Spasticity assessment with muscle coactivation of elbow flexors during passive stretch in Post-stroke Hemiplegia.

the assessment of muscle properties is an essential prerequisite in the treatment of post-stroke muscle spasticity. Previous studies have shown that muscle coactivation, which reflects the simultaneous activation of agonist and antagonist muscle groups, is associated with muscle spasticity during voluntary contraction. However, current spasticity assessment approaches do not often consider muscle coactivation for passive contraction measured with surface electromyography (sEMG). The purpose here is to evaluate the validity and reliability of muscle co-activation based on sEMG for assessing spasticity of post-stroke patients. This study was conducted on 39 chronic hemiplegia post-stroke patients with varying degrees of elbow flexor spasticity. The severity of spasticity was assessed with Modified Ashworth Scale (MAS). The patients produced elbow flexion passively on affected arm. Two-channel surface sEMG recordings were acquired simultaneously for the biceps and triceps muscles. The effectiveness and reliability of the EMG-based spasticity assessment method were evaluated using Spearman's correlation analysis and intra class correlation coefficients (ICCs). The results showed that there was a statistically significant positive relationship between the level of activity and the coactivation index (R=0.710, P=0.003), while the ICCs for intra trial measures ranged between 0.928 and 0.976. Muscle coactivation is a promising tool for continuously quantifying muscle spasticity in post-stroke patients, suggesting that the EMG-based muscle coactivation index could be useful for assessing motor function.

Assessment of responsiveness of four hand-related scales in stroke patients.

Self-reporting scales are commonly utilized in determining appropriate treatment strategies and follow-up in hand-related disorders. Responsiveness is described as the ability of a scale to detect clinically significant changes. We aimed to evaluate responsiveness of Michigan Hand Outcomes Questionnaire (MHQ), Duruöz Hand Index (DHI), Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and ABILHAND questionnaire in stroke patients. Fifty-one stroke patients were assessed in this descriptive study. Participants received conventional stroke rehabilitation program consisting of 30 sessions. Brunnstrom stages of the stroke patients were recorded before and after treatment. MHQ, DHI, DASH, ABILHAND questionnaire and patient satisfaction scores were filled in by participants before and after the conventional rehabilitation program. Significant improvements were found in MHQ, DHI, DASH, ABILHAND, patient satisfaction scores and Brunnstrom motor recovery stages after the rehabilitation program (p < 0.001). Responsiveness values of the scales were calculated as MHQ (effect size (ES) = - 0.74; standardized response mean (SRM) = - 1.25), DHI (ES = 0.64; SRM = 1.22), DASH (ES = 0.71; SRM = 1.01), and ABILHAND (ES = - 0.55; SRM = - 1.22). Our study revealed that MHQ, DHI, DASH and ABILHAND are responsive scales in detecting treatment-related changes in stroke patients. MHQ, DHI, DASH and ABILHAND can be used in the evaluation of treatment responses in stroke patients.

Validity and reliability of the Turkish versions of Assessment of Children's Hand Skills and Children's Hand-Skills Ability Questionnaire in children with hemiplegic cerebral palsy.

BACKGROUND: Assessment of Children's Hand Skills (ACHS) and Children's Hand-Skills Ability Questionnaire (CHSQ) are interconnected hand skills assessment tools that together contain parent questionnaire and observational assessment. With this quality, ACHS and CHSQ enable the therapist to obtain information about the child's real-life performances as well as to conduct a clinical observational assessment. The purpose of this study was to investigate the validity and reliability of the Turkish versions of ACHS and CHSQ in children with hemiplegic cerebral palsy (HCP). METHODS: A total of 112 children with HCP between 2 and 12 years of age were included. All participants were subjected to ACHS, CHSQ, Shriners Hospital Upper Extremity Evaluation (SHUEE) and ABILHAND-Kids. Convergent construct validity was investigated through analysing the relationship between ACHS and SHUEE and between CHSQ and ABILHAND-Kids. Discriminative construct validity was investigated through analysing the differences between genders for CHSQ and ACHS. For reliability, test-retest interclass correlation coefficient (ICC) and internal consistency Cronbach's alpha were calculated and analysed. RESULTS: ACHS showed very strong relationships with SHUEE's spontaneous functional analysis (r = 0.86) and grip-release function (r = 0.86) parameters with a strong relationship with positional dynamic analysis (r = 0.78). CHSQ's leisure (r = 0.80), school/education (r = 0.75) and activities of daily living (r = 0.76) domains showed strong relationships with the ABILHAND-Kids. There was no difference between genders for ACHS and all domains of CHSQ (p > 0.05). All domains and total score of ACHS and CHSQ had perfect test-retest reliability (ICC > 0.90). ACHS had perfect internal consistency (Cronbach's α = 0.98); CHSQ had very high internal consistency (Cronbach's α = 0.84). CONCLUSIONS: The Turkish versions of ACHS (ACHS-TR) and CHSQ (CHSQ-TR) are valid and reliable hand skills assessment tools in children with HCP.

