A comparison of knee kinematic characteristics of stroke patients and age-matched healthy volunteers

Effectiveness of mid thoracic spine mobilization on postural balance and gait ability in subacute stroke patients: A randomized clinical trial

BACKGROUND

Although mulligan sustained natural apophyseal glides (SNAG) and maitland mobilization (MM) are common interventions for musculoskeletal disease, no study has directly compared the effectiveness of mid-thoracic spine mobilization in subacute stroke patients.

OBJECTIVE

To investigate the effects of mid-thoracic spine mobilization (SNAG vs. MM) on postural balance and gait ability in subacute stroke patients.

METHODS

Fifty subacute stroke patients were randomly allocated to the SNAG (n= 17), MM (n= 16), and control (n= 17) groups, each receiving a neuro-developmental therapy program for four successive weeks. The SNAG and MM groups additionally received mid-thoracic spine mobilization (T4∼8). The primary outcome measure was postural sway, and secondary outcome measures included the five times sit-to-stand test (FTSST), functional reach test (FRT), 10-m walk test (10MWT), 6-minute walk test (6MWT) and global rating of change (GRC).

RESULTS

Participants reported no adverse events, and there was no loss to follow-up. The SNAG and MM group patients demonstrated significant improvements (p< 0.05) in postural sway, FTSST, FRT, 10MWT, and 6MWT compared with those in the control group, with no between-group differences.

CONCLUSIONS

Mid-thoracic spine mobilization allows significant improvements in postural balance and gait ability in subacute stroke patients, with no differences between the SNAG and MM techniques.

Comparison of the Journey II bicruciate stabilised (JII-BCS) and GENESIS II total knee arthroplasty for functional ability and motor impairment: the CAPAbility, blinded, randomised controlled trial

OBJECTIVES

To determine if a newer design of total knee replacement (TKR) (Journey II BCS) produces superior patient-reported outcomes scores and biomechanical outcomes than the older, more established design (Genesis II).

SETTING

Patients were recruited from an NHS University Hospital between July 2018 and October 2019 with surgery at two sites. Biomechanical and functional capacity measurements were at a University Movement and Exercise Laboratory.

PARTICIPANTS

80 participants undergoing single-stage TKR.

INTERVENTIONS

Patients were randomised to receive either the Journey II BCS (JII-BCS) or Genesis II TKR.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome was the Oxford Knee Score (OKS), at 6 months. Secondary outcomes were: OKS Activity and Participation Questionnaire, EQ-5D-5L and UCLA Activity scores, Timed Up and Go Test, 6 min walk test, lower limb kinematics and lower limb muscle activity during walking and balance.

RESULTS

This study found no difference in the OKS between groups. The OKS scores for the JII-BCS and Genesis II groups were mean (SD) 42.97 (5.21) and 43.13 (5.20) respectively, adjusted effect size 0.35 (-2.01,2.71) p=0.771In secondary outcome measures, the Genesis II group demonstrated a significantly greater walking range-of-movement (50.62 (7.33) vs 46.07 (7.71) degrees, adjusted effect size, 3.14 (0.61,5.68) p=0.02) and higher peak knee flexion angular velocity during walking (mean (SD) 307.69 (38.96) vs 330.38 (41.40) degrees/second, adjusted effect size was 21.75 (4.54,38.96), p=0.01) and better postural control (smaller resultant centre of path length) during quiet standing than the JII-BCS group (mean (SD) 158.14 (65.40) vs 235.48 (176.94) mm, adjusted effect size, 59.91 (-105.98, -13.85) p=0.01.).

CONCLUSIONS

In this study population, the findings do not support the hypothesis that the Journey II BCS produces a better outcome than the Genesis II for the primary outcome of the OKS at 6 months after surgery.

TRIAL REGISTRATION NUMBER

ISRCTN32315753.

