Disa K. Sommerfeld

Spasticity After Stroke Its Occurrence and Association With Motor Impairments and Activity Limitations

Background and Purpose— There is no consensus concerning the number of patients developing spasticity or the relationship between spasticity and disabilities after acute stroke. The aim of the present study was to describe the extent to which spasticity occurs and is associated with disabilities (motor impairments and activity limitations). Methods— Ninety-five patients with first-ever stroke were examined initially (mean, 5.4 days) and 3 months after stroke with the Modified Ashworth Scale for spasticity; self-reported muscle stiffness; tendon reflexes; Birgitta Lindmark motor performance; Nine Hole Peg Test for manual dexterity; Rivermead Mobility Index; Get-Up and Go test; and Barthel Index. Results— Of the 95 patients studied, 64 were hemiparetic, 18 were spastic, 6 reported muscle stiffness, and 18 had increased tendon reflexes 3 months after stroke. Patients who were nonspastic (n=77) had statistically significantly better motor and activity scores than spastic patients (n=18). However, the correlations between muscle tone and disability scores were low, and severe disabilities were seen in almost the same number of nonspastic as spastic patients. Conclusions— Although spasticity seems to contribute to disabilities after stroke, spasticity was present in only 19% of the patients investigated 3 months after stroke. Severe disabilities were seen in almost the same number of nonspastic as spastic patients. These findings indicate that the focus on spasticity in stroke rehabilitation is out of step with its clinical importance. Careful and continual evaluation to establish the cause of the patient’s disabilities is essential before a decision is made on the most proper rehabilitation approach.

Spasticity and Its Association with Functioning and Health-Related Quality of Life 18 Months after Stroke

Background: There is no consensus concerning the presence of spasticity or the relationship between spasticity and functioning and spasticity and health-related quality of life (HRQL) in the stable phase after stroke. Objective: The aim of the present study was to describe, 18 months after stroke, the frequency of spasticity and its association with functioning and HRQL. Methods: In a cohort of 66 consecutive patients with first-ever stroke, studied prospectively, the following parameters were assessed 18 months after stroke: spasticity, by the Modified Ashworth Scale (0–4 points with 1+ as the modification), muscle stiffness, by self-report, abnormal tendon reflexes, by physical examination, motor performance, by the Lindmark Motor Assessment Scale, mobility, by the Rivermead Mobility Index, activities of daily living, by the Barthel Index, and HRQL, by the Swedish Short Form 36 Health Survey Questionnaire (SF-36). Results: Of 66 patients studied, 38 were hemiparetic; of these, 13 displayed spasticity, 12 had increased tendon reflexes, and 7 reported muscle stiffness 18 months after stroke. Weak (r < 0.5) to moderate (r = 0.5–0.75) correlations were seen between spasticity and functioning scores. Correlations between spasticity and HRQL were generally weak (r < 0.5). Hemiparetic patients without spasticity had significantly better functioning scores and significantly better HRQL on 1 of the 8 SF-36 health scales (physical functioning) than patients with spasticity. Conclusions: Few patients displayed spasticity 18 months after stroke. Spasticity might contribute to impairment of movement function and to limitation of activity, but seems to have a less pronounced effect on HRQL.

Spasticity After Stroke An Overview of Prevalence, Test Instruments, and Treatments

ABSTRACTThe objective of this study was to present an overview of the prevalence of spasticity after stroke as well as of test instruments and treatments. Recent studies show that spasticity occurs in 20%–30% of all stroke victims and in less than half of those with pareses. Although spasticity may occur in paretic patients after stroke, muscle weakness is more likely to be the reason for the pareses. Spasticity after stroke is more common in the upper than the lower limbs, and it seems to be more common among younger than older people. To determine the nature of passive stretch, electromyographic equipment is needed. However, the Modified Ashworth Scale, which measures the sum of the biomechanical and neural components in passive stretch, is the most common instrument used to grade spasticity after stroke. Treatment of spasticity with physiotherapy is recommended, although its beneficial effect is uncertain. The treatment of spasticity with botulinum toxin in combination with physiotherapy is suggested to improve functioning in patients with severe spasticity. A task-specific approach rather than a neurodevelopmental approach in assessing and treating a patient with spasticity after stroke seems to be preferred.

