ABSTRACTS OF FIECENT LITEFiATURE ON 
TREATMENT OUTCOMES IN STROKE

A lthough very m any research stud ies on stroke w ere publish­
ed in the last tw o years, very few of them  w ere concerned w ith 
treatm ent outcom e. T h o se w hich w ere tended to be limited to 
investigating single treatm ent techniques or adjuncts to physio­
therapy treatm ent. N o t one study investigated the effects of 
neurodevelopm ental therapy in hem iplegia, highlighting the ur­
gent need for clinical research in this field.

T he follow ing abstracts w ere com piled by the Education C om ­
m ittee of IB ITA H , the International B obath Instructors A ssocia­
tion for A dult H em iplegia. They are reproduced w ith IB ITA H 's 
perm ission and w ith appreciation for w h at that organisation is 
doing to im prove our skills in the m anagem ent of hem iplegia and 
related conditions.

CAN SEN SORY STIMULATION IMPROVE THE FUNCTIONAL 
OUTCOME IN STRO KE PATIENTS?
Johanson K, Lindgren I, Widner H et al. Neurology Nov
1993:43(11);2189-92___________________________________
After obtaining informed consent, we randomised 78 patients with severe 
hemiparesis o f the left or right side within 10 days o f stroke onset: 40 to 
a control group receiving daily physiotherapy and occupational therapy, 
and 38 to a group that, in addition, we treated with sensory stimulation 
(acupuncture) twice a week for 10 weeks. The median age was 76 years 
for both groups. Motor function, balance, and ADL (Barthel’s Index) 
were assessed before the start of treatment and at 1 and 3 months after 
stroke onset; ADL was also assessed after 12 months. We assessed the 
quality of life fOI.) using the Nottingham Health Profile 3. 6 and 12 
months after stroke onset. Patients given sensory stimulation recovered 
faster and to a larger extent than the controls, with a significant difference 
for balance, mobility. ADL. OL. and days spent at hospital/nursing 
homes. Whether acupuncture per se is responsible for the differences 
requires further study.

RESTORATION OF GAIT IN NONAMBULATORY HEMI­
PARETIC PATIENTS B Y  TREADMILL TRAINING WITH PAR­
TIAL BODY-W EIGHT SUPPORT
Hesse S, Bertelt C, Schaffrin A et al. Arch Phys M ed R ehabil Oct 
1994:75(10); 1087-93____________________________________________

The effect of a treadm ill training w ith partial body-w eight 
support w as investigated in nine nonam bulatory hem iparetic 
patients w ith a m ean poststroke interval o f 129 days. They had 
received regular physiotherapy w ithin a com prehensive stroke 
rehabilitation program  at least 3 w eeks before the treadm ill train­
ing w ithout m arked im provem ent o f their gait ability. After 25 
additional treadmill training sessions scoring of functional per­
formance and conventional gait analysis show ed a definite im ­
provem ent: gait ability, assessed by the Functional Am bulation 
Category (0 to 5) im proved w ith a m ean of 2.2 points, other m otor 
functions, assessed by the Riverm ead M otor A ssessm ent Score 
w ith a m ean of +3.9 points for gross function (range 0 to 13) and 
of +3.2 points for leg and trunk section (range 0 to 10) and gait 
cycle param eters (p .01). M uscle tone and strength o f the paretic 
low er limb rem ained stable. W e suggest that treadm ill training 
with partial body-w eight support could augm ent restoration of 
am bulation and other m otor functions in hem iparetic patients by 
active and repetitive training.

THE EFFECTS OF CASTING ON UPPER E X T RE M ITY  MOTOR 
DISORDERS A FTER BRAIN INJURY
Hill J. Am J  Occup Ther. March 1994:48(3);219-24_________________
O BJECTIVES. This study compares casting to traditional techniques, 
such as passive range o f motion, static stretch, and splinting, in the 
treatment o f the hypertonic upper extremity in individuals with severe 
brain injury. METHOD. Fifteen subjects with brain injury were ran­
domly assigned to one o f two groups. One group received a month of 
casting followed by a month o f traditional therapy; the second group 
received 1 month o f traditional therapy followed by casting. The sub­
jects’ limbs were evaluated for range o f motion, clinical indications of 
spasticity, and functional use o f the extremity at three intervals —  before 
intervention, after the first month o f intervention, and after the second 
month o f intervention. Two sample t-tests and paired t-tests were used 
in data analysis. RESU LTS. All but one subject showed a greater 
improvement in range o f motion with casting than with traditional 
treatment; 11 subjects showed a greater improvement in clinical meas­
ures of spasticity with casting. There was no apparent correlation be­
tween these measures and functional use o f the extremity. CONCLU­
SION. These findings suggest that casting is more effective than tradi­
tional techniques in reducing contracture and in decreasing hypertonicity 
in some cases. T he greater improvements in these motor indicators with 
casting did not translate into greater gains in functional use of the upper 
extremities.

