Nuray Yozbatiran

A standardized approach to performing the action research arm test

The study of stroke and its treatment in human subjects requires accurate measurement of behavioral status. Arm motor deficits are among the most common sequelae after stroke. The Action Research Arm Test (ARAT) is a reliable, valid measure of arm motor status after stroke. This test has established value for characterizing clinical state and for measuring spontaneous and therapy-induced recovery; however, sufficient details have not been previously published to allow for performance of this scale in a standardized manner over time and across sites. Such an approach to ARAT scoring would likely reduce variance between investigators and sites. This report therefore includes a manual that provides a highly detailed and standardized approach for assigning ARAT scores. Intrarater reliability and interrater reliability, as well as validity, with this approach were measured and are excellent. The ARAT, when performed in a standardized manner, is a useful tool for assessment of arm motor deficits after stroke.

Motor assessment of upper extremity function and its relation with fatigue, cognitive function and quality of life in multiple sclerosis patients

OBJECTIVES The aim of this study was to assess the motor function of upper extremity and its relation with fatigue, cognitive function and quality of life in Multiple Sclerosis (MS) patients. DESIGN Cross-sectional and controlled study. SETTING Outpatient clinic in a university hospital. SUBJECTS Thirty-one patients with MS (25 women, 6 men; mean age 39.74 +/- 10.10 years; mean EDSS, 2.56 +/- 1.91) and 30 healthy subjects (20 women, 10 men; mean age 33.56 +/- 8.85 years) were enrolled into the study. MAIN MEASURES Nine-hole peg test (9-HPT) and Valpar Component Work Sample Test (VCWS-4), Upper Extremity Index (UEI), Paced Auditory Serial Addition Test (PASAT), Fatigue Severity Scale (FSS), and the Multiple Sclerosis Quality of Life-54 (MSQOL-54). RESULTS MS patients showed significant impairment in upper extremity motor functions, cognitive function and excessive fatigue compared to controls (p < 0.05). 9-HPT in MS group correlated with EDSS, UEI and MSQOL-54 physical health and cognitive function, whereas VCWS-4 scores (assembly right, assembly left and disassembly) correlated only with EDSS and UEI. No correlation was found between the VCWS-4 and cognitive function and fatigue in both of the groups. Compared to control group, a strong correlation existed between the 9-HPT and VCWS-4 in MS patients (p < 0.05). CONCLUSION The results indicate that disability level (EDSS), UEI and cognitive function in MS patients are related with impairment in upper extremity motor function. This again contributes to an impairment in physical domain of quality of life. A strong correlation of the 9-HPT with VCWS-4 supports the use of the 9-HPT as a measure of manual dexterity and gross motor functions.

Safety and Behavioral Effects of High-Frequency Repetitive Transcranial Magnetic Stimulation in Stroke

Background and Purpose— Electromagnetic brain stimulation might have value to reduce motor deficits after stroke. Safety and behavioral effects of higher frequencies of repetitive transcranial magnetic stimulation (rTMS) require detailed assessment. Methods— Using an active treatment-only, unblinded, 2-center study design, patients with chronic stroke received 20 minutes of 20 Hz rTMS to the ipsilesional primary motor cortex hand area. Patients were assessed before, during the hour after, and 1 week after rTMS. Results— The 12 patients were 4.7±4.9 years poststroke (mean±SD) with moderate–severe arm motor deficits. In terms of safety, rTMS was well tolerated and did not cause new symptoms; systolic blood pressure increased from pre- to immediately post-rTMS by 7 mm Hg (P=0.043); and none of the behavioral measures showed a decrement. In terms of behavioral effects, modest improvements were seen, for example, in grip strength, range of motion, and pegboard performance, up to 1 week after rTMS. The strongest predictor of these motor gains was lower patient age. Conclusions— A single session of high-frequency rTMS to the motor cortex was safe. These results require verification with addition of a placebo group and thus blinded assessments across a wide spectrum of poststroke deficits and with larger doses of 20 Hz rTMS.