Location and severity of spasticity in the first 1-2 weeks and at 3 and 18 months after stroke.

Background and purpose:  There is no consensus concerning the location or severity of spasticity, or how this changes with time after stroke. The purpose was to describe: the location and severity of spasticity, in different muscle groups, during the first 1–2 weeks and at 3 and 18 months after stroke; the association between the severity of spasticity and control of voluntary movements; and the occurrence of spasticity in younger versus older patients.

The impact of somatosensory function on activity performance and length of hospital stay in geriatric patients with stroke

Objective: To investigate in geriatric patients with stroke the relationship between somatosensory function, activity performance and the length of stay (LOS) in either hospital or nursing home. Design: Survey. Setting: Stroke unit and geriatric rehabilitation unit. Subjects: One hundred and fifteen consecutive patients with acute stroke ≥65 years old. Main outcome measures: Clinically assessed somatosensory function, activity of daily living according to the Barthel Index (BI) (0–100 points), mobility according to the Rivermead Mobility Index (RMI) (0–15 points) and LOS. Results: Ten days after stroke onset, the patients with normal (n = 46), impaired (n = 31) and nonassessable (n = 38) somatosensory function scored 85, 40 and 0 points respectively on the BI, and 8.5, 2 and 0 points respectively on the RMI. Forty-one of 46 patients (89%) with normal somatosensory function were discharged home within three months, compared with 10 of 31 patients (32%) with impaired somatosensory function and three of 38 patients (8%) who were nonassessable. These between-group differences were statistically significant (p < 0.001). Multiple regression, to adjust for the impact of age, social situation and bladder function on outcome still proved a statistically significant (p < 0.001) predictive value of normal somatosensory function. Conclusions: Normal somatosensory function is related to high activity levels and short LOS more often than somatosensory impairment is related to activity limitations and long LOS.

Hemiplegic limb synergies in stroke patients.

Welmer AK, Widén Holmqvist L, Sommerfeld DK: Hemiplegic limb synergies in stroke patients. Am J Phys Med Rehabil 2006;85:112–119. Objective:To describe the extent to which the voluntary movements of hemiparetic stroke patients are restricted to the hemiplegic limb synergies (which are marked by the inability to master individual joint movements) described by Brunnström. The study also aimed to describe the extent to which the synergies are related to functioning. Design:In a prospective observational study design, 64 consecutive hemiparetic stroke patients were assessed with Brunnström’s hemiplegic limb synergies, the modified Ashworth scale for spasticity, the Rivermead mobility index, and the Barthel ADL index. Results:Three months after stroke, 8 of the 64 patients were moving completely or partly within the synergies. All patients whose movements were restricted to the synergies also exhibited spasticity. Hemiparetic patients whose movements were restricted to the synergies had significantly worse functioning scores than hemiparetic patients whose movements were not restricted to the synergies although severe disabilities were seen in both groups. Conclusions:Three months after stroke, the voluntary movements of only 13% of hemiparetic stroke patients were restricted to the synergies. The synergies were associated with spasticity and activity limitations. The use of the synergies might only be suitable for a small fraction of hemiparetic patients—namely, those displaying spasticity.

