Is the proportional recovery rule applicable to the lower limb after a first-ever ischemic stroke?

Janne M. Veerbeek, Caroline Winters, Erwin E.H. van Wegen, Gert Kwakkel*

*Corresponding author for this work

    Research output: Contribution to JournalArticleAcademicpeer-review


    Objective To investigate (a) the applicability of the proportional recovery rule of spontaneous neurobiological recovery to motor function of the paretic lower extremity (LE); and (b) the presence of fitters and non-fitters of this prognostic rule poststroke. When present, the clinical threshold for fitting nor non-fitting would be determined, as well as within-subject generalizability to the paretic upper extremity (UE). Methods Prospective cohort study in which the Fugl-Meyer Assessment (FMA)-LE and FMA-UE were measured <72 hours and 6 months poststroke. Predicted maximum potential recovery was defined as [FMA-LEmax−FMA-LEinitial = 34 –FMA-LEinitial]. Hierarchical clustering in 202 first-ever ischemic stroke patients distinguished between fitting and not fitting the rule. Descriptive statistics determined whether fitters and non-fitters for LE were the same persons as for UE. Results 175 (87%) patients fitted the FMA-LE recovery rule. The observed average improvement of the fitters was ~64% of the predicted maximum potential recovery. In the non-fitter group, the maximum initial FMA-LE score was 13 points. Fifty-one out of 78 patients (~65%) who scored below the identified 14-point threshold at baseline fitted the FMA-LE rule. Non-fitters were more severely affected than fitters. All non-fitters of the FMA-LE rule did also not fit the proportional recovery rule for FMA-UE. Conclusions Proportional recovery seems to be consistent within subjects across LE and UE motor impairment at the hemiplegic side in first-ever ischemic hemispheric stroke subjects. Future studies should investigate prospectively distinguishing between fitters and not-fitters within the subgroup of patients who have initial low FMA-LE scores. Subsequently, patients could be stratified based on fitting or not fitting the recovery rule as this would impact rehabilitation management and trial design.

    Original languageEnglish
    Article numbere0189279
    JournalPLoS ONE
    Issue number1
    Publication statusPublished - 1 Jan 2018


    The present work was part of the EPOS research project funded by the “Wetenschappelijk College Fysiotherapie” (grant number 33368) of the Royal Dutch Society for Physical Therapy (KNGF), the Netherlands. This part of the EPOS project was co-financed by the Dutch National Institute of Health (ZonMw) (grant number 89000001) as a part of the EXPLICIT-stroke programme ( The authors thank all EPOS assessors in the stroke units of the participating university centers and local hospitals (AMC Amsterdam; Erasmus MC Rotterdam; LUMC Leiden; UMC Sint Radboud; UMC Utrecht; VUmc Amsterdam; Amphia Hospital Breda; Diaconessen Hospital Leiden; Franciscus Hospital Roosendaal) and in the affiliated nursing homes (ie, St. Jacob, Zonnehuis and Cordaan/ Berkenstede in Amsterdam, Laurens Antonius Binnenweg and Reumaverpleeghuis in Rotterdam, Albert van Koningsbruggen in Utrecht and Wiekendaal in Roosendaal) for performing the measurements. The authors also thank the patients who participated in the study.

    FundersFunder number
    Koninklijk Nederlands Genootschap voor Fysiotherapie


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