Lisa: Thanks everyone for tuning in. The majority of my clinical experience has been in the adult rehab setting, specifically in inpatient rehabilitation. For the past two years, I have served as an outcome assessor in the rehab laboratory at Ohio State under Dr. Stephen Page. Dr. Page has various research studies that are going at multiple different times. My role is to evaluate these research subjects at the beginning of their research trial and then at the end. One of the outcome measures that I am very familiar with is the Fugl-Meyer Assessment for the Upper Extremity. When I was in full-time practice, I wish I had been more familiar with the Fugl-Meyer. I think it is a great tool that has many uses across different settings within the stroke population. It would have served as a great supplement to some of the other assessments that I used with patients in inpatient rehab. Perhaps that is why you have tuned in today--you want to learn more about different assessments that you can use, whether you work in inpatient rehab, outpatient, acute care, or in skilled care. The Fugl-Meyer is a great way to expand your OT toolkit when working with the stroke population.
Hopefully, you have access to the Fugl-Meyer score sheet. It is a PDF that I have provided in the handouts. The term video is used a little bit throughout the PDF. Just ignore that. This has to do with Dr. Page's lab, and it does not impact scoring at all. Before we dive into the individual items of the Fugl-Meyer, I would like to give you a little bit of background on the Fugl-Meyer Assessment itself.
Background
The Fugl-Meyer was originally developed in 1975. Dr. Fugl-Meyer and some of his colleagues put this assessment together and developed the different test items. Even though we are just going to focus on the upper extremity motor function section of the Fugl-Meyer, it has additional sections. There is a section on joint motion and pain, balance, sensation and lower extremity motor function. And of the different items in those sections add up to a total of 226 points. The upper extremity motor section is just 66 points. We will talk about how to score each of those different items of the upper extremity motor function section in a moment.
Back in the mid '70s, Dr. Fugl-Meyer and his colleagues developed the Fugl-Meyer Assessment because they wanted a measure that could quantify motor recovery after stroke. There are other measures like the Barthel Disability Index and the FIM, the Functional Independence Measure. They capture function more than anything else. I know that function is the bread and butter of our profession, but sometimes capturing function is not quite enough to really capture how much the patient is really progressing in different areas, specifically motor recovery of the upper extremity. The Fugl-Meyer was developed to serve as a complement to those other assessments. The Fugl-Meyer specifically looks at motor recovery after stroke.
Here are some background statistics on stroke itself. I pulled these statistics from the American Heart Association's 2016 executive summary. Stroke impacts just fewer than 800,000 people each year. Stroke is the fifth leading cause of death in the United States. Back in 2014, stroke was the fourth leading cause of death in the United States so this is encouraging as those rates are going down. There are 795,000 people each year that have incidents of stroke or recurrent stroke events. Of those individuals, hemiparesis is the most common deficit, affecting approximately 70% to 80% of stroke survivors. Even with the best medical care, 50% of stroke survivors still experience some sort of residual effect of hemiparesis even after their course of therapy.
How does this all relate to back to the Fugl-Meyer? The Fugl-Meyer has been examined by different researchers and only been studied with the stroke population. I have had patients that have had hemiparesis related to other conditions like a resection of a brain tumor or traumatic brain injury. However, the Fugl-Meyer is developed just for the stroke population and would not be appropriate for other conditions as it has only been tested with the stroke population. Ischemic stroke, hemorrhagic stroke, and events like arterial venous malformation rupture all fall underneath the umbrella of hemorrhagic stroke. The reason why it is not appropriate to use with other populations is because stroke recovery follows a predictable pattern when talking about the motor system.
Upper Extremity Recovery
Motor function returns in a sequence after starting with flaccid paralysis. Sometimes, I use the term milestones when I think of this predicable pattern of motor recovery after stroke. If we look at this flowchart in Figure 1, it give us a better idea as to what these predictable patterns are.
Figure 1. UE recovery sequence.
When a patient has a stroke, they will first experience flaccid paralysis of the upper extremity. After that phase is over, they progress to these different recovery phases. The Fugl-Meyer was developed to follow these different sequential steps. You will notice on the PDF that reflexes are one of the first items that you are going to assess. After their reflexes return, then we start to see some tone and spasticity develop. The Modified Ashworth Scale is a tool that you could use to evaluate the severity of a patients tone and spasticity. After that period of tone and spasticity, hopefully our stroke patients start to develop some voluntary movement. However, in this stage, voluntary movement oftentimes is influenced by flexor and extensor synergy patterns. Even though our patients might be able to actively move their affected upper extremity, we notice that their movement is not normal as it is influenced by these flexor and extensor synergies. After our patients show signs of emerging flexor and extensor synergy with voluntary movement, typically they progress to voluntary movement that less influenced by those synergistic patterns. Ideally, we want all of our patients to return to having normal movement. "Normal" is movement on the affected side that is the same as the unaffected side. Going back to that previous statistic I mentioned, 50% of our stroke survivors are going to have some type of residual weakness related to hemiparesis. Even though normal movement is always the goal, 50% of our hemiparetic stroke patients are going to experience residual weakness after stroke.