REHABILITATION OF WALKING WITH ELEC TRO M YO G ­
RAPHIC BIO FEED BA CK IN FOOT-DROP A FTER  STRO KE 
Intiso D, Snatilli V, Grasso M G et al. Stroke June 1994:25(6);! 189-92 
BACKGROUND AND PURPOSE: Alterations o f gait cycle and foot- 
drop on the paretic limb are characteristic of stroke patients. Elec­
tromyographic biofeedback treatment has been used in rehabilitation of 
walking, but results are controversial. We performed gait analysis to 
evaluate the efficacy of electromyographic biofeedback compared with 
physical therapy. METHODS. Sixteen patients with ischemic stroke 
were enrolled in the study. The experimental group (4 men, 4 women) 
received electromyographic biofeedback treatment together with physi­
cal therapy. The control group (5 men, 3 women) was treated with 
physical therapy only. Clinical and functional evaluations before and 
after treatment were performed using Canadian Neurological, Adams, 
Ashworth, Basmajian, and Barthel Index scales. Computerised gait 
analysis was performed in all patients. R ESU LTS. Electromyographic 
biofeedback patients showed significantly increased scores on the 
Adams scale (P .05) and Basmajian scale'fP .01). Gait analysis in this 
group showed a recovery of foot-drop in the swing phase (P .02) after 
training. CONCLUSIONS. Our data confirm that the electromyographic 
biofeedback technique increases muscle strength and improves recovery 
of functional locomotion in patients with hemiparesis and foot-drop after 
cerebral ischemia.

UPPER E X T REM ITY  W EIGHT-BEARING E FFEC T ON CORTI­
COSPINAL E X C ITA B IL ITY  FOLLOWING STRO KE 
Brouwer B J, Ambury P. Arch Phys M ed R eh ab il August
1994:75(8);861-6_______________________________________
The effects o f upper extremity weight-bearing on the excitability of 
corticospinal neurons projecting to the flexor carpi ulnaris (FCU) muscle 
of patients having had cerebrovascular accidents (strokes) were exam­
ined. Alternate transcranial magnetic and ulnar nerve stimulation were

SA J o u r n a l P h y s io th e r a p y , V o l 5 2  N o  2 M a y  1996 P a g e  4 5

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applied and peristimulus time histograms of single FCU motor unit 
discharge times were generated to provide information about the cortical 
and segmental postsynaptic potentials (PSPs), respectively. Recordings 
from 10 patients and 5 control subjects indicated the cortically evoked 
PSPs were initially abnormally small in the stroke group (p .01). 
Following weight-bearing the cortical projection strength to FCU mo­
toneurons increased in stroke patients (p .05) only. The composite group 
la PSP was reduced in 2 patients, but data could not be obtained from 
the remaining subjects. It is concludcd that upper extremity weight-bear- 
ing normalises corticospinal facilitation of FCU motor units in stroke 
patients. A sustained increase in motor cortical excitability through 
augmented afferent input may be responsible.

THE EFFECTS OF FUNCTIONAL ELECTRICAL STIMULATION 
ON SHOULDER SUBLUXATION, ARM FUNCTION RECOV­
E R Y , AND SHOULDER PAIN IN HEMIPLEGIC STROKE PA­
TIENTS.
Faghri P D, Rodgers M M, Glaser R M e l  al. A rch Phys M ed R ehabil
January 1994:75(l);73-9_________________________________________
The purpose of this study was to evaluate the effectiveness of a functional 
electrical stimulation (FES) treatment program designed to prevent 
glenohumeral joint stretching and subsequent subluxation and shoulder 
pain in stroke patients.
Twenty-six recent hemiplegic stroke patients with shoulder muscle 
flaccidity were randomly assigned to either a control group (n = 13; 5 
female, and 8 male) or experimental group (n = 13; 6 female, and 7 male). 
Both groups received conventional physical therapy. The experimental 
group received additional FES therapy where two flaccid/paralysed 
shoulder muscles (supraspinatus and posterior deltoid) were induced to 
contract repetitively up to 6 hours a day for 6 weeks. Duration of both 
the FES session and muscle contraction/relaxation ratio were progres­
sively increased as performance improved. The experimental group 
showed significant improvements in arm function, electromyographic 
activity of the posterior deltoid, range of motion, and reduction in 
subluxation (as indicated by x-ray) compared with the control group. We 
concluded that the FE S program was effective in reducing the severity 
of shoulder subluxation and pain, and possibly facilitating recovery of 
arm function.

