Effects of Transcranial Direct Current Stimulation Combined With Neuromuscular Electrical Stimulation on Upper Extremity Motor Function in Patients With Stroke.

OBJECTIVE: The aim of the study was to investigate the treatment effects of transcranial direct current stimulation combined with neuromuscular electrical stimulation on the motor function of upper extremity in persons with stroke. DESIGN: This study was a pilot double-blind randomized controlled trial. Twenty-six patients due to stroke onset of more than 6 mos were randomly allocated to three groups: transcranial direct current stimulation combined with neuromuscular electrical stimulation group, transcranial direct current stimulation group, or control group. In addition to conventional rehabilitation, all subjects received one of the three protocols in a total of 15 sessions for 3 wks. RESULTS: A significant difference among the three groups was found for the change scores of the Fugl-Meyer Assessment upper extremity subscale from pretreatment to 1-mo follow-up (P = 0.02), in favor of the transcranial direct current stimulation combined with neuromuscular electrical stimulation group. Moreover, the transcranial direct current stimulation combined with neuromuscular electrical stimulation group showed significant within-group improvement on the Fugl-Meyer Assessment upper extremity (from preintervention to postintervention, P = 0.01) and the Action Research Arm Test (from preintervention to postintervention and to 1-mo postintervention, P = 0.03 and P = 0.04, respectively). CONCLUSIONS: This preliminary study reveals that combining transcranial direct current stimulation and neuromuscular electrical stimulation with regular rehabilitation programs may enhance better upper extremity functional improvement than regular rehabilitation programs alone in patients with chronic stroke.

Mechanism of Fatigue Induced by Different Cycling Paradigms With Equivalent Dosage.

Leg cycling is one of the most common modes of exercise used in athletics and rehabilitation. This study used a novel cycling setting to elucidate the mechanisms, central vs. peripheral fatigue induced by different resistance with equivalent works (watt∗min). Twelve male adults received low and relatively high resistance cycling fatigue tests until exhausted (RPE > 18) in 2 weeks. The maximal voluntary contraction, voluntary activation level, and twitch forces were measured immediately before and after cycling to calculate General (GFI), central (CFI), and peripheral (PFI) fatigue indices of knee extensors, respectively. The results showed that the CFI (high: 92.26 ± 8.67%, low: 78.32 ± 11.77%, p = 0.004) and PFI (high: 73.76 ± 17.32%, low: 89.63 ± 11.01%, p < 0.017) were specific to the resistance of fatigue protocol. The GFI is influenced by the resistance of cycling to support the equivalent dosage. This study concluded that the mechanism of fatigue would be influenced by the resistance of fatigue protocol although the total works had been controlled.

Immediate effects of noxious and innocuous thermal stimulation on brain activation in patients with stroke.

Case-control studies have shown that noxious thermal stimulation (TS) can improve arm function in patients with stroke. However, the neural mechanisms underlying this improvement are largely unknown. We explored functional neural activation due to noxious and innocuous TS intervention applied to the paretic arm of patients with stroke. Sixteen participants with unilateral cortical infarctions were allocated to one of two groups: noxious TS (8 patients; temperature combination: hot pain 46°C to 47°C, cold pain 7°C-8°C) or innocuous TS (n = 8; temperature combination: hot 40°C-41°C, cold 20°C-21°C). All subjects underwent fMRI scanning before and after 30 min TS intervention and performed a finger tapping task with the affected hand. Immediate brain activation effects were assessed according to thermal type (noxious vs. innocuous TS) and time (pre-TS vs post-TS). Regions activated by noxious TS relative to innocuous TS (P < .05, adjusted for multiple comparisons) were related to motor performance and sensory function in the bilateral primary somatosensory cortices, anterior cingulate cortex, insula, thalamus, hippocampus and unilateral primary motor cortex, secondary somatosensory cortex at the contralateral side of lesion, and unilateral supplementary motor area at the ipsilateral side of lesion. Greater activation responses were observed in the side contralateral to the lesion, suggesting a significant intervention effect. Our preliminary findings suggest that noxious TS may induce neuroplastic changes unconstrained to the local area.Trial registration: NCT01418404.

