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Objective: To assess the effectiveness of alternating hot-cold water immersion (AHCWI) in patients with acute stroke., Design: A single-blind pilot randomized controlled trial., Setting: Department of Rehabilitation Medicine of a medical center., Participants: Early stroke survivors (N=24) with moderate-to-severe arm paresis., Interventions: In addition to conventional rehabilitation, eligible patients were randomly assigned to an AHCWI group (n=12, for AHCWI) or a control group (n=12, for upper limb [UL] cycling exercises) 5 times per week for 6 weeks., Main Outcome Measures: The Fugl-Meyer Assessment motor-UL (FMA-UL) score, Motricity Index-UL (MI-UL) score, modified Motor Assessment Scale (MMAS; including its UL sections, MMAS-UL) score, Berg Balance Scale score, Barthel Index (BI), and modified Ashworth Scale score were assessed by the same uninvolved physical therapist at baseline and after 4 and 6 weeks of intervention., Results: Compared with the control group, the AHCWI group performed better, with significant group effects (P<.05), and exhibited significant improvements in FMA-UL, MI-UL, and MMAS-UL scores at 4 and 6 weeks (P<.05). Although the remaining outcomes were not significantly different, they favored the AHCWI group. Notably, a significant difference was observed in the BI at 4 weeks (P=.032). Significant changes in the muscle tone or adverse effects were not observed in either group after the intervention., Conclusions: AHCWI with stroke rehabilitation is feasible and may facilitate motor function recovery of the paretic UL after a stroke., (Copyright © 2024 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To determine the accuracy of an algorithm, using clinical measures only, on a sample of persons with first-ever stroke in the United States (US). It was hypothesized that algorithm accuracy would fall in a range of 70%-80%., Design: Secondary analysis of prospective, observational, longitudinal cohort; 2 assessments were done: (1) within 48 hours to 1 week poststroke and (2) at 12 weeks poststroke., Setting: Recruited from a large acute care hospital and followed over the first 6 months after stroke., Participants: Adults with first-ever stroke (N=49) with paresis of the upper limb (UL) at ≤48 hours who could follow 2-step commands and were expected to return to independent living at 6 months., Intervention: Not applicable., Main Outcome Measures: The overall accuracy of the algorithm with clinical measures was quantified by comparing predicted (expected) and actual (observed) categories using a correct classification rate., Results: The overall accuracy (61%) and weighted κ (62%) were significant. Sensitivity was high for the Excellent (95%) and Poor (81%) algorithm categories. Specificity was high for the Good (82%), Limited (98%), and Poor (95%) categories. Positive predictive value (PPV) was high for Poor (82%) and negative predictive value (NPV) was high for all categories. No differences in participant characteristics were found between those with accurate or inaccurate predictions., Conclusions: The results of the present study found that use of an algorithm with clinical measures only is better than chance alone (chance=25% for each of the 4 categories) at predicting a category of UL capacity at 3 months post troke. The moderate to high values of sensitivity, specificity, PPV, and NPV demonstrates some clinical utility of the algorithm within health care settings in the US., (Copyright © 2021 The American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To investigate upper limb (UL) energy demand during unilateral arm crank submaximal exercise testing in individuals with stroke compared with healthy controls and the relationship between UL energy demand and UL activity in individuals with stroke., Design: Cross-sectional, observational study., Setting: Research laboratory., Participants: Individuals with chronic stroke (n=14) and controls (n=12), matched for age, sex, and body mass index (N=26)., Interventions: Not applicable., Main Outcome Measures: UL energy demand was measured as peak oxygen consumption (V̇o 2 )/peak load during unilateral arm crank submaximal exercise testing. UL activity was measured using the Box and Block Test (BBT) and Grooved Pegboard Test (GPT)., Results: The energy demand of the paretic side compared with the nonparetic side of the stroke group was 0.43 mL/kg/min/W (95% confidence interval, 0.03-0.83, P=.005) greater than the dominant compared with the nondominant side of the control group. The median difference between sides in peak V̇o 2 /peak load was 52% for the group with stroke compared with 11% for the control group. Positive correlations between the median percentage difference between the paretic and the nonparetic side of peak V̇o 2 /peak load and BBT were 0.72 (P=.004) and of V̇o 2 /peak load and GPT was 0.77 (P=.002)., Conclusions: The higher energy demand of the paretic UL during unilateral arm crank submaximal exercise testing than the nonparetic and both UL of the controls together with the strong relationship between energy demand and UL activity suggest that the energy demand of the paretic UL has the potential to affect real-life UL activity after stroke., (Copyright © 2021 The American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To investigate the STRoke Interactive Virtual thErapy (STRIVE) intervention on upper-extremity clinical outcomes in community-dwelling stroke survivors., Design: Assessor-blinded randomized controlled trial., Setting: Study screening and testing was conducted in a university clinic. Participants completed the virtual therapy (VT) intervention in a community-based stroke support group setting., Participants: Of 124 stroke survivors initially assessed, 60 participants were recruited (time poststroke, 13.4±8.9 y). Participants were allocated to either VT or control group using a block randomization design and were stratified by sex., Interventions: Participants were randomized to receive 8 weeks of VT or usual care. The intervention consisted of approximately 45 minutes of twice weekly VT training on the Jintronix Rehabilitation System., Main Outcome Measures: Between-group differences in the Fugl-Meyer Upper Extremity scale and Action Research Arm Test score were joint primary outcomes in this study., Results: Significant between-group differences for the Fugl-Meyer Upper Extremity scale were seen at the end of the intervention (F 1, 1 =5.37, P=.02, d=0.41). No significant differences were observed with the Action Research Arm Test. No adverse events were reported., Conclusions: We demonstrated clinically meaningful improvements in gross upper extremity motor function and use of the affected arm after a VT intervention delivered via a community-based stroke support group setting. This data adds to the contexts in which VT can be used to improve upper limb function. Use of VT in community-based rehabilitation in chronic stroke recovery is supported., (Copyright © 2020 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To investigate the effect of timing and magnitude of horizontally directed propulsive forces to the center of mass (COM) on the metabolic cost of walking (COW) for individuals poststroke., Design: Repeated-measures, within-subject design., Setting: Research laboratory., Participants: A total of 9 individuals with chronic hemiparesis poststroke and 7 unimpaired similarly aged controls (N=16)., Intervention: Individuals walked on a treadmill in 2 separate studies. First, we compared the metabolic COW with an anterior force applied to the COM that (1) coincided with paretic propulsion or (2) was applied throughout the gait cycle. Next, we compared the metabolic COW with anterior (assistive) or posterior (resistive) forces applied during paretic propulsion., Main Outcome Measure: Metabolic COW., Results: The COW was significantly greater in the Stroke group. Anterior (propulsive) assistance reduced the COW differently based on group. The Stroke group exhibited a 12% reduction in COW when assistance was provided only during paretic propulsion, but not when assistance was provided throughout the gait cycle. In contrast, the Control group demonstrated reduced COW during both anterior assistance conditions. In addition, we observed that resistance during paretic propulsion (simulated hemiparesis for Control group) significantly increased the COW., Conclusions: Systematically manipulating propulsive forces at the body's COM had a profound influence on metabolic cost. The timing of propulsive forces to the COM is important and needs to coincide with paretic terminal stance. Additional internally or externally generated propulsive forces applied to the body's COM poststroke may produce a lower metabolic COW., (Copyright © 2018 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To describe gait characteristics of patients without clinical evidence of lower limb hypertonia within 2 months of stroke and explore the relationship between gait and residual motor function., Design: Cohort study., Setting: Motion analysis laboratory in a tertiary-care free-standing rehabilitation hospital., Participants: Consecutive sample of 73 eligible inpatients (first-known stroke <2 months postonset, walking independently, modified Ashworth score of 0 in the paretic lower limb) and 27 healthy controls (N=100)., Interventions: Not applicable., Main Outcome Measures: Gait speed, stride and step lengths and cadences, stance time, single-support and double-support times, and associated symmetry measures in patients at self-selected normal speed and controls at very slow speed (51.1±32.6 cm/s and 61.9±21.8 cm/s, respectively, P=.115); Fugl-Meyer lower extremity motor score (FM-LE) and isometric knee flexion and extension strength in patients., Results: Except the stride/step cadence, all temporospatial parameters significantly differed between the stroke and control participants. Furthermore, significantly greater asymmetries were found in the patients for the overall stance time, initial double-support and single-support times, and step cadence, reflecting smaller values in the paretic than nonparetic limb. Most temporospatial parameters moderately to strongly correlated with the gait speed (|r|: .72-.94, P<.0001), FM-LE (|r|: .42-.62, P≤.0005), and paretic knee flexor strength (|r|: .47-.57, P≤.0004)., Conclusions: Gait of patients without clinical evidence of lower limb hypertonia within 2 months of stroke is characterized by many temporospatial deviations and asymmetries. The self-selected normal gait speed, FM-LE, and paretic knee flexor strength can discriminate gait impairments in these patients shortly before inpatient discharge. It remains to be determined whether the observed relationships between paretic knee flexor strength and gait measures warrant the development of interventions for strengthening of the paretic knee flexors in order to improve gait early poststroke., (Copyright © 2018 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To compare the effects of conventional core stabilization and dynamic neuromuscular stabilization (DNS) on anticipatory postural adjustment (APA) time, balance performance, and fear of falls in chronic hemiparetic stroke., Design: Two-group randomized controlled trial with pretest-posttest design., Setting: Hospital rehabilitation center., Participants: Adults with chronic hemiparetic stroke (N=28)., Interventions: Participants were randomly divided into either conventional core stabilization (n=14) or DNS (n=14) groups. Both groups received a total of 20 sessions of conventional