Effect of overground gait training with 'Mobility Assisted Robotic System-MARS' on gait parameters in patients with stroke: a pre-post study.

OBJECTIVE: To observe the effect of overground gait training with 'Mobility Assisted Robotic System-MARS' on gait parameters in patients with stroke. PATIENTS & METHODS: This prospective pre-post study was conducted in a tertiary teaching research hospital with 29 adult stroke patients, with age up to 65 years. Patients fulfilling the inclusion criteria were divided in 2 groups based on the duration of stroke (≤ 6 months-sub-acute & > 6 months-chronic stroke) and provided overground gait training with MARS robot for 12 sessions (1 h/session) over a period of 2-3 weeks. Primary outcome measures were; 10-Meter walk test-10MWT, 6-min' walk test-6MWT and Timed up & Go-TUG tests. Secondary outcome measures were Functional Ambulation Category-FAC, Modified Rankin Scale-MRS and Scandinavian Stroke Scale-SSS. RESULTS: No adverse events were reported. Twenty-five patients who were able to perform 10-MWT at the beginning of study were included in the final analysis with 12 in sub-acute and 13 in chronic stroke group. All primary and secondary outcome measures showed significant improvement in gait parameters at the end of the training (p < 0.05) barring 10-Meter walk test in sub-acute stroke group (p = 0.255). Chronic stroke group showed significant minimum clinically important difference-MCID difference in endurance (6MWT) at the end of the training and both groups showed better 'minimal detectable change-MDC' in balance (TUG) at the end of the training. CONCLUSIONS: Patients in both the groups showed significant improvement in walking speed, endurance, balance and independence at the end of the training with overground gait training with MARS Robot. CLINICAL TRIAL REGISTRY: National Clinical Trial Registry of India (CTRI/2021/08/035695,16/08/2021).

Ankylosing spondylitis masquerading as generalized spasticity in a patient with spinal cord injury in neurological rehabilitation setting: A case report.

A thorough history and examination in rehabilitation settings are paramount. We present a case of spinal cord injury with quadriparesis with severe axial stiffness and increasing spasticity not responding to high doses of medication. Only after repeated inquiry, patient gave history of symptoms suggestive of ankylosing spondylitis (AS). Initiating treatment for AS resulted in decreased stiffness and spasticity and improved functional outcome in the patient.

Effectiveness of Peripheral Median, Radial, and Ulnar Nerve Block at Wrist along with Intra-Articular Steroid Injection in Shoulder Joint in Management of Complex Regional Pain Syndrome of Upper Limb: 1-Week Follow-Up Study.

Background: Complex regional pain syndrome (CRPS) of upper limbs is one of the under-recognized painful disabling condition seen in many neurological conditions. Objective: To see the effectiveness of peripheral nerve blocks (PNB) along with intra-articular injection in shoulder joint in the improvement of pain, swelling and range of motion (ROM) of the upper limb in CRPS. Methods: It was a single-center, prospective study in male and female patients between 18 and 70 years with CRPS of the upper limb due to any etiology, within one year of illness. Single-dose of the intra-articular shoulder joint injection and peripheral nerve blocks at the wrist with steroid, 2% lignocaine, and sterile water was given. The primary outcome measure was a reduction in pain in the upper limb, assessed with a visual analog scale (VAS). Secondary outcome measures were an improvement in passive ROM of joints and a decrease in swelling of the hand. The significance of the P value was adjudged against an alpha of 0.05. Results: Thirty-three patients (25 men), with a mean (SD) age of 55.2 (9.4) years, and mean (SD) duration of illness of 101.9 (76.8) days were included. After 1 week, there was a significant improvement (P < 0.05) in the ROM of joints. The decrease in pain scores on VAS [mean difference -5.1 (CI -5.7, -4.5)] and reduction in hand swelling [mean difference -0.9 (CI -1.1, -0.7)] was also significant. Conclusion: Peripheral median, radial, and ulnar nerve block at wrist along with intra-articular steroid injection in the shoulder joint is an effective method of management of CRPS of the upper limb.

Transcranial Color Coded Duplex Sonography Findings in Stroke Patients Undergoing Rehabilitation: An Observational Study.

