Measurement of ankle plantar flexor spasticity following stroke: Assessment of a new quantitative tool.

OBJECTIVE: To assess the ability of a newly developed portable instrument (the Electric Spastic Ankle Measure (E-SAM)) to quantitatively measure ankle plantar flexor muscle tone and spasticity. DESIGN: Comparison of quantitative measurements of the E-SAM with those obtained manually with the Modified Ashworth Scale (MAS). PARTICIPANTS: Seven adult men with stroke of more than 8 months' duration with a MAS score of 3, and 7 healthy age-matched control subjects. MAIN OUTCOME MEASURES: Quantitative measurements of the reactive and viscoelastic components of muscle tonus and spasticity. RESULTS: Analysis of the pooled data of all subjects revealed 2 components: an initial negative peak (indicating visco-elasticity), and subsequent positive peaks (denoting reactive contractions of the plantar flexor muscles). Positive, reactive contraction, peaks of the subjects with stroke were significantly higher than those of age-matched controls (p<0.01, t-test). CONCLUSION: The E-SAM appears to provide meaningful information on muscle tone and spasticity that is more specific and quantitative than that obtained with the MAS. While further study is necessary, this instrument shows promise as an easy-to-use clinical and research tool for the measurement of spasticity and muscle viscosity.

Comparative functional genomics revealed conservation and diversification of three enhancers of the isl1 gene for motor and sensory neuron-specific expression.

Islet-1 (Isl1) is a member of the Isl1 family of LIM-homeodomain transcription factors (LIM-HD) that is expressed in a defined subset of motor and sensory neurons during vertebrate embryogenesis. To investigate how this specific expression of isl1 is regulated, we searched for enhancers of the isl1 gene that are conserved in vertebrate evolution. Initially, two enhancer elements, CREST1 and CREST2, were identified downstream of the isl1 locus in the genomes of fugu, chick, mouse, and human by BLAST searching for highly similar elements to those originally identified as motor and sensory neuron-specific enhancers in the zebrafish genome. The combined action of these elements is sufficient for completely recapitulating the subtype-specific expression of the isl1 gene in motor neurons of the mouse spinal cord. Furthermore, by direct comparison of the upstream flanking regions of the zebrafish and human isl1 genes, we identified another highly conserved noncoding element, CREST3, and subsequently C3R, a similar element to CREST3 with two CDP CR1 recognition motifs, in the upstream regions of all other isl1 family members. In mouse and human, CRESTs are located as far as more than 300 kb away from the isl1 locus, while they are much closer to the isl1 locus in zebrafish. Although all of zebrafish CREST2, CREST3, and C3R activate gene expression in the sensory neurons of zebrafish, CREST2 of mouse and human does not have the sequence necessary for sensory neuron-specific expression. Our results revealed both a remarkable conservation of the regulatory elements regulating subtype-specific gene expression in motor and sensory neurons and the dynamic process of reorganization of these elements whereby each element increases the level of cell-type specificity by losing redundant functions with the other elements during vertebrate evolution.

Twenty-seven years of complication-free life with clean intermittent self-catheterization in a patient with spinal cord injury: A case report.

Currently, clean intermittent self-catheterization (CISC) is the most prevalent method of bladder management in patients with spinal cord injury (SCI) at discharge from rehabilitation centers. However, half of the patients discontinue using CISC and change to other methods of bladder management several months postdischarge despite the fact that it the best way to prevent urinary tract complications. Few studies, however, report the long-term consequences of CISC. In this case, we present a woman in her early fifties who had sustained thoracic SCI and had continued using CISC for 27 years without developing any complications. The possible reasons for her success were absence of incontinence because of underactive and normal capacity bladder; normal upper-extremity functions and absence of marked spasticity of lower extremities that facilitated CISC technique; and absence of sociovocational problems, enabling her to keep proper intervals between catheterizations each day. This case indicates that CISC is useful for long-term bladder management in patients with SCI, even for 25 years or more. Long-term outcomes of CISC and factors leading to success need to be delineated in future studies with larger samples.

