**5. Conclusion**

78 Rehabilitation Medicine

Most relations were found within subjects between changes in muscle variables of PL and changes in scores at the BBS, a sitting and standing balance measure and the FM, an impairment measure developed to assess physical recovery after stroke (Sanford et al., 1993). Moreover, changes in flexor strength are positively related with changes in the 10m walking speed, which means the more increase in hamstring strength, the bigger the increase in walking speed. In our cross-sectional study (Horstman et al., 2008) strong significant correlations were found between muscle variables of both PL and NL and various tests of functional performance. However, in the present study if we look within subjects, we hardly see any correlations between changes in muscle variables of NL and changes in scores at the functional performance tests over time. This indicates that longitudinal data are essential to gain the required information regarding which (muscle) variables should be trained to induce improvements in functional performance, because

A question that remains to be answered is what may have caused the improvements in functional recovery? It is suggested that functional gains experienced by patients with stroke are primarily attributable to spontaneous recovery (changes over time that occur naturally) of functional performance of which eighty percent occurs within six months after the onset of stroke (Lind, 1982). Others state that there is some recovery between 1 and 6 months in almost all acute patients with stroke (Wade & Hewer, 1987) and that at 6 months 60% of people with initial hemiparesis have achieved functional independence in daily activities such as toileting and walking short distances (Mayo et al., 1999; Patel et al., 2000.) To facilitate neuroplasticity and cortical reorganization, it would be interesting to also investigate sensory stimulation in future studies with patients with stroke (Nudo et al., 1996; Johansson, 2000) since sensory impairments of all modalities are common after stroke (Carey, 1995). Moreover, sensory deficits are associated with the degree of weakness and the degree of stroke severity related to mobility, independence in activities of daily living, and recovery (De Haart et al., 2004; Lin, 2005). Addressing sensory deficits that accompany muscle weakness may improve impaired processing of afferent signals which in turn may contribute to improved muscle activation, gait patterns, and responses to perturbation

Secondary changes as a result of stroke could be expected in skeletal muscle, e.g. changes in myofiber type (De Deyne et al*.*, 2004) or number and size of motor units. The latter is already reported in the second week after stroke onset (Jorgensen & Jacobsen, 2001). For instance, a change in muscle fiber composition, characterized by selective type II fiber atrophy and predominance of (slow twitch, oxidative) type I fibers has been shown in paretic muscles (Edstrom, 1970; Scelsi et al., 1984; Dietz et al., 1986; Dattola et al., 1993; Hachisuka et al., 1997), which would lead to concomitant changes in contractile speed of the muscle fibers towards those of slow muscles. We can imagine that such a change in fiber type composition can be combated, for instance by training, during the first year after stroke, so that muscle speed characteristics can be restored. Bohannon concludes in his review (Bohannon, 2007b) that resistance training programs are effective at increasing strength in patients who have experienced a stroke but there is no clear evidence for the effect of strength training on functional activities after stroke (Morris et al*.*, 2004). Main results of Saunders' review (Saunders et al*.*, 2004) include only 4 strength training trials (Inaba et al., 1973; Kim et al., 2001; Ouellette et al., 2004; Winstein et al., 2004) and lack non-

cross-sectional data are not exclusive enough.

during gait and stance (El-Abd & Ibrahim, 1994).

The (small) alterations in the muscle variables correlated well with the improvements in scores on tests of functional performance. Although the correlations do not necessarily imply causality, we think (intrinsic) muscle speed and strength are important variables which can potentially be prolific targets to improve during rehabilitation. It is therefore recommended to investigate the effects of strength training of the thigh muscles during at least the first 6 months after stroke. From such an intervention study on functional recovery it can be elucidated whether increasing strength and speed really improves functional performance.

#### **6. References**


Functional Recovery and Muscle Properties After Stroke: A Preliminary Longitudinal Study 81

Duncan PW, Goldstein LB, Horner RD, Landsman PB, Samsa GP, Matchar DB. (1994).

