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Purpose: The Fugl-Meyer Assessment is the most used and highly recommended clinical assessment of sensorimotor function after stroke. A standardized use of the scale in different countries requires translation and cultural validation to the target language. The objective of the study was to develop an official Italian version of the scale by transcultural translation and validation.Methods: A standardized multistep translation protocol was adopted to achieve optimal conceptual and semantic equivalence. The developed Italian version was validated in 10 post-stroke hemiparetic patients. Items with low intra- and interrater agreement, quantified as percentage of agreement

Background and aims Poststroke shoulder pain is a common complication. We aimed to investigate the prevalence of poststroke shoulder pain, with attention to the neuropathic component, and the relationship between poststroke shoulder pain and upper limb improvement in motor function, strength, disability, and quality of life after upper limb rehabilitation. Methods This is a secondary analysis of a multicenter randomized controlled trial to compare upper limb conventional or robotic rehabilitation on 224 patients enrolled in eight rehabilitation centers. We assessed poststroke shoulder pain (using the Numerical Rating Scale and the Douleur Neuropathique 4), and upper limb motor function, strength, disability, and quality of life at baseline (T0), after 30 rehabilitation sessions (T1), and three months after the end of rehabilitation (T2). Results A moderate/severe poststroke shoulder pain was reported by 28.9% of patients, while 19.6% of them showed a neuropathic component. At T0, the intensity of pain was higher in women and in patients with neglect syndrome, positively correlated with the time since stroke and disability and negatively correlated with motor function, strength, and the physical aspects of the quality of life. Moderate/severe pain and neuropathic component significantly reduced after both treatments and this reduction was maintained at T2. Finally, the intensity of pain at baseline was negatively correlated with the improvement of upper limb motor function. Conclusions Poststroke shoulder pain negatively impact on motor performance, strength, disability, and physical aspects of the quality of life as well as on upper limb motor recovery; however, it can be reduced after a robotic or a conventional rehabilitation. Therefore, we suggest considering poststroke shoulder pain when planning the rehabilitation intervention.

Background and purpose After stroke, only 12% of survivors obtain complete upper limb (UL) functional recovery, while in 30% to 60% UL deficits persist. Despite the complexity of the UL, prior robot-mediated therapy research has used only one robot in comparisons to conventional therapy. We evaluated the efficacy of robotic UL treatment using a set of 4 devices, compared with conventional therapy. Methods In a multicenter, randomized controlled trial, 247 subjects with subacute stroke were assigned either to robotic (using a set of 4 devices) or to conventional treatment, each consisting of 30 sessions. Subjects were evaluated before and after treatment, with follow-up assessment after 3 months. The primary outcome measure was change from baseline in the Fugl-Meyer Assessment (FMA) score. Secondary outcome measures were selected to assess motor function, activities, and participation. Results One hundred ninety subjects completed the posttreatment assessment, with a subset (n = 122) returning for follow-up evaluation. Mean FMA score improvement in the robotic group was 8.50 (confidence interval: 6.82 to 10.17), versus 8.57 (confidence interval: 6.97 to 10.18) in the conventional group, with no significant between-groups difference (adjusted mean difference -0.08, P = 0.948). Both groups also had similar change in secondary measures, except for the Motricity Index, with better results for the robotic group (adjusted mean difference 4.42, P = 0.037). At follow-up, subjects continued to improve with no between-groups differences. Discussion and conclusions Robotic treatment using a set of 4 devices significantly improved UL motor function, activities, and participation in subjects with subacute stroke to the same extent as a similar amount of conventional therapy. Video Abstract is available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A291).

The aim of this study is to test the feasibility of a new protocol of upper limb treatment, using a set of four robotic and sensor-based devices in sub-acute stroke patients in a multicenter study aimed to evaluate the efficacy of robotic therapy compared with conventional therapy. Participants are recruited in 8 centers and randomized to either the robotic group or the conventional group. The outcomes were selected according to the International Classification of Functioning, Disability and Health domains, to evaluate body function, activities and participation. A total of 247 participants were randomized, 224 of whom received the allocated intervention. Our results demonstrate the feasibility of our rehabilitation protocol in a multicenter clinical trial and in clinical practice.

Objective: To determine the prognostic value of clinical assessment and motor evoked potentials for upper limb strength and functional recovery after acute stroke, and to establish the possible use of motor evoked potentials in rehabilitation. Design: A prospective study. Subjects: Fifty-two patients with hemiparesis were enrolled one month post-stroke; 38 patients concluded the study at 12 months. Methods: Motor evoked potentials were recorded at baseline and after one month. Upper limb muscular strength (Medical Research Council Scale, MRC) and functional tests (Frenchay Arm Test, Barthel Index) were used as dependent outcome variables 12 months later. Motor evoked potentials were classified as present or absent. Predictive values of motor evoked potentials and MRC were evaluated. Results: At 12 months, patients with baseline recordable motor evoked potentials showed a good functional recovery (positive predictive value 94%). The absence of motor evoked potentials did not exclude muscular strength recovery (negative predictive value 95%). Motor evoked potentials had a higher positive predictive value than MRC only in patients with MRC < 2. Conclusion: Motor evoked potentials could be a supportive tool to increase the prognostic accuracy of upper limb motor and functional outcome in hemiparetic patients, especially those with severe initial paresis (MRC < 2) and/or with motor evoked potentials absent in the post-stroke acute phase.