core stabilization or DNS training for 30 minutes per session 5 times a week during the 4-week period., Main Outcome Measures: Electromyography was used to measure the APA time for bilateral external oblique (EO), transverse abdominis (TrA)/internal oblique (IO), and erector spinae (ES) activation during rapid shoulder flexion. Trunk Impairment Scale (TIS), Berg Balance Scale (BBS), and Falls Efficacy Scale (FES) were used to measure trunk movement control, balance performance, and fear of falling., Results: Baseline APA times were delayed and fear of falling was moderately high in both the conventional core stabilization and DNS groups. After the interventions, the APA times for EO, TrA/IO, and ES were shorter in the DNS group than in the conventional core stabilization group (P<.008). The BBS and TIS scores (P<.008) and the FES score (P<.003) were improved compared with baseline in both groups, but FES remained stable through the 2-year follow-up period only in the DNS group (P<.003)., Conclusions: This is the first clinical evidence highlighting the importance of core stabilization exercises for improving APA control, balance, and fear of falls in individuals with hemiparetic stroke., (Copyright © 2018 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To compare self-reported with sensor-measured upper limb (UL) performance in daily life for individuals with chronic (≥6mo) UL paresis poststroke., Design: Secondary analysis of participants enrolled in a phase II randomized, parallel, dose-response UL movement trial. This analysis compared the accuracy and consistency between self-reported UL performance and sensor-measured UL performance at baseline and immediately post an 8-week intensive UL task-specific intervention., Setting: Outpatient rehabilitation., Participants: Community-dwelling individuals with chronic (≥6mo) UL paresis poststroke (N=64)., Interventions: Not applicable., Main Outcome Measures: Motor Activity Log amount of use scale and the sensor-derived use ratio from wrist-worn accelerometers., Results: There was a high degree of variability between self-reported UL performance and the sensor-derived use ratio. Using sensor-based values as a reference, 3 distinct categories were identified: accurate reporters (reporting difference ±0.1), overreporters (difference >0.1), and underreporters (difference <-0.1). Five of 64 participants accurately self-reported UL performance at baseline and postintervention. Over half of participants (52%) switched categories from pre-to postintervention (eg, moved from underreporting preintervention to overreporting postintervention). For the consistent reporters, no participant characteristics were found to influence whether someone over- or underreported performance compared with sensor-based assessment., Conclusions: Participants did not consistently or accurately self-report UL performance when compared with the sensor-derived use ratio. Although self-report and sensor-based assessments are moderately associated and appear similar conceptually, these results suggest self-reported UL performance is often not consistent with sensor-measured performance and the measures cannot be used interchangeably., (Copyright © 2018 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To systematically characterize the effect of flexion synergy expression on the manifestation of elbow flexor stretch reflexes poststroke, and to relate these findings to elbow flexor stretch reflexes in individuals without neurologic injury., Design: Controlled cohort study., Setting: Academic medical center., Participants: Participants (N=20) included individuals with chronic hemiparetic stroke (n=10) and a convenience sample of individuals without neurologic or musculoskeletal injury (n=10)., Interventions: Participants with stroke were interfaced with a robotic device that precisely manipulated flexion synergy expression (by regulating shoulder abduction loading) while delivering controlled elbow extension perturbations over a wide range of velocities. This device was also used to elicit elbow flexor stretch reflexes during volitional elbow flexor activation, both in the cohort of individuals with stroke and in a control cohort. In both cases, the amplitude of volitional elbow flexor preactivation was matched to that generated involuntarily during flexion synergy expression., Main Outcome Measures: The amplitude of short- and long-latency stretch reflexes in the biceps brachii, assessed by electromyography, and expressed as a function of background muscle activation and stretch velocity., Results: Increased shoulder abduction loading potentiated elbow flexor stretch reflexes via flexion synergy expression in the paretic arm. Compared with stretch reflexes in individuals without neurologic injury, paretic reflexes were larger at rest but were approximately equal to control muscles at matched levels of preactivation., Conclusions: Because flexion synergy expression modifies stretch reflexes in involved muscles, interventions that reduce flexion synergy expression may confer the added benefit of reducing spasticity during functional use of the arm., (Copyright © 2017 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To compare sitting posture and movement strategies between chronic hemiparetic and healthy subjects while performing a drinking task, using statistical parametric mapping (SPM) and feature analysis., Design: Cross-sectional study., Setting: A university physical therapy department., Participants: Participants (N=26) consisted of chronic hemiparetic (n=13) and healthy individuals (n=13) matched for sex and age., Interventions: Not applicable., Main Outcome Measures: The drinking task was divided into phases: reaching, transporting the glass to mouth, transporting the glass to table, and returning to initial position. An SPM 2-sample t test was used to compare the entire kinematic waveforms of different joint angles (trunk, scapulothoracic, humerothoracic, elbow). Joint angles at the beginning and end of the motion, movement time, peak velocity timing, trajectory deviation, normalized integrated jerk, and range of motion were extracted from the motion data. Group differences for these parameters were analyzed using independent t tests., Results: At the static posture and beginning of the reaching phase, patients showed a shoulder position more deviated from the midline and externally rotated with increased scapula protraction, medial rotation, anterior tilting, trunk anterior flexion and inclination to the paretic side. Altered spatiotemporal variables throughout the task were found in all phases, except for the returning phase. Patients returned to a similar posture as the task onset, except for the scapula, which was normalized after the reaching phase., Conclusions: Chronic hemiparetic subjects showed more deviations in the proximal joints during seated posture and reaching. However, the scapular movement drew nearer to the healthy individuals' patterns after the first phase, showing an interesting point to consider in rehabilitation programs., (Copyright © 2017 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To compare the immediate effects of conventional treadmill gait and guidance tubing gait (GTG) on electromyographic neuromuscular imbalance and knee joint kinematics in hemiparetic gait., Design: Case-control study., Setting: University medical center., Participants: Participants (N=33; 19 men, 14 women) were patients with hemiparetic stroke (n=18 [experimental]; mean age ± SD, 39.2±16.8y) and healthy controls (n=15; mean age ± SD, 26.3±2.6y)., Interventions: The GTG was provided for approximately 30 minutes and involved application of an assistive guidance force using the tubing, specifically to improve knee joint stabilization during midstance and increase knee joint flexion during midswing phase., Main Outcome Measures: Clinical tests included the Korean Mini-Mental State Examination, Modified Ashworth Scale, Berg Balance Scale, manual muscle test, and knee joint range of motion and sensory tests. Knee joint muscle electromyographic and kinematic analyses were determined at pretest and posttest., Results: After the intervention, the experimental group showed significantly greater improvements in balanced quadriceps and hamstring electromyographic coactivation and knee joint kinematics relative to the control group (P=.005). The GTG intervention decreased overactive hamstring activity (P=.018) and reciprocally increased quadriceps activity (P<.001). The knee joint kinematic analysis showed significant changes in the hemiparetic stroke group (P=.004)., Conclusions: This study demonstrates the effectiveness of the tubing gait condition to restore knee joint muscle imbalance and kinematics in individuals with hemiparetic stroke who present with an abnormal hyperextension knee gait., (Copyright © 2016 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To compare the long-term effects of external focus (EF) and internal focus (IF) of attention after 4 weeks of arm training., Design: Randomized, repeated-measures, mixed analysis of variance., Setting: Outpatient clinic., Participants: Individuals with stroke and moderate-to-severe arm impairment living in the community (N=33; withdrawals: n=3)., Interventions: Four-week arm training protocol on a robotic device (12 sessions)., Main Outcome Measures: Joint independence, Fugl-Meyer Assessment, and Wolf Motor Function Test measured at baseline, discharge, and 4-week follow-up., Results: There were no between-group effects for attentional focus. Participants in both groups improved significantly on all outcome measures from baseline to discharge and maintained those changes at 4-week follow-up regardless of group assignment (joint independence EF condition: F 1.6,45.4 =17.74; P<.0005; partial η 2 =.39; joint independence IF condition: F 2,56 =18.66; P<.0005; partial η 2 =.40; Fugl-Meyer Assessment: F 2,56 =27.83; P<.0005; partial η 2 =.50; Wolf Motor Function Test: F 2,56 =14.05; P<.0005; partial η 2 =.35)., Conclusions: There were no differences in retention of motor skills between EF and IF participants 4 weeks after arm training, suggesting that individuals with moderate-to-severe arm impairment may not experience the advantages of an EF found in healthy individuals. Attentional focus is most likely not an active ingredient for retention of trained motor skills for individuals with moderate-to-severe arm impairment, whereas dosage and intensity of practice appear to be pivotal. Future studies should investigate the long-term effects of attentional focus for individuals with mild arm impairment., (Copyright © 2017 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To investigate the measurement properties of the Functional Test of the Hemiparetic Upper Extremity (FTHUE) and examine how its score may or may not inform design of a rehabilitation program., Design: The FTHUE was recently used in the Interdisciplinary Comprehensive Arm Rehabilitation Evaluation randomized controlled trial. This circumstance provided the opportunity to examine the psychometric properties of the FTHUE as it pertains to contemporary poststroke rehabilitation and recovery models., Setting: Outpatient rehabilitation clinic., Participants: Participants (N=109; mean age, 61.2±13.5y; mean days poststroke, 46±20.3) with resultant hemiparesis in the upper extremity., Interventions: Not applicable., Main Outcome Measures: Dimensionality was examined with confirmatory factor analysis (CFA), and person and item measures were derived with Rasch item response analysis. Therapists' notes were also reviewed., Results: The