Effects of an Anterior Ankle-Foot Orthosis on Postural Stability in
Stroke Patients with Hemiplegia.
The problem of maintaining the posture of a hemiplegic stroke
patient remains a challenging one. This study ( Am J Phys Med
Rehabil 2008;87) is aiming to evaluate the effects of an anterior
leaflet ankle-foot orthosis (AFO) on postural stability in stroke
patients with hemiplegia.
Twenty-one stroke patients with hemiplegia resulting from new-onset
stroke and ten normal subjects were included in this study.
The SMART balance master system was used to assess the postural
stability by measuring the ankle strategy, maximal stability, and
velocity of center-of-gravity (COG) movement under the six different
conditions.
Each patient was tested with and without an anterior AFO as compared
with normal subjects. When wearing an anterior AFO, patients used
ankle strategy more than hip strategy to maintain postural stability
in all the six sensory conditions. An anterior AFO also provided
stroke patients with better maximal stability under relatively
challenging conditions.
The study concluded that in the early stage of recovery, the use of
an anterior AFO may assist stroke patients with hemiplegia to
improve their postural stability.
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Retention
of upper limb function in stroke survivors: the EXCITE randomised
trial
I am sure that
the Stroke Rehabilitation community will welcome the results of this
randomised trial (Lancet Neurology 2008; 7:33-40).
The aim of constraint-induced movement therapy (CIMT) is to promote
use of a limb that is functionally impaired after a stroke. In one
form of CIMT to treat upper limb impairment, use of the less
severely affected arm is restricted for many hours each weekday over
2 consecutive weeks. The EXCITE trial has previously shown the
efficacy of this intervention for patients 3–9 months poststroke who
were followed-up for the next 12 months. Wolf SL et al assessed the
retention of improvements 24 months after the intervention.
In the EXCITE trial, 106 of 222 participants who had mild to
moderate poststroke impairments were randomly assigned to receive
CIMT rather than usual and customary care. The researchers assessed
this group of patients every 4 months for the primary outcome
measure of impaired upper limb function, as measured with the Wolf
motor function test (WMFT) and the motor activity log (MAL).
Health-related quality of life, measured with the stroke impact
scale (SIS), was a secondary outcome measure. Analysis was per
protocol.
The effects at 24 months after treatment did not decline from those
at 12 months for time taken to complete the WMFT, for weight lifted
in the WMFT, for WMFT grip strength, for amount of use in the MAL,
or for how well the limb was used in the MAL.
The additional changes were in the direction of increased
therapeutic effect.
The study concluded that patients who have mild to moderate
impairments 3–9 months poststroke have substantial improvement in
functional use of the paretic upper limb and quality of life 2 years
after a 2-week CIMT intervention. Thus, this intervention has
persistent benefits.
The effects of Botulinum Toxin A (BTX-A) on plantarflexor
spasticity, stiffness and gait in chronic stroke
  Plantarflexor
(PF) spasticity secondary to stroke can decrease mobility and reduce
function. BTX-A treatment is increasingly used clinically to reduce
spasticity, but its effectiveness on mobility has not been
established. This pilot study from Queen’s University in Canada
which was presented in the European Stroke Conference on 30th
May 2007 in Glasgow, UK examined PF spasticity, gait kinematics and
kinetics following BTX-A treatment. Six patients with chronic
spastic hemiparesis, capable of ambulation without an ankle-foot
orthosis, received BTX-A injections into the affected gastrocnemius,
soleus and tibialis posterior muscles. At baseline, two weeks (T1)
and one month (T2) after this treatment, they underwent a three
dimensional, bilateral gait analysis at normal walking speed. This
provided temporal-spatial, displacement and power information for
the ankle and joint displacement information for the knee throughout
stance. The results showed that the gait speed, step length and
strides per minute remained stable over time (p>0.41). There was a
decrease in asymmetry of the maximum power absorption of the ankle
between the affected and non-affected sides at T2 (p=0.013) and
total power generation at the ankle at T2 (p=0.016). There were no
significant changes in ankle and knee kinematics over time. A trend
towards increased ankle dorsiflexion (p<0.13) and increased knee
range (p<0.21) on the affected side was observed at T2. Changes in
gait were accompanied by a reduction in PF spasticity.
