Post-stroke fatigue: how it relates to motor fatigability and other modifiable factors in people with chronic stroke.

Post-stroke fatigue (PSF) is a common symptom associated with disability and decreased quality of life. Distinction can be made between perceived fatigue and fatigability. The first aim of this study was to evaluate the prevalence of perceived fatigue and fatigability amongst patients with chronic stroke and to explore how these two parameters relate. The second aim was to study the relationship between modifiable factors (sleep disorders, anxiety, depression and activities of daily living) and fatigue in this population. Sixty-two patients with chronic stroke (> 6 months) were included. Perceived fatigue was evaluated using the Fatigue Severity Scale (FSS). Motor fatigability was assessed with the percent change in meters walked from first to last minute of the 6-min Walk Test and an isometric muscular fatigability test. Subjects also completed self-report questionnaires assessing anxiety and depression (Hospital Anxiety and Depression Scale-HADS), sleep quality (Pittsburgh Sleep Quality Index-PSQI) and activity limitations (ACTIVLIM-stroke). Seventy-one percent of participants presented PSF. There was no correlation between the FSS and motor fatigability. FSS significantly correlated with HADS-Anxiety (ρ = 0.53, P < 0.001), HADS-depression (ρ = 0.63, P < 0.001), PSQI (ρ = 0.51, P < 0.001) and ACTIVLIM (ρ = - 0.30, P < 0.05). A linear regression model showed that the HADS-Depression, the PSQI and the ACTIVLIM explained 46% of the variance of the FSS. A high proportion of chronic stroke patients presents PSF, with no relation between their fatigue and fatigability. Perceived fatigue is associated with potentially modifiable factors: anxious and depressive symptoms, poor sleep quality and activity limitations. Registered at ClinicalTrials.gov (NCT04277234) (21/02/2019).

Clinical and electrophysiological investigation of spastic muscle overactivity in patients with disorders of consciousness following severe brain injury.

OBJECTIVE: The clinical and electrophysiological profile of spastic muscle overactivity (SMO) is poorly documented in patients with disorders of consciousness (DOC) following severe cortical and subcortical injury. We aim at investigating the link between the clinical observations of SMO and the electrophysiological spastic over-reactivity in patients with prolonged DOC. METHODS: We prospectively enrolled adult patients with DOC at least 3 months post traumatic or non-traumatic brain injury. The spastic profile was investigated using the Modified Ashworth Scale and the Hmax/Mmax ratio. T1 MRI data and impact of medication were analyzed as well. RESULTS: 21 patients were included (mean age: 41 ±â€¯11 years; time since injury: 4 ±â€¯5 years; 9 women; 10 traumatic etiologies). Eighteen patients presented signs of SMO and 11 had an increased ratio. Eight patients presented signs of SMO but no increased ratio. We did not find any significant correlation between the ratio and the MAS score for each limb (all ps > 0.05). The presence of medication was not significantly associated with a reduction in MAS scores or Hmax/Mmax ratios. CONCLUSIONS: In this preliminary study, the Hmax/Mmax ratio does not seem to reflect the clinical MAS scores in patients with DOC. This supports the fact they do not only present spasticity but other forms of SMO and contracture. SIGNIFICANCE: Patients with DOC are still in need of optimized tools to evaluate their spastic profile and therapeutic approaches should be adapted accordingly.

Soleus H reflex and motor unit number estimation after tibial nerve block and neurotomy in patients with spastic equinus foot.

OBJECTIVE: To assess and compare, clinically and electrophysiologically, the effects on muscle innervation and spasticity of selective anaesthetic nerve block and selective neurotomy of the motor-nerve branch to the soleus muscle in patients with spastic equinus foot. METHODS: Eleven hemiplegic patients were studied before and after anaesthetic tibial-nerve block, and at two months and one year after tibial nerve neurotomy. Triceps surae spasticity and strength, walking speed, gait kinematics of the ankle, maximal amplitude of the H reflex and of the M-response and the Hmax/Mmax ratio of the soleus muscle, and the mean motor unit action potential area and motor unit number estimation (MUNE) of the soleus muscle were calculated on the normal and spastic side. RESULTS: Spasticity and equinovarus improved in a similar fashion after tibial nerve block and neurotomy. The soleus Hmax/Mmax ratio decreased by 42% after tibial nerve block and 77% after neurotomy. The soleus MUNE decreased by 52% after tibial nerve block and by 86% after neurotomy. CONCLUSION: Diagnostic nerve block predicts the spasticity and gait improvement, which is expected after neurotomy. The clinical improvement was similar after block and neurotomy. Nerve block is associated with a 50% decrease in the soleus Hmax/Mmax ratio and soleus MUNE. The median 80% neurotomy is associated with an 80% decrease in the soleus Hmax/Mmax ratio and soleus MUNE.