CFA results support unidimensionality, and 16 of 17 items fit the Rasch model. The Rasch person separation (2.17) and item separation (4.50) indices, ability strata (3.22), person reliability (.82), and item reliability (.95) indicate good measurement properties. Item difficulties ranked from -6.46 to 3.43 logits; however, there was a substantial ceiling effect of person measures. Post hoc examination of therapists' written observations indicated that the scoring criteria are not sensitive to the movement strategy used for task completion., Conclusions: The FTHUE's item difficulty hierarchy indicated that scores adequately distinguished the ability to perform simple versus complex motor movements of functional tasks. However, the FTHUE scoring method did not allow inclusion of the type of movement strategy used to accomplish task items. Therefore, we suggest modifications to the FTHUE that would allow it to be used for collaborative treatment planning and align well with more contemporary perspectives on treatment theory., (Copyright © 2017 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To examine the validity of 5 robot-based assessments of arm motor function poststroke., Design: Cross-sectional study., Setting: Outpatient clinical research center., Participants: Volunteer sample of participants (N=40; age, >18y; 3-6mo poststroke) with arm motor deficits that had reached a stable plateau., Interventions: Not applicable., Main Outcome Measures: Clinical standards included the arm motor domain of the Fugl-Meyer Assessment (FMA) and 5 secondary motor outcomes: hand/wrist subsection of the arm motor domain of the FMA, Action Research Arm Test, Box and Block test (BBT), hand motor subscale of the Stroke Impact Scale Version 2.0, and Barthel Index. Robot-based assessments included wrist targeting, finger targeting, finger movement speed, reaction time, and a robotic version of the BBT. Anatomical measures included percent injury to the corticospinal tract (CST) and extent of injury of the hand region of the primary motor cortex obtained from magnetic resonance imaging., Results: Participants had moderate to severe impairment (arm motor domain of the FMA scores, 35.6±14.4; range, 13.5-60). Performance on the robot-based tests, including speed (r=.82; P<.0001), wrist targeting (r=.72; P<.0001), and finger targeting (r=.67; P<.0001), correlated significantly with the arm motor domain of the FMA scores. Wrist targeting (r=.57-.82) and finger targeting (r=.49-.68) correlated significantly with all 5 secondary motor outcomes and with percent CST injury. The robotic version of the BBT correlated significantly with the clinical BBT but was less prone to floor effects. Robot-based assessments were comparable to the arm motor domain of the FMA score in relation to percent CST injury and superior in relation to extent of injury to the hand region of the primary motor cortex., Conclusions: The present findings support using a battery of robot-based methods for assessing the upper extremity motor function in participants with chronic stroke., (Copyright © 2017 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To determine the immediate effect of a portable, myoelectric elbow-wrist-hand orthosis on paretic upper extremity (UE) impairment in chronic, stable, moderately impaired stroke survivors., Design: Observational cohort study., Setting: Outpatient rehabilitation clinic., Participants: Participants exhibiting chronic, moderate, stable, poststroke, UE hemiparesis (N=18)., Interventions: Subjects were administered a battery of measures testing UE impairment and function. They then donned a fabricated myoelectric elbow-wrist-hand orthosis and were again tested on the same battery of measures while wearing the device., Main Outcome Measures: The primary outcome measure was the UE Section of the Fugl-Meyer Scale. Subjects were also administered a battery of functional tasks and the Box and Block (BB) test., Results: Subjects exhibited significantly reduced UE impairment while wearing the myoelectric elbow-wrist-hand orthosis (FM: t 17 =8.56, P<.0001) and increased quality in performing all functional tasks while wearing the myoelectric elbow-wrist-hand orthosis, with 3 subtasks showing significant increases (feeding [grasp]: z=2.251, P=.024; feeding [elbow]: z=2.966, P=.003; drinking [grasp]: z=3.187, P=.001). Additionally, subjects showed significant decreases in time taken to grasp a cup (z=1.286, P=.016) and increased gross manual dexterity while wearing a myoelectric elbow-wrist-hand orthosis (BB test: z=3.42, P<.001)., Conclusions: Results suggest that UE impairment, as measured by the Fugl-Meyer Scale, is significantly reduced when donning a myoelectric elbow-wrist-hand orthosis, and these changes exceeded the Fugl-Meyer Scale's clinically important difference threshold. Further, utilization of a myoelectric elbow-wrist-hand orthosis significantly increased gross manual dexterity and performance of certain functional tasks. Future work will integrate education sessions to increase subjects' ability to perform multijoint functional movements and attain consistent functional changes., (Copyright © 2017. Published by Elsevier Inc.)

Objectives: To determine the characteristics of motor planning surrounding initial contact during gait through examination of thigh muscle timing, amplitude, and co-contraction of the paretic and nonparetic limbs in people poststroke, and to investigate whether muscle timing, amplitude, and clinical performance measures of balance and mobility differ based on the level of co-contraction., Design: Observational study., Setting: University-based research laboratory., Participants: Individuals (n=27) in the subacute phase after stroke and healthy controls (n=8) (N=35)., Interventions: Not applicable., Main Outcome Measures: Timing (onset and offset) and normalized amplitude (percent electromyography maximum) of the biceps femoris (BF) and rectus femoris (RF) muscles were measured during terminal swing and early stance. A co-contraction index (CCI) was calculated for the BF and RF muscle activity. Individuals with CCI values equal to or below the mean of the healthy group were in the low CCI group, whereas those with values above the mean were in the high CCI group. Functional balance and mobility evaluation used the Community Balance and Mobility Scale (CB&M)., Results: For the paretic and nonparetic limbs, measures of timing, amplitude, and co-contraction were similar for both limbs. Compared with the healthy group, the high CCI group had lower CB&M scores, longer durations, and higher levels of RF and BF muscle activity, whereas the low CCI group had electromyographic measures statistically similar to healthy controls., Conclusions: The motor control of gait after subacute stroke is characterized by symmetry of timing and amplitude of muscle recruitment at the knee. High co-contraction levels surrounding the knee were associated with lower functional balance and mobility. These findings suggest a compensatory strategy of increased co-contraction in those with more impairment while maintaining symmetry of lower-limb biomechanics between limbs., (Copyright © 2016 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To examine whether selection of the nonparetic or paretic leg as the weight-bearing leg in item 13 (standing unsupported one foot in front) and item 14 (standing on one leg) of the Berg Balance Scale (BBS) influences the item scores, and thus the total score., Design: Cross-sectional study., Setting: University-based rehabilitation laboratory., Participants: Community-dwelling people (N=63, aged ≥50y) with chronic stroke., Interventions: Not applicable., Main Outcome Measure: BBS., Results: The 4 BBS total scores ranged from 48.4 to 50.7. The total score was significantly lower when a participant was asked to step forward with the nonparetic leg in item 13, and stand on the paretic leg in item 14. Fewer participants received a maximum score with the BBS1 formulation than the others. In addition, the correlations with walking speed and Activities-specific Balance Confidence Scale scores were greatest with the BBS1 score., Conclusions: Our findings suggest that BBS1 was the most challenging formulation for our participants; this might serve to minimize the ceiling effect of the BBS. These findings provide a rationale for amending the BBS administration guidelines with the BBS1 formulation., (Copyright © 2016 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To investigate (1) the intrarater, interrater, and test-retest reliability of the timed 360° turn test in subjects with stroke; (2) the concurrent validity of the timed 360° turn test by exploring its correlation with other measures of stroke-specific impairments; and (3) the cutoff times that best discriminate individuals with stroke from healthy older adults., Design: Cross-sectional study., Setting: University-based rehabilitation center., Participants: Individuals with chronic stroke (n=72) and healthy individuals (n=35) of similar age (N=107)., Interventions: Not applicable., Main Outcome Measures: The timed 360° turn test was administered along with the Fugl-Meyer assessment of the lower extremity, measurement of muscle strength of ankle dorsiflexors and plantarflexors using a handheld dynamometer, Berg Balance Scale, limit of stability test, five times sit-to-stand (FTSTS) test, 10-m walk test, and timed Up and Go (TUG) test., Results: The 360° turn times showed excellent intrarater, interrater, and test-retest reliability in individuals with stroke. A minimal detectable change of .76 seconds was found for subjects turning toward the affected side and 1.22 seconds for subjects turning toward the unaffected side. The 360° turn times were found to correlate significantly with Fugl-Meyer assessment of the lower extremity scores, dosiflexor strength of the affected ankle, plantarflexor strength of both ankles, FTSTS test times, balance performance, gait speed, and TUG test times. The 360° turn times of 3.43 to 3.49 seconds were shown to discriminate reliably between individuals with stroke and healthy older adults., Conclusions: The timed 360° turn test is a reliable and an easily administered clinical tool to assess the turning ability of subjects with chronic stroke., (Copyright © 2016 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To test the hypothesis that participants with stroke will exhibit appropriate increase in muscle activation of the paretic leg when taking a long step with the nonparetic leg compared to during steady-state walking, with a consequent increase in biomechanical output and symmetry during the stance phase of the modified gait cycle., Design: Single-session observational study., Setting: Clinical research center in an outpatient hospital setting., Participants: Adults with chronic poststroke hemiparesis (N=15)., Interventions: Participants walked on an instrumented treadmill while kinetic, kinematic, and electromyogram data were recorded. Participants performed steady-state walking and a separate trial of the long-step adaptability task in which they were instructed to intermittently take a longer step with the nonparetic leg., Main Outcome Measures: Forward progression, propulsive force, and neuromuscular activation during walking., Results: Participants performed the adaptability task successfully and demonstrated greater neuromuscular activation in appropriate paretic leg muscles, particularly increased activity in paretic plantarflexor muscles. Propulsion and forward progression by the paretic leg were also increased., Conclusions: These findings support