Recovery of standing balance and functional mobility after stroke. Measurement of Motor Recovery After Stroke: Outcome Assessment and Sample Size Requirements Analysis and Comparison of the Psychometric Properties of Three Balance Measures for Stroke Patients Variables Explaining Functional Recovery Following Motor Stroke Occurence and Clinical Predictors of Spasticity After Ischemic Stroke A Modified National Institutes of Health Stroke Scale for Use in Stroke Clinical Trials: Preliminary Reliability and Validity Impact of Time on Improvement of Outcome After Stroke Reliability of the Fugl-Meyer assessment for testing motor performance in patients following stroke. An evaluation of two different exercise regimes during the first year following stroke: A randomised controlled trial Controlled Education of patients after Stroke (CEOPS)- nurse-led multimodal and long-term interventional program involving a patient’s caregiver to optimize secondary prevention of stroke: study protocol for a randomized controlled trial Action observation for upper limb function after stroke: evidence-based review of randomized controlled trials Comparing stroke rehabilitation outcomes between acute inpatient and nonintense home settings. Are the modified “simple questions” a valid and reliable measure of health related quality of life after stroke? Intra-limb coordination deficit in stroke survivors and response to treatment. Facilitation of Sensory and Motor Recovery by Thermal Intervention for the Hemiplegic Upper Limb in Acute Stroke Patients: A Single-Blind Randomized Clinical Trial Efficacy of coupling repetitive transcranial magnetic stimulation and physical therapy to reduce upper-limb spasticity in patients with stroke: a randomized controlled trial. Development of a Novel, Weighted, Quantifiable Stroke Scale: Japan Stroke Scale
OBJECTIVE To examine the extent to which recovery of functional balance and mobility is accompanied by change in a few specific physiologic measures of postural control . DESIGN Longitudinal prospect i ve study . SETTING Laboratory setting in Ontario . PARTICIPANTS Twenty-seven volunteers ( age , 64.2+/-13.7y ) undergoing 4 weeks of rehabilitation after stroke participated . At initial testing , patients were 32.7+/-18.4 days poststroke and exhibited a moderate level of motor recovery ( lower-extremity and postural control , stages 3 - 4 on the Chedoke-McMaster Stroke Assessment Impairment Inventory ) . INTERVENTIONS Not applicable . MAIN OUTCOME MEASURES Three functional measures ( Berg Balance Scale , Clinical Outcome Variables Scale , gait speed ) were assessed . Three physiologic measures ( electromyographic data of hamstrings and soleus muscles bilaterally , postural sway , arm acceleration )  were taken while subjects stood quietly on a force platform and while they performed a rapid shoulder flexion movement of the nonparetic upper extremity . RESULTS After 1 month of rehabilitation , there was an overall significant improvement in all outcome measures ( functional , physiologic ) . However , 10 patients failed to show any improvement in the electromyographic activation of hamstrings muscle on the paretic side in response to the rapid arm movement . These patients compensated by increasing the anticipatory activation of the nonparetic hamstrings . CONCLUSION After stroke , patients showed improvement in both physiologic and functional measures of balance and mobility over a 1-month period . We have identified some patients who may be using compensatory strategies to increase function . The factors that may predict those patients who are likely to use compensatory strategies awaits further study Background and Purpose The purpose of this study was to analyze recovery of motor function in a cohort of patients presenting with an acute occlusion in the carotid distribution . Analysis of recovery patterns is important for estimating patient care needs , establishing therapeutic plans , and estimating sample sizes for clinical intervention trials . Methods We prospect ively measured the motor deficits of 104 stroke patients over a 6-month period to identify earliest measures that would predict subsequent motor recovery . Motor function was measured with the  Fugl-Meyer Assessment .  