Relative contributions of neural mechanisms versus muscle mechanics in promoting finger extension deficits following stroke.

The origins of impaired finger and hand function were examined in 10 stroke survivors with chronic spastic hemiparesis, with the intent of assessing whether mechanical restraint or altered neurophysiological control mechanisms are responsible for the well-known impairment of finger extension. Simultaneous extension of all four metacarpophalangeal (MCP) joints of the impaired hand was either externally imposed using a rotary actuator or attempted voluntarily by the subject. Trials were conducted both before and after administration of a local anesthetic, blocking the median and ulnar nerves at the elbow. The anesthetic was administered to reduce the activity of the muscles flexing the MCP joints, in order to distinguish mechanical from neuronal resistance to imposed MCP rotation. We found that the nerve blockade resulted in a reduction in velocity-dependent torque (P = 0.01), thereby indicating significant joint impedance due to spasticity. Blockade also produced a posture-dependent reduction in static torque in declaratively relaxed subjects (P = 0.04), suggesting some tonic flexor activity for specific hand postures. No change in either extensor isometric (P = 0.33) or isokinetic (0.53) torque was apparent, but 3 of the 10 subjects did exhibit substantial (>10 degrees ) improvement in voluntary MCP extension following the blockade. This improvement seemed largely due to a decrease in inappropriate flexor activity during the movement, rather than an increase in extensor activity. We argue that persistent and inappropriate flexor activation plays a role in limiting voluntary finger extension, and that this activation is potentially a reflection of altered supraspinal control of key spinal pathways. In all cases, this inappropriate activation was compounded by weakness, apparent in both the extensor and flexor muscles.

Improvement of sleep apnea in a patient with cerebral palsy.

Intrathecal baclofen (ITB) can reduce spasticity in adults and children with cerebral palsy. Benefits of ITB therapy include improved Ashworth scores, activities of daily living, and mobility. The impact of ITB therapy on sleep apnea in patients with cerebral palsy has not been reported. This case report describes a 29-yr-old female with mixed spastic athetoid quadriparetic cerebral palsy with dystonia, gross motor function IV, who had sleep apnea, requiring nightly continuous positive airway pressure. She received ITB with the goal to improve her wheelchair positioning and decrease her excessive movements. After the initiation of the ITB, reduction of her spasticity and dystonia was noted, as well as improvement of her sleep apnea. This case suggests that ITB therapy may improve respiratory function through reduction of respiratory muscle spasticity.

Recovery of functional status after right hemisphere stroke: relationship with unilateral neglect.

OBJECTIVE: To evaluate relationships between unilateral spatial neglect and both overall and cognitive-communicative functional outcomes in patients with right hemisphere stroke. DESIGN: Assessment of overall and cognitive-communicative function was conducted on admission to acute rehabilitation, at discharge, and at 3-month follow-up. SETTING: Urban, acute inpatient rehabilitation facility. PATIENTS: Fifty-two consecutive admissions of adult right-handed patients with a single, right hemispheric stroke, confirmed by computed tomography scan. MAIN OUTCOME MEASURES: The FIM instrument and reading comprehension and written expression items of the Rehabilitation Institute of Chicago Functional Assessment Scale(R). RESULTS: Patients made significant functional gains between admission and discharge, and between discharge and follow-up on the FIM. Severity of neglect was correlated with total, motor, and cognitive FIM scores at admission, discharge, and follow-up. Subjects with neglect had significantly more days from onset to admission and a longer length of rehabilitation stay than subjects without neglect. FIM outcomes were significantly different for subject groups with more severe neglect. Both the presence of neglect and its severity were significantly related to functional outcomes for reading and writing. CONCLUSIONS: Patients with neglect show reduced overall and cognitive-communicative functional performance and outcome than patients without neglect. Further studies are needed to explore causal relationships between these factors.

Incidence of and risk factors for medical complications during stroke rehabilitation.