the assertion that the nonparetic long-step task may be effective for use in poststroke locomotor rehabilitation to engage the paretic leg and promote recovery of walking., (Copyright © 2016 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To investigate whether elastic resistance training can induce comparable levels of muscle activity as conventional machine training in patients with chronic stroke., Design: Comparative study., Setting: Outpatient rehabilitation facility., Participants: Stroke patients (N=18) with hemiparesis (mean age, 57 ± 8y)., Interventions: Patients performed 3 consecutive repetitions at 10 repetition maximum of unilateral knee extension and flexion using elastic resistance and conventional machine training., Main Outcome Measures: Surface electromyography was measured in vastus lateralis, vastus medialis, biceps femoris, and semitendinosus and was normalized to maximal electromyography (% of max) of the nonparetic leg., Results: In the paretic leg, agonist muscle activity ranged from 18% to 24% normalized electromyography (% of max) (nEMG) during knee flexion and from 32% to 40% nEMG during knee extension. For knee extension, vastus lateralis nEMG was higher during machine exercise than during elastic resistance exercise (40% [95% confidence interval {CI}, 33-47] vs 32% [95% CI, 25-39]; P=.003). In the nonparetic leg, agonist muscle activity ranged from 54% to 61% during knee flexion and from 52% to 68% during knee extension. For knee flexion semitendinosus nEMG was higher (61% [95% CI, 50-71] vs 54% [95% CI, 44-64]; P=.016) and for knee extension vastus medialis nEMG was higher (68% [95% CI, 60-76] vs 56% [95% CI, 48-64]; P<.001) during machine exercise than during elastic resistance exercise. By contrast, antagonist coactivation was significantly higher during knee flexion when performed using elastic resistance compared with the machine. Lastly, there were no differences in perceived exertion between exercise modalities., Conclusions: Machine training appears to induce slightly higher levels of muscle activity in some of the investigated muscles compared to elastic resistance during lower limb strength training in patients with chronic stroke. The higher level of coactivation during knee flexion when performed using elastic resistance suggests that elastic resistance exercises are more difficult to perform. This is likely due to a higher level of movement instability., (Copyright © 2016 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To assess the feasibility of measuring ventilatory threshold (VT) in adults with walking impairments due to stroke. Secondary objectives are to assess reliability of VT over trials; assess whether participants could sustain treadmill walking at VT; and compare mean heart rate during sustained treadmill walking to estimated heart rate reserve (HRR)., Design: Cross-sectional, single-group design., Setting: University research laboratory., Participants: Volunteer sample of adults (N=8) with impaired walking resulting from chronic stroke., Interventions: Three submaximal treadmill walking tests on 3 separate days; a 30-minute treadmill walking session on a fourth day., Main Outcome Measures: Gas exchange variables were measured, and 2 independent observers identified VT. Mean heart rate response to treadmill walking at VT was measured and compared with estimated 40% of HRR., Results: VT was measured successfully in 88% of all trials. There was no difference in VT among trials (P=.17). After multiple imputations to account for 3 missing data points, the intraclass correlation coefficient was .87 (95% confidence interval, .80-.95). All participants were able to walk for 20 minutes at VT. Mean ± SD heart rate during the session was 66.0%±8.0% of estimated maximal heart rate. There was no significant difference between mean heart rate and estimated HRR values (P=.70)., Conclusions: In adults with impaired walking resulting from stroke, VT can be safely measured during submaximal treadmill walking. Participants were able to sustain walking at VT, and this value may provide an appropriate stimulus for aerobic exercise prescription in this population., (Copyright © 2015 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To determine how interhemispheric balance in stroke, measured using transcranial magnetic stimulation (TMS), relates to balance defined using neuroimaging (functional magnetic resonance [fMRI], diffusion-tensor imaging [DTI]) and how these metrics of balance are associated with clinical measures of upper-limb function and disability., Design: Cross sectional., Setting: Laboratory., Participants: Patients with chronic stroke (N = 10; age, 63 ± 9 y) in a population-based sample with unilateral upper-limb paresis., Interventions: Not applicable., Main Outcome Measures: Interhemispheric balance was measured with TMS, fMRI, and DTI. TMS defined interhemispheric differences in the recruitment of corticospinal output, size of the corticomotor output maps, and degree of mutual transcallosal inhibition that they exerted on one another. fMRI studied whether cortical activation during the movement of the paretic hand was lateralized to the ipsilesional or to the contralesional primary motor cortex (M1), premotor cortex (PMC), and supplementary motor cortex (SMA). DTI was used to define interhemispheric differences in the integrity of the corticospinal tracts projecting from the M1. Clinical outcomes tested function (upper extremity Fugl-Meyer [UEFM]) and perceived disability in the use of the paretic hand (Motor Activity Log [MAL] amount score)., Results: Interhemispheric balance assessed with TMS relates differently to fMRI and DTI. Patients with high fMRI lateralization to the ipsilesional hemisphere possessed stronger ipsilesional corticomotor output maps (M1: r = .831, P = .006; PMC: r = .797, P = .01) and better balance of mutual transcallosal inhibition (r = .810, P = .015). Conversely, we found that patients with less integrity of the corticospinal tracts in the ipsilesional hemisphere show greater corticospinal output of homologous tracts in the contralesional hemisphere (r = .850, P = .004). However, an imbalance in integrity and output do not relate to transcallosal inhibition. Clinically, although patients with less integrity of corticospinal tracts from the ipsilesional hemisphere showed worse impairments (UEFM) (r = -.768, P = .016), those with low fMRI lateralization to the ipsilesional hemisphere had greater perception of disability (MAL amount score) (M1: r = .883, P = .006; PMC: r = .817, P = .007; SMA: r = .633, P = .062)., Conclusions: In patients with chronic motor deficits of the upper limb, fMRI may serve to mark perceived disability and transcallosal influence between hemispheres. DTI-based integrity of the corticospinal tracts, however, may be useful in categorizing the range of functional impairments of the upper limb. Further, in patients with extensive corticospinal damage, DTI may help infer the role of the contralesional hemisphere in recovery., (Copyright © 2015 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: First, to evaluate the clinical effectiveness of a virtual reality (VR)-based telerehabilitation program in the balance recovery of individuals with hemiparesis after stroke in comparison with an in-clinic program; second, to compare the subjective experiences; and third, to contrast the costs of both programs., Design: Single-blind, randomized, controlled trial., Setting: Neurorehabilitation unit., Participants: Chronic outpatients with stroke (N=30) with residual hemiparesis., Interventions: Twenty 45-minute training sessions with the telerehabilitation system, conducted 3 times a week, in the clinic or in the home., Main Outcome Measures: First, Berg Balance Scale for balance assessment. The Performance-Oriented Mobility Assessment balance and gait subscales, and the Brunel Balance Assessment were secondary outcome measures. Clinical assessments were conducted at baseline, 8 weeks (posttreatment), and 12 weeks (follow-up). Second, the System Usability Scale and the Intrinsic Motivation Inventory for subjective experiences. Third, cost (in dollars)., Results: Significant improvement in both groups (in-clinic group [control] and a home-based telerehabilitation group) from the initial to the final assessment in the Berg Balance Scale (ηp(2)=.68; P=.001), in the balance (ηp(2)=.24; P=.006) and gait (ηp(2)=.57, P=.001) subscales of the Tinetti Performance-Oriented Mobility Assessment, and in the Brunel Balance Assessment (control: χ(2)=15.0; P=.002; experimental: χ(2)=21.9; P=.001). No significant differences were found between the groups in any balance scale or in the feedback questionnaires. With regard to subjective experiences, both groups considered the VR system similarly usable and motivating. The in-clinic intervention resulted in more expenses than did the telerehabilitation intervention ($654.72 per person)., Conclusions: First, VR-based telerehabilitation interventions can promote the reacquisition of locomotor skills associated with balance in the same way as do in-clinic interventions, both complemented with a conventional therapy program; second, the usability of and motivation to use the 2 interventions can be similar; and third, telerehabilitation interventions can involve savings that vary depending on each scenario., (Copyright © 2015 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To compare the efficacy of gait training using a single-leg version of the Hybrid Assistive Limb (HAL) on the paretic side with conventional gait training in individuals with subacute stroke., Design: Randomized open controlled pilot trial., Setting: Hospitalized care., Participants: Convenience sample of 44 patients who met the criteria; 12 patients refused. After randomization (N=32), 10 patients withdrew and a total of 22 poststroke participants (HAL group: n=11; conventional group: n=11) completed the randomized controlled trial., Interventions: All participants received twelve 20-minute sessions in 4 weeks of either HAL (wearing the single-leg version of the HAL on their paretic side) or conventional (performed by skilled and experienced physical therapists) gait training., Main Outcome Measures: Outcome measures were evaluated prior to training and after 12 sessions. Functional Ambulation Category (FAC) was the primary outcome measure, whereas secondary outcome measures included maximum walking speed, timed Up and Go test, 6-minute walk distance, Short Physical Performance Battery, Fugl-Meyer Assessment of Lower Extremity, and isometric muscle strength (hip flexion and extension, knee flexion and extension)., Results: No participants withdrew because of adverse effects. Participants who received gait training with the HAL showed significantly more improvement in the FAC than those who received conventional gait training (95% confidence interval, .02-.88; P=.04). Secondary measures did not differ between the 2 groups., Conclusions: The results obtained in this randomized controlled trial suggest that a gait training program with the HAL could improve independent walking more efficiently than conventional gait training., (Copyright © 2014 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To investigate the effectiveness of mirror therapy (MT) combined with bilateral arm training and graded activities to improve motor performance in the paretic upper limb after stroke., Design: Randomized, controlled, assessor-blinded study., Setting: Inpatient stroke rehabilitation center of a tertiary care teaching hospital., Participants: Patients with first-time ischemic or