Validity of the Community Balance and Mobility Scale in Community-Dwelling Persons After Stroke

Knorr S, Brouwer B, Garland SJ. Validity of the Community Balance and Mobility Scale in community-dwelling persons after stroke.

Objectives

To examine the convergent validity, sensitivity to change, floor and ceiling effects of the Community Balance and Mobility Scale (CB&M) in community-dwelling stroke survivors. The secondary objective was to determine the correlations between the CB&M and lower-limb motor recovery and strength.

Design

Validity study.

Setting

Two university-based research centers.

Participants

Community-dwelling persons after stroke (N=44; 24 men, 20 women; mean age, 62.6±12.6y). Baseline measures were taken 3 months after the onset of stroke (98.6±52.6d); participants were reassessed 8 months poststroke (246.8±57.2d).

Interventions

Not applicable.

Main Outcome Measures

CB&M, Berg Balance Scale (BBS), Timed Up & Go (TUG), Chedoke McMaster Stroke Assessment (CMSA) Impairment Inventory for leg and foot, concentric bilateral isokinetic strength of the lower-limb flexor and extensor muscle groups using a dynamometer. The magnitude of the associations and the standardized response means (SRMs) among the CB&M, BBS, and TUG were used to examine the convergent validity and sensitivity to change, respectively.

Results

Moderate to high convergent validities (ρ=.70 to .83, P<.001) were observed among the CB&M, BBS, and TUG. The CB&M was moderately correlated with the CMSA leg and foot scores (ρ=.61 and .63, respectively, P<.001) and the paretic limb strength (ρ=.67, P<.001). The CB&M demonstrated the greatest ability to detect change between the baseline and follow-up assessments (SRM=.83).

Conclusions

The CB&M is valid and sensitive to change in assessing functional balance and mobility in ambulatory stroke survivors with moderate to mild neurologic impairments.     

Change of Strength and Rate of Rise of Tension Relate to Functional Arm Recovery After Stroke

Renner CIE, Bungert-Kahl P, Hummelsheim H. Change of strength and rate of rise of tension relate to functional arm recovery after stroke.

Objective

To examine the relationship between individual strength parameters and functional motor ability over time during rehabilitation in stroke patients.

Design

A multiple-baseline experiment with assessment at inclusion and after 3 and 6 weeks.

Setting

Secondary-care rehabilitation center.

Participants

A convenience sample of 16 subacute stroke patients.

Interventions

Not applicable.

Main Outcome Measures

Maximal voluntary force and rate of rise of tension of hand grip, wrist extension, and elbow flexion and extension were recorded at all 3 times. At the same time, functional motor assessments were evaluated by the Action Research Arm Test (ARAT), Box and Block test, and Rivermead Test.

Results

We found no correlation between maximal voluntary force increases of various muscle contractions measurements. Neither the increase of grip strength nor that of wrist extension force correlated with improvement in ARAT score. Yet the improvement in the rate of rise of tension of hand grip (Spearman rho=.91) and of wrist extension (Spearman rho=.73) correlated with the improvement of the ARAT score and explained 77% of the variance of the ARAT.

Conclusions

The change in the rate of rise of tension of the hand grip has a better predictive value for the functional recovery compared to the change in maximal voluntary force in patients with moderate arm and hand weakness after stroke. The rate of rise of tension of hand grip seems an adequate quantifiable parameter to detect small improvements during functional recovery.     

Does treadmill exercise improve performance of cognitive or upper-extremity tasks in people with chronic stroke? A randomized cross-over trial

Ploughman M, McCarthy J, Bossé M, Sullivan HJ, Corbett D. Does treadmill exercise improve performance of cognitive or upper-extremity tasks in people with chronic stroke? A randomized cross-over trial.

Objective

To determine whether acute exercise, using a body-weight-supported treadmill, improves performance on subsequent cognitive tests or an upper-extremity task in people with stroke.

Design

The study was a within-subject, cross-over design in which 21 subjects received, randomly, 2 different testing sequences separated by an interval of 7 to 10 days.

Setting

Outpatient department of a rehabilitation hospital.