BACKGROUND AND PURPOSE: The aims of this study were to examine the frequency, types, and clinical factors associated with medical complications that occur during inpatient rehabilitation and to identify risk factors for complications that require a transfer to an acute care facility. METHODS: A cohort of 1029 patients consecutively admitted for inpatient stroke rehabilitation was studied. Demographic and stroke information, impairment, preexisting medical conditions, and admission laboratory abnormalities were recorded. Medical complications, defined as new or exacerbated medical problems, were documented for each patient. Complications that required transfer off rehabilitation were noted. Univariate and multiple logistic regression analyses were used to determine factors that were associated with risk of medical complications and risk of transfer off rehabilitation. RESULTS: Seventy-five percent of patients experienced >/=1 medical complication during rehabilitation. Significant factors for the development of any medical complication included greater neurological deficit (odds ratio [OR], 4.10; confidence interval [CI], 1.88 to 8.91), hypoalbuminemia (OR, 1.71; 95% CI, 1.15 to 2.52), and history of hypertension (OR, 1.81; 95% CI, 1.27 to 2.59). Nineteen percent of patients had a medical complication that required transfer to an acute care facility. Significant factors for transfers were elevated admission white blood cell counts (OR, 1.92; 95% CI, 1.32 to 2.79), low admission hemoglobin levels (OR, 1.89; 95% CI, 1.32 to 2.68), greater neurological deficit (OR, 2.46; 95% CI, 1.37 to 4.39), and a history of cardiac arrhythmia (OR, 1.79; 95% CI, 1.18 to 2.67). CONCLUSIONS: Medical complications are common among patients undergoing stroke rehabilitation. A significant number of these medical complications may require a transfer to an acute facility.

Review of preorthotic biomechanical considerations.

The application of an ankle-foot orthosis in poststroke hemiplegia can improve the mechanics of ambulation and functional gait. However, prior to the fitting of an orthotic, the clinician should perform a thorough assessment of the biomechanical elements contributing to mobility problems within the patient. Many of these problems such as joint contracture or weakness should be addressed through physical therapy interventions prior to orthotic prescription. This article reviews the common biomechanical elements that contribute to mobility and gait disability in patients with stroke with special attention to orthotic management.

Isolated cardiac metastasis of cervical carcinoma presenting as disseminated intravascular coagulopathy. A case report.

BACKGROUND: An isolated cardiac metastasis from cervical carcinoma is very rare. This report describes the unusual presentation in a patient diagnosed and successfully treated for stage IB squamous cell carcinoma of the cervix, presenting six months later with disease metastatic to the heart. CASE: A 44-year-old woman presented with hand swelling and bruising. She had undergone successful surgical treatment of a stage IB squamous cell cervical carcinoma six months previously. Computed tomography revealed a large mass in the right ventricle, confirmed by echocardiography. The patient underwent surgery, where the mass was biopsied and debulked under a cardiopulmonary bypass. Frozen section confirmed metastatic squamous cell carcinoma. The patient was discharged with follow-up radiation and chemotherapy. CONCLUSION: All women with myocardial abnormalities and a history of squamous cell carcinoma of the cervix should be suspected of developing a myocardial metastasis until proven otherwise.

The prevention and management of complications after stroke.

Medical, neurologic, and psychiatric complications can interfere with optimal recovery after stroke and increase the cost of care. Ideally, preventing these complications would be the best and most cost-effective treatment. This article reviews the clinical implications and management strategies for venous thromboembolism, spasticity, and depression after stroke.

Stroke rehabilitation. 2. Co-morbidities and complications.

This self-directed learning module highlights new advances in the understanding of co-morbid conditions and medical complications of stroke. It is part of the chapter on stroke rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article covers co-morbid conditions of stroke patients, including cardiovascular disease, diabetes, and sleep apnea. It reviews recent information on complications of stroke, including deep venous thrombosis, dysphagia and aspiration, hospital-acquired infections, depression, falls, spasticity, shoulder pain, and seizures. Treatment advances in diabetes, depression, and spasticity are highlighted. Recent information is presented regarding exercise guidelines for the stroke patient with cardiovascular disease, the relationship between stroke and sleep apnea, prophylaxis of deep venous thrombosis, the changing spectrum of hospital-acquired infections, malnutrition in stroke patients, the problem of falls during rehabilitation, the evaluation and management of poststroke shoulder pain, and the risk of seizures after stroke.

Stroke rehabilitation. 3. Rehabilitation management.

This self-directed learning module highlights new advances in the treatment of patients after stroke by means of a case study format. It is part of the chapter on stroke rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article discusses both medical and rehabilitation issues that arise in the care of persons with strokes involving the right and left middle cerebral arteries and the vertebral artery. Cases were chosen to cover problems seen in both older and younger persons. Management of common sequelae that are typical of these stroke syndromes and identification of common co-morbidities are included.

Hemiplegia and contralateral upper limb claudication--a case of dual disability from pseudoaneurysm of the brachiocephalic artery: a brief report.

