Posts Tagged hemiparesis

[Abstract] The effect of robot therapy assisted by surface EMG on hand recovery in post-stroke patients. A pilot study

Abstract

Background: Hemiparesis caused by a stroke negatively limits a patient’s motor function. Nowadays, innovative technologies such as robots are commonly used in upper limb rehabilitation. The main goal of robot-aided therapy is to provide a maximum number of stimuli in order to stimulate brain neuroplasticity. Treatment applied in this study via the AMADEO robot aimed to improve finger flexion and extension.
Aim: To assess the effect of rehabilitation assisted by a robot and enhanced by surface EMG.
Research project: Before-after study design.
Materials and methods: The study group consisted of 10 post-stroke patients enrolled for therapy with the AMADEO robot for at least 15 sessions. At the beginning and at the end of treatment, the following tests were used for clinical assessment: Fugl-Meyer scale, Box and Block test and Nine Hole Peg test. In the present study, we used surface electromyography (sEMG) to maintain optimal kinematics of hand motion. Whereas sensorial feedback, provided by the robot, was vital in obtaining closed-loop control. Thus, muscle contraction was transmitted to the amplifier through sEMG, activating the mechanism of the robot. Consequentially, sensorial feedback was provided to the patient.
Results: Statistically significant improvement of upper limb function was observed in: Fugl-Meyer (p = 0.38) and Box and Block (p = 0.27). The Nine Hole Peg Test did not show statistically significant changes in motor skills of the hand. However, the functional improvement was observed at the level of 6% in the Fugl-Meyer, 15% in the Box and Block, and 2% in the Nine Hole Peg test.
Conclusions: Results showed improvement in hand grasp and overall function of the upper limb. Due to sEMG, it was possible to implement robot therapy in the treatment of patients with severe hand impairment.

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[Abstract] Evolution of upper limb kinematics four years after subacute robot-assisted rehabilitation in stroke patients

Purpose: To assess functional status and robot-based kinematic measures four years after subacute robot-assisted rehabilitation in hemiparesis.

Material and methods: Twenty-two patients with stroke-induced hemiparesis participated in a ≥3-month upper limb combined program of robot-assisted and occupational therapy from two months post-stroke, and received community-based therapy after discharge. Four years later, nineteen (86%) participated in this long-term follow-up study. Assessments two, five and 54 months post-stroke included Fugl-Meyer (FM), Modified Frenchay Scale (MFS, at Month 54) and robot-based kinematic measures of targeting tasks in three directions, north, paretic and non-paretic: distance covered, velocity, accuracy (RMS error from straight line) and smoothness (number of velocity peaks; upward changes in accuracy and smoothness measures represent worsening). Analysis was stratified by FM score at two months: ≥17 (Group 1) or < 17 (Group 2). Correlation between impairment (FM) and function (MFS) was explored at 54 months.

Results: Fugl-Meyer scores were stable from five to 54 months (+1[-2;4], median[1st;3rd quartiles], ns). Kinematic changes in the three directions pooled were: distance covered, -1[-17;2]% (ns); velocity, -8[-32;28]% (ns); accuracy, +6[-13;98]% (ns); smoothness, +44[-6;126]% (p<0.05). Group 2 showed decline vs Group 1 (p<0.001) in FM (Group 1, +3[1;5], p<0.01; Group 2, -7[-11;-1], ns) and accuracy (Group 1, -3[-27;38]%, ns; Group 2, +29[17;140]%, p<0.001). At 54 months, FM and MFS were highly correlated (Pearson’s rho = 0.89; p<0.001).

Conclusions: While impairment appeared stable four years after robot-assisted upper limb training during subacute post-stroke phase, kinematic performance deteriorated in spite of community-based therapy, especially in patients with more severe impairment.

 

via Evolution of upper limb kinematics four years after subacute robot-assisted rehabilitation in stroke patients: International Journal of Neuroscience: Vol 0, No ja

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[Abstract] Application of Commercial Games for Home-Based Rehabilitation for People with Hemiparesis: Challenges and Lessons Learned

Objective: To identify the factors that influence the use of an at-home virtual rehabilitation gaming system from the perspective of therapists, engineers, and adults and adolescents with hemiparesis secondary to stroke, brain injury, and cerebral palsy.