Pulmonary barotrauma: assessment and investigation in divers.

Decompression illness (DCI) is an uncommon problem but can be significant in terms of morbidity and, very rarely, mortality. The mechanisms of DCI are pulmonary barotrauma and decompression sickness due to inert gas supersaturation. After the initial management phase, identification of predisposing factors is important to help advise divers regarding future risk and avoidance. Here we present four cases of DCI where pulmonary barotrauma was the likely causative mechanism. We highlight the important features in assessment for pulmonary barotrauma and advising divers on the risk of a recurrence.

Quantitative assessment of knee extensor thrust, flexed-knee gait, insufficient knee flexion during the swing phase, and medial whip in hemiplegia using three-dimensional treadmill gait analysis.

BACKGROUND: Most people with hemiplegia experience gait changes after a stroke. Abnormal gait patterns in stroke patients vary across subjects and this make it difficult to assess the cause of gait abnormalities. Therefore, it is necessary to quantitatively evaluate abnormal gait patterns through gait analysis for stroke patients. OBJECTIVE: To develop and evaluate the validity of quantitative assessments of the degree of knee extensor thrust, flexed-knee gait, insufficient knee flexion during the swing phase, and medial whip. METHODS: Forty-six healthy control subjects and 112 people with hemiplegia participated. From the 112 patients, 50 patients were selected into each abnormal gait pattern (knee extensor thrust, flexed-knee gait, insufficient knee flexion during the swing phase, and medial whip) with some overlap. Participants were instructed to walk on a treadmill and were recorded using a three-dimensional motion analysis system. An index to quantify each of the four abnormal gait patterns exhibited by the patients was calculated from the three-dimensional coordinate data. The indices were developed based on the definition of the abnormal gait patterns. The index values for the patients were compared with those of healthy subjects as well as with the results of observational gait assessment by three physical therapists with expertise in gait analysis. RESULTS: Strong correlation was observed between the index value and the median observational rating for all four abnormal gait patterns (-0.64 to -0.86). Most of the patients with an abnormal gait pattern had a higher index value than the healthy subjects. CONCLUSIONS: The use of these indices in gait analysis of people with hemiplegia can help to diagnose severity of gait disorder, determine the appropriate treatment, and evaluate the effectiveness of the treatment.

Relationship between functional connectivity and motor function assessment in stroke patients with hemiplegia: a resting-state functional MRI study.

INTRODUCTION: Resting-state functional magnetic resonance imaging (fMRI) has been used to examine the brain mechanisms of stroke patients with hemiplegia, but the relationship between functional connectivity (FC) and treatment-induced motor function recovery has not yet been fully investigated. This study aimed to identify the brain FC changes in stroke patients and study the relationship between FC and motor function assessment using the resting-state fMRI. METHODS: Seventeen stroke patients with hemiplegia and fifteen healthy control subjects (HCSs) were recruited in this study. We compared the FC between the ipsilesional primary motor cortex (M1) and the whole brain of the patients with the FC of the HCSs and studied the FC changes in the patients before and after conventional rehabilitation and motor imagery therapy. Additionally, correlations between the FC change and motor function of the patients were studied. RESULTS: Compared to the HCSs, the FC in the patient group was significantly increased between the ipsilesional M1 and the ipsilesional inferior parietal cortex, frontal gyrus, supplementary motor area (SMA), and contralesional angular and decreased between the ipsilesional M1 and bilateral M1. After the treatment, the FC between the ipsilesional M1 and contralesional M1 increased while the FC between the ipsilesional M1 and ipsilesional SMA and paracentral lobule decreased. A statistically significant correlation was found between the FC change in the bilateral M1 and the Fugl-Meyer assessment (FMA) score change. CONCLUSION: Our results revealed an abnormal motor network after stroke and suggested that the FC could serve as a biomarker of motor function recovery in stroke patients with hemiplegia.