hemorrhagic stroke (N=20), confined to the territory of the middle cerebral artery, occurring <6 months before the commencement of the study., Intervention: The MT and control group participants underwent a patient-specific multidisciplinary rehabilitation program including conventional occupational therapy, physical therapy, and speech therapy for 5 d/wk, 6 h/d, over 3 weeks. The participants in the MT group received 1 hour of MT in addition to the conventional stroke rehabilitation., Main Outcome Measures: The Upper Extremity Fugl-Meyer Assessment for motor recovery, Brunnstrom stages of motor recovery for the arm and hand, Box and Block Test for gross manual hand dexterity, and modified Ashworth scale to assess the spasticity., Results: After 3 weeks of MT, mean change scores were significantly greater in the MT group than in the control group for the Fugl-Meyer Assessment (P=.008), Brunnstrom stages of motor recovery for the arm (P=.003) and hand (P=.003), and the Box and Block Test (P=.022). No significant difference was found between the groups for modified Ashworth scale (P=.647)., Conclusions: MT when combined with bilateral arm training and graded activities was effective in improving motor performance of the paretic upper limb after stroke compared with conventional therapy without MT., (Copyright © 2014 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To evaluate poststroke recovery of paretic lower extremity loading, walking ability, and self-reported physical function; and to identify subject characteristics associated with recovery., Design: Inception cohort study, with testing at monthly intervals from 1 to 6 months poststroke., Setting: Medical center and research laboratory., Participants: Volunteer sample of individuals with first-ever, unilateral, noncerebellar stroke (N=33). A total of 78 individuals underwent screening, and 45 were found to be eligible. Of these, 8 declined participation, 2 were excluded because of deteriorating cognitive status, and 2 were lost to follow-up. The remaining 33 individuals enrolled in the study, and 30 (91%) completed the study., Interventions: Not applicable., Main Outcome Measures: Outcomes were loading of the paretic lower extremity when standing up from a chair, self-selected gait speed (GS), and Physical Functioning Index., Results: Data analyses using linear mixed models indicated that subjects improved over time for all outcomes. Baseline Fugl-Meyer (FM) lower extremity motor scale score was a predictor of immediate poststroke performance for paretic lower extremity loading and self-selected GS, and a predictor of recovery rate for paretic lower extremity loading. Factors identified as having significant effects on performance at 6 months poststroke were baseline FM lower extremity motor scale score for paretic lower extremity loading and self-selected GS and baseline star cancellation score (from the Behavioral Inattention Test) for paretic lower extremity loading., Conclusions: Individuals with better baseline paretic lower extremity motor function have better ability to load that extremity during functional activities and faster walking speeds, and these advantages are still present at 6 months poststroke. Individuals with severe visuospatial neglect demonstrate less ability to load the paretic leg during functional activities at 6 months poststroke., (Copyright © 2014 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To investigate the preliminary effectiveness of surface electromyography (sEMG) biofeedback delivered via interaction with a commercial computer game to improve motor control in chronic stroke survivors., Design: Single-blinded, 1-group, repeated-measures design: A1, A2, B, A3 (A, assessment; B, intervention)., Setting: Laboratory and participants' homes., Participants: A convenience sample of persons (N=9) between 40 and 75 years of age with moderate to severe upper extremity motor impairment and at least 6 months poststroke completed the study., Intervention: The electromyography-controlled video game system targeted the wrist muscle activation with the goal of increasing selective muscle activation. Participants received several laboratory training sessions with the system and then were instructed to use the system at home for 45 minutes, 5 times per week for the following 4 weeks., Main Outcome Measures: Primary outcome measures included duration of system use, sEMG during home play, and pre/post sEMG measures during active wrist motion. Secondary outcomes included kinematic analysis of movement and functional outcomes, including the Wolf Motor Function Test and the Chedoke Arm and Hand Activity Inventory-9., Results: One third of participants completed or exceeded the recommended amount of system use. Statistically significant changes were observed on both game play and pre/post sEMG outcomes. Limited carryover, however, was observed on kinematic or functional outcomes., Conclusions: This preliminary investigation indicates that use of the electromyography-controlled video game impacts muscle activation. Limited changes in kinematic and activity level outcomes, however, suggest that the intervention may benefit from the inclusion of a functional activity component., (Copyright © 2014 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To investigate the longevity and cumulative impact of multiple sessions of passive, cyclical stretching of the digits on hand function in subacute stroke survivors., Design: Before-after trial with intervention repeated on 3 consecutive days., Setting: Research laboratory., Participants: Individuals (N=27) with moderate to severe hand impairment, 2 to 6 months (subacute, n=12) and >7 months (chronic, n=15) poststroke., Interventions: Subjects wore an actuated glove orthosis that cyclically moved their fingers and thumb from a relaxed/flexed posture into neutral extension for 30 minutes on 3 consecutive days., Main Outcome Measures: Three hand-specific tasks from the Graded Wolf Motor Function Test, Box and Block Test (BBT), grip strength, and lateral pinch strength. Recordings were taken before stretching and at 3 time points, each separated by 30 minutes after completion of stretching on each day., Results: Significant improvement was observed immediately after the stretching for both groups. Improvements in the subacute group were largely maintained up to 1 hour poststretching, with significant carryover from day to day for some outcomes measures such as the BBT (P=.006) and grip strength (P=.012). In contrast, improvements after stretching for the chronic group were transient, with the changes largely dissipating over time and no significant cumulative effect across days., Conclusions: Cyclical stretching of the digits had a lasting and reinforcing effect on improving hand motor control for subacute stroke survivors. Incorporation of cyclical stretching before active hand therapy may prove to be a beneficial treatment for stroke survivors, especially during the subacute phase of recovery., (Copyright © 2014 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To investigate the effect of 4 to 6 weeks of exergaming with a computer mouse embedded within an arm skate on upper limb function in survivors of chronic stroke., Design: Intervention study with a 4-week postintervention follow-up., Setting: In home., Participants: Survivors (N=13) of chronic (≥6 mo) stroke with hemiparesis of the upper limb with stable baseline Fugl-Meyer assessment scores received the intervention. One participant withdrew, and 2 participants were not reassessed at the 4-week follow-up. No participants withdrew as a result of adverse effects., Intervention: Four to 6 weeks of exergaming using the arm skate where participants received either 9 (n=5) or 16 (n=7) hours of game play., Main Outcome Measure: Upper limb component of the Fugl-Meyer assessment., Results: There was an average increase in the Fugl-Meyer upper limb assessment score from the beginning to end of the intervention of 4.9 points. At the end of the 4-week period after the intervention, the increase was 4.4 points., Conclusions: A 4- to 6-week intervention using the arm skate significantly improved arm function in survivors of chronic stroke by an average of 4.9 Fugl-Meyer upper limb assessment points. This research shows that a larger-scale randomized trial of this device is warranted and highlights the potential value of using virtual reality technology (eg, computer games) in a rehabilitation setting., (Copyright © 2014 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To investigate short-term and long-term effects of repetitive peripheral magnetic stimulation (rpMS) on spasticity and motor function., Design: Monocentric, randomized, double-blind, sham-controlled trial., Setting: Neurologic rehabilitation hospital., Participants: Patients (N=66) with severe hemiparesis and mild to moderate spasticity resulting from a stroke or a traumatic brain injury. The average time ± SD since injury for the intervention groups was 26 ± 71 weeks or 37 ± 82 weeks., Interventions: rpMS for 20 minutes or sham stimulation with subsequent occupational therapy for 20 minutes, 2 times a day, over a 2-week period., Main Outcome Measures: Modified Tardieu Scale and Fugl-Meyer Assessment (arm score), assessed before therapy, at the end of the 2-week treatment period, and 2 weeks after study treatment. Additionally, the Tardieu Scale was assessed after the first and before the third therapy session to determine any short-term effects., Results: Spasticity (Tardieu >0) was present in 83% of wrist flexors, 62% of elbow flexors, 44% of elbow extensors, and 10% of wrist extensors. Compared with the sham stimulation group, the rpMS group showed short-term effects on spasticity for wrist flexors (P=.048), and long-term effects for elbow extensors (P<.045). Arm motor function (rpMS group: median 5 [4-27]; sham group: median 4 [4-9]) did not significantly change over the study period in either group, whereas rpMS had a positive effect on sensory function., Conclusions: Therapy with rpMS increases sensory function in patients with severe limb paresis. The magnetic stimulation, however, has limited effect on spasticity and no effect on motor function., (Copyright © 2014 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To determine whether nonparetic arm force overinhibits the paretic arm in patients with chronic unilateral poststroke hemiparesis., Design: Case-control neurophysiological and behavioral study of patients with chronic stroke., Setting: Research institution., Participants: Eighty-six referred patients were screened to enroll 9 participants (N=9) with a >6 month history of 1 unilateral ischemic infarct that resulted in arm hemiparesis with residual ability to produce 1Nm of wrist flexion torque and without contraindication to transcranial magnetic stimulation. Eight age- and handedness-matched healthy volunteers without neurologic diagnosis were studied for comparison., Interventions: Not applicable., Main Outcome Measure: Change in interhemispheric inhibition targeting the ipsilesional primary motor cortex (M1) during nonparetic arm force. We hypothesized that interhemispheric inhibition would increase more in healthy controls than in patients with hemiparesis., Results: Healthy age-matched controls had significantly greater increases in inhibition from their active to resting M1 than patients with stroke from their active contralesional to resting ipsilesional M1 in the same scenario (20%±7% vs -1%±4%, F1,12=6.61, P=.025). Patients with greater increases in contralesional to ipsilesional inhibition were better performers on the 