Neuromotor changes in participants with a concussion history can be detected with a custom smartphone app

Neuromotor dysfunction after a concussion is common, but balance tests used to assess neuromotor dysfunction are typically subjective. Current objective balance tests are either cost- or space-prohibitive, or utilize a static balance protocol, which may mask neuromotor dysfunction due to the simplicity of the task. To address this gap, our team developed an Android-based smartphone app (portable and cost-effective) that uses the sensors in the device (objective) to record movement profiles during a stepping-in-place task (dynamic movement). The purpose of this study was to examine the extent to which our custom smartphone app and protocol could discriminate neuromotor behavior between concussed and non-concussed participants. Data were collected at two university laboratories and two military sites. Participants included civilians and Service Members (N = 216) with and without a clinically diagnosed concussion. Kinematic and variability metrics were derived from a thigh angle time series while the participants completed a series of stepping-in-place tasks in three conditions: eyes open, eyes closed, and head shake. We observed that the standard deviation of the mean maximum angular velocity of the thigh was higher in the participants with a concussion history in the eyes closed and head shake conditions of the stepping-in-place task. Consistent with the optimal movement variability hypothesis, we showed that increased movement variability occurs in participants with a concussion history, for which our smartphone app and protocol were sensitive enough to capture.

Trunk and lower extremity biomechanics during sit-to-stand after stroke: A systematic review

OBJECTIVES

This systematic review aimed to pool available evidence of differences in trunk and lower extremity biomechanics during the different phases of a sit-to-stand (STS) task between persons with stroke and to healthy controls.

METHODS

Four electronic databases (Medline, Web of Science, EMBASE, and Cochrane Library) were systematically searched up to, and including, December 2021. Studies were included if they investigated kinematic, kinetic and/or electromyographic outcome measures of adults with stroke during STS and compared results with healthy controls. Data from eligible studies were categorized according to STS subphases if reported (Phase I: Movement onset to seat-off; Seat-off; Phase II: Seat-off to movement termination; Whole task [if no subtasks reported]). The Newcastle-Ottawa Scale was used to assess risk of bias.

RESULTS

Twenty-one studies were included in this systematic review. Methodological quality ranged from 13% to 75%; mean score was 55%. The findings of this systematic review suggest that after stroke, people rise to stand (phase I) with increased lateral trunk flexion and displacement of the center of pressure (COP) towards the non-paretic side, decreased anterior pelvic tilt, decreased hip flexion and altered timing of lower limb muscle activation. In addition, during phase II, lateral pelvic translation and weight distribution asymmetry was increased, knee extension velocity was decreased and delayed, stabilization was decreased and COP velocity was increased compared with healthy subjects.

CONCLUSIONS

This systematic review clearly showed changes in kinematics, kinetics and muscle recruitment after stroke, with differences between the different phases of STS. Therapeutic interventions should focus on subphases of this functional task to optimize performance in daily living.

Design and validation of a novel 3D-printed wearable device for monitoring knee joint kinematics

Gait analysis provides an important tool for the study and clinical evaluation of conditions which affect knee joint biomechanics. Collection of knee joint kinematics in real world environments during locomotor activities of daily living could provide quantitative evidence to help understand functional impairment. Unfortunately, the high cost and necessary technical expertise associated with current commercially available systems for kinematic monitoring serve as an impediment to their adoption outside of specialized research groups. We have developed a low-cost, custom wearable device to address these shortcomings. The 3D printed device is capable of measuring knee flexion/extension (F/E) and adduction/abduction (AD/AB) angles. Here, we present a gold standard validation of the novel device against an optoelectronic motion capture system (MCS). Data were collected during a treadmill walking task from 8 participants on 2 separate occasions. Agreement with the MCS was quantified via root mean squared error (RMSE), coefficients of multiple correlation (CMC), paired dependent t-tests and Bland-Altman analyses. The wearable device had an overall RMSE of 3.0° and 2.7° and a CMC of 0.97 and 0.91 in F/E and AD/AB respectively. Wearable device error showed no significant differences between test occasions, and Bland-Altman analyses showed low bias with narrow limits of agreement. These results demonstrate the capability of the device to accurately and reliably monitor knee F/E and AD/AB angles showing strong potential for field implementation.

Biomechanical correlates for recovering walking speed following a stroke. The potential of tibia to vertical angle as a therapy target

BACKGROUND

Recovering independent walking is a priority for stroke survivors. Community walking requires speeds exceeding the average values typically achieved at discharge (0.7 m/s). To improve outcomes there is a need to clarify the factors associated with recovery of functional walking speeds.

