Reminder of important clinical lesson

CASE REPORT

Improvement in arm and hand function after
a stroke with task-oriented training
Sharon Israely,1 Gerry Leisman,1,2,3 Eli Carmeli1
1

Department of Physical
Therapy, University of Haifa,
Haifa, Israel
2
Department of Neuroscience,
The National Institute for Brain
and Rehabilitation Sciences,
Nazareth, Israel
3
Department of Clinical
Neurophysiology, Universidad
de Ciencias Medicas de La
Habana, La Habana, Cuba
Correspondence to
Professor Gerry Leisman,
g.leisman@alumni.manchester.
ac.uk
Accepted 4 March 2017

SUMMARY
A man aged 77 years sustained a left-hemisphere stroke
with right hemiparesis. After spending 10 days in the
hospital, he was referred to an area rehabilitation centre.
There he carried out daily physical, occupational and
speech therapy, with an emphasis on task-oriented
treatment. The patient’s upper-extremity motor
performance was evaluated at admission to the
rehabilitation centre and before leaving the hospital by 3
different measurement tools: the upper-extremity motor
part of the Fugl-Meyer assessment scale,
electromyography in hand-reach and grasp and object
manipulation and handwriting tasks. Significant
improvement in hand function was observed in proximal
as well as in distal skills. Significant improvement in
handwriting skills and decreased impairment level of the
upper extremity had considerable effects on the quality
of life of the patient. The case report emphasises the
importance of intensive task-oriented training during the
first 3 months after stroke to support the natural
recovery of the lesioned area.

BACKGROUND

To cite: Israely S,
Leisman G, Carmeli E. BMJ
Case Rep Published online:
[please include Day Month
Year] doi:10.1136/bcr-2017219250

A stroke is one of the leading causes of long-term
disability, as many people lose their functional capacity and independence.1 Previous reports suggested that up to 30% of patients are permanently
disabled with 20% requiring institutional care
3 months poststroke.2 Disability after a stroke has
significant implications on the self-esteem and
family relations of patients. From an economic
standpoint, a stroke costs $US13 000 on average in
the first 30 days of an acute event.1
Independence in activity of daily living is closely
related to proficiency in dexterity skills, which
refers to the ability to grasp and manipulate
objects, by accurate and coordinated hand and
finger movements.3 Although strongly correlated,
hand and finger control is often more impaired and
harder to rehabilitate than proximal upper extremity control after a stroke.4 5 It was suggested that
the ipsilateral cortico-spinal and reticulospinal
tracts are better able to compensate for the motor
deficits of the proximal rather than the distal
muscles of the limb.4 This case report demonstrates
a successful functional recovery of proximal and
distal motor skills of the upper extremity after
stroke.
The nature of the functional recovery demonstrates the importance of adhering to motor learning principles to support the intrinsic neurological
recovery, including intensive training,6–8 using taskspecific9 and challenging exercises10 within

variability of practice.11 A task-oriented treatment
(TOT) using these principles was previously
reported to be superior to traditional neurodevelopmental approaches12 and to standard physical or
occupational therapy delivered with the same intensity and duration.13 Thielman et al14 reported a
better reaching trajectory and improved reachingperformance with TOT compared with resistive
exercise training. Other studies, on the other hand,
reported non-significant differences in outcomes
between TOT and standard occupational therapy,15
or minor superiority over standard care or placebo.

