title: Assessing Wolf Motor Function Test as Outcome Measure for Research in Patients After Stroke Bihemispheric brain stimulation facilitates motor recovery in chronic stroke patients Probability of regaining dexterity in the flaccid upper limb: impact of severity of paresis and time since onset in acute stroke. The PREP algorithm predicts potential for upper limb recovery after stroke. Efficacy of EMG-triggered electrical arm stimulation in chronic hemiparetic stroke patients. Intra-rater and inter-rater reliability at the item level of the Action Research Arm Test for patients with stroke. Inter-individual Variability in the Capacity for Motor Recovery After Ischemic Stroke Intermittent theta burst stimulation over ipsilesional primary motor cortex of subacute ischemic stroke patients: A pilot study The predictive value of cortical activation by passive movement for motor recovery in stroke patients. Post-stroke reorganization of hand motor area: a 1-year prospective follow-up with focal transcranial magnetic stimulation Effects of passive-active movement training on upper limb motor function and cortical activation in chronic patients with stroke: a pilot study. Functional recovery of the paretic upper limb after stroke: who regains hand capacity? Corticospinal integrity and motor impairment predict outcomes after excitatory repetitive transcranial magnetic stimulation: a preliminary study. Prognostic value of motor evoked potentials in motor function recovery of upper limb after stroke. Plasticity of motor cortex excitability induced by rehabilitation therapy for writing
abstract: Background and Purpose — The Wolf Motor Function Test ( WMFT ) is a new time-based method to evaluate upper extremity performance while providing insight into joint-specific and total limb movements . This study addresses selected psychometric attributes of the WMFT applied to a chronic stroke population . Methods — Nineteen individuals after stroke and with intact cognition and sitting balance were age- and sex-matched with 19 individuals without impairment . Subjects performed the WMFT and the upper extremity portion of the Fugl-Meyer Motor Assessment ( FMA ) on 2 occasions ( 12 to 16 days apart ) , with scoring performed independently by 2 r and om raters . Results — The  WMFT and FMA demonstrated agreement ( P < 0.0001 ) between raters at each session .  WMFT  scores for the dominant and nondominant extremities of individuals without impairment were different ( P ≤0.05 ) from the more and less affected extremities of subjects after stroke . The FMA score for the more affected extremity of subjects after stroke was different ( P ≤0.05 ) from the dominant and nondominant extremities . However , the FMA score for the less affected upper extremity of individuals after stroke was not different ( P > 0.05 ) from the dominant and nondominant extremities of individuals without impairment . The WMFT and FMA scores were related ( P < 0.02 ) for the more affected extremity in individuals after stroke . Conclusions — The interrater reliability , construct validity , and criterion validity of the WMFT , as used in these subject sample s , are supported Objective : Motor recovery after stroke depends on the integrity of ipsilesional motor circuits and interactions between the ipsilesional and contralesional hemispheres . In this sham-controlled r and omized trial , we investigated whether noninvasive modulation of regional excitability of bilateral motor cortices in combination with physical and occupational therapy improves motor outcome after stroke . Methods : Twenty chronic stroke patients were r and omly assigned to receive 5 consecutive sessions of either 1 ) bihemispheric transcranial direct current stimulation ( tDCS ) ( anodal tDCS to upregulate excitability of ipsilesional motor cortex and cathodal tDCS to downregulate excitability of contralesional motor cortex ) with simultaneous physical/occupational therapy or 2 ) sham stimulation with simultaneous physical/occupational therapy .  Changes in motor impairment ( Upper Extremity Fugl-Meyer ) and motor activity ( Wolf Motor Function Test ) assessment s were outcome measures while functional imaging parameters were used to identify neural correlates of motor improvement . Results : The improvement of motor function was significantly greater in the real stimulation group ( 20.7 % in Fugl-Meyer and 19.1 % in Wolf Motor Function Test scores ) when compared to the sham group ( 3.2 % in Fugl-Meyer and 6.0 % in Wolf Motor Function Test scores ) . The effects outlasted the stimulation by at least 1 week . In the real-stimulation group , stronger activation of intact ipsilesional motor regions during paced movements of the affected limb were found postintervention whereas no significant activation changes were seen in the control group . Conclusions : The combination of bihemispheric tDCS and peripheral sensorimotor activities improved motor functions in chronic stroke patients that outlasted the intervention period . This novel approach may potentiate cerebral adaptive processes that facilitate motor recovery after stroke . Classification of evidence : This study provides Class I evidence that for adult patients with ischemic stroke treated at least 5 months after their first and only stroke , bihemispheric tDCS and simultaneous physical/occupational therapy given over 5 consecutive sessions significantly improves motor function as measured by the Upper Extremity Fugl-Meyer assessment ( raw change treated 6.1 ± 3.4 , sham 1.2 ± 1.0 ) BACKGROUND AND PURPOSE To improve the accuracy of early postonset prediction of motor recovery in the flaccid hemiplegic arm , the effects of change in motor function over time on the accuracy of prediction were evaluated , and a prediction model for the probability of regaining dexterity at 6 months was developed . METHODS In 102 stroke patients , dexterity and paresis were measured with the  Action Research Arm Test , Motricity Index , and Fugl-Meyer motor evaluation .  