Luc Vereeck

Effect of a Therapeutic Intervention for the Hemiplegic Upper Limb in the Acute Phase After Stroke A Single-Blind, Randomized, Controlled Multicenter Trial

BACKGROUND AND PURPOSE Arm function recovery is notoriously poor in stroke patients. The effect of treatment modalities, particularly those directed at improving upper limb function, has been studied primarily in chronic stroke patients. The purpose of this study was to investigate the effect of a specific therapeutic intervention on arm function in the acute phase after stroke. METHODS In a single-blind, randomized, controlled multicenter trial, 100 consecutive patients were allocated to either an experimental group that received an additional treatment of sensorimotor stimulation or to a control group. The intervention was applied for 6 weeks. Patients were evaluated for level of impairment (Brunnström-Fugl-Meyer test) and disability (Action Research Arm test, Barthel Index) before, midway, and after the intervention period and at follow-up 6 and 12 months after stroke. RESULTS Patients in the experimental group performed better on the Brunnström-Fugl-Meyer test than those in the control group throughout the study period, but differences were significant only at follow-up. Results on the Action Research Arm test and Barthel Index revealed no effect at the level of disability. The effect of the therapy was attributed to the repetitive stimulation of muscle activity. The treatment was most effective in patients with a severe motor deficit and hemianopia or hemi-inattention. No adverse effects due to the intervention were found. CONCLUSIONS Adding a specific intervention during the acute phase after stroke improved motor recovery, which was apparent 1 year later. These results emphasize the potential beneficial effect of therapeutic interventions for the arm.

Trunk performance after stroke and the relationship with balance, gait and functional ability

Objective: To evaluate trunk performance in non-acute and chronic stroke patients by means of the Trunk Control Test and Trunk Impairment Scale and to compare the Trunk Control Test with the Trunk Impairment Scale and its subscales in relation to balance, gait and functional ability after stroke. Subjects: Fifty-one stroke patients, attending a rehabilitation programme, participated in the study. Main measures: Subjects were evaluated with the Trunk Control Test, Trunk Impairment Scale, Tinetti balance and gait subscales, Functional Ambulation Category, 10-m walk test, Timed Up and Go Test and motor part of the Functional Independence Measure. Results: Participants obtained a median score of 61 out of 100 on the Trunk Control Test and 11 out of 23 for the Trunk Impairment Scale. Twelve participants (24%) obtained the maximum score on the Trunk Control Test; no subject reached the maximum score on the Trunk Impairment Scale. Measures of trunk performance were significantly related with values of balance, gait and functional ability. Multivariate linear regression analysis showed an additional, significant contribution of the dynamic sitting balance subscale of the Trunk Impairment Scale in addition to the Trunk Control Test total score for measures of gait and functional ability (model R2 = 0.55-0.62). Conclusions: This study clearly indicates that trunk performance is still impaired in non-acute and chronic stroke patients. When planning future follow-up studies, use of the Trunk Impairment Scale has the advantage that it has no ceiling effect.

Clinical assessment of balance: Normative data, and gender and age effects

The purpose of this study was to provide age specific normative data of clinical gait and balance tests and to determine to what extent gender contributes to differences in postural control. Standing balance and walking performance was tested in 318 asymptomatic adults. The logistic regression, using both 10- and 30-second time limits as a dichotomization point, revealed a significant age effect for standing on foam with eyes closed, tandem Romberg with eyes closed (TR-EC), and one leg stance (eyes open and closed). The actual effect of decline was different for each test. Both tandem gait and dynamic gait index showed a ceiling effect up to 60 years of age, with a rapid decline of performance for subjects in their seventies. Linear regression equations indicated that for both men and women, timed up and go test (TUG) times increased with age, but even older subjects should perform the TUG in 10 seconds or less. Women performed significantly poorer on the TUG and TR-EC (30-second time limit).