Materials and Methods: This study reports on qualitative findings from a study, involving seven adults (two female; mean age: 65 ± 8 years) and three adolescents (one female; mean age: 15 ± 2 years) with hemiparesis, evaluating the feasibility and clinical effectiveness of a home-based custom-designed virtual rehabilitation system over 2 months. Thematic analysis was used to analyze qualitative data from therapists’ weekly telephone interview notes, research team documentation regarding issues raised during technical support interactions, and the transcript of a poststudy debriefing session involving research team members and collaborators.

Results: Qualitative themes that emerged suggested that system use was associated with three key factors as follows: (1) the technology itself (e.g., characteristics of the games and their clinical implications, system accessibility, and hardware and software design); (2) communication processes (e.g., preferences and effectiveness of methods used during the study); and (3) knowledge and training of participants and therapists on the technology’s use (e.g., familiarity with Facebook, time required to gain competence with the system, and need for clinical observations during remote therapy). Strategies to address these factors are proposed.

Conclusion: Lessons learned from this study can inform future clinical and implementation research using commercial videogames and social media platforms. The capacity to track compensatory movements, clinical considerations in game selection, the provision of kinematic and treatment progress reports to participants, and effective communication and training for therapists and participants may enhance research success, system usability, and adoption.

 

via Application of Commercial Games for Home-Based Rehabilitation for People with Hemiparesis: Challenges and Lessons Learned | Games for Health Journal

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[Abstract] Motor skill changes and neurophysiologic adaptation to recovery-oriented virtual rehabilitation of hand function in a person with subacute stroke: a case study.

Abstract

PURPOSE:

The complexity of upper extremity (UE) behavior requires recovery of near normal neuromuscular function to minimize residual disability following a stroke. This requirement places a premium on spontaneous recovery and neuroplastic adaptation to rehabilitation by the lesioned hemisphere. Motor skill learning is frequently cited as a requirement for neuroplasticity. Studies examining the links between training, motor learning, neuroplasticity, and improvements in hand motor function are indicated.

METHODS:

This case study describes a patient with slow recovering hand and finger movement (Total Upper Extremity Fugl-Meyer examination score = 25/66, Wrist and Hand items = 2/24 on poststroke day 37) following a stroke. The patient received an intensive eight-session intervention utilizing simulated activities that focused on the recovery of finger extension, finger individuation, and pinch-grasp force modulation.

RESULTS:

Over the eight sessions, the patient demonstrated improvements on untrained transfer tasks, which suggest that motor learning had occurred, as well a dramatic increase in hand function and corresponding expansion of the cortical motor map area representing several key muscles of the paretic hand. Recovery of hand function and motor map expansion continued after discharge through the three-month retention testing.

CONCLUSION:

This case study describes a neuroplasticity based intervention for UE hemiparesis and a model for examining the relationship between training, motor skill acquisition, neuroplasticity, and motor function changes. Implications for rehabilitation Intensive hand and finger rehabilitation activities can be added to an in-patient rehabilitation program for persons with subacute stroke. Targeted training of the thumb may have an impact on activity level function in persons with upper extremity hemiparesis. Untrained transfer tasks can be utilized to confirm that training tasks have elicited motor learning. Changes in cortical motor maps can be used to document changes in brain function which can be used to evaluate changes in motor behavior persons with subacute stroke.

 

via Motor skill changes and neurophysiologic adaptation to recovery-oriented virtual rehabilitation of hand function in a person with subacute stroke: … – PubMed – NCBI

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[ARTICLE] Efficacy and Safety of AbobotulinumtoxinA (Dysport) for the Treatment of Hemiparesis in Adults With Upper Limb Spasticity Previously Treated With Botulinum Toxin: Subanalysis From a Phase 3 Randomized Controlled Trial – Full Text

Abstract

Objective

To assess the efficacy and safety of abobotulinumtoxinA in adults with upper limb spasticity previously treated with botulinum toxin A (BoNT-A).

Design

post hoc analysis from a Phase 3, prospective, double-blind, randomized, placebo-controlled study (NCT01313299).

Setting

A total of 34 neurology or rehabilitation clinics in 9 countries.

Participants

Adults aged 18-80 years with hemiparesis, ≥6 months after stroke or traumatic brain injury. This analysis focused on a subgroup of subjects with previous onabotulinumtoxinA or incobotulinumtoxinA treatment (n = 105 of 243 in the total trial population) in the affected limb. The mean age was 52 years, and 62% were male.