The decrease in side-to-side differences in power generation and
absorption reflects improved gait symmetry following treatment. The
increased ability to produce work suggests improved gait efficiency
following BTX-A treatment in conjunction with reduced spasticity.
The inability to detect significant change in kinematic variables
may be due to the small sample and large variability thus reducing
statistical power. As recruitment continues, the importance of the
trends observed should emerge to better describe the effects of BTX-A
on gait and the sustainability of any benefits.
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Stroke
patients' experiences of return to work.
The aim of this
study was to describe the experience of return to work (RTW) after
stroke from the patient's
perspective.
Six patients who
had their first ever stroke in 2001, were <65 years of age and were
working at the time of their stroke were included in this study.
Information was obtained via an open-ended interview ( Disabil
Rehabil. 2006 Sep 15;28(17):1051-60).
Rehabilitation was
perceived as primarily aimed at restoring bodily functions and a
return to everyday activities, rather than at promoting a return to
work. It was not experienced as adapted to the participants' needs
or their age. The workplace was experienced as very important in the
rehabilitation process. When the informants experienced that the
rehabilitation professionals were not taking action, they took
control of the situation themselves. The informants expressed pride
in their own capacity to take the initiative and in their ability to
take action. The informants' adaptation to a new role at work was
perceived as facilitated by the understanding and positive attitude
of co-workers.
The study concluded that among this group of
stroke patients, the individual patient's capacity and ability to
return to work was enhanced by motivation or "will" and
self-efficacy in combination with external support. Self-efficacy
was not only a personal trait or internal factor; it was enhanced
and encouraged in interaction with contextual conditions. There are
similarities between the RTW process and processes of health
promotion.
Empirical
models to enhance stroke rehabilitation.
Models
identifying functional indicators most strongly associated with favourable
and unfavourable outcomes may bolster evidence to improve stroke
rehabilitation assessment and intervention. This study (Disabil Rehabil.
2006; 28(16):1027-34) examined the feasibility of decision analysis
methods for developing data-driven models that examined associations
between specific functional indicators and global disability.
Data
were derived from functional assessment of 67 participants 3 months
following stroke. Decision analysis methods were used to examine specific
activity and body function indicators associated with global disability,
and the degree of limitation or impairment that contributed to favourable
and unfavourable outcomes, in 2 models. The feasibility of decision
analysis methods was evaluated.
The
results showed that of the 26 activity indicators, dressing was most
strongly associated with global disability, followed by bill mailing,
shopping and sweeping. Of 15 body function indicators, facial weakness and
mental functions were most strongly associated with global disability.
This study
concluded that decision analysis methods show promise for developing
models examining associations between specific functional indicators and
disability. Further study with these methods may identify specific
priorities for functional assessment and intervention in stroke
rehabilitation
Non-invasive
brain stimulation: a new strategy to improve neurorehabilitation after
stroke?
Motor impairment resulting
from chronic stroke can have extensive physical, psychological, financial,
and social implications despite available neurorehabilitative treatments.
Recent studies in animals showed that direct epidural stimulation of the
primary motor cortex surrounding a small infarct in the affected
hemisphere elicits improvements in motor function.
In human beings, proof of
principle studies from different laboratories showed that non-invasive
transcranial magnetic stimulation and direct current stimulation that
upregulate excitability within M1affected hemisphere or
downregulate excitability in the intact hemisphere (M1intact
hemisphere) results in improvement in motor function in patients
with stroke. Possible mechanisms mediating these effects can include the
correction of abnormally persistent interhemispheric inhibitory drive from
M1intact hemisphere to M1affected hemisphere in the
process of generation of voluntary movements by the paretic hand, a
disorder correlated with the magnitude of impairment. In this paper we
review these mechanistically oriented interventional approaches.
These findings suggest
that transcranial magnetic stimulation and transcranial direct current
stimulation could develop into useful adjuvant strategies in
neurorehabilitation but have to be further assessed in multicentre
clinical trials ( The Lancet Neurology 2006; 5(8): 708-712).