Background Transcranial color-coded duplex sonography (TCCD) provides information on intracranial blood flow status in stroke patients and can predict rehabilitation outcomes. Objective This study aimed to assess middle cerebral artery (MCA) parameters using TCCD in MCA territory stroke patients admitted for rehabilitation and correlate with clinical outcome measures. Materials and Methods Patients aged 18 to 65 years with a first MCA territory stroke, within 6 months of onset were recruited. The clinical outcome scales and TCCD parameters were assessed at both admission and discharge. The scales used were the Scandinavian stroke scale (SSS), Barthel Index (BI), modified Rankin Scale (mRS), Fugl-Meyer upper extremity scale (FMA-UE), modified motor assessment scale (mMAS) scores. TCCD parameters measured were MCA peak systolic, end diastolic, mean flow velocities (MFV), and index of symmetry (SI) and were correlated with clinical scores. Results Fourteen patients were recruited with median age of 56.5 years, median duration of stroke was 42.5 days. Mean flow velocities of affected and unaffected MCA were 46.2 and 50.7 cm/s, respectively. Flow velocities and SI did not change between the two assessments. There was significant improvement in clinical outcome scores at discharge. Significant correlation was observed for patient group with SI > 0.9 at admission with FMA-UE, SSS, and BI scores at discharge ( p < 0.05). Conclusion Flow velocity parameters did not change during in-patient rehabilitation. Patients with symmetric flow at admission had improved clinical outcomes measure scores at discharge. Thus SI can predict rehabilitation outcomes in stroke survivors.

Rehabilitation outcomes in patients with post-COVID-19 vaccine-associated Guillain-Barre syndrome.

Objective: With COVID-19 vaccination campaign worldwide, associated Guillain-Barre syndrome (GBS) is being increasingly reported from different countries. The objectives of the study were to observe the clinical profile and rehabilitation outcomes in patients with post-COVID-19 vaccine-associated GBS. Material and Method: This prospective study was conducted in neurological rehabilitation unit with in-patients. A detailed customized rehabilitation program was formulated based on the clinical status and associated complications. Outcome measures were documented on the day of admission and at discharge and compared. Results: The study included 16 patients (eight males) of which 15 (93.75%) received the CoviShield (AstraZeneca) and 1 Covaxin (Bharat Biotech) vaccine. The median (IQR) duration of first symptom was 9 (18.25) days and for motor symptoms 18 (12.75) days. Functional improvement was observed in patients using Barthel index scores and Hughes disability scores and overall neuropathy limitation scale. All rehabilitation outcomes showed a statistically significant improvement (P < 0.05) from the time of admission to discharge. At discharge, complete independence in activities of daily living was achieved in 4 (25%) patients and 5 (31.25%) were minimally dependent. Three (18.75%) patients were walking independently, seven (43.75%) with minimal support, and four with walker (25%). Nine (56.25%) patients needed bilateral ankle-foot orthosis and two bilateral knee gaiters for locomotion. Conclusion: Comprehensive inpatient rehabilitation interventions in patients with post-COVID-19 vaccine-associated GBS result in significant functional recovery.

Sexual dysfunction and sexual concerns among persons with disability due to myelopathy: A cross-sectional study.

Objectives: We have very little information about sexual activity and concerns of patients with myelopathy from India. The objectives of this study were to assess the sexual dysfunction and sexual concerns among patients with myelopathy due to spinal cord lesion (SCL). Materials and Methods: This study was a single-center, cross-sectional, and hospital-based study among male and female patients in the age-group 18-50 years, with disability due to myelopathy due to SCL. The data were collected using a self-designed, pretested, and semi-structured questionnaire by face-to-face interview. Results: Eighty participants were recruited in the study, of which 62 (77.5%) were men. The mean standard deviation (SD) age of the participants was 33.7 (8.6) years, and mean (SD) age at time of illness was 31.4 (8.6) years with median duration of 17 months. Among 62 males, psychogenic erection was impaired in 77.2%, reflex erection was impaired in 78.9%, and ejaculation was affected in 70.7%. Orgasm was absent or reduced in 66.1% males. Among 18 female participants, psychogenic genital arousal was reduced in 66.5%, reflex genital arousal was impaired in 55.5%, and orgasm was absent in 38.8% subjects. Sexual desire in these patients was unchanged in 41 (51.2%) and decreased or absent in 39 (48.8%). Sexual activity involvement was there in 46 (57.5%) and 34 (42.5%) had not involved in any kind of sexual activity after injury/illness. The main reasons of non-involvement in sexual activity were bladder and bowel accidents, spasticity, and difficulty in positioning. Conclusion: Comprehensive neurological rehabilitation should address sexual function of affected individual to allow them highest level of function and quality of life.