Influence of Alternate Hot and Cold Thermal Stimulation in Cortical Excitability in Healthy Adults: An fMRI Study.

Stroke rehabilitation using alternate hot and cold thermal stimulation (altTS) has been reported to improve motor function in hemiplegia; however, the influence of brain excitability induced by altTS remains unclear. This study examined cortical activation induced by altTS in healthy adults, focusing on motor-related areas. This involved a repeated crossover experimental design with two temperature settings (innocuous altTS with alternate heat-pain and cold-pain thermal and noxious altTS with alternate heat and cold thermal) testing both arms (left side and right side). Thirty-one healthy, right-handed participants received four episodes of altTS on four separate days. Functional magnetic resonance imaging scans were performed both before and after each intervention to determine whether altTS intervention affects cortical excitability, while participants performed a finger-tapping task during scanning. The findings revealed greater response intensity of cortical excitability in participants who received noxious altTS in the primary motor cortex, supplementary motor cortex, and somatosensory cortex than in those who received innocuous altTS. Moreover, there was more motor-related excitability in the contra-lateral brain when heat was applied to the dominant arm, and more sensory-associated excitability in the contra-lateral brain when heat was applied to the nondominant arm. The findings highlight the effect of heat on cortical excitability and provide insights into the application of altTS in stroke rehabilitation.

Effects of the hybrid of neuromuscular electrical stimulation and noxious thermal stimulation on upper extremity motor recovery in patients with stroke: a randomized controlled trial.

BACKGROUND: Neuromuscular electrical stimulation (NMES) and noxious thermal stimulation (NTS) have been developed and incorporated in stroke rehabilitation. OBJECTIVE: This study aimed to compare the effects of NMES, NTS, and the hybrid of NMES and NTS ("Hybrid") on motor recovery of upper extremity (UE) for patients with stroke. METHODS: We conducted a prospective, single-blind randomized controlled trial with concealed allocation. Forty-three patients with chronic stroke (onset >6 months) were randomly assigned to three groups (NMES, NTS, and "Hybrid"). In addition to conventional rehabilitation, participants received 30 min of NMES or 30 min of NTS or 15 min of NTS followed by 15 min of NMES. The treatment period was 8 weeks, 3 days/week, 30 min/time. The UE subscale of Fugl-Meyer assessment (UE-FMA, the primary outcome), Motricity index, modified Ashworth scale, and Barthel index were administered by a blinded assessor at baseline, posttreatment, and one-month follow-up. RESULTS: Most of the participants had mild-to-moderate disability in activity of daily living. No significant differences in the outcome measures at posttreatment and one-month follow-up were found among the NMES group (n = 13), NTS group (n = 13), and the hybrid of NMES and NTS group (n = 17). However, significant score changes in UE-FMA (p < 0.025) from baseline to posttreatment and one-month follow-up were found for the "Hybrid" group. CONCLUSIONS: This study reveals that the hybrid of NMES and NTS therapy appears to be beneficial to UE recovery after stroke but is not superior to NMES or NTS alone.

No Difference Between Noxious and Innocuous Thermal Stimulation on Motor Recovery of Upper Extremity in Patients With Acute Stroke: A Randomized Controlled Trial With 6-Month Follow-up.