Adhesive capsulitis of the hip: three case reports.

PURPOSE: To describe the diagnosis and treatment of adhesive capsulitis of the hip (ACH). METHOD: A literature review and consideration of three case reports. DISCUSSION: Adhesive capsulitis of the hip is a supposedly rare but probably underestimated condition which predominantly affects middle-aged women. Clinical assessment reveals a painful limitation of joint mobility. The diagnosis is confirmed by arthrography, where the crucial factor is a joint capacity below 12ml. Osteoarthritis and complex regional pain syndrome type 1 are the two main differential diagnoses. Whether the treatment is pharmacological, physical or surgical depends on the aetiology of the condition. Physiotherapy is essential for limiting residual deficits and functional impairments. CONCLUSION: Adhesive capsulitis of the hip is probably more common than suggested by the limited medical literature. The condition is frequently idiopathic but can be secondary to another joint pathology. The first-line treatment consists of sustained-release corticosteroid intra-articular injections and physical therapy. Arthroscopy and manipulation under anaesthesia may be useful in cases of ACH which are refractory to treatment.

Physical therapy in patients with disorders of consciousness: Impact on spasticity and muscle contracture.

BACKGROUND: Spasticity is a frequent complication after severe brain injury, which may prevent the rehabilitation process and worsen the patients' quality of life. OBJECTIVES: In this study, we investigated the correlation between spasticity, muscle contracture, and the frequency of physical therapy (PT) in subacute and chronic patients with disorders of consciousness (DOC). METHODS: 109 patients with subacute and chronic disorders of consciousness (Vegetative state/Unresponsive wakefulness syndrome - VS/UWS; minimally conscious state - MCS and patients who emerged from MCS - EMCS) were included in the study (39 female; mean age: 40±13.5y; 60 with traumatic etiology; 35 VS/UWS, 68 MCS, 6 EMCS; time since insult: 38±42months). The number of PT sessions (i.e., 20 to 30 minutes of conventional stretching of the four limbs) was collected based on patients' medical record and varied between 0 to 6 times per week (low PT = 0-3 and high PT = 4-6 sessions per week). Spasticity was measured with the Modified Ashworth Scale (MAS) on every segment for both upper (UL) and lower limbs (LL). The presence of muscle contracture was assessed in every joint. We tested the relationship between spasticity and muscle contracture with the frequency of PT as well as other potential confounders such as time since injury or anti-spastic medication intake. RESULTS: We identified a negative correlation between the frequency of PT and MAS scores as well as the presence of muscle contracture. We also identified that patients who received less than four sessions per week were more likely to be spastic and suffer from muscle contracture than patients receiving 4 sessions or more. When separating subacute (3 to 12 months post-insult) and chronic (>12months post-insult) patients, these negative correlations were only observed in chronic patients. A logit regression model showed that frequency of PT influenced spasticity, whereas neither time since insult nor medication had a significant impact on the presence of spasticity. On the other hand, PT, time since injury and medication seemed to be associated with the presence of muscle contracture. CONCLUSION: Our results suggest that, in subacute and chronic patients with DOC, PT could have an impact on patients' spasticity and muscles contractures. Beside PT, other factors such as time since onset and medication seem to influence the development of muscle contractures. These findings support the need for frequent PT sessions and regular re-evaluation of the overall spastic treatment for patients with DOC.

Reliability and limits of agreement of circumferential, water displacement, and optoelectronic volumetry in the measurement of upper limb lymphedema.

We conducted a reliability comparison study to determine the intrarater and inter-rater reliability and the limits of agreement of the volume estimated by circumferential measurements using the frustum sign method and the disk model method, by water displacement volumetry, and by infrared optoelectronic volumetry in the assessment of upper limb lymphedema. Thirty women with lymphedema following axillary lymph node dissection surgery for breast cancer surgery were enrolled. In each patient, the volumes of the upper limbs were estimated by three physical therapists using circumference measurements, water displacement and optoelectronic volumetry. One of the physical therapists performed each measure twice. Intraclass correlation coefficients (ICCs), relative differences, and limits of agreement were determined. Intrarater and interrater reliability ICCs ranged from 0.94 to 1. Intrarater relative differences were 1.9% for the disk model method, 3.2% for the frustum sign model method, 2.9% for water displacement volumetry, and 1.5% for optoelectronic volumetry. Intrarater reliability was always better than interrater, except for the optoelectronic method. Intrarater and interrater limits of agreement were calculated for each technique. The disk model method and optoelectronic volumetry had better reliability than the frustum sign method and water displacement volumetry, which is usually considered to be the gold standard. In terms of low-cost, simplicity, and reliability, we recommend the disk model method as the method of choice in clinical practice. Since intrarater reliability was always better than interrater reliability (except for optoelectronic volumetry), patients should therefore, ideally, always be evaluated by the same therapist. Additionally, the limits of agreement must be taken into account when determining the response of a patient to treatment.

