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To investigate the clinical feasibility of a newly developed, portable, gait assistive robot (WA-H, ‘walking assist for hemiplegia’) for improving the balance function of patients with stroke-induced hemiplegia.
Thirteen patients underwent 12 weeks of gait training on the treadmill while wearing WA-H for 30 minutes per day, 4 days a week. Patients' balance function was evaluated by the Berg Balance Scale (BBS), Fugl-Meyer Assessment Scale (FMAS), Timed Up and Go Test (TUGT), and Short Physical Performance Battery (SPPB) before and after 6 and 12 weeks of training.
There were no serious complications or clinical difficulties during gait training with WA-H. In three categories of BBS, TUGT, and the balance scale of SPPB, there was a statistically significant improvement at the 6th week and 12th week of gait training with WA-H. In the subscale of balance function of FMAS, there was statistically significant improvement only at the 12th week.
Gait training using WA-H demonstrated a beneficial effect on balance function in patients with hemiplegia without a safety issue.
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To assess the efficacy of high-frequency repetitive transcranial magnetic stimulation (rTMS) on balance function in patients with chronic stroke.
Thirty participants with chronic stroke were enrolled in this study. High frequency (10 Hz) rTMS was delivered with butterfly-coil on trunk motor spot. Each patient received both real and sham rTMS in a random sequence. The rTMS cycles (real or sham) were composed of 10 sessions each, administered over two weeks, and separated by a 4-week washout period. Balance function was measured by Berg Balance Scale and computerized dynamic posturography to determine the effect of rTMS before and one day after the end of each treatment period, as well as at a 1-month follow-up.
The balance function was significantly improved after high frequency rTMS as compared with that after sham rTMS (p<0.05). There was no serious adverse effect in patients during the treatment period.
In the chronic stroke patients, high frequency rTMS to the trunk motor area seems to be a helpful way to improve balance function without any specific adverse effects. Further studies are needed to identify the underlying mechanism and generate a detailed protocol.
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To evaluate the beneficial effect of botulinum toxin A (Botox) injection into the subscapularis muscle on intractable hemiplegic shoulder pain.
Six stroke patients with intractable hemiplegic shoulder pain were included. Botulinum toxin A was injected into the subscapularis muscle. Intractable hemiplegic shoulder pain was evaluated using an 11-point numerical rating scale. Pain-free range of motion was assessed for shoulder abduction and external rotation. The spasticity of the shoulder internal rotator was measured using the modified Ashworth scale. Assessments were carried out at baseline and at 1, 2, 4, and, if possible, 8 weeks.
Intractable hemiplegic shoulder pain was improved (p=0.004) after botulinum toxin injection into the subscapularis muscle. Restricted shoulder abduction (p=0.003), external rotation (p=0.005), and spasticity of the shoulder internal rotator (p=0.005) were also improved. Improved hemiplegic shoulder pain was correlated with improved shoulder abduction (r=–1.0, p<0.001), external rotation (r=–1.0, p<0.001), and spasticity of the internal rotator (r=1.0, p<0.001).
Botulinum toxin A injection into the subscapularis muscle appears to be valuable in the management of intractable hemiplegic shoulder pain.
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To investigate the effect of radial extracorporeal shock wave therapy (rESWT) on hemiplegic shoulder pain (HSP) syndrome.
In this monocentric, randomized, patient-assessor blinded, placebo-controlled trial, patients with HSP were randomly divided into the rESWT (n=17) and control (n=17) groups. Treatment was administered four times a week for 2 weeks. The visual analogue scale (VAS) score and Constant-Murley score (CS) were assessed before and after treatment, and at 2 and 4 weeks. The Modified Ashworth Scale and Fugl-Meyer Assessment scores and range of motion of the shoulder were also assessed.
