Henk J. Arwert

Velocity effects on the scapulo-humeral rhythm.

OBJECTIVE: The objective of this study is to verify the assumption that the three-dimensional (3-D) shoulder motions can be described by means of an interpolation of statically recorded postures and thus, support the application of non-invasive but static techniques for motion analysis of the shoulder. BACKGROUND: During shoulder motions the scapula moves underneath the skin. Recording of motions is only possible by means of invasive methods. An alternative for the recording is palpation of skeletal landmarks on the scapula and subsequent digitization. The method is non-invasive and relatively easy, but static. Motions are modelled by means of interpolation of the subsequent position recordings. Validity of this method, however, has never been demonstrated. METHODS: Seven subjects performed an alternating abduction-adduction motion of the arm in a plane 30 degrees forward rotated with respect to the frontal plane, at three sub-maximal frequencies: 0.04, 0.25 and 0.50 Hz. The humeral and scapular motions were recorded by means of a two-dimensional (2-D) X-ray video system. The motions of the humerus, the scapular spine and the glenoid ridge were defined by angles, and the sinusoidal motion curves were characterized by means of the offset, the amplitude and the phase of the motions. RESULTS: By means of Repeated Measurements Multi-Variate Analysis of Variance, a significant effect of arm motion on the phase and the amplitude of the scapular motion was found. However, the magnitude of the effects are negligibly small for the present applications at sub-maximal arm motion velocities. CONCLUSIONS: For normal arm motions in the vertical plane, the kinematics of the shoulder skeleton can be derived by the interpolation of statically recorded positions of the bones. RELEVANCE: The 3-D motions of the shoulder are the result of the kinematic constraints of the skeletal system and the coordinated muscle forces, and are only one of the few characteristics that can be quantified. The motions contain relevant information which is essential in the analysis of clinical disorders, e.g. sub-acromial disorders and glenohumeral subluxation, the evaluation of clinical interventions and physiotherapy, and in the analysis of ergonomic and biomechanical problems.

Shoulder pain and external rotation in spastic hemiplegia do not improve by injection of botulinum toxin A into the subscapular muscle

Objective: To study the effect of botulinum toxin A in the subscapular muscle on shoulder pain and humerus external rotation. Methods: 22 stroke patients with spastic hemiplegia, substantial shoulder pain and reduced external rotation of the humerus participated in a randomised, double blind, placebo controlled effect study. Injections of either botulinum toxin A (Botox, 2×50 units) or placebo were applied to the subscapular muscle at two locations. Pain was scored on a 100 mm vertical Visual Analogue Scale; external rotation was recorded by means of electronic goniometry. Assessments were carried out at 0 (baseline), 6 and 12 weeks. Results: 21 patients completed the study. We observed no significant changes in pain or external rotation as a result of administration of botulinum toxin A. External rotation improved significantly (p = 0.001) for both the treatment group (20.4° (16.6) to 32.1° (14.0)) and the control group (10.3° (19.5) to 23.7° (20.7)) as a function of time. Conclusions: Application of botulinum toxin A into the subscapular muscle for reduction of shoulder pain and improvement of humeral external rotation in spastic hemiplegia does not appear to be clinically efficacious.

Electromyography of shoulder muscles in relation to force direction

In a static force task the electromyographic level of 14 shoulder muscles including 3 rotator cuff muscles was related to force direction. Surface and wire electrodes were used. The force direction of maximal electromyography (principal action) was identified for every muscle. The principal action expresses the function of a muscle in a special situation. The deltoid was active in a force direction that could be understood from its anatomy. The trapezius and serratus were mainly involved in stabilizing the scapula in upward and outward force directions. Large multiarticular muscles such as the pectoralis and the latissimus were active in downward and forward forces. The rotator cuff seems to have a specific role in stabilizing the glenohumeral joint. These data can be compared with data of patients with shoulder disorders and with kinematic data of a shoulder model.

Validity of the Michigan Hand Outcomes Questionnaire in Patients With Stroke.

OBJECTIVE To investigate the measurement properties of the Dutch version of the Michigan Hand Outcomes Questionnaire (MHQ) in patients with stroke. DESIGN Validation study. SETTING Outpatient rehabilitation clinic. PARTICIPANTS Consecutive patients with stroke (N=51; mean age, 60±11y; 16 women [31%]). INTERVENTIONS Patients were asked to complete the MHQ (57 items) and Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36). Additional assessments included the Barthel Index and performance tests for hand function (Action Research Arm Test, Nine Hole Peg Test, Frenchay Arm Test, Motricity Index). MAIN OUTCOME MEASURES Associations between the MHQ and other outcome measures were determined using Spearman correlation coefficients and the internal consistency of the MHQ using Cronbach α. Floor or ceiling effects were present if >15% of the patients scored minimal or maximal scores, respectively. Test-retest reliability was established by the intraclass correlation coefficient. RESULTS The mean MHQ total score was 70.0±22.4, with Cronbach α being .97. The MHQ total score correlated significantly with the physical component summary of the SF-36, the Barthel Index, and all hand function performance tests (P<.01). The MHQ total score showed no floor or ceiling effects. The test-retest intraclass correlation coefficient was .97. CONCLUSIONS This study provides preliminary evidence that the MHQ is an internally consistent, valid, and reliable hand function questionnaire in outpatients after stroke, although these results need to be further confirmed.