BACKGROUND: Thermal stimulation (TS) has been developed and incorporated into stroke rehabilitation. However, whether noxious and innocuous TS induce the same effects on motor function recovery after stroke is still unknown. A comparative study of different temperature combination regimens is needed. OBJECTIVE: To compare the short- and long-term effectiveness between noxious and innocuous TS on motor recovery of upper extremity in patients with acute stroke. DESIGN: Randomized, controlled trial with concealed allocation, intention-to-treat analysis and blinded outcome assessors. SETTING: A university hospital rehabilitation department in Taiwan. PARTICIPANTS: A total of 79 patients with acute ischemic stroke were recruited. The majority had moderate to severe motor impairment of the upper extremity (UE). INTERVENTION: In addition to traditional rehabilitation, the experimental group (n = 39) underwent noxious TS (heat pain 46-47°C/cold pain 7-8°C), and the control group (n = 40) received innocuous TS (heat 40-41°C/cold 20-21°C). TS intervention was applied for 30 minutes once per day and for a total of 20-24 times during hospital stay. A custom-made TS instrument, comprising 2 thermal stimulators and their respective thermal pads constructed in a closed-loop system, was used. OUTCOMES: The Fugl-Meyer upper extremity score (the primary outcome), Action Research Arm Test, Motricity Index, Barthel Index, and modified Ashworth scale (the secondary outcomes) were administered by a blinded assessor at baseline, post-12th TS, post-intervention, 1-month, and 6-month follow-ups. RESULTS: No significant differences between groups were found on the primary outcome at postintervention and follow-up assessments. At 1-month follow-up, the innocuous group showed a small effect (partial η2 = 0.02) that was greater than that of the noxious group, but that effect was eliminated at 6 months. Both groups presented significant within-group improvements over time (both P < .001). CONCLUSIONS: Combining noxious TS with traditional rehabilitation did not yield better short-term or long-term results than combining innocuous TS with traditional rehabilitation on UE functional recovery for individuals with acute stroke. LEVEL OF EVIDENCE: II.

Effects of Transcranial Direct Current Stimulation With Sensory Modulation on Stroke Motor Rehabilitation: A Randomized Controlled Trial.

OBJECTIVE: To test whether a multistrategy intervention enhanced recovery immediately and longitudinally in patients with severe to moderate upper extremity (UE) paresis. DESIGN: Double-blind, randomized controlled trial with placebo control. SETTING: Outpatient department of a local medical center. PARTICIPANTS: People (N=25) with chronic stroke were randomly assigned to 1 of 2 groups: a transcranial direct current stimulation with sensory modulation (tDCS-SM) group (n=14; mean age ± SD, 55.3±11.4y) or a control group (n=11; mean age ± SD, 56.9±13.5y). INTERVENTIONS: Eight-week intervention. The tDCS-SM group received bilateral tDCS, bilateral cutaneous anesthesia, and high repetitions of passive movements on the paretic hand. The control group received the same passive movements but with sham tDCS and sham anesthesia. During the experiment, all participants continued their regular rehabilitation. MAIN OUTCOME MEASURES: Voluntary UE movement, spasticity, UE function, and basic activities of daily living. Outcomes were assessed at baseline, at postintervention, and at 3- and 6-month follow-ups. RESULTS: No significant differences were found between groups. However, there was a trend that the voluntary UE movement improved more in the tDCS-SM group than in the control group, with a moderate immediate effect (partial η2 [ηp2]=.14, P=.07) and moderate long-term effects (3-mo follow-up: ηp2=.17, P=.05; 6-mo follow-up: ηp2=.12, P=.10). Compared with the control group, the tDCS-SM group had a trend of a small immediate effect (ηp2=.02-.04) on reducing spasticity, but no long-term effect. A trend of small immediate and long-term effects in favor of tDCS-SM was found on UE function and daily function recovery (ηp2=.02-.09). CONCLUSIONS: Accompanied with traditional rehabilitation, tDCS-SM had a nonsignificant trend of having immediate and longitudinal effects on voluntary UE movement recovery in patients with severe to moderate UE paresis after stroke, but its effects on spasticity reduction and functional recovery may be limited.

Effect of thermal stimulation on corticomotor excitability in patients with stroke.