VAS scores improved post-intervention and at the 2-week and 4-week follow-up in the intervention group (p<0.05). Respective differences in VAS scores between baseline and post-intervention in the intervention and control groups were –1.69±1.90 and –0.45±0.79, respectively (p<0.05), between baseline and 2-week follow-up in the intervention and control groups were –1.60±1.74 and –0.34±0.70, respectively (p<0.05), and between baseline and 4-week follow-up in the intervention and control groups were –1.61±1.73 and –0.33±0.71, respectively (p<0.05). Baseline CS improved from 19.12±11.02 to 20.88±10.37 post-intervention and to 20.41±10.82 at the 2-week follow-up only in the intervention group (p<0.05).
rESWT consisting of eight sessions could be one of the effective and safe modalities for pain management in people with HSP. Further studies are needed to generalize and support these results in patients with HSP and a variety conditions, and to understand the mechanism of rESWT for treating HSP.
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Interventions for Post-Stroke Shoulder Pain: An Overview of Systematic Reviews
To examine the association between motor evoked potentials (MEPs) in lower limbs and ambulatory outcomes of hemiplegic stroke patients.
Medical records of hemiplegic patients with the first ever stroke who received inpatient rehabilitation from January 2013 to May 2014 were reviewed. Patient who had diabetes, quadriplegia, bilateral lesion, brainstem lesion, severe musculoskeletal problem, and old age over 80 years were excluded. MEPs in lower limbs were measured when they were transferred to the Department of Rehabilitation Medicine. Subjects were categorized into three groups (normal, abnormal, and absent response) according to MEPs findings. Berg Balance Scale (BBS) and Functional Ambulation Category (FAC) at initial and discharge were compared among the three groups by one-way analysis of variance (ANOVA). Correlation was determined using a linear regression model.
Fifty-eight hemiplegic patients were included. BBS and FAC at discharge were significantly (ANOVA, p<0.001) different according to MEPs findings. In linear regression model of BBS and FAC using stepwise selection, patients' age (p<0.01), BBS at admission (p<0.01), and MEPs (p<0.01) remained significant covariates. In regression assumption model of BBS and FAC at admission, MEPs and gender were significant covariates.
Initial MEPs of lower limbs can prognosticate the ambulatory outcomes of hemiplegic patients.
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To investigate the effects of a shoulder sling on balance in patients with hemiplegia.
Twenty-seven hemiplegic stroke patients (right 13, left 14) were enrolled in this study. The subjects' movement in their centers of gravity (COGs) during their static and dynamic balance tests was measured with their eyes open in each sling condition-without a sling, with Bobath's axillary support (Bobath sling), and with a simple arm sling. The percent times in quadrant, overall, anterior/posterior, and medial/lateral stability indexes were measured using a posturography platform (Biodex Balance System SD). Functional balance was evaluated using the Berg Balance Scale and the Trunk Impairment Scale. All balance tests were performed with each sling in random order.
The COGs of right hemiplegic stroke patients and all hemiplegic stroke patients shifted to, respectively, the right and posterior quadrants during the static balance test without a sling (p<0.05). This weight asymmetry pattern did not improve with either the Bobath or the simple arm sling. There was no significant improvement in any stability index during either the static or the dynamic balance tests in any sling condition.
The right and posterior deviations of the hemiplegic stroke patients' COGs were maintained during the application of the shoulder slings, and there were no significant effects of the shoulder slings on the patients' balance in the standing still position.
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To analyze the differences in the vertical ground reaction force (GRF) variables of hemiplegic patients compared with a control group, and between the affected and unaffected limbs of hemiplegic patients using foot scans.
Patients (n=20) with hemiplegia and healthy volunteers (n=20) underwent vertical force analysis. We measured the following: the first and second peak forces (F1, F2) and the percent stances at which they occurred (T1, T2); the vertical force impulse (VFI) and stance times. The GRF results were compared between the hemiplegic patients and control individuals, and between the affected and unaffected limbs of hemiplegic patients. Additionally, we analyzed the impulse of the unaffected limb according to the motor assessment scale (MAS), Brunnstrom stage, and a Timed Up and Go Test.