Impact of inpatient rehabilitation on quality of life among stroke patients.

Objective: Despite remarkable progression in the treatment of stroke, the life quality and social related events caused by stroke have received limited attention in our country. Quality of life (QOL) assessment is an important part of the evaluation of stroke patients and their management. The objective of this study was to assess QOL in patients with stroke at the time of admission in rehabilitation unit and to assess the impact of inpatient rehabilitation on change in QOL in these patients. Materials and Methods: Adult patients with first arterial stroke of any duration, with presentation as hemiplegia, were recruited. The clinical outcome scales and 36-Item Short Form Health Survey (SF-36) parameters for QOL were assessed at both admission and discharge. The scales used were Scandinavian stroke scale (SSS), Barthel Index (BI), and modified Rankin Scale. SF-36 scores were assessed after 6 weeks of discharge also. Results: Ten patients with median age of 36.5 years and median duration of stroke 75 days were recruited. There was significant improvement in functional scores of BI and SSS scales at the time of discharge. Majority of the components of both physical and mental domains of QOL SF-36 questionnaire showed significant improvement. The QOL scores after 6 weeks of discharge did not show significant change except for the emotional well-being. Conclusion: The QOL in patients with stroke improves with inpatient rehabilitation along with motor and functional scores. Improved functional independence leads to better emotional state after discharge also.

Post-Stroke Depression and Its Effect on Functional Outcomes during Inpatient Rehabilitation.

Objective The aim of the study is to observe the effect of post-stroke depression on functional outcomes during inpatient rehabilitation. Materials and Methods The design involved is prospective observational study. The location involved is Neurological Rehabilitation unit in a tertiary care university hospital. The study period ranges from October 2019 to April 2020. The participants involved are the patients with first ever stroke, male and female with age ≥18 years and duration less than 1 year. All participants were assessed at admission and after 14 sessions of inpatient rehabilitation by depression subscale of Hospital Anxiety and Depression Scale (HADS-D) and Hamilton Depression Rating Scale (HDRS). The stroke outcomes measures used were: Barthel Index (BI), Scandinavian Stroke Scale (SSS), and Modified Rankin Scale (MRS). Results There are a total of 30 participants (18 males) with median stroke duration of 90 days. The median age of the patients was 58 years. Sixteen patients had ischemic and 14 had hemorrhagic stroke. Out of these, 57% ( n = 17) had symptoms of depression (HADS-D >7). Participants in both groups (with and without depression) showed improvement in all the functional outcome measures (BI, SSS, MRS) at the time of discharge as compared with admission scores. The changes in the outcome measures were statistically significant within groups ( p < 0.05) but not significant between the groups ( p > 0.05). Conclusion The post-stroke depression is common among stroke survivors of less than 1 year duration. There was no significant difference in the functional outcomes between stroke patients with depression and those without depression with inpatient rehabilitation program.

Rare Clinical Presentation in a Case of Pediatric Guillain-Barré Syndrome and Rehabilitation Outcome.

Nearly half of patients with Guillain-Barré syndrome (GBS) have cranial nerve involvement. Ocular muscle weakness or ophthalmoplegia occurs in ~10% of these patients. Patients presenting with bilateral ptosis, with or without ophthalmoplegia, is a rare finding. Anti-GQ1b antibody has been found in Miller Fisher syndrome and GBS with ophthalmoplegia variants. We report a case of GBS in a young boy presenting with rare presentation of tetraplegia, bilateral ptosis, and facial palsy, no ataxia but ophthalmoplegia with seronegative anti-GQ1b antibody. Patient showed recovery in cranial nerves involvement as well as with motor and functional recovery after 3 weeks of inpatient rehabilitation (Barthel Index score improved to 60/100 at the time of discharge from 20/100 at the time of admission). He was independent for most of the activity of daily livings including ambulation at the time of discharge from rehabilitation unit ( p < 0.001).