Intervention

Study subjects were randomized 1:1:1 to receive a single injection session with abobotulinumtoxinA 500 or 1000 U or with placebo in the most hypertonic muscle group among the elbow, wrist, or finger flexors (primary target muscle group [PTMG]), and ≥2 additional muscle groups from the upper limb.

Main Outcome Measurements

Efficacy and safety measures were assessed, including muscle tone (Modified Ashworth Scale [MAS] in the PTMG), Physician Global Assessment (PGA), perceived function, spasticity, active movement, and treatment-emergent adverse events.

Results

At week 4, more subjects had ≥1 grade improvement in MAS for the PTMG with abobotulinumtoxinA versus placebo (abobotulinumtoxinA 500 U, 81.1%; abobotulinumtoxinA 1000 U, 75.0%; placebo, 25.0%). PGA scores ≥1 were achieved by 75.7% and 87.5% of abobotulinumtoxinA 500 and 1000 U subjects versus 41.7% with placebo. Perceived function (Disability Assessment Scale), spasticity angle (Tardieu Scale), and active movement were also improved with abobotulinumtoxinA. There were no treatment-related deaths or serious adverse events.

Conclusions

The efficacy and safety of abobotulinumtoxinA in subjects previously treated with BoNT-A were consistent with those in the total trial population. Hence, abobotulinumtoxinA is a treatment option in these patients, and no difference in initial dosing appears to be required compared to that in individuals not treated previously.

 

Introduction

Upper limb spasticity (ULS) is common after stroke or traumatic brain injury (TBI). The impact can be highly significant, including abnormal hand and arm positions, impaired self-care, and limited passive/active range of motion, as well as additional burden to the caregiver [1-5].

The effectiveness of treatment with intramuscularly injected botulinum toxin A (BoNT-A) in reducing muscle tone in patients with ULS is well established [5-8]. Several guidelines now recommend BoNT-A injections as a first-line treatment option in these patients [6,7,9-11].

AbobotulinumtoxinA (Dysport; Ipsen Biopharm, Wrexham, UK) is a BoNT-A preparation approved in the United States and Europe for the treatment of ULS in adult patients [12,13]. A recent clinical trial examined the efficacy and safety of a single injection session of abobotulinumtoxinA (500 or 1000 U) in 243 adults with ULS who had hemiparesis at least 6 months after stroke or TBI [14]. The effects observed included improvements in muscle tone, perceived function, spasticity, and active range of motion. Furthermore, the treatment was well tolerated, and all treatment-related adverse events (AEs) were mild or moderate in severity.

Among the subjects enrolled in this study, 105 had previously undergone treatment in the upper limb with onabotulinumtoxinA or incobotulinumtoxinA. The aim of the present analysis was to assess the efficacy and safety of abobotulinumtoxinA in adults with ULS who had been previously treated with a BoNT-A, and to describe the doses of abobotulinumtoxinA administered to these subjects. […]

Continue —> Efficacy and Safety of AbobotulinumtoxinA (Dysport) for the Treatment of Hemiparesis in Adults With Upper Limb Spasticity Previously Treated With Botulinum Toxin: Subanalysis From a Phase 3 Randomized Controlled Trial – ScienceDirect

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[ARTICLE] Kinect-based individualized upper extremity rehabilitation is effective and feasible for individuals with stroke using a transition from clinic to home protocol – Full Text PDF

Purpose: To investigate the effectiveness and feasibility of Kinect-based upper
extremity rehabilitation on functional performance in chronic stroke survivors.
Methods: This was a single cohort pre-post test study. Participants (N=10; mean age =
62.5 ± 9.06) engaged in Kinect-based training three times a week for four to five weeks
in a university laboratory. To simulate a clinic to home transfer condition,
individualized guidance was given to participants at the initial three sessions followed
by independent usage. Outcomes included Fugl-Meyer assessment of upper extremity,
Wolf Motor Function Test, Stroke Impact Scale, Confidence of Arm and Hand
Movement and Active Range of Motion. Participant experience was assessed using a
structured questionnaire and a semi-structured interview.
Results. Improvement was found in Fugl-Meyer assessment scores (p=0.001), Wolf
Motor Function Test, (p=0.008), Active Range of Motion (p<0.05) and Stroke Impact
Scale-Hand function (p=0.016). Clinically important differences were found in FuglMeyer
assessment scores (Δ= 5.70 ± 3.47) and Wolf Motor Function Test (Δ Time= –
4.45 ± 6.02; ∆ Functional Ability Scores= 0.29 ± 0.31). All participants could use the
system independently and recognized the importance of exercise individualization by
the therapist.
Conclusions. The Kinect-based UE rehabilitation provided clinically important
functional improvements to our study participants.