The F1s and F2s of the affected and unaffected limbs were significantly less than those of the normal control individuals (p<0.05). The T1s of both the affected and unaffected limbs of the patients were greater than control individuals, whilst the T2s were lower (p<0.05). Greater impulses and stance times were recorded on both sides of the patients than in the limbs of the control individuals (p<0.05). The MAS, Brunnstrom stage and Timed Up and Go Test results were significantly correlated with the VFI of the unaffected limbs (p<0.05).
The high impulse values of the unaffected limb were associated with complications during gait rehabilitation. Therefore, these results suggest that unaffected limbs should also be taken into consideration in these patients.
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To assess the effect of motor imagery, as a rehabilitation method in stroke, on F-wave parameters that undergo changes during upper motor neuron involvement.
Twenty-one fully conscious hemiparetic stroke survivors with a completely plegic hand (power 0/5) and a minimum interval of 72 hours since stroke were recruited into this study. The mean F-wave latency, amplitude, and persistence in the median and ulnar nerves were measured in both the affected and non-affected sides at rest and in the paretic hand during a mental task. Comparison was made between data from the affected hand and the non-affected hand as well as between data from the affected hand at baseline and during motor imagery.
Patients had significantly different F-wave persistence between the affected and non-affected sides (paired t-test, p<0.001). Motor imagery could improve F-wave persistence in both the investigated nerves (paired t-test, p=0.01 for ulnar nerve and p<0.001 for median nerve) and F-response amplitude in the median nerve (paired t-test, p=0.01) of the affected limb.
The amplitude and persistence of F-wave were improved during motor imagery, representing F-wave facilitation. This result suggests that motor imagery can restore motor neuron excitability, which is depressed after stroke.
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To evaluate the feasibility and effectiveness of a knee-ankle-foot orthosis powered by artificial pneumatic muscles (PKAFO).
Twenty-three hemiplegic patients (age, 59.6±13.7 years) were assessed 19.7±36.6 months after brain lesion. The 10-m walking time was measured as a gait parameter while the individual walked on a treadmill. Walking speed (m/s), step cycle (cycle/s), and step length (m) were also measured on a treadmill with and without PKAFO, and before and after gait training. Clinical parameters measured before and after gait training included Korean version of Modified Bathel Index (K-MBI), manual muscle test (MMT), and Modified Ashworth Scale (MAS) of hemiplegic ankle. Gait training comprised treadmill walking for 20 minutes, 5 days a week for 3 weeks at a comfortable speed.
The 10-m walking time, walking speed, step length, and step cycle were significantly greater with PKAFO than without PKAFO, and after gait training (both p<0.05). K-MBI was improved after gait training (p<0.05), but MMT and MAS were not.
PKAFO may improve gait function in hemiplegic patients. It can be a useful orthosis for gait training in hemiplegic patients.
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To evaluate the effects of functional electrical stimulation (FES) to ankle dorsiflexor (DF) and ankle plantarflexor (PF) on kinematic and kinetic parameters of hemiplegic gait.
Fourteen post-stroke hemiplegic patients were considered in this study. Electrical stimulation was delivered to ankle DF during the swing phase and ankle PF during the stance phase via single foot switch. Kinematic and kinetic data were collected using a computerized motion analysis system with force plate. Data of no stimulation (NS), DF stimulation only (DS), DF and PF stimulation (DPS) group were compared among each other.
Peak ankle dorsiflexion angle during swing phase is significantly greater in DS group (-1.55°±9.10°) and DPS group (-2.23°±9.64°), compared with NS group (-6.71°±11.73°) (p<0.05), although there was no statistically significant difference between DS and DPS groups. Ankle plantarflexion angle at toe-off did not show significant differences among NS, DS, and DPS groups. Peak knee flexion in DPS group (34.12°±13.77°) during swing phase was significantly greater than that of NS group (30.78°±13.64°), or DS group (32.83°±13.07°) (p<0.05).
In addition to the usual FES application stimulating ankle DF during the swing phase, stimulation of ankle PF during stance phase can help to increase peak knee flexion during the swing phase. This study shows the advantages of stimulating the ankle DF and PF using single foot switch for post-stroke gait.
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To assess the plantar pressure distribution during the robotic-assisted walking, guided through normal symmetrical hip and knee physiological kinematic trajectories, with unassisted walking in post-stroke hemiplegic patients.