Selective Control of the Upper Extremity Scale: validation of a clinical assessment tool for children with hemiplegic cerebral palsy.

AIM: The ability to determine the relationship between selective motor control and upper extremity function in children with unilateral cerebral palsy (CP), and to measure the functional outcome and efficacy of interventions designed to improve selective motor control, has been limited by the lack of an objective, validated tool. The primary objective of this study is to describe the development of a clinical tool entitled Selective Control of the Upper Extremity Scale (SCUES), and present evidence of its validity and reliability. METHOD: Content validity was established through an expert panel (eight clinicians, mean and median of 17y of clinical experience, range 2-30y). Intra- and interrater reliability was determined by six occupational therapists who scored 10 participant studies. Construct validity of the SCUES was established by comparison to the spontaneous functional analysis section of the Shriners Hospitals Upper Extremity Evaluation, the Manual Ability Classification System, and the Box and Block test for 25 children with unilateral CP. RESULTS: The content validity ratio values were greater than 0 (indicating >50% agreement) for 33 of the 34 items (97%), and equal or greater than 0.5 (indicating ≥75% agreement) for 26 of the 34 items (76%). Intrarater reliability was excellent (intraclass correlation coefficient [ICC] >0.75) for all segments and joints of the affected extremity. Interrater reliability was excellent for all segments and joints of the affected extremity except the shoulder (ICC=0.72). The SCUES was strongly correlated with the SHUEE (Spearman's rho=0.69, p=0.003). The SCUES was not correlated with the Manual Ability Classification System (rho=-0.24, p=0.369) or the Box and Block test (rho=0.47, p=0.066). INTERPRETATION: Psychometric analysis of the SCUES revealed comparable validity to other accepted video-based clinical assessment tools for the upper extremity in children with CP.

A low-cost body inertial-sensing network for practical gait discrimination of hemiplegia patients.

Gait analysis is widely used in detecting human walking disorders. Current gait analysis methods like video- or optical-based systems are expensive and cause invasion of human privacy. This article presents a self-developed low-cost body inertial-sensing network, which contains a base station, three wearable inertial measurement nodes, and the affiliated wireless communication protocol, for practical gait discrimination between hemiplegia patients and asymptomatic subjects. Every sensing node contains one three-axis accelerometer, one three-axis magnetometer, and one three-axis gyroscope. Seven hemiplegia patients (all were abnormal on the right side) and 7 asymptomatic subjects were examined. The three measurement nodes were attached on the thigh, the shank, and the dorsum of the foot, respectively (all on the right side of the body). A new method, which does not need to obtain accurate positions of the sensors, was used to calculate angles of knee flexion/extension and foot in the gait cycle. The angle amplitudes of initial contact, toe off, and knee flexion/extension were extracted. The results showed that there were significant differences between the two groups in the three angle amplitudes examined (-0.52±0.98° versus 6.94±2.63°, 28.33±11.66° versus 47.34±7.90°, and 26.85±8.6° versus 50.91±6.60°, respectively). It was concluded that the body inertial-sensing network platform provided a practical approach for wearable biomotion acquisition and was effective for discriminating gait symptoms between hemiplegia and asymptomatic subjects.

Further evidence of validity of the Modified Melbourne Assessment for neurologically impaired children aged 2 to 4 years.