Introduction

Stroke is the leading cause of long-term adult disability in the United States [1].
More than a half of survivors continue suffering from upper-limb hemiparesis poststroke with only 5% of people recovering their full arm function [2]. The persistent
upper-limb dysfunction significantly impairs motor performance, and results in a
serious decline in functional ability as well as quality of life [3]. Intensive and repeated
practice with the paretic arm appears necessary to enhance arm recovery and facilitate
neural reorganization [4-7]. Nevertheless, the healthcare system provides limited
amounts and duration of therapy, making it difficult for stroke survivors to achieve
maximal arm recovery before discharge from outpatient rehabilitation or home care
[8,9]. Therefore, identifying novel modalities that are accessible and affordable to the
general public while allowing continued practice of the arm is imperative for improving
long-term upper-limb outcomes after stroke.
One potential approach is the use of low-cost virtual reality (VR)-based systems,
for example, the Microsoft Kinect system. The Kinect is a vision-based motion
capturing system that can detect gesture and movements of the body through its RGA
camera and depth sensors. It allows users to interact with the VR-based system without
holding or wearing specialized equipment or markers for tracking. Users can play
games or practice exercises using natural movements while observing the performance of their virtual avatars shown in real-time on the computer screen. Through this interactive observation and feedback, stroke survivors can correct their movements towards more normal patterns. Furthermore, the Kinect is small and portable, thus enabling stroke survivors to practice exercises in a familiar and private environment. […]

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[ARTICLE] Home-based neurologic music therapy for arm hemiparesis following stroke: results from a pilot, feasibility randomized controlled trial – Full Text

To assess the feasibility of a randomized controlled trial to evaluate music therapy as a home-based intervention for arm hemiparesis in stroke.

A pilot feasibility randomized controlled trial, with cross-over design. Randomization by statistician using computer-generated, random numbers concealed in opaque envelopes.

Participants’ homes across Cambridgeshire, UK.

Eleven people with stroke and arm hemiparesis, 3–60 months post stroke, following discharge from community rehabilitation.

Each participant engaged in therapeutic instrumental music performance in 12 individual clinical contacts, twice weekly for six weeks.

Feasibility was estimated by recruitment from three community stroke teams over a 12-month period, attrition rates, completion of treatment and successful data collection. Structured interviews were conducted pre and post intervention to establish participant tolerance and preference. Action Research Arm Test and Nine-hole Peg Test data were collected at weeks 1, 6, 9, 15 and 18, pre and post intervention by a blinded assessor.

A total of 11 of 14 invited participants were recruited (intervention n = 6, waitlist n = 5). In total, 10 completed treatment and data collection.

It cannot be concluded whether a larger trial would be feasible due to unavailable data regarding a number of eligible patients screened. Adherence to treatment, retention and interview responses might suggest that the intervention was motivating for participants.

Continue —>  Home-based neurologic music therapy for arm hemiparesis following stroke: results from a pilot, feasibility randomized controlled trialClinical Rehabilitation – Alexander J Street, Wendy L Magee, Andrew Bateman, Michael Parker, Helen Odell-Miller, Jorg Fachner, 2018

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[Abstract] Effect of postural insoles on gait pattern in individuals with hemiparesis: A randomized controlled clinical trial.

Abstract

Introduction

Recovering the ability to walk is an important goal of physical therapy for patients who have survived cerebrovascular accident (stroke). Orthotics can provide a reduction in plantar flexion of the ankle, leading to greater stability in the stance phase of the gait cycle. Postural insoles can be used to reorganize the tone of muscle chains, which exerts an influence on postural control through correction reflexes. The aim of the present study was to perform kinematic and spatiotemporal analyses of gait in stroke survivors with hemiparesis during postural insole usage.