Fifty-four patients were r and omly assigned to a training set for model development ; 50 patients were assigned to a test set for model validation . In a second analysis , patients were stratified on basis of time and stroke severity . The sample size required to detect a 50 % improvement in residual motor function was calculated for each level of impairment and at three points in time . Results At baseline the initial Fugl-Meyer motor scores accounted for only half the variance in 6-month motor function ( r2=0.53 , p<0.001 ) . After 5 days , both the 5-day motor and sensory scores explained 74 % of the variance ( p<0.001 ) . After 30 days , the 30-day motor score explained 86 % of the variance ( p<0.001 ) . Application of these best models to the test set confirmed the results obtained with the training set . Sample -size calculations revealed that as severity and time since stroke increased , sample sizes required to detect a 50 % improvement in residual motor deficits decreased . Conclusions Most of the variability in motor recovery can be explained by 30 days after stroke . These findings have important implication s for clinical practice and research Background and Purpose — This study compared the psychometric properties of 3 clinical balance measures , the  Berg Balance Scale ( BBS ) , the Balance subscale of the Fugl-Meyer test ( FM-B ) , and the Postural Assessment Scale for Stroke Patients ( PASS ) , in stroke patients with a broad range of neurological and functional impairment from the acute stage up to 180 days after onset . Methods — One hundred twenty-three stroke patients were followed up prospect ively with the 3 balance measures 14 , 30 , 90 , and 180 days after stroke onset ( DAS ) . Reliability ( interrater reliability and internal consistency ) and validity ( concurrent validity , convergent validity , and predictive validity ) of each measure were examined . A comparison of the responsiveness of each of the 3 measures was made on the basis of the entire group of patients and 3 separate groups classified by degree of neurological severity . Results — The FM-B and BBS showed a significant floor or ceiling effect at some DAS points , whereas the PASS did not show these effects . The BBS , FM-B , and PASS all had good reliability and validity for patients at different recovery stages after stroke . The results of effect size demonstrated fair to good responsiveness of all 3 measures within the first 90 DAS but , as expected , only a low level of responsiveness at 90 to 180 DAS . The PASS was more responsive to changes in severe stroke patients at the earliest period after stroke onset , 14 to 30 DAS . Conclusions — All 3 measures tested showed very acceptable levels of reliability , validity , and responsiveness for both clinicians and research ers . The PASS showed slightly better psychometric characteristics than the other 2 measures Abstract : Few well‐ design ed descriptive studies focus exclusively on patients after motor stroke . This study describes a cohort of participants after motor stroke and assesses the extent to which five key variables explain the variation in functional recovery 3 months after stroke . Prospect i ve data were collected ( N = 100 ) on age , lesion volume , motor strength , cognition , and poststroke function during the acute care hospital admission . Instruments included magnetic resonance imaging ( MRI ) to provide a measure of lesion volume , the  Mini‐Mental State Examination ( MMSE ) and the Neurobehavioral Cognitive Status Examination ( NCSE )  to measure cognitive status , and the  National Institutes of Health Stroke Scale ( NIHSS ) to measure motor strength . The Functional Independence Measure ( FIMTM ) was used to measure baseline function and functional recovery 3 months after stroke . Descriptive and hierarchical multiple regression analyses were used to describe the cohort and predict functional recovery . The means for key variables during acute care were 65 ( ±15 ) years of age , lesion volume  21.5 ( ±44.7 ) cm3 , NIHSS 6.34 ( ±3.55 ) , MMSE 24.38 ( ±4.82 ) , NCSE 64.33 ( ±13 ) , and FIMTM 94.05 ( ±19.31 ) . Age , cognitive status , and initial function accounted for 42 % of the variance in functional recovery 3 months after stroke . Results indicate that neuroscience nurses need to add cognition to their focus during the fast‐paced acute phase of care following motor stroke Background and Purpose — There is currently no consensus on ( 1 ) the percentage of patients who develop spasticity after ischemic stroke , ( 2 ) the relation between spasticity and initial clinical findings after acute stroke , and ( 3 ) the impact of spasticity on activities of daily living and health-related quality of life . Methods — In a prospect i ve cohort study , 301 consecutive patients with clinical signs of central paresis due to a first-ever ischemic stroke were examined in the acute stage and 6 months later . At both times , the degree and pattern of paresis and muscle tone , the Barthel Index , and the EQ-5D score , a st and ardized instrument of health-related quality of life , were evaluated . Spasticity was assessed on the Modified Ashworth Scale and defined as Modified Ashworth Scale > 1 in any of the examined joints . Results — Two hundred eleven patients ( 70.1 % ) were reassessed after 6 months . Of these , 42.6 % ( n=90 ) had developed spasticity . A more severe degree of spasticity ( Modified Ashworth Scale ≥3 ) was observed in 15.6 % of all patients . The prevalence of spasticity did not differ between upper and lower limbs , but in the upper limb muscles , higher degrees of spasticity ( Modified Ashworth Scale ≥3 ) were more frequently ( 18.9 % ) observed than in the lower limbs ( 5.5 % ) . Regression analysis used to test the differences between upper and lower limbs showed that patients with more severe paresis in the proximal and distal limb muscles had a higher risk for developing spasticity ( P≤0.001 ) . Spasticity of the upper and lower limb was more frequent in patients with hemihypesthesia than in patients without sensory deficits ( P≤0.001 ) . Patients with spasticity showed a lower Barthel Index and EQ-5D score compared with the group without spasticity . Conclusions — Spasticity was present in 42.6 % of patients with initial central paresis . However , severe spasticity was relatively rare . Predictors for the development of spasticity were a severe degree of paresis and hemihypesthesia at stroke onset Background and Purpose — The National Institutes of Health Stroke Scale ( NIHSS ) is accepted widely for measuring acute stroke deficits in clinical trials , but it contains items that exhibit poor reliability or do not contribute meaningful information . To improve the scale for use in clinical research , we used formal clinimetric analyses to derive a modified version , the mNIHSS . We then sought to demonstrate the validity and reliability of the new mNIHSS . Methods — The mNIHSS was derived from our prior clinimetric studies of the NIHSS by deleting poorly reproducible or redundant items ( level of consciousness , face weakness , ataxia , dysarthria ) and collapsing the sensory item into 2 responses . Reliability of the mNIHSS was assessed with the certification data originally collected to assess the reliability of investigators in the National Institute of Neurological Disorders and Stroke ( NINDS ) rtPA ( recombinant tissue plasminogen activator ) Stroke Trial . Validity of the mNIHSS was assessed with the outcome results of the NINDS rtPA Stroke Trial . Results — Reliability was improved with the mNIHSS : the number of scale items with poor & kgr ; coefficients on either of the certification tapes decreased from 8 ( 20 % ) to 3 ( 14 % ) with the mNIHSS . With the use of factor analysis , the structure underlying the mNIHSS was found identical to the original scale . On serial use of the scale , goodness of fit coefficients were higher with the mNIHSS . With data from part I of the trial data , the proportion of patients who improved ≥4 points within 24 hours after treatment was statistically significantly increased by tPA ( odds ratio , 1.3 ; 95 % confidence limits , 1.0 , 1.8;P = 0.05 ) . Likewise , the odds ratio for complete/nearly complete resolution of stroke symptoms 3 months after treatment was 1.7 ( 95 % confidence limits , 1.2 , 2.6 ) with the mNIHSS . Other outcomes showed the same agreement when the mNIHSS was compared with the original scale . The mNIHSS showed good responsiveness , ie , was useful in differentiating patients likely to hemorrhage or have a good outcome after stroke . Conclusions — The mNIHSS appears to be identical clinimetrically to the original NIHSS when the same data are used for validation and reliability . Power appears to be greater with the mNIHSS with the use of 24-hour end points , suggesting the need for fewer patients in trials design ed to detect treatment effects comparable to rtPA . The mNIHSS contains fewer items and might be simpler to use in clinical research trials . Prospect i ve analysis of reliability and validity , with the use of an independently collected cohort , must be obtained before the mNIHSS is used in a research setting Background and Purpose — Longitudinal conducted studies show that neurologic and functional recovery show faster recovery in the first weeks poststroke . The aim of the present study was to study the effects of progress of time on observed improvements in motor strength , synergisms , and activities during the first 16 weeks poststroke . Methods — Based on data from a previous study , 101 patients with first-ever ischemic middle cerebral artery strokes were prospect ively investigated during the first 16 weeks after stroke . Progress of time was categorized into 8 biweekly time intervals and was used as the independent covariate in a first-order longitudinal regression model . The biweekly time change ( progress of time ) was related to improvement in upper and lower limb motor recovery assessed with Fugl-Meyer score and Motricity Index , reduction in visuospatial inattention based on the letter cancellation task , and improvement in walking ability , dexterity , and activities of daily living measured with the Functional Ambulation Categories , Action Research Arm test , and Barthel Index . Results — Time explained a significant change of 8.4 ( 42 % ) measurement units on the Barthel Index for the first 10 weeks poststroke , 1.1 ( 22 % ) measurement units on Functional Ambulation Categories , and 19 % on the Action Research Arm test for the first 6 and 8 weeks poststroke . Approximately 25 % ( for Fugl-Meyer – arm ) to 26 % ( for Motricity Index – arm ) of the significant change in measurements units was explained by time alone for the upper limb compared with 33 % for Fugl-Meyer – leg and 39 % for Motricity Index – leg of the lower limb . Time accounted for a reduction of 16 % in the letter cancellation task . Observed associations did not change after controlling for covariates such as age , gender , hemisphere of stroke , type of stroke , or intervention . Conclusion — Progress of time is an independent covariate that reflects spontaneous recovery of body functions and activities explaining ≈16 % to 42 % of the observed improvements in the first 6 to 10 weeks after stroke onset BACKGROUND AND PURPOSE The purpose of this study was to establish the interrater reliability of assessment s made with the Fugl-Meyer evaluation of physical performance in a rehabilitation setting . SUBJECTS Twelve patients ( 7 male , 5 female ) , aged 49 to 86 years ( mean = 66 ) , who had sustained a cerebrovascular accident participated in the study . All patients were admitted consecutively to a rehabilitation center and were between 6 days and 6 months poststroke . METHODS Three physical therapists , each with more than 10 years of experience , assessed the patients in a r and omized and balanced order using this assessment . The therapists st and ardized the assessment approach prior to the study but did not discuss the procedure once the study began . RESULTS The overall reliability was high ( overall intraclass correlation coefficient = .96 ) , and the intraclass correlation coefficients for the subsections of the assessment varied from .61 for pain to .97 for the upper extremity . CONCLUSION AND DISCUSSION The relative merits of using the Fugl-Meyer assessment as a research tool versus a clinical assessment for stroke are discussed The purpose of this r and omised controlled trial was to evaluate the effects of two different exercise approaches during the first 12 months post stroke on Instrumental Activities of Daily Living ( IADL ) , motor function , gait performance , balance , grip strength , and muscle tone . This study is a double-blind longitudinal r and omised trial of first-time-ever stroke patients . Seventy-five patients were included : 35 in an intervention group and 40 in a self-initiated exercise group .  After discharge from acute rehabilitation , patients assigned in the intervention group had physiotherapy for a minimum amount of 80 hours during the first year . Patients in the self-initiated exercise group were not recommended any specific therapy besides treatment when needed . Main outcome measures were Instrumental Activities of Daily Living according to Fillenbaum , Motor Assessment Scale , 6-Minute Walk Test , Berg Balance Scale , Timed Up- and -Go Test , grip strength , Modified Ashworth Scale , and pulse monitoring . The patients were tested on admission , at discharge , and after 3 , 6 , and 12 months post stroke by an experienced investigator , blinded to group assignment . Twelve months post stroke showed higher levels of independence in all items of the Instrumental Activities of Daily Living Test and improvements in the results of Motor Assessment Scale , 6-Minute Walk Test , Berg Balance Scale , Timed Up- and -Go , and grip strength in both groups . Only a few significant differences were seen between groups , and they were in favour of the self-initiated exercise group ( e.g. , ability to use the telephone independently ) . Attending examination sessions following each intervention phase appeared to be strong motivators for training , irrespective of group allocation Background Setting up a follow-up secondary prevention program after stroke is difficult due to motor and cognitive impairment , but necessary to prevent recurrence and improve patients ’ quality of life . To involve a referent nurse and a caregiver from the patient ’s social circle in nurse-led multimodal and long-term management of risk factors after stroke could be an advantage due to their easier access to the patient and family . The aim of this study is to compare the benefit of optimized follow up by nursing personnel from the vascular neurology department including therapeutic follow up , and an interventional program directed to the patient and a caregiving member of their social circle , as compared with typical follow up in order to develop a specific follow-up program of secondary prevention of stroke . Methods / design The design is a r and omized , controlled , clinical trial