OBJECTIVE: This study examined the immediate effects of noxious and innocuous thermal stimulation intervention on corticomotor excitability for the paretic arm in patients with stroke. DESIGN: Sixteen patients with stroke for more than 3 mos were randomly assigned into the experimental and control groups. All participants received the thermal stimulation protocol on the affected arm for 30 mins. The experimental group received noxious heat (46°C-47°C) and cold (7°C-8°C) stimuli, and the control group received innocuous heat (40°C-41°C) and cold (20°C-21°C) stimuli. Corticomotor excitability was assessed to measure the motor threshold, size of cortical motor output map, and mean motor evoked potentials for the abductor pollicis brevis by focal transcranial magnetic stimulation before and after 30 mins of thermal stimulation intervention program. RESULTS: The findings of transcranial magnetic stimulation revealed a significant increase in map size of the affected hemisphere and mean motor evoked potentials in the experimental group. Moreover, significant differences in the change values of map size (7.0 [7.9] for the experimental group vs. -1.7 [2.9] for the control group, P = 0.03) and mean (SD) motor evoked potentials (0.4 [8.9] mV for the experimental group vs. -0.1 [0.1] mV for the control group, P = 0.03) were found. CONCLUSIONS: The preliminary results suggest that the noxious 30 mins of thermal stimulation intervention induced neurophysiologic changes in the motor cortex of the lesioned hemisphere.

Comparison of the test-retest reliability of the balance computerized adaptive test and a computerized posturography instrument in patients with stroke.

OBJECTIVE: To compare the test-retest reliabilities of the scores of the Balance Computerized Adaptive Test (CAT) and the Biodex Balance System in patients with stroke. DESIGN: A repeated-measures design (at a 1-wk interval) was used to examine the test-retest reliabilities of the scores of the Balance CAT and the Biodex Balance System. SETTING: One rehabilitation unit in a local hospital. PARTICIPANTS: Patients (N=50) with stroke for more than 6 months and undergoing outpatient rehabilitation completed the Balance CAT and the eyes open (EO)/closed (EC) tests, but only 17 patients finished the Limit of Stability (LOS) test because they were unable to reach all the targets. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The Balance CAT and 2 computerized tests of the Biodex Balance System, namely the EO/EC test and the LOS, were used to evaluate balance function. RESULTS: The test-retest reliabilities of the scores of the Balance CAT (Pearson r=.92, minimal detectable change [MDC] percent=12.8%) was excellent. Those of the EO/EC and LOS tests were poor to good (Pearson r=.56-.85, MDC%=50.8%-126.9%). CONCLUSIONS: The test-retest reliabilities of the scores of the Balance CAT were sufficient for assessing balance function in patients with stroke. Moreover, the test-retest reliabilities of the scores of the Balance CAT, one of the functional balance measures, were superior to those of the Biodex Balance System, 1 type of computerized posturography instrument. Therefore, the Balance CAT may be a more reliable measure for clinicians and researchers to use in assessing the balance function of patients with stroke for more than 6 months.

Effect of biofeedback cycling training on functional recovery and walking ability of lower extremity in patients with stroke.

This study aimed to investigate the effectiveness of biofeedback cycling training on lower limb functional recovery, walking endurance, and walking speed for patients with chronic stroke. Thirty-one patients with stroke (stroke onset >3 months) were randomly assigned into two groups using a crossover design. One group (N = 16; mean: 53.6 ± 10.3 years) underwent conventional rehabilitation and cycling training (30 minutes/time, 5 times per week for 4 weeks), followed by only conventional rehabilitation for another 4 weeks. The other group (N = 15; mean: 54.5 ± 8.0 years) underwent the same training in reverse order. The bike used in this biofeedback cycling training was the MOTOmed viva2 Movement Trainer. Outcome measures included the lower extremity subscale of Fugl-Meyer assessment (LE-FMA), the 6-minute walk test (6MWT), the 10-meter walk test (10MWT), and the modified Ashworth scale (MAS). All participants were assessed at the beginning of the study, at the end of the 4(th) week, and at the end of the 8(th) week. Thirty participants completed the study, including the cycling training interventions and all assessments. The results showed that improvements in the period with cycling training were significantly better than the noncycling period in the LE-FMA (p < 0.05), 6MWT (p < 0.001), 10MWT (p < 0.001), and MAS (p < 0.001) scores. No significant carryover effects were observed. The improvements on outcome measures were significantly different between the cycling period and the noncycling period after adjusting for potential confounding factors in the multivariate analysis of variance (p < 0.001). The study result indicates that the additional 4-week biofeedback cycling training could lead to improved LE functional recovery, walking endurance, and speed for patients with chronic stroke.

