Joanne M. Wagner

Upper extremity use in people with hemiparesis in the first few weeks after stroke.

The purposes of this report were to: 1) determine the amount of upper extremity use in people with hemiparesis post stroke during their inpatient rehabilitation stay, and 2) to examine the relationships between upper extremity use and impairments and activity limitations at this early time point after stroke. We studied 34 subjects with mild-to-moderate acute hemiparesis (mean time since stroke = 9.3 days) and 10 healthy control subjects. Upper extremity use was measured over 24 hours using bilateral wrist accelerometers. Upper extremity impairments and activity limitations were measured using standard clinical techniques and tests. We found that healthy control subjects use their dominant and nondominant upper extremities 8–9 hours per day. Hemiparetic subjects used their affected and unaffected upper extremities substantially less than control subjects, 3.3 and 6.0 hours per day, respectively. Seven of ten impairment level measures and each of the activity level measures were related to affected upper extremity use. The impairment measures that were related to upper extremity use were those measures that assessed the ability to activate muscles (ie active range of motion and force production) and the measurement of shoulder pain. Our data show that affected upper extremity use is minimal during the inpatient rehabilitation stay, especially given that patients in this setting are required to have 3 hours of therapy per day. We speculate that accelerometer measurements of upper extremity use could be used in a variety of settings and that the objective information they provide would be of great value to clinicians as they select treatments and evaluate progress.

Sensorimotor Impairments and Reaching Performance in Subjects With Poststroke Hemiparesis During the First Few Months of Recovery

Background and Purpose Little is known about the relationship between upper-extremity (UE) sensorimotor impairment and reaching performance during the first few months after stroke. The purpose of this study was to examine: (1) how measures of UE sensorimotor impairment are related to the speed, accuracy, and efficiency of reaching in subjects with hemiparesis during the subacute phase after stroke and (2) how impairments measured during the acute phase after stroke may predict the variance in reaching performance a few months later. Subjects and Methods Upper-extremity sensorimotor impairments and reaching performance were evaluated in 39 subjects with hemiparesis at 2 time points: during the acute phase (8.7±3.6 [X̄±SD] days) and the subacute phase (108.7±16.5 days) after stroke. Ten subjects who were healthy (control subjects) were evaluated once. Regression analyses were used to determine which impairments were the best predictors of variance in reaching performance in the subacute phase after stroke. Results Only a small amount of variance (<30%) in reaching performance was explained at the subacute time point, using either acute or subacute impairments as predictor variables. Of the impairments measured, UE strength deficits were the strongest, most consistent predictors of the variance in reaching performance during the first 3 months after stroke. Discussion and Conclusion Surprisingly, the detailed clinical assessment of UE sensorimotor impairment, measured at the acute or subacute phase after stroke, did not explain much of the variance in reaching performance during the subacute phase after stroke. The findings that UE strength deficits (ie, decreased active range of motion and isometric force production) were the most common predictors of the variance in reaching performance during the first 3 months after stroke are consistent with the current viewpoint that impaired volitional muscle activation, clinically apparent as UE weakness, is a prominent contributing factor to UE dysfunction after stroke.

Recovery of Grasp versus Reach in People with Hemiparesis Poststroke

Background and Objective. The authors recently found that grasping was not relatively more disrupted than reaching in people with acute hemiparesis. They now extend this work to the recovery of reach versus grasp. Methods. Hemiparetic subjects were tested acutely, after 90 days, and then after 1 year poststroke, and a control group was evaluated once. Using kinematic techniques, subjects were studied performing reach and reach-to-grasp movements. The authors quantified 3 characteristics of performance for each movement: speed, accuracy, and efficiency, where an efficient movement was defined as a movement directly to the target without extraneous or abnormally circuitous movements. To evaluate the relative deficits and recovery in reach versus grasp, performance measures were converted to z scores using control group means and standard deviations. Results. The authors’ results showed that, starting with small deficits in speed acutely, both reach speed and grasp speed improved over time. Deficits in accuracy were greater in the reach than the grasp acutely, and these deficits lessened such that by the 90-day time point, the relative accuracy of the 2 movements was the same. In contrast, deficits in efficiency were greater in the grasp than the reach acutely, and grasp efficiency did not recover. The majority of recovery in reaching and grasping occurred by the 90-day time point, with little change occurring between the 90-day and 1-year time points. Conclusions. The authors hypothesize that, in chronic hemiparesis, purposeful movements requiring distal control may be more impaired than purposeful movements requiring proximal control, not because of the initial lesion, but because, over the course of recovery, spared components of the descending motor systems may be able to compensate for the accuracy deficits in reaching (proximal control) but not the efficiency deficits in grasping (distal muscular control).

