Gunes Yavuzer

Mirror Therapy Improves Hand Function in Subacute Stroke: A Randomized Controlled Trial

OBJECTIVE To evaluate the effects of mirror therapy on upper-extremity motor recovery, spasticity, and hand-related functioning of inpatients with subacute stroke. DESIGN Randomized, controlled, assessor-blinded, 4-week trial, with follow-up at 6 months. SETTING Rehabilitation education and research hospital. PARTICIPANTS A total of 40 inpatients with stroke (mean age, 63.2y), all within 12 months poststroke. INTERVENTIONS Thirty minutes of mirror therapy program a day consisting of wrist and finger flexion and extension movements or sham therapy in addition to conventional stroke rehabilitation program, 5 days a week, 2 to 5 hours a day, for 4 weeks. MAIN OUTCOME MEASURES The Brunnstrom stages of motor recovery, spasticity assessed by the Modified Ashworth Scale (MAS), and hand-related functioning (self-care items of the FIM instrument). RESULTS The scores of the Brunnstrom stages for the hand and upper extremity and the FIM self-care score improved more in the mirror group than in the control group after 4 weeks of treatment (by 0.83, 0.89, and 4.10, respectively; all P<.01) and at the 6-month follow-up (by 0.16, 0.43, and 2.34, respectively; all P<.05). No significant differences were found between the groups for the MAS. CONCLUSIONS In our group of subacute stroke patients, hand functioning improved more after mirror therapy in addition to a conventional rehabilitation program compared with a control treatment immediately after 4 weeks of treatment and at the 6-month follow-up, whereas mirror therapy did not affect spasticity.

Motor Recovery and Cortical Reorganization After Mirror Therapy in Chronic Stroke Patients A Phase II Randomized Controlled Trial

Objective. To evaluate for any clinical effects of home-based mirror therapy and subsequent cortical reorganization in patients with chronic stroke with moderate upper extremity paresis. Methods. A total of 40 chronic stroke patients (mean time post .onset, 3.9 years) were randomly assigned to the mirror group (n = 20) or the control group (n = 20) and then joined a 6-week training program. Both groups trained once a week under supervision of a physiotherapist at the rehabilitation center and practiced at home 1 hour daily, 5 times a week. The primary outcome measure was the Fugl-Meyer motor assessment (FMA). The grip force, spasticity, pain, dexterity, hand-use in daily life, and quality of life at baseline—posttreatment and at 6 months—were all measured by a blinded assessor. Changes in neural activation patterns were assessed with functional magnetic resonance imaging (fMRI) at baseline and posttreatment in an available subgroup (mirror, 12; control, 9). Results. Posttreatment, the FMA improved more in the mirror than in the control group (3.6 ± 1.5, P < .05), but this improvement did not persist at follow-up. No changes were found on the other outcome measures (all Ps >.05). fMRI results showed a shift in activation balance within the primary motor cortex toward the affected hemisphere in the mirror group only (weighted laterality index difference 0.40 ± 0.39, P < .05). Conclusion. This phase II trial showed some effectiveness for mirror therapy in chronic stroke patients and is the first to associate mirror therapy with cortical reorganization. Future research has to determine the optimum practice intensity and duration for improvements to persist and generalize to other functional domains.

Kinetic and kinematic characteristics of gait in patients with medial knee arthrosis

We compared the mechanics of gait in 13 patients with early medial arthrosis (OA) of the knee and 13 normal controls, by measuring gait events, kinematic and kinetic parameters. In the OA group, walking velocity, cadence and stride length were reduced and stride time and double support time accordingly increased on both sides, the overall stance phase was prolonged in the OA group, but the stance phase and swing phase peak flexion were reduced. The varus in the stance phase and the valgus in the swing phase were increased. The extensor moment in the loading response was increased and the flexor moment at late stance reduced in the OA group. Patients with OA had a greater valgus (abductor) and internal rotation moment during the stance phase. The times to second vertical force peak (VFP) were similar in the two groups. Values of VFP1 and VFP2 were lower in the OA group. Our findings indicate that computerized gait analysis can be used to reveal various mechanical abnormalities accompanying arthrosis of the knee joint at an early stage. Some of these abnormalities may have etiologic implications, but others may represent secondary changes developed in part as a compensatory mechanism in knee OA.