conducted in the French Stroke Unit of the Strokavenir network . In total , 410 patients will be recruited and r and omized in optimized follow up or usual follow up for 2 years . In both group , patients will be seen by a neurologist at 6 , 12 and 24 months . The optimized follow up will include follow up by a nurse from the vascular neurology department , including therapeutic follow up , and a training program on secondary prevention directed to the patient and a caregiving member of their social circle . After discharge , a monthly telephone interview , in the first year and every 3 months in the second year , will be performed by the nurse . At 6 , 12 and 24 month , the nurse will give the patient and caregiver another training session . Usual follow up is only done by the patient ’s general practitioner , after classical information on secondary prevention of risk factors during hospitalization . The primary outcome measure is blood pressure measured after the first year of follow up . Blood pressure will be measured by nursing personnel who do not know the group into which the patient has been r and omized . Secondary endpoints are associated mortality , morbidity , recurrence , drug side-effects and medico-economic analysis . Discussion The result of this trial is expected to provide the benefit of a nurse-led optimized multimodal and long-term interventional program for management of risk factors after stroke , personalizing the role of the nurse and including the patient ’s caregiver . Trial registration Clinical Trials.gov , NCT 02132364 . Registered on 7 May 2014 . EUDRACT , A 00473 - 40 [ Purpose ] The purpose of this study was to suggest evidence d information about action observation to improve upper limb function after stroke . [ Methods ] A systematic review of r and omized controlled trials involving adults aged 18 years or over and including descriptions of action observation for improving upper limb function  was undertaken . Electronic data bases were search ed , including MEDLINE , CINAHL , and PEDro ( the Physiotherapy Evidence Data base ) , for articles published between 2000 to 2014 . Following completion of the search es , two review ers independently assessed the trials and extracted data using a data extraction form . The same two review ers independently documented the method ological quality of the trials by using the PEDro scale . [ Results ] Five r and omized controlled trials were ultimately included in this review , and four of them ( 80 % ) reported statistically significant effects for motor recovery of upper limb using action observation intervention in between groups . [ Conclusion ] This review of the literature presents evidence attesting to the benefits conferred on stroke patints result ing from participation in an action observation intervention . The body of literature in this field is growing steadily . Further work needs to be done to evaluate the evidence for different conditions after stroke and different duration of intervention OBJECTIVE To compare outcomes in stroke survivors who received rehabilitation services in an acute inpatient rehabilitation setting ( multidisciplinary rehabilitation team ) with outcomes in survivors in a home-based setting ( family caregivers , limited team supervision ) . DESIGN R and omized clinical trial , with mean follow-up after 60 days . SETTING Inpatient rehabilitation setting and home-based setting s. PATIENTS Sixty patients ( age range , 43 - 80yr ) who had a stroke between 1996 and 1999 and had been referred after medical stabilization , r and omly divided into 2 groups : group 1 , inpatient rehabilitation ; group 2 , home-based rehabilitation . INTERVENTIONS Group 1 : therapeutical and neuromuscular exercises with occupational therapy with professional supervision ; group 2 : conventional exercises with family caregiver and limited professional supervision . MAIN OUTCOME MEASURES Spasticity was evaluated with the Ashworth Scale , motor status with Brunnstrom 's stages , functional status with the FIM instrument , and cognitive status with the Mini-Mental State Examination before and after rehabilitation . RESULTS Patients rehabilitated in acute inpatient setting s had better motor , functional , and cognitive outcomes ( p < .05 ) . Spasticity changes did not differ between the groups . CONCLUSION Intense inpatient rehabilitation services for stroke survivors provide significantly more favorable functional and cognitive outcomes with relatively low complications than did nonintense rehabilitation efforts in home setting OBJECTIVES Two “ simple questions ” were developed as a minimalist measurement tool to assess outcome in large trials and epidemiological studies after stroke . A previous study of their validity had disclosed ambiguities in their wording . In this study , the clarity , validity , and