Participants

Of 72 potential participants in the convenience sample, 21 people with chronic stroke completed the study. They were 0.5 to 5 years after only 1 documented stroke, were able to walk with or without a cane, were able to grasp with the affected hand, and scored more than 24 on the Mini-Mental State Examination.

Interventions

One session of body-weight-supported treadmill walking for 20 minutes at 70% of estimated heart rate reserve or level 13 on the Borg rating of perceived exertion scale. The control condition consisted of a 20-minute review of a home exercise program with a physiotherapist.

Main Outcome Measures

Cognitive tests included Trail Making Tests Parts A and B, Symbol Digit Substitution Test, and Paced Auditory Serial Addition Test. The Action Research Arm Test (ARAT) measured hemiplegic upper-extremity motor skill.

Results

Treadmill exercise improved movement of the hemiplegic upper extremity (P=.04) but not cognitive performance. The improvement in the ARAT occurred without a change in strength (measured by grip strength) and was negatively correlated with maximum treadmill speed (R²=.20; P=.04).

Conclusions

These findings suggest that acute treadmill exercise improves subsequent skilled movement of the hemiplegic upper extremity that seems unrelated to attention, visuomotor processing, or strength. The etiology and duration of this enhancing effect are worth further study. The existence of an exercise-cognition relationship in people with stroke is an intriguing area of future research.     

Test position and hip strength in healthy adults and people with chronic stroke

Barbic S, Brouwer B. Test position and hip strength in healthy adults and people with chronic stroke.

Objective

To determine if peak torques generated by the hip flexors and extensors are dependent on test position in healthy adults and in people with chronic stroke.

Design

Cross-sectional study.

Setting

Motor performance laboratory.

Participants

Volunteers were 10 young (20.7±1.5y), 10 older adults (62.1±7y), and 10 stroke survivors (60.6±10y) who were an average of 5 years poststroke.

Interventions

Not applicable.

Main Outcome Measures

Isokinetic (60°/s) peak concentric hip flexor and extensor torques (in Nm/kg) generated in supine and standing positions.

Results

Peak flexor torques measured in standing were generally higher than in supine (P=.018); a pattern evident in all groups, but significant only in stroke. An interaction between test position and group for hip extensor strength (P=.016) reflected 2 distinct patterns in which torques were highest in standing among the young subjects and highest in supine after stroke.

Conclusions

Isokinetic hip flexor and extensor strength measured in standing and supine are comparable in young and older healthy people. In chronic stroke, the test position may over or underestimate maximum peak torque depending on the muscle group tested, particularly on the side ipsilateral to the lesion. These findings may have implications for predicting functional ability from strength measurements.     

Reproducibility of the ABILOCO Questionnaire and Comparison Between Self-Reported and Observed Locomotion Ability in Adult Patients With Stroke

Caty GD, Theunissen E, Lejeune TM. Reproducibility of the ABILOCO questionnaire and comparison between self-reported and observed locomotion ability in adult patients with stroke.

Objectives

To test the reproducibility of the ABILOCO questionnaire. To validate the patient self-reporting method and the third-party assessment of the stroke patients' locomotion ability by a treating physical therapist.

Design

Prospective study.

Setting

University hospital.

Participants

Adult stroke patients (N=28; 59±13y). The time since stroke ranged from 3 to 253 weeks.

Interventions

Not applicable.

Main Outcome Measure

The ABILOCO questionnaire.

Results

The results of patient self-assessment and the results of the third-party assessments by the physiotherapists at a 2-week interval were highly correlated (intraclass correlation coefficient [ICC]=.77 and ICC=.89, respectively). The results of the patient self-assessment and the third-party assessment by the physical therapist were both well correlated to assessment by an independent medical examiner who observed the patient during the 13 ABILOCO activities (ICC=.69 and ICC=.87, respectively).

Conclusions

The use of ABILOCO as a self-reporting questionnaire is a valid and reproducible method for assessing locomotion ability in patients with stroke in daily clinical practice and research.     

Functional significance of ipsilesional motor deficits after unilateral stroke

Chestnut C, Haaland KY. Functional significance of ipsilesional motor deficits after unilateral stroke.