Normalized Movement Quality Measures for Therapeutic Robots Strongly Correlate With Clinical Motor Impairment Measures

In this paper, we analyze the correlations between four clinical measures (Fugl-Meyer upper extremity scale, Motor Activity Log, Action Research Arm Test, and Jebsen-Taylor Hand Function Test) and four robotic measures (smoothness of movement, trajectory error, average number of target hits per minute, and mean tangential speed), used to assess motor recovery. Data were gathered as part of a hybrid robotic and traditional upper extremity rehabilitation program for nine stroke patients. Smoothness of movement and trajectory error, temporally and spatially normalized measures of movement quality defined for point-to-point movements, were found to have significant moderate to strong correlations with all four of the clinical measures. The strong correlations suggest that smoothness of movement and trajectory error may be used to compare outcomes of different rehabilitation protocols and devices effectively, provide improved resolution for tracking patient progress compared to only pre- and post-treatment measurements, enable accurate adaptation of therapy based on patient progress, and deliver immediate and useful feedback to the patient and therapist.

Effects of intense exercise in chronic spinal cord injury

Background:Exercise has beneficial effects on muscle and motor function after spinal cord injury (SCI). Little is known regarding effects of prolonged intense exercise (IE) in humans with chronic SCI.Design:Prospective, non-randomized, controlled observational study. The intervention was either a multimodal IE program (n=21) or a control (CTL) intervention consisting of self-regulated exercise (n=8).Objective:Measure sensorimotor function over 6 months in relation to an IE program.Setting:Single outpatient center.Subjects:Subjects with chronic SCI (n=29 total), mainly ASIA Impairment Scale A and B, injury levels C4-T11.Results:Baseline neurological assessments (for example, ASIA motor score, 39±3 vs 42±5, IE vs CTL, P>0.5, mean±s.e.m.) did not differ between the two groups. During the 6 months, IE subjects averaged 7.3±0.7 h per week exercise, not significantly different from CTL subjects (5.2±1.3 h per week, P>0.1). However, after 6 months, IE subjects showed significantly greater motor gains than CTL subjects in the main outcome measure, ASIA motor score (change of 4.8±1.0 vs −0.1±0.5 points, P=0.0001). The main outcome measure was calculated by ASIA motor score. These IE subject ASIA motor gains correlated with number of exercise hours per week (r=0.53, P<0.02), and with type of specific IE components, particularly load bearing.Conclusions:Multimodal IE can significantly improve motor function in subjects with chronic SCI. An organized program may provide greater motor benefits than a self-regulated program; load bearing might be of particular value. IE might have therapeutic value in chronic SCI, and as an adjunct to other restorative therapies.

Electrical stimulation of wrist and fingers for sensory and functional recovery in acute hemiplegia

Objective: To investigate the effects of a short-term electrical stimulation in conjunction with neurodevelopmental exercises on sensory and functional recovery of hemiparetic upper limb in acute stroke patients. Design: Controlled clinical trial with alternate allocation. Setting: Acute inpatient medical care setting of a university hospital. Subjects: Thirty-six acute stroke patients (18 TENS group; 18 control group) who experienced their first stroke were studied. Intervention: Both groups received 1 h/day neurodevelopmental exercises in accordance with Bobath for 10 days. In addition to exercises the TENS group received electrical stimulation of the wrist and finger extensors for 1 h. Main outcome measures: Kinaesthesia and position sense tests, a hand function test and a hand movement scale were performed before and after treatment. Results: Both groups showed considerable improvement in kinaesthesia sense and position sense after treatment. Comparison of the two groups after treatment revealed that this difference was not significant (P>0.05). Both groups showed improvement in hand movement scores (P<0.05), whereas hand function improved only in the TENS group (P<0.05). Conclusion: The results of this study indicated that additional stimulation of the hand and fingers leads to an improved sensorimotor outcome immediately after the intervention.

ROBOTIC TRAINING AND ClINICAl ASSESSMENT OF UPPER ExTREMITy MOvEMENTS AFTER SPINAl CORD INJURy: A SINGlE CASE REPORT

CASE REPORT A 28-year-old woman, with incomplete spinal cord injury at the C2 level, classified as American Spinal Injury Impairment Scale C (AIS), participated in a robotic rehabilitation program 29 months after injury. Robotic training was provided to both upper extremities using the MAHI Exo-II, an exoskeleton device designed for rehabilitation of the upper limb, for 12 × 3-h sessions over 4 weeks. Training involved elbow flexion/extension, forearm supination/pronation, wrist flexion/extension, and radial/ulnar deviation. RESULTS Outcome measures were Action Research Arm Test, Jebsen-Taylor Hand Function Test, and AIS-upper extremity motor score. Safety measures included fatigue, pain and discomfort level using a 5-point rating scale. Following training, improvements were observed in the left arm and hand function, whereas the right arm and hand function showed no improvement in any of the functional outcome measures. No excessive pain, discomfort or fatigue was reported. CONCLUSION Data from one subject demonstrate valuable information on the feasibility, safety and effectiveness of robotic-assisted training of upper-extremity motor functions after incomplete spinal cord injury.