Material and Methods

Twenty stroke victims were randomly divided into two groups: 12 in the experimental group, who used insoles with corrective elements specifically designed for equinovarus foot, and eight in the control group, who used placebo insoles with no corrective elements. Both groups were also submitted to conventional physical therapy. The subjects were analyzed immediately following insole placement and after three months of insole usage. The SMART-D 140® system (BTS Engineering) with eight cameras sensitive to infrared light and the 32-channel SMART-D INTEGRATED WORKSTATION® were used for the three-dimensional gait evaluation.

Results

Significant improvements were found in kinematic range of movement in the ankle and knee as well as gains in ankle dorsiflexion and knee flexion in the experimental group in comparison to the control group after three months of using the insoles.

Conclusion

Postural insoles offer significant benefits to stroke survivors regarding the kinematics of gait, as evidenced by gains in ankle dorsiflexion and knee flexion after three months of usage in combination with conventional physical therapy.

Keywords:

via Effect of postural insoles on gait pattern in individuals with hemiparesis: A randomized controlled clinical trial – Journal of Bodywork and Movement Therapies

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[ARTICLE] Active rehabilitation training system for upper limb based on virtual reality – Full Text

 

In this article, an active rehabilitation training system based on the virtual reality technology is designed for patients with the upper-limb hemiparesis. The six-axis inertial measurement unit sensors are used to acquire the range of motion of both shoulder and elbow joints. In order to enhance the effect of rehabilitation training, several virtual rehabilitation training games based on the Unity3D engine are designed to complete different tasks from simple level to complicated level. The purpose is to increase the patients’ interest during the rehabilitation training. The basic functions of the virtual rehabilitation task scenes are tested and verified through the single-joint training and the multi-joint compounding training experiments. The experimental results show that the ranges of motion of both shoulder and elbow joints can reach the required ranges of a normal human in the rehabilitation training games. Therefore, the system which is easy to wear, low cost, wireless communication, real-time data acquisition, and interesting virtual rehabilitation task games can provide an effective rehabilitation training process for the upper-limb hemiparesis at home.

The upper limb has many degrees of freedom, and it is also a complex part of the human body by which people can accomplish fine movements during their activities in daily life. With the intensification of the aging problem in the world, the amount of stroke hemiparesis has shown a growing trend, especially in China, which has an enormous population.1 Approximately 30%–50% of these stroke survivors will suffer from chronic hemiparesis, especially involving their hands. In addition, spinal cord injury (SCI) and traffic accident survivors may also find limb movements’ disorder. Injury within the cervical region of the cord leads to tetraplegia, which leads to impairment of all four limbs. An estimated result shows that 55% of new cases will result in tetraplegia, while the other 45% will experience paraplegia due to injury below the cervical level.2Limb hemiparesis which is caused by stroke, SCI, or traffic accidents not only gives the patient’s daily life a great deal of inconvenience and even more makes the patient suffer from great mental pain but also brings a heavy stress and medical burden for the patient’s family and society. Technology has been developed in an effort to facilitate rehabilitation for the patient. Upper-limb rehabilitation is one of the fastest growing areas in modern neurorehabilitation. Quality of life can be improved with efficient therapy.3 At present, rehabilitation therapy of upper limb with traditional rehabilitation therapy is commonly used, that is, rehabilitation therapists perform rehabilitation trainings on individuals. Now with the development of robot technology, the rehabilitation of robot-assisted training is also rising up. The MIT-Manus4 is an example of end-effector-based and arm-rehabilitation robotic device, while the ARMin device5 is an example of arm-rehabilitation exoskeletons which also allows pronation/supination of the lower arm and wrist flexion/extension. It could be operated in three modes: passive mobilization, active game-supported arm therapy, and active training of activities of daily living (ADLs). The end-effector-based robots have practical advantages (usability, simplicity, and cost-effectiveness), and exoskeleton robots have biomechanical advantages (better guidance). Currently, the automatic rehabilitation devices on market as mentioned above are mostly complex and expensive, which are often used in the hospitals and clinics are not affordable to ordinary patients. Therefore, one of the research objectives aims to develop the upper-limb rehabilitation training system with minimal structure and low cost and can be used in patient’s home. But in China, it can be seen that patients with upper-limb orthosis in home is only for fixing the arm and just move autonomously according to the setting angle. The researches on intelligent domestic rehabilitation device just begins, most of which are in the experimental stage and not yet market oriented.6,7