IMMEDIATE EFFECTS OF THE TOE SPREADER ON THE 
TONIC TOE FLEXION REFLEX
de Saca LR, Catlin PA, Segal R L . Phys Ther. June I994:74(6);561-7Q 
BACKGROUND AND PURPOSE. The purpose o f the study was to 
determine whether the use of a toe spreader to inhibit the tonic toe flexion 
reflex (TTFR) immediately alters temporal-distance gait characteristics, 
plantar surface contact, or muscle activity in the limb exhibiting the 
TTFR of subjects with hemiparesis secondary to supraspinal lesion. 
SUBJECTS. Eighteen adults with hemiparesis secondary to supraspinal 
lesions served as subjects for the standing portion o f the study. Sixteen 
of the subjects participated in the gait portion of the study. METHODS. 
The study was a randomised, within-subject, between-conditions com­
parison consisting of standing and gait phases, with four conditions for 
each phase (shoe off, toe spreader off/on, shoe on, toe spreader off/on). 
Measures performed were ink footprint gait analysis and integrated 
electromyography from the limb exhibiting the TTFR. RESULTS. Pres­
ence of the TTFR  was reduced significantly with the use of the toe 
spreader Vp.Wity nnd radenee were increased significantly by use of 
the toe spreader. CONCH JSION AND DISCUSSION. The toe spreader 
may he a useful treatment option for improving gait. The clinical signifi­
cance o f these findings, however, will depend on the functional context 
of toe-spreader use.

REFLEX SYMPATHETIC DYSTROPHY IN HEMIPLEGIA - TWO 
CASE REPORTS AND REVIEW  OF THE LITERATURE 
Yen H L, Kong K H, Tan E S. Ann A cad  M ed Singapore May
1994:23(3);39l-5________________________________________________
Reflex sympathetic dystrophy (RSD) can be precipitated by a variety of 
events. We report two cases of RSD in hemiplegic patients detected 
within three months o f the cerebrovascular accidents. Diagnosis of RSD 
was based upon clinical and scintigraphic findings. Management in­
cluded elevation, range of movement of the affected joints and analge­
sics. With treatment, the pain and swelling subsided, range of motion of 
joints improved and the patients were able to participate in the rehabili­
tation programme. A high index of suspicion, early diagnosis and ag­
gressive treatment were found to be essential for the successful treatment 
of RSD.

SENSORY STIMULATION PROMOTES NORMALISATION OF 
POSTURAL CONTROL AFTER STROKE 
Magnusson M, Johansson K, Johansson B B. Stroke June
1994:25(6);! 176-80______________________________________________
BACKGROUND AND PURPOSE. In a randomised study of hemi­
paretic stroke patients with a median age of 75 years, functional recovery 
was significantly better in those who received additional sensory stimu­
lation (n = 38), including electrostimulation, than in control patients (n 
= 40) given the same physiotherapy and occupational therapy; group 
differences for balance, mobility, and activities of daily living were 
significant. The present study was designed to investigate postural 
control in patients who survived more than 2 years after stroke onset. 
METHODS. The 48 survivors (mean, 2.7 years; range, 2.0 to 3.8 years), 
22 from the treatment group and 26 from the control group, were 
compared with 23 age-matched healthy subjects. Subjects were per­
turbed by vibrators applied to calf muscles or with galvanic vestibular 
stimulation. We evaluated postural control in terms o f sway variances or 
sway velocities and the dynamics of postural control as a feedback 
system using system identification with a model previously validated for 
human postural control. RESULTS. Significantly more patients o f the 
treatment group than of the control group maintained stance during 
perturbations (P .01). Among patients capable of maintaining stance 
during perturbation, the control patients were characterised by signifi­
cant divergence from normal values in two of the three characteristic 
parameters of dynamic postural control (ie. swiftness and stiffness; P 
.05) compared with the' treatment subgroup or age-matched subjects. 
CONCLUSIONS. The course of sensory stimulation enhanced recovery 
of postural function, an enhancement still significant 2 years after the 
lesion and treatment. The differences and near normalisation o f charac- 
teristic parameters of dynamic postural control among treated patients 
suggest that improved recovery after sensory stimulation may be 
achieved by patients regaining normal or near normal dynamics of 
human postural control.