Objective

To determine whether ipsilesional motor skills, which have been related to independent functioning, are present chronically after unilateral stroke and are more common in people with apraxia than in those without apraxia.

Design

Observational cohort comparing the performance of an able-bodied control group, stroke patients with left- or right-hemisphere damage matched for lesion volume, and left-hemisphere stroke patients with and without ideomotor limb apraxia.

Setting

Primary care Veterans Affairs and private medical center.

Participants

Volunteer right-handed sample; stroke patients with left- or right-hemisphere damage about 4 years poststroke; a control group of demographically matched, able-bodied adults.

Interventions

Not applicable.

Main Outcome Measures

Total time to perform the (1) Williams doors test and the (2) timed manual performance test (TMPT), which includes parts of the Jebsen-Taylor Hand Function Test.

Results

Ipsilesional motor deficits were present after left- or right-hemisphere stroke when using both measures, but deficits were consistently more common in patients with limb apraxia only for the TMPT.

Conclusions

These findings add to a growing literature that suggests that ipsilesional motor deficits may have a functional impact in unilateral stroke patients, especially in patients with ideomotor limb apraxia.     

Levodopa improves procedural motor learning in chronic stroke patients

Rösser N, Heuschmann P, Wersching H, Breitenstein C, Knecht S, Flöel A. Levodopa improves procedural motor learning in chronic stroke patients.

Objective

To test the hypothesis that administration of dopamine precursor levodopa improves procedural motor learning (defined as the ability to acquire novel movement patterns gradually through practice) in patients with residual motor deficits in the chronic phase after stroke (≥1y after stroke).

Design

A double-blind, placebo-controlled, randomized crossover design.

Setting

Neurology department in a German university.

Participants

Eighteen patients with chronic motor dysfunction because of stroke (13 men, 5 women; age range, 53-78y; mean time poststroke ± SD, 3.3±2.1y).

Intervention

Patients received 3 doses of levodopa (100mg of levodopa plus 25mg of carbidopa) or placebo before 1 session of procedural motor learning.

Main Outcome Measures

Procedural motor learning performed by using the paretic hand assessed by using a modified version of the serial reaction time task with a probabilistic sequence. The primary outcome measure was the difference in reaction times between random and sequential elements.

Results

Levodopa significantly improved our primary outcome measure, procedural motor learning, compared with placebo (P<.05). Reaction times to random elements, analysis of error rates, psychophysical assessments, and performance in a simple motor task were comparable between conditions, indicating that better learning under levodopa was not caused by differences in response styles, arousal, mood, or motor reaction times but that levodopa modulated learning.

Conclusions

Our results show that levodopa may improve procedural motor learning in patients with chronic stroke, in line with our hypothesis. These findings suggest that this interventional strategy in combination with customary rehabilitative treatments could significantly improve the outcome of neurorehabilitation in the chronic stage after stroke. (Clinicaltrials.gov identifier NCT00126087.)     

5-Repetition Sit-to-Stand Test in Subjects With Chronic Stroke: Reliability and Validity

Mong Y, Teo TW, Ng SS. 5-repetition sit-to-stand test in subjects with chronic stroke: reliability and validity.

Objectives

To examine the (1) intrarater, interrater, and test-retest reliability of the 5-repetition sit-to-stand test (5-repetition STS test) scores, (2) correlation of 5-repetition STS test scores with lower-limb muscle strength and balance performance, and (3) cut-off scores among the 3 groups of subjects: the young, the healthy elderly, and subjects with stroke.

Design

Cross-sectional study.

Setting

University-based rehabilitation center.

Participants

A convenience sample of 36 subjects: 12 subjects with chronic stroke, 12 healthy elderly subjects, and 12 young subjects.

Interventions

Not applicable.

Main Outcome Measures

5-Repetition STS test time scores; hand-held dynamometer measurements of hip flexors, and knee flexors and extensors; ankle dorsiflexors and plantarflexors muscle strength; Berg Balance Scale (BBS); and limits of stability (LOS) test using dynamic posturography.

