Yavuzer, M.G.

Motor recovery and cortical reorganization after mirror therapy in chronic stroke patients: A phase II randomized controlled trial (Article)

2011-03-01T00:00:00Z

Objective. To evaluate for any clinical effects of home-based mirror therapy and subsequent cortical reorganization in patients with chronic stroke with moderate upper extremity paresis. Methods. A total of 40 chronic stroke patients (mean time post.onset, 3.9 years) were randomly assigned to the mirror group (n = 20) or the control group (n = 20) and then joined a 6-week training program. Both groups trained once a week under supervision of a physiotherapist at the rehabilitation center and practiced at home 1 hour daily, 5 times a week. The primary outcome measure was the Fugl-Meyer motor assessment (FMA). The grip force, spasticity, pain, dexterity, hand-use in daily life, and quality of life at baseline-posttreatment and at 6 months-were all measured by a blinded assessor. Changes in neural activation patterns were assessed with functional magnetic resonance imaging (fMRI) at baseline and posttreatment in an available subgroup (mirror, 12; control, 9). Results. Posttreatment, the FMA improved more in the mirror than in the control group (3.6 ± 1.5, P <.05), but this improvement did not persist at follow-up. No changes were found on the other outcome measures (all Ps >.05). fMRI results showed a shift in activation balance within the primary motor cortex toward the affected hemisphere in the mirror group only (weighted laterality index difference 0.40 ± 0.39, P <.05). Conclusion. This phase II trial showed some effectiveness for mirror therapy in chronic stroke patients and is the first to associate mirror therapy with cortical reorganization. Future research has to determine the optimum practice intensity and duration for improvements to persist and generalize to other functional domains.

Quantitative gait characteristics of children who had successful unilateral clubfoot operation (Article)

2010-12-01T00:00:00Z

Objectives: In this study, we aimed to evaluate the functional results of patients operated for unilateral clubfoot who had good clinical outcome with gait analysis. We also investigated the deviation from the normal, and determined the compensation mechanisms by comparing this data with the unaffected feet and with the feet of healthy children. Methods: Sixteen children [10 boys, 6 girls; mean age, 6.8 years (range 4-9 years)] with surgically treated unilateral clubfoot and 24 age-matched healthy children were included in the study. Foot length, calf circumference, ankle range of motion, and radiographic measurements were recorded. All time-distance (walking velocity, cadence, step time, step length, double support time), kinematic (joint rotation angles of pelvis, hip, knee, and ankle in sagittal, coronal and transverse planes), and kinetic (ground reaction forces, moments, and powers of hip, knee, and ankle) data were evaluated. Results: Calf circumference and ankle range of motion of involved extremity were significantly less than the unaffected side (p<0.05). Quantitative gait data revealed that children with clubfoot had slower walking velocity (0.75±0.25 m/sec vs. 1.02±0.18 m/sec, p=0.01), shorter stride length (0.72±0.23 m vs. 0.91±0.05 m, p=0.01) than healthy children group. Affected foot of unilateral clubfoot patients had more toe-in than healthy children (-14.24±21.78° vs. 18.54±7.90°, p=0.001). Unaffected side showed increased pelvic excursions and medio-lateral ground reaction forces as well as decreased ankle and hip motion in sagittal plane. Conclusion: Even asymptomatic well-treated children with unilateral clubfoot may have gait deviations both in the affected and unaffected sides. These alterations may also be the result of the subclinical involvement of the so called healthy foot by disease (clubfoot) as well as the compensatory mechanisms.

The Authors Respond (Article)

2009-12-01T00:00:00Z

Repeatability and variation of quantitative gait data in subgroups of patients with stroke (Article)

2008-04-01T00:00:00Z

We aimed to determine the repeatability and variation of quantitative gait data in patients with stroke and to compare the subgroups in terms of gait variability. Time-distance and kinematic characteristics of gait were evaluated in 90 inpatients (30 women) with hemiparesis (mean ± S.D. age 57.7 ± 12.5 years and time since stroke 5.99 ± 6.46 months). Subgroups were based on "gender", "side of paresis", "lesion type", "motor recovery level", "sensory status", "time since stroke" and "walking velocity". Repeatability was adequate to excellent in all stroke subgroups (ICC range 0.48-0.98). Walking velocity was the most repeatable gait parameter after stroke. Variation in step length was significantly higher in women than in men (CV 16% versus 9%, p < 0.05). Slow walkers (walking velocity <0.34 m/s) had a higher variation than fast walkers in step length (CV 12.5% versus 7.5%, p < 0.01), single support time (CV 11.9% versus 6.3%, p < 0.05), peak hip extensions in stance (CV 11.5% versus 3.7%, p < 0.01) and knee flexion in swing (CV 11.8% versus 6.5%, p < 0.05). In our stroke patients, their age, time since injury, lesion characteristics, impaired proprioception or level of motor recovery had no effect on gait variability. For better interpretation of quantitative gait data, clinicians should consider that variation in step length, single support time, peak hip extension in stance and knee flexion in swing differs according to walking velocity after stroke.