Relationships between Sensorimotor Impairments and Reaching Deficits in Acute Hemiparesis

To determine the relationships between sensorimotor impairments and upper extremity reaching performance during the acute phase of stroke and to determine which, if any, measures of sensorimotor impairment can predict variance in reaching performance during this phase. Methods. Sensorimotor impairments of upper extremity (UE) strength, active range of motion, isolated movement control, light touch sensation, joint position sense, spasticity, and shoulder pain were evaluated in a group of 46 individuals with acute hemiparesis (mean time since insult = 9.2 days). Subjects performed a reaching task to a target placed on their affected side. Three-dimensional kinematic analyses were used to assess reaching speed, accuracy, and efficiency. Forward stepwise multiple linear regression analyses were used to determine which impairment was the best predictor of variance in reaching performance. Results. Measures of UE strength predicted the largest proportion of variance in the speed, accuracy, and efficiency of forward reaching. Isolated movement control, somatosensory deficits, and elbow spasticity predicted smaller amounts of variance in reaching performance. Conclusions. The authors’ data show that deficits in strength appear to be the most influential sensorimotor impairment associated with limited reaching performance in subjects with acute hemiparesis.

Upper Extremity Muscle Activation during Recovery of Reaching in Subjects with Post-stroke Hemiparesis

OBJECTIVE To investigate upper extremity muscle activation and recovery during the first few months after stroke. METHODS Subjects with hemiparesis following stroke were studied performing a reaching task at an acute time point (mean=9 days post-stroke) and then again at a subacute time point (mean=109 days post-stroke). We recorded kinematics and electromyographic activity of six upper extremity muscles. RESULTS At the acute time point, the hemiparetic group had delayed muscle onsets, lower modulation ratios, and higher relative levels of muscle activation (%MVIC) during reaching than controls. From the acute to the subacute time points, improvements were noted in all three variables. By the subacute phase, muscle onsets were similar to controls, while modulation ratios remained lower than controls and %MVIC showed a trend toward being greater in the hemiparetic group. Changes in muscle activation were differentially related to changes in reaching performance. CONCLUSIONS Our data show that improvements in muscle timing and decreases in the relative level of volitional activation may underlie improved reaching performance in the early months after stroke. SIGNIFICANCE Given that stroke is one of the leading causes of persistent physical disability, it is important to understand how the ability to activate muscles changes during the early phases of recovery after injury.

Functional outcome after isolated acetabular fractures.