9-hole peg test of paretic arm function., Conclusions: Our findings reveal that producing force with the nonparetic arm does not necessarily overinhibit the paretic arm. Though our study is limited in generalizability by the small sample size, we found that greater active contralesional to resting ipsilesional M1 inhibition was related with better recovery in this subset of patients with chronic poststroke., (Copyright © 2014 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To explore potential predictors of self-reported paretic arm use at baseline and after task-specific training (TST) in survivors of stroke., Design: Data were obtained from a randomized controlled trial of somatosensory stimulation and upper limb TST in chronic stroke., Setting: University laboratory., Participants: Chronic (≥3mo) survivors of stroke (N=33; mean age, 62y; mean stroke duration, 38mo)., Interventions: Participants received 12 sessions of TST preceded by either active (n=16) or sham (n=17) somatosensory stimulation to all 3 peripheral nerves., Main Outcome Measures: Demographic and clinical characteristics were entered stepwise into multiple linear regression analyses to determine the factors that best predict baseline Motor Activity Log (MAL) amount of use rating and change 3 months after TST., Results: The Action Research Arm Test (ARAT) score predicted the amount of use at baseline (R(2)=.47, P<.001); in using this model, an ARAT score of 54 (maximum of 57) is required to score 2.5 on the MAL (use described as between rarely and sometimes). After TST the change in the ARAT score predicted the change in the amount of use (R(2)=.31, P=.001). The predictive power of the model for change at 3 months increased if the Fugl-Meyer Assessment wrist component score was added (R(2)=.41, P=.001)., Conclusions: Utilization of the paretic upper limb in activities of daily living requires high functional ability. The increase in self-reported arm use after TST is dependent on the change in functional ability. These results provide further guidance for rehabilitation decisions., (Copyright © 2014 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To investigate the relationship of white matter integrity and path of the corticospinal tract (CST) on arm function before and after constraint-induced (CI) movement therapy in children with hemiparetic cerebral palsy (CP) and adults with chronic stroke., Design: Study 1 used a multiple-baseline pre-post design. Study 2 was a randomized controlled trial., Setting: Outpatient rehabilitation laboratory., Participants: Study 1 included children with hemiparetic CP (n=10; mean age ± SD, 3.2±1.7y). Study 2 included adults with chronic stroke (n=26; mean age ± SD, 65.4±13.6y) who received either CI therapy or a comparison therapy., Interventions: Children in study 1 received CI therapy for 3.5h/d for 15 consecutive weekdays. Adults in study 2 received either CI therapy or a comparison therapy for 3.5h/d for 10 consecutive weekdays., Main Outcome Measures: Diffusion tensor imaging was performed to quantify white matter integrity. Motor ability was assessed in children using the Pediatric Motor Activity Log-Revised and Pediatric Arm Function Test, and in adults with the Motor Activity Log and Wolf Motor Function Test., Results: Participants in both studies improved in real-world arm function and motor capacity. Children and adults with disrupted/displaced CSTs and children with reduced fractional anisotropy values were worse on pretreatment tests of motor function than participants with unaltered CSTs. However, neither integrity (fractional anisotropy) nor distorted or disrupted path of the CST affected motor improvement after treatment., Conclusions: Participants who had reduced integrity, displacement, or interruption of their CST performed worse on pretreatment motor testing. However, this had no effect on their ability to benefit from CI therapy. The results for children and adults are consistent with one another., (Copyright © 2014 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To establish the time course of recovery regarding smoothness of upper limb movements in the first 6 months poststroke., Design: Cohort study with 3-dimensional kinematic measurements in weeks 1, 2, 3, 4, 5, 8, 12, and 26 poststroke., Setting: Onsite 3-dimensional kinematic measurements in stroke units, rehabilitation centers, nursing homes, and patients' homes., Participants: Patients (N=44; 19 women, 25 men; mean age ± SD, 58±12y) with a first-ever unilateral ischemic stroke and incomplete upper limb paresis (27 left sided, 17 right sided) were included., Interventions: Not applicable., Main Outcome Measures: In each measurement, an electromagnetic motion tracker acquired hand and finger trajectories during a reach-to-grasp task. Movement duration was determined, and smoothness of hand transport and grasp aperture was quantified by normalized jerk. With the use of random coefficient analysis, the effect of progress of time on smoothness of hand transport and grasp aperture was investigated., Results: During the first 5 weeks poststroke, there was a significant contribution of progress of time to reductions in movement duration and normalized jerk of hand transport and grasp aperture (P<.01)., Conclusions: The present longitudinal 3-dimensional kinematic study showed that smoothness of paretic upper limb movements improves in the first 8 weeks poststroke. This improvement suggests that motor control normalizes in the first 8 weeks poststroke and can be mostly explained by spontaneous neurologic recovery that occurs typically in the first weeks poststroke. Future 3-dimensional kinematic studies should investigate whether therapies starting early after stroke can improve the quality of motor control beyond spontaneous neurologic recovery., (Copyright © 2014 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To determine if individuals with chronic stroke were able to sustain their peak gait speed during the 6-minute walk test (6MWT), and to explore this sustainability across community ambulation potential subgroups., Design: Prospective cross-sectional study., Setting: University-based research laboratory, hospitals, and stroke support groups., Participants: A sample of individuals with chronic stroke (N=48) completed a series of questionnaires and physical outcome measures, including gait mat assessment, during a single visit., Interventions: Not applicable; 1-time cross-sectional data collection., Main Outcome Measures: During the 6MWT, we measured peak gait speed and end gait speed to assess sustainability, along with beginning gait speed, total distance walked, and rating of perceived exertion. We also assessed maximum gait speed during the 10-meter walk test (10MWT). Finally, we examined these gait outcomes across the subgroups., Results: During the 6MWT, peak gait speed declined from .89m/s (SD=.38) to an end speed of .82m/s (SD=.36), whereas perceived exertion increased from 7.7 (SD=2.6) to 11.8 (SD=3.6). This peak gait speed was slower than the 10MWT maximum speed of 1.06m/s (SD=.51), but faster than the 6MWT beginning speed of .81m/s (SD=.34). The unlimited community ambulator subgroup was the primary contributor to sustainability differences., Conclusions: Predicting community ambulation potential based on the discrete gait speed from the 10MWT and endurance based on the average from the 6MWT might be incomplete if gait speed sustainability is not also assessed., (Copyright © 2013 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To examine the stepping performance during voluntary and waist-pull perturbation-induced step initiation in people with chronic stroke., Design: Repeated-measures single-case design., Setting: University-based research laboratory., Participants: Community-dwelling stroke survivors (N=10)., Interventions: Not applicable., Main Outcome Measures: Ground reaction forces and kinematic data were recorded to assess anticipatory postural adjustments (APAs) and step characteristics for both voluntary and induced stepping conditions., Results: Induced stepping was performed with both the paretic (35% trials) and nonparetic legs (65% trials). Induced first steps occurred earlier and were executed faster than rapid voluntary steps. Compared with voluntary stepping, induced first step APAs were shorter in duration. Step height was higher with the nonparetic leg for both stepping conditions. Use of the paretic leg increased (52%) during the diagonal perturbations that passively unloaded the stepping limb compared with the use of the paretic leg (33%) for forward perturbations., Conclusions: The results indicated differences in executing voluntary and induced stepping, and between the paretic and nonparetic limbs in individuals with chronic stroke. The findings suggested guidelines for using stepping as a component of neurorehabilitation programs for enhancing balance and mobility. Additional larger-scale studies remain to be undertaken to further investigate these issues., (Copyright © 2013 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To compare the motor relearning effect of a surface peroneal nerve stimulator (PNS) versus usual care on lower limb motor impairment, activity limitation, and quality of life among chronic stroke survivors., Design: Single-blinded randomized controlled trial., Setting: Teaching hospital of academic medical center., Participants: Chronic stroke survivors (N=110; >12wk poststroke) with unilateral hemiparesis and dorsiflexion strength of ≤4/5 on the Medical Research Council scale., Interventions: Subjects were stratified by motor impairment level and then randomly assigned to ambulation training with either a surface PNS device or usual care (ankle-foot orthosis or no device) intervention. Subjects were treated for 12 weeks and followed up for 6 months posttreatment., Main Outcome Measures: Lower limb portion of the Fugl-Meyer (FM) Assessment (motor impairment), the modified Emory Functional Ambulation Profile (mEFAP) performed without a device (functional ambulation), and the Stroke Specific Quality of Life (SSQOL) scale., Results: There was no significant treatment group main effect or treatment group by time interaction effect on FM, mEFAP, or SSQOL raw scores (P>.05). The time effect was significant for the 3 raw scores (P<.05). However, when comparing average change scores from baseline (t1) to end of treatment (t2, 12wk), and at 12 weeks (t3) and 24 weeks (t4) after end of treatment, significant differences were noted only for the mEFAP and SSQOL scores. The change in the average scores for both mEFAP and SSQOL occurred between t1 and t2, followed by relative stability thereafter., Conclusions: There was no evidence of a motor relearning effect on lower limb motor impairment in either the PNS or usual-care groups. However, both the PNS and usual-care groups demonstrated significant improvements in functional mobility and quality of life during the treatment period, which were maintained at 6-month follow-up., (Copyright © 2013 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To examine the effects of thermal stimulation (TS) on the lower extremity (LE) movement and function in patients with stroke., Design: A double-blinded randomized controlled trial., Setting: A university hospital., Participants: Patients (N=34) at least 3 months after stroke were randomly assigned into the experimental and the control groups., Interventions: In addition to regular rehabilitation, the experimental group received a 30-minute noxious TS protocol (heat pain 46-47°C/cold pain 2-3°C) 3days/wk for 8 weeks, and the control group