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Official Journal of the , , , ,
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Indexed/Abstracted in: CINAHL, Current Contents/Clinical Medicine, EMBASE, PubMed/MEDLINE, Science Citation Index Expanded (SciSearch), Scopus
Impact Factor 2,063
Online ISSN 1973-9095
Boccignone A. *, Khan Sefid M., Rizzo G. *, Ortolani M., Orto-lani L.
From the Independent Orthopedic Rehabilitation Unit Padova University Hospital
*Rehabilitation Unit, ULSS 16, - Padova, Italy
Background. Hemiplegia of vascular origin is characterised by the lack of voluntary motor activity in the side of the body contralateral to the site of the central lesion. The resulting neurological symptoms are generally presented as a typical position: prevalent spastic hypertonia in the muscles with antigravity function, namely the flexor muscles of the arm and the extensor muscles of the leg. This distribution explains the typical position of the hemiplegic patient: the leg is stretched out with the foot tending to be club-footed and turned in; the arm abducted and semi-flexed, the wrist bent and the hand closed with the thumb inside the four fingers. This is what is usually meant by the synergic extensor pattern of the inferior limb and flexor of the superior limb. Instead we used the term movements outside the pattern to describe the possibility to recruit a muscle or group of muscles outside this synergic pattern. In clinical practice we observed that the capacity to voluntarily recruit the muscles of the paretic leg outside the synergic extensor pattern was, in terms of clinical observation, predictive of an improved recovery of upright stature control, a more efficient gait and an overall improvement in terms of self-sufficiency. Our study aimed to demonstrate the validity or otherwise of this proposal.
Methods. A prospective study was carried out over one year, between February 1999 and February 2000, and included patients who had been referred for physiatric consultancy during hospitalisation after stroke. This series included 45 patients, 18 women and 27 men, with a mean age of 70 years (SD 9.31), admitted to the Recovery and Functional Rehabilitation Ward of the Geriatric Hospital of Padua (USL 16). The first physiatric assessment, which was performed while the patient was on the acute ward, evaluated the voluntary motor activity (assisted or otherwise) of the inferior plegic limb. In particular, it evaluated the presence of voluntary recruitment of the hip and knee flexor and extensor muscles (the movements were performed in supine decubitus and while the foot remained in contact with the bed). After this evaluation, patients were divided into two groups: a first group of 36 patients with a mean age of 69 years (SD 9.64), 15 women and 21 men, who presented motor activity outside the synergic extensor pattern; a second group of 9 patients with a mean age of 74 years (SD 6.58), 3 women and 6 men, who only presented motor activity in the synergic extensor pattern.
The following rehabilitative techniques were used for hemiplegic patients: Bobath’s technique and therapeutic cognitive exercise. The choice of one or other technique was casual, depending on the availability of the Bobath or Perfetti therapist when the patient was admitted to the Recovery and Functional Re-education ward. In a field in which it is not always easy to choose and apply one of the numerous methods available, we used Functional Independence Measure (FIM) as a means of evaluating functional recovery given that it has been amply used in literature to evaluate hemiplegic patients owing to its validity, reliability and sensitivity. The study took place in two stages comprising an initial functional evaluation prior to rehabilitative treatment and one after treatment prior to discharge. The descriptive analysis was carried out by calculating the mean and standard deviation; results were analysed using the t-test for paired data to evaluate functional improvements within each group. Mann-Whitney’s test for summed ranks was used to evaluate the reliability of the presence of voluntary movements outside the normal pattern at the first physiatric assessment as a possible marker correlated to an improved functional outcome.
Results. In the group of patients with movements outside the normal pattern the FIM scale was performed an average of 38.4 days after stroke (SD 21.9). The mean score on entry was 45.83 (SD 17.5) and 90.1 (SD 23.6) on discharge after rehabilitative treatment lasting an average of 70.9 days (SD 45.4). In view of the data obtained, we can affirm that the group with the presence of movements outside the normal pattern showed a mean increase in FIM score of 47.9 points (SD 15.2). The results obtained, evaluated using the FIM scale, were statistically significant using the t-test for paired data (p<0.001).
In the group of patients who only presented movements that fitted the pattern the FIM scale was performed an average of 32.5 days after stroke (SD 8.4). The mean score on entry was 26.56 (SD 12.5) and 52.33 (SD 31.5) on discharge after rehabilitative treatment lasting an average of 79.3 days (SD 19.7). In view of the data obtained, we can affirm that the subgroup who only showed movements that fitted the pattern showed a mean increase in FIM score of 25.8 points (SD 20.5). Although to a lesser extent than in the first group, the results obtained were statistically significant using the t-test for paired data (p<0.01).
Conclusions. From a comparison of the two groups, it was observed that the group of hemiplegic patients who presented movements of the inferior plegic limb outside the normal pattern at the time of the first assessment showed a mean increase in FIM score which was 85.6% higher than that in the group of hemiplegics with movements that fitted the normal pattern, although the latter benefited from longer rehabilitative treatment (approximately 13% longer) than the first group. Using the Mann-Whitney test for summed ranks, we can affirm that the presence of movements of the inferior paretic limb outside the normal pattern at the first physiatric assessment is a positive predictive factor for the functional outcome at discharge evaluated using the FIM scale, with a statistical significance of p<0.002. These data and their subsequent statistical elaboration appear to confirm the initial hypothesis of our study. In the light of these results we believe we have identified a relatively efficient clinical marker for predicting the functional outcome of hemiplegic patients and if this finding is accepted by experts working in the rehabilitative field, it could be included in a multivariate analysis with the other predictive factors of functional outcome mentioned earlier, thereby enabling a higher degree of prognosis.