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. 2018 Jan 12;13(1):e0189279.
doi: 10.1371/journal.pone.0189279. eCollection 2018.

Is the proportional recovery rule applicable to the lower limb after a first-ever ischemic stroke?

Janne M Veerbeek  1   2   3   4   5 , Caroline Winters  1   2   3 , Erwin E H van Wegen  1   2   3 , Gert Kwakkel  1   2   3   6   7
Affiliations

Is the proportional recovery rule applicable to the lower limb after a first-ever ischemic stroke?

Janne M Veerbeek et al. PLoS One. .

Abstract

Objective: To investigate (a) the applicability of the proportional recovery rule of spontaneous neurobiological recovery to motor function of the paretic lower extremity (LE); and (b) the presence of fitters and non-fitters of this prognostic rule poststroke. When present, the clinical threshold for fitting nor non-fitting would be determined, as well as within-subject generalizability to the paretic upper extremity (UE).

Methods: Prospective cohort study in which the Fugl-Meyer Assessment (FMA)-LE and FMA-UE were measured <72 hours and 6 months poststroke. Predicted maximum potential recovery was defined as [FMA-LEmax-FMA-LEinitial = 34 -FMA-LEinitial]. Hierarchical clustering in 202 first-ever ischemic stroke patients distinguished between fitting and not fitting the rule. Descriptive statistics determined whether fitters and non-fitters for LE were the same persons as for UE.

Results: 175 (87%) patients fitted the FMA-LE recovery rule. The observed average improvement of the fitters was ~64% of the predicted maximum potential recovery. In the non-fitter group, the maximum initial FMA-LE score was 13 points. Fifty-one out of 78 patients (~65%) who scored below the identified 14-point threshold at baseline fitted the FMA-LE rule. Non-fitters were more severely affected than fitters. All non-fitters of the FMA-LE rule did also not fit the proportional recovery rule for FMA-UE.

Conclusions: Proportional recovery seems to be consistent within subjects across LE and UE motor impairment at the hemiplegic side in first-ever ischemic hemispheric stroke subjects. Future studies should investigate prospectively distinguishing between fitters and not-fitters within the subgroup of patients who have initial low FMA-LE scores. Subsequently, patients could be stratified based on fitting or not fitting the recovery rule as this would impact rehabilitation management and trial design.

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Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

Figures

Fig 1
Fig 1. Exclusion flow-chart.
Fig 2
Fig 2. Proportional recovery of the lower extremity: Predicted maximum potential recovery (FMA-LEmax−FMA-LEinitial) versus observed ΔFMA-LE.
◻ subgroup of fitters (N = 175; blue), ○ subgroup of non-fitters (N = 27; red). For the fitters, R2 of the FMA-LEmax for ΔFMA-LE was 76.8%, and the regression line y = 0.64 (95%CI 0.59–0.69) x– 0.24 (95%CI -1.15–0.66). Note that the two data points at the top right corner were also identified as a subgroup in the hierarchical cluster analysis. However, they were added to the ‘fitter’ group because their ΔFMA-LEobserved was almost identical with the predicted maximum potential recovery. Also, note that there were 15 patients who scored 1 to 3 points lower on the FMA-LE at 6 months, in comparison to the baseline measurement. See further explanation in text. CI, Confidence Interval; FMA, Fugl-Meyer Assessment; LE, Lower Extremity.
Fig 3
Fig 3. Consistency of proportional recovery between FMA-LE and FMA-UE expressed in percentages (%).
◻ subgroup of FMA-UE fitters (N = 137; blue), ◼ subgroup of FMA-UE non-fitters (N = 65; blue), ○ subgroup of FMA-LE fitters (N = 175; red), ● subgroup of FMA-LE non-fitters (N = 27; red). FMA, Fugl-Meyer Assessment; LE, Lower Extremity; UE, Upper Extremity.
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Publication types

Grants and funding

The present work was part of the EPOS research project funded by the “Wetenschappelijk College Fysiotherapie” (grant number 33368) of the Royal Dutch Society for Physical Therapy (KNGF), the Netherlands. This part of the EPOS project was co-financed by the Dutch National Institute of Health (ZonMw) (grant number 89000001) as a part of the EXPLICIT-stroke programme (www.explicit-stroke.nl).