Spasticity in disorders of consciousness: a behavioral study.

BACKGROUND: Spasticity is a frequent complication after severe brain injury, which may impede the rehabilitation process and diminish the patients' quality of life. AIM: We here investigate the presence of spasticity in a population of non-communicative patients with disorders of consciousness. We also evaluate the correlation between spasticity and potential factors of co-morbidity, frequency of physical therapy, time since insult, presence of pain, presence of tendon retraction, etiology and diagnosis. DESIGN: Cross-sectional study. SETTING: University Hospital of Liège, Belgium. POPULATION: Sixty-five patients with chronic (>3 months post insult) disorders of consciousness were included (22 women; mean age: 44±14 y; 40 with traumatic etiology; 40 in a minimally conscious state; time since insult: 39±37 months). METHODS: Spasticity was measured with the Modified Ashworth Scale (MAS) and pain was assessed using the Nociception Coma Scale-Revised (NCS-R). RESULTS: Out of 65 patients, 58 demonstrated signs of spasticity (89%; MAS≥1), including 40 who showed severe spasticity (61.5%; MAS≥3). Patients with spasticity receiving anti-spastic medication were more spastic than unmedicated patients. A negative correlation was observed between the severity of spasticity and the frequency of physical therapy. MAS scores correlated positively with time since injury and NCS-R scores. We did not observe a difference of spasticity between the diagnoses. CONCLUSION: A large proportion of patients with disorders of consciousness develop severe spasticity, possibly affecting their functional recovery and their quality of life. The observed correlation between degrees of spasticity and pain scores highlights the importance of pain management in these patients with altered states of consciousness. Finally, the relationship between spasticity and treatment (i.e., pharmacological and physical therapy) should be further investigated in order to improve clinical care. CLINICAL REHABILITATION IMPACT: Managing spasticity at first signs could improve rehabilitation of patients with disorders of consciousness and maximize their chances of recovery. In addition, decreasing this trouble could allow a better quality of life for these non-communicative patients.

Axillary schwannoma masquerading as cervical radiculopathy.

A 58-year-old woman, suffering from radicular-like pain in the left arm for 3 years, presented an entirely negative cervical imaging. Careful clinical examination disclosed Tinel's sign in the axilla. This clinical finding led to further investigation of this region. Computed tomography and magnetic resonance imaging disclosed a small tumour highly suggestive of a schwannoma. Surgical exploration and microscopic examination confirmed a diagnosis of schwannoma located on the radial trunk of the left brachial plexus. After tumour excision, the patient had immediate relief of pain without sensitive or motor sequelae. No recurrence has been observed after 3 years.

Abdominal wall weakness and lumboabdominal pain revealing neuroborreliosis: a report of three cases.

The authors report three cases of thoracic radiculoneuropathy disclosing neuroborreliosis. All three patients had low back and abdominal pain and two had marked abdominal wall paresis. EMG confirmed a motor involvement of the lower thoracic roots and CSF analysis revealed a lymphocytic meningitis in all three cases. Antibodies against Borrelia burgdorferi were present in both the serum and the CSF. A favourable outcome was obtained in all three patients with appropriate antibiotherapy. The differential diagnosis of this misleading presentation is discussed.

[Selective fasicular neurotomy for spastic equinovarus foot deformity in cerebral palsy children]. / La neurotomie fasciculaire sélective dans le traitement du pied varus équin spastique de l'enfant infirme moteur d'origine cérébrale.

Spasticity is usually treated by rehabilitation, orthosis, chemical denervations, orthopaedic surgery and neurosurgery. Selective fascicular neurotomy is a neurosurgical procedure consisting in partial section of selected motor nerves innervating spastic muscles. Neurotomy is indicated in cases of localised disabling spasticity without musculotendinous shortening, resistant to chemical denervation and for which a motor nerve block with anaesthetic has given a good functional result. Neurotomy includes division of the afferent Ia and Ib fibers, unable to recover, leading to permanent disappearance of the spasticity. Neurotomy also includes section of the motor efferent fibers with transient paresis as a result. In adults, neurotomy provides functional improvement in 81 to 97% of cases. In case of posterior tibial neurotomy, improved walking stability and a decrease in foot equinus and knee recurvatum is observed. In children, the risk of deformity recurrence seems higher because of motor axonal reinnervation: indications must therefore be carefully considered and rehabilitation provided after surgery.

