Psychometric properties of a modified Wolf Motor Function test for people with mild and moderate upper-extremity hemiparesis

OBJECTIVE: To test the necessity of videotaping, test-retest reliability, and item stability and validity of a modified Wolf Motor Function Test (WMFT) for people with mild and moderate chronic upper-extremity (UE) hemiparesis caused by stroke. DESIGN: Raters of videotape versus direct observation; test-retest reliability over 3 observations, item stability, and criterion validity with upper-extremity Fugl-Meyer Assessment (FMA) in the mildly and moderately impaired groups. SETTING: Academic research center. PARTICIPANTS: Sixty-six subjects with chronic UE hemiparesis who participated in a large intervention study. Subjects were classified into mild and moderate groups for additional analyses. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Mean and median times of task completion, functional ability, and strength (weight to box) measures of the WMFT. FMA scores for validity assessment. RESULTS: In a subgroup of 10 subjects, the intraclass correlation coefficient (ICC) for videotape versus direct observation ranged from .96 to .99. For the whole group, test-retest reliability using ICC2,1 ranged from .97 to .99; stability of the test showed that administration 1 differed from administrations 2 and 3 but administrations 2 and 3 did not differ; item analysis showed that 4 of 17 items changed across time, and validity, using a correlation with UE FMA, ranged from .86 to .89. Separate mild- and moderate-group analyses were similar to whole-group results. CONCLUSIONS: Videotaping the modified WMFT was not necessary for accurate scoring. The modified WMFT is reliable and valid as an outcome measure for people with chronic moderate and mild UE hemiparesis and is stable, but 1 repeat testing is recommended when practical.     

A community-based upper-extremity group exercise program improves motor function and performance of functional activities in chronic stroke: a randomized controlled trial

OBJECTIVE: To assess the effects of a community-based exercise program on motor recovery and functional abilities of the paretic upper extremity in persons with chronic stroke. DESIGN: Randomized controlled trial. SETTING: Rehabilitation research laboratory and a community hall. PARTICIPANTS: A sample of 63 people (> or =50y) with chronic deficits resulting from stroke (onset > or =1y). INTERVENTIONS: The arm group underwent an exercise program designed to improve upper-extremity function (1h/session, 3 sessions/wk for 19wk). The leg group underwent a lower-extremity exercise program. MAIN OUTCOME MEASURES: The Wolf Motor Function Test (WMFT), Fugl-Meyer Assessment (FMA), hand-held dynamometry (grip strength), and the Motor Activity Log. RESULTS: Multivariate analysis showed a significant group by time interaction (Wilks lambda=.726, P=.017), indicating that overall, the arm group had significantly more improvement than the leg group. Post hoc analysis demonstrated that gains in WMFT (functional ability) (P=.001) and FMA (P=.001) scores were significantly higher in the arm group. The amount of improvement was comparable to other novel treatment approaches such as constraint-induced movement therapy or robot-aided exercise training previously reported in chronic stroke. Participants with moderate arm impairment benefited more from the program. CONCLUSIONS: The pilot study showed that a community-based exercise program can improve upper-extremity function in persons with chronic stroke. This outcome justifies a larger clinical trial to further assess efficacy and cost effectiveness.     

Effects of robot-aided bilateral force-induced isokinetic arm training combined with conventional rehabilitation on arm motor function in patients with chronic stroke

OBJECTIVE: To analyze the effects of conventional rehabilitation combined with bilateral force-induced isokinetic arm movement training on paretic upper-limb motor recovery in patients with chronic stroke. DESIGN: Single-cohort, pre- and postretention design. SETTING: Rehabilitation department at a medical university. PARTICIPANTS: Twenty subjects who had unilateral strokes at least 6 months before enrolling in the study. INTERVENTION: A training program (40min/session, 3 sessions/wk for 8wk) consisting of 10 minutes of conventional rehabilitation and 30 minutes of robot-aided, bilateral force-induced, isokinetic arm movement training to improve paretic upper-limb motor function. MAIN OUTCOME MEASURES: The interval of pretest, post-test, and retention test was set at 8 weeks. Clinical arm motor function (Fugl-Meyer Assessment [FMA], upper-limb motor function, Frenchay Arm Test, Modified Ashworth Scale), paretic upper-limb strength (grip strength, arm push and pull strength), and reaching kinematics analysis (peak velocity, percentage of time to peak velocity, movement time, normalized jerk score) were used as outcome measures. RESULTS: After comparing the sets of scores, we found that the post-test and retention test in arm motor function significantly improved in terms of grip (P=.009), push (P=.001), and pull (P=.001) strengths, and FMA upper-limb scale (P<.001). Reaching kinematics significantly improved in terms of movement time (P=.015), peak velocity (P=.035), percentage of time to peak velocity (P=.004), and normalized jerk score (P=.008). Improvement in reaching ability was not sustained in the retention test. CONCLUSIONS: Preliminary results showed that conventional rehabilitation combined with robot-aided, bilateral force-induced, isokinetic arm training might enhance the recovery of strength and motor control ability in the paretic upper limb of patients with chronic stroke.     