Effects of noxious versus innocuous thermal stimulation on lower extremity motor recovery 3 months after stroke.

OBJECTIVE: To examine the effects of thermal stimulation (TS) on the lower extremity (LE) movement and function in patients with stroke. DESIGN: A double-blinded randomized controlled trial. SETTING: A university hospital. PARTICIPANTS: Patients (N=34) at least 3 months after stroke were randomly assigned into the experimental and the control groups. INTERVENTIONS: In addition to regular rehabilitation, the experimental group received a 30-minute noxious TS protocol (heat pain 46-47°C/cold pain 2-3°C) 3days/wk for 8 weeks, and the control group received a 30-minute innocuous TS protocol (heat 40-41°C/cold 23-24°C) 3d/wk for 8 weeks. MAIN OUTCOME MEASURES: The Low Extremity subscale of the Stroke Rehabilitation Assessment of Movement (LE-STREAM), the Mobility subscale of STREAM (Mob-STREAM), the Functional Ambulation Category (FAC), the Barthel Index (BI), the Postural Assessment Scale for Stroke Patients (PASS), and the Modified Ashworth Scale (MAS) were administered by a blinded rater at baseline, posttreatment (8wk), and follow-up (12wk). RESULTS: Twenty-three participants completed the study protocol and all outcome measurements. No preexisting group differences between the experimental group (n=11) and the control group (n=12) were found on demographic and clinical variables. Compared with baseline, the experimental group showed significant improvements at posttreatment and follow-up on the LE-STREAM, Mob-STREAM, FAC, and BI (P<.05) while the control group showed no significant improvements for all outcome measures. As for the between-group comparison, significant differences were seen at follow-up (12wk) on the LE-STREAM, Mob-STREAM, BI, and MAS. CONCLUSIONS: Our findings indicate that an 8-week program of noxious TS combined with a traditional stroke rehabilitation program can improve the LE-related movement and function in patients with stroke for more than 3 months.

Test-retest reproducibility of two short-form balance measures used in individuals with stroke.

The aim of this study is to determine the test-retest reproducibility of the seven-item Short-Form Berg Balance Scale (SFBBS) and the five-item Short-Form Postural Assessment Scale for Stroke Patients (SFPASS) in individuals with chronic stroke. Fifty-two chronic stroke patients from two rehabilitation departments were included in the study. Both balance measures were administered twice 7 days apart. Test-retest reliability was analysed using the weighted κ (κ(w)) statistic for each item and intraclass correlation coefficients (ICC(2,1)) for the total scores of both measures. Agreement was expressed as the SEM, minimal detectable change and limits of agreement by Bland and Altman analysis. Test-retest agreements were good to very good for SFBBS and SFPASS, with weighted κ values ranging from 0.75 to 0.89 and 0.66 to 0.84, respectively. The ICCs for the total SFBBS and SFPASS scores were excellent (ICC(2,1): SFBBS=0.99; SFPASS=0.93). The SEMs for both measures were less than 10% of the score range; the minimal detectable changes of the SFBBS and SFPASS were 2.83 and 2.16, respectively, indicating that both measures had a small and acceptable measurement error. Both measures showed good reproducibility. These results indicate that the SFBBS and SFPASS are useful for clinicians and researchers for the evaluation of balance performance and to determine whether the change score of an individual with stroke is real.

