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S. Arpa and S. Ozcakir
ercises were designed as isometric, isotonic and progressive
resistive for each patient according to their capabilities. Lower
extremity exercises were performed via EMG BF in Group 1,
while a sham technique was used for patients in Group 2. Pa-
tients in Group 1 received visual and auditory feedback during
exercise, whereas Group 2 received no feedback. The inpatient
rehabilitation programme lasted for 10 sessions (5 days a week
for 2 weeks). All patients were trained to perform a routine home
exercise programme at discharge and were encouraged at the
1 st and 3 rd month visits to continue exercises. A flow diagram
of the study is presented in Fig. 1. Patients were assessed by
the clinical and functional parameters listed below before and
after treatment and at follow-up visits. siological activity of the muscles: maximal isometric contraction
(peak torque, Nm) was noted for knee extension in a sitting
position at 30° and 60° and for ankle dorsiflexion at 0° and 15°.
Electrophysiological activity of the muscles tested with
surface electrodes of the EMG BF instrument (Neurotrac ETS
Simplex 2005, Hampshire, UK): after the electrode placement
on the belly of the target muscle, patients were instructed to
contract the muscle 5 times with maximal effort. The highest
score and the mean score (microvolt) were noted.
Assessment Intervention
Neurotrac ETS Simplex 2005 was used for EMG BF. The soft-
ware was uploaded on a laptop, and 50 × 50 mm, self-adhesive,
EMG-TENS electrodes were used. Active electrodes were
placed 4 cm apart longitudinally, with 1 placed on the belly of
the muscle. The ground electrode was placed on the other lower
extremity 2–3 cm above the patella. The “stroke” mode of the
instrument was used with a 5-s contraction and a 5-s relaxation
time lasting for 15 min for each of the tibialis anterior and qua-
driceps femoris muscles. This programme was conducted 5 days
a week for 2 weeks. With the supervision of a physiotherapist
experienced in the EMG BF applications, muscle strengthening
exercises were performed after the electrode placement. The
Active range of motion (ROM) of the ankle and knee joint were
muscle threshold was calculated for every patient and muscle
measured with a goniometer while the patient was lying in a
individually, and it was accepted as 40% of the mean after 5
supine position.
maximum contractions. The treatment group was able to see
the monitor and follow the work done by the muscles and
Muscle strength was tested with an isokinetic dynamometer
hear the feedback noise when the previously identified thres-
(Cybex Humac Norm 2004, CSMi, MA, USA) and electrophy-
hold was exceeded. The sham group
worked with the computer volume off
and the monitor turned around so that
! hemiplegia due to
34 patients with
the patient did not receive any visual
cerebrovascular disease were enrolled
Enrollment
according ! to inclusion criteria
or auditory feedback. After 10 ses-
sions of treatment, both groups were
advised to continue the home exercise
programme.
!
Randomized (n=34)
The data were analysed using the
SPSS 17.0 for Windows (Chicago,
IL, USA) software package. The
Allocation
normality of the variables was tested
Allocated to a rehabilitation program
Allocated to a rehabilitation program
with the Shapiro-Wilk test. Since
including EMG BF assisted lower extremity
including sham EMG BF assisted lower
the variables were not normally dist-
exercises (n = 17)
extremity exercises (n = 17)
ributed, they were given as median
!
!
(range) values. Two independent and
Pretreatment
dependent groups were compared
Patients were evaluated according to the
Patients were evaluated according to the
using the Mann-Whitney U test and the
study parameters (n =17)
study parameters (n =17)
Wilcoxon test, respectively. Cohen’s d
was calculated as an effect size estima-
Follow-Up (1st)
tion (10). Categorical variables were
month)
Patients were evaluated according to
Patients were evaluated according to the
given with the n (%) values. Pearson
the study parameters (n =17)
study parameters ( n =17)
χ 2 test was used to compare categorical
variables. The significance level was
Follow-Up (3 rd )
set as α = 0.05.
month)
Spasticity was evaluated with the MAS (Modified Ashworth
Scale). 0: No increase in muscle tone; 1: Slight increase in
muscle tone, manifested by a catch and release or by minimal
resistance at the end of the range of motion (ROM) when the
affected part(s) is/are moved in flexion or extension; 2: Slight
increase in muscle tone, manifested by a catch in the middle
range and resistance throughout the remainder of the ROM,
but affected part(s) moved easily; 3: More marked increase in
muscle tone through most of the ROM, but affected parts moved
easily 4: Considerable increase in muscle tone, passive move-
ment difficult; 5: Affected part(s) rigid in flexion or extension.
Patients were evaluated according to the
study parameters ( n =16) One patient
excluded because of hip fracture (fall)
Patients were evaluated according to the
study parameters (n =16) One patient died
(unknown etiology)
Functional assessment was made with the Barthel Index (9),
and time to walk 10 m (the time needed to walk 10 m with or
without an assistive device was recorded in s).
Analysis
Analysed (n =16)
Fig. 1. Flow diagram of the study.
www.medicaljournals.se/jrm
Analysed (n =16)
RESULTS
Twenty-two men and 12 women
with a median age of 58.5 years
(range 18–78) were enrolled in