Additional Exercises Improve Trunk Performance After Stroke: A Pilot Randomized Controlled Trial:

Background. Sitting balance and the ability to perform selective trunk movements are important predictors of functional outcome after stroke. However, studies evaluating the effect of exercises aimed at improving trunk performance are sparse. Objective. To examine the effect of additional trunk exercises on trunk performance after stroke. Methods. An assessor-blinded randomized controlled trial was carried out at an inpatient stroke rehabilitation center. In total 33 participants were assigned to an experimental group (n = 17) or a control group (n = 16). In addition to conventional therapy, the experimental group received 10 hours of individual and supervised trunk exercises; 30 minutes, 4 times a week, for 5 weeks. Trunk performance was evaluated by the Trunk Impairment Scale (TIS) and its subscales of static and dynamic sitting balance and coordination. A general linear repeated measures model was used to analyze the results of our study. Results. No significant differences were found pretreatment between the 2 groups for the collected demographic variables, stroke-related parameters, clinical measures, number of therapy sessions received, and primary outcome measure used. Posttreatment, a significantly better improvement was noted in the experimental group compared to the control group for the dynamic sitting balance subscale only; measuring selective lateral flexion initiated from the upper and lower part of the trunk, (P = .002, post hoc power calculation = .90, effect size = 1.16). Conclusions. Our results suggest that, in addition to conventional therapy, trunk exercises aimed at improving sitting balance and selective trunk movements have a beneficial effect on the selective performance of lateral flexion of the trunk after stroke.

Randomized controlled trial of truncal exercises early after stroke to improve balance and mobility.

Background. Sitting balance and the ability to perform selective truncal movements are important predictors of functional outcome after stroke. However, few clinical trials have evaluated the effect of truncal exercises. Objective. The authors assessed the effect of additional truncal exercises on truncal function, standing balance, and mobility. Methods. An assessor-blinded randomized controlled trial was carried out at a stroke rehabilitation hospital. A total of 33 participants (mean 35 days post onset) were randomly assigned to an experimental group (n = 18) or a control group (n = 15). In addition to conventional therapy, the experimental group received 16 hours of truncal exercises. The control group received 16 hours of sham treatment. Truncal function was evaluated by the Trunk Impairment Scale (TIS) and standing balance and mobility by the Tinetti Test. The Romberg with eyes open and eyes closed, Four Test Balance Scale (FTBS), Berg Balance Scale (BBS), Rivermead Motor Assessment Battery (RMAB), Functional Ambulation Categories, and Dynamic Gait Index (DGI) were performed to elucidate the findings of the primary outcome measures. Results. A treatment effect was found for the experimental group on the TIS (P < .001), Tinetti Test (P < .001), FTBS (P = .014), BBS (P = .007), RMAB (P < .001), and DGI (P = .006). Conclusions. In addition to conventional therapy, truncal exercises have a beneficial effect on truncal function, standing balance, and mobility in people after stroke.

The dizziness handicap inventory and its relationship with functional balance performance.

Objective: The purpose of this study was to describe the relation between the Dizziness Handicap Inventory (DHI) and balance performance measures. Study Design: Retrospective case series. Setting: Outpatient balance clinic in a tertiary referral center. Patients: Patients referred with dizziness or imbalance of vestibular and nonvestibular origin. Outcome Measures: DHI, Romberg with Jendrassik maneuver, standing on foam, tandem Romberg, single-leg stance, the timed up and go test, the Dynamic Gait Index (DGI), tandem gait, and the 10-m walking test. Results: The mean age of participants (n = 214) was 53.9 years. The mean DHI total score was 35.1, ranging from 0 to 96. Spearman rank correlation coefficients (rS) between DHI and the static balance tests were fair and ranged between −0.42 (p < 0.01) for single-leg stance with eyes closed and −0.51 (p < 0.01) for single-leg stance with eyes open. Only the Romberg test with Jendrassik maneuver correlated weakly (rS = −0.25; p < 0.01) with the DHI. Correlations with the walking tests were moderate, the connection with the DGI being the strongest one (rS = −0.69; p < 0.01). Forty-two percent of the variance in DHI scores in our patients was accounted for by the DGI score (r2 = 0.417). Conclusion: Functional balance tests involving locomotion correlate better with DHI scores when compared with static balance measures. The DGI explains a large component of handicap in dizzy and unsteady patients, which advocates its use in these patients.