Cross-cultural adaptation and validation of multiple sclerosis quality of life questionnaire (MSQOL-54) in a Turkish multiple sclerosis sample

OBJECTIVE Multiple sclerosis (MS) is a chronic progressive disease with multiple neurological impairments. The disease can also dramatically affect the health-related quality of life of patients. The objective of this study was to investigate the validation of the translated and cross-culturally adapted MSQOL-54 in 183 Turkish MS patients. METHODS 183 adults classified as having definite MS patients were enrolled into the study. Patients were classified into four severity groups according to the expanded disability status scale (EDSS); group I (EDSS 0-4), group II (EDSS 4.5-5.5), group III (EDSS 6-6.5) and group IV (EDSS 7-8). MSQOL-54 questionnaire were translated and culturally adapted into Turkish. Associations between age, gender, disease duration, EDSS score, marital status, education and health insurance and the MSQOL-54 physical and mental health composite scores were determined. RESULTS The mean age of the 183 patients (138 female and 45 male) was 39+/-10 years. The questionnaire was well accepted but small cultural adaptations were required. EDSS scores showed significant associations with the MSQOL-54 physical and mental health composite scores. From the different EDSS groups only, the group I (EDSS 0-4) score was significantly associated with the physical health composite as well as the disease duration showed significant correlation with the physical and mental composite scores. None of the other EDSS groups and the other parameters showed correlation with physical health composite or mental health composite. CONCLUSION Assessment of quality of life of MS patients in addition to disease severity and disability level is important, because it provides unique information that is important to patients and to clinicians. A translation of an existing MS-targeted HRQOL measure from US English into Turkish was easily administered and well accepted in a Turkish MS sample.

Design and validation of the RiceWrist-S exoskeleton for robotic rehabilitation after incomplete spinal cord injury

SUMMARY Robotic devices are well-suited to provide high intensity upper limb therapy in order to induce plasticity and facilitate recovery from brain and spinal cord injury. In order to realise gains in functional independence, devices that target the distal joints of the arm are necessary. Further, the robotic device must exhibit key dynamic properties that enable both high dynamic transparency for assessment, and implementation of novel interaction control modes that significantly engage the participant. In this paper, we present the kinematic design, dynamical characterization, and clinical validation of the RiceWrist-S, a serial robotic mechanism that facilitates rehabilitation of the forearm in pronation-supination, and of the wrist in flexion-extension and radial-ulnar deviation. The RiceWrist-Grip, a grip force sensing handle, is shown to provide grip force measurements that correlate well with those acquired from a hand dynamometer. Clinical validation via a single case study of incomplete spinal cord injury rehabilitation for an individual with injury at the C3-5 level showed moderate gains in clinical outcome measures. Robotic measures of movement smoothness also captured gains, supporting our hypothesis that intensive upper limb rehabilitation with the RiceWrist-S would show beneficial outcomes.

Effects of fitness and aquafitness exercises on physical fitness in patients with chronic low back pain

Abstract Objectives: To evaluate the effects of two different fitness programmes (water versus land based) on physical fitness level in patients with chronic low back pain. Design: Randomised controlled study. Subjects: Thirty patients with chronic low back pain randomly followed a land based fitness programme or an aquafitness programme. Methods: Subjects were evaluated with the Eurofit test battery for their physical fitness level. Both groups followed their programmes under supervision of a physiotherapist 3 days/week for 4 weeks. Results: Differences of measurements were not significant between the two groups. Significant differences were shown in both groups after the therapy programme with regard to aerobic fitness, motor fitness (single leg balance test with eyes open or closed), musculoskeletal fitness, pain reports, Sorensen and Oswestry low back pain disability index scores. No significant difference was found between the groups. Conclusion: Supervised aquafitness programmes have effects similar...