CASE PRESENTATION
Clinical history
The patient was a right-handed dominant man (age
77) with high school education. When he was in
his 20s, he worked in agriculture for about
10 years. Since his early 30s, he worked as a
factory worker. Later on, when he was about
40 years, he worked as a car mechanic. Since the
age of 70, as his conditioning deteriorated, he performed mostly administrative functions of the
garage. He suffered from high blood pressure since
the age of 27, having received treatment since the
age of 40. Additionally, he received antianxiety and
depression-lowering medications for many years.
About 10 years ago, he claimed to have had
major difficulty walking up a mountain which, in
retrospect, the wife associated with heart disease.
On the day of the stroke, he reported for work as
usual. After a rest, he awoke at 18:30, when he
fell. On admission to the hospital, he reportedly
suffered from weakness on the right side of his
body and face and impaired speech. A CT scan
revealed no evidence of brain damage. After spending a few hours in the emergency room, his motor
function seemed to improve. He was able to walk
without aid and spoke relatively normally. He
returned home with no additional treatment or
directions.
The next morning, he was admitted to hospital
once again, due to weakness on the right side of his
body, with major difficulty in standing and walking.
He also sustained weakness in his right upper
extremity. He was unable to dress independently,
care for his own needs and feed himself.
Additionally, his mouth was partially paralysed,
which made it difficult for him to speak. He stayed
for about 12 hours in the emergency room before
he was transferred to the neurology department.
He was hospitalised for 10 days before transfer to a
geriatric rehabilitation centre. A recurrent CT scan
revealed a lacunar infarction at the left basal

Israely S, et al. BMJ Case Rep 2017. doi:10.1136/bcr-2017-219250

1

Reminder of important clinical lesson
ganglia. The hospital provided little physiotherapy or rehabilitation services and rehabilitation services started after the patient’s
transfer to the geriatric facility. At discharge from the hospital,
he could barely stand even with substantial assistance. Partial
active shoulder and elbow movements existed, but the movement were not functional. Distal movements of the wrist and
fingers were scarce and also not functional.
At the geriatric rehabilitation centre, he received daily physical, occupational and speech therapy, with an emphasis on
task-oriented training.16 Emergence of voluntary movements
was gradual, in the proximal and distal segments of the upper
extremity. During the first week of hospitalisation, the patient
was assisted in implementing the therapeutic exercises. Distal
control over the wrist and fingers was severely impaired. A significant change in proximal and distal upper extremity functionality was observed in the third and fourth weeks after the
stroke. The patient was able to carry out more challenging tasks
in variable conditions.
In addition to the accepted rehabilitation protocol, the
patient’s upper extremity motor function was evaluated, at the
level of impairment as well as at the disability level. The motor
function assessments were performed twice, once on admission
(T1) and again on discharge (T2). Included in the assessments
were three measurement tools: the upper-extremity motor part
of the Fugl-Meyer (FM) assessment scale, electromyography
(EMG) in hand reach, grasp and object manipulation, and handwriting tasks.

Medications
Hypertension (ACE inhibitor, diuretics) CILAZAPRIL—
HYDROCHLORTHIAZIDE CD
Hypertension (calcium inhibitor)—amlodipine
Hypertension (constipation)—normalex/polyethylene glycol
Hypertension (selective β2-adrenoreceptor blocking agent)—
lopressor/metoprolol tartrate USP
Lipid-lowering drug (HMG-CoA reductase inhibitor)—statins
Blood thinner (anticoagulant)—warfarin/apixaban (In Rambam
hospital, instead of Qumadin)

Prostate (dihydrotestosterone (DHT) inhibitor)—dutasteride
Antipanic (benzodiazepine)—clonazepam
Antidepressant/antianxiety (SSRI)—cipralex/escitalopram

INVESTIGATIONS
The upper extremity motor section of the FM scale
The level of impairment based on Brunnstrom’s stages of recovery after a stroke,17 including assessment of reflexes, arm movements in and out of synergy, the ability to isolate movement to
the shoulder, elbow and wrist and to grasp various objects.18
The scale is rated between 0 (substantial impairment) and 66
points (normal function).

Handwriting performance
Handwriting performance was evaluated by using a
Computerized Penmanship Evaluation Tool (ComPET) measuring spatial, temporal and pressure measures of handwriting.19
The patient was seated in front of a standard table with his
affected arm on the table for writing purposes. A bench was
placed underneath his feet if necessary. Five handwriting tasks
were evaluated, including writing full name, signature, ID
number, short sentence and connecting numbered dots. Each
handwriting task was carried out once, except in cases where
the pen was dropped as a result of a loose grip. Each handwriting task was evaluated by three measures: writing velocity per
writing stroke (cm/s), pen pressure (1024 non-scaled units
scale), off-paper (the time the pen was not in contact with the
writing surface) time per writing stroke (s). Handwriting measures were calculated separately for each handwriting task. For
the purpose of this case report, handwriting measures were averaged across the five handwriting tasks. Figure 1 illustrates an
example of handwriting tasks performed by a healthy participant and by a patient who sustained a stroke.