reliability of a modified version of these simple questions were examined . The relation between patients ' responses to these questions and two widely used generic measures of health related quality of life were also studied . METHODS A hospital based stroke register cohort of 152 patients , who were all visited at home by a study nurse , was used to study validity . A cohort of 1753 patients derived from the International Stroke Trial was used to study the relation with measures of quality of life . The sensitivity , specificity , and accuracy with which responses to each question predicted the patients ' outcome measured using st and ard instruments was assessed . The distribution of scores for the EuroQol and SF-36 was examined for patients classified as dependent , independent , and fully recovered by the combined use of the modified simple questions . RESULTS The modified “ dependency ” question had excellent sensitivity ( > 85 % ) , specificity ( > 79 % ) , and accuracy ( > 82 % ) for identifying dependency after stroke . The “ problems ” question had good sensitivity ( 65–88 % ) and moderate specificity ( 36–72 % ) for the detection of problems in a broad range of domains . The combined use of the modified dependency and problems questions provided a valid , simple , and reliable overall indicator of health related quality of life after stroke . CONCLUSIONS The modified simple questions have excellent face validity and good measurement properties for the assessment of outcome after stroke . They are particularly well suited for large epidemiological studies and r and omised trials PURPOSE Purpose one was to characterize the consistency of intra-limb hip/knee ( H/K ) coordination according to a measure of average coefficient of correspondence ( ACC ) across strides . Purpose two was to investigate H/K ACC validity and ability to discriminate pre-/post-treatment change in stroke survivors . METHODS Five healthy controls and 32 chronic ( > 12 mos ) stroke survivors were enrolled , and H/K ACC was calculated for both groups . Comparison between controls and stroke was made using the Mann-Whitney Test . Convergent validity of H/K ACC was tested using the Pearson Correlation model with gait speed and the 6 min Walk Test ( 6MWT ) . Stroke survivors were r and omized to either : ( 1 ) gait training with functional neuromuscular stimulation ( FNS ) using intramuscular ( IM ) electrodes or ( 2 ) gait training without FNS . Both groups had treatment 1.5 h/day , 5 days/week , for 12 weeks , including .5 h coordination exercise , .5 h body weight supported treadmill training ( BWSTT ) , and .5 h over ground gait training . The FNS-IM group used FNS-IM for all treatment components ; the No-FNS group did not . Pre-/post-treatment comparisons were made using ANOVA . RESULTS H/K ACC detected a significant difference between controls versus stroke involved limb ( p=.0001 ) and controls versus stroke uninvolved limb ( p=.042 ) . The H/K ACC measure was well-correlated with gait speed ( r=.70 ) and 6MWT ( r=.69 ) . H/K ACC showed a significant treatment response to FNS-IM ( p=.003 ) , but not No-FNS ( p=.747 ) . CONCLUSIONS H/K ACC sensitively discriminated between controls versus stroke involved or uninvolved limbs . H/K ACC was valid , with significant correlations with both walking speed and 6MWT .  FNS-IM produced a significant gain in H/K ACC , and No-FNS did not Background and Purpose — Thermal stimulation ( TS ) is commonly used in orthopedic rehabilitation , but the role of TS in the facilitation of sensorimotor recovery in hemiplegic patients remains unknown . This study addressed the issue of TS intervention in the facilitation of functional outcomes . Methods — Forty-six stroke survivors were r and omly assigned to st and ard rehabilitation treatment and st and ard treatment plus TS ( 30 minutes daily for 6 weeks ) . Twenty-nine patients completed the experiment . Six measures , including Brunnstrom stage , modified motor assessment scale , grasping strength , angles of wrist extension and flexion , sensation by monofilament , and muscle tone by modified Ashworth scale , were performed weekly to evaluate sensory and motor functional outcomes . Results — The performance of Brunnstrom stage and wrist extension and sensation were improved significantly after TS intervention . Recovery rates of 6 measures after TS were significantly higher than those of the control , except for grasping . Similar muscle tones were found in both groups . Conclusion — TS on the paretic h and significantly enhances the recovery of several aspects of sensory and motor functions in hemiplegic stroke patients OBJECTIVE To assess the efficacy of inhibitory repetitive transcranial magnetic stimulation ( rTMS ) for decreasing upper-limb muscle tone after chronic stroke . DESIGN A r and omized sham-controlled trial