Thromboembolic obstruction of the brachiocephalic artery can have significant functional consequences because it threatens arterial circulation to the right upper limb and right cerebrum. A case is presented of a young man who sustained right basal ganglia infarct 2 mo after suffering multiple gunshot wounds to his chest. The severity of his hemiplegia rendered his left arm nonfunctional. Later, he developed progressive symptoms of right upper limb claudication, making it impossible to perform activities of daily living independently with the hemiplegic technique. Arteriography revealed a pseudoaneurysm near the bifurcation of the brachiocephalic artery; the likely source was thromboembolism to the right common carotid and right subclavian artery. Surgical ligation of the subclavian artery and vascular bypass from the common carotid to the brachial artery restored blood flow to his right upper limb. The arm claudication was relieved, and he was again able to perform activities of daily living independently. This case represents an unusual cause of dual disability with bilateral upper limb dysfunction from a single thromboembolic source. Accurate diagnosis and treatment prevented this patient from developing permanent impairment and restored him to functional independence.

Stroke rehabilitation: clinical predictors of resource utilization.

OBJECTIVE: To identify predictors of rehabilitation hospital resource utilization for patients with stroke, using demographic, medical, and functional information available on admission. DESIGN: Statistical analysis of data prospectively collected from stroke rehabilitation patients. SETTING: Large, urban, academic freestanding rehabilitation facility. PARTICIPANTS: A total of 945 stroke patients consecutively admitted for acute inpatient rehabilitation. MAIN OUTCOME MEASURES: Resource utilization was measured by rehabilitation length of stay (LOS) and mean hospital charge per day (CPD). METHODS: Independent variables were organized into categories derived from four consecutive phases of clinical assessment: (1) patient referral information, (2) acute hospital record review and patient history, (3) physical examination, and (4) functional assessment. Predictors for LOS and CPD were identified separately using four stepwise multiple linear regression analyses starting with variables from the first category and adding new category data for each subsequent analysis. RESULTS: Severe neurologic impairment, as measured by Rasch-converted NIH stroke scale and lower Rasch-converted motor measure of the Functional Independence Measure (FIM) instrument predicted longer LOS (F2,824 = 231.9, p < .001). Lower Rasch-converted motor FIM instrument measure, tracheostomy, feeding tube, and a history of pneumonia, coronary artery disease, or renal failure predicted higher CPD (F6,820 = 90.2, p < .001). CONCLUSION: Stroke rehabilitation LOS and CPD are predicted by different factors. Severe impairment and motor disability are the main predictors of longer LOS; motor disability and medical comorbidities predict higher CPD. These findings will help clinicians anticipate resource needs of stroke rehabilitation patients using medical history, physical examination, and functional assessment.

Tailoring therapy to a stroke patient's potential.

Stroke survivors can be plagued by numerous medical complications, including aspiration pneumonia, heart disease, depression, and venous thromboembolism. Given the impairment already caused by stroke itself, these patients require careful management by a comprehensive rehabilitation team. Dr Harvey discusses common stroke syndromes, possible complications, and appropriate rehabilitation options covering a variety of circumstances.

Impairment and disability: their relation during stroke rehabilitation.

OBJECTIVES: To describe the association between impairment and disability during stroke rehabilitation and to examine the effects of rehabilitation by studying the degree of disability reduction experienced by stroke patients who did not have significant reductions in impairment levels. DESIGN: Statistical analysis of items from a database of prospectively collected information on stroke patients admitted for rehabilitation. SETTING: Large urban academic freestanding rehabilitation facility. PARTICIPANTS: Four hundred two patients consecutively admitted for comprehensive acute stroke inpatient rehabilitation. MAIN OUTCOME MEASURES: The National Institutes of Health Stroke Scale (NIHSS) was used to measure impairment and the Functional Independence Measure (FIM) was used to measure disability. Motor and cognitive subscales of the FIM instrument were evaluated. Raw NIHSS and FIM scores were converted to linear measures using Rasch analysis. METHODS: Relationships were studied between converted NIHSS and the two FIM subscales for admission, discharge, and change scores using linear regression analysis. In a second analysis, two groups of patients were identified; the 342 patients who experienced no substantial reduction of impairment comprised the "no impairment reduction (NIR) group," and the 60 patients who had a significant reduction of impairment level comprised the "impairment reduction (IR) group." Multivariate analysis of variance was used to determine and compare the amount of change in motor and cognitive FIM measures over time for each of the two groups. RESULTS: NIHSS correlated significantly with motor and cognitive FIM subscores for admission, discharge, and change measures; R2 values ranged between .02 and .36. Both the NIR group and the IR group experienced significant decreases in disability during rehabilitation. The differences in discharge FIM measures between the two groups were relatively small. CONCLUSIONS: Although stroke-related impairment and disability are significantly correlated with each other, reduced impairment level alone does not fully explain the reduced disability that occurs during rehabilitation. Even patients without substantial impairment reduction demonstrate disability reduction during rehabilitation, suggesting that rehabilitation has an independent role in improving function beyond that explained by neurologic recovery alone.