received a 30-minute innocuous TS protocol (heat 40-41°C/cold 23-24°C) 3d/wk for 8 weeks., Main Outcome Measures: The Low Extremity subscale of the Stroke Rehabilitation Assessment of Movement (LE-STREAM), the Mobility subscale of STREAM (Mob-STREAM), the Functional Ambulation Category (FAC), the Barthel Index (BI), the Postural Assessment Scale for Stroke Patients (PASS), and the Modified Ashworth Scale (MAS) were administered by a blinded rater at baseline, posttreatment (8wk), and follow-up (12wk)., Results: Twenty-three participants completed the study protocol and all outcome measurements. No preexisting group differences between the experimental group (n=11) and the control group (n=12) were found on demographic and clinical variables. Compared with baseline, the experimental group showed significant improvements at posttreatment and follow-up on the LE-STREAM, Mob-STREAM, FAC, and BI (P<.05) while the control group showed no significant improvements for all outcome measures. As for the between-group comparison, significant differences were seen at follow-up (12wk) on the LE-STREAM, Mob-STREAM, BI, and MAS., Conclusions: Our findings indicate that an 8-week program of noxious TS combined with a traditional stroke rehabilitation program can improve the LE-related movement and function in patients with stroke for more than 3 months., (Copyright © 2013 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To investigate the relative and absolute reliabilities of the myotonometer., Design: Psychometric study., Setting: Three medical centers., Participants: Patients with stroke (N=61)., Interventions: Not applicable., Main Outcome Measures: Muscle tone, elasticity, and stiffness of relaxed affected deltoid, triceps brachii, biceps brachii, extensor digitorum, flexor carpi radialis, and flexor carpi ulnaris were measured twice, 30 minutes apart, using the myotonometer. Intraclass correlation coefficient, a relative reliability index, was calculated for 3 muscular properties and for each muscle to examine the degree of consistency and agreement between the 2 test sessions. Absolute reliability indices, including the SEM, smallest real difference, and Bland-Altman limits of agreement, were used to quantify measurement errors and check systematic biases of the 2 test sessions., Results: The intraclass correlation coefficients were .83 to .95 for muscle tone, elasticity, and stiffness of all muscle groups. The SEM and the smallest real difference of muscle tone, elasticity, and stiffness of the biceps were the smallest among the 6 muscles tested. The Bland-Altman analyses showed no systematic bias between most of the repeated measurements. Compared with other muscles, biceps had narrower limits-of-agreement ranges, indicating that the myotonometric measurements of the biceps had higher stability and less variation over time., Conclusions: The myotonometer reliably measures muscular properties, with good relative and absolute reliabilities. These findings are useful for clinicians and researchers to assess muscle properties reliably and determine whether a real change has occurred in groups and on individual levels of patients with stroke., (Copyright © 2013 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To determine whether the preferred pattern of arm use after unilateral hemispheric damage was associated with better everyday functioning. Our previous work showed that right-handed stroke patients with right hemisphere damage (RHD) used their right, ipsilesional arm most frequently, while those with left hemisphere damage (LHD) used both arms together most frequently. This effect was explained by right-hand preference, but its relationship to functional performance is not known., Design: Observational cohort., Setting: Research laboratory., Participants: Stroke patients (n=60; 30 RHD, 30 LHD) and healthy controls (n=52)., Interventions: Not applicable., Main Outcome Measures: The Functional Impact Assessment was used to assess performance on instrumental activities of daily living (IADLs)., Results: The preferred patterns of arm use were similar to those in our previous report. However, it was the greater use of both arms together that was associated with better IADL performance in both stroke groups. Ipsilesional arm use alone was not significantly associated with IADL performance in the RHD group and was associated with poorer performance in the LHD group., Conclusions: The modal arm use pattern did not always optimize IADL functioning. Better IADL functioning in both stroke groups was associated with the use of both arms together, which is the most common arm use pattern of healthy individuals doing these same IADLs. An important practical question that arises from these findings is whether bilateral arm rehabilitation should be emphasized, because using both arms together is the best predictor of better performance on everyday tasks., (Copyright © 2012 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To investigate the determinants of limb preference for initiating compensatory stepping poststroke., Design: Retrospective chart review., Setting: Inpatient rehabilitation., Participants: Convenience sample of individuals admitted to inpatient rehabilitation with poststroke hemiparesis., Interventions: Not applicable., Main Outcome Measures: Compensatory stepping responses were evoked using a lean-and-release postural perturbation. The limb used to initiate compensatory stepping was determined. The relationships between stepping with the paretic limb and premorbid limb dominance, weight bearing on the paretic limb in quiet standing, ability to bear weight on the paretic limb, preperturbation weight bearing on the paretic limb, and lower-limb motor recovery scores were determined., Results: The majority (59.1%) of responses were steps initiated with the nonparetic limb. Increased lower-limb motor recovery scores and preperturbation weight bearing on the nonparetic limb were significantly related to increased frequency of stepping with the paretic limb. When the preferred limb was physically blocked, an inappropriate response was initiated in 21% of trials (ie, nonstep responses or an attempt to step with the blocked limb)., Conclusions: This study reveals the challenges that individuals with poststroke hemiparesis face when executing compensatory stepping responses to prevent a fall after a postural perturbation. The inability or challenges to executing a compensatory step with the paretic limb may increase the risk for falls poststroke., (Copyright © 2012 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To estimate the cost of stair ascent and descent in relation to a measured standard of strength and metabolic (aerobic) capacities in persons with chronic stroke compared with healthy adults., Design: Descriptive cross-sectional study., Setting: Motion analysis laboratory., Participants: Persons with stroke (n=10) and sex- and age-matched older adults (n=10)., Intervention: Not applicable., Main Outcome Measures: Lower limb peak joint moments generated during stair walking, expressed as a percentage of the respective isokinetic peak torque, provided an estimate of the relative strength cost. The oxygen consumed during stair walking as a percentage of the maximum oxygen consumption estimated from a submaximal cycle ergometer test reflected the relative aerobic cost of stair ambulation., Results: During ascent, plantarflexor strength cost was highest on the affected side (stroke) compared with the less affected side and control subjects. The costs associated with the knee extensors were highest in stroke (both sides) for both ascent and descent, and similarly the costs were highest for the less affected and affected plantarflexors during descent. No differences were detected between the affected and less affected sides. The oxygen consumed when ambulating 1 flight of stairs was comparable between groups, but the relative aerobic cost of stair ascent and descent was higher in stroke survivors because of their lower aerobic capacity., Conclusions: To our knowledge, this is the first study to compare the relative costs of stair ambulation in people with stroke and healthy controls. The higher strength and aerobic costs associated with stair negotiation in stroke resulting primarily from reduced strength and aerobic capacities, respectively, may limit mobility., (Copyright © 2012 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To examine the internal consistency, validity, responsiveness, and advantages of the Wolf Motor Function Test (WMFT) and compare these results to the Action Research Arm Test (ARAT) in participants with mild to moderate hemiparesis within the first few months after stroke., Design: Data were collected as part of the Very Early Constraint-Induced Therapy for Recovery from Stroke (VECTORS) trial, an acute, single-blind randomized controlled trial of constraint-induced movement therapy. Subjects were studied at baseline (day 0), after treatment (day 14), and after 90 days (day 90) poststroke., Setting: Inpatient rehabilitation hospital; follow-up 3 months poststroke., Participants: Hemiparetic subjects (N=51) enrolled in the VECTORS trial., Intervention: None., Main Outcome Measures: At each time point, subjects were tested on (1) the WMFT and ARAT, (2) clinical measures of sensorimotor impairments, (3) reach and grasp movements performed in the kinematics laboratory, and (4) clinical measures of disability. Blinded raters performed all evaluations. Analyses at each time point included calculating effect size as indicators of responsiveness, and correlation analyses to examine relationships between WMFT scores and other measures., Results: The WMFT is internally consistent, valid, and responsive in the early stages of stroke recovery. Sensorimotor and kinematic measures of reach and grasp support the construct validity of the WMFT., Conclusions: In an acute stroke population, the WMFT has acceptable reliability, validity, and responsiveness to change over time. However, when compared with the ARAT, the higher training and testing burdens may not be offset by the relatively small psychometric advantages., (Copyright © 2012 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To examine the short-term effects of a newly developed hemiparetic gait training in which patients walk with a prosthesis applied to the nonparetic leg in the flexed knee position., Design: Pre-post nonrandomized controlled trial., Setting: Rehabilitation center and gait laboratory of a university hospital., Participants: Community-dwelling ambulatory volunteers (N=22) with chronic hemiparesis caused by a unilateral stroke., Intervention: Study subjects participated in a gait training program using either a below-knee prosthesis or a treadmill. Treadmill gait training was performed at a speed approximating the maximum gait velocity for each patient. The 3-week program consisted of a 5-minute gait training session 2 to 3 times a day., Main Outcome Measures: The ground reaction forces, stance time, step length and cadence during walking at a comfortable speed, and maximum gait speed, as well as the Berg Balance Score, were estimated before and after each training program., Results: In comparison with changes after the treadmill gait training, analyses of covariance demonstrated a significant increase of the fore-aft ground reaction forces during the paretic propulsion phase and a significant increase in the relative durations of the paretic and nonparetic single stance involved in a gait cycle after the prosthetic gait training (P<.05)., Conclusions: Prosthetic gait training