibialis anterior muscle MEPs and motor recovery of crural leg muscles (odds ratio [OR]=18.00; 95% confidence interval [CI], 1.31-894.40), but not for vastus medialis muscle MEPs and proximal motor recovery (OR=6.00; 95% CI,.53-303.00). We found no association between vastus medialis muscle MEPs and recovery of ambulation. However, tibialis anterior muscle MEPs seemed to provide a test with prognostic value for the ability to perform independent transfers (OR=17.50; 95% CI, 1.36-267.00), but not for walking (OR=5.25; 95% CI,.40-77.57). Patients in the paresis subgroup experienced more favorable motor and functional recovery than did those in the paralysis subgroup. CONCLUSIONS: Tibialis anterior muscle MEPs registered in subacute phase after stroke may provide important prognostic information, both for motor recovery of the crural muscles and for the ability to perform independent transfers in patients with initial complete paralysis of the lower extremity. Vastus medialis muscle MEPs were not predictive for motor and functional recovery.     

The course of apraxia and ADL functioning in left hemisphere stroke patients treated in rehabilitation centres and nursing homes

OBJECTIVE: To study the course of apraxia and daily life functioning (ADL) in left hemisphere stroke patients with apraxia. DESIGN: Prospective cohort study. SETTING: Rehabilitation centres and nursing homes. SUBJECTS: One hundred and eight left hemisphere stroke patients with apraxia, hospitalized in rehabilitation centres and nursing homes. MEASURES: ADL-observations, Barthel ADL Index, Apraxia Test, Motricity Index. RESULTS: During the study period of 20 weeks, patients showed small improvements in apraxia (standardized mean differences of 0.19 and 0.33) and medium-sized improvements in ADL functioning (standardized mean differences from 0.37 to 0.61). About 88% of the patients were still apraxic at week 20. Less improvement in apraxia was observed in initially less severe apraxic patients. Less improvement in ADL functioning was found to be associated with more severe apraxia, a more independent initial ADL score, higher age, impaired motor functioning and longer time between stroke and first assessment. CONCLUSIONS: Apraxia in stroke patients is a persistent disorder, which has an adverse influence on ADL recovery.     

Hand function and motor cortical output poststroke: are they related?

OBJECTIVES: To characterize hand function and cortical excitability in chronic and subacute stages of stroke recovery and to describe the relations between these measures. DESIGN: Observational, case-control, and cohort pre-post inpatient rehabilitation. SETTING: Motor performance laboratory. PARTICIPANTS: Fourteen community-living chronic and 14 subacute inpatient stroke survivors volunteered. Fourteen similarly aged healthy subjects served as a control group. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Finger tapping, peg placing, and strength were measured as indicators of hand function. The amplitude and latency of motor-evoked potentials (MEPs) and the duration of the silent period in the first dorsal interosseous muscle elicited by transcranial magnetic stimulation (TMS) reflected the integrity of excitatory and inhibitory cortical circuits. RESULTS: Diminished hand function, small MEPs, and prolonged silent-period durations were evident in stroke compared with control subjects. Longer MEP latencies and smaller amplitudes distinguished subacute from chronic stroke. Side-to-side asymmetries were greatest in the subacute group for all TMS outcomes, although this lessened over time based on the subsample retested at discharge. Greater side-to-side MEP amplitude symmetry and lower motor threshold (lesioned side) were associated with better hand function in subacute and chronic stroke, respectively. CONCLUSIONS: Cortical excitability is an important determinant of hand function poststroke and evolves with the time elapsed since the stroke event. The unique neural correlates of hand function evident in subacute and chronic stroke may reflect different phases of neuromuscular recovery.     