Edstrom L. (1970). Selective changes in the sizes of red and white muscle fibres in upper motor lesions and Parkinsonism. *Journal of Neurological Sciences* Dec;11(6):537-50. El-Abd MAR, Ibrahim IK. (1994). Impaired afferent control in patients with spastic

Fugl-Meyer AR, Jaasko L, Leyman I, Olsson S & Steglind S. (1975). The post-stroke

Gerrits KH, Beltman MJ, Koppe PA, Konijnenbelt H, Elich PD, de Haan A & Janssen TW.

Gray CS, French JM, Bates D, Cartlidge NE, James OF, Bates D. (1990). Motor recovery

Gresham GE, Duncan PW, Stason WB, Adams HP, Adelman AM, Alexander DN, Bishop

Hachisuka K, Umezu Y & Ogata H. (1997). Disuse muscle atrophy of lower limbs in hemiplegic patients. *Archives of Physical Medicine and Rehabilitation* Jan;78(1):13-8 Harris ML, Polkey MI, Bath PM & Moxham J. (2001). Quadriceps muscle weakness following acute hemiplegic stroke. *Clinical Rehabilitation* Jun;15(3):274-81 Hendricks HT, van Limbeek J, Geurts AC, Zwarts MJ. (2002). Motor recovery after stroke: a

Holden MK, Gill KM & Magliozzi MR. (1986). Gait assessment for neurologically impaired patients. Standards for outcome assessment. *Physical Therapy* Oct;66(10):1530-9 Holden MK, Gill KM, Magliozzi MR, Nathan J & Piehl-Baker L. (1984). Clinical gait

Horgan NF, Finn AM. (1997). Motor recovery following stroke: a basis for evaluation.

Horstman AM, Beltman MJ, Gerrits KH, Koppe P, Janssen TW, Elich P & de Haan A. (2008).

Horstman AM, Gerrits KH, Beltman MJ, Koppe PA, Janssen TW & de Haan A. (2010).

*Physical Medicine and Rehabilitation* Mar;75(3):312-7.

*Scandinavian Journal of Rehabilitation Medicine* 7(1):13-31

following acute stroke). *Age and Ageing* May;19(3):179-84

Health Care Policy and Research. AHCPR Publication 95-0662

June;25(6):1181-88

Mar;90(3):480-7

Nov;83(11):1629-37

*Therapy* Jan;64(1):35-40

Jul;28(4):251-61

*Disability and Rehabilitation* Feb;19(2):64-70

*Physical Medicine and Rehabilitation* Jan;91(1):123-8

Similar motor recovery of upper and lower extremities after stroke. *Stroke* 

hemiplegia at different stages of recovery: contribution to gait disorder. *Archives of* 

hemiplegic patient. 1. a method for evaluation of physical performance.

(2009). Isometric muscle function of knee extensors and the relation with functional performance in patients with stroke. *Archives of Physical Medicine and Rehabilitation* 

DS, Diller L, Donaldson NE, Granger CV, Holland AL, Kelly-Hayes M, McDowell FH, Myers L, Phipps MA, Roth EJ, Siebens HC, Tarvin GA, Trombley CA. (1995). *Clinical Practice Guideline Number 16: Post-Stroke Rehabilitation.* Rockville, Md: US Department of Health and Human Services, Public Health Service, Agency for

systematic review of the literature. *Archives of Physical Medicine and Rehabilitation* 

assessment in the neurologically impaired. Reliability and meaningfulness. *Physical* 

Intrinsic muscle strength and voluntary activation of both lower limbs and functional performance after stroke. *Clinical Physiology and Functional Imaging*

Intrinsic properties of the knee extensor muscles after subacute stroke. *Archives of* 


Bohannon RW & Walsh S. (1991). Association of paretic lower extremity muscle strength

Bohannon RW & Walsh S. (1992). Nature, reliability, and predictive value of muscle

Bonita R, Beaglehole R. (1988). Recovery of motor function after stroke. *Stroke* Dec; 19(12):

Cameron D & Bohannon RW. (2000). Criterion validity of lower extremity Motricity Index

Carey, LM. (1995). Somatosensory loss after stroke. *Critical Reviews in Physical &* 

Carin-Levy G, Greig C, Young A, Lewis S, Hannan J & Mead G. (2006). Longitudinal changes in muscle strength and mass after acute stroke. *Cerebrovasc Dis* 21(3):201-7 Collen FM, Wade DT, Robb GF & Bradshaw CM. (1991). The Rivermead Mobility Index: a

