In order to clarify the specificity and to standardize the method for evaluating grade of the impairment, the motor function in hemiplegia following cerebrovascular accident was examined by means of the ADL (activities of daily living) test and the motor functional test.
Part 1 ADL test
Twenty items of ADL were tested, the score of 0-3 points being given to each activity. Forty-six patients were tested over 136 times, and the scores were analyzed in relation to motor function of each extremity and that of the trunk. The conclusions are as follows:
1) Such activities that can be compensated by the non-affected side mark high scores even before treatment.
2) The activity of proximal joints improves during treatment more remarkably than that of distal ones. Compensation by the non-affected side is made more skillful by treatment.
3) The activities of the upper extremity reach the maximum level sooner than those of lower extremity.
Part 2 Motor functional test
The ADL test is insufficient for clarifing motor function of the diseased extremity itself. The manual muscle testing method is useful for flaccid paralysis but not for spastic paralysis because of poly-articular synergy. In this study, therefore, seven patterns of mono- or poly-articular movements were difined, and each of them was scored 0-5 points according to the magnitude of independent voluntary motion capable in that pattern. Conclusions obtained from 341 patients are as follows:
1) Hemiplegic patients are classified into the following three types according to the course and plateau of motor restoration of the upper extremity after stroke. A) The flaccid type in which the upper extremity remains flaccid and the finger function is quite poor and does not show even flexor synergy. B) The spastic type associated with spasticity of various degree. In this type the motor function shows only flexor synergy, and facilitation of flexor movement is restored in the order of elbow, fingers and wrist. C) The flaccid or weak spastic type characterized by relatively good finger function even immediately after stroke. In this type motor disturbance is mainly due to weakness of proximal muscles. In the majority of patients of this type the motor function is over the stage of extensor synergy.
2) For a patient to be categorized “independent” in the sense of ADL, he must be able to (a) to raise the diseased leg in supine position, (b) to raise the diseased arm beyond the level of the head and (c) to oppose the thumb to the middle finger or farther ones.

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The upper extremity orthoses and externally powered flexor hinge splints available today for rehabilitation of quadriplegic patients due to high cervical cord injury with specific reference to the increase in their mobility and independence are comparatively discussed.
In order to use wrist driven flexor hinge splint effectively, patients with spinal cord injury at C₆ functional level (including the C₅ level patients who had muscle transplant of brachioradialis to wrist extensors) must have power to lift at least 1.4kg of weight voluntarily and be able to hold it at 45 degrees of wrist extension. Since the muscles lose about a grade in case of transplant, brachioradialis should be at least GOOD to NORMAL in standard muscle testing for determining the surgical indication.
In application of 4 different external power devices the following points are discussed.
1) Electrophysiological splint has disadvantages of inconsistent performance due to the extreme fatigability of the paralyzed muscle although the strength of 2-3kg pinch is thought to be ideal.
2) Flexor hinge splint with McKibben muscle has advantages of mechanical dependability and short period required for training, but has disadvantages of frequent filling of CO₂ gas and the pinch can be too strong for anesthetic fingers.
3) Flexor hinge splint with electric torque motor has an advantage of stopping the motor automatically according to the size of objects picked and simplicity of charging the battery overnight although the disadvantages include frequent mechanical repair and the switch control being affected by unstable postures as in the cases of McKibben muscle control.
4) Flexor hinge splint with myoelectric control has a great advantage in increasing the mobility of C₄ patients who are otherwise completely dependent and also the fact myoelectric control is not affected by unstable postures is considered as an advantage while the disadvantages include the problem in patients with excessive perspiration due to the usage of surface electrodes and the fairly long period required for training.
At present stage, combined application of flexor hinge splint with myoelectric control and balanced forearm orthoses (BFO) is far superior to an electric arm with tongue control or multiple channel control using available muscles.

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