[Streptococcus milleri subacute spinal cord abscess. Apropos of a case]. / Abcès médullaire subaigu à Streptococcus milleri. A propos d'un cas.

Since 1830, more than eighty cases of spinal cord abscesses have been reported. In half of these cases, it was unfortunately a post-mortem diagnosis. Magnetic resonance imaging (MRI) now gives new possibilities in the diagnosis and treatment of this rare pathology. We report here a case of cervical spinal cord abscess due to Streptococcus milleri. The clinical and laboratory findings, the MRI features, the pathogenicity of the offending pathogen and the surgical approach are discussed and compared with the data from the literature. The functional course was unexpectedly favourable in this patient. MRI allows prompt diagnosis and a precise localisation of the suspected abscess. Rapid surgical drainage is a critical prognostic factor for effective management of spinal cord abscess.

Influence of ankle-foot orthoses on kinematic segmental covariation among stroke patients.

OBJECTIVES: To evaluate the effect of ankle-foot orthosis on lower limbs kinematic segmental covariation (KSC) among stroke patients. METHODS: Ten chronic hemiparetic spastic stroke patients presenting with a lack of ankle dorsiflexion were assessed with instrumented gait analysis under three conditions: wearing a shoe, with a prefabricated ankle-foot orthosis (AFO), and with a dynamic AFO. Kinematic parameters were recorded and computed KSC was calculated according to Borghese's methodology. RESULTS: Contrary to the prefabricated AFO, the dynamic AFO improved KSC of the paretic side. We observed a high correlation between the external mechanical work and the affected side's KSC. In the unaffected side, KSC was globally unchanged. CONCLUSION: In stroke patients, wearing a dynamic AFO improves KSC of the paretic lower limb only.

Treatment of genu recurvatum in hemiparetic adult patients: a systematic literature review.

INTRODUCTION AND METHODS: We carried out a systematic review of the literature on treatment of genu recurvatum in hemiparetic adult patients by searching the PubMed, Pedro, Trip Database and Science Direct databases. The following keywords were used: (recurvatum or hyperextension or knee) and (hemiplegia or hemiparesis). RESULTS: Nine articles met our selection criteria. Four assessed retraining methods (functional electric stimulation or electrogoniometric feedback), two assessed orthopaedic or neurosurgical treatments and three articles focused on orthoses. DISCUSSION AND CONCLUSION: Even though all the various treatments produced encouraging results, most of the reviewed studies presented methodological limitations. Moreover, none of the selected articles suggested a treatment strategy which takes account of the various aetiologies in genu recurvatum. On the basis of some of the reviewed articles and our own clinical experience, we propose an aetiology-specific treatment strategy for genu recurvatum patients. In a broad patient population, this categorization could form the basis for testing the specificity of each treatment method as a function of the cause of genu recurvatum. This approach could help confirm the clinical indications and identify the most appropriate treatment for each patient.

Preliminary study of large and small peripheral nerve fibers in Charcot-Marie-Tooth disease, type I.

Histologic studies of Charcot-Marie-Tooth disease, type I, show a contrast between the lesions of myelinated fibers and the normality of unmyelinated fibers. Conventional electrophysiologic tests only demonstrate the alteration of myelinated fibers but do not study unmyelinated fiber function. We present routine clinical tests that are easily available and effective for the evaluation of small unmyelinated fibers: thermal threshold testing for warmth to evaluate small C unmyelinated somatic fibers and sympathetic skin responses to evaluate small C unmyelinated sympathetic fibers. Five unrelated patients with a diagnosis of Charcot-Marie-Tooth disease, type I, confirmed by biopsy were investigated. All of these patients showed marked reduction or absence of motor and sensory conduction velocities and severe denervation at needle examination. By contrast, thermal threshold testing for warmth and sympathetic skin responses were normal, confirming the normality of small C unmyelinated somatic and sympathetic fibers. We conclude that these noninvasive tests are helpful in the diagnosis of Charcot-Marie-Tooth disease, type I.

Pyrexia due to pyogenic sacroiliitis with iliopsoas abscess after spinal cord injury.