Longitudinal robustness of variables predicting independent gait following severe middle cerebral artery stroke: a prospective cohort study

OBJECTIVE: To determine within the first 10 weeks post onset the most robust variables in the prediction of recovery of independent gait at six months post stroke. DESIGN: A prospective cohort study. SUBJECTS: One hundred and one first ever ischaemic middle cerebral artery stroke patients. None of these patients were able to walk at onset and all suffered from a marked hemiplegia. SETTING: Twenty-four determinants, possibly related to recovery of gait at six months, were measured within 14 days following stroke onset. Based on Functional Ambulation Categories (FAC) independent gait was classified into present (FAC > or = 4) or absent (FAC < 4). Bivariate logistic regression analysis was used to select determinants. Only significant determinants during the entire 10-week period were used for further weekly multivariate logistic prediction modelling of independent gait at six months post stroke. RESULTS: After six months post onset 62% (N = 63) regained independent gait. Age, Barthel Index, Trunk Control Test, Motricity Index of arm and leg, Brunnstrom Fugl-Meyer stage of leg motor recovery, and type of intervention were significant determinants in bivariate analysis, but age of patient and Barthel Index were the most robust determinants in the final prediction model. Weekly re-evaluation produced sensitivity values between 89% and 96% and specificity values between 53% and 62%. CONCLUSION: In initially non-ambulatory stroke patients age and Barthel Index were the most robust variables during the first 10-week poststroke period in the prediction of independent walking at six months. However, prediction of non-ambulation at six months proved to be less accurate.     

电针治疗对早期康复急性脑卒中患者运动功能的影响

目的观察电针治疗对早期康复急性脑卒中偏瘫患者运动功能的影响。方法75例急性期脑卒中患者随机分为电针治疗组(38例)和对照组(37例),两组患者均常规行药物治疗加早期康复,治疗组增加电针疗法。分别于治疗前及治疗后以神经功能缺损评分(NFI)、简式Fugl-Meyer评分(FMA)、修订Barthel指数(MBI)评定两组患者的运动功能。结果治疗后,两组患者的评分均较治疗前明显提高(P<0.01),但电针治疗组患者的评分明显优于对照组(P<0.01)。结论早期康复急性脑卒中患者介入电针治疗效果优于单一治疗。     

早期康复治疗对急性脑卒中运动功能恢复的影响

探讨早期康复治疗对急性脑卒中偏瘫患者发病1个月时运动功能恢复的影响。方法:将57例脑卒中患者随机分为康复组和对照组。于发病后7—23天,对康复组30例脑卒中患者,用以Bobath为主的运动疗法进行康复训练,至病后1个月时结束,对照组27例脑卒中患者不接受康复训练。两组药物治疗基本相同。用Fugl-Meyer运动功能评定法(FMA)评定患者的运动功能;用脑卒中患者临床神经功能缺损程度评分标准(ND)评定患者的病情严重程度。结果:康复治疗前后康复组与对照组比较肌张力差异均无显著性(P>0.05);康复治疗前、后ND的差值康复组与对照组比较差异有显著性(P=0.01),康复治疗后,康复组神经功能缺损程度明显减轻;康复治疗前、后FMA评分的差值,康复组与对照组比较,上肢差异有显著性(P<0.05),下肢差异无显著性(P>0.05)。结论:脑卒中发病1个月内,早期短期的康复治疗,可降低临床神经功能缺损积分,提高患者的上肢运动功能。     

脑卒中残损评价表的临床应用

目的 :应用脑卒中残损评价表 (SIAS)探讨脑卒中偏瘫患者早期康复的疗效。方法 :5 0例急性脑卒中患者随机分为康复组和对照组各 2 5例 ,治疗药物基本相同 ,康复组同时接受康复治疗。康复组患者根据开始康复治疗的时间又分为康复A(病程 <12d)和康复B(病程 >12d)。所有患者治疗前和治疗 3个月时各进行 1次SIAS评定。结果 :治疗 3个月时康复组患者的运动功能、肌张力、躯干平衡、关节活动范围、疼痛分项评分及总分与对照组比较 ,均差异有显著性 ;感觉功能、视空间认知、语言及健侧肢体功能差异无显著性。康复A运动功能、肌张力分项评分和总分上均显著高于康复B。结论 :SIAS临床应用显示早期康复治疗可有效改善偏瘫患者的功能。     

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及日常生活能力的影响,并观察脑卒中偏瘫患者上下肢运动功能的恢复程度有无差别。方法选择急性脑卒中偏瘫患者96例,随机分为康复组和对照组(每组48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-Meyer运动功能积分法(FMA)测评,日常生活能力用Barthd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,但其改善幅度康复组明显优于对照组(P＜0.01)。康复组FMA平均值转化为运动最大程度百分比,治疗前后下肢均较上肢为高,但治疗后FMA的提高程度上下肢没有显著性差异(P＞0.05)。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。从残损水平分析,经过康复治疗后,脑卒中偏瘫患者上下肢运动障碍的恢复程度在病后2个月内是相同的。     