would have different effects on a hemiparetic gait than treadmill gait training. The gait-related task inducing the dominant use of the paretic leg to support the body may be useful as a rehabilitative treatment to improve the kinetic abilities in the paretic stance period., (Copyright © 2011 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To analyze the effects of electric treadmill inclination on the gait of individuals with chronic hemiparesis., Design: Descriptive, observational study., Setting: Laboratory for human movement analyses of UFRN., Participants: Individuals (N=18) with a mean age of 55.3 ± 9.3 years and a lesion time of 36 ± 22.8 months., Interventions: Not applicable., Main Outcome Measures: Subjects were assessed for functional independence (FIM) and balance (Berg Balance Scale). Spatial-temporal variables were observed as well as the angular variation of the hip, knee, and ankle in the sagittal plane, while the individuals walked on the treadmill at 3 different inclinations (0%, 5%, and 10%)., Results: There was an increase in stance time between 0% and 5% (0.83 ± 0.21 vs 0.87 ± 0.20; P=.011) and 0% and 10% (0.83 ± 0.21 vs 0.88 ± 0.23; P=.021). The other spatial-temporal variables did not change. During initial contact there was an increase in the hip, knee, and ankle flexion angle. An increase in hip amplitude was also observed between 0% and 10% (37.83 ± 5.23 vs 41.12 ± 5.63; P<.001) and 5% and 10% (38.80 ± 5.96 vs 41.12 ± 5.63; P=.002) and in knee amplitude between 0% and 10% (47.51 ± 15.07 vs 50.30 ± 12.82; P=.040), as well as decreased hip extension and increased dorsiflexion., Conclusions: Treadmill inclination promoted angular alterations such as an increase in hip, knee, and ankle angle during initial contact and the swing phase and an increase in the amplitude of movement of the hip and knee, as well as an increase in stance time of the paretic lower limb., (Copyright © 2011 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To identify all published studies using the Arm Motor Ability Test (AMAT), a standardized, laboratory-based measure for selected upper extremity activities of daily living (ADLs); and to summarize its current uses and provide recommendations for its future use., Data Sources: An Ovid online search was performed using the terms "Arm Motor Ability Test" and "AMAT." The reference lists of all articles obtained were reviewed for additional studies not appearing in the literature search. In addition, the original manual for the use and administration of the AMAT was reviewed., Study Selection: All studies examining the psychometric properties of the AMAT or using the AMAT as an outcome measure were identified. Articles simply mentioning the AMAT without providing data and case reports or abstracts (other than those addressing a specific aspect of the scale of interest) were excluded., Data Extraction: Studies were reviewed by the primary author. No formal system of quality review was used., Data Synthesis: The AMAT has been used as an outcome measure in stroke rehabilitation research examining upper extremity robotics, functional electrical stimulation, and cortical stimulation. The most recent version contains 10 ADL tasks, each of which is composed of 1 to 3 subtasks. Of the 3 domains originally proposed, only the "functional ability" domain is routinely assessed. Psychometric studies have demonstrated good reliability and at least reasonable construct validity. The instrument's sensitivity to change over time is less well established, and no recommendation can be made regarding a minimal clinically important difference., Conclusions: We recommend that the 10-item version of the AMAT and assessment of only the functional ability domain be adopted as standard going forward. Further research should include examination of sensitivity over time, minimal clinically important change, reliability and validity in the mid and lower range of scores, and in neurologic diagnoses other than stroke., (Copyright © 2011 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To investigate the effects of hemiparesis on handwriting using a 3-dimensional movement analyzer., Design: Comparative case study., Setting: Ambulatory care clinic., Participants: Right-handed patients (n=25; mean age +/- SD, 62.3+/-10y) with mild right hemiparesis secondary to subcortical stroke, and age-matched (n=10; 65.6+/-13y) and age-unmatched (n=15; 32.4+/-10y) control subjects., Interventions: Not applicable., Main Outcome Measures: Time required to write a Japanese character of 2 different sizes and average speed of handwriting at the pen tip. Average radii of tracks of the moving pen tip, metacarpal head of the index finger, and distal end of the forearm during writing. Correlation coefficients of the instantaneous speed-time graph of the pen tip with that of the index finger and with that of the distal forearm during writing., Results: Time for writing with the hemiparetic right hand was longer than that with the unaffected left hand (P=.05 approximately .03), while it was shorter in healthy control subjects (P=.07 approximately .05). In contrast with the left-hand writing, the track radius of the pen tip of the right-hand writing in patients with hemiparesis with normal joint position sense was significantly larger than that of the finger or distal forearm (P=.01). The finding was the same as in the young and elderly control subjects. This right-left difference disappeared in the patients with hemiparesis with position sense impairment. The correlation coefficient of speed between the pen tip and the finger was larger in right-hand than left-hand writing in the control and sensory-normative patients with hemiparesis even though the difference was significant only in the healthy elderly subjects (P=.03). Irrespective of the right or left hand use, the correlation coefficient between the pen tip and the finger or distal forearm significantly increased as the character size increased (P=.03 approximately 6 x10(-6)) in all subjects and patients. However, this size-related difference was less significant in the patients with sensory impairment., Conclusions: The characteristics of handwriting movement by the dominant hand were preserved in patients with mild dominant-hand hemiparesis when joint position sense was normative but were lost in those with position sense impairment.

Objective: To determine whether onabotulinumtoxinA injections and task practice training with or without functional electrical stimulation (FES) improve upper limb motor function in chronic spastic hemiparesis., Design: Randomized controlled trial., Setting: Outpatient spasticity clinic., Participants: Participants (N=23) had chronic spastic hemiparesis with moderate-severe hand impairment based on Chedoke-McMaster Assessment greater than or equal to 2., Interventions: OnabotulinumtoxinA injections followed by 12 weeks of postinjection task practice. Participants randomly assigned to FES group were also fitted with an orthosis that provided FES., Main Outcome Measures: Motor Activity Log (MAL)-Observation was the primary outcome. Secondary outcomes were Action Research Arm Test (ARAT) and MAL-Self-Report., Results: For the entire cohort, MAL-Observation mean item scores improved significantly from baseline to week 6 (P=.005) but did not remain significant at week 12. MAL-Self-Report mean item scores improved significantly (P=.009) from baseline to week 6 and remained significantly higher (P=.014) at week 12. ARAT total scores also improved significantly from baseline to week 6 (P=.018) and were sustained at week 12 (P=.032). However, there were no significant differences between the FES and no-FES groups for any outcome variable over time., Conclusions: Rehabilitation strategies that combine onabotulinumtoxinA injections and task practice therapy are feasible and effective in improving upper-limb motor function and reducing spasticity in patients with chronic spastic hemiparesis. However, the cyclic FES protocol used in this study did not increase gains achieved with the combination of onabotulinumtoxinA and task practice alone.

Objective: To investigate corticomotor changes induced by body weight-supported treadmill training (BWSTT) in patients with short or long poststroke duration., Design: Single-blinded and randomized controlled trial., Setting: Neurologic physical therapy research laboratory., Participants: Hemiparesis patients (N=18) whose motor-evoked potentials could be induced participated in this study. Subjects in each hemiparesis postonset of short (<6 mo) or long (>12 mo) duration group were randomly assigned to either the control or experimental group., Interventions: Subjects in the experimental groups participated in BWSTT for 4 weeks. Those in the control groups received the general exercise program., Main Outcome Measures: The primary outcomes were motor threshold and map size of the abductor hallucis muscle in the ipsilesional hemisphere. The secondary outcome was Fugl-Meyer Assessment. Outcome measures were blindly assessed before and after completing the 4 weeks of training., Results: The 4-week BWSTT resulted in a decrease of motor threshold and an increase of map size in subjects with hemiparesis of short duration, whereas only the expansion of the map size was noted in subjects with hemiparesis of long duration. Improvement of motor control occurred in subjects with hemiparesis of both short and long duration after BWSTT., Conclusions: The BWSTT results in similar improvement in motor control but different patterns of treatment-induced cortical reorganization in subjects with different poststroke durations., (Copyright 2010 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Unlabelled: Horstman AM, Gerrits KH, Beltman MJ, Koppe PA, Janssen, TW, de Haan A. Intrinsic properties of the knee extensor muscles after subacute stroke., Objective: To characterize muscle properties of paretic lower-limb (PL) and nonparetic lower-limb (NL) knee extensors in patients with subacute stroke., Design: Case-control study., Setting: Rehabilitation center research laboratory., Participants: Patients with subacute stroke (n=14) and able-bodied age-matched control subjects (n=12)., Interventions: Not applicable., Main Outcome Measures: Half relaxation times (HRTs) and maximal rates of torque development (MRTDs) were assessed as indicators of contractile speed using both voluntary and electrically evoked contractions. Moreover, changes in torque were measured during a fatigue protocol (35 electrically evoked intermittent contractions; 1.5s on, 2s off) and recovery., Results: No differences among groups were found for normalized MRTDs during electrically evoked contractions (P=.117). However, during voluntary contractions both PLs (53% of control, P=.022) and NL (71% of control, P<.001) had significantly lower MRTD compared with control. Both PL (134% of control, P=.001) and NL (123% of control, P=.032) had significantly higher HRTs than control, indicating muscle slowing in patients with subacute stroke. PLs fatigued more and faster than control (P=.011) and both PL and NL recovered slower (P<.001)., Conclusions: The changes in HRTs and fatigue suggest adaptations in muscle properties toward slower, more fatigable muscle shortly after stroke. The inability to make use of contractile speed because of impaired neural activation seems the most limiting factor during the initial phase of torque development in PL. Thus, besides strengthening, muscle endurance and speed should also be addressed during rehabilitation., (Copyright (c) 2010 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)