Manual mobilization of the wrist: a pilot study in rehabilitation of patients with a chronic hemiplegic hand post-stroke.

STUDY DESIGN: Prospective pilot cohort study, quasi-experimental design. INTRODUCTION: Restricted hand mobility, limitation in activities and participation, due to relative immobilization of the hemiplegic hand are frequently reported after stroke. PURPOSE OF THE STUDY: To establish whether manual mobilization of the wrist has an additional value in the treatment of the hemiplegic hand. METHODS: Eighteen patients received treatment twice a week for a period of 6 weeks. Both treatment groups received therapy based upon the Dutch guidelines for stroke. In the intervention group, a 10-min manual mobilization of the wrist was integrated. The primary outcomes were active and passive wrist mobility and activity limitation. The secondary outcomes were spasticity, grip strength, and pain. Data were collected at 0, 6 and 10 weeks. Statistical analysis was performed using the Friedman's test, related t-test, Wilcoxon test, independent t-test, and Mann-Whitney U-test. RESULTS: Statistically significant differences were found in the intervention group; between T0 and T2 measurements in active wrist extension (+18°; p < 0.001), in passive wrist extension (+15°; p < 0.001), and in the Frenchay Arm Test (+2 points, 18%; p = 0.038). This significant improvement was not found in the control group. Statistically significant differences were found between the two groups in active and passive wrist extension (p < 0.001; p = 0.002), as well as a change in Frenchay Arm Test (p = 0.01). CONCLUSION: This study suggests that manual mobilization of the wrist has a positive influence on the recovery of the hemiplegic hand. Replication of the results is needed in a large scale randomized controlled trial. LEVEL OF EVIDENCE: 4.

Comparison of electric stimulation methods for reduction of triceps surae spasticity in spinal cord injury.

OBJECTIVES: To compare the effect of 3 methods of electric stimulation to reduce spasticity of the triceps surae in patients with complete spinal cord injury (SCI) and to investigate the carryover effect. DESIGN: Placebo-controlled study with repeated measurements after the interventions. SETTING: Research department affiliated with a rehabilitation hospital in the Netherlands. PARTICIPANTS: Ten patients with a complete SCI were recruited from the outpatient population of the rehabilitation hospital. All subjects had American Spinal Injury Association grade A impairment scores, except for one, who had grade C. The patients had no voluntary triceps surae contractibility. INTERVENTIONS: Forty-five minutes of cyclic electric stimulation of the agonist, antagonist, or dermatome of the triceps surae or a placebo approach. MAIN OUTCOME MEASURES: Outcome measures were the Modified Ashworth Scale (MAS), clonus score, and the H-reflex and M wave (H/M) ratio. The electromyographic response to a stretch of the soleus over the whole range of motion was also determined. The magnitude and ankle angle at which the electromyographic response started were calculated. RESULTS: Stimulation of the agonist provided a significant reduction in the MAS compared with the placebo approach (P<.001). There was no significant change in the H/M ratio or the electromyographic response amplitude after any of the stimulation methods, whereas stimulation of the antagonist muscle resulted in a significant reduction in the ankle angle at which the electromyographic response started, compared with the placebo approach (P<.037). CONCLUSIONS: Triceps surae stimulation reduces the MAS for that specific muscle, whereas the angle at which the reflex starts changes after antagonist stimulation.

Effect of electrical stimulation of hamstrings and l3/4 dermatome on gait in spinal cord injury.

Objective. To determine the effect of electrical stimulation of hamstrings and L3/4 dermatome on the swing phase of gait. Materials and Methods. Five subjects with incomplete spinal cord injury (SCI) with spasticity were included. Two electrical stimulation methods were investigated, i.e., hamstrings and L3/4 dermatome stimulation. Both interventions were applied during the swing phase of gait. The main outcome measures were step length, maximum hip, and knee flexion during the swing phase of gait. In three subjects changes of spinal inhibition during gait were evaluated using the Hoffman reflex/m (motor)-wave (H/M) ratio at mid swing. Results. The hip flexion decreased 4.6° (p < 0.05) when the hamstrings were stimulated during the swing phase, whereas the knee flexion was not changed. The step length did not change significantly. One subject showed a decrease of the H/M ratio to a nonpathologic level during hamstrings stimulation. Conclusion. It was concluded that hamstrings stimulation during the swing phase results in a reduction of the hip flexion in all five SCI subjects. The H/M ratio of the vastus lateralis was normalized using hamstrings stimulation in one of three subjects. Stimulation of the L3/4 dermatome provides no significant changes in gait performance, but in one subject the H/M ratio increased.

Development of a new method for objective assessment of spasticity using full range passive movements.

OBJECTIVE: To develop a method for assessment of spasticity, in which the whole range of motion (ROM) at a wide variation of speeds is applied. DESIGN: Cross-sectional design to study construct validity. SETTING: Research department affiliated with a rehabilitation hospital in The Netherlands. PARTICIPANTS: Nine patients with complete spinal cord injury recruited from the rehabilitation hospital. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Thirty to 45 stretches over the whole ROM were applied to the triceps surae muscle at varying velocities measuring from 30 degrees to 150 degrees/s. Electromyographic responses were measured in order to assess reflex excitability. The torque over the ankle joint was measured during the whole stretch. The angle and velocity at which the reflex was initiated was also determined. RESULTS: The electromyographic responses increased significantly at increasing stretch velocities (P<.001). The applied maximum angles are reproducible (intraclass correlation coefficient, .81) and provide representative torque responses. CONCLUSIONS: The assessment method of spasticity using full range passive movements provides objective outcomes. The angular velocity is responsible for an exponential increase in amplitude of the electromyographic response.

Gait impairments in a group of patients with incomplete spinal cord injury and their relevance regarding therapeutic approaches using functional electrical stimulation.

The purpose of this study is to determine the most important impairments affecting the gait pattern of the incomplete spinal cord injury (SCI) patient and the potential impact of their treatment. The study consists of two parts. Firstly, a survey amongst 16 professionals was done to find out the impact of the impairments in incomplete-SCI patients. Secondly, gait data from 21 individuals were analyzed to determine the most common impairments. Frequently observed and relevant impairments were: inadequate hip extension (occurrence 76%), limited hip flexion (52%), limited knee flexion (71%), excess of plantar flexion (76%), and impaired foot contact (52%). In conclusion, for gait improvement in incomplete spinal cord injured patients not only ankle movements must be treated, which is done frequently, but also hip extension/flexion and knee flexion are important for gait restoration. The impact on the gait and potential solutions of these impairments are discussed.