Development of a new measure to assess trunk impairment after stroke (trunk impairment scale): its psychometric properties.

OBJECTIVE: The purpose of this study was to investigate reliability, validity, internal structure, and responsiveness of our newly developed Trunk Impairment Scale (TIS) for patients with stroke. DESIGN: A total of 73 patients with stroke participated in this prospective study. Interrater reliability (weighted kappa statistics), content validity (principal component analysis), concurrent validity (Spearman's rank correlation with the Trunk Control Test), predictive validity (prediction of discharge FIM scores), and responsiveness (standardized response mean values) were examined. Internal consistency and item difficulties were analyzed with Rasch analysis. RESULTS: The weighted kappa of each TIS item ranged from 0.66 to 1.0. Principal component analysis revealed that the TIS measured a domain similar to the Stroke Impairment Assessment Set trunk items but different from the Stroke Impairment Assessment Set motor and visuospatial items. The TIS correlated with the Trunk Control Test (r = 0.91). To predict discharge FIM motor scores, addition of the TIS as one of the predictors to age, time from onset, and admission FIM score increased the adjusted R2 from 0.66 to 0.75. With Rasch analysis, the misfit was acceptable, except for the abdominal muscle strength item. The difficulty patterns were similar at admission and discharge, except for the abdominal muscle strength item. The responsiveness of the TIS was satisfactory and comparable with that of the Trunk Control Test (standardized response mean values, 0.94 and 1.06). CONCLUSIONS: Our newly developed TIS is reliable, valid, and responsive for use in stroke outcome research.

Physical fitness in persons with hemiparetic stroke: its structure and longitudinal changes during an inpatient rehabilitation programme.

OBJECTIVE: To test the hypothesis that the structure of fitness in patients with hemiparetic stroke can be categorized into impairment/disability, cardiopulmonary, muscular and metabolic domains, and to study longitudinal changes in their fitness during an inpatient rehabilitation programme. DESIGN: Structure analysis of multiple fitness parameters with principal component analysis (PCA), and a before and after trial. SETTING: Tertiary rehabilitation centre in Japan. PATIENTS: One hundred and seven consecutive inpatients with hemiparetic stroke. INTERVENTION: A conventional stroke rehabilitation programme consisting of 80 minutes of physical therapy and occupational therapy sessions five days a week, and daily rehabilitation nursing for a median duration of 105.5 days. MAIN OUTCOME MEASURES: Principal component scores extracted from measurement of paresis/daily living (the Stroke Impairment Assessment Set (SIAS) and the Functional Independence Measure (FIM)); muscular (grip strength (GS), knee extensor torque, and cross-sectional areas of thigh muscles); metabolic (body mass index (BMI) and fat accumulation on CT); cardiopulmonary (heart rate oxygen coefficient (HR-O2-Coeff) obtained with a graded bridging activity and a 12-minute propulsion distance). RESULTS: PCA categorized the original 15 variables into four factors corresponding to paresis/activities of daily living, muscular, metabolic and cardiopulmonary domains, and explained 78.1% of the total variance at admission and 69.6% at discharge. Except the metabolic domain, PCA scores for the other three domains improved significantly at discharge (paired t-test, p < 0.05). CONCLUSION: The hypothetical structure of fitness was confirmed, and the PCA scores were useful in following longitudinal changes of fitness during inpatient rehabilitation.

Functional status and muscle strength in people with Duchenne muscular dystrophy living in the community.