Objective To evaluate objectively the effectiveness of current surgical management of displaced acetabular fractures. To provide insight into how these evaluation methods can be used to identify areas in which improvements in surgery and rehabilitation can be pursued to improve patient outcomes. Design Consecutive case series. Setting University medical center. Patients Fifteen patients were studied, each with an isolated, displaced acetabular fracture treated with a Kocher-Langenbeck approach. Main Outcome Measures Primary outcome measures included hip muscle strength, including work (Joules/minute) and maximum torque (30°/second) for abductors/adductors and flexors/extensors. Gait analysis of patients and able-bodied cohorts, including stride length, speed, and cadence, were also assessed. Motion analysis during gait was also studied for each body segment, including the trunk, pelvis, hip, knee, and ankle, in the sagittal, frontal, and axial planes. Motion data for the affected side was compared with motion data for the unaffected side, and linear gait findings for the study patients were compared to able-bodied cohorts. An assessment of clinical outcome was performed by completion of a validated Musculoskeletal Function Assessment (MFA) questionnaire and the were results correlated with muscle strength and gait analysis. Secondary outcome measures included adequacy of fracture reduction, radiographic grade, the presence and severity of heterotopic ossification at the time of the most recent follow-up, and passive range of motion of the affected and unaffected hips. Results No statistical differences in muscle strength for each of the major muscle groups were found when the affected limb was compared with the unaffected limb. No statistical differences were found between the study patients and the able-bodied cohorts with regards to stride length, gait speed, and cadence. The only significant difference found in body segment position was trunk inclination. When the study patients were compared with able-bodied cohorts, the patients tended to walk with greater forward inclination of their trunks; this was true for all phases of gait. Total MFA scores averaged 22 (range, 0–57). Patients could be separated into two separate groups based on their total MFA score. One group (n = 6) had an average MFA score of 7 (range, 0–10), while a second group (n = 9) had an average MFA score of 32 (range, 12–57). The scores of study patients as a whole, and those of each individual group of patients, were compared with known MFA scores for nonpatients and patients in the Orthopaedic Trauma Association/Association for the Study of Internal Fixation (OTA/AO) injury group (hip and thigh). When the muscle strengths of these two groups of patients were compared, all hip flexion and extension variables were significantly weaker in the group with an average MFA score of 32, whereas none of the gait variables were different between the two groups. At an average follow-up of 24 months, seven patients had an excellent radiographic grade, four patients had a good grade, two patients had a fair grade, and two patients had a poor grade. These radiographic grades were in contrast to achieving an anatomic reduction in eleven patients, a satisfactory reduction in three patients, and an unsatisfactory reduction in one patient. Heterotopic ossification was found in eight patients, four patients had Grade 1, and four patients, had Grade 2. No statistically significant differences were observed when each MFA group was compared with each of these radiographic variables. Passive hip range of motion was not statistically different when the affected hip was compared with the unaffected hip. Conclusions Standardized muscle strength determination, gait, and motion analysis, and completion of an MFA questionnaire provided a thorough and revealing evaluation of patients who have undergone open reduction and internal fixation (ORIF) of a displaced acetabular fracture. Minimal alterations in body posture and affected limb motion were present in patients displaying relatively normal gait parameters, including stride length, speed, and cadence. Despite dissection of the hip musculature during surgery, normal muscle strength recovery was possible after operative repair of these acetabular fractures. However, functional outcome, as determined by MFA scores, was considerably poorer in those patients with significantly weaker hip flexion and extension strength, compared with those of patients with more desirable MFA scores. Based on the current data, it appears that the use of these and similar evaluation instruments can allow determination of factors that negatively affect outcome (hip flexion and extension strength), which otherwise may remain unknown. It is possible that identification and treatment of these factors will improve the quality of life for patients after this type of injury.

Gait Changes as the Result of Deformity Reconstruction Surgery in a Group of Adults With Lumbar Scoliosis

Study Design. This was a prospective analysis of adult spinal deformity patients having fusions from the thoracic spine down to L5 or the sacrum. Gait analysis was performed before surgery and 1 and 2 years postoperatively, as was questionnaire analysis. Objectives. To compare the preoperative and postoperative gait of revision and primary patients having long fusions to the distal lumbar spine or sacrum with that of a group of able-bodied adults. The experimental hypothesis was that both patient groups would have significantly compromised preoperative gait and gait endurance compared to the able-bodied group and that significant changes would be noted in both groups at 1 and 2 years postoperation. Summary of Background Data. Spinal reconstructive surgery is often performed on adults with progressive lumbar spinal deformities. These patients can be divided into two major groups. The first are those patients who have degenerative changes superimposed on idiopathic scoliosis (primary patients) without previous operative treatment; the second are those patients who have already had a long fusion to L4, L5, or the sacrum (revision patients). Methods. Twenty-nine women participated in the investigation (8 primary, 12 revision, 9 able-bodied controls). A gait analysis was performed before surgery and 1 and 2 years postoperation. Walking endurance (time) was estimated from a submaximal graded treadmill exercise test. Motion variables describing the gait of the subjects, as well as gait speed, were determined. The SRS, Oswestry questionnaires, and an analog pain scale were also administered. Results. The primary group showed no adverse changes in lower extremity kinematics after surgery, and their gait speed improved such that it was not significantly different from the able-bodied group at 2 years postoperation. The revision group displayed lower extremity gait kinematics that were significantly different from the able-bodied group before surgery, but were no longer different from the able-bodied 2 years after surgery. They also had a significant increase in gait endurance. Questionnaire data indicated significant improvements for both groups after surgery. Conclusions. Objective gait data quantifying the efficacy of reconstructive spinal surgery in both primary and revision patients indicated improved gait. Gait endurance was improved in the revision group, and gait speed for the primary was not significantly different from able-bodied at 2 years postoperation. Clinically, it would appear that rehabilitation strategies to improve gait endurance and gait speed could be implemented to further improve the gait of these patients.