For model development , 23 c and i date determinants were selected . Logistic regression analysis was used for prognostic factors and model development . RESULTS At 6 months , some dexterity in the paretic arm was found in 38 % , and complete functional recovery was seen in 11.6 % of the patients . Total anterior circulation infa rcts , right hemisphere strokes , homonymous hemianopia , visual gaze deficit , visual inattention , and paresis were statistically significant related to a poor arm function . Motricity Index leg scores of at least 25 points in the first week and Fugl-Meyer arm scores of 11 points in the second week increasing to 19 points in the fourth week raised the probability of developing some dexterity ( Action Research Arm Test > or=10 points ) from 74 % ( positive predictive value [ PPV ] , 0.74 ; 95 % confidence interval [ CI ] , 0.63 to 0.86 ) to 94 % ( PPV , 0.83 ; 95 % CI , 0.76 to 0.91 ) at 6 months . No change in probabilities of prediction dexterity was found after 4 weeks . CONCLUSIONS Based on the Fugl-Meyer scores of the flaccid arm , optimal prediction of arm function outcome at 6 months can be made within 4 weeks after onset . Lack of voluntary motor control of the leg in the first week with no emergence of arm synergies at 4 weeks is associated with poor outcome at 6 months Stroke is a leading cause of adult disability and the recovery of motor function is important for independence in activities of daily living . Predicting motor recovery after stroke in individual patients is difficult . Accurate prognosis would enable realistic rehabilitation goal - setting and more efficient allocation of re sources . The aim of this study was to test and refine an algorithm for predicting the potential for recovery of upper limb function after stroke . Forty participants were prospect ively enrolled within 3 days of ischaemic stroke . First ,  shoulder abduction and finger extension strength  were grade d 72 h after stroke onset to compute a shoulder abduction and finger extension score . Secondly , transcranial magnetic stimulation was used to assess the functional integrity of descending motor pathways to the affected upper limb . Third , diffusion-weighted magnetic resonance imaging was used to assess the structural integrity of the posterior limbs of the internal capsules . Finally , these measures were combined in the PREP algorithm for predicting an individual 's potential for upper limb recovery at 12 weeks , measured with the Action Research Arm Test . A cluster analysis was used to independently group patients according to Action Research Arm Test score at 12 weeks , for comparison with predictions from the PREP algorithm . There was excellent correspondence between the cluster analysis of Action Research Arm Test score at 12 weeks and predictions made with the PREP algorithm . The algorithm had positive predictive power of 88 % , negative predictive power of 83 % , specificity of 88 % and sensitivity of 73 % . This study provides preliminary data in support of the PREP algorithm for the prognosis of upper limb recovery in individual patients .  PREP may enable tailored planning of rehabilitation and more accurate stratification of patients in clinical trials PURPOSE EMG-triggered electrostimulation ( EMG-ES ) may improve the motor performance of affected limbs of hemiparetic stroke patients even in the chronic stage . This study was design ed to characterize cortical activation changes following intensified EMG-ES in chronic stroke patients and to identify predictors for successful rehabilitation depending on disease severity . METHODS We studied 9 patients with severe residual hemiparesis , who underwent 8 weeks of daily task-orientated multi-channel EMG-ES of the paretic arm .  