post-stroke. So, and the way that it does that is it looks at movement in combining and out of synergy. It also looks at grasp and a function and it also looks at coordination as well as reflex activity. Okay, so those are the things that the constructs that it's measuring.
Alright, so if we think about the kind of Brunstrom staging of stroke and we think about that kind of typical recovery that we see post cortical stroke at least, right. What do we see first from a motor perspective? Flaccidity, okay? So, and not everybody fits this description, but the majority of patients, you'll see flaccidity first, okay? So in that case, you see no movement, right?
Just kind of hanging, arms kind of hanging out there. What do we see next? Spasticity or movement in synergistic patterns or both, okay?
And that is, she's so good at this, that's why. Okay. That's why we're looking here at can the person move within a synergy? Is the synergistic activation helping them to be able to move? What's the next step, hopefully?
Moving out of synergy, right, or fractionated movement again. The muscle tone may or may not be normal at that point. They may still have spasticity, but they're able to move out of the synergistic activation. There are very specific instructions on how the Fugl-Meyer is supposed to be administered.
And this is one of the reasons why it takes so long. So I'm going to tell you that the few... so this is her affected arm.
We're gonna pretend I'm switching arms because you're closer to me. You're really challenging me. I know. It's too early for this, isn't it?
So the procedure is that you're supposed to have the person do the movement on their unaffected side. So the first movement that we're gonna do, just for now, is this. So picky.
I know. That movement, okay? I'm gonna have her do that three times. So you're starting... starting here actually, here to here, here to here, and three.
Okay, right, that's the unaffected side. The next thing that I'm supposed to do is check the passive range of motion within that movement on the affected side. Then I'm going to have her actively try to perform that movement.
Three times, yes I said three times. So go for it. Excellent.
And if she can't get into the starting position I can put her in the starting position. Good, try it again. One more time.
Okay, excellent job. Now that is the procedure for every single item. That's why it takes so long. Okay, three times, three times and three times. We are scoring the highest performance.
This is different than probably any other test that we're going to tell you about because most tests we are saying to you guys what score the lowest because we're trying to capture deficit. This test is looking at motor recovery. So we want to capture the highest. I'm going to tell you that I'm okay if you don't do three.
Trials of each. Okay? Okay with that because it takes a very very long time But do understand that's the procedure.
What I'm not okay with is if you don't do it on the good side first Okay, or check the passive range of motion. So you need to do that procedure every time. Today for the purposes of being speedy I'm not going to do the passive range of motion and I'm not going to do that for every single item because I just want to go through it so That you guys can practice. Does that make sense? Write that down in your notes because on the practical you need to do the passive range of motion on the affected and you need to do a trial at least one trial on the unaffected.
Yes? You always try the active. Yeah. I mean chances are if she starts here there's gonna be some sort of passive movement that I can get her to.
She might be tight like she was a little tight but she's probably not gonna be stuck here. So, all right. So, that was just an overview.
Yes. Yes. Correct. And they're supposed to do it three times.
Yes. Yes. Yes.
So, you're saying for the practical, like, which one of us is doing it? Once is fine. Can you practice doing it, like, the three times, and you just move this on, or you won't move? You don't?
Mm-hmm. We don't typically move you guys on because we're the patients, so we wouldn't know to move you on because we're clueless patients. I don't mean that in a bad way, but we typically don't move you on.
That's why I'm saying for the practical it's okay for you guys not to do the three trials. You guys are managing your own time during the practical because we're the patients. I would even say, I might be going out on a limb here, but clinically if I were to use this test, I probably wouldn't have time to do three trials unless I was doing a research study. Then I would follow that protocol.
Clinically, I probably would only do it once, maybe twice to make sure that I know what I'm seeing. But from a research perspective, you'd have to do it three. Three sets or three reps?
Three reps. So you're doing one, two, three, and then passive range of motion on this side, and then one, two, three, back. Well, you can do three if you want, but that's going to take a long time. Okay, so that was the overview. Now let's go through kind of item by item. The items are scored mostly on a three-point Likert scale 0, 1, or 2. A couple of them are only dichotomous.
Each number or each Likert scale number has its own criteria and some of them are very different. So you need to be able, you know, kind of be familiar with that and understand that. The first activity or the first item, number one, is reflex activity.
All you're doing here is straight DTRs. Okay, I don't have it. Boop. And boop.
Okay. And seeing what kind of activity that you have. This is one of the dichotomous items. You're looking at no reflex activity or reflex activity.
Okay, you're not looking at quality. Later we're going to look at quality if the person qualifies for us to look at quality. All we're looking for is that do they have a reflex or do they not.
Someone who's in a very flaccid stage may not have a reflex at all. Someone who's progressing through the stage. and has more synergistic activation, may have hyperactive reflexes. You don't care about that right now.
You only care did you elicit a reflex. The next two items. The next two items are looking at movement within synergy. The first movement you're going to look at is flexor synergy.
