The efficacy of Wii-based Movement Therapy for upper limb rehabilitation in the chronic poststroke period: a randomized controlled trial.

BACKGROUND: More effective and efficient rehabilitation is urgently needed to address the prevalence of unmet rehabilitation needs after stroke. This study compared the efficacy of two poststroke upper limb therapy protocols. AIMS AND/OR HYPOTHESIS: We tested the hypothesis that Wii-based movement therapy would be as effective as modified constraint-induced movement therapy for post-stroke upper-limb motor rehabilitation. METHODS: Forty-one patients, 2-46 months poststroke, completed a 14-day program of Wii-based Movement Therapy or modified Constraint-induced Movement Therapy in a dose-matched, assessor-blinded randomized controlled trial, conducted in a research institute or patient's homes. Primary outcome measures were the Wolf Motor Function Test timed-tasks and Motor Activity Log Quality of Movement scale. Patients were assessed at prebaseline (14 days pretherapy), baseline, post-therapy, and six-month follow-up. Data were analyzed using linear mixed models and repeated measures analysis of variance. RESULTS: There were no differences between groups for either primary outcome at any time point. Motor function was stable between prebaseline and baseline (P > 0·05), improved with therapy (P < 0·001); and improvements were maintained at six-months (P > 0·05). Wolf Motor Function Test timed-tasks log times improved from 2·1 ± 0·22 to 1·7 ± 0·22 s after Wii-based Movement Therapy, and 2·6 ± 0·23 to 2·3 ± 0·24 s after modified Constraint-induced Movement Therapy. Motor Activity Log Quality of Movement scale scores improved from 67·7 ± 6·07 to 102·4 ± 6·48 after Wii-based Movement Therapy and 64·1 ± 7·30 to 93·0 ± 5·95 after modified Constraint-induced Movement Therapy (mean ± standard error of the mean). Patient preference, acceptance, and continued engagement were higher for Wii-based Movement Therapy than modified Constraint-induced Movement Therapy. CONCLUSIONS: This study demonstrates that Wii-based Movement Therapy is an effective upper limb rehabilitation poststroke with high patient compliance. It is as effective as modified Constraint-induced Movement Therapy for improving more affected upper limb movement and increased independence in activities of daily living.

Botulinum toxin modulates cortical maladaptation in post-stroke spasticity.

INTRODUCTION: Maladaptive plasticity involving the unaffected hemisphere (UH) in stroke patients may contribute to post-stroke deficits, including spasticity. We investigated the central and peripheral effects of botulinum toxin in post-stroke spasticity to determine whether there is modulation of cortical processes in the UH. METHODS: Transcranial magnetic stimulation and peripheral nerve excitability studies were undertaken in 5 stroke patients with upper limb spasticity before (T1) and 6 weeks after (T2) botulinum injection. RESULTS: Transcranial magnetic stimulation demonstrated inexcitable motor cortices of the affected hemisphere at T1 and T2, and short-interval intracortical inhibition (SICI) in the UH was significantly reduced at T1. At T2, SICI in the UH increased significantly compared with T1, normalizing to controls, and was found to be associated with clinical improvements in spasticity. Peripheral excitability parameters were unchanged after injection. CONCLUSION: Cortical excitability changes were demonstrated in UH, suggesting that the clinical benefits of botulinum toxin relate to modulation of abnormal central reorganization (maladaptive plasticity) in post-stroke spasticity.

Investigating muscle selection for botulinum toxin-A injections in adults with post-stroke upper limb spasticity.

BACKGROUND: Limited empirical information exists regarding botulinum toxin-A injector decision-making practices for adult upper limb post-stroke spasticity. The design of most studies prevents such an assessment, as injection sites and dosage are mandated by researcher protocols. This contrasts to usual injector practices, where individualized decision-making is the standard of care. DESIGN: Secondary data analysis from an Australian randomized controlled trial of 90 adults with upper limb post-stroke spasticity where experienced clinicians followed their standard clinical injecting practice rather than a mandated injection regimen. METHODS: Clinicians were hypothesized to tailor their injection practices according to the subject's degree of spasticity and/or the type of functional gain desired. Hypothesis testing was conducted using non-parametric analysis. RESULTS: Muscle selection and botulinum toxin-A dosage were not significantly associated with spasticity severity or with patient-identified goals. Between-site differences in injection practices suggested that injector beliefs, rather than patient characteristics, were the dominant feature driving botulinum toxin-A injection strategy for post-stroke upper limb spasticity. CONCLUSION: This result looks into the "black box" of rehabilitation, revealing significant variation in injector beliefs. Findings suggest that further scientific work is required to maximize the efficacy of botulinum toxin-A injections in post-stroke upper limb spasticity management.

