Marcus Pohl

Computerized Arm Training Improves the Motor Control of the Severely Affected Arm After Stroke A Single-Blinded Randomized Trial in Two Centers

Background and Purpose— To compare a computerized arm trainer (AT), allowing repetitive practice of passive and active bilateral forearm and wrist movement cycle, and electromyography-initiated electrical stimulation (ES) of the paretic wrist extensor in severely affected subacute stroke patients. Method— A total of 44 patients, 4 to 8 weeks after stroke causing severe arm paresis (Fugl–Meyer Motor Score [FM, 0 to 66] <18), were randomly assigned to either AT or ES. All patients practiced 20 minutes every workday for 6 weeks. AT patients performed 800 repetitions per session with the robot and ES patients performed 60 to 80 wrist extensions per session. The primary outcome measure was the blindly assessed FM (0 to 66), and the secondary measures were the upper limb muscle power (Medical Research Council [MRC] sum, 0 to 45) and muscle tone (Ashworth score sum, 0 to 25), assessed at the beginning and end of treatment and at 3-month follow-up. Results— The AT group had a higher Barthel Index score at baseline, but the groups were otherwise homogenous. As expected, FM and MRC sum scores improved overtime in both groups but significantly more in the robot AT group. The initial Barthel Index score had no influence. In the robot AT group, FM score was 15 points higher at study end and 13 points higher at 3-month follow-up than the control ES group. MRC sum score was 15 points higher at study end and at 3-month follow-up compared with the control ES group. Muscle tone remained unchanged, and no side effects occurred. Conclusion— The computerized active arm training produced a superior improvement in upper limb motor control and power compared with ES in severely affected stroke patients. This is probably attributable to the greater number of repetitions and the bilateral approach.

Immediate effects of speed-dependent treadmill training on gait parameters in early Parkinson’s disease

OBJECTIVE To compare the immediate effects of different training interventions on gait parameters in patients with early Parkinsons disease (PD). DESIGN Randomized, multiple intervention crossover pilot study. SETTING A rehabilitation center for adult persons with neurologic disorders. PARTICIPANTS Seventeen patients with early PD (Hoehn and Yahr stages I through III) and gait disturbances. INTERVENTION Patients were randomly assigned to varying sequences of the following interventions over 4 consecutive days: structured speed-dependent treadmill training (STT), limited progressive treadmill training (LTT), conventional gait training (CGT), and a control intervention. MAIN OUTCOME MEASURES Basic gait parameters (overground walking speed and stride length at self-adapted speeds) and parameters of gait analysis based on vertical ground reaction forces. RESULTS STT and LTT improved all basic gait parameters and the double stance duration compared with preintervention values (P<.05). No changes were found after CGT and the control intervention (P<.05). Significantly higher gains were observed in all basic gait parameters after STT and LTT when compared with CGT and the control intervention (P<.05). Additionally, a greater reduction of double stance duration was found after STT than after the control intervention (P<.001). No significant differences in gains were observed between STT and LTT, or between CGT and the control intervention, in all gait parameters. CONCLUSION The main disturbances of gait in PD, namely, speed and stride length, can be improved through a single intervention of STT or LTT, but not through CGT and the control intervention.

Reliability of the Modified Tardieu Scale and the Modified Ashworth Scale in adult patients with severe brain injury: a comparison study:

Objective: To assess and to compare the reliability of the Modified Tardieu Scale with the Modified Ashworth Scale in patients with severe brain injury and impaired consciousness. Design: Cross-sectional observational comparison study. Setting: An early rehabilitation centre for adults with neurological disorders. Subjects: Thirty patients with impaired consciousness due to severe cerebral damage of various aetiologies. Measurement protocol: Four experienced physical therapists rated each patient in a randomized order once daily for two consecutive days. Shoulder, elbow, wrist, hip, knee and ankle spasticity were assessed by the use of Modified Tardieu Scale and Modified Ashworth Scale data collection procedures. Main outcome measures: Test - retest and inter-rater reliability (k=kappa value) of the Modified Tardieu Scale and the Modified Ashworth Scale. Results: The test-retest reliability of the Modified Ashworth Scale was moderate to good (k = 0.47-0.62) and of the Modified Tardieu Scale moderate to very good (k = 0.52-0.87). Test - retest reliability was significantly higher within the Modified Tardieu Scale in comparison with the Modified Ashworth Scale (Z<1.96; p<0.05) except for shoulder extensor and internal rotator muscles (Z<1.96; p<0.05). Although inter-rater reliability of both scales was poor to moderate (Modified Ashworth Scale: k = 0.16-0.42; Modified Tardieu Scale: k = 0.29-0.53), significantly higher k-values were revealed with the Modified Tardieu Scale for all tested muscle groups (Z<1.96; p<0.05) except for wrist extensors (Z<1.96; p<0.05). Conclusion: In patients with severe brain injury and impaired consciousness the Modified Tardieu Scale provides higher test-retest and inter-rater reliability compared with the Modified Ashworth Scale and may therefore be a more valid spasticity scale in adults.