Fifteen hemiplegic stroke patients, who were able to walk a minimum of ten meters independently but with asymmetric gait patterns, were enrolled in this study. All the patients performed both the robotic-assisted walking (Lokomat) and the unassisted walking on the treadmill with the same body support in random order. The contact area, contact pressure, trajectory length of center of pressure (COP), temporal data on both limbs and asymmetric index of both limbs were obtained during both walking conditions, using the F-Scan in-shoe pressure measurement system.
The contact area of midfoot and total foot on the affected side were significantly increased in robotic-assisted walking as compared to unassisted walking (p<0.01). The contact pressure of midfoot and total foot on affected limbs were also significantly increased in robotic-assisted walking (p<0.05). The anteroposterior and mediolateral trajectory length of COP were not significantly different between the two walking conditions, but their trajectory variability of COP was significantly improved (p<0.05). The asymmetric index of area, stance time, and swing time during robotic-assisted walking were statistically improved as compared with unassisted walking (p<0.05).
The robotic-assisted walking may be helpful in improving the gait stability and symmetry, but not the physiologic ankle rocker function.
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To evaluate diaphragmatic motion via M-mode ultrasonography and to correlate it with pulmonary function in stroke patients.
This was a preliminary study comprised of ten stroke patients and sixteen healthy volunteers. The M-mode ultrasonographic probe was positioned in the subcostal anterior region of the abdomen for transverse scanning of the diaphragm during quiet breathing, voluntary sniffing, and deep breathing. We analyzed diaphragmatic motion and the relationship between diaphragmatic motion and pulmonary function.
All stroke patients had restrictive pulmonary dysfunction. Compared to that exhibited by control subjects, stroke patients exhibited a significant unilateral reduction in motion on the hemiplegic side, primarily during volitional breathing. Diaphragmatic excursion in right-hemiplegic patients was reduced on both sides compared to that in control subjects. However, diaphragmatic excursion was reduced only on the left side and increased on the right side in left-hemiplegic patients compared to that in control subjects. Left diaphragmatic motion during deep breathing correlated positively with forced vital capacity (rho=0.86, p=0.007) and forced expiratory volume in 1 second (rho=0.79, p=0.021).
Reductions in diaphragmatic motion and pulmonary function can occur in stroke patients. Thus, this should be assessed prior to the initiation of rehabilitation therapy, and M-mode ultrasonography can be used for this purpose. It is a non-invasive method providing quantitative information that is correlated with pulmonary function.
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Kernohan-Woltman notch phenomenon (KWP) is an ipsilateral motor weakness due to compression of the contralateral cerebral peduncle. We report two cases of KWP following traumatic brain injury. In case 1, ipsilateral hemiplegia was noted after right subdural hemorrhage. Although magnetic resonance imaging showed no abnormal signal changes on cerebral peduncle, diffusion tensor tractography (DTT) revealed interruption of corticospinal tract (CST) at lower level of the midbrain level. In case 2, there was abnormal signal change of the right cerebral peduncle contralateral to the primary lesion and we could not reconstruct right CST. Case 1 showed unsatisfactory motor recovery even after 15 months, and follow-up DTT showed no change. In case 2, follow-up DTT was not performed, but her ipsilateral hemiparesis had almost disappeared during the 15 months. DTT would be useful in detecting ipsilateral hemiparesis due to KWP and the clinical course may differ according to the lesion characteristics.
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To explore the effect of visual and haptic vertical stimulation on standing balance in post-stroke patients.
Twenty-five post-stroke patients were recruited. We measured left/right standing pressure differences and the center of pressure (COP) parameters for each patient under three different conditions: no stimulation, visual, and haptic stimulated conditions. First, patients stood on a posturography platform with their eyes blindfolded. After a rest period, the patients stood on the same platform with their eyes fixed to a 1.5-m luminous rod, which was placed at a vertical position in front of the patients. After another rest period, the patients again stood touching a vertically placed long rod in their non-hemiplegic hand with their eyes blindfolded. We collected the signals from the feet in each condition and obtained the balance indices.