Another problem is that the patients are treated with low initiative and dull training process which does not motivate them, while the treatment effect is not obvious.8,9 Computer games based on virtual reality (VR) are a good way to mobilize the patients’ initiative in the training, so the rehabilitation effect on a particular movement task will be greatly improved.10 VR environments provide an excellent method to manipulate task conditions in training. The effects and the intensity of training can be enhanced and designed more challenging, since the implementation of VR can build a channel both visual and haptic communication can be involved in. The research on VR system which is applied to rehabilitation training was initiated a few years ago. Mazzone et al.11 made a study on the effect of rehabilitation training for patients with shoulder joints training using VR technology. This study aimed to determine whether performance of shoulder exercises in virtual reality gaming (VRG) results in similar muscle activation as non-VRG exercise. The conclusion was drawn that exercise with VRG should be effective to reduce shoulder pain caused by spinal injury. Fischer et al.12 conducted a preliminary study claim that stroke patients could assist themselves in training their hands in the virtual environment. The purpose of this pilot study was to investigate the impact of assisted motor training in a virtual environment on hand function for the stroke survivors. Participants had 6 weeks of training in reach-to-grasp of both virtual and actual objects. After the training period, participants in all three groups demonstrated a decrease in time to perform some of the functional tasks. These designs based on VR have achieved some success and then the second research objective is to add the VR technology to the intelligent domestic rehabilitation device. These studies are mainly designed for the single joint of the upper-limb rehabilitation training. Therefore, it is necessary to carry out the research on multi-joint combined training device for patients who can just stay home by training with VR tasks of adjustable game levels.

Another important element which needs to be considered as an ultimate success using at home is its ease of use. Therefore, simple active rehabilitation device should be developed. The setup time of such device should be fast, besides measurement, treatment approaches, and incorporating gaming, and should provide intuitive interfaces that can be directly utilized by the individuals. This study will introduce an active rehabilitation training system for upper limb based on VR technology, which has some advantages such as simple structure, easy to manipulate, and portable for household. It also mobilizes patients’ initiative with adjustable difficulty level of VR tasks so that the individuals’ rehabilitation effect of the upper limb is obviously improved.

The active rehabilitation training system for upper limb based on VR is designed for the pronation/supination and flexion movement trainings of the elbow joint and the extension/flexion and abduction exercises of the shoulder joint. By adding the games in training processes, the patients may actively participate in rehabilitation trainings, while the efficiency will be greatly improved. The portable and easy-to-use design of this system can effectively reduce the problem of the medical resources shortage in the rehabilitation field.

Overall scheme of the system

The system is composed of two parts: the upper-limb posture detection system and the virtual rehabilitation training task scene, as shown in Figure 1.

figure

Figure 1. Schematic diagram of an active rehabilitation training system for upper limb based on VR.

 

Continue —> Active rehabilitation training system for upper limb based on virtual realityAdvances in Mechanical Engineering – Jianhai Han, Shujun Lian, Bingjing Guo, Xiangpan Li, Aimin You, 2017

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[ARTICLE] The spasticity in the motor and functional disability in adults with post-stroke hemiparetic

Abstract

Introduction: Spasticity acts as a limiting factor in motor and functional recovery after Stroke, impairing the performance of daily living activities.

Objective: To analyze the influence of spasticity on main muscle groups and to associate it with motor impairment and functional level of chronic hemiparetic patients after stroke.

Methods: Twenty-seven chronic hemiparetic patients of both sexes were selected at the Physical Therapy and Occupational Therapy Service of the Unicamp Clinics Hospital. Assessments were carried out in two sessions, in the first one the motor impairment (Fugl-Meyer Assessment – FM) and functional impairment (Barthel Index – BI) were evaluated, and in the second, the degree of spasticity of the main muscle groups (Modified Ashworth Scale – MAS).

Results: A negative correlation was detected between upper limb spasticity and motor and functional impairment. No muscle group evaluated in the lower limbs showed correlation between muscle tone and the level of impairment of the lower extremity on FM and the functional level measured by BI.

Conclusion: Spasticity has been shown to be a negative influence factor in the level of motor and functional impairment of the upper limbs of chronic hemiparetic patients after stroke.

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via The spasticity in the motor and functional disability in adults with post-stroke hemiparetic | de Oliveira Cacho | Fisioterapia em Movimento

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