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Chapter 4
CHAPTER CONTENTS
Muscle strength 68 Generation of power 76
Contribution of contractile speed 76
Co-contraction of antagonists 70
Power output 78
During isometric contractions 70
During dynamic contractions 71 Relationship between muscle performance
and function 80
Abnormal tone 72
Strength training 80
Non-neural components of increased
tone 74 Conclusion 81
Voluntary activation 74
MUSCLE STRENGTH
Muscle strength has only been seriously considered in stroke reha-
bilitation in relatively recent years. Initial concerns that measure-
ments would be unreliable (e.g. Rothstein et al 1989) and
Muscle Strength 69
40
30
20
10
0
0 1 2 3 4 5 6
Time after stroke (months)
70 Muscle Performance after Stroke
CO-CONTRACTION OF ANTAGONISTS
During isometric There is some controversy in the literature about the presence and
contractions extent of excessive co-contraction of antagonist muscles. During
isometric contractions we have not found evidence for this
(Davies et al 1996, Newham and Hsiao 1998, 2001) in agreement
with Svantesson et al (2000) and Gowland et al (1992). However,
its presence has been reported by Chae et al (2002a). It may be that
there are differences in specific stroke populations in this respect,
and the extent of co-contraction does vary between limbs and
muscle groups (Figure 4.2) (Newham and Hsiao 2001), speed of
required contractions (Basmajian and De Luca 1985) and familiari-
ty with the task (De Luca and Mambrito 1987). There is evidence
that upper limb muscles are more affected by excessive co-contrac-
tion of agonists and antagonists after stroke (Kamper and Rymer
2001).
We have found that the extent of co-contraction during maximal
isometric knee extension and flexion is similar in both legs of stroke
subjects compared with control subjects (Figure 4.2) (Davies et al
1996, Newham and Hsiao 2001). Furthermore, the extent of co-con-
traction remained similar in the stroke subjects over a period of
many months during which both strength and function improved.
Co-contraction of Antagonists 71
0.1
Extension Flexion
ABNORMAL TONE
The abnormal tone frequently associated with stroke has long
been one of the main focuses of rehabilitation, and for many years
the restoration of ‘normal’ tone was one of the key aims of treat-
ment. Tone may be low immediately after the brain lesion, but in
the rehabilitation phase the problem is usually one of increased
tone. The prevalence of increased tone has recently been estimated
as affecting 38% of people 1 year after stroke, even though several
joints were assessed (Watkins et al 2002). This is lower than previ-
ous estimates and fits with the clinical impression that abnormal
tone is considered to be less of a problem than it used to be. The
reason for this is unknown and could be the result of medical man-
agement, rehabilitation, or a combination of both.
The phenomenon of increased muscle tone after upper motor
neuron lesions is regarded as ‘hypertonia’, and this term is often
used interchangeably with spasticity. The most widely accepted
definition of spasticity is ‘a motor disorder characterized by a veloc-
ity dependent increase in tonic stretch reflexes (“muscle tone” with
exaggerated tendon jerks, resulting from hyper-excitability of the
stretch reflex as one component of the upper motor neurone syn-
drome’; Lance 1980). However, the increased resistance to passive
movement (hypertonia) is affected not only by the stretch reflex and
may contain both neural and non-neural components.
Abnormal Tone 73
20.00
and paretic (pale blue) limbs
of the stroke patients showed
increased resistance compared 15.00
with the control subjects (dark
blue) (P < 0.01). Mean and
SEM. (Data from Davies et al 10.00
1996.)
5.00
0.00
74 Muscle Performance after Stroke
VOLUNTARY ACTIVATION
Another possible explanation for decreased voluntary force gener-
ation could be that of incomplete voluntary activation. This has
been studied during isometric contractions, mainly using the
twitch superimposition technique (Belanger and McComas 1981,
Hurley et al 1994, Newham and Hsiao 1998, 2001, Rutherford et al
1986), in a number of musculoskeletal conditions where it has
been found to be a common finding.
There is evidence that voluntary activation failure is present
after stroke. Whilst it is perfectly possible that neurological dis-
ease, particularly brain lesions, may impair the ability for maximal
voluntary activation, this has rarely been directly investigated.
Some indirect evidence has resulted from EMG studies (Gowland
et al 1992, Sahrmann and Norton 1977, Tang and Rymer 1981). It
has also been shown that the number of functioning motor units is
reduced after stroke (McComas et al 1973) and also that the motor
unit firing frequency is reduced (Rosenfalck and Andreassen 1980,
Voluntary Activation 75
Tang and Rymer 1981). The twitch speed is also reduced (Newham
et al 1996). These factors could all affect voluntary activation.