RESEARCH QUESTION

Which biomechanical variables correlate significantly with improved walking speed following rehabilitation in acute stroke patients.

METHODS

The study was embedded in a larger clinical trial testing efficacy of a gait training splint. Participants, within 6 weeks of their stroke and exhibiting abnormal gait, were recruited. Using a valid and reliable video-based system, specific kinematic measures were recorded before randomisation (baseline), after a 6-week rehabilitation phase (outcome) and six months after stroke (follow-up). Measures of temporospatial symmetry, knee angular velocity and tibia to vertical angle were added to clinical measures and correlated with change in speed.

RESULTS

23 participants were recruited, (mean age 67.7 ± 16.7 years, 19.2 ± 9.0 days after stroke and 73.9% male), with 20/23 assessed at outcome and 17/23 at follow-up. Drop out was due to withdrawal (3) and technical failure (3). Walking speed increased by 0.15 ± 0.21 m/s (outcome), and 0.21 ± 0.14 m/s (follow-up) from baseline (0.50 ± 0.20 m/s). This increase correlated with an increase in step length (r=0.88) and change in angle of tibia at initial contact (r=-0.59), foot flat (r=-0.61) and terminal contact (r=0.54).

SIGNIFICANCE

This study of gait recovery among acute stroke patients demonstrated modest improvements in walking speed. Walking speed by follow-up (0.71 m/s) classified the group as community walkers (>0.66 m/s) but still too slow to safely use a pedestrian road crossing. Change in step length and tibia to vertical angle significantly correlated with increased walking speed. This finding provides distinctive targets for therapy aimed at improving community walking among stroke survivors. This hypothesis should be tested prospectively in future studies.

Sonographic soft tissue arthritic changes associated with post-stroke hemiplegic knee pain: utility of musculoskeletal ultrasound in a resource-limited setting

Purpose

Post-stroke arthritic changes that may compromise rehabilitation have been described in the upper and lower limbs. We aimed at evaluating the soft tissue arthritic changes associated with pain in hemiplegic knees of stroke patients in our environment.

Material and methods

Hemiplegic and non-hemiplegic knees of 48 stroke patients as well as both knees of 26 apparently healthy controls were evaluated with a 7.5-12 MHz linear ultrasound probe. History of knee pain, and socio-demographic, laboratory, and clinical data were recorded for all study participants. Muscle tone and power as well as functional ambulatory category (FAC) were graded for the stroke patients. Data was analysed using SPSS version 20.

Results

Pain was reported more often in hemiplegic than non-hemiplegic knees (n = 16 vs. n = 6, p = 0.021). The frequencies of soft tissue arthritic changes found, which included reduced lateral and medial femoral cartilage thickness, suprapatellar effusion, and irregular cartilage-bone margin, were similar between hemiplegic and non-hemiplegic knees (p > 0.05). Suprapatellar effusion and reduced lateral femoral cartilage thickness were more prevalent in the hemiplegic knees compared to the healthy control knees (p < 0.05). Stroke patients with pes anserinus tendinosis had greater risk of hemiplegic knee pain (HKP) when compared to stroke patients without this lesion (OR = 10; 95% CI: 1.7-61). FAC, muscle tone, and power showed no association with HKP.

Conclusions

Soft tissue arthritic changes associated with knee pain are comparable between hemiplegic and non-hemiplegic knees of stroke patients. The risk of knee pain in stroke is higher in the presence of pes anserinus tendinosis.

Quantifying sit-to-stand and stand-to-sit transitions in free-living environments using the activPAL thigh-worn activity monitor

PURPOSE

Standing up, sitting down and walking require considerable effort and coordination, which are crucial indicators to rehabilitation (e.g. stroke), and in older populations may indicate the onset of frailty and physical and cognitive decline. Currently, there are few reports robustly quantifying sit-to-stand and stand-to-sit transitions in free-living environments. The aim of this study was to identify and quantify these transitions using the peak velocity of sit-to-stand and stand-to-sit transitions to determine if these velocities were different in a healthy cohort and a mobility-impaired population.