Stroke rehabilitation in Australia in a freestanding inpatient rehabilitation unit compared with a unit located in an acute care hospital.

OBJECTIVE: To study the functional outcome of stroke rehabilitation from 2 units that are similar in most aspects except for location: freestanding rehabilitation units (FSRU) versus acute care hospital (acute hospital rehabilitation unit [AHRU]). DESIGN: An observational retrospective cohort study. SETTING: Rehabilitation units in university-affiliated hospitals in Australia. METHODS: Five-year data on functional outcomes of stroke rehabilitation and rehabilitation process measures from an FSRU were compared with data from the subsequent 5 years after the same unit was relocated to an AHRU. MAIN OUTCOME MEASUREMENTS: Time from stroke onset to rehabilitation assessment, time to transfer to rehabilitation, length of stay (LOS), Functional Independence Measure (FIM) score, Motor Assessment Scale (MAS) score, transfer back to acute care, walking velocity, and discharge destination. RESULTS: Data on 357 patients from an FSRU and 372 patients from an AHRU who completed the rehabilitation program are presented. Baseline characteristics, such as age, gender, stroke location, stroke type, and risk factors, were similar in the 2 groups. There was no difference in outcomes such as FIM score, MAS score, walking velocity, or discharge destination. On regression analysis, the patients in an FSRU had a longer LOS (37.6 versus 35.9 days) and were more likely to be transferred to acute care than from an AHRU (12.4% versus 5.4%). The episode LOS (total LOS in acute and rehabilitation units) was nearly identical in the 2 settings at 52.6 days (15 in acute care + 37.6 days in an FSRU and 16.7 in acute care + 35.9 days in an AHRU). CONCLUSIONS: Stroke rehabilitation effectiveness is not related to the proximity of a rehabilitation facility to acute medical services. However, the increased need for the transfer of patients with medical complications from FSRU to acute care, longer LOS in an FSRU, and greater difficulty in obtaining consultations from other medical specialties persuade us to recommend a unit co-located with acute care services instead of an FSRU.

Treadmill walking with body weight support in subacute non-ambulatory stroke improves walking capacity more than overground walking: a randomised trial.

QUESTIONS: Is treadmill walking with body weight support during inpatient rehabilitation detrimental to walking quality compared with assisted overground walking? Does it result in better walking capacity, perception of walking or community participation? DESIGN: Analysis of secondary outcomes of a randomised trial with concealed allocation, assessor blinding and intention-to-treat analysis. PARTICIPANTS: 126 patients unable to walk within 4 weeks of a stroke who were undergoing inpatient rehabilitation. INTERVENTION: The experimental group undertook up to 30 minutes of treadmill walking with body weight support via an overhead harness per day while the control group undertook up to 30 minutes of overground walking. OUTCOME MEASURES: The secondary outcomes were walking quality and capacity, walking perception, community participation and falls. RESULTS: Six months after entering the study, there was no difference between the groups of independent walkers in terms of speed (MD 0.10 m/s, 95% CI -0.06 to 0.26) or stride (MD 6 cm, 95% CI -7 to 19). The independent walkers in the experimental group walked 57 m further (95% CI 1 to 113) in the 6 min walk than those in the control group. The experimental group (walkers and non-walkers) rated their walking 1 point out of 10 (95% CI 0.1 to 1.9) higher than the control group. There was no difference between the groups in community participation or number of falls. CONCLUSION: Treadmill training with body weight support results in better walking capacity and perception of walking compared to overground walking without deleterious effects on walking quality.

Randomized trial of treadmill walking with body weight support to establish walking in subacute stroke: the MOBILISE trial.