AIM: This paper reports the second phase of a study to extend the Melbourne Assessment for use with children with neurological impairment aged 2 to 4 years. The aim was to establish if (1) children's scores on the Modified Melbourne Assessment (MMA) and the Quality of Upper Extremity Skills Test (QUEST) showed a moderate to high, positive relation, (2) children had comparable behaviours for task and time demands on both tools, and (3) scores on the MMA could discriminate between children with mild, moderate, and severe levels of upper limb impairment. METHOD: An observational study of 30 children (19 males, 11 females) with neurological impairment aged 2 to 4 years. Twenty-four children had spasticity (20 with a unilateral and four with a bilateral impairment) and two children presented with athetosis, two with ataxia, and two with hypotonia. RESULTS: A high, positive relation was found between children's scores on the MMA and the QUEST (ρ=0.90; p=0.001). The clinical use of the MMA was comparable to the QUEST. MMA scores were able to discriminate between children's levels of upper limb impairment as determined by clinicians' ratings (F(2,27) =67.76, p=0.001). INTERPRETATION: These findings suggest the MMA can be clinically useful for children as young as 2.5 years and has the advantage of being valid for use with older children. Scores from the tool can also provide therapists with a quantitative means of consistently reporting level of upper limb impairment.

Construction and pilot assessment of the Upper Limb Assessment in Daily Living Scale.

OBJECTIVE: The upper limb function of hemiplegic patients is currently evaluated using scales that assess physical capacity or daily activities under test conditions. The present scale, the Upper Limb Assessment in Daily Living (ULADL) Scale, was developed to explore the subjective and objective functional capacities of such patients in a proximal to distal sequence. METHODS: A group of experts constructed a scale addressing 17 upper limb functions (five active passive and 12 active) which could be explored by a questionnaire (Q) and a test (T). Reproducibility, internal consistency, concurrent validity (Rivermead Motor Assessment (RMA)) and learning effect were estimated in a multicentre study. RESULTS: 49 stroke patients were each rated three times within 7 days by a total of 21 physicians, yielding a total of 142 ratings. The ULADL took 16±8 min to complete compared with 9±5 min for the RMA. Cronbach's alpha coefficient was 0.95 for Q and 0.97 for the practical tests (T). The global Q and T scores, and in particular the global Q score, were slightly higher at the second rating. The intra-rater intraclass correlation coefficient (ICC) was 0.65 (95% CI (0.44 to 0.79)) for Q and 0.97 (0.95 to 0.98) for T, and the inter-rater ICC was 0.95 for both Q and T. The Bland and Altman method showed good intra- and inter-rater reliability with no systematic trend. Correlation coefficients for ULADL versus RMA were >0.80 for both Q and T. CONCLUSIONS: The ULADL Scale has good psychometric properties and can explore patients with different degrees of upper limb impairment.

Predicting hand motor recovery in severe stroke: the role of motor evoked potentials in relation to early clinical assessment.

OBJECTIVE: The primary aim of this study was to compare the predictive value of motor evoked potentials (MEPs) and early clinical assessment with regard to long-term hand motor recovery in patients with profound hemiplegia after stroke. METHODS: The sample was an inception cohort of 39 stroke patients with an acute, ischemic, supratentorial stroke and an initial upper-extremity paralysis admitted to an academic hospital. Hand motor function recovery was defined at 26 weeks poststroke as a Fugl-Meyer Motor Assessment (FMA) hand score>3 points. The following prognostic factors were compared at week 1 and week 3 poststroke: motor functions as assessed by the FMA upper-extremity and lower-extremity subscores, and the presence of an MEP in the abductor digiti minimi and biceps brachii muscle. RESULTS: Both the presence of an abductor digiti minimi-MEP and any motor recovery in the FMA upper-extremity subscore showed a positive predictive value of 1.00 at weeks 1 and 3. The FMA lower-extremity subscore showed the best negative predictive value (0.90; 95% CI 0.78-1.00 at week 1 and 0.95; 95% CI 0.87-1.00 at week 3). CONCLUSIONS: In stroke patients with an initial paralysis of the upper extremity the presence or absence of an MEP has similar predictive value compared with early clinical assessment with regard to long-term hand motor recovery.

Comparison of the Melbourne Assessment of Unilateral Upper Limb Function and the Quality of Upper Extremity Skills Test in hemiplegic CP.