Surface EMG
The patient’s skin was shaved and cleaned before electrode
placement. Four wireless electrodes were placed on the upper
trapezius, anterior deltoid, biceps and triceps muscles. A 5 cm

Figure 1 llustration of handwriting
output in Hebrew from: (A) a healthy
participant, (B) a pretreatment patient
after a stroke and (C) from the same
patient at post-treatment follow-up
testing. The ComPET system enables
the evaluation of kinematic measures
as well as the pen pressure on the
writing surface. The hardware device
captures the motion of the pen 6 mm
above the writing surface. The motion
of the pen off-surface is illustrated by
bright grey lines between the letters.
Clear differences in the off-surface
motion of the pen exist between
healthy handwriting and the
handwriting of the patient.

2

Israely S, et al. BMJ Case Rep 2017. doi:10.1136/bcr-2017-219250

Reminder of important clinical lesson
cube was placed in front of the tested shoulder, at the wrist location of the maximal hand-reaching distance. A voice prompt was
programmed to be activated every 20 s for five consecutive
tasks. The patient was instructed to carry out the task when
hearing the voice prompt of the EMG machine. The task consisted of reaching, grasping the cube and passing it 20 cm to the
side, at equal distance from the body. EMG data of the shoulder
and arm muscles were used to evaluate the synergistic activation
of the proximal muscles of the shoulder and arm during execution of hand-reaching, grasping and object manipulation. EMG
measures were averaged across five repetitions of the task. The
muscle activity was measured using three indices:
1. Muscle onset: Muscle activity latency from voice prompt:
this is indicated by an abrupt increase in muscle activity
from the voice prompt. The time gap was measured to indicate the reaction time from the voice prompt until the initial
muscle contraction.
2. Per cent maximum isometric contraction: The intensity of
muscle activation normalised according to the maximal isometric contraction (MVC). This measure implies the relative
exertion of each muscle during the execution of the task
relative to the MVC.
3. Coactivation index (CI): the CI was measured to assess the
coactivation ratio between each muscle compared with the
deltoid muscle, based on previous studies.20 The deltoid
muscle was set to be the reference muscle, so each of the
other three muscle activations was referred to the deltoid
muscle. Each pair of muscle-%MVCs were overlaid and

plotted. The maximum function of these two muscles
expresses the higher amplitude between the two muscles for
each data point. The minimum function of these two
muscles expresses the lower amplitude between the two
muscles for each data point. The CI was calculated by dividing the minimum function by the maximum function.
Therefore, the CI values were normalised to be between 0
and 1. Figure 2 illustrates the method for calculating the CI.
For each pair of muscles, the minimum and the maximum
functions CI values were evaluated.

TREATMENT
Task-oriented training
The treatment protocol at the rehabilitation centre consisted of
daily 1-hour physical therapy and daily 1-hour occupational
therapy sessions for 3 weeks and a daily 1-hour session of
speech therapy three times per week, also for 3 weeks. Although
physical and occupational therapy dealt with the practice of
daily activities, occupational therapy focused on upper extremity
functions, such as feeding, dressing and using objects by hand,
while physical therapy focused on locomotion, walking, stair
climbing, balancing and transfers. Treatment sessions were constructed based on fundamental principles of motor learning, for
example, intensive,10 task-specific,9 challenging10 and variable
training.11 21 Task-specific, challenging training tasks that are
context-dependent were reported to enhance motor performance9 by increasing participation and engagement in practice