Before and after treatment , arm function was evaluated clinical ly and cortical activation patterns were assessed with functional MRI ( fMRI ) and /or transcranial magnetic stimulation ( TMS ) . RESULTS As response to therapy , arm function improved in a subset of patients with more capacity in less affected subjects , but there was no significant gain for those with Box & Block test values below 4 at inception . The clinical improvement , if any , was accompanied by an ipsilesional increase in the sensorimotor cortex ( SMC ) activation area in fMRI and enhanced intracortical facilitation ( ICF ) as revealed by paired TMS . The SMC activation change in fMRI was predicted by the presence or absence of motor-evoked potentials ( MEPs ) on the affected side . CONCLUSIONS The present findings support the notion that intensified EMG-ES may improve the arm function in individual chronic hemiparetic stroke patients but not in more severely impaired individuals . Functional improvements are paralleled by increased ipsilesional SMC activation and enhanced ICF supporting neuroplasticity as contributor to rehabilitation . The clinical score at inception and the presence of MEPs have the best predictive potential OBJECTIVE To examine the intra- and inter-rater reliability of the Action Research Arm Test ( ARAT ) at the item level after stroke . DESIGN An intra-rater and inter-rater reliability study . SUBJECTS Thirty-five participants ( median age 62 years , median time post-stroke 22 months ) with impaired upper extremity function after stroke were included in the study . METHODS Two physiotherapists simultaneously , but independently , assessed the participants ' performance in all 19 items of the ARAT twice in 1 day . A rank-based statistical method for paired ordinal data , including calculation of percentage agreement ( PA ) , systematic disagreements ( relative position ( RP ) , relative concentration ( RC ) ) and individual variability ( relative rank variance ( RV ) ) was used . RESULTS Satisfactory intra-rater and inter-rater agreement was noted for all items except item 19 , which was just below satisfactory level . Within and between raters , small but non-negligible systematic disagreements were found for items 11 , 14 and 19 and for items 1 , 4 , 17 and 19 , respectively . There was no disagreement due to r and om variance within or between raters . CONCLUSION The ARAT is a highly reliable observational rating scale at the item level after stroke . Awareness regarding the small systematic disagreements demonstrated in some items is , however , recommended when using ARAT Background . Motor recovery after stroke is predicted only moderately by clinical variables , implying that there is still a substantial amount of unexplained , biologically meaningful variability in recovery . Regression diagnostics can indicate whether this is associated simply with Gaussian error or instead with multiple sub population s that vary in their relationships to the clinical variables . Objective . To perform regression diagnostics on a linear model for recovery versus clinical predictors . Methods . Forty-one patients with ischemic stroke were studied . Impairment was assessed using the upper extremity Fugl-Meyer Motor Score . Motor recovery was defined as the change in the upper extremity Fugl-Meyer Motor Score from 24 to 72 hours after stroke to 3 or 6 months later . The clinical predictors in the model were age , gender , infa rct location ( subcortical vs cortical ) , diffusion weighted imaging infa rct volume , time to re assessment , and acute upper extremity Fugl-Meyer Motor Score . Regression diagnostics included a Kolmogorov-Smirnov test for Gaussian errors and a test for outliers using Studentized deleted residuals . Results . In the r and om sample , clinical variables explained only 47 % of the variance in recovery . Among the patients with the most severe initial impairment , there was a set of regression outliers who recovered very poorly . With the outliers removed , explained variance in recovery increased to 89 % , and recovery was well approximated by a proportional relationship with initial impairment ( recovery ≅ 0.70 × initial impairment ) . Conclusions . Clinical variables only moderately predict motor recovery . Regression diagnostics demonstrated the existence of a sub population of outliers with severe initial impairment who show little recovery . When these outliers were removed , clinical variables were good predictors of recovery among the remaining patients , showing a tight proportional relationship to initial impairment BACKGROUND We demonstrated that prolonged transcranial magnetic intermittent theta burst stimulation ( iTBS , 1200 pulses/session = iTBS1200 ) produces longer-lasting facilitation in corticospinal excitability than ordinary form of iTBS in healthy subjects . OBJECTIVE Here we show the safety and small-scale efficacy of iTBS1200 over ipsilesional primary motor cortex ( M1 ) in subacute stroke patients . METHODS Twelve patients with first-time , subacute ischemic stroke of the middle cerebral artery were r and omized into two groups that received 10 daily-sessions of either iTBS1200 or sham stimulation ( n=6/group ) over ipsilesional M1 h and region in addition to medical and rehabilitation treatments . The primary outcome measures were safety and tolerability . The secondary outcome measures included the National Institute of Health Stroke Scale ( NIHSS ) , Upper Extremity Fugl-Meyer Test ( UE-FMT ) , Action Research Arm Test ( ARAT ) , active motor thresholds (aMTs)/motor-evoked potentials ( MEPs ) from the extensor carpi radialis ( ECR ) , and magnetoencephalography on post-intervention day 1 and post-stroke day 60 . RESULTS iTBS or sham stimulation was well tolerated by all patients without seizures or significant adverse effects . Compared with the matched controls , the iTBS group showed measurable improvements in the NIHSS and the proximal