Results

Excellent intrarater reliability of intraclass correlation coefficient (ICC) (range, .970-.976), interrater reliability (ICC=.999), and test-retest reliability (ICC range, .989-.999) were found. Five-repetition STS test scores were also found to be significantly associated with the muscle strength of affected and unaffected knee flexors (ρ=-.753 to -.830; P<.00556) of the subjects with stroke. No significant associations were found between 5-repetition STS test and BBS and LOS tests in subjects with stroke. Cut-off scores of 12 seconds were found to be discriminatory between healthy elderly and subjects with stroke at a sensitivity of 83% and specificity of 75%.

Conclusions

The 5-repetition STS test is a reliable measurement tool that correlates with knee flexors muscle strength but not balance ability in subjects with stroke.     

Incomplete Bladder Emptying in Patients With Stroke: Is Detrusor External Sphincter Dyssynergia a Potential Cause?

Meng NH, Lo SF, Chou LW, Yang PY, Chang CH, Chou EC. Incomplete bladder emptying in patients with stroke: is detrusor external sphincter dyssynergia a potential cause?

Objectives

To delineate the frequency, clinical risk factors, and urodynamic mechanisms of incomplete bladder emptying (IBE) among patients with recent stroke.

Design

Retrospective study.

Setting

Inpatient setting in the rehabilitation ward of a university hospital.

Participants

All patients with acute stroke admitted for rehabilitation between January and December 2005, excluding those with a history of lower-urinary tract symptoms and urologic diseases. Eighty-two patients (42 women and 40 men; mean age, 65.5y) were included.

Interventions

Not applicable.

Main Outcome Measures

We measured postvoid residual (PVRs) by catheterization or by using an ultrasonic bladder scanner. Twenty-five patients (30.5%) had IBE with PVRs greater than 100mL on 2 consecutive days. Patients with IBE were evaluated by a urologist and subsequently underwent urodynamic studies.

Results

The presence of IBE was significantly associated with urinary tract infection (P<.001) and aphasia (P=.046). The presence of IBE was not related to sex, stroke location, nature of stroke (hemorrhagic or ischemic), history of diabetes mellitus, or previous stroke. Urodynamic studies done on 22 patients with IBE revealed acontractile detrusor in 8 patients (36%) and detrusor underactivity in 3 (14%). Eleven patients (50%) had detrusor-external sphincter dyssynergia (DESD) combined with normative detrusor function (5 patients) or detrusor hyperactivity (6 patients); all but 1 of these patients had a supratentorial lesion. The presence of DESD was associated with a longer onset-to-evaluation interval (P=.008) and spasticity of the stroke-affected lower limb (P=.002). Diabetes mellitus was associated with the presence of acontractile detrusor or detrusor underactivity (P=.03).

Conclusions

IBE is common among patients with stroke and is caused by decreased detrusor contractility or DESD. Spasticity of the external urethral sphincter is a possible pathophysiologic mechanism of DESD.     

Internally and Externally Paced Finger Movements Differ in Reorganization After Acute Ischemic Stroke

Askim T, Indredavik B, Håberg A. Internally and externally paced finger movements differ in reorganization after acute ischemic stroke.

Objective

To identify adaptive changes within the motor network for internally and externally paced finger movements in the acute and chronic phase after ischemic stroke.

Design

A functional magnetic resonance imaging study of internally and externally paced thumb-index-finger opposition 4 to 7 days and 3 months after stroke and in healthy controls. Images were compared within and between groups, with the actual number of movements as regressors.

Setting

Stroke Unit, University Hospital.

Participants

Twelve patients with mild to moderate acute ischemic stroke and 15 controls (N=27).

Intervention

Stroke unit treatment focused on very early rehabilitation, followed by early supported discharge service.

Main Outcome Measure

Differences in brain activation between patients and controls and between the tasks.

Results

Patients showed significant improvement in hand function at follow-up. Brain activity related to internally paced finger movements normalized with time. For the externally paced, accurate timing task, brain activity in the chronic phase differed from that seen in the controls despite successful recovery of hand function. In comparing the externally and internally paced tasks, a trend toward recruiting a premotor-parietal-striatal network was found in patients in the chronic phase, whereas controls had increased activation of a sensorimotor network consisting of primary motor cortex, supplementary motor cortex, superior parietal lobe, thalamus, and cerebellum.