Reference Values and Psychometric Properties of the Lower Extremity Motor Coordination Test

Objectives

(1) To create predictive nomograms for the dominant and nondominant limbs on the Lower Extremity Motor Coordination Test (LEMOCOT) using reference values, and (2) to determine the inter- and intrarater reliability for the LEMOCOT; the best scoring method (first vs mean of the first 2 vs mean of the last 2 vs mean of 3 vs the highest of 3 trials); the best testing method (direct vs video observation); and the ability to detect real change (smallest real difference [SRD] and standard error of the measurement [SEM]).

Design

Normative and methodological study.

Setting

Metropolitan area.

Participants

Healthy individuals (N=320, 50% women) in 7 age groups: 20 to 29, 30 to 39, 40 to 49, 50 to 59, 60 to 69, 70 to 79, and ≥80 years. Each group had 50 participants, except for ≥80 years (n=20).

Interventions

Not applicable.

Main Outcome Measure

LEMOCOT.

Results

Age and sex explained 48% of the variance in the LEMOCOT scores for the dominant limb and 44% for the nondominant limb (125<F<148; P<.001). No significant differences were found regarding the different scoring methods (.12<F<1.02; .10<P<.92), and all of them demonstrated good reliability (intraclass correlation coefficients between .90 and .99; P<.001). There was agreement between scores from direct and video observation (limits of agreement −1.99 to 1.85; −1.55 to 1.62). Appropriate SEM (2.27–1.85) and SRD (6.27–5.11) values were found.

Conclusions

Reference values were determined for the LEMOCOT, and predictive nomograms were created based on age and sex. The LEMOCOT is reliable, needing only 1 trial (after familiarization) to generate reliable scores; can be scored from either direct or video observation; and has the ability to detect real change over time.     

Isometric muscle torque in children 5 to 15 years of age: normative data

OBJECTIVE: To establish reference values of arm and leg muscle strength as measured by isometric torque production in healthy children. DESIGN: Measurement of isometric muscle strength in healthy children. SETTING: Public school. PARTICIPANTS: Healthy children (N=149; 76 boys, 73 girls) ages 5 to 15 years. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Isometric torque values of 12 arm and leg muscle groups of healthy children as measured by a handheld dynamometer. RESULTS: Normative data were obtained for children 5 to 15 years of age. There was an increase in torque with age and weight and a strong correlation with both age and weight. There were few differences between boys and girls. Equations for predicted torque taking into account age, weight, and sex were calculated. The agreement between examiners was excellent. CONCLUSIONS: Studies on growing children require comparison to healthy (normal) children to assess the amount of deviation from normal and to be able to draw conclusions of change over time. The reference values for torque in combination with a predicted value based on the child's age, weight, and sex make it possible to compare over time and between subjects and provide a tool for evaluation of physical status and efficacy of therapy.     

The drawing test: assessment of coordination abilities and correlation with clinical measurement of spasticity

OBJECTIVE: To assess the correlation between kinematic measures of movement (Drawing Test) and a clinical measure of spasticity (Ashworth Scale). DESIGN: Correlation study of Drawing Test and the Ashworth Scale scores. SETTING: Inpatient rehabilitation center. PARTICIPANTS: Forty-five poststroke hemiplegic subjects with various levels of spasticity (up to Ashworth Scale score of 3) and 8 able-bodied subjects with no sensorimotor deficits in their upper extremities. INTERVENTIONS: Subjects made self-paced, radial point-to-point movements between the left, and the right corners of a square (200 x 200 mm) on the surface of a drawing tablet. Hand coordinates were recorded from the mouse, which was attached to the hand. MAIN OUTCOME MEASURES: Correlation between (1) Drawing Test scores (time to perform the movement, radial [ y ] and tangential [ x ] distances between the end point of the movement and the target endpoint, standard error of the mean calculated as distances between the recorded path and its radial linear fit), and (2) Ashworth Scale scores. RESULTS: Drawing Test scores correlated highly with Ashworth Scale scores in 49 of 53 subjects, based on the multiple linear regression analysis. CONCLUSIONS: The Drawing Test, a quantitative metric of movement ability, correlated highly to the Ashworth Scale, a clinical measure of spasticity.     