Patient reported outcomes of hand function three years after stroke

Abstract Objective: To comprehensively describe hand function and associated factors among stroke survivors by means of the Michigan Hand Outcomes Questionnaire (MHQ; 6 domains; score 0–100, worst–best). Methods: In this cross-sectional study, stroke patients were invited to complete a set of questionnaires on hand function, socio-demographic characteristics, mental functioning, daily activities, quality of life, and caregiver strain. Stroke characteristics were collected retrospectively from medical records. Multiple linear regression analysis adjusted for age, sex, and duration of follow-up was used to identify factors associated with MHQ score. Results: 207 out of 576 eligible patients responded (36%); mean age 63.8 years (SD14.2), 125 males (60.4%). Mean time since stroke was 36.3 months (SD9.9). In 85% of the patients, the MHQ Total score was less than 100 points (median 79.9, IQR 63.0–95.8). The median scores of the domains were: overall hand function 75.0, daily activities 90.5, work 85.0, pain 100, appearance 93.8, and satisfaction with hand function 83.3. A lower MHQ Total score was significantly associated with a lower Barthel Index at hospital discharge, a lower level of education, a supratentorial stroke and with unfavorable outcomes regarding physical and mental functioning, quality of life, and caregiver strain. Conclusion: Patients can perceive limitations on several domains with respect to hand function 2–5 years after stroke. Problems related to the appearance of the hand and satisfaction with hand function can be relevant and should be considered accordingly. Persistent hand problems after stroke are related to a more severe, supratentorial stroke in lower educated patients.

The Longer-term Unmet Needs after Stroke Questionnaire: Cross-Cultural Adaptation, Reliability, and Concurrent Validity in a Dutch Population

BACKGROUND Unmet needs are common after stroke. We aimed to translate the 22-item Longer-term Unmet Needs after Stroke (LUNS) Questionnaire and validate it in a Dutch stroke population. METHODS The LUNS was translated and cross-culturally adapted according to international guidelines. After field testing, the Dutch version was administered twice to a hospital-based cohort 5-8 years after stroke. Participants were also asked to complete the Frenchay Activity Index (FAI) and Short Form (SF)-12. To explore acceptability, the response and completion rates as well as number of missing items were computed. For concurrent validity, the differences in health status (FAI, SF-12) between groups who did and did not report an unmet need were calculated per item. To determine the 14-day test-retest reliability, the percentage of agreement between the first and the second administration was calculated for each item. RESULTS Seventy-eight of 145 patients (53.8%) returned the initial Dutch LUNS (average age 68.3 [standard deviation 14.0] years, 59.0% male); 66 of these patients (84.6%) fully completed it. Of all items, 3.3% were missing. Among completers, the median number of unmet needs was 3.5 (2.0-5.0; 1.0-14.0). For 15 of 22 items, there was a significant association with the FAI or SF-12 Mental or Physical Component Summary scales. The percentage of agreement ranged from 69.8% to 98.1% per item. CONCLUSIONS Among the 53.8% who completed the survey, the LUNS was concluded to be feasible, reliable, and valid; two-thirds of its items were related to activities and quality of life. Its usefulness and acceptability when administered in routine practice require further study.

What is Important in E-health Interventions for Stroke Rehabilitation? A Survey Study among Patients, Informal Caregivers, and Health Professionals.

Incorporating user requirements in the design of e-rehabilitation interventions facilitates their implementation. However, insight into requirements for e-rehabilitation after stroke is lacking. This study investigated which user requirements for stroke e-rehabilitation are important to stroke patients, informal caregivers, and health professionals. The methodology consisted of a survey study amongst stroke patients, informal caregivers, and health professionals (physicians, physical therapists and occupational therapists). The survey consisted of statements about requirements regarding accessibility, usability and content of a comprehensive stroke e-health intervention (4-point Likert scale, 1=unimportant/4=important). The mean with standard deviation was the metric used to determine the importance of requirements. Patients (N=125), informal caregivers (N=43), and health professionals (N=105) completed the survey. The mean score of user requirements regarding accessibility, usability and content for stroke e-rehabilitation was 3.1 for patients, 3.4 for informal caregivers and 3.4 for health professionals. Data showed that a large number of user requirements are important and should be incorporated into the design of stroke e-rehabilitation to facilitate their implementation.

Caregiver burden after stroke: changes over time?

Abstract Introduction and aim: Many caregivers of stroke patients experience a high burden. This study aims to describe the course of burden in individual caregivers in the first year after stroke. Methods: This study is part of the Stroke Cohort Outcomes of REhabilitation study, a multicentre, longitudinal cohort study including consecutive stroke patients admitted to two rehabilitation facilities. Caregivers were asked to complete the Caregiver Strain Index and questions on their sociodemographic characteristics 6 and 12 months post admission. Patients’ sociodemographic and clinical characteristics were extracted from medical records. Results: A total of 129 caregivers were included, 72 completed the Caregiver Strain Index twice. Of them, 19 (26.4%) were men, median age 59 (range 27–78) years. A consistently high or low burden was reported by 15 (20.8%) and 49 (68.1%), respectively, whereas 8 (11.1%) reported a high burden at either 6 (n = 3) or 12 months (n = 5). Discussion: In the majority of caregivers of stroke patients the perceived caregiver burden is consistent over time. However, as in 11.1% caregiver burden changes from 6 to 12 months, caregiver burden should be measured repeatedly until 12 months after stroke. Caregivers living together with a patient who suffered a haemorrhagic stroke seem to be more at risk for a high burden. Implications for rehabilitation Many caregivers of stroke patients experience a high burden. The Caregiver Strain Index score at 6 months is a good predictor for the score at 12 months. In some caregivers the high burden is not yet present at 6 months, therefore monitoring caregiver burden throughout the first year after stroke seems warranted. Caregivers living together with a patient who suffered a haemorrhagic stroke seem to be more at risk for a high burden.