Conclusions

After ischemic stroke, brain activity subserving an internally paced motor task normalized with time, whereas motor activity in response to an externally paced task became dependent on a premotor network. These findings underscore the importance of task-specific training in the rehabilitation of stroke patients. In the future, physiotherapists should evaluate the possibility of enhancing the recovery of a more efficient network for externally paced tasks.     

Reliability of a new instrument for measuring plantarflexor muscle strength

Örtqvist M, Gutierrez-Farewik EM, Farewik M, Jansson A, Bartonek Å, Broström E. Reliability of a new instrument for measuring plantarflexor muscle strength.

Objectives

To test the reliability of a new muscle strength testing instrument (the Strength Measuring Chair [SMC]) designed to quantify isometric strength in the lower extremities, and to determine the agreement between the SMC and an isokinetic dynamometer (Biodex).

Design

Isometric strength tests were performed in plantarflexors with 2 different knee positions (60°, 30°). Measurements were taken at 3 different sessions.

Setting

Strength testing laboratory.

Participants

Twenty-three able-bodied adults and 15 able-bodied children.

Interventions

Not applicable.

Main Outcome Measure

Isometric plantarflexor strength.

Results

The reliability of isometric strength measurements of plantarflexors taken in the SMC was excellent for both the adult and children groups (intraclass correlation coefficient range, .84−.87). A Bland-Altman 95% limit of agreement test showed no systematic variation in 3 of the 4 SMC test observations; systematic variation was only observed in the adult group at a knee position of 30°. There was no systematic difference in the adult group between the SMC and the isokinetic dynamometer, but there was a systematic variation in the children’s group.

Conclusions

The SMC reliably measured isometric plantarflexor strength in the tested populations.     

Effects of Motor Imagery on Hand Function During Immobilization After Flexor Tendon Repair

Stenekes MW, Geertzen JH, Nicolai J-P, De Jong BM, Mulder T. Effects of motor imagery on hand function during immobilization after flexor tendon repair.

Objective

To determine whether motor imagery during the immobilization period after flexor tendon injury results in a faster recovery of central mechanisms of hand function.

Design

Randomized controlled trial.

Setting

Tertiary referral hospital.

Participants

Patients (N=28) after surgical flexor tendon repair were assigned to either an intervention group or a control group.

Intervention

Kinesthetic motor imagery of finger flexion movements during the postoperative dynamic splinting period.

Main Outcome Measures

The central aspects of hand function were measured with a preparation time test of finger flexion in which subjects pressed buttons as fast as possible following a visual stimulus. Additionally, the following hand function modalities were recorded: Michigan Hand Questionnaire, visual analog scale for hand function, kinematic analysis of drawing, active total motion, and strength.

Results

After the immobilization period, the motor imagery group demonstrated significantly less increase of preparation time than the control group (P=.024). There was no significant influence of motor imagery on the other tested hand function (P>.05). All tests except kinematic analysis (P=.570) showed a significant improvement across time after the splinting period (P≤.001).

Conclusions

Motor imagery significantly improves central aspects of hand function, namely movement preparation time, while other modalities of hand function appear to be unaffected.     

ABILOCO: a Rasch-built 13-item questionnaire to assess locomotion ability in stroke patients

Caty GD, Arnould C, Stoquart GG, Thonnard J-L, Lejeune TM. ABILOCO: a Rasch-built 13-item questionnaire to assess locomotion ability in stroke patients.

Objective

To develop a questionnaire (ABILOCO), based on the Rasch measurement model, that can assess locomotion ability in adult stroke patients (International Classification of Functioning, Disability and Health activity domain).

Design

Prospective study and questionnaire development.

Setting

A faculty hospital.

Participants

Adult stroke patients (N=100) (age, 64±15y). The time since stroke ranged from 1 to 260 weeks.

Intervention

A preliminary questionnaire included 43 items representing a large sample of locomotion activities. This questionnaire was tested on the 100 stroke patients, and their responses were analyzed using the Rasch model (RUMM 2020 software) to select items that had an ordered rating scale and fitted a unidimensional model.