METHODS

Free-living sit-to-stand and stand-to-sit acceleration data were recorded from 21 healthy volunteers and 34 stroke survivors using activPAL3™ monitors over a one-week period. Thigh inclination velocity was calculated from these accelerometer data. Maximum velocities were compared between populations.

RESULTS

A total of 10,299 and 11,392 sit-to-stand and stand-to-sit transitions were recorded in healthy volunteers and stroke survivors, respectively. Healthy volunteers had significantly higher overall mean peak velocities for both transitions compared with stroke survivors [70.7°/s ± 52.2 versus 44.2°/s ± 28.0 for sit-to-stand, P < 0.001 and 74.7°/s ± 51.8 versus 46.0°/s ± 31.9 for stand-to-sit; P < 0.001]. Mean peak velocity of transition was associated with increased variation in peak velocity across both groups.

CONCLUSION

There were significant differences in the mean peak velocity of sit-to-stand and stand-to-sit transitions between the groups. Variation in an individual's mean peak velocity may be associated with the ability to perform these transitions. This method could be used to evaluate the effectiveness of interventions following injury such as stroke, as well as monitor decline in functional ability.

Neuromechanical Differences Between Successful and Failed Sit-to-Stand Movements and Response to Rehabilitation Early After Stroke

BACKGROUND

Recovery of the sit-to-stand (StS) movement early after stroke could be improved by targeting physical therapy at the underlying movement deficits in those people likely to respond.

AIM

To compare the movement characteristics of successful and failed StS movements in people early after stroke and identify which characteristics change in people recovering their ability to perform this movement independently following rehabilitation.

METHODS

Muscle activity and kinematic (including center of mass, CoM) data were recorded from 91 participants (mean 35 days after stroke) performing the StS movement before (baseline), immediately after (outcome), and 3 months after (follow-up) rehabilitation. Three subgroups (never-able [n = 19], always-able [n = 51], and able-after-baseline [n = 21]) were compared at baseline with the able-after-baseline subgroup compared before and after rehabilitation.

RESULTS

The subgroups differed at baseline for quadriceps onset time ( P = .009) and forward body position when quadriceps peaked ( P = .038). Following rehabilitation, the able-after-baseline subgroup increased their forward position ( P < .001), decreased the time difference between bilateral quadriceps peaks ( P < .001) and between quadriceps and hamstrings peaks on the nonhemiplegic side ( P = .007). An improved performance in the always-able subgroup was associated with a number of baseline factors, including forward positioning ( P = .002) and time difference between peak activity of bilateral quadriceps ( P = .001).

CONCLUSIONS

This neuromechanical study of StS before and after rehabilitation in a sample of people early after stroke identified the importance of temporal coupling between forward trunk movement and quadriceps and hamstrings' activity. These findings advance the science of stroke rehabilitation by providing evidence-based therapy targets to promote recovery of the StS movement.

A flexible wearable sensor for knee flexion assessment during gait

BACKGROUND

Gait analysis plays an important role in the diagnosis and management of patients with movement disorders but it is usually performed within a laboratory. Recently interest has shifted towards the possibility of conducting gait assessments in everyday environments thus facilitating long-term monitoring. This is possible by using wearable technologies rather than laboratory based equipment.

RESEARCH QUESTION

This study aims to validate a novel wearable sensor system's ability to measure peak knee sagittal angles during gait.

METHODS

The proposed system comprises a flexible conductive polymer unit interfaced with a wireless acquisition node attached over the knee on a pair of leggings. Sixteen healthy volunteers participated to two gait assessments on separate occasions. Data was simultaneously collected from the novel sensor and a gold standard 10 camera motion capture system. The relationship between sensor signal and reference knee flexion angles was defined for each subject to allow the transformation of sensor voltage outputs to angular measures (degrees). The knee peak flexion angle from the sensor and reference system were compared by means of root mean square error (RMSE), absolute error, Bland-Altman plots and intra-class correlation coefficients (ICCs) to assess test-retest reliability.

RESULTS

Comparisons of knee peak flexion angles calculated from the sensor and gold standard yielded an absolute error of 0.35(±2.9°) and RMSE of 1.2(±0.4)°. Good agreement was found between the two systems with the majority of data lying within the limits of agreement. The sensor demonstrated high test-retest reliability (ICCs>0.8).