Figure 2 Illustration of the processed, normalised electromyography (EMG) waveform of the anterior deltoid and upper trapezius. The values are
scaled on the basis of 80% of the maximum isometric voluntary contraction (MVC) (A). The minimum function (- - -) and the maximum function
(____) were processed from the original EMG data of each pair of muscles. The co-activation index was calculated by dividing the minimum
function by the maximum function (B).
Israely S, et al. BMJ Case Rep 2017. doi:10.1136/bcr-2017-219250

3

Reminder of important clinical lesson
through motivational salience.22 Training tasks were chosen by
sharing treatment goals with the patient and his relatives, considering the degree of disability in a specific daily task, to
enhance engagement and motivation through the sessions.
Each exercise in the treatment session was chosen to target a
specific functional skill, and consisted of several subtasks, such
as reaching, grasping and manipulating an object. This could be
applied to brushing teeth, using a fork and knife, dressing,
drinking a glass of water, flipping a page in a book, etc.
Practising hand-reaching, grasping and object manipulation, for
example, could be carried out either sitting or standing.
Changing the size, weight, texture and hardness of the objects
induced changes in the type of grip. Using a small tin induced a
cylinder grip, while flipping a paper induced a pinching grip, a
grip that was also used to hook clips onto a rope. Threading
a ring onto sticks in different locations in space in a standing
position required balancing, improved the shoulder range of
motion, spatial orientation and decision-making. Other examples of exercises included grasping little objects such as beans
and coins, collecting beans with a teaspoon, rotating a screw,
inserting pegs into a peg-board and cutting clay with a knife.
Exercises were practised in sets of about 2 min. The number of
repetitions per set was varied depending on the complexity
and the difficulty of the task. Two-minute practice of a representative reaching, grasping and object manipulation task
would yield 8–15 repetitions. Each set of exercises was
repeated 4–5 times (ie, one block), with varying the features
of the tasks as detailed.14 23 Variability of practice was previously reported to enhance retention and transfer of the training task.9 11 Thus, a representative treatment session of 1 hour
of occupational therapy consisted of about 200 practised
repetitions.
The duration and frequency of treatment sessions were determined according to the practical constraints of the therapist and
facility. Examples of protocols from previous studies consisted
of five 1-hour treatment sessions per week, for 4 weeks,9 six
1-hour treatment sessions per weeks for 3 weeks,24 five halfhour sessions per week for 6 weeks25 or an increased dose of
more than a total of 30 treatment hours during the first month
poststroke.6 Constraint-induced movement therapy was suggested to be implemented, providing 3–6 daily hours/5 days a
week/2 weeks.26 Krakauer et al8 suggested that a limited
number of repetitions per treatment session in human patients
may limit motor recovery, compared with animal studies that
used twice as many repetitions per treatment session. Direct
handwriting training was not a principal concern during the
occupational therapy training sessions.
The patient was encouraged to execute as many successful
repetitions as possible. Although the emphasis was on achieving
the goals of the tasks, the therapist constructed each exercise in
order to minimise the use of compensation strategies. For
example, shoulder abduction during hand-reaching tasks could
be minimised by one or more techniques, such as: limiting the
demand of the task by decreasing the shoulder flexion during
the execution of the task during standing, while the object is on
a table or low shelf. When necessary, the patient was instructed
to practise while standing with the paretic shoulder near a wall,
or by letting the patient hold a narrow pillow under his armpits.
Additionally, the therapist provided knowledge of results feedback with external focus,27 by asking the patient to follow a
straight trajectory line guided by adhesive tape on the table.
Feedback that focused on external factors were previously
reported to enhance motor performance in other contexts and
also in the automation of skills.27 28
4