with a 4-week follow-up . SETTING Research hospital . PARTICIPANTS Patients with stroke ( N=20 ) with poststroke upper limb spasticity . INTERVENTIONS The experimental group received rTMS to the primary motor cortex of the unaffected side ( 1500 pulses ; 1Hz ; 90 % of resting motor threshold for the first dorsal interosseous muscle ) in 10 sessions , 3d/wk , and physical therapy ( PT ) . The control group received sham stimulation and PT . MAIN OUTCOME MEASURES Modified Ashworth scale ( MAS ) , upper-extremity Fugl-Meyer assessment , FIM , range of motion , and stroke-specific quality -of-life scale . All outcomes were measured at baseline , after treatment ( postintervention ) , and at a 4-week follow-up . A clinical ly important difference was defined as a reduction of ≥1 in the MAS score . RESULTS Friedman test revealed that PT is efficient for significantly reducing the upper limb spasticity of patients only when it is associated with rTMS . In the experimental group , 90 % of the patients at postintervention and 55.5 % at follow-up showed a decrease of ≥1 in the MAS score , representing clinical ly important differences . In the control group , 30 % of the patients at postintervention and 22.2 % at follow-up experienced clinical ly meaningful changes . There were no differences between the groups at any time for any of the other outcome measures , indicating that both groups demonstrated similar behaviors over time for all variables . CONCLUSIONS rTMS associated with PT can be beneficial in reducing poststroke spasticity . However , more studies are needed to clarify the clinical changes underlying the reduction in spasticity induced by noninvasive brain stimulations Background and Purpose — Several stroke scales are available for estimation of the severity of stroke , but none of them provides information regarding the relative weights of the observed variables . To define an integrated severity of stroke , we developed a quantifiable stroke scale with weighted variables that apply conjoint analysis to calculate the relative weight of each item . Methods — We selected 10 variables ( consciousness , language , neglect , hemianopsia , gaze , pupillary abnormality , facial palsy , plantar reflex , sensation , and weakness ) based on the multivariate analysis of the Keio Stroke Patient Data base Battery . The variables were categorized and evaluated for their distribution and sensitivity . The categorizations were then modified and rechecked . The procedure was repeated until the appropriate categorization was obtained from 198 patients . A temporary stroke scale without weight was then formulated , and the reliability of the scale was examined and revised with 80 new stroke patients . As a next step , 150 neurologists were asked to rank a set of 27 virtual patients , each with a different combination of variables , according to severity . From these rankings , conjoint analysis was used to derive utility scores ( weights ) for each factor level . Results — The relative weights of each of the factors were as follows : consciousness 49.8 % , language 9.9 % , weakness of lower extremity 7.3 % , pupillary abnormality 6.8 % , gaze palsy 5.6 % , weakness of arm 4.3 % , weakness of h and 3.7 % , neglect 3.7 % , facial palsy 2.4 % , plantar reflex 2.2 % , hemianopsia 2.2 % , and sensory impairment 2.1 % . The total score for a patient could be calculated from the sum of the scores for each of the variables ranging from −0.38 to 27.86 . Scoring of 100 patients with acute stroke was carried out , and the changes in scores were followed for validation . Longitudinal clinical monitoring of the patients correlated well with the scores in each patient . The interrater and intrarater reliabilities of the scale were excellent ( weighted & kgr ; 0.83 ; Cronbach ’s & agr ; 0.998 ) . Conclusions — The Japan Stroke Scale is a parametric stroke scale that provides a quantitative measure of the severity of stroke . Each of the variables of the scale has a relative weight according to the severity of stroke . Reliability and responsiveness were proved to be excellent . The present data revealed a potentiality for the Japan Stroke Scale to be a universally accepted and reliable st and ardized system from the clinimetrical point of view
None of the review ed measurement tools demonstrated satisfactory results for all psychometric properties evaluated , and the majority lacked evidence concerning validity and absolute reliability .
This systematic review found limited evidence to support the use of most of clinical measures of spasticity for people post-stroke .
This review identified various clinical measures of spasticity that have been investigated in people after stroke .
PURPOSE To identify and appraise the literature on clinical measures of spasticity that has been investigated in people after stroke .