Measurement properties of the NIH Stroke Scale during acute rehabilitation.

BACKGROUND AND PURPOSE: The scale of stroke impairment characteristics by Brott and associates, the National Institutes of Health (NIH) Stroke Scale, has been used widely in various studies of stroke outcome; however, the measurement properties of the items applied to patients during medical rehabilitation have not been evaluated thoroughly. This study evaluated the extent to which scale items cohere to define a unidimensional construct and have a useful range for application to patients during medical rehabilitation. METHODS: Rating scale (or Rasch) analysis of the 15 NIH Stroke Scale items was conducted using the BIGSTEPS computer program to evaluate (1) the range of impairment assessed by the items, (2) the items' coherence with an underlying construct of impairment, and (3) range of impairment measured in rehabilitation patients. We sought to maximize the range of impairment measured by conducting analyses recursively; at each subsequent step, the worst fitting item was deleted or rescored. The sample comprised 1291 admission and discharge records from 693 rehabilitation inpatients with stroke. RESULTS: Thirteen items arrayed the sample across a sufficient range of impairment. The limb ataxia item fit poorly and was deleted; lower ratings for this item were associated with higher scores on the total scale. Pupillary response was also deleted because ratings reflected poor congruence with the total score. Best language was rescored because intermediate ratings were inconsistently related to the total score. Patients with hemorrhagic strokes had poorer fitting measures than did patients with ischemic strokes. CONCLUSIONS: The items in a revised NIH Stroke Scale worked well together to define the severity of impairment resulting from stroke that is observed during medical rehabilitation. Directions regarding limb ataxia should be modified to indicate untestability due to hemiplegia.

Deep vein thrombosis in stroke. The use of plasma D-dimer level as a screening test in the rehabilitation setting.

BACKGROUND AND PURPOSE: Venous thromboembolism is a leading cause of morbidity and mortality during the acute recovery period after stroke. This study investigated the utility of plasma D-dimer level as a diagnostic test for deep vein thrombosis (DVT) in patients hospitalized for stroke rehabilitation. METHOD: Plasma samples were drawn from 105 nonambulatory rehabilitation patients with recent ischemic or hemorrhagic stroke and assayed for D-dimer with an enzyme-linked immunosorbent method. Samples were drawn within 24 hours of venous duplex ultrasound (VDU) screening for DVT. Optimal discriminant analysis was used to determine whether plasma D-dimer level, age, sex, days after stroke onset, stroke etiology. National Institutes of Health Stroke Scale score, and ambulatory status could correctly classify patients' DVT status. RESULTS: Fourteen of 105 patients had DVT identified by VDU scan. Of all attributes, only D-dimer level had significant ability to discriminate between patients with or without DVT (P < .0001). The optimal cut point for predicting DVT was D-dimer = 1591 ng/mL, resulting in 79% sensitivity, 78% specificity, 35% positive predictive value, and 96% negative predictive value. Reducing the D-dimer cut point to 1092 ng/mL improved both sensitivity and negative predictive value to 100% but reduced specificity to 66% and positive predictive value to 31%. CONCLUSIONS: A D-dimer level < or = 1092 ng/mL can exclude the presence of DVT in stroke rehabilitation patients. When a D-dimer level > 1092 ng/mL occurs, further diagnostic testing is necessary to confirm DVT. Plasma D-dimer level is a simple and inexpensive screening test for DVT during stroke rehabilitation.

White matter MR hyperintensities in adult patients with congenital rubella.