Compared with the no stimulation condition, significant improvements were observed for most of the COP parameters including COP area, length, and velocity for both the visual and haptic vertical stimulation conditions (p<0.01). Additionally, when we compared visual and haptic vertical stimulation, visual vertical stimulation was superior to haptic stimulation for all COP parameters (p<0.01). Left/right standing pressure differences, increased, although patients bore more weight on their paretic side when vertical stimulation was applied (p>0.01).
Both visual and haptic vertical stimulation improved standing steadiness of post-stroke patients. Notably, visual vertical stimulation was more effective than haptic stimulation.
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To investigate the relationship between the rotator cuff tear (RCT) and the muscle strength in hemiplegic side, and the effects of paralysis on the affected shoulders in hemiplegic patients.
A cross-sectional observational study performed in a university hospital was presented. The study enrolled 55 participants with hemiplegia of diverse degree of motor paresis, excluding those with bilateral lesions, history of major trauma or other co-existing musculoskeletal disorders of the shoulder. The main outcome measurements were muscle strength of the affected upper extremity (based on Medical Research Council scale), RCTs of the bilateral shoulders (by ultrasonography), and presence of shoulder pain, subluxation of the glenohumeral joint, passive range of motions, and subacromial spurs.
Comparing each side of the shoulders, the prevalence of shoulder pain and supraspinatus muscle tear was higher (p<0.0001, p=0.007), and the range of motion was restricted (p<0.0001, p<0.0001, p<0.0001, p<0.0001) in the affected side. There was a significant trend toward higher prevalence of RCT and shoulder subluxation in the weaker shoulder (p=0.019, p<0.0001). In a multivariate analysis, Manual Muscle Test grade of less than three was an independent risk factor for RCT (p=0.025).
RCT in hemiplegia had a linear trend with muscle weakness in the affected side and the degree of weakness was an independent risk factor for the occurrence of RCT. In addition, shoulder pain, limitation of range of motions, and RCT were more frequent on the hemiplegic side of the shoulders. It is the first study to reveal a linear trend between RCT and upper extremity weakness and will provide physicians an insight to the management of RCTs in hemiplegic patients.
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To investigate the effectiveness of the daily living activity and motor evoked potential (MEP) in the subacute stroke patients.
Nineteen subjects with subacute ischaemic/hemorrhagic stroke developed in the last three months were enrolled, and MEP was measured with transcranial magnetic stimulation. Functional Independence Measure (FIM) score were evaluated in both groups before and 4 weeks after comprehensive rehabilitative management. According to the presence of MEP response in the affected hemisphere, subjects were divided into MEP positive and negative group.
There was no significant difference between the two groups in age, sex, and post-onset duration. Four weeks later, the change in total FIM and self-care score improved significantly in the MEP-positive group, when compared to the MEP-negative group (p<0.05). However, cognitive improvement had no relationship with MEP responsiveness.
We concluded that initial measurement of MEP is a useful assessment tool in predicting functional outcome of subacute stroke patients.
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Spontaneous cervical epidural hematoma (SCEH) is an uncommon cause of acute nontraumatic myelopathy. SCEH presenting as Brown-Sequard syndrome is extremely rare. A 65-year-old man had motor weakness in the left extremities right after his mother's funeral. He received thrombolytic therapy under the impression of acute cerebral infarction at a local hospital. However, motor weakness of the left extremities became aggravated without mental change. After being transferred to our hospital, he showed motor weakness in the left extremities with diminished pain sensation in the right extremities. Diagnosis of SCEH was made by cervical magnetic resonance imaging. He underwent left C3 to C5 hemilaminectomy with hematoma removal. It is important for physicians to be aware that SCEH can be considered as one of the differential diagnoses of hemiplegia, since early diagnosis and management can influence the neurological outcome. We think that increased venous pressure owing to repetitive Korean traditional deep bows may be the cause of SCEH in this case.
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To explore the relationship between a number of clinically relevant variables and sonographic imaging data in respect to the level of impairment experienced in the affected and unaffected shoulders of hemiplegic stroke patients.