Mirror Therapy Improves Hand Function in Subacute Stroke: A Randomized Controlled Trial (Article)

2008-03-01T00:00:00Z

Yavuzer G, Selles R, Sezer N, Sütbeyaz S, Bussmann JB, Köseoǧlu F, Atay MB, Stam HJ. Mirror therapy improves hand function in subacute stroke: a randomized controlled trial. Objective: To evaluate the effects of mirror therapy on upper-extremity motor recovery, spasticity, and hand-related functioning of inpatients with subacute stroke. Design: Randomized, controlled, assessor-blinded, 4-week trial, with follow-up at 6 months. Setting: Rehabilitation education and research hospital. Participants: A total of 40 inpatients with stroke (mean age, 63.2y), all within 12 months poststroke. Interventions: Thirty minutes of mirror therapy program a day consisting of wrist and finger flexion and extension movements or sham therapy in addition to conventional stroke rehabilitation program, 5 days a week, 2 to 5 hours a day, for 4 weeks. Main Outcome Measures: The Brunnstrom stages of motor recovery, spasticity assessed by the Modified Ashworth Scale (MAS), and hand-related functioning (self-care items of the FIM instrument). Results: The scores of the Brunnstrom stages for the hand and upper extremity and the FIM self-care score improved more in the mirror group than in the control group after 4 weeks of treatment (by 0.83, 0.89, and 4.10, respectively; all P<.01) and at the 6-month follow-up (by 0.16, 0.43, and 2.34, respectively; all P<.05). No significant differences were found between the groups for the MAS. Conclusions: In our group of subacute stroke patients, hand functioning improved more after mirror therapy in addition to a conventional rehabilitation program compared with a control treatment immediately after 4 weeks of treatment and at the 6-month follow-up, whereas mirror therapy did not affect spasticity.

Repeatability of lower limb three-dimensional kinematics in patients with stroke (Article)

2008-01-01T00:00:00Z

The within- and between-session repeatability of time-distance and sagittal plane kinematic gait parameters were evaluated in 20 hemiparetic patients with sub-acute stroke. A test-retest design was used in which the patients were tested during two sessions within a 2 h period. Each session comprised three consecutive trials. The intraclass correlation coefficients (ICCs) for time-distance parameters ranged from 0.82 to 0.99. The within- and between-session repeatability of pelvis, hip, knee and ankle kinematic waveforms were high: the mean coefficient of multiple correlations (CMCs) ranged from 0.85 to 0.95. The within-session coefficient of variation (CV%) for time-distance parameters ranged from 3.9 to 14.1, whereas, between-session CV% ranged from 6.1 to 17.2, showing similar but higher variability. The within- and between-session CV% for sagittal plane kinematics of the paretic lower limb ranged from 3.6 to 32.4. The results indicate that time-distance parameters and sagittal plane gait kinematics of the paretic lower limb, measured by the Vicon 370 gait analysis system, are repeatable and can be used to assess treatment effects after stroke.

Effect of Sensory-Amplitude Electric Stimulation on Motor Recovery and Gait Kinematics After Stroke: A Randomized Controlled Study (Article)