SIGNIFICANCE

These results show the ability of the sensor to monitor knee peak sagittal angles with small margins of error and in agreement with the gold standard system. The sensor has potential to be used in clinical settings as a discreet, unobtrusive wearable device allowing for long-term gait analysis.

Comparison of the impact of a single session of isokinetic or isotonic muscle stretch on gait in patients with spastic hemiparesis

Objective: To establish if isokinetic and isotonic muscle stretch (with or without weight-bearing) of the ankle plantar flexors improves gait in hemiplegic patients. A further aim was to compare the effectiveness of these treatment methods.

Design: A randomized, parallel group prospective study.

Setting: A stroke rehabilitation unit.

Subjects: Ambulatory hemiparetic stroke patients with mild to moderately severe muscle hypertonia of the lower limb and a group of healthy control subjects.

Intervention: Subjects were randomized to receive a single 20-min session of isokinetic muscle stretch or isotonic muscle stretch with or without weight-bearing.

Outcome measures: Selected kinematic, kinetic and spatio-temporal gait parameters were measured at baseline, immediately after the muscle stretch and 24 h later.

Results: Sixty-six patients and 21 healthy control subjects were recruited and completed the study. There were statistically significant differences between the patient groups and the healthy subjects on most of the gait parameters studied. However, the differences between the patient groups or between the three measurements over time for each type of muscle stretch did not reach statistical significance.

Conclusions: A single session of isokinetic or isotonic muscle stretch (with or without weight-bearing) of the ankle plantar flexors has no clinically observable effect on the gait of hemiplegic stroke patients.

Functional strength training and movement performance therapy produce analogous improvement in sit-to-stand early after stroke: early-phase randomised controlled trial

OBJECTIVES

Restoring independence in the sit-to-stand (STS) task is an important objective for stroke rehabilitation. It is not known if a particular intervention, strength training or therapy focused on movement performance is more likely to improve STS recovery. This study aimed to compare STS outcomes from functional strength training, movement performance therapy and conventional therapy.

DESIGN

Randomised controlled trial.

SETTING

Acute stroke units.

PARTICIPANTS

Medically well patients (n=93) with recent (<42 days) stroke. The mean age of patients was 68.8 years, mean time post ictus was 33.5 days, 54 (58%) were male, 20 showed neglect (22%) and 37 (40%) had a left-sided brain lesion.

INTERVENTIONS

Six weeks of either conventional therapy, functional strength training or movement performance therapy. Subjects were allocated to groups on a random basis.

MAIN OUTCOME MEASURES

STS ability, timing, symmetry, co-ordination, smoothness and knee velocity were measured at baseline, outcome (after 6 weeks of intervention) and follow-up (3 months after outcome).

RESULTS

No significant differences were found between the groups. All three groups improved their STS ability, with 88% able to STS at follow-up compared with 56% at baseline. Few differences were noted in quality of movement, with only symmetry when rising showing significantly greater improvement in the movement performance therapy group; this benefit was not evident at follow-up.

CONCLUSIONS

Recovery of the STS movement is consistently good during stroke rehabilitation, irrespective of the type of therapy experienced. Changes in quality of movement did not differ according to group allocation, indicating that the type of therapy is less important. Clinical trial registration number NCT00322192.

A Randomized Controlled Evaluation of the Efficacy of an Ankle-Foot Cast on Walking Recovery Early After Stroke: SWIFT Cast Trial