Test-retest reliability, validity, and sensitivity of the Chedoke arm and hand activity inventory: a new measure of upper-limb function for survivors of stroke

OBJECTIVES: To estimate the test-retest reliability and validity of the Chedoke Arm and Hand Activity Inventory (CAHAI) and to test whether the CAHAI was more sensitive to change in upper-limb function than the Impairment Inventory of the Chedoke-McMaster Stroke Assessment (CMSA) and the Action Research Arm Test (ARAT). DESIGN: Construct validation process. SETTING: Inpatient/outpatient rehabilitation facilities. PARTICIPANTS: Stratified sample of 39 survivors of stroke: 24 early (mean age, 71.4 y; mean days poststroke, 27.3) and 15 chronic (mean age, 64.0 y; mean days poststroke, 101.7). INTERVENTION: Regular therapy. MAIN OUTCOME MEASURES: Intraclass correlation coefficients (ICCs), receiver operating characteristic (ROC), standard error of measurement, and correlation coefficients. RESULTS: High interrater reliability was established with an ICC of .98 (95% confidence interval [CI], .96-.99). The minimal detectable change score was 6.3 CAHAI points. Higher correlations were obtained between the CAHAI and the ARAT and CMSA scores compared with the CMSA shoulder pain scores (1-sided, P=.001). Areas under the ROC curves were as follows: CAHAI, .95 (95% CI, 0.87-1.00); CMSA, .76 (95% CI, .61-.92); and ARAT, .88 (95% CI, 0.76-1.00). CONCLUSIONS: High interrater reliability and convergent and discriminant cross-sectional validity were established for the CAHAI. The CAHAI is more sensitive to clinically important change than the ARAT.     

The influence of early aerobic training on the functional capacity in patients with cerebrovascular accident at the subacute stage

OBJECTIVE: To investigate the effect of early aerobic training on the aerobic and functional abilities of patients in the subacute stage of cerebrovascular accident (CVA). DESIGN: Randomized controlled trial. SETTING: Rehabilitation unit in Israel. PARTICIPANTS: Ninety-two patients who had a first CVA were randomly assigned to an exercise-training group or to a control group. INTERVENTION: Aerobic training with a leg cycle ergometer for 8 weeks. MAIN OUTCOME MEASURES: Workload, exercise time, resting and submaximal blood pressure and heart rate, and functional abilities. RESULTS: A trend toward improvement was found in all aerobic parameters for the experimental group, but only heart rate at rest (P=.02), workload, and work time (P<.01) improved significantly. A trend for improvement was also found in all parameters of function for the experimental group, but only stair climbing was significantly better (P<.01). An interaction (95% confidence interval, 1.7-17.21) was found between age and aerobic training on walking distance. Although no significant effect was found in the group of younger patients (aged <65y), a significant difference in favor of training was noted in the group of older patients. CONCLUSIONS: Patients with CVA in the subacute stage improved some of their aerobic and functional abilities after submaximal aerobic training.     

良肢位在脑卒中患者早期康复护理中的影响

目的探讨良肢位对脑卒中偏瘫患者早期康复护理效果的影响.方法 200例脑卒中患者随机分为2组.康复组(100例)采用早期床上良肢位摆放、早期肢体被动运动等康复护理方法.对照组(100例)采用偏瘫常规护理和肢体被动运动方法.结果经4周的康复护理,康复组患者肌力恢复Ⅲ级以上者为80例,88%以上的患者未出现并发症.对照组肌力恢复Ⅲ级以上者为78例,71%以上的患者不同程度地出现了一系列并发症,康复组并发症发生率大大低于对照组.结论良肢位在脑卒中患者早期康复护理中对预防并发症有明显作用.     

Effectiveness of Home- and Community-Based Rehabilitation in a Large Cohort of Patients Disabled by Cerebrovascular Accident: Evidence of a Dose-Response Relationship

Objectives

To (1) assess the effectiveness of home- and community-based rehabilitation (HCBR) in a large cohort of individuals with disabilities secondary to cerebrovascular accident (CVA); and (2) evaluate the responsiveness to treatment of the Mayo-Portland Adaptability Inventory (MPAI-4) to changes resulting from HCBR in this patient group.

Design

Retrospective analysis of program evaluation data for treatment completers and noncompleters.

Setting

HCBR conducted in 7 geographically distinct U.S. cities.

Participants

Individuals with CVA (n=738) who completed the prescribed course of rehabilitation (completed course of treatment [CCT]) compared with 150 individuals who were precipitously discharged (PD) before program completion.

Intervention

HCBR delivered by certified professional staff on an individualized basis.

Main Outcome Measures

Mayo-Portland Adaptability Inventory (MPAI-4) completed by professional consensus on admission and at discharge.