OBJECTIVE: To describe activity limitation of people with Duchenne muscular dystrophy who are living in the community and to correlate it with age and muscle strength. DESIGN: Descriptive, correlational. SUBJECTS: Twenty-seven children with Duchenne muscular dystrophy aged 7-14 years who are living in the community. METHODS: The subjects' activity limitation was evaluated using the Functional Independence Measure and the muscle strength of their major upper and lower limb muscles was evaluated with manual muscle testing. The Functional Independence Measure was correlated with age and manual muscle testing, and the pattern of activities of daily living limitations and factors related to it were analysed. RESULTS: There were significant correlations between age and averaged MMT score (Spearman's rho = -0.63, p < 0.01), age and Functional Independence Measure motor score (rho = -0.52, p < 0.01), and Functional Independence Measure motor score and averaged manual muscle testing (rho = 0.77, p < 0.01). At similar manual muscle testing level, children with good cognitive function (Functional Independence Measure cognitive score > or = 26) showed significantly higher Functional Independence Measure motor scores than those with poor cognitive function (Mann-Whitney U test, p < 0.01). For individual Functional Independence Measure items, eating and bowel management were the easier, whereas transfer and stair climbing were the more difficult. Patients with mean muscle strength > or = grade 3 were rated as relatively independent, while those with a mean muscle strength < grade 3 were rated as maximal or total assistance (Mann-Whitney U test, p < 0.05). CONCLUSION: Activities of daily living in patients with Duchenne muscular dystrophy are related to age and muscle strength, and manual muscle testing grade 3 is an important cut-off point to predict their disability.

The physiological functional loss of single thenar motor units in the stroke patients: when does it occur? Does it progress?

OBJECTIVE: We examined the time at which loss of functioning motor units occurs on the hemiparetic side, the relationship between that loss and hemiparetic severity, and how long that loss continues. METHODS: Sample surface motor unit action potentials (S-MUAPs) were evoked in F-waves. They entirely represent the activity of the relative numbers of different shape S-MUAPs for each abductor pollicis brevis muscle. S-MUAPs from selected population of F-waves were averaged after aligning onset latency. Motor unit number was obtained by dividing the maximum M-potential negative peak amplitude by the averaged S-MUAP one. RESULTS: The motor unit number on the hemiparetic side was significantly lower than that on the unaffected side in stroke patients who had suffered hemiparesis for more than 9 days. This motor unit loss was greater in patients with severe hemiparesis. One year after onset, the chronic stroke patients showed the same motor unit loss on hemiparetic side as they had 3-4 months after onset. CONCLUSIONS: Motor unit loss on the hemiparetic side is present as early as the second week after onset and is correlated with hemiparesis severity, and this loss continues out to 1 year. This may be due to trans-synaptic degeneration that occurs secondarily to upper motor neuron lesion.

Rehabilitation research from a non-English speaking country published in peer-reviewed English journals--the Japanese experience.

PURPOSE: To study the status of contribution by non-English speaking countries to international rehabilitation literature taking Japan as an example, and to suggest recommendations to overcome the language barrier. METHOD: Descriptive study using a systematic MEDLINE search with outcome measures of annual numbers and proportions of articles by Japanese physiatrists published in peer-reviewed English rehabilitation journals, and of categories and types of studies. A database containing 292 relevant articles were used for analysis. RESULTS: The publications have steadily increased annually both in absolute number and in proportion. The number was the largest for Arch Phys Med Rehabil (16.8%), followed by Am J Phys Med Rehabil (12.3%), Prosthet Orthot Int (8.6%), Disabil Rehabil (5.1 %) and so on. The percentage by category was the highest for stroke (26.0%), followed by spinal cord injury (11.6%), neurophysiology (11.6%) and amputation (6.2%), 67.8% of the articles were related to evaluation, 6.5% to outcome studies and 25.7% to therapy. The majority were descriptive studies (45.5%), followed by case control studies (13.0%), before-and-after trials (12.3%), case reports (7.2%) and others. CONCLUSION: The contribution from Japan to international rehabilitation literature is increasing. Measures were suggested to facilitate more scientific contribution by non-English speaking researchers.

Trunk muscles in persons with hemiparetic stroke evaluated with computed tomography.

