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PLoS One. 2018 Jan 12;13(1):e0189279. doi: 10.1371/journal.pone.0189279. eCollection 2018.

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

Veerbeek JM1,2,3,4,5, Winters C1,2,3, van Wegen EEH1,2,3, Kwakkel G1,2,3,6,7.

Author information

Department of Rehabilitation Medicine, VU University Medical Center, Amsterdam, The Netherlands.
Amsterdam Movement Sciences, Amsterdam, the Netherlands.
Amsterdam Neuroscience, Amsterdam, the Netherlands.
Division of Vascular Neurology and Neurorehabilitation, University of Zurich, Zurich, Switzerland.
Cereneo, Center for Neurology and Rehabilitation, Vitznau, Switzerland.
Rehabilitation Research Center, Reade, Amsterdam, the Netherlands.
Department of Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, Illinois, United States of America.



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).


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.


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.


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.

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