At the beginning of the rehabilitation process, the patient
experienced difficulties in grasping small objects that required
opposition of the thumb against other fingers. This was also
observed in the hand section of the FM assessment score as well
as in the handwriting assessment. The proximal segments of the
upper extremity, on the other hand, appeared to be less affected.
The impairment in distal function was also observed in tasks
such as feeding, dressing and writing. Feeding training consisted
of having the patient cut modelling clay with a knife and fork.
Weakening of the wrist joint was also observed, especially close
to the patient’s admission to the hospital. Extension of the
fingers was partial, making it difficult for the patient to open
the hand before grasping objects. Flaccid paralysis, which is
common phenomenon at the early recovery stages after a stroke,
was apparent as opposed to hypertonicity of the finger flexors
that is more common in the later stages after a stroke when
spasticity appears. This assumption was also verified by examination of spasticity, which was applied by the modified Ashworth
scale.29 Thus, when necessary, wrist stabilisation was applied by
taping or by reaching the objects at a natural supinated/pronated
position that minimises the gravity forces. Specific exercises
were applied to train tasks necessary to manage in the kitchen,
such as taking groceries in and out of the refrigerator, opening a
tap, filling a glass of water, opening a jar of coffee or taking a
jar from a shelf.

RESULTS
The upper extremity motor section of the FM scale
The total score for this measure was significantly improved from
40/66 at T1 to 58/66 points at T2. This improvement indicated
an improvement in function that was manifested in better proximal as well as distal function. The proximal subscore improved
from 27/42 points at T1 to 39/42 points at T2. The distal subscore improved from 13/24 points at T1 to 19/24 points at T2.
The score increased from only 6 to 12 points when analysing
just the 14 points of the hand section of the FM score.

Handwriting
At the initial assessment, the patient was not able to complete
the task of writing a short sentence. Therefore, results refer to
the mean values of each measure from the tasks that were
carried out. The average handwriting velocity increased from
1.972 at T1 to 4.37 cm/s at T2, the average pen pressure
increased from 104.253 to 196.266 non-scaled units and the
average off-paper time decreased from 1.936 to 0.69 s.

Surface EMG
The results of the EMG tests are summarised in table 1. We
arbitrarily decided to mark the 30% change in measures as a significant difference between T1 and T2. The muscle onset of all
the muscles was increased from T1 to T2. The intensity of
muscle activation, that is, %MVC, decreased significantly from
T1 to T2 in the trapezius (2.241 to 0.786), biceps (0.687 to
0.544) and the deltoid (0.356 to 0.247), but increased in the
triceps (1.7866 to 2.06). The CI between the deltoid and
triceps decreased from 0.218 at T1 to 0.149 at T2, but
increased from 0.175 at T1 to 0.358 at T2 between the deltoid
and trapezius muscles.

DISCUSSION
The first month after a stroke is a critical time period where
major plastic changes within the brain occur that promote the
motor recovery potential.8 Indeed, the patient’s motor performance was significantly improved in the first month after the
Israely S, et al. BMJ Case Rep 2017. doi:10.1136/bcr-2017-219250

Reminder of important clinical lesson
Table 1 Differences of EMG measures between T1 and T2
Onset (s)

Upper trapezius
Anterior deltoid
Biceps
Triceps

%MIVC

Coactivation ratio

T1

T2

% change

T1

T2

% change

T1

T2

% change

0.805
0.868
0.951
0.873

1.059
1.135
1.206
1.145

131.522
130.740
126.840
131.232

2.242
0.356
0.687
1.787

0.786
0.247
0.544
2.060

35.061
69.382
79.185
115.303

0.175

0.358

204.5714

0.536
0.218

0.473
0.149

88.26274
68.22344

The coactivation ratio was calculated between the anterior deltoid muscle and each of the other muscles; therefore, there is no score for this muscle in this domain. Bright grey
indicates significant decrease in scores (higher than 30%) between T1 and T2. Dark grey indicates a significant increase in scores (higher than 30%) between T1 and T2.