Neuropathic Pain in Guillain-Barre Syndrome: Association with Rehabilitation Outcomes and Quality of Life.

BACKGROUND: Neuropathic pain contributes significantly to the morbidity and affects the quality of life adversely in Guillain-Barre syndrome (GBS). OBJECTIVE: To study neuropathic pain profile in GBS and association with rehabilitation outcomes and effect on the quality of life. METHODS: Observational study conducted in rehabilitation setting of a tertiary care hospital among adult GBS patients of less than 3 months duration. Assessment was done at the time of admission and discharge with Pain-detect questionnaire (PD-Q), Neuropathic pain scale (NPS), SF 36 survey, Medical Research Council (MRC) score, INCAT sensory sum score (ISS), Overall Disability sum-score (ODSS), Hughes disability score (HDS), Hospital Anxiety and Depression scale (HADS), and Fatigue Severity scale (FSS). Neuropathic pain was managed as per routine protocol and rehabilitation program was individualized. RESULTS: 32 participants (26 males) with median age of 34.50 years were included. Eighteen (56.25%) patients had neuropathic pain on PD-Q at admission. The median intensity of pain on NPS scale was 47 at admission which decreased significantly to 14 at discharge. Pain group showed significant association with sensory impairment, CSF protein, and emotional domains of QOL while no association with disability. CONCLUSION: Neuropathic pain is associated with sensory impairment in GBS and markedly affects the quality of life, especially emotional, family, and social activities.

Clinical and sociodemographic profiles of persons with spinal cord injury.

AIM: To collect and correlate the sociodemographic and clinical details of persons with spinal cord injury who were admitted to the Department of Neurological Rehabilitation. OBJECTIVES: To assess the sociodemographic characteristics and collect the clinical profiles of persons with spinal cord injury and to correlate their sociodemographic and clinical details. MATERIALS AND METHODS: A retrospective file review was done over a period of 2 years from January 2017 to December 2018 to study patients with spinal cord injury who were admitted to the Neurological Rehabilitation ward of NIMHANS, Bengaluru, Karnataka, India. RESULTS: A total of 60 patients were admitted with spinal cord injury. The mean age was 32.39 years and majority of the patients were young married males. Most of them belong to the low socioeconomic status and are housewives and daily wage laborers. Falls and road traffic accidents are the causes for the injury. Anxiety and depression are high among traumatic spinal cord injury patients. CONCLUSION: This information may contribute to prevent SCI and to improve the quality of life of patients with SCI. It has implications for the primary care physicians who are at first contact to identify and refer them for specialized super speciality district hospitals for further treatment as they pose a great threat to public health and their proportions are increasing. It is imperative that trauma care is included in graduate medical training as well to facilitate early intervention after initial screening.

Urinary Symptoms and Bladder Dysfunction in Patients with Neuromyelitis Optica Spectrum Disorders: Evaluation with Urodynamics and Management.

Objective To assess lower urinary tract symptoms (LUTSs) in patients with neuromyelitis optica spectrum disorders (NMOSDs) and bladder dysfunction through urodynamics (filling and voiding phase of cystometrography) and management based on findings. Patients and Methods The study included 42 (34 females) patients admitted to the rehabilitation department. Neurologic evaluation was performed and severity of myelitis was assessed using the American Spinal Injury Association Impairment Scale. All patients underwent urodynamics, and management was based on the findings. Results Mean age was 34.5 years (range: 11-64 years; standard deviation: 13.1). Twenty-three (54.8%) patients had a first episode of myelitis, whereas 19 patients had relapses (number of episodes varying from 2 to 7). Eleven (26%) patients had increased frequency, 16 (37%) had urgency, 12 (28%) had urge incontinence, 8 (18.6%) had stress incontinence, 22 (52.4%) had nocturia, 31 (72%) had retention of urine, 22 (52.4%) had incomplete evacuation, and 14 (33.3%) patients had mixed urinary complaints. The common urodynamic findings were neurogenic detrusor overactivity (NDO) with detrusor-sphincter dyssynergia (DSD) in 14 (33.3%) patients, NDO without DSD in 8 (19%), and acontractile detrusor in 20 (47.6%). Pharmacotherapy was advised to 22 (52.4%) patients, whereas clean intermittent catheterization (CIC)/self-catheterization was advised to 39 (92.9%) patients. Conclusions Urinary retention was observed to be the most common urinary complaint in patients with NMOSD followed by NDO with or without sphincter dyssynergia. Urodynamics should be performed in all patients with LUTSs for best management. CIC remains the gold standard for the management of neurogenic bladder dysfunction.

