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CURRENT ISSUEEUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE

A Journal on Physical Medicine and Rehabilitation after Pathological Events

Official Journal of the Italian Society of Physical and Rehabilitation Medicine (SIMFER), European Society of Physical and Rehabilitation Medicine (ESPRM), European Union of Medical Specialists - Physical and Rehabilitation Medicine Section (UEMS-PRM), Mediterranean Forum of Physical and Rehabilitation Medicine (MFPRM), Hellenic Society of Physical and Rehabilitation Medicine (EEFIAP)
In association with International Society of Physical and Rehabilitation Medicine (ISPRM)
Indexed/Abstracted in: CINAHL, Current Contents/Clinical Medicine, EMBASE, PubMed/MEDLINE, Science Citation Index Expanded (SciSearch), Scopus
Impact Factor 2,063

Frequency: Bi-Monthly

ISSN 1973-9087

Online ISSN 1973-9095

 

Europa Medicophysica 2001 June;37(2):93-9

    ORIGINAL ARTICLES

Predictive role of voluntary movements of the leg in the functional outcome of hemiplegia

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.

language: English


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