Background. Timely provision of an ankle-foot orthosis (AFO) orthotist customized for individuals early after stroke can be problematic. Objective. To evaluate the efficacy of a therapist-made AFO (SWIFT Cast) for walking recovery. Methods. This was a randomized controlled, observer-blind trial. Participants (n = 105) were recruited 3 to 42 days poststroke. All received conventional physical therapy (CPT) that included use of “off-the-shelf” and orthotist-made AFOs. People allocated to the experimental group also received a SWIFT Cast for up to 6 weeks. Measures were undertaken before randomization, 6 weeks thereafter (outcome), and at 6 months after stroke (follow-up). The primary measure was walking speed. Clinical efficacy evaluation used analysis of covariance. Results. Use of a SWIFT Cast during CPT sessions was significantly higher (P < .001) for the SWIFT Cast (55%) than the CPT group (3%). The CPT group used an AFO in 26% of CPT sessions, compared with 11% for the SWIFT Cast group (P = .005). At outcome, walking speed was 0.42 (standard deviation [SD] = 0.37) m/s for the CPT group and 0.32 (SD = 0.34) m/s for the SWIFT Cast group. Follow-up walking speed was 0.53 (SD = 0.38) m/s for the CPT group and 0.43 (0.34) m/s for the SWIFT Cast group. Differences, after accounting for minimization factors, were insignificant at outcome (P = .345) and follow-up (P = .360). Conclusion and implications. SWIFT Cast did not enhance the benefit of CPT, but the control group had greater use of another AFO. However, SWIFT Cast remains a clinical option because it is low cost and custom-made by therapists who can readily adapt it during the rehabilitation period.

Subjective measures in sit-to-stand task in post-stroke hemiparesis: comment on Brière, Nadeau, Lauzière, and Gravel (2013)

In a recent study, Brière, Nadeau, Lauzière, and Gravel (2013 ) examined the perceptions of individuals post-stroke on their weight-bearing distribution and knee effort distribution in sit-to-stand tasks. The present comment emphasized the importance of the feeling of post-stroke hemiparesis in sit-to-stand task and identified areas of improvements of the target study.

An isokinetic training program for reducing falls in a community-dwelling older adult: a case report

BACKGROUND

With the population older than 65 years, projected to double by the year 2030, falls in older adults are a substantial health concern. Muscle strength deficits are one of the multifactorial components linked to increased fall risk, and decreasing these deficits has been one of the goals of interventions designed to decrease fall risk. These interventions have traditionally focused on improving peak torque; however, recent research suggests that exercise protocols that focus on the rate of torque development (RTD) may be more effective in decreasing fall risk.

PURPOSE

This case report examines clinical outcomes following implementation of an isokinetic strengthening protocol coupled with a balance program designed to reduce fall risk in a community-dwelling older adult.

METHODS

The individual was a 70-year-old woman with a history of 3 falls over the past 8 months and no related medical etiology who had self-limited her activities because of fear of another fall. She was classified as having substantial risk for future falls because of fall history, increased fear of falling, and below age norms on the Berg Balance Scale (BBS), and the Timed Up and Go (TUG). The treatment program consisted of 12 weeks of high-intensity isokinetic knee extensor training, high challenge dynamic gait and balance activities, and core strengthening. The isokinetic protocol consisted of 4 sets of 10 concentric-only repetitions at speeds of 240°/sec and 300°/sec for a total of 8 work sets. Dynamic gait activities incorporating directional and obstacle drills, and rocker and balance boards were used for balance training activities. Progressive theraband exercises were used for core strengthening. As her home program, the participant was encouraged to return to line dancing twice per week. During the 12-week protocol, the participant completed two 90-minute therapy sessions and two 90-minute dance classes per week.

RESULTS

After the 12 weeks of treatment, knee extensor peak torque at 150 ms improved on the right from 67.8 N to 107.1 N (57.9% increase), and on the left from 65.1 N to 97.6 N (49.9% increase). The BBS score improved from 45 to 52; and the TUG improved from 14.0 to 8.6 seconds. Both final scores exceeded fall risk cutoffs (BBS = 48; TUG = 13.5 seconds) and the change score exceeded minimal detectable change (BBS = 7; TUG 5.4 seconds).

CONCLUSIONS

The treatment program produced improvements in knee extensor peak torque and RTD, but more importantly, the final scores on the clinical outcome measures placed the participant above established fall-risk cutoff scores. Although future research with increased numbers of participants and a control group should be conducted to confirm this study's results, these findings support the use of isokinetic training to reduce fall risk in older adults.

The SWIFT Cast trial protocol: a randomized controlled evaluation of the efficacy of an ankle-foot cast on walking recovery early after stroke and the neural-biomechanical correlates of response

RATIONALE

An ankle-foot cast may enable people to repeatedly practice walking with a more normal movement pattern early after stroke.