STUDY DESIGN: Single case report. OBJECTIVES: To present an unusual cause of fever in a patient with spinal cord injury (SCI). SETTING: University Hospital, Belgium. METHODS: A 52-year-old man with a complete T9 paraplegia was admitted to hospital with a 7 day history of fever above 39 degrees C without pain and without gastrointestinal, urinary, or respiratory complaints. The patient had had a flap coverage for a sacral pressure ulcer 6 months prior to admission. RESULTS: Bone scintigraphy demonstrated markedly increased activity in the left sacroiliac joint. Computed tomography (CT) revealed an infection of the left sacroiliac joint with a large abscess involving the iliopsoas muscle. The responsible organism, Pseudomonas aeruginosa, was isolated from abscess liquid obtained by CT-guided aspiration. We postulated that P. aeruginosa had colonized the eschar and, due to the proximity, infected the sacroiliac joint and the adjacent iliopsoas muscle. Prompt intravenous antibiotic therapy ensured clinical improvement and radiological regression. CONCLUSION: Pyogenic sacroiliitis is a relatively rare condition that may be difficult to diagnose in patients with normal sensation, and even more so in SCI patients. As far as we know, psoas abscess associated with pyogenic sacroiliitis has never been described in SCI patients. This infectious pathology must be kept in mind in SCI patients with fever of unknown origin and with a history of sacral eschar.

The influence of skin temperature on latency and amplitude of the sympathetic skin response in normal subjects.

The influence of skin temperature on latency and amplitude of the sympathetic skin response (SSR) was studied in 10 normal subjects. SSRs were elicited in all four limbs of each subject by electrical stimulation after cooling of the right arm and after cooling of the right hand only. At low skin temperature, the latency was prolonged and the amplitude decreased. Latency and amplitude were linearly correlated with skin temperature of the right arm. There were no changes in the left arm and the legs, which basically excludes involvement of central pathways in these response parameters. With regard to the skin temperature of the arm, a temperature correction factor of 0.088 s/degrees C was calculated for latency. With regard to the skin temperature of the hand, latency prolongation was significantly greater after cooling of the whole arm. This suggests that not only the neuroglandular junction, but also the postganglionic sympathetic C fibers were responsible for latency modifications. In contrast, amplitude was reduced similarly after cooling of the whole arm and the hand only, suggesting that mainly the neuroglandular junction is responsible for amplitude modifications. We conclude that skin temperature is a mandatory measurement in the study of the SSR.

Acute corticosteroid myopathy in intensive care patients.

Several recent studies have attributed the occurrence of acute myopathy in intensive care unit patients to the combination of corticosteroids and neuromuscular junction blocking agents (NMBAs) used for mechanical ventilation. We present 4 patients who developed acute myopathy after administration of high doses of glucocorticoids during sedation with propofol without any NMBAs. All patients had elevated creatine kinase levels. Electrophysiological studies indicated normal motor and sensory nerve conduction velocities but reduced motor nerve response amplitudes. Needle electromyography identified abnormal spontaneous activity; motor unit potentials were polyphasic of low amplitude and short duration, characteristic of a myopathic process. Muscle biopsy demonstrated a prominent acute necrotizing myopathy in all 4 patients with a loss of thick filaments. Our observations support glucocorticoids rather than NMBAs as the main offending drug in acute corticosteroid myopathy. The predisposing factor should be the hypersensitivity of paralyzed muscles to corticosteroids regardless of the drug inducing paralysis: NMBAs or propofol.

Lyme borreliosis neuropathy. A case report.

Lyme borreliosis is responsible for a large variety of peripheral neurologic manifestations including axonal polyneuropathy, radiculopathy, and facial nerve palsy. The prevalence of the disease must draw our attention on the possible responsibility of Borrelia burgdorferi in the pathogenesis of such symptomatology. Electrophysiologic studies demonstrate a proximal and distal axonal involvement, whereas neuropathologic studies suggest that vasculitis might be one of the primary pathophysiologic mechanisms. Electromyography provides a useful diagnostic tool and an important measure of response to treatment. Although peripheral neuropathy usually improves, our case report confirms the fact that chronic neurologic manifestations may not consistently resolve with appropriate treatment.

Cervical spinal cord injury in sapho syndrome.

Cervical spinal fracture and pseudarthrosis are previously described causes of spinal cord injury (SCI) in patients with spondylarthropathy. SAPHO (Synovitis Acne Pustulosis Hyperostosis Osteitis) syndrome is a recently recognized rheumatic condition characterized by hyperostosis and arthro-osteitis of the upper anterior chest wall, spinal involvement similar to spondylarthropathies and skin manifestations including palmoplantar pustulosis and pustular psoriasis. We report the first case of SAPHO syndrome disclosed by SCI related to cervical spine ankylosis.