The effect of early customized vestibular rehabilitation on balance after acoustic neuroma resection

Objective: To compare the effect of early customized vestibular rehabilitation with general instructions in patients after acoustic neuroma surgery. Setting: Tertiary referral centre. Subjects: Fifty-three patients after surgery. Design: A prospective assessor-blinded, randomized controlled trial. Interventions: After stratification for age (<50 years; ≥50 years), patients were randomly allocated into groups receiving general instructions or customized vestibular rehabilitation protocols for 12 weeks. Outcome measures: Standing Balance Sum, Timed Up and Go test, Tandem Gait and Dynamic Gait Index. Balance performance was assessed preoperatively, at discharge (one week after surgery), three, six, nine, 12, 26 and 52 weeks after surgery. Results and discussion: All subjects clearly improved within the first six weeks after surgery. However, older subjects receiving vestibular rehabilitation performed significantly (P<0.05) better on standing balance, Timed Up and Go test and Tandem Gait, when compared with the older group that received only general instructions. This effect persisted up to 12 weeks and also became apparent on the Dynamic Gait Index. In addition, the older vestibular rehabilitation group had better balance scores at 12 weeks when compared with their original preoperative scores (P<0.05). This pattern remained even up to one year after surgery (P<0.05). Conclusion: In patients over 50, early vestibular rehabilitation facilitates recovery of postural control after acoustic neuroma surgery. Customized vestibular rehabilitation should be given in addition to general instructions that stress the need of exposure to movement. Retention of the early beneficial effects even one year after surgery stresses the importance of customized vestibular rehabilitation.

Contraversive Pushing and Inattention of the Contralesional Hemispace

The aim of this study was to investigate, in 114 stroke patients, the frequency of occurrence of a largely unknown neurological disorder, characterized by a postural imbalance due to a ‘pushing away’ reaction of the body towards the contralesional side of space, in function of hemispheric lesion localization and gender. The study also investigate the relation of this contraversive pushing with active movement, somatosensory perception deficits and, in particular, inattention of contralesional hemispace and body. The similarity of the presence of contraversive pushing and the syndrome of spatial hemineglect together with a gender-related differentiation suggest the existence of a “pusher syndrome”, in which the pathophysiology points in the direction of a spatial higher-order processing deficit, related to spatial inattention, underlying the higher frequency and severity of contraversive pushing after right brain lesions. This project was funded by a Special Doctoral Grant of the Fund for Scientific Research (F.W.O.) - Flanders, Belgium.

Influence of sensory loss on the perception of verticality in stroke patients

Purpose: The aim of this study was to investigate the relationship between somatosensory loss and perception of verticality in stroke patients suffering single-hemisphere lesions. Method: Somatosensory loss was measured using the Rivermead Assessment for Somatosensory Performance (RASP). Perception of verticality was assessed with the Subjective Visual Vertical (SVV) and the Subjective Postural Vertical (SPV) tests. Absolute Values of SVV and SPV were used to analyze the amount of deviation in relation to somatosensory loss. Results: Thirty-two patients were included in the study (mean age = 45.91 SD = 31.88 years). Analysis showed that somatosensory loss was related to results of the SVV (r = −0.552, p = 0.001, Pearson Rank) and the SPV (r = −0.661, p < 0.001, Spearman Ï). Furthermore, results showed that both joint-related (SVV: r = −0.411, p = 0.019, Pearson Rank; SPV: r = −0.597, p = 0.001, Spearman Ï) and skin-related (SVV: r = −0.595, p < 0.001, Pearson Rank; SPV: r = −0.663, p < 0.001, Spearman Ï) somatosensory information is related to verticality perception. Conclusions: This study provides evidence that perception of verticality is related to somatosensory loss, which means that somatosensory loss will lead to a larger amount of deviation of SVV and SPV in relation to the gravitational vector. Furthermore, it is interesting to note that both SVV and SPV are influenced by somatosensory loss. Implications for Rehabilitation Somatosensory information is related to both visual and postural aspects of verticality perception. Both joint- and cutaneous-related modalities of sensory information are related to perception of verticality. Sensory training could be important in the recovery of verticality perception.

Psychometric properties of functional balance tests in children: a literature review

Identifying balance problems are the first step towards monitoring and rehabilitation. Therefore, this paper aims to make an overview of the psychometric properties of the functional balance tests available for children.