Role of Virtual Reality in Balance Training in Patients with Spinal Cord Injury: A Prospective Comparative Pre-Post Study.

STUDY DESIGN: Prospective comparative pre-post study. PURPOSE: To evaluate the effects of game-based virtual reality (VR) training program for trunk postural control and balance in patients with spinal cord injury (SCI) and to assess the results according to the motor completeness (severity) of lesions using the American Spinal Injury Association Impairment Scale (AIS). OVERVIEW OF LITERATURE: Training with VR based gaming has a role to play in improving balance in patients with SCI. METHODS: Patients with SCI (traumatic and non-traumatic) for <6 months were included in this hospital-based study. Participants were divided into two groups: experimental group (EG) consisting 21 patients, and control group (CG) consisting 12. Both groups underwent the conventional rehabilitation program. An additional training with semi-immersive VR therapy was conducted 5 days a week for 3 weeks in the EG with the focus on balance rehabilitation using the "Rhetoric." The outcome measures were the Berg Balance Scale (BBS), balance section of the Tinetti Performance-Oriented Mobility Assessment (POMA-B), and Functional Reach Score (FRS). RESULTS: Both groups consisted of young participants (mean age, 28 and 30.5 years, respectively) and predominantly men (>80%). One-third of them had tetraplegia and two-third had paraplegia. Between-group analyses showed no statistically significant differences in the main effects between groups (p-value: BBS, 0.396; POMA-B, 0.238; FRS, 0.294), suggesting that the EG group did not show significant improvement in the trunk and posture at the end of training sessions than the CG group. Similarly, no significant difference was observed according to the severity (completeness) of SCI in the between-group analyses using the AIS (A/B vs. C/D). CONCLUSIONS: VR is an adjunctive therapy for balance rehabilitation in patients with SCI.

GNE myopathy - A cross-sectional study on spatio-temporal gait characteristics.

GNE myopathy is a rare, predominantly distal myopathy, involving mainly the lower limbs and presenting with gait disturbances. In this cross-sectional study gait evaluation of 23 (14 men) genetically confirmed GNE myopathy patients was done using Instrumented walkway analysis (GAITRite®) along with video gait capture. We recorded the topographical pattern of muscles involvement in lower limbs and correlated Functional Ambulation Profile-FAP and Medical Research council-MRC grading of lower limb scores with duration of illness. Early foot flat, foot drop gait with wider out-toed stance and higher perturbations with increased pressure at heel and decreased arm swing were noted. Muscle topography showed predominant weakness in ankle dorsi-flexors, flexor hallucis longus, extensor hallucis longus, hip adductors and knee flexors with stark sparing of quadriceps and relative sparing of hip- abductors, extensors, flexors and ankle plantar-flexors. Gait parameters in women were significantly more affected than men (p < 0.05) for the same duration of illness. FAP score and MRC grading of lower limb scores correlated significantly with duration of illness (p < 0.05). We observed that ankle dorsiflexors were affected earliest with sparing of quadriceps muscles in these patients.

Effectiveness of Caregivers' Yoga Module on Psychological Distress and Mental Well-Being among Caregivers of Patients Admitted to Neurological Rehabilitation Wards of a Tertiary Care Institute, Bengaluru, Karnataka, India.