We have studied voluntary activation failure in the quadriceps
during isometric contractions throughout the first 6 months after
stroke (Hsiao 1998, Newham and Hsiao 2001). Significant volun-
tary activation failure, compared with matched control subjects,
was found bilaterally. Furthermore, it was greater in the paretic
muscle group and remained unchanged over 6 months (Figure
4.5). Similar findings have been reported in the paretic upper limb
by Kamper and Rymer (2001) and also Riley and Bilodeau (2002),
who found that the extent of activation failure increased during
prolonged activity.
The presence of voluntary activation failure supports the theory
that the neurological insult has direct effects on skeletal muscle. It
could be due to a failure of motor unit recruitment or reduced fir-
ing rates in the active units. Furthermore, it is striking that the acti-
vation failure in our study was bilateral. While many studies do
not investigate the so-called ‘unaffected’ limbs, there is a growing
body of evidence that the consequences of a unilateral cerebrovas-
cular accident are manifested bilaterally (Bohannon and Walsh
1992, Chollett et al 1991, Colebatch and Gandevia 1989, Davies
et al 1996, Harris et al 1997).
Voluntary activation failure might also be expected to coexist
with excessive activity of antagonist muscles, but this was not the
case in our study (Figure 4.2). The failure might also be caused by
an interruption of the corticospinal pathways after stroke. If this
was the case, then recovery of activation failure would imply that
either a reorganization of the central nervous system or collateral
10
0
3 6
Time after stroke (months)
76 Muscle Performance after Stroke
GENERATION OF POWER
There have been numerous investigations of muscle strength – iso-
metric and dynamic – after stroke, and the clear consensus is that a
level of weakness exists that would be expected to adversely affect
normal function. Although these studies are valuable, it is impor-
tant to bear in mind that our main requirement of muscles is to
generate power. Because power is the product of force and veloci-
ty, the speed at which force can be generated is of crucial impor-
tance. There is no functional benefit in having large muscles,
capable of generating high forces, if movement can only be per-
formed at velocities below those required for safe function.
Therefore, speed and its determinants will now be considered,
along with the literature on the generation of power after stroke.
50.00
Power output The work on isometric strength generation is valuable and inform-
ative. Nevertheless it is important to remember that the main func-
tional requirement of skeletal muscle is to generate power and
movement. Since power is the product of force and velocity, the
isometric studies showing that both of these are reduced after
stroke clearly indicate that power is also reduced. However, the
reduction in power will be greater than the reduction in either
force or velocity alone. Direct studies of power output (the rate of
doing work) after stroke are rare.
We studied the power output of the knee flexors and extensors
at a range of angular velocities up to 300˚/s in the first 6 months
after stroke (Hsiao and Newham 2001). Most of the stroke subjects
Generation of Power 79
STRENGTH TRAINING
Once the presence and importance of muscle weakness is accept-
ed, then the obvious question is what can be done to improve it.
There is no reason to think that the muscles of people affected by
stroke are incapable of hypertrophy, and repeated high-intensity
effort may well improve the failure of voluntary activation since
there are known to be both neural and peripheral responses to
strength training.
The traditional belief is that high-intensity muscle contractions
should be avoided because they may initiate or exacerbate abnor-
mal increases in muscle tone. However, the evidence does not sup-
port this belief. The review by Ng and Shepherd (2000) cited
numerous studies that found that both muscle strength and func-
tion were improved by strength training without increasing
abnormal muscle activation.
Conclusion 81
Table 4.1 Characteristics of the quadriceps stretch reflex before and after an exercise session
consisting of repeated maximal isometric and isokinetic voluntary contractions at angular velocities
of 30–300°/s. There was no indication of increased excitability after exercise.
Non-paretic Paretic
Before After Before After
Amplitude (mV) 0.18 ± 0.03 0.18 ± 0.03 0.13 ± 0.03 0.11 ± 0.02
Onset latency (ms) 19.25 ± 0.67 20.85 ± 1.09 20.05 ± 0.69 19.47 ± 0.78
Peak latency (ms) 24.10 ± 0.64 25.55 ± 0.93 25.68 ± 0.97 25.29 ± 1.09
CONCLUSION
The work described in this chapter highlights both the novelty and
importance of the work of Carr and Shepherd in stroke rehabilita-
tion. They were innovators with an interest in the role of muscle
strength in the function of people who have had a stroke. It has
since been clearly shown by them and others that muscles are
weak after stroke and that muscle weakness is related to function.
They do not get stronger during traditional rehabilitation or spon-
taneously with increased activity. However, high-intensity con-
tractions, once viewed as something to be avoided at all costs, do
not generally increase muscle tone and improve both strength
and function. The interest of Carr and Shepherd in muscle and
stroke initiated studies that revealed voluntary activation failure,
82 Muscle Performance after Stroke
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