stroke as indicated by the FM score and the handwriting performance. Significant improvement in FM scores reached the
minimal clinically important difference value of 10 points.30
The patient’s FM score increased by 18 points, which was
almost equally divided between the distal and the proximal
subscores.
The changes in the EMG measures were ambiguous in
terms of whether the overall muscle pattern changes indicated
more efficient movement control or more abnormal muscle
patterns, indicating increased compensation usage. The %
MVC was significantly decreased in the trapezius and deltoid
muscles, indicating that less effort was necessary to execute the
task. These changes might be attributed to more efficient
control due to enhanced neurological drive to the agonist
muscle.31 32 Thus, less effort is needed to accomplish the same
task.
The CI, on the other hand, demonstrated inconsistent results
between different pairs of muscles, demonstrating that improvements in task performance probably resulted from two different
but simultaneous mechanisms: motor learning and compensation.33 The CI between the anterior deltoid and the upper trapezius was increased, in contrast to decreased CI between the
anterior deltoid and the triceps. The CI of the EMG represents
the extent to which two muscles are activated together during
the whole sequence of the task with respect to the activation of
each of the muscles separately. Increased coactivation between
the upper trapezius and the anterior deltoid may indicate an
abnormal synergistic activation of the trapezius to facilitate the
shoulder flexion necessary for reaching, implying an increased
usage of compensations. Overusing the trapezius muscle was
previously mentioned as an indication of using compensation
strategies for execution of demanding tasks,34 especially when
compensating for weakness of the deltoid muscle.
Decreased coactivation between the anterior deltoid and the
triceps may have two possible interpretations. First: one muscle
is dominantly activated compared with the other muscle; or
second: the two muscles activate with about the same amplitude
but at different timing, for example: if muscle 1 is activated at
the beginning of the task and muscle 2 at the end of the task.
Shoulder–elbow coordination in hand reaching requires simultaneous shoulder flexion and elbow extension, which has been
shown to be impaired after a stroke.35 36 Therefore, it was
anticipated that we would observe an increase in coactivation
between these two muscles with a simultaneous enhanced task
performance. Table 1 indicates that the %MVC of the triceps
was significantly larger than the %MVC of the deltoid at T1,
and that the gap between the muscles %MVC’s got larger at
T2. Therefore, the end result was that the CI between these
muscles was decreased. The %MVC measure refers to the
EMG amplitude normalised according to the maximal
Israely S, et al. BMJ Case Rep 2017. doi:10.1136/bcr-2017-219250

isometric exertion, and not to the absolute force contribution
for task execution. We assume that this unexpected result
might be attributed to two reasons: (1) the method for calculating the CI was not suitable for interpreting the activation
ratios between muscles; (2) the studied task involved four
phases: reaching, grasping, manipulating and back from
reaching. Changes in activation timing of these muscles,
during these phases, could cause a decreased overlap between
the total %MVC’s area under the curves (refer the CI calculation (figure 2)).
Inconsistency between the %MVC and the CI measures for
certain muscles might be attributed to the analysis methodology.
The %MVC measure defines the degree of activation of each
muscle relative to itself during MVC. The CI, on the other
hand, refers to the degree of contraction of each muscle relative
to the contraction of the deltoid muscle, taking into account the
amplitude of each pair of muscles, as well as the activation
timing of these muscles. Other methods for calculating the CI,
such as dividing the area under the curves of the target muscle
by the reference muscle, would be easy to apply, but would not
reflect the time domain. In this study, the CI was calculated by
dividing the common %MVC area of two muscles by the total
%MVC area of these muscles together. Figure 2 demonstrates
how, theoretically, the CI can decrease even though the
common area of the pair of muscles can increase, due to the
larger ‘growth’ in non-common muscle activation between the
tested muscles.
The significant changes in kinematic and kinetic data that
were measured during the patient’s handwriting might be associated with restoration of lost dexterity skills and improved
executive function. Increased pen pressure during writing indicated enhanced ability to grip the pen while separately moving
the fingers during the writing process. Previous studies have
shown that finger movements carry out between-letter adjustments, while between-word movements are executed by the
wrist, shoulder and arm movements.37 Additionally, this
enhanced ability to use a tripod grip was also observed in the
hand-grasp section of the FM scale. The significant increased
writing velocity and significant decrease in off-paper time might
be attributed to better control of isolated finger movements as
well as in more proficient kinaesthetic information processing,
motor memory and visuospatial organisation (ie, executive function).38–40 Indeed, previous studies have revealed significant deficits in executive function in patients who sustained
haemorrhagic lesions at the putamen.41
The improvement in task performance that was described
above might be accomplished by two processes: motor learning
and by using movement compensation strategies.8 34 Motor
learning refers to restoration of normal movement patterns
reflecting a true recovery of structure and function lost due to a
5