Main Outcome Measure

The ABILOCO questionnaire.

Results

The retained items resulted in a 13-item questionnaire, which includes a wide range of locomotion abilities well targeted to the sample population, leading to good reliability (R=.93). The item calibration was independent of age, sex, time since stroke, and affected side. The concurrent validity of ABILOCO was also investigated by comparing it with well-known, criterion standard scales (Functional Walking Category, Functional Ambulation Categories, item 12 of the FIM instrument evaluating walking ability) and the walking speed measured with the 10-meter walk test.

Conclusions

The ABILOCO questionnaire presents good psychometric qualities to measure locomotion ability in adult stroke patients. Its range and measurement precision make it attractive for clinical use throughout the rehabilitation process and for clinical research.     

A 1-Year Follow-Up After Shortened Constraint-Induced Movement Therapy With and Without Mitt Poststroke

Brogårdh C, Lexell J. A 1-year follow-up after shortened constraint-induced movement therapy with and without mitt poststroke.

Objective

To explore the long-term benefits of shortened constraint-induced movement therapy (CIMT) in the subacute phase poststroke.

Design

A 1-year follow-up after shortened CIMT (3h training/d for 2wk) where the participants had been randomized to a mitt group or a nonmitt group.

Setting

A university hospital rehabilitation department.

Participants

Poststroke patients (N=20, 15 men, 5 women; mean age 58.8y; on average 14.8mo poststroke) with mild to moderate impairments of hand function.

Interventions

Not applicable.

Main Outcome Measures

The Sollerman hand function test, the modified Motor Assessment Scale, and the Motor Activity Log test. Assessments were made by blinded observers.

Results

One year after shortened CIMT, participants within both the mitt group and the nonmitt group showed statistically significant improvements in arm and hand motor performance and on self-reported motor ability compared with before and after treatment. No significant differences between the groups were found in any measure at any time.

Conclusions

Shortened CIMT seems to be beneficial up to 1 year after training, but the restraint may not enhance upper motor function. To determine which components of CIMT are most effective, larger randomized studies are needed.     

Effects of electric stimulation-assisted cycling training in people with chronic stroke

Janssen TW, Beltman JM, Elich P, Koppe PA, Konijnenbelt H, de Haan A, Gerrits KH. Effects of electric stimulation-assisted cycling training in people with chronic stroke.

Objective

To evaluate whether leg cycling training in subjects with chronic stroke can improve cycling performance, aerobic capacity, muscle strength, and functional performance and to determine if electric stimulation (ES) to the contralateral (paretic) leg during cycling has additional effects over cycling without ES.

Design

A randomized controlled trial, with a partial double-blind design.

Setting

A rehabilitation center.

Participants

Twelve stroke patients (range, 18-70y), more than 5 months poststroke, with lower-extremity hemiparesis.

Intervention

Subjects were randomly assigned to groups that performed cycling exercise, one with ES evoking muscle contractions and a control group with ES not evoking muscle contractions. Subjects, blinded for group assignment, trained twice a week for 6 weeks.

Main Outcome Measures

Changes in aerobic capacity and maximal power output, functional performance, and lower-limb muscle strength.

Results

Aerobic capacity and maximal power output significantly increased by 13.8%±19.1% and 38.1%±19.8%, but muscle strength was not significantly enhanced after training. Functional performance improved (ie, scores on the Berg Balance Scale increased by 6.9%±5.8% (P=.000) and the six-minute walk test improved by 14.5%±14.1% (P=.035). There was no significant effect on the Rivermead Mobility Index (P=.165). Training-induced changes were not significantly different between the 2 groups. Changes in cycling performance and aerobic capacity were not significantly related to changes in functional performance.

Conclusions

This study showed that a short cycling training program on a semirecumbent cycle ergometer can markedly improve cycling performance, aerobic capacity, and functional performance of people with chronic stroke. The use of ES had no additional effects in this specific group of subjects with chronic stroke.     

Predicting Home and Community Walking Activity in People With Stroke

Fulk GD, Reynolds C, Mondal S, Deutsch JE. Predicting home and community walking activity in people with stroke.