The validity and reliability of the Turkish version of the Fibromyalgia Impact Questionnaire

Abstract This study was undertaken to translate and adapt the Fibromyalgia Impact Questionnaire (FIQ) into the Turkish language and investigate its validity and reliability for Turkish female fibromyalgia (FM) patients. After translation into Turkish, we administered the FIQ and Health Assessment Questionnaire (HAQ) to 51 women with fibromyalgia. As well as socio-demographic characteristics, the severity of relevant clinical symptoms, e.g., pain intensity, fatigue, and sleep disturbance, were assessed by visual analog scales. A tender point score (TPS) was calculated from tender points conducted by thumb palpation. Test–retest reliability, internal consistency, and concurrent and construct validities of FIQ were evaluated. Test–retest reliability and internal consistency were good at 0.81 and 0.72, respectively. Correlation between FIQ and HAQ scores was 0.43, which was low but statistically significant. Significant moderate correlations were obtained between the FIQ items and severity of clinical symptoms (0.63–0.77), except TPS, 0.31. The FIQ is a reliable and valid instrument for measuring functional disability in Turkish female FM patients.

Effects of ankle-foot orthoses on hemiparetic gait

Objective: Ankle-foot orthoses (AFOs) are widely used to provide optimal ambulation in people with hemiplegia. In this study we evaluated the mechanical effects of metallic and plastic AFOs on severely hemiparetic stroke patients. Methods: Twelve hemiparetic patients were analysed on a Vicon 370 Motion Analysis System. Spatiotemporal, kinematic and kinetic parameters were measured. Results: The two types of orthoses generally had similar positive effects on hemiplegic gait parameters, increasing cadence, walking speed, single and double step length, ankle dorsiflexion angle at heel strike and swing. The metallic AFO was better at increasing the ankle dorsiflexion angle than the plastic AFO. Conclusion: Hemiplegic gait was improved by both orthoses. However, metallic AFOs provided better stabilization of the ankle, allowing improved heel strike and push-off.

Adaptation of the Functional Independence Measure for use in Turkey

Objective: To adapt the Functional Independence Measure (FIM) for use in Turkey and to assess its validity and reliability. Design: After the translation procedure, reliability was assessed using internal consistency, inter-rater reliability (kappa) and the intraclass correlation coefficient (ICC). Construct validity was tested by association with impairments and by fit of data to the Rasch model. Setting: The study was undertaken in an inpatient rehabilitation unit of the Department of Physical Medicine and Rehabilitation, Faculty of Medicine, University of Ankara. Subjects: Consecutive stroke (n = 51) and spinal cord injury (SCI) (n = 62) patients admitted for rehabilitation over a period of three years were assessed at admission and discharge. Results: Internal consistency was good for stroke, and for SCI. The level of agreement between two raters was sufficient with kappa levels of above 0.48 for SCI and above 0.44 for stroke. Minimum ICC found was 0.90. Construct validity showed expected associations with the impairment scales. However, Rasch analysis showed that bladder and bowel items compromise unidimensionality in the motor scale. Conclusion: Adaptation of the FIM has been successful and it can be used in Turkey as long as the limitations are recognized.

Adaptation of the modified Barthel Index for use in physical medicine and rehabilitation in Turkey.

The aim of this study was to adapt the modified Barthel Index for Turkey and to determine its reliability and validity. After the translation procedure, 50 stroke patients and 50 spinal cord injury patients, undergoing inpatient rehabilitation were assessed by the newly adapted index at admission and discharge. Reliability was tested using internal consistency, inter-rater reliability and the intra-class correlation coefficient. Construct validity was assessed by association with impairments (Brunnstrom motor stages in stroke, American Spinal Injury Association motor/sensory scores and impairment scale in spinal cord injury) and by Rasch analysis. Internal consistency was good at 0.93 for stroke, and 0.88 for spinal cord injury. The level of agreement between two raters was sufficient with Kappa levels of above 0.5 for spinal cord injury and above 0.6 for stroke. Intra-class correlation coefficients were 0.99 and 0.77 for stroke and spinal cord injury, respectively. The newly adapted index showed expected associations with the impairment scales, confirming its construct validity. However, Rasch analysis showed that bladder and bowel items compromise unidimensionality. In conclusion, adaptation of the modified Barthel Index has been successful and it can be used in Turkey as long as its limitations are recognized.