Robot-aided therapy and the recovery of the hemiparetic arm after stroke.
A
limited number of clinical studies have examined the effect of poststroke
rehabilitation with robotic devices on hemiparetic arm function. The
authors systematically reviewed the literature to assess the effect of
robot-aided therapy on stroke patients' upper-limb motor control and
functional abilities (J Rehabil Res Dev. 2006 Mar-Apr;43(2):171-84).
Eight
clinical trials were identified and reviewed. For four of these studies,
the authors also pooled short-term mean changes in Fugl-Meyer scores
before and after robot-aided therapy. They found that robot-aided therapy
of the proximal upper limb improves short- and long-term motor control of
the paretic shoulder and elbow in subacute and chronic patients; however,
the authors found no consistent influence on functional abilities. In
addition, robot-aided therapy appears to improve motor control more than
conventional therapy.
Acupuncture for stroke
rehabilitation.
Acupuncture for stroke has been used in China for hundreds of years and is
increasingly
practiced in some Western countries.
The
authors searched the Cochrane Stroke Group Trials Register (November 2005),
the Cochrane Complementary Medicine Field Trials Register (November 2005),
the Cochrane Central Register of Controlled Trials (The Cochrane Library
Issue 3, 2005), MEDLINE (1966 to November 2005), EMBASE (1980 to November
2005), CINAHL (1982 to November 2005), AMED (1985 to November 2005), the
Chinese Stroke Trials Register (November 2005), the Chinese Acupuncture
Trials Register (November 2005), the Chinese Biological Medicine Database
(1977 to November 2005), the National Center for Complementary and
Alternative Medicine Register (November 2005), and the National Institute of
Health Clinical Trials Database (November 2005).
They hand
searched four Chinese journals and checked reference lists of all papers
identified for further trials (Cochrane Database Syst Rev. 2006 Jul 193:
CD004131).
Five
trials (368 patients) met the inclusion criteria. Methodological quality was
considered inadequate in all trials. Although the overall estimate from four
trials suggested the odds of improvement in global neurological deficit was
higher in the acupuncture group compared with the control group,this
estimate may not be reliable since there was substantial heterogeneity.
One trial
showed no significant improvement of motor function between the real
acupuncture group and the sham acupuncture group, but the confidence
interval was wide and included clinically significant effects in both
directions. No data on death, dependency, institutional care, change of
neurological deficit score, quality of life or adverse events were
available. The study concluded that currently there is no clear evidence on
the effects of acupuncture on subacute or chronic stroke. Large,
methodologically-sound trials are required.
Quality of Care
After Stroke
Limited data are available on management of outpatients with stroke
or transient ischaemic attack (TIA) and on clinicians’ reasons for
withholding procedures recommended by guidelines. This study
(Stroke. 2006; 37: 1844.) is assessing to what extent guidelines are
appropriately applied after ischaemic stroke or TIA, in admitted
patients as well as outpatients.
A survey was conducted in 11 centers in the Netherlands, which
prospectively enrolled 579 admitted patients and 393 outpatients.
Data were collected by trained research assistants.
Recommended acute procedures were provided in the majority of
admitted patients, but less often in outpatients: brain imaging (98%
and 93%, respectively), 12-lead ECG (96% and 81%), laboratory tests
(97% and 86%), aspirin within 48 hours (90% and 68% of eligible
patients). Secondary preventive measures were not always taken in
both eligible inpatients and eligible outpatients: carotid
endarterectomy (provided in 31% and 30% of patients), antiplatelet
agents (93% and 90%), oral anticoagulants (60% and 48%),
antihypertensive agents (57% and 44%), and cholesterol-lowering
therapy (71% and 52%). Reasons for withholding recommended
procedures were plausible for almost all admitted patients, but were
unclear in the majority of outpatients.
The study concluded that high-quality acute care is provided in
admitted ischaemic stroke patients, whereas secondary prevention was
comparably poor. Although the majority of the centers have
rapid-access TIA clinics, there is still substantial potential to
improve quality of stroke care in outpatients.
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February 2008