Collin C & Wade D. (1990). Assessing motor impairment after stroke: a pilot reliability study. *Journal of Neurology, Neurosurgery, and Psychiatry* Jul;53(7):576-9 Corrigan D & Bohannon RW. (2001). Relationship between knee extension force and stand-

Dattola R, Girlanda P, Vita G, Santoro M, Roberto ML, Toscano A, Venuto C, Baradello A &

De Haart M, Geurts A, Huidekoper SC, Fasotti L, van Limbeek I. (2004). Recovery of

de Ruiter CJ, Kooistra RD, Paalman MI & de Haan A. (2004). Initial phase of maximal

Desrosiers J, Malouin F, Richards C, Bourbonnais D, Rochette A, Bravo G. (2003).

after stroke. *International Journal of Rehabilitation Research* Jun;26(2):109-16 Dietz V, Ketelsen UP, Berger W & Quintern J. (1986). Motor unit involvement in spastic

Duncan PW, Goldstein lB, Matchar D, Divine GW, Feussner J. (1992). Measurement of motor

different knee angles. *Journal of Applied Physiology* Nov;97(5):1693-701 Demeurisse G, Demol O & Robaye E. (1980). Motor evaluation in vascular hemiplegia.

*Archives of Physical Medicine and Rehabilitation* June;85(6):886-95

further development of the Rivermead Motor Assessment. *International Disability* 

up performance in community-dwelling elderly women. *Archives of Physical* 

Messina C. (1993). Muscle rearrangement in patients with hemiparesis after stroke: an electrophysiological and morphological study. *European Neurology* 33(2):109-14 De Deyne PG, Hafer-Macko CE, Ivey FM, Ryan AS & Macko RF. (2004). Muscle molecular

phenotype after stroke is associated with gait speed. *Muscle & Nerve* Aug;30(2):209-

standing balance in post-acute stroke patients: a rehabilitation cohort study.

voluntary and electrically stimulated knee extension torque development at

Comparison of changes in upper and lower extremity impairments and disabilities

paresis. Relationship between leg muscle activation and histochemistry. *Journal of* 

recovery after stroke. Outcome assessment and sample size requirements. *Stroke*

*Stroke and Cerebrovascular Diseases* 1(3): 129-133

scores. *Clinical Rehabilitation* Apr;14(2):208-11

*Medicine and Rehabilitation* Dec;82(12):1666-72

*Rehabilitation Medicine* 7:51-91

*Studies* Apr-Jun;13(2):50-4

*European Neurology* 19(6), 382-9

*Neurological Sciences* Aug;75(1):89-103

Aug;23:1084–89

1497–1500

15

*Physical Medicine and Rehabilitation* Aug;73(8):721-5

and standing balance with stair-climbing ability in patients with stroke. *Journal of* 

performance measures in patients with hemiparesis following stroke. *Archives of* 


Functional Recovery and Muscle Properties After Stroke: A Preliminary Longitudinal Study 83

Nudo RJ, Wise BM, SiFuentes F, Milliken GW. (1996). Neural substrates for the effects of

Ouellette MM, LeBrasseur NK, Bean JF, Phillips E, Stein J, Frontera WR & Fielding RA.

Patterson SL, Forrester LW, Rodgers MM, Ryan AS, Ivey FM, Sorkin JD & Macko RF. (2007).

Pijnappels M, Reeves ND, Maganaris CN & van Dieen JH. (2008). Tripping without falling;

Pohl PS, Duncan P, Perera S, Long J, Liu W, Zhou J & Kautz SA. (2002). Rate of isometric

Sanford J, Moreland J, Swanson LR, Stratford PW & Gowland C. (1993). Reliability of the

Saunders DH, Greig CA, Mead GE, Young A. (2009) Physical fitness training for stroke

Scelsi R, Lotta S, Lommi G, Poggi P & Marchetti C. (1984). Hemiplegic atrophy.