早期康复对急性脑卒中ALD的促进作用

目的 探讨早期康复治疗对急性脑卒中偏瘫患者上、下肢运动功能和日常生活活动能力的影响。方法 选择急性脑卒中偏瘫患者96例,随机分为康复组和对照组（每组48例）。用前瞻性研究方法对两组进行比较分析。康复组在给予物治疗的同时,还进行正规的康复训练;对照组仅给予药物治疗。分别于入选治疗前24h和治疗后6－8周进行测评。采用Brunnstrom分级法评定运动功能,采用Barthel指数评定日常生活活动能力（ADL）。结果 经6－8周治疗后,两组在Barthel指数和Brunnstrom分级上均有一定程度的改善,康复组的改善幅度明显优于对照组（P＜0．01）。结论 急性脑卒中偏瘫患者接受早期康复治疗,能明显改善肢运动功能,提高日常生活活动能力。     

Prediction of reflex sympathetic dystrophy in hemiplegia by evaluation of hand edema

OBJECTIVE: To determine the predictive value of measurements of hand edema for the development of reflex sympathetic dystrophy (RSD). DESIGN: Cohort study. SETTING: Departments of rehabilitation medicine in 3 general hospitals and 1 rehabilitation hospital in Japan. PARTICIPANTS: Thirty-four stroke patients. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Measurement of the circumference of the middle finger was used to evaluate hand edema. The degree of hand edema was expressed by the ratio of circumference of the middle finger (RCMF) in the affected side to that in the uninvolved extremity. RESULTS: Eight of 34 patients developed clinical RSD from 2 to 4 months after stroke. Hand edema showed a significant relationship to the development of RSD (ie, the patients who had an RCMF of above 1.06 at 4 weeks poststroke had significantly higher incidence of RSD than those with a lower RCMF; P=.0127). CONCLUSION: It is possible to predict the development of RSD in hemiplegia by measuring hand edema 4 weeks poststroke.     

早期康复治疗对脑卒中偏瘫患者平衡功能和日常生活活动能力的影响

目的:探讨早期康复治疗对脑卒中患者3个月和6个月后平衡功能和日常生活活动能力(ADL)的影响。方法:将80例脑卒中偏瘫患者随机分成康复组(40例)和对照组(40例)进行临床对照研究,两组均常规进行神经内科药物治疗,康复组加以运动疗法,对每例患者在入组时、病程3个月和6个月分别用Fugl-Meyer测试平衡功能和改良Barthel指数(MBI)测试ADL能力。结果:康复组3次平衡功能积分分别为2.71±2.42、8.74±2.02、10.28±2.35,MBI分别为20.66±13.45、67.72±18.90、80.55±16.33,对照组平衡功能为3.44±2.89、7.27±2.20、8.44±2.79,MBI为27.24±16.18、57.36±19.67、70.69±23.30;两组前后比较和组间比较差异均有显著性意义(P<0.05);两组的变化均数比较康复组6个月后平衡功能和ADL恢复优于对照组(P<0.001)。平衡功能和ADL呈正相关(r=0.791)。结论:早期康复治疗对脑卒中患者的平衡功能和日常生活活动能力有良好的促进作用。     

偏瘫体操对脑卒中患者运动功能及日常生活活动能力的影响

目的观察偏瘫体操对脑卒中患者运动功能及日常生活活动能力的影响。方法将60例脑卒中偏瘫患者随机分为康复组和体操组,均接受常规PT、OT训练(采用神经发育促进技术),共8周。体操组在此基础上配合偏瘫体操训练。分别于治疗前、治疗8周后采用Fugl-Meyer评测法(FMA)评定两组患者的运动功能,采用改良Barthel指数(MBI)评定日常生活活动(ADL)能力,比较两组患者的评分变化。结果治疗前,两组患者的FMA和MBI评分差异无显著性意义(P>0.05);治疗后,体操组患者的评分明显优于康复组(P<0.01)。结论偏瘫体操结合常规康复训练可明显促进脑卒中偏瘫患者的运动功能及ADL能力。     