Changes in hip spasticity and strength following selective dorsal rhizotomy and physical therapy for spastic cerebral palsy

Hip adductor spasticity and strength in participants with cerebral palsy (CP) were quantified before and after selective dorsal rhizotomy (SDR) and intensive physical therapy. Twenty-four participants with cerebral palsy (CP group) and 35 non-disabled participants (ND controls) were tested with a dynamometer (OP group: mean age 8 years 5 months, 13 males, 11 females; ND group: mean age 8 years 6 months, 19 males, 16 females). According to the Gross Motor Function Classification System (GMFCS), of the 24 participants with CP, eight were at level I, six were at level II, and 10 participants were at level III. For the spasticity measure, the dynamometer quantified the resistive torque of the hip adductors during passive abduction at 4 speeds. The adductor strength test recorded a maximum concentric contraction. CP group spasticity was significantly reduced following SDR and adductor strength was significantly increased after surgery. Both pre- and postoperative values remained significantly less than the ND controls. Spasticity results agreed with previous studies indicating a reduction. Strength results conflicted with previous literature subjectively reporting a decrease following SDR. However, results agreed with previous objective investigations examining knee and ankle strength, suggesting strength did not decrease following SDR.

Dynamometer-based measure of spasticity confirms limited association between plantarflexor spasticity and walking function in persons with multiple sclerosis

The literature shows inconsistent evidence regarding the association between clinically assessed plantar-flexor (PF) spasticity and walking function in ambulatory persons with multiple sclerosis (pwMS). The use of a dynamometer-based spasticity measure (DSM) may help to clarify this association. Our cohort included 42 pwMS (27 female, 15 male; age: 42.9 +/- 10.1 yr) with mild clinical disability (Expanded Disability Status Scale score: 3.6 +/- 1.6). PF spasticity was assessed using a clinical measure, the modified Ashworth Scale (MAS), and an instrumented measure, the DSM. Walking function was assessed by the timed 25-foot walk test (T25FWT), the 6-minute walk test (6MWT), and the 12-item Multiple Sclerosis Walking Scale (MSWS-12). Spearman rho correlations were used to evaluate relationships between spasticity measures, measures of walking speed and endurance, and self-perceived limitations in walking. The correlation was small between PF spasticity and the T25FWT (PF maximum [Max] MAS rho = 0.27, PF Max DSM rho = 0.26), the 6MWT (PF Max MAS rho = -0.20, PF Max DSM rho = -0.21), and the MSWS-12 (PF Max MAS rho = 0.11, PF Max DSM rho = 0.26). Our results are similar to reports in other neurologic clinical populations, wherein spasticity has a limited association with walking dysfunction.

Gait changes as the result of deformity reconstruction surgery in a group of adults with lumbar scoliosis: Point of view

Study Design. This was a prospective analysis of adult spinal deformity patients having fusions from the thoracic spine down to L5 or the sacrum. Gait analysis was performed before surgery and 1 and 2 years postoperatively, as was questionnaire analysis. Objectives. To compare the preoperative and postoperative gait of revision and primary patients having long fusions to the distal lumbar spine or sacrum with that of a group of able-bodied adults. The experimental hypothesis was that both patient groups would have significantly compromised preoperative galt and gait endurance compared to the able-bodied group and that significant changes would be noted in both groups at 1 and 2 years pastoperation. Summary of Background Data. Spinal reconstructive surgery is often performed on adults with progressive lumbar spinal deformities. These patients can be divided into two major groups. The first are those patients who have degenerative changes superimposed on idiopathic scoliosis (primary patients) without previous operative treatment; the second are those patients who have already had a long fusion to L4, L5, or the sacrum (revision patients). Methods. Twenty-nine women participated in the investigation (8 primary, 12 revisan, 9 able-bodied contrais]. A gait analysis was performed before surgery and 1 and 2 years postoperation. Walking endurance (time) was estimated from a submaximal graded treadmill exercise test. Motion variables describing the gait of the subjecte, as well as gait speed, were determined. The SRS, Oswestry questionnaires, and an analog pain scale were also administered. Results. The primary group showed no adverse changes in Iower extremity kinematics after surgery, and their gait speed improved such that it was not significantly different from the able-bodied group at 2 years postoperation. The revision group dispiayed lower extremity gait kinematics that were significantly different from the able-bodied group before surgery, but were no longer different from the able-bodied 2 years after surgery. They also had a significant increase in gait endurance. Questionnaire data indicated significant improvements for both groups after surgery. Conclusions. Objective gait data quantifying the efficacy of reconstructive spinal surgery in both primary and revision patients indicated improved gain. Gait endurance was improved in the revision group, and gait speed for the primary was not significantly different from able-bodied et 2 years postoperation. Clinically, it would appear that rehabilitation strstegies to improve gait endurance and gait speed could be implemented to further improve the gait of there patients.