Reminder of important clinical lesson
brain lesion.34 Compensation strategies refer to the usage of
alternative movement patterns to accomplish a task.34
Compensation strategies can be achieved by excess use of the
non-injured hand, or by executing the task by applying abnormal movement pattern of the injured hand. Therefore, it is
necessary to consider which of these two processes were dominant during the recovery of the patient performance. Each task in
the FM assessment score was evaluated by considering each
component of the movement, thus minimising the possibility of
using compensation strategies when performing the task.
Similarly, the EMG measures indicate the timing, amplitude and
relation between activation of muscles. Therefore, we assume
that compensation strategies during task execution can be captured in the EMG data analysis. The handwriting measures were
intended to assess the handwriting process and not its final
product, so that it could not be biased by compensation strategies. Increased pen pressure, for example, can only be
managed by enhanced grip-force, assuming that there is no
change in the type of grip. Other studies that evaluate the legibility of handwriting might be exposed usage of compensation
strategies that could not be identified during the analysis.
Considering the results of the three measurement tools, we
assume that the improvements in the outcome measures resulted
from motor learning and compensation.
Another issue of concern was the chronology of events and
the factors that could have positively contributed to or interfered with the recovery of the patient. The patient was admitted
to the hospital ∼1 hour after the stroke. This time period is
short enough to permit intervention that was previously
reported to decrease the degree of disability after a stroke.42 An
initial CT scan revealed no indication of cerebral infarction. The
patient stayed in the emergency room under supervision from
19:30 until 02:00, before discharge, apparently due to the possibility that he experienced a transient ischaemic attack. At discharge, he walked on his feet without assistance and his
speaking sounds normal.
After staying at night at home, the patient was transferred at
08:00 to another hospital, due to difficulties in bearing weight
on the right side of the body and deterioration in speaking.
Another CT scan reported a suspected ischaemic lacunar infarction of the BG. During the first 5–7 days of hospitalisation, the
patient was supervised with minimal physical intervention that
included getting out of bed, sitting and walking a few steps in
the room and moderate activation of the upper extremities. In
retrospect, the two consecutive motor deterioration events due
to CNS lesions raise the question of whether the clinical evaluation at the emergency room was sufficient. To the best of our
knowledge, the answer is yes. Indications for discharge from the
emergency room in cases of suspected stroke are beyond the
scope of this case report. However, other tests should perhaps
be considered in assisting clinicians with making better
decisions.
At T2, the patient demonstrated lower degrees of impairment,
which were also associated with better functioning and independence. Dexterity skills such as buttoning and inserting a key
into the lock were more difficult to execute. Handwriting was
recovered to a large extent. The patient returned to write with
his injured hand. However, he avoided writing more than short
sentences, signature and date. Rehabilitation of handwriting
using the paretic hand was previously suggested for patients
with an FM score of 45 points or above.5 This case report indicates that recovery of handwriting might be achieved even in
more impaired cases.
6

Learning points
▸ Behavioural testing is most likely a useful adjunct to
evaluation in the emergency room and might include
neuropsychological screening for anomia and other changes
in perceptual-motor and cognitive functions.
▸ Task-oriented training is necessary to challenge a patient’s
motor and executive capacities.
▸ Ambiguous results of the electromyography measures and
impairment reduction, as measured by the Fugl-Meyer
assessment scale, may suggest that motor learning and
compensatory mechanisms achieved enhanced motor
performance. Recovery of handwriting is feasible also in
patients with substantial distal motor impairment 2 weeks
after a stroke.
▸ Specific handwriting exercises should be considered to
enhance the patient’s handwriting skills.

Acknowledgements Professor Sara Rosenblum assisted in the preparation of the
manuscript.
Contributors SI evaluated the patient and decided on the treatment plan, as well
as recording electrophysiological data. GL and EC analysed the data and all three
authors equally contributed to writing the final paper.
Competing interests None declared.
Patient consent Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.

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