Cyclic functional electrical stimulation does not enhance gains in hand grasp function when used as an adjunct to onabotulinumtoxinA and task practice therapy: a single-blind, randomized controlled pilot study.

OBJECTIVE: To determine whether onabotulinumtoxinA injections and task practice training with or without functional electrical stimulation (FES) improve upper limb motor function in chronic spastic hemiparesis. DESIGN: Randomized controlled trial. SETTING: Outpatient spasticity clinic. PARTICIPANTS: Participants (N=23) had chronic spastic hemiparesis with moderate-severe hand impairment based on Chedoke-McMaster Assessment greater than or equal to 2. INTERVENTIONS: OnabotulinumtoxinA injections followed by 12 weeks of postinjection task practice. Participants randomly assigned to FES group were also fitted with an orthosis that provided FES. MAIN OUTCOME MEASURES: Motor Activity Log (MAL)-Observation was the primary outcome. Secondary outcomes were Action Research Arm Test (ARAT) and MAL-Self-Report. RESULTS: For the entire cohort, MAL-Observation mean item scores improved significantly from baseline to week 6 (P=.005) but did not remain significant at week 12. MAL-Self-Report mean item scores improved significantly (P=.009) from baseline to week 6 and remained significantly higher (P=.014) at week 12. ARAT total scores also improved significantly from baseline to week 6 (P=.018) and were sustained at week 12 (P=.032). However, there were no significant differences between the FES and no-FES groups for any outcome variable over time. CONCLUSIONS: Rehabilitation strategies that combine onabotulinumtoxinA injections and task practice therapy are feasible and effective in improving upper-limb motor function and reducing spasticity in patients with chronic spastic hemiparesis. However, the cyclic FES protocol used in this study did not increase gains achieved with the combination of onabotulinumtoxinA and task practice alone.

Effect of baseline spastic hemiparesis on recovery of upper-limb function following botulinum toxin type A injections and postinjection therapy.

OBJECTIVE: To determine whether baseline hand spastic hemiparesis assessed by the Chedoke-McMaster Assessment influences functional improvement after botulinum toxin type A (BTX-A) injections and postinjection therapy. DESIGN: Prospective cohort study. SETTING: Outpatient spasticity clinic. PARTICIPANTS: Participants (N=14) with spastic hemiparesis divided into 2 groups: Chedoke-McMaster Assessment Hand-Higher Function (stage> or =4, n=5) and Chedoke-McMaster Assessment Hand-Lower Function (stage=2 or 3, n=9). INTERVENTIONS: Upper-limb BTX-A injections followed by 6 weeks of postinjection therapy. MAIN OUTCOME MEASURES: Primary outcomes were Motor Activity Log-28 and Motor Activity Log items. Secondary outcomes were Action Research Arm Test (ARAT), Motor Activity Log-Self-Report, and Modified Ashworth Scale (MAS). Measures were assessed at baseline (preinjection), 6 weeks, 9 weeks, and 12 weeks postinjection. RESULTS: Primary and secondary outcomes improved significantly over time in both groups. Although no significant differences in ARAT or MAS change scores were noted between groups, Chedoke-McMaster Assessment Hand-Higher Function group demonstrated greater change on Motor Activity Log-28 (P=.013) from baseline to 6 weeks and Motor Activity Log items (P=.006) from baseline to 12 weeks compared to Chedoke-McMaster Assessment Hand-Lower Function group. CONCLUSIONS: BTX-A injections and postinjection therapy improved hand function and reduced spasticity for both Chedoke-McMaster Assessment Hand-Higher Function and Chedoke-McMaster Assessment Hand-Lower Function groups. Clinicians should expect to see larger gains for persons with less baseline impairment.

Predictors of pericardial effusion after orthotopic heart transplantation.