Results

With the use of analysis of covariance, MPAI-4 total scores at discharge for CCT participants were compared with those of PD participants, with admission MPAI-4, age, length of stay, and time since event as covariates. CCT participants showed greater improvement than PD participants (F=99.48, P<.001) with a moderate effect size (partial η²=.10). Group differences and effect sizes were similar for the 3 index scores: Ability (F=75.96, P<.001; partial η²=.08), Adjustment (F=99.67, P<.001; partial η²=.10), and Participation (F=69.15, P<.001; partial η²=.07).

Conclusions

Individuals in the CCT group who received the entire planned course of HCBR showed greater improvement on all MPAI-4 indexes than those in the PD group who were discharged before completing the prescribed program. This dose-response relationship provides evidence of a causal relationship between treatment and outcome.     

Recovery of standing balance and functional mobility after stroke

OBJECTIVE: To examine the extent to which recovery of functional balance and mobility is accompanied by change in a few specific physiologic measures of postural control. DESIGN: Longitudinal prospective study. SETTING: Laboratory setting in Ontario. PARTICIPANTS: Twenty-seven volunteers (age, 64.2+/-13.7y) undergoing 4 weeks of rehabilitation after stroke participated. At initial testing, patients were 32.7+/-18.4 days poststroke and exhibited a moderate level of motor recovery (lower-extremity and postural control, stages 3-4 on the Chedoke-McMaster Stroke Assessment Impairment Inventory). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Three functional measures (Berg Balance Scale, Clinical Outcome Variables Scale, gait speed) were assessed. Three physiologic measures (electromyographic data of hamstrings and soleus muscles bilaterally, postural sway, arm acceleration) were taken while subjects stood quietly on a force platform and while they performed a rapid shoulder flexion movement of the nonparetic upper extremity. RESULTS: After 1 month of rehabilitation, there was an overall significant improvement in all outcome measures (functional, physiologic). However, 10 patients failed to show any improvement in the electromyographic activation of hamstrings muscle on the paretic side in response to the rapid arm movement. These patients compensated by increasing the anticipatory activation of the nonparetic hamstrings. CONCLUSION: After stroke, patients showed improvement in both physiologic and functional measures of balance and mobility over a 1-month period. We have identified some patients who may be using compensatory strategies to increase function. The factors that may predict those patients who are likely to use compensatory strategies awaits further study.     

Reconsidering the motor recovery plateau in stroke rehabilitation

Termination of motor rehabilitation is often recommended as patients with cerebrovascular accident (CVA) become more chronic and/or when they fail to respond positively to motor rehabilitation (commonly termed a "plateau"). Managed-care programs frequently reinforce this practice by restricting care to patients responding to therapy and/or to the most acute patients. When neuromuscular adaptation occurs in exercise, rather than terminating the current regimen, a variety of techniques (eg, modifying intensity, attempting different modalities) are used to facilitate neuromuscular adaptations. After presenting the concepts of the motor recovery plateau and adaptation, we similarly posit that patients with CVA adapt to therapeutic exercise but that this is not indicative of a diminished capacity for motor improvement. Instead, like traditional exercise circumstances, adaptive states can be overcome by modifying regimen aspects (eg, intensity, introducing new exercises). Findings suggesting that patients with chronic CVA can benefit from motor rehabilitation programs that apply novel or different parameters and modalities. The objectives of this commentary are to (1) to encourage practitioners to reconsider the notion of the motor recovery plateau, (2) to reconsider chronic CVA patients' ability to recover motor function, and (3) to use different modalities when accommodation is exhibited.     

Robotic therapy for chronic motor impairments after stroke: Follow-up results

OBJECTIVES: To study the effects of robotic rehabilitation in persons with chronic motor impairments after stroke and to examine whether improvements in motor abilities were sustained 4 months after the end of therapy. DESIGN: Pretest-posttest design. SETTING: Rehabilitation hospital, outpatient care. PARTICIPANTS: Volunteer sample of 42 persons with persistent hemiparesis from a single, unilateral stroke within the past 1 to 5 years. INTERVENTION: Robotic therapy for the paretic upper limb consisted of either sensorimotor active-assistive exercise, or progressive-resistive training during repetitive, planar reaching tasks, 3 times a week for 6 weeks. MAIN OUTCOME MEASURES: Modified Ashworth Scale, Fugl-Meyer Assessment (FMA), Motor Status Scale (MSS) score, and Medical Research Council motor power score. RESULTS: No significant differences were found among pretreatment clinical evaluations. Statistically significant gains from admission to discharge and from admission to follow-up (P<.05) were found on the FMA, MSS score for shoulder and elbow, and motor power score. CONCLUSIONS: Short-term, goal-directed robotic therapy can significantly improve motor abilities of the exercised limb segments in persons with chronic stroke that are sustained 4 months after discharge. This suggests that motor recovery can be enhanced by repetitive exercise training more than 1 year after stroke.