This study investigated interrater reliability and measurement error of the Melbourne Assessment of Unilateral Upper Limb Function (Melbourne Assessment) and the Quality of Upper Extremity Skills Test (QUEST), and assessed the relationship between both scales in 21 children (15 females, six males; mean age 6y 4mo [SD 1y 3mo], range 5-8y) with hemiplegic CP. Two raters scored the videotapes of the assessments independently in a randomized order. According to the House Classification, three participants were classified as level 1, one participant as level 3, eight as level 4, three as level 5, one participant as level 6, and five as level 7. The Melbourne Assessment and the QUEST showed high interrater reliability (intraclass correlation 0.97 for Melbourne Assessment; 0.96 for QUEST total score; 0.96 for QUEST hemiplegic side). The standard error of measurement and the smallest detectable difference was 3.2% and 8.9% for the Melbourne Assessment and 5.0% and 13.8% for the QUEST score on the hemiplegic side. Correlation analysis indicated that different dimensions of upper limb function are addressed in both scales.

The interrater and intrarater reliability of the Modified Ashworth Scale in the assessment of muscle spasticity: limb and muscle group effect.

The Modified Ashworth Scale (MAS) is a clinical scale used to assess muscle spasticity. While the evidence indicates that the reliability of the MAS is better in the upper limb and in certain distal muscle groups, no investigation has compared the effect of limbs and muscle groups on the MAS reliability. This study aimed to evaluate the effect of limb and muscle group on the reliability of the MAS in patients with spastic hemiplegia. Thirty subjects with upper and lower limb muscle spasticity were recruited for this trial. Two female experienced physiotherapists participated in this examination of reliability, and rated each patient in a randomized order in a single session. For the intrarater reliability, the second rater repeated the test 1 week later. Shoulder adductor, elbow flexor, wrist flexor, hip adductor, knee extensor, and ankle plantar flexor were tested on the hemiplegic side. Results demonstrated moderate inter (kappa=0.514, SE=0.046, p < 0.001) and intrarater (kappa=0.590, SE=0.051, p<0.001) reliability. For the inter and intrarater reliability, the agreement obtained for the upper and lower limb was similar. In the upper limb, the agreement between raters on the distal wrist flexor was significantly higher than the agreement on the proximal shoulder adductor. In the lower limb, there was a similar agreement between raters on the distal ankle plantar flexor and proximal hip adductor. For within rater, the agreement on the proximal and distal muscles of both limbs was not statistically significant. The Modified Ashworth Scale had moderate reliability. The limbs had no effect on the reliability. The agreement on distal wrist flexor in the upper limb was significantly higher between rater than in the proximal shoulder adductor. The agreement obtained with the MAS was not good, which questions the validity of the measurements.

Analysis of the correlation between three methods used in the assessment of children with cerebral palsy.

The primary aim of this study was to assess the correlations between gait analysis, magnetic resonance imaging (MRI), and Gross Motor Function Measure (GMFM) scores in children with cerebral palsy (CP). These common diagnostic tools were used to evaluate 21 children affected by CP (mean age: 6 years, range: 5-13 years; 8 females and 13 males; 5 left hemiplegics, 4 right hemiplegics, 12 diplegics). In particular, in order to compare gait analysis data with other diagnostic evaluations, the Normalcy Index (NI) was used. The results showed a good correlation between the NI and the results of MRI, and between NI and the GMFM score (r=-0.76). Therefore, this investigation demonstrated that there exists a strong relationship between gait analysis and other clinical evaluation tools.

The Capacity Profile: a method to classify additional care needs in children with neurodevelopmental disabilities.

The aim of this study was to determine the interrater reliability and stability over time of the Capacity Profile (CAP). The CAP is a standardized method for classifying additional care needs indicated by current impairments in five domains of body functions: physical health, neuromusculoskeletal and movement-related, sensory, mental, and voice and speech, in children from 3 to 18 years of age. The intensity of care in each domain is defined from 0 (no need for additional care) to 5 (needs help with every activity). The intensity of additional care in each of the five separate domains indicates the CAP for the individual child. We developed the CAP to inform the parents and other caregivers of children with non-progressive, permanent neurodevelopmental disabilities, such as cerebral palsy and myelomeningocele, about the consequences of these conditions. To determine interrater agreement and stability over time, the CAPs of 67 children (39 males, 28 females) with a neurodevelopmental disability (mean age 18y [SD 1.2y]; range 14-22y) were assessed based on a semi-structured interview. In addition, the CAPs of the same individuals at the age of 3 years were determined based on a chart review. Interrater agreement of the CAP at the age of 3 was good to very good (weighted kappa 0.64-0.92). Agreement between the CAP at the age of 18 and the CAP at the age of 3 (providing evidence for stability over time) was also good (weighted kappa 0.68-0.77), except for the domain 'physical health functions', about which agreement was relatively poor (0.47). We conclude that the CAP is a reliable instrument for classifying the additional needs of a child with a non-progressive, permanent neurodevelopmental disability. The preliminary evidence for the stability over time of such needs according to the CAP should be validated in a prospective study.