LIMITED FINE HAND USE AFTER STROKE AND ITS ASSOCIATION WITH OTHER dISABILITIES

OBJECTIVE To describe the recovery of fine hand use and the associations between fine hand use and, respectively, somatosensory functions, grip strength, upper extremity movements and self-care, in the first week and at 3 and 18 months after stroke, and to describe whether these associations change over time. DESIGN Prospective observational study. PATIENTS Sixty-six consecutive patients with stroke. METHODS The following parameters were assessed in the first week, and at 3 and 18 months after stroke: fine hand use, grip strength (not assessed in the first week), touch, proprioceptive and upper extremity movement functions; and self-care. RESULTS Seventy percent of all patients had limited fine hand use in the first week, 41% at 3 months and 45% at 18 months after stroke. The associations between fine hand use and the other functioning were moderate to high, but decreased over time for fine hand use and, respectively, somatosensory functions, upper extremity movements and self-care. CONCLUSION Limited fine hand use is common after acute stroke. Our results suggest that, with time after stroke, upper extremity movements and self-care become less dependent on fine hand use and fine hand use becomes less dependent on touch function, although no ultimate conclusions can be drawn on causality.

Disability test 10 days after acute stroke to predict early discharge home in patients 65 years and older

Objective: To identify prognostic instruments for the planning of care after acute stroke. Design: Prospective study. Setting: Stroke unit and geriatric rehabilitation unit. Subjects: One hundred and fifteen consecutive acute stroke patients ≥65 years old. Main outcome measures: Univariate and multivariate survival analyses. Length of hospital stay and residential form up to three months after onset. Results: The average length of stay was significantly shorter if age <80 years, male, living with another person, normal sensory ability, Barthel Index (BI) score ≥35 and Rivermead Mobility Index (RMI) score ≥4, assessed 10 days after onset. Multivariate analysis, also including BI subtests, showed that RMI score ≥4, which corresponds to the ability to rise from a chair in less than 15 seconds and remain erect for 15 seconds with or without aid, 10 days after onset, had the greatest impact on early discharge home after acute stroke, together with normal bladder function (BI subtest six), normal sensory ability and living with another person. Conclusion: The best predictor of early discharge home, 10 days after stroke onset, was the ability to rise from a chair with or without aid. This simple and quickly conducted test requires no special equipment and in the present study had a very high predictive value.

Pain following stroke, initially and at 3 and 18 months after stroke, and its association with other disabilities

A general hypothesis is that pain following stroke (PFS) causes disabilities. However, the clinical implication of PFS on other disabilities after stroke and vice versa has not been fully investigated. The aims of this observational study were to analyze the correlation between PFS and other disabilities at different time points after stroke, whether PFS can be a predictor of coming disabilities and whether other disabilities can be predictors of coming PFS.

Long-term health states relevant to young persons with stroke living in the community in southern Stockholm – a study of self-rated disability and predicting factors

Purpose: The purpose was to explore self-rated long-term disability and to analyze whether initial stroke-related, personal and environmental factors can predict disability in a population-based sample of community-dwelling young (<65 years) persons suffering a stroke in 2000–2006. Method: Data on initial stroke-related, personal and environmental factors were retrieved from medical records. A study-specific posted questionnaire was used. Results: Of the 158 young persons with stroke, 78% had suffered a mild stroke. Tiredness was the most commonly reported mental impairment (86%) followed by impaired memory (67%). A majority reported limitations/restrictions in returning to leisure activities (58%) and work (52%). Stroke-related, personal and environmental factors failed to predict self-reported mental and physical impairments, but predicted activity limitations/participation restrictions with an acceptable power of accuracy (0.70–0.73) but a low sensitivity (0.28–0.59). Conclusions: A majority of these young persons were diagnosed with a mild stroke but experienced long-term mental impairments and activity limitations/participation restrictions that could not be predicted by initial stroke-related, personal and environmental factors solely. Therefore, regular long-term assessments irrespective of initial stroke severity are warranted in order to identify disabilities and improve the state of health among young persons with stroke when needed. Implications for Rehabilitation A majority of young persons with stroke are diagnosed with a mild stroke but experience long-term disability that cannot be predicted by initial stroke-related factors solely. Regular long-term assessments are warranted in order to identify disabilities and improve the state of health among young persons with stroke.