Functional significance of the subcortical vascular syndrome in the rehabilitative setting

Functional status of cortical and subcortical nonhemorrhagic stroke survivors and the effect of lesion laterality

The purpose of this study is to examine the effects of cortical and subcortical infarcts and lesion laterality on the functional status of stroke survivors. Medical records of 72 stroke survivors admitted to an acute inpatient rehabilitation facility with a single nonhemorrhagic lesion were retrospectively reviewed. Multivariate analysis of variance was used to assess the effects of lesion level and hemisphere on admission and discharge Functional Independence Measure (FIM) and FIM gain. Admission FIM-Total and its subdimensions exhibited significant overall level (Wilk's lambda = 2.5; P = 0.03) and hemisphere-specific (Wilk's lambda = 2.3; P = 0.04) effects. Significant interaction between factors was noted only for the communication subdimension. Significant level and hemisphere-specific main effects were noted for admission FIM-Total (P < 0.01 and P = 0.02, respectively). There were significant level-specific main effects for self-care (P = 0.01) and mobility (P = 0.03) and hemisphere and level-specific main effects for communication (P < 0.01 and P < 0.01, respectively) and social cognition (P = 0.02 and P = 0.01, respectively). Discharge FIM-Total and its subdimensions exhibited significant overall level (Wilk's lambda = 2.5; P = 0.03) and hemisphere-specific (Wilk's lambda = 3.4; P = 0.01) effects. Discharge FIM subdimensions did not exhibit significant interaction between factors. Discharge FIM-Total was significant with respect to lesion level (P = 0.01) but not with respect to hemisphere (P = 0.08). There was a significant level-specific main effect for self-care (P = 0.01) and level and hemisphere-specific main effects for communication (P < 0.01 and P < 0.01, respectively) and social cognition (P = 0.01 and P = 0.01, respectively). FIM gain scores did not exhibit significant level (Wilk's lambda = 1.1; P = 0.36) or hemisphere-specific (Wilk's lambda = 1.4; P = 0.24) effects. The data suggest that the lesion level and hemisphere are important determinants of the function of nonhemorrhagic stroke survivors during inpatient rehabilitation.

Electromyogram-triggered neuromuscular stimulation for improving the arm function of acute stroke survivors: a randomized pilot study

OBJECTIVE

To assess the efficacy of electromyogram (EMG)-triggered neuromuscular stimulation (EMG-stim) in enhancing upper extremity motor and functional recovery of acute stroke survivors.

DESIGN

A pilot randomized, single-blinded clinical trial.

SETTING

Freestanding inpatient rehabilitation facility.

PATIENTS

Nine subjects who were within 6 weeks of their first unifocal, nonhemorrhagic stroke were randomly assigned to either the EMG-stim (n = 4) or control (n = 5) group. All subjects had a detectable EMG signal (>5 microV) from the surface of the paretic extensor carpi radialis and voluntary wrist extension in synergy or in isolation with muscle grade of <3/5.

INTERVENTION

All subjects received two 30-minute sessions per day of wrist strengthening exercises with EMG-stim (experimental) or without (control) for the duration of their rehabilitation stay.

MAIN OUTCOME MEASURES

Upper extremity Fugl-Meyer motor assessment and the feeding, grooming, and upper body dressing items of the Functional Independence Measure (FIM) were assessed at study entry and at discharge.

RESULTS

Subjects treated with EMG-stim exhibited significantly greater gains in Fugl-Meyer (27.0 vs 10.4; p = .05), and FIM (6.0 vs 3.4; p = .02) scores compared with controls.

CONCLUSION

Data suggest that EMG-stim enhances the arm function of acute stroke survivors.

Functional measures of first-stroke rehabilitation inpatients: usefulness of the Functional Independence Measure total score with a clinical rationale

OBJECTIVE

The Functional Independence Measure (FIM) was used to measure function in first-stroke patients on admission to and discharge from a rehabilitation center, and to determine gain; all data were analyzed by a clinically oriented approach.

DESIGN

All patients admitted after a first supratentorial stroke to a comprehensive rehabilitation facility over a 2-year period were examined prospectively with the FIM. Diagnosis was determined by neuroimaging. Data were collected continuously and stored in the departmental database. For analysis of data, the patients were divided by side of lesion (right or left hemisphere), main clinical syndrome (presence or absence of neglect or aphasic syndromes in those with damage to the right or left hemisphere, respectively), type of lesion (ischemic, hemorrhagic, etc), and site of lesion (cortical or subcortical).

SETTING

Neurological rehabilitation ward.

PATIENTS

The study population included 151 patients of average age 60.8 years; 60% were men. All were admitted an average of 28.9 days after stroke and rehabilitated for 109.3 days.

MAIN OUTCOME MEASURE

The raw FIM total score was determined at 48 to 72 hours after admission and at discharge. FIM gain was calculated by subtracting the FIM discharge score from the FIM admission score for each individual. Length of stay was also recorded.

RESULTS

There was no difference in average total FIM scores when patients were divided by side of damage (right or left hemisphere). Significant findings were obtained for the various parameters when the clinical criterion was applied. Patients with neglect or aphasia syndromes showed significantly higher gains despite their lower FIM admission scores, but they had a much longer in-hospital stay.

CONCLUSION

The raw FIM total score is a simple, practical, and efficient measure of function in first-stroke patients on admission for rehabilitation, provided an appropriate clinical approach is used during data analysis. Results can be used for comparison with similar measures, determination of admission and discharge policy, and program evaluation. The presence of neglect and aphasic syndromes has a significant effect on the various measures. Length of stay in rehabilitation is also of paramount importance in stroke patients with special clinical syndromes.