The starting position for this is the opposite, this is her affected side, the opposite side. She's going to start with her hand on her knee and she's going to move into this position. So I checked the passive range and now I'm going to watch her complete the movement.
So you're going to go ahead. Now she's going to do that for us a couple of times and we're going to look at the scoring for this. If you look at your scoring sheet, you'll see that the...
My spot, I'm sorry. I should have stapled. Here we go.
Okay, so the flexor synergy, number two on the scoring sheet, shows you each movement that we're going to score. We're going to score each of those movements on this zero, one, and two scale. So the zeros cannot be performed, one is performed partly, and two is performed faultlessly. Okay?
Zero means cannot perform. Can't move from here at all. Faultlessly is this.
So anywhere in between that is going to be a one. Okay? But you are not looking at everything together. You're looking at each separate movement or area that joint here.
So can you just keep doing that a few times? So you're looking at elevation. This is of the shoulder.
Do we have elevation people? Do we have elevation people? Of the shoulder. I think that's right. Yeah.
Okay. We got some substitution. But we don't have elevation of the shoulder, right? So that would be a zero. How about shoulder retraction?
Now for this you have to kind of be looking back. I'm not sure that it's faultless, but we've got it. So we might just, I would.
Put that a one, yep. How about abduction? Zero, yep, I don't see any abduction there. Now, this is where your observational analysis comes in handy because you guys think you see elevation, but you're not seeing elevation of the arm, right?
You're seeing actual... So what would be... You mean shoulder flexion?
Yes. You're lifting the arm up. I'm not getting this. I'm not getting the lift. Because you don't...this is not normal movement.
We're looking at normal motor recovery, normal movement. I think there's a shoulder elevation, like shoulder shrug. No, that's not what you're looking for. No, you're looking for like, am I flexing my shoulder? Yeah.
Am I getting shoulder flexed? Because remember guys, that she's coming from here, and what did she do? She did this. So there really isn't any elevation there, right?
And if you saw a little bit, you could score a one. That's fine. From this angle, I see nothing. Yes. So we could say, we could talk about elevation as being up, but abduction is this, because she's supposed to be like at 90 degrees of abduction.
This is my position. It's faultless. So if I'm doing this.
So if you guys think that you see a little elevation you can score a one. Okay and again this is the scale is what it is. You're using your observational skills.
That make sense? Okay external rotation. Keep yourself in the head.
Keep yourself in the head. You see any external rotation? No.
Okay, elbow flexion. What do you score it? Two. Two. So remember when I moved her into passive...
She's a one, okay? So remember, faultless is completely normal movement, the same as the other side. Show me the other side again.
You're actually supposed to be back here. Oh, my bad. It's not quite a salute.
Is the salute off to the side over here? Yeah. It's supposed to look like the other side.
That would be her faultless. Faultless is, well, this is hoping that the person doesn't have bilateral effects, but faultless should be the other side, should be the unaffected side. Okay.
I don't want to throw that in there on you, but there are bilateral effects of stroke, but we won't go there. All right, and then forearm supination. She doesn't have much, right? And again, if you guys are unsure, you can watch her other side again.
You can move her passively to see how much range that she has. Okay, that's okay. Even in the practical, I would rather see you guys do that than make a guess.
All right, go ahead and... If you have to watch it more than once, go for it. Okay, it's fine. Because once, sometimes you can't get it.
Okay, so what you're doing then, if you look at the score sheet, this is out of 12 because you have six movements, right? So the top score you can get for that item would be 12. So you're scoring each one of them individually and then adding that score together. Everybody good? Okay.
So the next one is extension synergy. And remember, you guys can see what that's, I mean, that is the flexion synergy that we've taught you guys, right? Basically, that's the synergy that we see people hanging out like this at, okay? When they're not necessarily stuck. when you see movement that's the movement that sometimes persists so that's what you're looking for.
The next one is you're looking at hand kind of to the side and you're asking the person then to reach out toward their opposite knee. So the starting position for flexor synergy is the ending position for this one. Okay so hand here and they're supposed to be going here.
So for this one you're looking at, can you go ahead and do that a couple times? You're looking at shoulder adduction and internal rotation, elbow extension, and forearm pronation. Okay, so let's watch her do it.
So does she have shoulder adduction and internal rotation? Can we see the other side? Yeah, see the other side.
So is that faultless? Is she moving faultlessly on this side compared to the other side? No, she's just compensating.
But does she move some? Yeah. She got some movement there, so I give her a one.
How about elbow extension? She's going from flexion to extension, it's just not full extension like we saw on the other side. So yeah, give her a one. She's like... You and the Fugl-Meyer dance.
Okay, and then forearm pronation. Show us the other side. Okay, yeah.
Don't freak out if you're one level off. If you call it faultless and I call it... whatever the other one is... partly, okay, that's okay. But if you say did not perform and I say faultless, that's a bigger deal.