Development of a computerized adaptive testing system of the Fugl-Meyer motor scale in stroke patients.

OBJECTIVE: To develop a computerized adaptive testing system of the Fugl-Meyer motor scale (CAT-FM) to efficiently and reliably assess motor function in patients with stroke. DESIGN: First, a simulation study was used to develop and examine the psychometric properties of the CAT-FM. Second, a field study was employed to determine the administration efficiency of the CAT-FM. SETTING: One medical center and 1 teaching hospital. PARTICIPANTS: Patients' responses (n=301) were used for the simulation study; 49 patients participated in the field study. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The 2 CAT-FM item banks (upper extremity and lower extremity) include 37 items from the original Fugl-Meyer scale. The reliability, validity, and responsiveness of the CAT-FM were determined by the simulation study. RESULTS: Two stopping rules (reliability ≥0.9 or an increase of reliability <.01 after testing an item) were used. The simulation study showed that the CAT-FM had high reliability (≥.93 for upper-extremity and lower-extremity subscales) and concurrent validity (Pearson r≥.91 for the upper-extremity and lower-extremity subscales and motor scale). The responsiveness was moderate (standardized response mean for the upper extremity=.67, lower extremity=.79, and motor=.77) for the 226 patients who completed both assessments at 14 and 90 days after stroke. The field study found that, on average, the time needed to administer the CAT-FM was 242 seconds with 4.7 items. CONCLUSIONS: The CAT-FM is an efficient, reliable, valid, and responsive clinical tool for assessing motor function in patients with stroke.

Development of a set of functional hierarchical balance short forms for patients with stroke.

OBJECTIVE: To develop a set of 3 hierarchical balance short forms (HBSF; containing sitting, standing, and stepping forms) to measure balance function in patients with stroke. DESIGN: First, we developed the HBSF, based on a previous data set, with each short form containing 6 items. Second, we examined the psychometric properties and efficiency of the HBSF. SETTING: Six teaching hospitals. PARTICIPANTS: Patients with stroke (n=764) for the first part of this study; inpatients and outpatients (n=85) for the second part of this study. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: We used the item bank (9 sitting-related, 14 standing-related, and 13 stepping-related items) from the Balance Computerized Adaptive Test to develop the HBSF. Both the HBSF and the Berg Balance Scale (BBS) were administered to patients, to determine the concurrent validity and time needed for administration of both measures. Each patient was assessed by 1 of the 3 short forms selected by a rater. RESULTS: The reliability of the HBSF was relatively high (reliability coefficients, .94-.95). The scores of the HBSF were highly correlated with those of the BBS (Spearman ρ=.80-.91), supporting the concurrent validity of the HBSF. The average time needed to administer the HBSF was 122 seconds (ie, about 40% of that for the BBS). CONCLUSIONS: Our results provide sufficient evidence that the HBSF is an efficient, reliable, valid, and practical way to measure balance function in patients with stroke.

Optimal scoring methods of hand-strength tests in patients with stroke.

The purpose of this study was to determine the optimal scoring methods for measuring strength of the more-affected hand in patients with stroke by examining the effect of reducing measurement errors. Three hand-strength tests of grip, palmar pinch, and lateral pinch were administered at two sessions in 56 patients with stroke. Five scoring methods were used to present the strength scores. The smallest real difference was used to provide information on the measurement error. The smallest real difference percentage was used to compare the effect on minimizing the error. Using mean score of tests for nonspastic patients carried out at least twice was found to be advisable to minimize measurement errors in the grip, palmar pinch, and lateral pinch tests. However, the use of hand-strength tests for patients with spasticity is limited because of the relatively high measurement errors.