PURPOSE: To observe and quantify white matter hyperintensities on MR images in adults with schizophrenialike symptoms who had had congenital rubella, in order to elucidate the neuropathologic sequelae of this perinatal viral infection and to explore the potential relationship of these lesions to schizophrenia. METHODS: Eleven deaf adult patients with documented prenatal rubella virus infection and schizophrenialike symptoms were compared with 19 age-matched patients with early-onset schizophrenia who did not have congenital rubella and with 18 age-matched control subjects. All MR images (obtained at 1.5 T) were evaluated by a neuroradiologist who was blinded to diagnosis and were rated for white matter lesions on a five-point scale: 0 = no lesions; 1 = 1 lesion less than 1 mm in diameter; 2 = 1 to 4 lesions 1 mm or greater; 3 = 5 to 10 lesions; 4 = more than 10 lesions or a single lesion more than 1 cm in diameter. In addition, the white matter hyperintensities were volumed objectively with a manual threshold technique. RESULTS: Ratings of white matter lesions were significantly higher in the rubella patients than in the control subjects: 6 of the 11 patients had ratings greater than 1 compared with 1 of the 18 control subjects and none of the 19 schizophrenic patients. Also, MR images in five rubella patients received ratings at the highest end of the scale of abnormality (3 or 4). The white matter hyperintensities were characterized as bilateral T2 signal hyperintensities in periventricular and subcortical regions, punctate or linear in shape; they were observed predominantly in parietal lobes. CONCLUSION: This quantitative MR study of adult rubella patients disclosed abnormal white matter lesions that may correspond to neurovascular lesions known neuropathologically. They do not appear to be directly related to schizophrenialike symptoms.

Major vascular injury from high-pressure water jet.

High-pressure water jets are used in industry as a cleaning and cutting tool. Penetrating injuries by these devices can produce minimal external evidence of extensive internal damage. We report a literature review and the case of a limb-threatening injury to the lower extremity caused by such a device.

A population of cells resident within embryonic and newborn rat skeletal muscle is capable of differentiating into multiple mesodermal phenotypes.

We have previously shown a population of putative mesenchymal stem cells in the connective tissue surrounding embryonic avian skeletal muscle. These cells differentiate into at least five recognizable phenotypes in culture: fibroblasts, chondrocytes, myotubes, osteoblasts, and adipocytes. We have now isolated a similar population of cells from fetal and newborn rat skeletal muscle. Cells from rat leg muscle were dissected, minced, and then enzymatically digested with a collagenase-dispase solution. The dissociated cells were plated and allowed to differentiate into two recognizable populations: myotubes and stellate mononucleated cells. The cells were then trypsinized, filtered through a 20 microm filter to remove the myotubes, frozen at -80 degrees C, then thawed and replated. In culture the cells maintained their stellate structure. However, under treatment with dexamethasone, a nonspecific differentiating agent, seven morphologic conditions emerged: cells with refractile vesicles that stained with Sudan black B (adipocytes), multinucleated cells that spontaneously contracted in culture and stained with an antibody to myosin (myotubes), round cells whose extracellular matrix stained with Alcian blue, pH 1.0 (chondrocytes), polygonal cells whose extracellular matrix stained with Von Kossa's stain (osteoblasts), cells with filaments that stained with an antibody to smooth muscle a-actin (smooth muscle cells), cells that incorporated acetylated low density lipoprotein (endothelial cells), and spindle-shaped cells that grew in a swirl pattern (fibroblasts). The initial population is tentatively classified as putative mesenchymal stem cells. The presence of these cells point to the existence of stem cells in the postembryonic mammal that could provide a basis for tissue regeneration as opposed to scar tissue formation during wound healing.

Brain dysmorphology in adults with congenital rubella plus schizophrenialike symptoms.

Brain morphology was quantified with magnetic resonance imaging (MRI) in adult patients with congenital rubella who also had schizophrenialike symptoms. MRIs were compared with those of adult early-onset schizophrenic patients without congenital rubella and age-matched healthy control subjects. The rubella patients had significantly smaller intracranial volumes and shorter stature than the schizophrenic patients or the controls; however, both patient groups had smaller cortical gray matter, but not white matter, volumes than the control group, even when the MRI volumes were corrected for head size and age. In addition, both patient groups showed significant enlargement of the lateral ventricles but not cortical sulci when compared with expected values of normal adults of the same age and head size. Overall, the pattern of dysmorphology was identical in the rubella and the schizophrenic groups. The observations in the rubella group are consistent with a developmental lesion that limits full brain growth, with the small intracranial volume due at least in part to a severe cortical gray matter volume deficit. Thus, the brain dysmorphology of congenital rubella may provide an instance of prenatal viral infection that models the schizophrenic pattern and provides indirect support for a developmental hypothesis of the neuropathogenesis of schizophrenia.