Fifty-one hemiplegic stroke patients (32 males, 19 females; 29 right-sided hemiplegics, 22 left-sided hemiplegics) participated in this study. A musculoskeletal radiologist conducted a sonographic exam on both the affected and unaffected shoulders of all patients and two physicians classified the severity of the injury on a six-point rating scale. Clinical variables including age, sex, duration of injury, spasticity and muscle power of the hemiplegic side, and level of functional activity of the shoulder were assessed.
The sonographic rating scores of hemiplegic shoulders were positively correlated with age (p<0.01) and negatively correlated with level of muscle spasticity (p<0.05). The sonographic rating scores of unaffected shoulders were positively correlated with duration of injury (p<0.01). Affected shoulders received sonographic rating scores that reflected significantly more impairment than those of unaffected shoulders (p<0.001), and pre-morbid handedness did not affect the relationship between impairment rating and shoulder injury status.
Hemiplegic stroke influences not only affected shoulders, but also unaffected sides. Proper management of spasticity, enhancement of motor recovery, and avoidance of unaffected shoulder overuse should be considered to prevent shoulder problems following strokes which result in hemiplegia.
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A 64-year-old woman suffering right hemiplegia came in with pain and swelling on her left knee, general weakness and poor oral intake for 2 months. On physical examination we were able to palpate a mass with irregular margin around the left suprapatellar area. From the results of the magnetic resonance imaging (MRI), synovial proliferative disease, infectious arthritis, or gouty arthritis was suspected. We performed a blood laboratory test to detect rheumatologic diseases, knee joint aspiration, and bone scan for differential diagnosis, and were able to diagnose rheumatoid arthritis (RA) from the results of blood laboratory, physical examination, and bone scan. Consequently, we started medications for controlling RA. Herein, we report a case of rheumatoid arthritis with unilateral knee synovial hypertrophy in hemiplegia. If a right hemiplegic patient has recurrent pain on the left knee and synovial hypertrophy, and fails to respond to treatment for osteoarthritis, early detection by evaluation for rheumatic disease is crucial to prevent severe sequelae influencing rehabilitation of hemiplegia.
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To investigate the effect of virtual reality training on unilateral spatial neglect in stroke patients.
Twenty-four stroke patients (14 males and 10 females, mean age=64.7) who had unilateral spatial neglect as a result of right hemisphere stroke were recruited. All patients were randomly assigned to either the virtual reality (VR) group (n=12) or the control group (n=12). The VR group received VR training, which stimulated the left side of their bodies. The control group received conventional neglect therapy such as visual scanning training. Both groups received therapy for 30 minutes a day, five days per week for three weeks. Outcome measurements included star cancellation test, line bisection test, Catherine Bergego scale (CBS), and the Korean version of modified Barthel index (K-MBI). These measurements were taken before and after treatment.
There were no significant differences in the baseline characteristics and initial values between the two groups. The changes in star cancellation test results and CBS in the VR group were significantly higher than those of the control group after treatment. The changes in line bisection test score and the K-MBI in the VR group were not statistically significant.
This study suggests that virtual reality training may be a beneficial therapeutic technique on unilateral spatial neglect in stroke patients.
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MethodThe subjects were 79 hemiplegic stroke patients (39 males, 40 felames, mean age 61.9 years). We measured the BMD of the subjects, compared the BMD of affected sides with that of unaffected sides, and evaluate the BMD in connection with stroke duration and affected sides.
ResultsThe reduction of the BMD in affected sides was highly correlated with the duration of hemiplegia, but the correlation was not shown in the case of those in unaffected sides. In addition, the difference of BMD in affected sides between those in unaffected sides had an obvious negative correlation with the stroke duration of left hemiplegia, but not with that of right hemiplegia.
ConclusionStroke patients have a high prevalence of osteoporosis and this findings were particularly prominent in people who suffer from left hemiplegia. Early rehabilitative care, including weight-bearing exercise and outdoor ambulation, is essential for left side hemiplegic patients in order to prevent possible complications.
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