OBJECTIVES: Pericardial effusion occurs frequently after orthotopic heart transplantation, but the causes of this complication have not been well described. This study was designed to identify factors predisposing toward the development of significant postoperative pericardial effusions in a large, single-institution population of orthotopic heart transplant recipients. METHODS: A retrospective review of more than 90 preoperative, intraoperative, and postoperative variables was conducted for 241 patients undergoing orthotopic heart transplantation from September 1988 to December 1999. Patients who had significant postoperative pericardial effusions develop were identified from postoperative echocardiograms by standard criteria. Factors associated with the development of significant pericardial effusions were determined by multivariate logistic regression analysis. RESULTS: Echocardiographic data were available for 203 of 241 transplant recipients. Forty-two patients (21%) had significant effusions develop. According to multivariate analysis, pericardial effusions were less likely to occur in recipients with a history of previous cardiac surgery (odds ratio 0.13, 95% confidence interval 0.05-0.36, P <.0001) and with greater weight (odds ratio 0.96, 95% confidence interval 0.94-0.99, P <.0048). Pericardial effusions were more likely to occur in patients who had received aminocaproic acid during the operation (odds ratio 5.92, 95% confidence interval 2.23-15.72, P <.0008). Patient survival and hospital length of stay did not differ between patients with and without postoperative pericardial effusions. CONCLUSIONS: Postoperative pericardial effusions develop in approximately 20% of patients undergoing orthotopic cardiac transplantation. On the basis of the risk factors identified in this study, prevention may prove difficult, although avoidance of the intraoperative use of aminocaproic acid may be helpful.

PulseCO: a less-invasive method to monitor cardiac output from arterial pressure after cardiac surgery.

BACKGROUND: Cardiac output is often monitored after cardiac operations with a pulmonary artery catheter. A new method has been introduced that measures cardiac output by lithium dilution (LiDCO) and uses these data to calibrate a system (PulseCO) that calculates cardiac output continuously from the energy of the arterial pressure waveform. It is unknown whether PulseCO measurements are valid early after cardiac surgery when changes in temperature and vascular tone or intermittent use of the arterial line for blood sampling may occur. This study assessed the reliability of cardiac output determinations by PulseCO in the first 8 hours after cardiac surgery. METHODS: After a one-time PulseCO calibration, cardiac output was measured in 20 patients who had undergone coronary artery bypass grafting at 0, 2, 4, 6, and 8 hours after arrival in the intensive care unit using (1) thermodilution through a pulmonary artery catheter (Thermo); (2) lithium dilution (LiDCO); and (3) PulseCO. Concordance correlations were calculated between methods, and differences were compared by Wilcoxon paired rank test and Bland-Altman analysis. RESULTS: Cardiac output ranged from 3.4 to 8.5 L/min. No significant differences were noted between measurements obtained by each technique at any time point. Concordance correlations and Bland-Altman analysis confirmed good agreement between PulseCO and Thermo determinations of cardiac output during the study interval. CONCLUSIONS: PulseCO measurements remain reliable without recalibration for at least 8 hours after cardiac surgery and may offer a less-invasive approach for early postoperative cardiac output monitoring.

Cognitive impairments and depressive symptoms did not impede upper limb recovery in a clinical repetitive task practice program after stroke: a pilot study.

OBJECTIVE: We examined whether cognitive impairments or depressive symptoms impeded improvement in upper limb function in a clinical repetitive task practice program. DESIGN: Participants had mild to moderate upper limb impairment after stroke (n = 20). We characterized baseline cognitive function and depressive symptoms using the Repeatable Battery of Neuropsychological Status and the Hamilton Rating Scale for Depression. We measured upper limb function at baseline, week 4, and week 24 using the Action Research Arm Test. RESULTS: Participants with and without cognitive impairments improved significantly over time (F(1,17) = 84.48, P < 0.001) regardless of cognitive status (t(31) = 1.42, P = 0.16) or time since stroke (t(17) = 0.07, P = 0.95). Participants with and without depressive symptoms improved significantly over time (F(1,18) = 86.29, P < 0.001), but participants with depressive symptoms demonstrated greater improvement than did participants with no depressive symptoms (t(31) = 3.19, P = 0.003), regardless of time since stroke (t(17) = 0.06, P = 0.95). CONCLUSIONS: Preliminary findings suggest that cognitive impairments and depressive symptoms may not impede benefit from repetitive task practice after stroke.