2007-06-01T00:00:00Z

Yavuzer G, Öken Ö, Atay MB, Stam HJ. Effect of sensory-amplitude electric stimulation on motor recovery and gait kinematics after stroke: a randomized controlled study. Objective: To evaluate the effects of sensory-amplitude electric stimulation (SES) of the paretic leg on motor recovery and gait kinematics of patients with stroke. Design: Randomized, controlled, double-blind study. Setting: Rehabilitation ward and gait laboratory of a university hospital. Participants: A total of 30 consecutive inpatients with stroke (mean age, 63.2y), all within 6 months poststroke and without volitional ankle dorsiflexion were studied. Intervention: Both the SES group (n=15) and the placebo group (n=15) participated in a conventional stroke rehabilitation program 5 days a week for 4 weeks. The SES group also received 30 minutes of SES to the paretic leg without muscle contraction 5 days a week for 4 weeks. Main Outcome Measures: Brunnstrom stages of motor recovery and time-distance and kinematic characteristics of gait. Results: Brunnstrom stages improved significantly in both groups (P<.05). In total, 58% of the SES group and 56% of the placebo group gained voluntary ankle dorsiflexion. The between-group difference of percentage change was not significant (P>.05). Gait kinematics was improved in both groups, but the between-group difference was not significant. Conclusions: In our patients with stroke, SES of the paretic leg was not superior to placebo in terms of lower-extremity motor recovery and gait kinematics.

Mirror Therapy Enhances Lower-Extremity Motor Recovery and Motor Functioning After Stroke: A Randomized Controlled Trial (Article)

2007-05-01T00:00:00Z

Sütbeyaz S, Yavuzer G, Sezer N, Koseoglu F. Mirror therapy enhances lower-extremity motor recovery and motor functioning after stroke: a randomized controlled trial. Objective: To evaluate the effects of mirror therapy, using motor imagery training, on lower-extremity motor recovery and motor functioning of patients with subacute stroke. Design: Randomized, controlled, assessor-blinded, 4-week trial, with follow-up at 6 months. Setting: Rehabilitation education and research hospital. Participants: A total of 40 inpatients with stroke (mean age, 63.5y), all within 12 months poststroke and without volitional ankle dorsiflexion. Interventions: Thirty minutes per day of the mirror therapy program, consisting of nonparetic ankle dorsiflexion movements or sham therapy, in addition to a conventional stroke rehabilitation program, 5 days a week, 2 to 5 hours a day, for 4 weeks. Main Outcome Measures: The Brunnstrom stages of motor recovery, spasticity assessed by the Modified Ashworth Scale (MAS), walking ability (Functional Ambulation Categories [FAC]), and motor functioning (motor items of the FIM instrument). Results: The mean change score and 95% confidence interval (CI) of the Brunnstrom stages (mean, 1.7; 95% CI, 1.2-2.1; vs mean, 0.8; 95% CI, 0.5-1.2; P=.002), as well as the FIM motor score (mean, 21.4; 95% CI, 18.2-24.7; vs mean, 12.5; 95% CI, 9.6-14.8; P=.001) showed significantly more improvement at follow-up in the mirror group compared with the control group. Neither MAS (mean, 0.8; 95% CI, 0.4-1.2; vs mean, 0.3; 95% CI, 0.1-0.7; P=.102) nor FAC (mean, 1.7; 95% CI, 1.2-2.1; vs mean, 1.5; 95% CI, 1.1-1.9; P=.610) showed a significant difference between the groups. Conclusions: Mirror therapy combined with a conventional stroke rehabilitation program enhances lower-extremity motor recovery and motor functioning in subacute stroke patients.

Walking After Stroke: Interventions to restore normal gait pattern (Doctoral Thesis)

2006-12-20T00:00:00Z

Stroke is the leading cause of adult disability and inpatient rehabilitation admissions. In spite of many efforts, approximately 35% of stroke survivors with initial paralysis of the leg do not regain useful walking function. Many (potential) impairments and limitations have caused a marked variation in gait patterns among stroke patients. Hemiparetic gait is characterized by slow and asymmetric steps with poor selective motor control, delayed and disrupted equilibrium reactions and reduced weight bearing on the paretic limb. Although some general characteristics of hemiparetic gait have been identified, individual differences are great, emphasizing the need for individual assessment to identify the problems and design therapeutic interventions to address them. To provide a rationale for the proper selection of therapeutic interventions, we assessed the effectiveness of balance training, electrical stimulation, arm sling and AFO to improve hemiparetic gait pattern after stroke. Treatment outcome was evaluated by relevant clinical assessments together with time-distance, kinematic and kinetic gait characteristics measured by a quantitative three-dimensional gait analysis system. We concluded that task-specific interventions together with external feedback (balance training with force platform feedback) and orthosis, either enabling feedback or substituting a lost function or both (arm sling and AFO) are effective in improvement of postural control and gait symmetry in hemiparetic patients with stroke. However, impairment-focused therapies without any volitional participation of the patients (neuromuscular or somatosensory electrical stimulation) are not superior to a conventional stroke rehabilitation program.