Prechtl's assessment of general movements: a diagnostic tool for the functional assessment of the young nervous system.

General movements (GMs) are part of the spontaneous movement repertoire and are present from early fetal life onwards until the end of the first half a year of life. GMs are complex, occur frequently, and last long enough to be observed properly. They involve the whole body in a variable sequence of arm, leg, neck, and trunk movements. They wax and wane in intensity, force and speed, and they have a gradual beginning and end. Rotations along the axis of the limbs and slight changes in the direction of movements make them fluent and elegant and create the impression of complexity and variability. If the nervous system is impaired, GMs loose their complex and variable character and become monotonous and poor. Two specific abnormal GM patterns reliably predict later cerebral palsy: 1) a persistent pattern of cramped-synchronized GMs. The movements appear rigid and lack the normal smooth and fluent character. Limb and trunk muscles contract and relax almost simultaneously. 2) The absence of GMs of fidgety character. So-called fidgety movements are small movements of moderate speed with variable acceleration of neck, trunk, and limbs in all directions. Normally, they are the predominant movement pattern in an awake infant at 3 to 5 months. Beside a sensitivity and specificity of 95% each, the assessment of GMs is quick, noninvasive, even nonintrusive, and cost-effective compared with other techniques, e.g., magnetic resonance imaging, brain ultrasound, and traditional neurological examination.

Effect of rater training on reliability of Melbourne Assessment of Unilateral Upper Limb Function scores.

The aim of this study was to explore the effect of rater training on interrater reliability, internal consistency, standard error of measurement, and rater familiarity for the Melbourne Assessment of Unilateral Upper Limb Function. Twenty-four participants (raters) were randomly assigned to either 'trained' (n=12) or 'untrained' (n=12) interventions; they then scored the same nine video recordings of children completing the instrument. The age range of the children was 5 years 5 months to 12 years; there were six males, three females, all with spastic cerebral palsy (five with quadriparesis and four with hemiparesis); Gross Motor Function Classification System levels were I (n=3), II (n=3), III (n=1), and IV (n=2). All participants were novice occupational therapists and had no previous experience of using the instrument. A significant difference in perceived test familiarity was found after scoring but not before: trained raters scored higher. A significant difference in total scores for all cases was found and in eight of 16 individual item total raw scores. Again, trained raters scored higher. Interrater reliability was high in both groups, except item 6 (untrained). Internal consistency was high in both groups, except items 6 and 9 (untrained). We conclude that training for novice users increases familiarity and results in raters' perceiving higher levels of performance in some items. The Melbourne Assessment has high reliability even for novice users.

Melbourne Assessment of Unilateral Upper Limb Function: construct validity and correlation with the Pediatric Evaluation of Disability Inventory.

The Melbourne Assessment of Unilateral Upper Limb Function (Melbourne Assessment) is an evaluation tool that objectively measures upper-extremity function in children with cerebral palsy (CP). This study investigates how well performance on the Melbourne Assessment relates to the child's actual performance in functional tasks. Eighteen children with CP (5 to 14 years of age; nine males, nine females) were assessed using the Melbourne Assessment and the Pediatric Evaluation of Disability Inventory (PEDI). Five children had spastic quadriplegia, eight had spastic diplegia, two had spastic hemiplegia and diplegia, two had athetosis, and one had hypotonic quadriplegia with mobile ventilator dependence. Children's performances were statistically correlated using Spearman's rho to establish the relation between these tools. Very high correlation coefficients were calculated between the Melbourne Assessment and self-care (0.939) and mobility domains (0.783) of the PEDI and the overall functional skills section of the PEDI (0.718). The Melbourne Assessment demonstrates excellent construct validity for upper limb functioning.