We conducted a cross-sectional applied study of individuals with stroke undergoing rehabilitation who admitted the neuro rehabilitation clinic of Rehabilitation Science faculty at Iran University of Medical Sciences. This study is approved by the ethic committee of Iran University of Medical Sciences.
The participants were stroke patients with unilateral hemiparesis
who signed the informed consent. By consecutive sampling, 30 stroke people with 6-24 month post stroke duration who were older than 40 years old entered the study. The inclusion criteria were:
•ability to walk 10 meter independently
•No history of other neurologic, orthopedic or cardiovascular disorders
•No history of injection of anti spastic drugs in recent 6 month or anti spasticity drugs 6 hours prior to study
•ability to follow multipart instructions. One who had pain in lower extremity or severe contracture and vision problems excluded from study.
One session was performed for familiarization with the place and the way evaluation would be executed. Data collection forms were used to gather information including: age, sex, height, weight, affected side, dominant side and duration post stroke
. The evaluation of spasticity, lower extremity strength and functional mobility were performed consecutively in one session.
In lower extremity, knee extensor and plantar flexor were selected; because, the dominant extensor synergy in lower extremity after stroke and the important role of these muscles in walking. MTS was used for clinical assessment of spasticity. In this method, the participants lay down in a relaxed and convenient supine position. Both lower extremities were in extension position.
Each muscle was tested once in two velocities (V1
). Firstly, in V1
(Slowest possible speed), full passive range of motion of joint (R2
) measured by the goniometer. In V3
(as fast as possible), the quality of muscle reaction was classified based on 0-5 grade, and if the catch or clonus appeared, the R1 (angle of catch or clonus appearance) was measured in the second movement of joint. Then, the angle of R2
was recorded [19
Quality of muscle reaction was rated as follows:
•0: No resistance throughout the course of the passive movement
•1: Slight resistance through the course of passive movement; no clear ‘‘catch’’ at a precise angle
•2: Clear catch at a precise angle, interrupting the passive movement, followed by release
•3: Fatigable clonus (10s when maintaining the pressure) appearing at a precise angle
•4: Un fatigable clonus (more than 10s when maintaining the pressure) at a precise angle
•5: Joint is immovable
Assessment of knee extensor spasticity performed so that the knee joint was positioned in full extension and hip joint in 30° flexion. The axis of goniometer was placed on the lateral femoral epicondyle
, the examiner’s one hand was above the lateral aspect of knee joint on the fixed arm and the other hand was above ankle joint on the movable arm. Then, the examiner moved the knee joint from extension to maximal flexion and measured R2
. For measuring R1
, the other one put the joint in the angle of catch or clonus and the examiner measured the angle. For evaluation of plantar flexor spasticity, the knee and ankle joints were positioned in extension. The examiner’s one hand was placed above the ankle joint, on the fixed arm which was parallel to longitudinal axis of fibula. Then, the examiner moved the ankle joint from full plantar flexion to maximal available dorsiflexion. The angles of R2
Lower extremity strength was evaluated with Motricity Index [20
]. The isometric strength of hip flexor, knee extensor and ankle dorsi flexor was assessed based on weighted MRC grades.
The participants should be sitting in a chair that had back support. Hip flexion was tested with the hip joint was bent 90°. The examiner instructed the patients to bring the knee towards the chin, while she monitored the contraction of hip flexors by placing her hand on the anterior of distal thigh. Then the examiner resisted the movement. According to the quality of muscle contraction the score is recorded. Examiner also should be aware of any trick motion such as leaning the back during the movement by placing one hand on their back. Knee extension was examined while it was bent at 90° flexion with the foot unsupported, followed by the examiner asked the participants to extend the knee and touch her hand which is held at the level of the knee, meanwhile she monitored the contraction of quadriceps with her other hand which gave resistance to movement. Then the score was recorded.
Furthermore, the movement of dorsiflexion was assessed as the ankle relaxed in a plantar flexed position, then the examiner placed her hand on the forefoot, while the patient was asked to dorsi flex the foot, the examiner palpated and also resisted the contraction of tibialis anterior with the other hand on the forefoot
. Finally, all three scores were summed and the Motricity Index for lower extremity was calculated (Table 1) [20
Functional mobility was evaluated with the endurance of 6 Minute Walk Test (6MWT), Timed up and Go test (TUG), Rivermead Mobility Index (RMI) and the speed of 10-Meter Walk Test (10-MWT). The sequence of performing tests was not based on special order. Walking tests were completed with participants wearing their shoes and usual assistive devices. In 6MWT, the subjects were instructed to walk as far as possible along a 30 M path within 6 minute with their comfortable speed and not to stop unless they needed and the total distance was measured. Heart rate and blood pressure were monitored before, during and at the end of the test. The test repeated twice with the interval of 10 minutes and the average of these two tests recorded as an indication of walking endurance [21
For performing 10-MWT, a measured course indoors is established with a length of 14 meters. Lines are drawn with tape at 0 meters, 2 meters, 12 meters and 14 meters. With the participant seated, the examiner instructed the participants to stand and walk to the end of line with the comfortable speed. The examiner started the stopwatch when the participant's first foot crossed the plane of 2 meter line and stopped it when the participant's first foot crossed the plane of the 12 meter line. The distance of 10 meter was divided by the time (s) taken to pass this distance. The test repeated three times with the rest of 5 minutes and the average of three trials calculated as the speed of walking [22
TUG is a test of mobility required to stand up from a chair with armrest, walk 3 meter, turn 180° and walk back to the chair and sit down. The participants were instructed to walk in comfortable pace. The time (seconds) taken to complete this task was measured with a stopwatch. The test repeated three times and the average recorded [23
The RMI is a dichotomous scale (0: inability to do 1: ability to do) consisting of 15 items that assess a patient’s ability in performing 15 common daily movements: turning over in bed, lying to sitting, sitting balance, sitting to standing, standing unsupported, transfer, walking inside with an aid if needed, stairs, walking outside (even ground), walking inside with no aid, picking off floor, walking outside (uneven ground), bathing, up and down 4 steps, and running. Each patient’s mobility performance is assessed by interviewing the patient and/or primary caregiver, except the item of “standing unsupported” which is administered by direct observation. The highest score, 15, indicates highest mobility situation [24