Article
Motor evoked potentials of the lower extremity in predicting motor recovery and ambulation after stroke: a cohort study 1

https://doi.org/10.1016/S0003-9993(03)00237-5Get rights and content

Abstract

Hendricks HT, Pasman JW, van Limbeek J, Zwarts MJ. Motor evoked potentials of the lower extremity in predicting motor recovery and ambulation after stroke: a cohort study. Arch Phys Med Rehabil 2003;84:1373–9.

Objective

To assess the prognostic value of motor evoked potentials (MEPs) in the lower extremity with respect to motor recovery and functional recovery in stroke patients.

Design

Cohort study.

Setting

The department of neurology at a university hospital.

Participants

Thirty-eight acute-stroke patients with complete paralysis (paralysis subgroup) or severe paresis (paresis subgroup) of the lower extremity. MEPs of the vastus medialis and the tibialis anterior muscles were recorded between days 3 and 10 after stroke onset.

Interventions

Not applicable.

Main outcome measures

A separate proximal leg motor score (maximum, 16 points) and crural motor score (maximum, 2 points) were defined within the lower-limb subset of the original Fugl-Meyer Motor Assessment to evaluate the motor performance at regular intervals until 6 months after stroke. The transfer item of the Barthel Index and the Functional Ambulation Categories scores were used to assess transfer and walking ability.

Results

For the paralysis subgroup (n=30), the follow-up was complete in 27 patients (2 patients died, 1 patient underwent above-knee amputation). At 26 weeks, 20 patients experienced proximal motor recovery (mean score ± standard deviation, 11.70±4.48), and 12 of them also showed crural motor recovery (mean score, 1.40±.51). Nine patients (33%) could perform an independent transfer safely, and 7 (26%) had learned to walk independently. Analysis revealed significant relationships for tibialis anterior muscle MEPs and motor recovery of crural leg muscles (odds ratio [OR]=18.00; 95% confidence interval [CI], 1.31–894.40), but not for vastus medialis muscle MEPs and proximal motor recovery (OR=6.00; 95% CI, .53–303.00). We found no association between vastus medialis muscle MEPs and recovery of ambulation. However, tibialis anterior muscle MEPs seemed to provide a test with prognostic value for the ability to perform independent transfers (OR=17.50; 95% CI, 1.36–267.00), but not for walking (OR=5.25; 95% CI, .40–77.57). Patients in the paresis subgroup experienced more favorable motor and functional recovery than did those in the paralysis subgroup.

Conclusions

Tibialis anterior muscle MEPs registered in subacute phase after stroke may provide important prognostic information, both for motor recovery of the crural muscles and for the ability to perform independent transfers in patients with initial complete paralysis of the lower extremity. Vastus medialis muscle MEPs were not predictive for motor and functional recovery.

Section snippets

Participants

Thirty-eight consecutive patients with acute ischemic stroke were recruited from the department of neurology at a university hospital during 1.5 years. The study population was from the region of Nijmegen, a middle-sized city in the eastern part of The Netherlands. Acute medical care for stroke patients is provided by several hospitals, including the university hospital. Stroke patients are admitted in an unselected manner, and, therefore, referral bias is not to be expected. Patients were

Results

Of the 38 initial patients, 30 had complete leg paralysis at inclusion (paralysis subgroup), and 8 had a combination of paresis of proximal muscles with paralysis of the crural muscles (paresis subgroup). Two patients in the paralysis subgroup died within 5 to 20 days after stroke onset, and another patient underwent an above-knee amputation (day 48) because of severe vasculopathy with ulceration at the heel. One patient in the paresis subgroup had a recurrent stroke (day 42). Twenty-seven

Discussion

Motor functions of the lower extremity represent an important determinant of the ability to regain ambulation after stroke.1, 2, 3 Based on this functional perspective, we examined the potential for motor recovery in acute-stroke patients with paralysis or severe paresis of the lower extremity. Compared with other studies, the recovery rate in our paralysis subgroup was high—66% experienced recovery of proximal motor functions—and in 33% of the patients, even crural motor recovery occurred

Conclusion

In patients with severe initial motor deficits of the lower extremity, considerable potential seems to exist for motor recovery, particularly for proximal leg muscles. Tibialis anterior muscle MEPs registered during the first week after stroke onset may provide important prognostic information, both for the motor recovery of crural muscles and for the ability to perform independent transfers. Vastus medialis muscle MEPs were not predictive of motor and functional recovery. The evidence

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