BACKGROUND AND PURPOSE: The main objective of this randomized trial was to determine whether treadmill walking with body weight support was effective at establishing independent walking more often and earlier than current physiotherapy intervention for nonambulatory stroke patients. METHODS: A randomized trial with concealed allocation, blinded assessment, and intention-to-treat analysis was conducted. One hundred twenty-six stroke patients who were unable to walk were recruited and randomly allocated to an experimental or a control group within 4 weeks of stroke. The experimental group undertook up to 30 minutes per day of treadmill walking with body weight support via an overhead harness whereas the control group undertook up to 30 minutes of overground walking. The primary outcome was the proportion of participants achieving independent walking within 6 months. RESULTS: Kaplan-Meier estimates of the proportion of experimental participants who achieved independent walking were 37% compared with 26% of the control group at 1 month, 66% compared with 55% at 2 months, and 71% compared with 60% at 6 months (P=0.13). The experimental group walked 2 weeks earlier, with a median time to independent walking of 5 weeks compared to 7 weeks for the control group. In addition, 14% (95% CI, -1-28) more of the experimental group were discharged home. CONCLUSIONS: Treadmill walking with body weight support is feasible, safe, and tends to result in more people walking independently and earlier after stroke. Trial Registration- ClinicalTrial.gov (NCT00167531).

Goal attainment scaling in the evaluation of treatment of upper limb spasticity with botulinum toxin: a secondary analysis from a double-blind placebo-controlled randomized clinical trial.

OBJECTIVE: To examine goal attainment scaling for evaluation of treatment for upper limb post-stroke spasticity with botulinum toxin-A. DESIGN: Secondary analysis of a multi-centre double-blind, placebo-controlled randomized clinical trial. SETTING: Six outpatient clinics in Australia. PARTICIPANTS: Patients (n=90) completing per protocol 2 cycles of treatment/placebo. Mean age 54.5 (standard deviation 13.2) years. Mean time since stroke 5.9 (standard deviation 10.5) years. INTERVENTIONS: Intramuscular botulinum toxin-A (Dysport 500-1000U) or placebo given at 0 and 12 weeks. Measurement points were baseline, 8 and 20 weeks. MAIN OUTCOME MEASURES: Individualized goal attainment and its relationship with spasticity and other person-centred measures - pain, mood, quality of life and global benefit. RESULTS: A significant treatment effect was observed with respect to goal attainment (Mann-Whitney z=-2.33, p< or = 0.02). Goal-attainment scaling outcome T-scores were highly correlated with reduction in spasticity (rho=0.36, p=0.001) and global benefit (rho=0.45, p<0.001), but not with other outcome measures. Goal-attainment scaling T-scores were lower than expected (median 32.4, interquartile range 29.6-40.6). Goals related to passive tasks were more often achieved than those reflecting active function. Qualitative analysis of goals nevertheless demonstrated change over a wide area of patient experience. CONCLUSION: Goal-attainment scaling provided a responsive measure for evaluating focal intervention for upper limb spasticity, identifying outcomes of importance to the individual/carers, not otherwise identifiable using standardized measures.

Do stroke patients with intracerebral hemorrhage have a better functional outcome than patients with cerebral infarction?

OBJECTIVE: To compare the functional outcome of stroke patients with cerebral infarction (CI) and intracerebral hemorrhage (ICH) after rehabilitation. DESIGN: Review of a prospectively maintained database of all stroke patients admitted to a rehabilitation unit during a 9.5-year period. SETTING: Rehabilitation unit in a university hospital in Australia. PATIENTS: A total of 718 consecutive stroke admissions (589 CI and 129 ICH) who met the inclusion criteria. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASUREMENTS: Functional Independence Measure (FIM) gain, FIM efficiency, Motor Assessment Scale (MAS) change, gait velocity, and discharge destination. RESULTS: Patients who had ICH were more severely disabled on admission compared with patients who had CI and achieved a greater functional improvement with rehabilitation, ie, a greater FIM efficiency and a greater MAS change. Admission FIM score, admission MAS score, and length of stay were significant explanatory variables for the discharge FIM and FIM gain in both ICH and CI patients. On general linear model analyses, stroke type remained a significant explanatory factor for FIM gain, after adjusting for admission FIM, length of stay, age, and days from stroke onset to rehabilitation admission, ie, stroke patients with ICH obtained a better functional outcome than patients with CI. Admission motor FIM, admission MAS, younger age, and increasing length of stay were independent predictors for FIM gain and discharge FIM for both CI and ICH groups. Admission cognitive FIM score predicted discharge FIM for both the CI and ICH groups and FIM gain in the ICH group but was not a predictor of FIM gain for the CI group. The majority of patients in both groups went home at discharge. CONCLUSIONS: Although patients with ICH had a greater level of disability on admission to rehabilitation, they achieved significantly greater gains in function than patients with CI after rehabilitation. This was found regardless of the severity of disability on admission.