UE-FMT scores on post-intervention day 1 and post-stroke day 60 . Nevertheless , the h and ARAT scores , aMT and MEPs from the paretic ECR were not different between groups . Post-movement beta synchronization increased over iTBS-conditioned M1 on post-intervention day 1 in testable patients . CONCLUSIONS Repetitive sessions of iTBS1200 over ipsilesional M1 of subacute stroke patients are safe and the potential benefits encourage a larger trial to determine the efficacy in stroke patients . ( Clinical Trials.gov : NCT-01323881 ) PURPOSE Contralateral primary sensori-motor cortex ( SM1 ) activation by passive movement was investigated by functional MRI ( fMRI ) at the early stage of stroke , to determine whether SM1 activation can be used to predict the degree of motor recovery of the hemiplegic h and . METHODS We studied 17 stroke patients who showed complete paralysis of a hemiplegic h and at onset . The motor function of the hemiplegic h and was assessed on 4 separate occasions ( at onset , at fMRI evaluation ( performed < 4 weeks after onset ) , and 3 and 6 months after onset ) . Significant motor recovery was defined as recovery of the affected h and to the extent of it being able to prehend an object against gravity at least at 6 months after onset . RESULTS The patients having an activated contralateral SM1 showed better motor recovery than those who did not . Only a fourth of the patients with an activated contralateral SM1 experienced a significant motor recovery , whereas none of the patients with an inactivated SM1 showed an improvement 6 months after onset , however , the incidence of significant motor recovery was not significantly difference between the two groups . CONCLUSION It appears that contralateral SM1 activation by passive movement in the early stage of stroke has a low predictive value for the motor recovery of the hemiplegic h and , because the activation of the contralateral SM1 by passive movement appears to be mediated by somatosensory input to the cortex from the thalamus rather than from the motor pathway OBJECTIVE Focal transcranial magnetic stimulation was used to test prospect ively corticospinal excitability changes and reorganization of first dorsal interosseous ( FDI ) motor cortical representation in 31 patients who experienced a first ischemic stroke in the middle cerebral artery territory . All had severe h and palsy at onset . METHODS Patients were assessed clinical ly with the Medical Research Council , Rankin , the National Institutes of Health stroke scales and Barthel Index at days 1 , 8 , 30 , 90 , 180 and 360 after stroke . The following parameters of FDI  motor evoked potential ( MEPS ) to focal transcranial magnetic stimulation were measured at the same delays : motor threshold , MEP amplitude , excitable cortical area , hot spot and center of gravity of FDI motor maps on affected and unaffected hemispheres . Correlations were sought between clinical and electrophysiological parameters . RESULTS In patients whose affected motor cortex remained excitable at day 1 , motor thresholds were not significantly different between sides and were similar to those of controls . Persistence of MEP on the affected side at day 1 was a strong predictor of good recovery . If present at day 1 , MEPs recorded in affected FDI were significantly smaller than of the opposite side or in normals and progressively recovered up to day 360 . In these patients , area of excitable cortex remained stable throughout the entire study . At day 1 , amplitudes of MEPs obtained in unaffected FDI were significantly larger than later . Between days 1 and 360 , we observed a significant displacement of center of gravity of motor maps towards more frontal regions on the affected side while no change was noted on the unaffected side . CONCLUSIONS Our data confirm the early prognosis value of transcranial magnetic stimulation in stroke . They indicate that the brain insult induces a transient hyperexcitability of the unaffected motor cortex . The evolution of FDI motor maps along the course of recovery mostly reflect corticospinal excitability changes but might also reveal some degree of brain plasticity . Most modifications observed occurred within 3 months of stroke onset OBJECTIVE To explore how repetitive passive-active movement training effects upper limb motor function and cortical activation in patients with stroke . DESIGN Single-group treatment trial with baseline comparisons . PATIENTS Ten chronic patients with stroke with paresis of the upper limb . METHODS Assessment s were performed during a 4-week baseline period before and once after 4 weeks of training using the Motor Assessment Scale of the upper limb , Nine Hole Peg Test , goniometer for range of movement and the modified Ashworth scale for muscle tone . Two patients underwent functional magnetic resonance imaging pre- and post-training . The treatment consisted of daily sessions of repeated functional reaching and grasping movements guided passively and attempted actively during 4 weeks . RESULTS The group improved in range of motion and Motor Assessment Scale scores . Subjects reported improvements in a variety of daily tasks requiring the use of the affected upper limb . Increases in cortical