ELECTRoMEChANICAL-ASSISTEd GAIT TRAINING AFTER STRokE: A SySTEMATIC REvIEW CoMPARING ENd-EFFECToR ANd EXoSkELEToN dEvICES

OBJECTIVES Although electromechanical-assisted gait training after stroke seems to be effective, in the absence of a direct comparison between electromechanical devices it is not clear which device may be the most effective for recovery of walking. The aim of this study was therefore to compare the effects of different devices used in gait training after stroke. DATA SOURCES We searched the Cochrane Stroke Group Trials Register, CENTRAL, MEDLINE, EMBASE, CINAHL, AMED, SPORTDiscus, PEDro, COMPENDEX and INSPEC. In addition, we hand-searched relevant conference proceedings, trials and research registers, checked reference lists and contacted authors to identify further trials. STUDY SELECTION Randomized studies were included. Authors independently selected trials for inclusion, assessed trial quality and extracted the data. DATA EXTRACTION Data were extracted with the help of a standardized data extraction form. DATA SYNTHESIS Data were pooled for meta-analysis. The primary outcome was the proportion of patients walking independently. RESULTS We included 18 trials involving 885 patients. We found significantly higher rates of independent walking in end-effector compared with exoskeleton-based training (p = 0.03). Complication rates in both groups were comparable. CONCLUSION The results suggest that the type of electromechanical-assisted device might influence the outcome of gait rehabilitation after stroke.

Electromechanical and Robot-Assisted Arm Training for Improving Arm Function and Activities of Daily Living After Stroke

Graeme J. Hankey MD, FRACP Section Editor More than two thirds of all patients after stroke have difficulties with reduced arm function. Electromechanical and robot-assisted arm training uses specialized machines to assist rehabilitation in practice and this type of training might improve arm function after stroke. This systematic review examined the effectiveness of electromechanical and robot-assisted arm training for improving activities of daily living and arm function and motor strength of patients after stroke and the acceptability and safety of the therapy. We searched the Cochrane Stroke Group Trials Register (last searched October 2007), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 3, 2007), MEDLINE (1950 to October 2007), EMBASE (1980 to …

Immediate effects of an individually designed functional ankle-foot orthosis on stance and gait in hemiparetic patients:

Objective: To evaluate the immediate effects of individually designed functional in-shoe ankle-foot orthoses (AFO) made of soft and hard cast on balance, standing, and gait parameters in hemiparetic patients. Design: Crossover design with randomized order of the intervention. Setting: A rehabilitation centre for adults with neurological disorders. Subjects: Twenty-eight patients with hemiparesis due to stroke or traumatic brain injury. Measures: Postural sway, standing and gait parameters based on ground reaction forces in two conditions: Patients were randomly assigned to varying sequences of wearing AFO in footwear or wearing footwear alone. Results: AFO significantly improved weight-bearing on the affected leg (affected/ unaffected side symmetry: 2.259 ± 1.5 with AFO versus 3.49 ± 2.5 without AFO, P B ± 0.05) and postural sway in stance (12.5 mm9 ± 5.2 with AFO versus 15.7 mm9 ± 6.7 without AFO, P < ± 0.05), double stance duration (21.19 ± 14.4% of gait cycle with AFO versus 25.99 ± 21.6% of gait cycle without AFO, P < ± 0.05), and symmetry ratios of gait parameters such as stance duration (2.09 ± 1.5 s with AFO versus 3.39 ± 3.6 s without AFO, P < ± 0.05) and deceleration forces (1.69 ± 0.5 with AFO versus 1.99 ± 0.6 without AFO, P < ± 0.05) during gait. No significant differences were observed in all other symmetry ratios of gait parameters. Conclusion: An individually designed functional in-shoe AFO can improve stance and gait parameters, even in a single use, in patients with hemiparesis.