Objective: To assess the ability of the Wisconsin Gait Scale to evaluate qualitative features of changes in hemiplegic gait in post-stroke patients. Design: A prospective observational study. Subjects: Ten healthy subjects and 56 hemiplegic outpatients, more than 12 months post-stroke, consecutively admitted in a rehabilitation centre. Methods: Patients were videotaped while walking at a comfortable speed. Quantitative and clinical gait parameters were derived from videotaped walking tasks at admission and at the end of a period of rehabilitation training. Qualitative features were assessed using the Wisconsin Gait Scale. Functional status was rated through the modified Barthel Index. Results: After training, the median Wisconsin Gait Scale score improved significantly (28 vs 26.5; p = 0.003). In particular, “weight shift to paretic side” and patterns during the swing phase of the affected leg were improved. Gait velocity (0.3 vs 0.4 m/sec; p = 0.001) and stride length (77 vs 85 cm; p = 0.0002) increased significantly, whereas number of steps (25 vs 23; p = 0.004), stride period (2.5 vs 2.3 sec; p = 0.04), and stance period (2.1 vs 2 sec; p = 0.03) of the unaffected side were reduced. The Barthel Index score increased (71 vs 78; p = 0.005). Conclusion: The Wisconsin Gait Scale is a useful tool to rate qualitative gait alterations of post-stroke hemiplegic subjects and to assess changes over time during rehabilitation training. It may be used when a targeted and standardized characterization of hemiplegic gait is needed for tailoring rehabilitation and monitoring results.

Pizzi A, Carlucci G, Falsini C, Verdesca S, Grippo A. Application of a volar static splint in poststroke spasticity of the upper limb. Objective To evaluate clinical and neurophysiologic effects of 3-month reflex inhibitory splinting (RIS) for poststroke upper-limb spasticity. Design Pretest-posttest trial. Setting Outpatient rehabilitation center. Participants Forty consecutive patients with hemiplegia and upper-limb spasticity after stroke that had occurred at least 4 months before. Intervention Patients wore an immobilizing hand splint custom-fitted in the functional position for at least 90 minutes daily for 3 months. Main Outcomes Measures Patients underwent measurement of (1) spasticity at the elbow and wrist according to Modified Ashworth Scale; (2) passive range of motion (PROM) at the wrist and elbow; (3) pain at the shoulder, elbow, and wrist using a visual analog scale; (4) spasms; and (5) comfort and time of splint application. The instrumental measure of spasticity was the ratio between the maximum amplitude of the H-reflex and the maximum amplitude of the M response (Hmax/Mmax ratio). Results A significant improvement of wrist PROM (F=8.92, P=.001) with greater changes in extension than in flexion, and a reduction of elbow spasticity (F=5.39, P=.002), wrist pain (F=2.89, P=.04), and spasms (F=4.33, P=.008) were observed. The flexor carpi radialis Hmax/Mmax ratio decreased significantly (F=4.2, P=.007). RIS was well tolerated. Conclusions RIS may be used as an integrative treatment of poststroke upper-limb spasticity. It can be used comfortably at home, in selected patients without functional hand movements, and in cases of poor response or tolerance to antispastic drugs.

Between-groups design with repeated measures.To quantify spastic hypertonia in spinal cord-injured (SCI) individuals.Rehabilitative Center, Italy.29 individuals with a motor complete SCI (American Spinal Injury Association impairment scale grade A or B) and 22 controls.According to the modified Ashworth scale (MAS), patients were subgrouped as SCI-1 (MAS=1, 1+) and SCI-2 (MAS=2, 3). Passive flexo-extensions of the knee were applied using an isokinetic device (LIDO Active) at 30°, 60°, 90° and 120° s(-1). We measured the peak torque, mean torque (MT) and work. Simultaneous electromyography (EMG) was recorded from leg muscles.At the speed of 120° s(-1) all SCI-2 patients presented EMG reflex activities in the hamstring muscle. All biomechanical parameter values increased significantly according to speed, but analysis of variance revealed a significant interaction between the angular velocity and group (F(d.f. 6, 138) = 8.89, P0.0001); post hoc analysis showed significantly greater torque parameter values in the SCI-2 group compared with the SCI-1 group and the control group at 90° and 120° s(-1). Receiver operating characteristic curves showed that using peak torque values the probability of correctly classifying a patient into SCI-1 and SCI-2 was 95%, compared with 70% for MT and 68% for work.The isokinetic device is useful for distinguishing individuals with a high level of spastic hypertonus. Examination of EMG activity may help ascertain whether increased muscle tone is caused by reflex hyper excitability and to determine whether muscle spasm is present. Peak torque and simultaneous EMG assessment should be considered for the evaluation of individuals with SCI in the rehabilitative context, that is, in measuring therapeutic interventions.