Objective

To determine the ability of the 6-minute walk test (6MWT) and other commonly used clinical outcome measures to predict home and community walking activity in high-functioning people with stroke.

Design

Cross-sectional.

Setting

Outpatient physical therapy clinic.

Participants

Participants (N=32) with chronic stroke (n=19; >6mo poststroke) with self-selected gait speed (GS) faster than .40m/s and age-matched healthy participants (n=13).

Interventions

Not applicable.

Main Outcome Measures

Independent variables: 6MWT, self-selected GS, Berg Balance Scale (BBS), lower extremity motor section of the Fugl-Meyer Assessment, and Stroke Impact Scale. Dependent variable: average steps taken per day during a 7-day period, measured using an accelerometer.

Results

6MWT, self-selected GS, and BBS were moderately related to home and community walking activity. The 6MWT was the only predictor of average steps taken per day; it explained 46% of the variance in steps per day.

Conclusions

The 6MWT is a useful outcome measure in higher functioning people with stroke to guide intervention and assess community walking activity.     

Selecting Patients for Rehabilitation After Acute Stroke: Are There Variations in Practice?

Ilett PA, Brock KA, Graven CJ, Cotton SM. Selecting patients for rehabilitation after acute stroke: are there variations in practice?

Objective

To investigate whether there were variations in practice in selection for rehabilitation after stroke, after adjustment for case mix.

Design

Prospective multicenter audit.

Setting

Seven acute stroke units in metropolitan and regional Victoria, Australia.

Participants

Consecutive acute stroke admissions (N=616).

Interventions

None.

Main Outcome Measures

Mobility Scale for Acute Stroke Score and Modified Barthel Index (MBI) scores for continence at day 3 poststroke, discharge destination from the acute hospital.

Results

Data were analyzed for 616 stroke survivors. Considerable variability in the percentage of cases accessing inpatient rehabilitation was observed in severe stroke (27%-67%) and mild stroke (27%-73%). To assess adjustment for case mix, a multinomial logistic regression was conducted with the outcome variable being discharge destination (home, rehabilitation, or nursing home), and the predictors being Mobility Scale for Acute Stroke Score, MBI continence scores, age, and social situation. The overall amount of variability explained in discharge destination by the predictors was 63% (Nagelkerke pseudo R²). The regression analysis was repeated, adding unit code as a predictor. Unit code was a significant contributor to the model (P<.01).

Conclusion

The results of the study indicate that, after adjusting for case mix, there may be variations in practice in selection for rehabilitation leading to inequities of access.     

Impact of associated conditions resulting from spinal cord injury on health status and quality of life in people with traumatic central cord syndrome

Noonan VK, Kopec JA, Zhang H, Dvorak MF. Impact of associated conditions resulting from spinal cord injury on health status and quality of life in people with traumatic central cord syndrome.

Objective

To determine the effect of associated spinal cord injury (SCI) conditions on the health status and quality of life (QOL) in people with traumatic central cord syndrome.

Design

Cross-sectional design.

Setting

Community-based.

Participants

Subjects (N=70) with traumatic central cord syndrome who were a minimum of 2 years postinjury.

Interventions

Not applicable.

Main Outcome Measures

Presence of associated SCI conditions (neuropathic pain, spasticity, bowel, bladder, and/or sexual dysfunction, decreased motor function); health status (36-Item Short-Form Health Survey [SF-36], symptom satisfaction); and QOL.

Results

The SF-36 physical component score (PCS) was lower in subjects who reported problems with bowel, bladder, and/or sexual function (−6.9; 95% confidence interval [CI], −11.6 to −2.2). The PCS was decreased in subjects with a lower motor score and this relationship was negatively affected by spasticity and being less educated. The SF-36 mental component score was negatively affected by neuropathic pain and a lower motor score. Neuropathic pain and a lower motor score were both associated with subjects being dissatisfied with their symptoms. Subjects who had a higher motor score were more likely to have a higher QOL (odds ratio, 1.7; 95% CI, 1.1 to 2.7).