Bone mineral density in patients with stroke.

The objectives of this study were to investigate the development and pathogenesis of osteoporosis in stroke in-patients, to compare the bone mineral density (BMD) of the paretic and non-paretic sides, to study longitudinal changes during the period on the rehabilitation ward and to relate BMD to demographic, impairment and disability variables. Participants were 32 first-stroke in-patients (19 men), with an average age of 62.4 ± 8.1 years. Demographic and clinical characteristics were documented. The BMD of lumbar spine, bilateral distal radius and femoral neck were measured and compared at admission and discharge. The associations between bone loss and age, sex, time since stroke, Brunnstrom motor recovery scores and functional independence measure motor (mFIM) scores were assessed. The mean percentage differences in BMD between paretic and non-paretic arms at discharge were 12% (P  < 0.001) and 3.5% (P  < 0.05), respectively, and between paretic and non-paretic legs were 5% (P  < 0.01) and 2% (P  < 0.05), respectively. There was a statistically significant correlation between BMD loss and Brunnstrom stage (r  = –0.41) and mFIM score at admission (r  = −0.42). In conclusion, patients with hemiparesis due to stroke are at increased risk of developing osteoporosis on the paretic side. Higher motor impairment and functional dependency at admission increases the risk. New strategies are needed for stroke patients to prevent further decreases in BMD and reduce the risk of fractures.

Reporting on reliability and validity of outcome measures in medical rehabilitation research

Purpose : To evaluate the degree to which published medical rehabilitation research offers evidence of reliability, validity and other clinimetric qualities of the data reported. Method : Descriptive study of published intervention research papers published in six US medical rehabilitation journals in 1997 and 1998. Selected characteristics of the papers and the outcome measures used were abstracted by one or two raters. Results : The 171 papers identified included 651 outcome measures. Some type of data reliability information was provided for 20.1% of these measures; for validity, this was 6.9%. However, this information was based on data collected for the sample studied for only 7.7% (reliability) and 0.6% (validity). Conclusions : Most rehabilitation research falls short of standards, including the Standards promulgated by an American Congress of Rehabilitation Medicine Advisory Group. Authors, peer reviewers and editors need to change their practices to improve this situation.

Validation of the Middlesex Elderly Assessment of Mental State (MEAMS) as a cognitive screening test in patients with acquired brain injury in Turkey

Purpose. Assessment of cognitive impairment with a valid cognitive screening tool is essential in neurorehabilitation. The aim of this study was to test the reliability and validity of the Turkish-adapted version of the Middlesex Elderly Assessment of Mental State (MEAMS) among acquired brain injury patients in Turkey. Methods. Some 155 patients with acquired brain injury admitted for rehabilitation were assessed by the adapted version of MEAMS at admission and discharge. Reliability was tested by internal consistency, intra-class correlation coefficient (ICC) and person separation index; internal construct validity by Rasch analysis; external construct validity by associations with physical and cognitive disability (FIM); and responsiveness by Effect Size. Results. Reliability was found to be good with Cronbachs α of 0.82 at both admission and discharge; and likewise an ICC of 0.80. Person separation index was 0.813. Internal construct validity was good by fit of the data to the Rasch model (mean item fit −0.178; SD 1.019). Items were substantially free of differential item functioning. External construct validity was confirmed by expected associations with physical and cognitive disability. Effect size was 0.42 compared with 0.22 for cognitive FIM. Conclusion. The reliability and validity of the Turkish version of MEAMS as a cognitive impairment screening tool in acquired brain injury has been demonstrated.