Mirror Therapy for Improving Motor Function After Stroke

Mirror therapy is used to improve motor function after stroke. During mirror therapy, a mirror is placed in the patient’s midsagittal plane, thus reflecting movements of the nonparetic side as if it were the affected side. This systematic review summarizes the effectiveness of mirror therapy for improving motor function, activities of daily living, pain, and visuospatial neglect in patients after stroke. We searched the Cochrane Stroke Group’s Trials Register (June 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 2), MEDLINE (1950 to June 2011), EMBASE (1980 to June 2011), CINAHL (1982 to June 2011), AMED (1985 to June 2011), PsycINFO (1806 to June 2011), and PEDro (June 2011). We also handsearched relevant conference proceedings, trials, and research registers; checked reference lists; and contacted trialists, researchers, and experts in our field …

Best Conventional Therapy Versus Modular Impairment-Oriented Training for Arm Paresis After Stroke: A Single-Blind, Multicenter Randomized Controlled Trial:

Background. The study investigated whether passive splinting or active motor training as either individualized best conventional therapy or as standardized impairment-oriented training (IOT) would be superior in promoting motor recovery in subacute stroke patients with mildly or severely paretic arms. Methods. A total of 148 anterior circulation ischemic stroke patients were randomly assigned to 45 minutes of additional daily arm therapy over 3 to 4 weeks as either ( a) passive therapy with inflatable splints or active arm motor therapy as either (b) individualized best conventional therapy (CONV) or ( c) standardized IOT, that is Arm BASIS training for severe paresis or Arm Ability training for mild paresis. Main outcome measures included the following: Fugl-Meyer arm motor score (severely paretic arms) and the TEMPA time scores (mildly affected arms). Pre—post (immediate effects) and pre—4 weeks follow-up analyses (long-term effects) were performed. Results. Overall improvements were documented (mean baseline and change scores efficacy: Fugl-Meyer, arm motor scores, 24.4, +9.1 points; TEMPA, 119, −26.6 seconds; P < .0001), but with no differential effects between splint therapy and the combined active motor rehabilitation groups. Both efficacy and effectiveness analyses indicated, however, bigger immediate motor improvements after IOT as compared with best conventional therapy (Fugl-Meyer, arm motor scores: IOT +12.3, CONV +9.2 points; TEMPA: IOT −31.1 seconds, CONV −20.5 seconds; P = .0363); for mildly affected patients long-term effects could also be substantiated. Conclusions. Specificity of active training seemed more important for motor recovery than intensity (therapy time). The comprehensive modular IOT approach promoted motor recovery in patients with either severe or mild arm paresis.

Mirror therapy for patients with severe arm paresis after stroke – a randomized controlled trial

Objective: To evaluate the effects of individual or group mirror therapy on sensorimotor function, activities of daily living, quality of life and visuospatial neglect in patients with a severe arm paresis after stroke. Design: Randomized controlled trial. Setting: Inpatient rehabilitation centre. Subject: Sixty patients with a severe paresis of the arm within three months after stroke. Interventions: Three groups: (1) individual mirror therapy, (2) group mirror therapy and (3) control intervention with restricted view on the affected arm. Main measures: Motor function on impairment (Fugl-Meyer Test) and activity level (Action Research Arm Test), independence in activities of daily living (Barthel Index), quality of life (Stroke Impact Scale) and visuospatial neglect (Star Cancellation Test). Results: After five weeks, no significant group differences for motor function were found (P > 0.05). Pre–post differences for the Action Research Arm Test and Fugl-Meyer Test: individual mirror therapy: 3.4 (7.1) and 3.2 (3.8), group mirror therapy: 1.1 (3.1) and 5.1 (10.0) and control therapy: 2.8 (6.7) and 5.2 (8.7). However, a significant effect on visuospatial neglect for patients in the individual mirror therapy compared to control group could be shown (P < 0.01). Furthermore, it was possible to integrate a mirror therapy group intervention for severely affected patients after stroke. Conclusion: This study showed no effect on sensorimotor function of the arm, activities of daily living and quality of life of mirror therapy compared to a control intervention after stroke. However, a positive effect on visuospatial neglect was indicated.

Electromechanical-Assisted Training for Walking After Stroke Updated Evidence

Improving walking after stroke is one of the main goals of rehabilitation. Electromechanical-assisted gait training uses specialist machines to assist walking practice and might help to improve walking after stroke. Our systematic review examined the effects of electromechanical and robotic-assisted gait training devices for improving walking after stroke and also assessed the acceptability and safety of this type of therapy. We searched the Cochrane Stroke Group Trials Register (last searched April 2012), the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library 2012, Issue 2), MEDLINE (1966 to November 2012), EMBASE (1980 to November …