AIMS

To evaluate the clinical efficacy of using an ankle-foot cast [soft scotch ankle-foot (SWIFT) Cast] to enhance walking recovery and to find whether site of stroke lesion and/or baseline biomechanical characteristics predict response to a SWIFT Cast.

DESIGN

Randomized, controlled, observer-blind trial.

STUDY

Participants (n = 120), 3-42 days after stroke with walking difficulty. All will receive conventional physical therapy. Those allocated to the experimental group will also receive a SWIFT Cast for up to six-weeks. During therapy sessions, the SWIFT Cast will be worn for retraining of walking as clinically appropriate. Outside therapy sessions, participants will initially wear the SWIFT Cast for the whole of their waking day, and this will be adjusted as clinically appropriate.

OUTCOMES

Measures will be undertaken before randomization, six-weeks thereafter and six-months after stroke. Primary outcome will be walking speed. Secondary outcomes will include the Functional Ambulation Category and efficiency of gait (e.g. step-time symmetry). Structural brain imaging using magnetic resonance imaging (standard fluid attenuated inversion recovery and T1-weighted high-resolution 'volume' spoiled gradient) will be undertaken at baseline. The clinical efficacy analysis will use analysis of covariance. The relationship between clinical response to therapy and biomechanical data will use correlation and multivariate regression techniques as required. For neuroimaging data, the relationship to clinical response to therapy will be computed using voxel-based lesion-symptom mapping. An interaction test across groups will identify which voxels are associated with different mean levels of treatment efficacy.

Psychometric properties of the modified Emory Functional Ambulation Profile in stroke patients

OBJECTIVE

To examine the test-retest reliability, convergent and predictive validity and responsiveness of the modified Emory Functional Ambulation Profile (mEFAP) in assessing gait function in stroke patients undergoing rehabilitation.

SUBJECTS

Forty subacute stroke inpatients were enrolled in the validity and responsiveness study. Twenty chronic patients participated in the reliability study.

SETTING

Rehabilitation department of a medical centre.

DESIGN

In the validity and responsiveness study, patients were tested using the mEFAP, 10-m walking speed test, Barthel Index and Rivermead Mobility Index at admission and at discharge. For the reliability study, the patients completed the mEFAP twice one week apart.

RESULTS

The patients' performances on the mEFAP were moderately to highly correlated with results of the 10-m walking speed test and Rivermead Mobility Index (absolute correlation coefficients > or = 0.67), indicating good convergent validity. Patients' performance on the mEFAP at admission was moderately correlated with the Barthel Index and Rivermead Mobility Index scores at discharge (Spearman's rank correlation coefficients = -0.52 and -0.78, respectively), indicating good predictive validity. The standardized response mean of the mEFAP was 1.1 (P < 0.0001), suggesting good responsiveness. The intraclass correlation coefficient ICC(3,1) for the mEFAP was 0.997, indicating excellent test retest reliability.

CONCLUSIONS

Our results provide strong evidence that the mEFAP has good reliability, validity and responsiveness for assessing stroke patients undergoing rehabilitation. The mEFAP is a useful scale for measuring walking function and recovery in stroke patients.

Ultrasonographic Findings in Hemiplegic Knees of Stroke Patients

Clinical and radiologic asymmetric arthritic differences between paralyzed and nonparalyzed limbs of stroke patients have been reported. Arthritic pathology aggravates motor dysfunction and compromises rehabilitation. Musculoskeletal ultrasonography plays an important role in showing soft tissue and the articular cartilage of the knee. Fifty-nine patients with either ischemic or hemorrhagic stroke-induced right or left hemiplegia were recruited to evaluate soft-tissue and intra-articular cartilage changes in hemiplegic knees of stroke patients using ultrasonography. An additional 15 subjects (30 knees) without knee disease or a history of knee trauma or surgery were used as controls. There were significant differences in suprapatellar effusion and patellar tendinitis between hemiplegic and nonhemiplegic knees. Suprapatellar effusion and pes anserinus tendinitis were correlated with Brunnstrom stage. The length of time since stroke onset was not significantly correlated with positive ultrasonographic findings in hemiplegic knees. In conclusion, ultrasonography is useful for detecting periarticular soft-tissue changes and intra-articular lesions in hemiplegic knees of stroke patients.