Examining changes in self-perceived quality of life in children and adolescents with physical disability using a longitudinal design.

PURPOSE: The study aimed to investigate the changes in self-perceived quality of life (QOL) of children and adolescents with physical disability (PD). METHOD: Two hundred students aged 10-18 with PD were recruited from primary and high schools in Taiwan to participate in this longitudinal study. The Student Version of the Comprehensive Quality of Life Scale (COMQOL-S) was used to measure self-perceived QOL, which was recorded at baseline, and 6, 12 and 18 months post-baseline. Statistically, linear mixed models were used to compare the QOL scores among the four time points. RESULTS: At the second, third and fourth visit, 192, 151 and 128 participants completed COMQOL-S, respectively. Significant changes over time were found in overall objective and subjective OQL scores (slope = 0.8, p = 0.002 and slope = -1.3, p < 0.001, respectively). Specifically, significant reductions of the subjective QOL scores over the period of the four visits were observed in five domains, namely, Productivity (slope  =  -1.7, p = 0.005), Intimacy (slope  =  -1.6, p = 0.004), Safety (slope = -1.6, p = 0.008), Place in community (slope  =  -1.4, p = 0.019) and Emotional wellbeing (slope  =  -2.5, p < 0.001). Age was negatively correlated with the change of overall subjective score. Positive correlation was found between the change in mean objective scores and mean subjective scores in the Intimacy and Productivity domains. CONCLUSIONS: Even though the conditions of material wellbeing and health can be kept steady, the overall QOL of children and adolescents with PD could still decline over time. This might be attributable to the fact that social life becomes more sophisticated when children become older.

The relative and absolute reliability of leg muscle strength testing by a handheld dynamometer.

To examine the relative and absolute interrater reliability of handheld dynamometers (HHD) for assessing the lower extremity muscle strength, maximal voluntary contractions (MVCs) of 16 young adults for bilateral hip and knee muscles were tested using the break method. Three MVCs of each muscle group were required for obtaining the muscle strength. Participants' muscle strengths were tested by 2 raters. The intraclass correlation coefficients (ICCs) and the smallest real differences (SRD) were used to examine the relative and absolute reliabilities, and the Bland-Altman analyses were used to check whether systematic bias exists. The results showed that the relative reliabilities of all muscle groups were excellent (ICCs = 0.83-0.92) except for the knee extensors (ICC = 0.60). The SRD represents the smallest difference that indicates a real change for a single subject. The SRD% of all muscle groups was acceptable (ranging from 8.4 to 22.8 %), with the hip extensors being the smallest and knee extensors being the largest. The reliability of the knee extensors was unsatisfactory because of poor relative and absolute reliabilities and systematic bias. In addition to assessing the relative reliability in strength measurement, the absolute reliability provides the data of the measurement error, which is useful information in clinical practice to know whether the change in strength of a subject is real. Hand-held dynamometer is a reliable tool for quantifying most of the hip and knee strength except for the knee extensors. Modifying the measuring technique for knee extension is needed in future studies to improve the reliability.

Effect of thermal stimulation on upper extremity motor recovery 3 months after stroke.

BACKGROUND AND PURPOSE: To examine the effect of thermal stimulation (TS) on upper extremity (UE) motor recovery in patients at least 3 months after stroke. METHODS: Participants were randomly assigned to either the experimental group or the control group. In addition to regular rehabilitation programs, the experimental group received an UE-TS protocol for 30 minutes per day (3 days/week for 8 weeks); the control group received the same TS protocol on lower extremity. The UE subscale of the Stroke Rehabilitation Assessment of Movement and the Action Research Arm Test were primary outcome measures. The Modified Ashworth Scale and the Barthel Index were secondary outcome measures. All measures were administered at baseline, after TS, and at 1-month follow-up. RESULTS: Twenty-three participants (12 in the experimental group) completed the study. After treatment, the experimental group showed significant improvement compared to the control group in the scores of the UE subscale of the Stroke Rehabilitation Assessment of Movement and Action Research Arm Test. At follow-up examination, a significant improvement in the experimental group was observed on the UE subscale of the Stroke Rehabilitation Assessment of Movement. CONCLUSIONS: The 8-week additional UE-TS protocol improved UE motor recovery for stroke patients 3 months after onset.

