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

Copyright © 2001 EDIZIONI MINERVA MEDICA

language: English

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


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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.

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