OBJECTIVES: To analyse side difference in bilateral trunk muscles in patients with hemiparetic stroke, to relate it with impairment and disability variables and to evaluate longitudinal changes. METHODS: In a sample of 83 inpatients with hemiparetic stroke undergoing rehabilitation, we measured the cross-sectional area of the paravertebral muscle and thigh muscles using computed tomography at admission and discharge. Classifying them by paravertebral muscle side difference (group I: contralateral > ipsilateral; II: contralateral = ipsilateral; III: contralateral < ipsilateral) we analysed group difference in the Stroke Impairment Assessment Set, the Functional Independence Measure and walk velocity. RESULTS: In contrast to thigh muscles, the paravertebral muscle cross-sectional area was significantly greater on the side contralateral to the brain lesion. Discharge paravertebral muscle cross-sectional area increased significantly from admission values. The Stroke Impairment Assessment Set, Functional Independence Measure and walk velocity were significantly lower in group I. CONCLUSION: The contralateral paravertebral muscle cross-sectional area was larger than the ipsilateral ones, and this was related to the degree of impairment and functional limitations.

Practical problems and management of seating through the clinical stages of Duchenne's muscular dystrophy.

OBJECTIVE: To describe seating problems in patients with Duchenne's muscular dystrophy (DMD), for the purpose of identifying management solutions that are practicable for both patient and caregiver. DESIGN: Case series. SETTING: A Japanese long-term care facility. PARTICIPANTS: Ninety-five patients with DMD (mean age, 15.9+/-4.4y; Swinyard stages: stage 5, n=17; stage 6, n=24; stage 7, n=33; stage 8, n=21). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Spinal deformity types, frequency and sites of pain, wheelchair propulsive ability, activities of daily living, and caregiving-related problems. RESULTS: Thirty-three percent of the patients belonged to the early straight group, 21% to the scoliotic group, 20% to the kyphoscoliotic group, 2% to the kyphotic group, and 24% to the extended spine group. The percentage needing support for sitting was higher in patients with spinal deformities (76% vs 0%, P<.05). Forty-one percent had pressure problems, and the percentage increased with advancing stages, with pain sites related to spinal deformity types. Self-feeding was difficult in 10 patients having spinal deformities. Four patterns of manual wheelchair propulsion were observed: upper extremity, anteroposterior trunk flexion, lateral trunk flexion, and wrist-hand patterns; and propulsion became increasingly less practical in this order. For toileting, more patients were cared for on wheelchairs with backrests reclined with stage progression. Of 60 caregivers, 58% experienced trauma related to seating systems. CONCLUSION: The seating problems that were identified enabled specific, practical suggestions to be made for better management.

Effect of pedaling exercise on the hemiplegic lower limb.

OBJECTIVE: To assess the effects of pedaling exercise on the muscle activities in hemiparetic lower limbs in patients with stroke. DESIGN: In this before-and-after trial, 17 nonambulatory patients with chronic hemiparetic stroke were recruited. Using a servo-dynamically controlled ergometer with a trunk support, the patients pedaled at a resistance of 5 N-m at their comfortable speeds. Muscle activities were recorded with surface electrodes from bilateral quadriceps femoris, medial hamstrings, tibialis anterior, and medial gastrocnemius, and integrated electromyograms were used for analysis of muscle activity patterns during the pedaling cycle. Muscle activities during pedaling were compared with those during voluntary knee extension of the affected limb before, immediately after, and 30 min after the pedaling. RESULTS: We found phasic muscle activities in the affected limb during pedaling that were antiphasic to the contralateral side. The muscle activities of quadriceps femoris and tibialis anterior increased significantly during pedaling compared with those during voluntary knee extension effort, whereas the muscle activity of medial hamstrings did not change. The postpedaling facilitation of quadriceps and tibialis anterior and the inhibition of gastrocnemius during voluntary knee extension effort lasted at least for 30 min. CONCLUSION: Pedaling could facilitate phasic and coordinated muscle activities even in patients with severe hemiparesis, and it is potentially an effective mode of muscle reeducation.

Psychometric properties of the Stroke Impairment Assessment Set (SIAS).