Background Caregivers of patients admitted to neurorehabilitation wards may experience higher psychological distress (PD) and poor mental well-being (MWB). This study aimed to empower caregivers to cope effectively with PD and maintain well-being by practicing yoga. Materials and Methods A total of 34 caregivers were randomized to the experimental group (EG) and waitlisted control group in a multiphase manner. Data were collected using sociodemographic schedule, Kessler's Psychological Distress scale-10, and Warwick-Edinburgh's Mental Well-being Scale. Caregivers' yoga module (CYM) consisting of satsanga (theory), asanas (postures), pranayama (breath control), imagery, meditation, and relaxation techniques was taught to those in the EG at 35 m/d for eight consecutive days. They were encouraged to continue on their own for another 3 weeks. Posttest data were collected from both groups on the 15th and 29th days. Analysis was done with IBM SPSS statistics version 22 (IBM Corp., Armonk, New York, United States). Results There was statistically significant reduction of PD and improvement of MWB among caregivers of EG within (PD: F = 17.78, p < 0.001; MWB: F = 5.48, p < 0.03) and between (PD: F = 15.87, p < 0.001; MWB: F = 15.87, p < 0.01) the groups after the CYM. A significant negative correlation was found between pretest MWB and PD ( r =-0.579, p < 0.01). Caregivers who were married and caregivers' perception of poor improvement of patient condition were significantly associated with PD. Conclusion Findings provide preliminary evidence for the effectiveness of CYM on PD and MWB among caregivers of patients admitted to neurorehabilitation wards.

Urinary Symptoms in Patients with Parkinson's Disease and Progressive Supranuclear Palsy: Urodynamic Findings and Management of Bladder Dysfunction.

OBJECTIVE: The objective of this study is to observe urinary symptoms in patients with Parkinson's disease (PD) and progressive supranuclear palsy (PSP) and advice bladder dysfunction management based on urodynamic study (UDS) findings. PATIENTS AND METHODS: Twenty-two patients (12 males) with PD and PSP (15 and 7, respectively) with urinary symptoms were included in this study. All patients except one were on levodopa and carbidopa medication. UDS was performed, and bladder management determined. RESULTS: Mean age was 60.4 years (range 41-73 years, standard deviation [SD] 8.4). Mean illness duration was 31.9 months (range 9-146 months, SD 31.0) and mean duration of urinary symptoms was 14.8 months (range 1-61 months, SD 15.8). Eighteen patients reported nocturia and 16 patients had urgency with or without urge incontinence. Three patients had retention and straining to void and 3 had mixed urinary complaints. Twelve out of 22 patients had absence of voluntary anal contraction on per-rectal examination. UDS was suggestive of 12 patients with neurogenic detrusor overactivity with or without sphincter dyssynergy. Six patients had normal detrusor pressure, and four patients were found to have contractile detrusor. Ten patients had significant postvoid residual. Bladder management included pharmacotherapy, supportive, and behavioral management as appropriate. CONCLUSIONS: Patients with PD/PSP are known to develop urinary symptoms during illness. Clinical complaints and UDS findings do not necessarily match. UDS is required to manage urinary symptoms. Most of the patients respond to oral antimuscarinic medications along with behavioral and supportive therapy.

Feasibility and Utility of Tele-Neurorehabilitation Service in India: Experience from a Quaternary Center.

BACKGROUND: Neurological rehabilitation service in developing countries like India is a great challenge in view of limited resources and manpower. Currently, neurological rehabilitation with a multidisciplinary team is limited to a few major cities in the country. Tele-neurorehabilitation (TNR) is considered as an alternative and innovative approach in health care. It connects the needy patients with the health-care providers with minimum inconvenience and yields cost-effective health care. AIM: The aim of this study was to study the socioclinical parameters, feasibility, and utility of TNR services in India. METHODOLOGY: A retrospective file review of TNR consultations provided through Telemedicine Center at a quaternary hospital-based research center in south India between August 2012 and January 2016. RESULTS: A total of 37 consultations were provided to the patients belonging to four districts of Karnataka. The mean age of the patients was 34.7 (±19.5) years, 23 (62.1%) were aged between 19 and 60 years, and 31 (83.8%) were male. Thirty-one patients (83.8%) had central nervous system-related disorders such as stroke, cerebral palsy, and tubercular meningitis with sequelae or neuromuscular disorders such as Guillain-Barre Syndrome and Duchenne muscular dystrophy. Twelve patients (32.4%) were advised to consult higher centers in the vicinity, and the rest was referred to the district hospital. CONCLUSION: The findings suggest that TNR services are feasible, effective, and less resource intensive in delivering quality telemedicine care in India. More clinical studies are required to elucidate its full utility at different levels and in different parts of the country.