Rehabilitation of postcardiac surgery stroke patients. Progress,outcomes, and comparisons with other stroke patients

OBJECTIVE: To examine the demographics, progress, and functional outcomes of all postcardiac surgery stroke patients admitted to the rehabilitation unit of an acute, tertiary general hospital over a 5-yr period and to compare this cohort with an age-matched control group of other stroke patients admitted during the same period. DESIGN: A retrospective chart review of 47 postcardiac surgery stroke and a matched control group of other stroke patients admitted to the rehabilitation unit. RESULTS: The mean age of the postcardiac surgery stroke patients was 70.80 +/- 8.37 yr, with 60% of patients being male. Their average length of stay on the rehabilitation unit was 15.64 +/- 11.96 days. Mean admit FIM total score was 65.64 +/- 16.33, with a discharge FIM total score of 86.77 +/- 18.93. Mean admit FIM motor score was 41.47 +/- 9.45, with a discharge FIM motor of 60.74 +/- 13.20. The other stroke group had significantly greater admit FIM total (P = 0.03), admit motor (P = 0.001), and discharge motor (P = 0.025) scores. FIM efficiency and motor and cognitive gains were comparable between the two groups. Length of stay on the rehabilitation unit was approximately 2 days less (P = 0.224) for the other stroke cohort. Ultimately, 39 (83%) of the postcardiac surgery stroke patients were discharged to the community compared with 45 (96%) of the other stroke patients (P = 0.19). CONCLUSIONS: The majority of postcardiac surgery stroke patients successfully completed a comprehensive inpatient rehabilitation program. They had lower admit FIM total scores and admit and discharge FIM motor scores than the other stroke group and were almost as likely to ultimately return to the community.     

经颅磁刺激在急性脑梗死运动功能康复中的作用

目的 研究经颅磁刺激对运动传导通路的易化作用及其脑卒中运动功能康复中的作用。资料与方法 选取65例住院的急性脑梗死患者,在基本治疗相同的情况下,治疗组给予14天的经颅磁刺激治疗。比较第1天和第14天的MEP（运动诱发电位）、CMCT（中枢运动传导时间）、肌力和Fugl-Meyer运动功能评分。结果 在Gug-Meyer运动功能评分、肌力和CMCT等方面：治疗前,两组无显著性差异;治疗后,两组分别与治疗前相比,均有非常显著性差异,治疗组的运动功能恢复明显优于对照组。治疗前后,两组之间的MEP潜伏期无显著性差异。结论 脑卒中急性期进行经颅磁刺激治疗,可明显缩短CMCT,有利于运动功能的恢复。     

Prevalence of chronic pain and its impact on health-related quality of life in stroke survivors

OBJECTIVES: To document the prevalence of chronic pain and to evaluate the effect of pain on quality of life (QOL) in patients 6 months or more after a stroke. DESIGN: Cross-sectional survey. SETTING: Outpatient clinic of a rehabilitation center. PARTICIPANTS: One hundred seven stroke patients (68 men, 39 women; mean age, 60.9 y) attending the outpatient clinic of a rehabilitation center. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Patients were interviewed on pain, QOL, mood, and functional status by using the short form of the Brief Pain Inventory (BPI), Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), Beck Depression Inventory, and Modified Barthel Index (MBI), respectively. RESULTS: Self-reported chronic pain was present in 45 patients (42%), with 32 having musculoskeletal pain and 13 central poststroke pain. It was significantly more common in patients with a shorter poststroke duration (P=.025), but was not related to the nature of stroke (infarct or bleed), age, gender, presence of depression, and MBI score. There was no difference in the SF-36 scores between patients with and without pain except for the domain of bodily pain. When compared with patients with musculoskeletal pain, patients with central poststroke pain were more likely to have sensory impairments (P=.009), higher pain scores on the question "least pain in the past 24 hours" of the BPI (P=.036), and lower scores on the vitality domain of the SF-36 (P=.042). CONCLUSION: Pain is common in chronic stroke patients, and it does not appear to have a significant effect on patients' QOL.