Shepherd RB. (2001). Exercise and training to optimize functional motor performance in

Shield A & Zhou S. (2004). Assessing voluntary muscle activation with the twitch

Shigematsu R, Rantanen T, Saari P, Sakari-Rantala R, Kauppinen M, Sipila S & Heikkinen E.

Smith MT & Baer GD. (1999). Achievement of simple mobility milestones after stroke.

Sullivan K, Klassen T & Mulroy S. (2006). Combined task-specific training and strengthening

stroke: driving neural reorganization? *Neural Plasticity* 8(1-2):121-9

the elderly. *Journal of Electromyography and Kinesiology* Apr;18(2):188-96 Podsiadlo D & Richardson S. (1991). The timed "Up & Go": a test of basic functional

*Archives of Physical Medicine and Rehabilitation* Jan;88(1):115-9

*Rehabilitation Research and Development* Nov-Dec;39(6):651-7

Jun;272(5269):1791–94

Oct;81(10):1357-63

Feb;39(2):142-8

Aug;18(4):320-4

*Therapy* Sep;30(3):130-41

*Physical Therapy* Jul;73(7):447-54

DOI: 10.1002/14651858.CD003316.pub3

vascular accidents. *Acta Neuropathologica* 62(4):324-31

interpolation technique. *Sports Medicine* 2004;34(4):253-67

*Archives of Physical Medicine and Rehabilitation* Apr;80(4):442-7

rehabilitative training on motor recovery after ischemic infarct. *Science* 

(2004). High-intensity resistance training improves muscle strength, self-reported function, and disability in long-term stroke survivors. *Stroke* Jun;35(6):1404-9 Patel AT, Duncan PW, Lai SM, Studenski S. (2000). The relation between impairments and

functional outcome post stroke *Archives of Physical Medicine and Rehabilitation* 

Determinants of walking function after stroke: differences by deficit severity.

lower limb strength, a limitation for balance recovery and a target for training in

mobility for frail elderly persons. *Journal of the American Geriatrics Society* 39,

knee extension strength development and walking speed after stroke. *Journal of* 

Fugl-Meyer assessment for testing motor performance in patients following stroke.

patients. *Cochrane Database of Systematic Reviews 2009*, Issue 4. Art. No.: CD003316.

Morphological findings in the anterior tibial muscle of patients with cerebral

(2006). Motor speed and lower extremity strength as predictors of fall-related bone fractures in elderly individuals. *Aging Clinical and Experimental Research*

effects on locomotor recovery post-stroke: a case study. *Journal of Neurologic Physical* 


Hubbard IJ, Parsons MW, Neilson C & Carey LM. (2009). Task-specific training: evidence for and translation to clinical practice. *Occupational Therapy International* 16(3-4):175-89 Inaba M, Edberg E, Montgomery J & Gillis MK. (1973). Effectiveness of functional training,

Johansson BB. (2000). Brain plasticity and stroke rehabilitation. The Willis lecture. *Stroke*

Jorgensen HS, Nakayama H, Raaschou HO, Vive-Larsen J, Stoier M & Olsen TS. (1995).

Jorgensen L & Jacobsen BK. (2001). Changes in muscle mass, fat mass, and bone mineral content in the legs after stroke: a 1 year prospective study. *Bone* Jun;28(6):655-9 Kim CM & Eng JJ. (2003). The relationship of lower-extremity muscle torque to locomotor

Kim CM, Eng JJ, MacIntyre DL & Dawson AS. (2001). Effects of isokinetic strength training

Kong KH, Chua KS, lee J. (2011). Recovery of upper limb dexterity in patients more than 1

Kooistra RD, de Ruiter CJ & de Haan A. (2005). Muscle activation and blood flow do not

Kwakkel G, Kollen B & Lindeman E. (2004). Understanding the pattern of functional

Lin S. (2005). Motor function and joint position sense in relation to gait performance in

Lind K. (1982). A synthesis of studies on stroke rehabilitation. *Journal of Chronic Diseases*

Marigold D, Eng J, Tokuno CD, Donnelly CA. (2004). Contribution of muscle strength and

Mayo NE, Wood-Dauphinee S, Ahmed S, Gordon C, Higgins J, McEwen S, Salbach N.