Pizzi A, Carlucci G, Falsini C, Verdesca S, Grippo A. Evaluation of upper-limb spasticity after stroke: a clinical and neurophysiologic study. Objectives To assess upper-limb spasticity after stroke by means of clinical and instrumental tools and to identify possible variables influencing the clinical pattern. Design Descriptive measurement study of a consecutive sample of patients with upper-limb spasticity after stroke. Setting Neurorehabilitation hospital. Participants Sixty-five poststroke hemiplegic patients. Interventions Not applicable. Main outcome measures Upper-limb spasticity, as assessed clinically (Modified Ashworth Scale [MAS], articular goniometry) and neurophysiologically (maximum H-reflex [Hmax], maximum M response [Mmax], Hmax/Mmax ratio). Results Poorer MAS scores were associated with lower passive range of motion (PROM) values at the wrist ( P =.01) and elbow ( P =.002). The flexor carpi radialis Hmax/Mmax ratio correlated directly with MAS scores at the wrist ( P =.005) and correlated inversely with PROM. The presence of pain in the fingers, wrist, and elbow was significantly associated only with lower PROM values at the wrist. Conclusions Upper-limb spasticity is involved in the development of articular PROM limitation after a stroke. Pain appears to be related to PROM reduction as well, but the exact causal relationship between these 2 factors is still unclear. The MAS and the Hmax/Mmax ratio correlated when evaluating poststroke spasticity; they characterize 2 different aspects of spasticity, clinical and neurophysiologic, respectively, and they could be used as an integrated approach to study and follow poststroke patients.

Botulinum toxin type A (BoNT/A) provides a valuable tool in the multi-modal treatment of spasticity. Incobotulinumtoxin A (InBoNT/A) is a highly purified BoNT/A agent, free of any complexing clostridial proteins.Clinical experience suggests that InBoNT/A is identical from efficacy, duration of therapeutic effect and tolerability profile. Our aim was to compare the effect of the CBoNT/A vs InBoNT/A on spasticity of the upper limb, evaluated with Modificated Aswhort Scale (MAS), and on amplitude of compound motor action potentials (CMAP) of biceps muscle in patients after brain stroke. A randomized, double-blind, parallel-group pilot single-centre study. Clinical and neurophysiological evaluation were performed at enrollment (T0), to 24 h (T1),one (T2) and three (T3) months from toxin injection. We recruited 9 subject. Both BoNTA reduced MAS scores but with no statistically significant difference. At T1 patients treated with IBoNT/A showed a greater reduction in CMAP compared with those treated with CBoNT/A. This difference is reduced at T2 but is again evident at T3. These data seem to indicate a tendency of IBoNT/A to present a more precocious and a longer duration effect respect to CBoNT/A. The low power of the statistical analysis, however, suggests to recruit a larger sample of patients.

About 50% of post-stroke patients remain aphasic a condition that greatly impede their reintegration to society. Results of Repetitive Transcranial Magnetic Stimulation (rTMS) as supplementary treatment for sub-acute post-stroke aphasia are controversial. We assessed the efficacy of inhibitory rTMS with conventional speech therapy to help recovery language performance in sub-acute stroke aphasia.In a randomised case-control double-blind study 12 non-fluent aphasic were consecutively enrolled. All patients suffered a first-ever stroke in the sub-acute stage defined as time since lesion onset from 1 month post-stroke. Patients were randomized either to receive real (low frequency on right-hemisphere homologue of Broca’s area) or sham rTMS, to a 3-week (5 day in a week). Immediately after each rTMS all patients received speech therapy. The speech performance was evaluated with Italian version of Aachener Aphasia Test (AAT), before (T0) and after (T1) treatments.Seven patients were treated with real rTMS and 5 patients with sham rTMS. Total and sub totals AAT scores showed a similar improvement in real and in sham rTMS groups between T0 and T1.In early phase of rehabilitation (

The purpose of this study was to assess the beneficial effect of BTX- A in the treatment of hemiplegic shoulder pain in chronic phase. 31 consecutive hemiplegic patients with different degree of hypertonus (groups 1 and 2) of the muscles of the painful shoulder, referred to 5 Rehabilitation Centers and underwent to neuromuscular blockade with pure BTX-A (150 Kd). The rating scales were: the FAT, the MAS, the pROM, the MRC and the VAS at rest and during nursing. Evaluations were performed at enrollment (T0), after 1 month (T1) and after 3 months post-treatment with BTX (T3). At T1 It has been observed a statistically significant reduction in VAS at rest and during nursing ( p p = 0.04) and passive ROM ( p