Psychometric comparisons of 3 functional ambulation measures for patients with stroke.

BACKGROUND AND PURPOSE: We compared the test-retest reliability, validity, and responsiveness of the Dynamic Gait Index, the 4-item Dynamic Gait Index, and the Functional Gait Assessment for assessment of walking in patients with stroke. METHODS: Forty-five outpatients participating in the validity and responsiveness study were tested using the 3 walking measures as well as the 10-m walk test, Barthel Index, and Postural Assessment Scale for Stroke Patients. We tested them during the first week, then again after 2 months and 5 months of therapy. Another 48 chronic patients completed the 3 measures twice, 1 week apart, in the test-retest reliability study. RESULTS: Thirty-five participants completed 3 time-point assessments. The Functional Gait Assessment showed the least floor and ceiling effects, indicating it has the best discriminative ability for patients with stroke with high walking function. We found the 3 measures were highly correlated with each other, indicating excellent concurrent validity, and all measures at the first week of therapy were moderately to highly correlated with the Barthel Index scores at 5 months, indicating good predictive validity. Responsiveness of the 3 measures was moderate during a 5-month period, and all showed good test-retest reliability. The minimal detectable changes between tests indicate acceptable random error. CONCLUSIONS: All 3 measures showed sufficient validity, responsiveness, and reliability for assessment of walking function in patients with stroke undergoing rehabilitation, but the Functional Gait Assessment is recommended for its psychometric properties.

Psychometric comparisons of 4 measures for assessing upper-extremity function in people with stroke.

BACKGROUND: Functional limitation of the upper extremities is common in patients with stroke. An upper-extremity measure with sound psychometric properties is indispensable for clinical and research use. OBJECTIVE: The purpose of this study was to compare the psychometric properties of 4 clinical measures for assessing upper-extremity motor function in people with stroke: the upper-extremity subscale of the Fugl-Meyer Motor Test (UE-FM), the upper-extremity subscale of the Stroke Rehabilitation Assessment of Movement, the Action Research Arm Test (ARAT), and the Wolf Motor Function Test. DESIGN: This was a prospective, longitudinal study. METHODS: Fifty-three people with stroke were evaluated with the 4 measures at 4 time points (14, 30, 90, and 180 days after stroke). Thirty-five participants completed all of the assessments. The ceiling and floor effects, validity (concurrent validity and predictive validity), and responsiveness of each measure were examined. Interrater reliability and test-retest reliability also were examined. RESULTS: All measures, except for the UE-FM, had significant floor effects or ceiling effects at one or more time points. The Spearman rho correlation coefficient for each pair of the 4 measures was > or =.81, indicating high concurrent validity. The predictive validity of the 4 measures was satisfactory (Spearman rho, > or =.51). The responsiveness of the 4 measures at 14 to 180 days after stroke was moderate (.52 < or = effect size < or = .79). The 4 measures had good interrater reliability (intraclass correlation coefficient [ICC], > or =.92) and test-retest reliability (ICC, > or =.97). Only the minimal detectable changes of the UE-FM (8% of the highest possible score) and the ARAT (6%) were satisfactory. LIMITATIONS: The sample size was too small to conduct data analysis according to type or severity of stroke. In addition, the timed component of the Wolf Motor Function Test was not used in this study. CONCLUSIONS: All 4 measures showed sufficient validity, responsiveness, and reliability in participants with stroke. The UE-FM for assessing impairment and the ARAT for assessing disability had satisfactory minimal detectable changes, supporting their utility in clinical settings.