SIMILAR MOTOR RECOVERY OF UPPER AND LOW ER E X ­
TREMITIES A FTER STROKE
Duncan P W, Goldstein L B, Homer R D e /  al. Stroke June
1994:25(6);! 181-8_______________________________________________
BACKGROUND AND PURPOSE. This study examined the validity of 
the clinical tenet that poststroke recovery of the upper extremity is less 
rapid and complete than poststroke recovery o f the lower extremity. 
Previous studies comparing upper and lower extremity recovery have 
evaluated disability rather than motor impairment. Individuals with 
lower extremity impairments may be more functional and appear less 
disabled than individuals with upper extremity impairments. Function of 
the upper extremity requires finer motor control, for which the patient 
can less readily compensated. Therefore, impairments and disability

SA J o u r n a l P h y s io t h e r a p y : V o l 5 2  N o  2 M a y  1996 P a g e  4 7

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would predictably be more highly correlated in this area. We tested the 
hypothesis that upper and lower extremity motor recovery are similar, j  
METHODS. The 95 patients selected for this study were enrolled in the 
Durham County Stroke Study and had been diagnosed with anterior 
circulation ischemic stroke. Each subject received Fugl-Meyer assess­
ments within 24 hours o f admission and then 5, 30, 90, and 180 days 
after stroke. We used these assessments to compare the time course and 
patterns of motor function of the upper and lower extremities. R E ­
SULTS. Repeated-measures ANOVA revealed that percent maximal 
motor recovery was significantly (P .001) affected by time after stroke ] 
but not by extremity (upper extremity versus lower extremity) (P = .32). j 
When stroke severity level is controlled, the upper and lower extremities I 
continue to show no difference in percent motor recovery (P = .19). ' 
CONCLUSIONS. In patients with anterior circulation ischemic stroke, ‘ 
the severity of motor impairment and the patterns of motor recovery are i 
similar for the upper and lower cxtremities..The most rapid recovery for 
both extremities occurs within 30 days.

VOLUNTARY MOVEMENT AT THE ELBO W  IN SPASTIC 
HEMIPARESIS
Fellows S J, Kaus C, Thilmann AF. Ann N eurol Sept 1994:36(3);397-
407____________________________________________________________
The relative importance o f hyperreflexia and paresis in disturbances of 
voluntary arm movement was studied in a group o f patients (n = 25) with | 
spasticity arising from a unilateral ischemic cerebral lesion. Patient 
performance was evaluated against data obtained from normal subjects 
(n = 15). Spastic patients achieved lower maximum movement velocities 
during flexion or extension than did normal subjects. The more marked 
the paresis of the elbow flexor and extensor muscles of the patients, 
relative to the strength o f the normal subjects, the greater was this 
reduction in maximum velocity. For a given velocity, however, the time 
taken to complete a movement and the time to reach the peak velocity 
were normal. No relationship was found between the degree of impair­
ment of voluntary movement and the level of passive muscle hypertonia 
in the antagonist. Although overactivity o f the antagonist muscle may 
play some role in disturbance o f movements made at low velocities 
without an opposing load, antagonist activity during movements made 
against a load (ie. under more natural conditions) was at or below normal 
levels, even in those patients with the most marked passive muscle 
hypertonia. It is concluded that agonist muscle paresis, rather than 
antagonist muscle hypertonia, plays the dominant role in the disturbance 
of voluntary elbow movement following stroke.

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CPA NATIONAL 
CONGRESS 1996
■  Canadian Physiotherapy A ssociation: 

N ational Congress, Victoria, British 
Columbia. M ay 31 -  Ju n e 3.

The theme for this year's Congress -  Turn and Face the Change -  reflects the 
complex and changing health care environment in which physiotherapists are 
currently working. The daily themes of “Changing Models of Health Care 
Delivery”, “Evidence-Based Practice” and “Marketing/Education” emphasise the 
positive and pro-active role physiotherapists can play in developing and influ­
encing health care delivery and policy. ;jv;s 3  
On Thursday May 30 the Keynote 
s p e a k e r (op e n in g  c e re m o n y ) is 
Gwynne Dyer, PhD: “Been There,
Done That: The Politics of Change”.
Plenary speakers are:
31 May: Marilyn J Bruner: “Flinging 
Yourself Forward”.
1 June: Neil Oldridge, PhD: “Health- 
Related Quality of Life: Experience 
with Patients in Cardiac Rehabilitation 
and with Patients undergoing Lumbar Spinal Surgery”>
2 June: James Vargo, PhD: “Comfortable Change -  an Oxymoron”.
3 June: Shirley Sahrmann, PhD, P T: “Diagnosis-Based Practice: A Requirement 
for Changing Health Care Delivery and Evidence-Based Practice”.
The Plenary Wrap-up speaker on Monday 3 June is Nancy McKay, P T: “Shaping 
our Futures: Changes, Choices and Commitment”.

SA J o u r n a l P h y s io th e r a p y , V o l 5 2  N o  2 M a y  7 9 9 6  P a g e  4 9

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