Mercier C & Bourbonnais D. (2004). Relative shoulder flexor and handgrip strength is related to upper limb function after stroke. *Clinical Rehabilitation* Mar;18(2):215-21 Morris SL, Dodd KJ & Morris ME. (2004). Outcomes of progressive resistance strength

Newham DJ & Hsiao SF. (2001). Knee muscle isometric strength, voluntary activation and

performance in people with stroke. *Physical Therapy* Jan;83(1):49-57

*Stroke and Cerebrovascular Diseases* Nov-Dec;10(6):265-73

*Journal of Applied Physiology* Mar;98(3):810-6

*Neurorehabilitation and Neural Repair* Dec;18(4):222-9

*Rehabilitation* Jun 15;23(9):379-86

Jan;53(1):28-35

Jan;31(1):223–230

May;76(5):406-12

28(2):105–11

5):281-99

6):258-68

Feb;35(2):133-49

203

active exercise, and resistive exercise for patients with hemiplegia. *Physical Therapy*

Outcome and time course of recovery in stroke. Part II: Time course of recovery. The Copenhagen Stroke Study. *Archives of Physical Medicine and Rehabilitation* 

on walking in persons with stroke: a double-blind controlled pilot study. *Journal of* 

year after stroke: frequency, clinical correlates and predictors *NeuroRehabilitation*

explain the muscle length-dependent variation in quadriceps isometric endurance.

recovery after stroke: Facts and theories. *Restorative Neurology and Neuroscience* 22(3-

chronic stroke patients. *Archives of Physical Medicine and Rehabilitation* Feb;86(2):197-

integration of afferent input to postural instability in persons with stroke.

(1999). Disablement following stroke. *Disability and Rehabilitation* May-Jun;21(5-

training following stroke: a systematic review. *Clinical Rehabilitation* Feb;18(1):27-39

antagonist co-contraction in the first six months after stroke. *Disability and* 


**6** 

**The Hierarchical Status of Mobility** 

Hui-Ya Chen1,2, Chih-Jung Yeh2,3, Ching-Yi Wang1,2\*,

*1Chung Shan Medical University/School of Physical Therapy, 2Center for Education and Research on Geriatrics and Gerontology,* 

Hui-Shen Lin2,3 and Meng-Chih Lee2,4

*3Institute of Public Health, 4Institute of Medicine,* 

*Taiwan* 

**Disability Predicts Future IADL Disability:** 

**A Longitudinal Study on Ageing in Taiwan** 

As the older population grows dramatically around the world, it is important that health care providers be able to maintain people with an extended life expectancy in an active stage for as long as possible. Being independent in gross mobility functioning is an indicator of healthy and successful aging (Guralnik and Kaplan, 1989). An effective tool that is easy to use for identifying those at early stage of physical function decline is imperative for

As people age, a majority of elderly individuals develop physical disability. Such development follows a hierarchical order, starting from mobility, then spreading into instrumental activities of daily living (IADL), and finally ending in basic activities of daily living (BADL) (Pinsky et al., 1987; Barberger-Gateau et al., 1995; Barberger-Gateau et al., 2000). As disability in mobility occurs at an earlier stage of the disablement process, it may be an effective indicator by which to identify older adults in an early stage of physical function decline. Identifying such older adults is imperative in order to provide timely

In the literature, mobility disability has been defined as at least one item requiring help, or being unable to perform independently using two items (climbing stairs and walking on a level surface) (Guralnik et al., 1994; Guralnik et al., 1995; Ostir et al., 1998) or three items (heavy housework, climbing stairs, and walking on a level surface) (Jette and Branch, 1981; Guralnik et al., 1994; Barberger-Gateau et al., 1995; Guralnik et al., 1995; Merrill et al., 1997; Barberger-Gateau et al., 2000; Ble et al., 2005; Yogev-Seligmann et al., 2008) in Rosow's scale (Rosow and Breslau, 1966). Using either two or three items, the disadvantage of a dichotomous mobility disability status is the inability to identify those with an intermediate status (those are

becoming disabled, but are not yet disabled and thus require timely intervention).

**1. Introduction** 

achieving this goal.

 \*

Corresponding Author

health promotion or early intervention programs.