activation in prefrontal and sensorimotor areas were observed in parallel with improvements of upper limb motor function in the 2 patients scanned . CONCLUSION The 4-week training programme improved h and motor function and ability . Cortical activation on functional magnetic resonance imaging changed in parallel suggesting reorganization of areas related to movements of the paretic limb OBJECTIVE To describe recovery of upper limb capacity after stroke during  inpatient rehabilitation  based on the Stroke Upper Limb Capacity Scale ( SULCS ) . DESIGN Prospect i ve observational study . SETTING Inpatient department of a rehabilitation center . PARTICIPANTS Patients with stroke ( N=299 ) admitted to a specialized stroke rehabilitation center . INTERVENTION Not applicable . MAIN OUTCOME MEASURES Upper limb capacity was assessed at the start and end of the rehabilitation phase with the SULCS ( range , 0 - 10 ) . The following demographic and clinical characteristics were registered : age , sex , side of stroke , stroke type , time since stroke , and length of stay in the rehabilitation center . RESULTS On admission , 125 patients had no h and capacity ( SULCS score , 0 - 3 ) , 58 had basic h and capacity ( SULCS score , 4 - 7 ) , and 116 had advanced h and capacity ( SULCS score , 8 - 10 ) . Of the patients without initial h and capacity , 41 % regained some h and capacity ( SULCS score , ≥4 ) at discharge . Of these , patients with SULCS scores of 2 and 3 had 29 and 97 times greater chance of regaining some h and capacity compared with patients with an initial SULCS score of 0 , respectively . Of the patients with initial basic h and capacity , 78 % regained advanced h and capacity at discharge . The SULCS score on admission explained 51 % of the SULCS score variance at discharge , while time since stroke was negatively associated with upper limb recovery , explaining an additional 7 % of the SULCS score variance at discharge . CONCLUSIONS Even patients with minimal proximal shoulder and elbow control of the upper paretic limb on admission in a rehabilitation center have a fair chance of regaining some h and capacity in the long-term after stroke , whereas patients without such proximal arm control have a much poorer prognosis for regaining h and capacity OBJECTIVE To identify the effective predictors for therapeutic outcomes based on intermittent theta-burst stimulation ( iTBS ) . DESIGN A sham-controlled , double-blind parallel study design . SETTING A tertiary hospital . PARTICIPANTS People with stroke ( N=72 ) who presented with unilateral hemiplegia . INTERVENTIONS Ten consecutive sessions of real or sham iTBS were implemented with the aim of enhancing h and function . Patients were categorized into 4 groups according to the presence ( MEP+ ) or absence ( MEP- ) of motor-evoked potentials ( MEPs ) and grip strength according to the Medical Research Council ( MRC ) scale . MAIN OUTCOME MEASURES Cortical excitability , Wolf Motor Function Test ( WMFT ) , finger-tapping task ( FT ) , and simple reaction time were performed before and after the sessions . RESULTS MEPs and the MRC scale were predictive of iTBS therapeutic outcomes . Group A ( MEP+ , MRC>1 ) exhibited the greatest WMFT change ( 7.6±2.3 , P<.001 ) , followed by group B ( MEP- , MRC>1 ; 5.2±2.2 score change ) and group C ( MEP- , MRC=0 ; 2.3±1.5 score change ) . These improvements were correlated significantly with baseline motor function and ipsilesional maximum MEP amplitude . CONCLUSIONS The effectiveness of iTBS modulation for poststroke motor enhancement depends on baseline h and grip strength and the presence of MEPs . Our findings indicate that establishing neurostimulation strategies based on the proposed electrophysiological and clinical criteria can allow iTBS to be executed with substantial precision . Effective neuromodulatory strategies can be formulated by using electrophysiological features and clinical presentation information as guidelines 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 prospect i ve 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 The mechanisms of rehabilitation-induced  plasticity in the motor system after stroke are not defined . The authors studied seven patients with residual poststroke agraphia , aphasia , and right hemiparesis . After a 40-minute rehabilitation therapy that promoted use of the paretic h and for writing , the authors observed a task-specific increase in recruitment of ipsilateral corticospinal pathways .  Rehabilitation aim ed to increase the use of the paretic h and may induce recruitment of previously silent ipsilateral corticospinal pathways even in poorly recovered poststroke patients
target: Based on the available evidence , motor evoked potentials at rest were the only biomarker that predicted motor outcome in individuals with severe arm impairment following stroke .
background: To build an underst and ing of the neurobiology underpinning arm recovery in people with severe arm impairment due to stroke , we conducted a pooled individual data systematic review to : 1 ) characterize brain biomarkers ; 2 ) determine relationship(s ) between biomarkers and motor outcome ; and 3 ) establish relationship(s ) between biomarkers and motor recovery .