OBJECTIVE: To review the psychometric properties of the Stroke Impairment Assessment Set (SAS), which was developed in 1990 as a comprehensive instrument to assess stroke impairment. METHOD: Articles related to the SIAS were retrieved from the MEDLINE and the Folia Centro Japonica. RESULTS: Thirty-five articles were retrieved and analyzed. 1) Scale quality: Rasch analysis demonstrated the unidimensionality of the SIAS. Factor analysis produced factors corresponding to the 6 SIAS subscales. 2) Interrater reliability: The weighted kappas were high except for the unaffected side quadriceps item for which the score distribution was skewed. 3) Concurrent validity: Significant correlations were found between a) SIAS motor items and the Motricity Index or the Brunnstrom stage, b) SIAS lower extremity scores and the Functional Independence Measure (FIMSM) locomotion scores, c) trunk scores and abdominal manual muscle testing, d) visuospatial scores and line bisection and copying task scores, and e) speech scores and the FIMSM communication scores. 4) Predictive validity: Three studies attempting to predict discharge functional status demonstrated that adding the SIAS as one of the predictors enhanced the predictive power 5) Responsiveness: The SIAS was more responsive to changes than the Motricity Index, the Brunnstrom stage, or the National Institutes of Health Stroke Scale. CONCLUSION: The SIAS is a useful measure of stroke impairment with well-established psychometric properties.

Current status of rehabilitation medicine in Asia: a report from New Millennium Asian Symposium on Rehabilitation Medicine.

With the aim of promoting rehabilitation medicine in Asian countries, where the number of persons with disability occupies a significant proportion in the world, New Millennium Asian Symposium on Rehabilitation Medicine was held in February 2001 in Tokyo, under the sponsorship of the Japanese Association of Rehabilitation Medicine. Twenty-three guest speakers from 14 Asian countries and regions participated in the 2-day meeting. With a structured questionnaire that was sent to the participants beforehand, demographic data related to rehabilitation practice and information on training and certification in rehabilitation medicine in the participating countries were collected, and presented at the meeting. Based on these data, the current status of rehabilitation medicine in Asia was summarized. The symposium marked an important step forward for the promotion of rehabilitation medicine in Asia.

[Examination of living environment upon return to home for patients with cervical spinal cord injury--report of a case].

Living environment is a problem for spinal cord injury patients upon their return to the society. There are also many instances of home care problems after hospital discharge. For cervical spinal cord injury patients in particular, appropriate intervention/assistance provided by the authorities in accordance with the level of residual function is essential, but there have been few reports on this issue. Here we report on a municipal facility for cervical spinal cord injury patients where a patient moved into upon hospital discharge that did not provide a suitable environment, and the burden posed on his family increased. The patient was a 55-year-old man with traumatic cervical spinal cord injury who was commuting to our rehabilitation center after hospital discharge. We investigated the environment in the municipal housing facility he had moved into, and examined the relationship between the level of cervical spinal cord injury function and ADL assessment before and after hospital discharge. The main problems were an increase in care provided by his wife due to unsuitable toilet facilities and insufficient public facilities concerning the living environment. In terms of ADL by FIM (functional independence measure), namely, toilet transfer, toilet motion and defecation control which he had performed independently at the time of hospital discharge, all had decreased to a level requiring assistance after he moved into the present apartment. Therefore, approach via welfare equipment compensation were undertaken. As a result, the burden for his wife diminished, but the ADL and FIM scores obtained were low. Thus, the living environment facilities for patients with cervical spinal cord injuries should be in accordance with the level of function and ADL, suggesting the necessity for the authorities to establish a cooperative system for running home facilities.

[The necessity of community rehabilitation for outpatients with a communication disorder].

In order to explore the necessity of community rehabilitation, we conducted a questionnaire survey of patients with a communication disorder who had finished speech therapy at our hospital during the period of April 1998 to November 2001. A total of fifty-four subjects answered the questionnaire. The following observations were made based on the results. 1. Fifty-nine percent of the respondents was experiencing some degree of difficulties in their daily life, and facing some sorts of psychological and social problems. 2. Fifty nine percent considered community rehabilitation was necessary, while only one respondent was actually receiving it. 3. The majority of respondents wished there were speech therapists in their area to provide a variety of services such as recreation and rehabilitation. These results suggest the importance of speech therapy through local welfare and social care facilities.