Conclusions

The associated SCI conditions bowel, bladder, and/or sexual dysfunction, neuropathic pain, decreased motor function, and spasticity negatively affect the health status of persons with traumatic central cord syndrome. Diminished motor recovery was the only associated SCI condition to impact QOL. By developing a conceptual model and adjusting for confounders, an estimate for each associated SCI condition's effect on patient outcomes was obtained. Our results indicate the importance of treating or ameliorating associated SCI conditions in order to maximize physical and mental functioning.     

Outcomes after metal-on-metal hip resurfacing: could we achieve better function?

Newman MA, Barker KL, Pandit H, Murray DW. Outcomes after metal-on-metal hip resurfacing: could we achieve better function?

Objective

To report functional outcomes after metal-on-metal (MOM) hip resurfacing.

Design

A cohort of 126 MOM hip resurfacing operations were reviewed 1 year after surgery.

Setting

Hospital trust specializing in orthopedic surgery.

Participants

Sixty-seven right and 59 left hips were reviewed in patients (N=120; 71 men, 49 women; mean age, 56±9y; range, 24-76y).

Interventions

Not applicable.

Main Outcome Measures

Administered once at follow-up. Function was measured using the Oxford Hip Score (OHS), Hip disability and Osteoarthritis Outcome Score, and UCLA Activity Score. Complications, pain, range of motion, Trendelenburg test, strength, walking, single-leg stand, stair climbing, and 10-m walk time were assessed.

Results

Overall examination was satisfactory with few complications. High functional levels were reported. The median OHS was 15 and median UCLA Activity Score 7 (active). For 25%, outcome was poor with persistent pain, reduced hip flexion (mean, 94.46°±12.7°), decreased strength (P<.001), restricted walking, and functional limitations.

Conclusions

Information about outcomes is important for patients undergoing surgery. Hip resurfacing remains an emergent technology, with further follow-up and investigation warranted. One explanation for suboptimal recovery may be current rehabilitation, originally developed after total hip arthroplasty. Rehabilitation tailored to hip resurfacing, paced for this active population and progressed to higher demand activities, may improve outcomes.     

Effects of Multijoint Spastic Reflexes of the Legs During Assisted Bilateral Hip Oscillations in Human Spinal Cord Injury

Onushko T, Hyngstrom A, Schmit BD. Effects of multijoint spastic reflexes of the legs during assisted bilateral hip oscillations in human spinal cord injury.

Objective

To investigate the timing and magnitude of muscle activation during an active-assist bilateral hip motor task in human spinal cord injury (SCI).

Design

A single test session using a novel robotic system to alternately flex and extend the hips from 40° of hip flexion to 10° of hip extension at 1 of 3 frequencies (.25, .50, .75Hz). Subjects were asked either to actively assist the movements or to remain relaxed during the imposed oscillations.

Setting

All data were collected in a research laboratory.

Participants

Ten subjects with motor incomplete (American Spinal Injury Association grade C or D) SCI and 10 individuals without neurologic injury participated in this study.

Interventions

Not applicable.

Main Outcome Measures

Electromyograms and joint torques were recorded from the lower extremities of SCI subjects and compared with electromyograms and joint torque patterns recorded from 10 neurologically healthy individuals completing the same tasks.

Results

In trials involving active assistance of the imposed hip oscillations, SCI subjects produced muscle activation patterns that were phased differently from muscle activity of neurologically intact subjects. SCI subjects generated peak torque at the end ranges of movement (ie, 40° hip flexion, 10° extension), whereas control subjects generated the greatest torque midway through the movements. Moreover, the phasing of active-assist hip torque in SCI subjects was similar to the phasing of reflexive hip torques produced during the unassisted condition (ie, SCI subjects instructed to relax), while control subjects produced no reflexive torques during unassisted trials.

Conclusions

The differences in the timing of muscle activity during the active-assist task in controls and SCI subjects highlights problems in generating appropriately timed muscle activity during ongoing movements. The similarity in muscle activity patterns for the active-assist and unassisted trials in SCI subjects further suggests that reflex feedback from hip afferents contributes substantially to muscle activation during active-assist movements. These findings demonstrate the disruptions in reflex regulation of movement in people with incomplete SCI and suggest that spastic reflexes might disrupt motor control.