Botulinum toxin A for treatment of upper limb spasticity following stroke: a multi-centre randomized placebo-controlled study of the effects on quality of life and other person-centred outcomes.

OBJECTIVE: Botulinum toxin is known to relieve upper limb spasticity, which is a disabling complication of stroke. We examined its effect on quality of life and other person-centred perspectives. DESIGN: A multi-centre, randomized, double-blind, placebo-controlled study. PATIENTS: Ninety-six patients were randomized (mean age 59.5 years) at least 6 months post-stroke. Mean time since stroke was 5.9 years. METHODS: Patients received either botulinum toxin type A or placebo into the affected distal upper limb muscles on 2 occasions, 12 weeks apart. Assessment was undertaken at baseline, 8, 12, 20 and 24 weeks. The primary outcome measure was the Assessment of Quality of Life scale (AQoL). Secondary outcome assessments included Goal Attainment Scaling (GAS), pain, mood, global benefit, Modified Ashworth Scale (MAS), disability and carer burden. RESULTS: The groups did not differ significantly with respect to quality of life, pain, mood, disability or carer burden. However, patients treated with botulinum toxin type A had significantly greater reduction in spasticity (MAS) (p < 0.001), which translated into higher GAS scores (p < 0.01) and greater global benefit (p < 0.01). CONCLUSION: Although no change in quality of life was demonstrated using the AQoL, botulinum toxin type A was found to be safe and efficacious in reducing upper limb spasticity and improving the ability to achieve personal goals.

Rehabilitation after total femur replacement: a report of 2 cases.

We describe the rehabilitation of 2 patients who underwent total femur replacement after neoplastic involvement of the bone. In the past, patients with cancer of the femur were generally advised to undergo a hip disarticulation or transfemoral amputation. It is now feasible to salvage the limb in selected patients, by excising the entire femur together with any contiguous soft tissue tumor and replacing it with an endoprosthesis. The surgical literature contains a number of reports on total femur replacement, which mention the rehabilitation aspects only briefly, but we found nothing on this relatively uncommon form of surgery in the rehabilitation literature. Physiotherapy techniques such as active assisted exercises, isometric exercises, and hydrotherapy are extremely useful during the early phase of rehabilitation to facilitate a graduated strengthening program. Certain exercises, such as active hip abduction or knee flexion, may not be permitted for several weeks to protect muscles that have been reattached to the prosthesis. Partial weight bearing may be required to allow incorporation of bone allograft around the prosthetic hip joint. Because of these factors patients with total femur replacement may need a longer period of rehabilitation (6-8wk) than patients with total hip or knee replacement. Patients with total femur replacement can, however, achieve full independence with an appropriate rehabilitation program.

Examination of shoulder positioning after stroke: A randomised controlled pilot trial.

Shoulder pain and stiffness is a serious problem in patients following stroke. The purpose of this study was to investigate the effect of a shoulder positioning protocol on shoulder joint pain and range in the affected upper limb. Twenty-eight subjects were randomly assigned to the experimental or control groups and participated in a multidisciplinary rehabilitation program. In addition, the experimental group received prolonged positioning of the shoulder daily for six weeks. Resting pain, pain on dressing, pain-free active abduction and passive external rotation range were measured on entry to the study and after six weeks. Twenty-three subjects completed the study. The differences between the groups were not statistically significant (p < 0.05), however, because of low statistical power the results are inconclusive.