Comprehensive assessment of gesture production: a new test of upper limb apraxia (TULIA).

BACKGROUND: Only few standardized apraxia scales are available and they do not cover all domains and semantic features of gesture production. Therefore, the objective of the present study was to evaluate the reliability and validity of a newly developed test of upper limb apraxia (TULIA), which is comprehensive and still short to administer. METHODS: The TULIA consists of 48 items including imitation and pantomime domain of non-symbolic (meaningless), intransitive (communicative) and transitive (tool related) gestures corresponding to 6 subtests. A 6-point scoring method (0-5) was used (score range 0-240). Performance was assessed by blinded raters based on videos in 133 stroke patients, 84 with left hemisphere damage (LHD) and 49 with right hemisphere damage (RHD), as well as 50 healthy subjects (HS). RESULTS: The clinimetric findings demonstrated mostly good to excellent internal consistency, inter- and intra-rater (test-retest) reliability, both at the level of the six subtests and at individual item level. Criterion validity was evaluated by confirming hypotheses based on the literature. Construct validity was demonstrated by a high correlation (r = 0.82) with the De Renzi-test. CONCLUSION: These results show that the TULIA is both a reliable and valid test to systematically assess gesture production. The test can be easily applied and is therefore useful for both research purposes and clinical practice.

An easy prediction of urinary incontinence duration after retropubic radical prostatectomy based on urine loss the first day after catheter withdrawal.

PURPOSE: We sought to predict the duration of urinary incontinence after radical prostatectomy based on potential risk factors. MATERIALS AND METHODS: We included 104 patients after radical retropubic prostatectomy at University Hospital Gasthuisberg, Leuven. To evaluate incontinence a 24-hour pad test, a 1-hour pad test, a visual analog scale and a questionnaire were used. Patients were considered continent when they stopped wearing incontinence pads, when 24 and 1-hour pad tests showed less than 2 gm urine loss, and when patients considered themselves continent. On univariate and multivariate analyses we examined the influence of different risk factors on the duration of incontinence. RESULTS: The amount of urine loss the first day after catheter withdrawal was the only predictor of the duration of urinary incontinence on univariate and multivariate analyses. Patient age was significant but only on univariate analysis. The duration of incontinence after prostatectomy was estimated. The average time needed to regain continence was 8, 16, 29, 29 and 70 days in men who lost 2 to 50, 51 to 100, 101 to 200, 201 to 500 and more than 500 gm urine, respectively, on day 1. CONCLUSIONS: The amount of urine loss on day 1 after catheter withdrawal is the most important predictive factor in terms of regaining urinary continence after radical prostatectomy. An estimation table can provide realistic information to the patient regarding the duration of urinary incontinence.

Elimination of two reef-building hydrocorals following the 1982-83 el nino warming event.

One probable extinction and one range reduction of eastern Pacific reef-building hydrocoral (Millepora) species mark the first documented cases of species eliminations resulting from the worldwide 1980s coral reef bleaching events. Two of 12 Panamanian coral species were eliminated suddenly from their former ranges by prolonged high sea temperatures during the 1982-83 El Niño-Southern Oscillation event. Three conditions contributed to their demise: high sensitivity to sea warming, populations confined to a small geographic area, and bathymetric restriction to the euphotic zone (

Tears of the supraspinatus tendon: assessment with indirect magnetic resonance arthrography in 67 patients with arthroscopic correlation.

BACKGROUND: Magnetic resonance (MR) arthrography is generally regarded as the gold standard for shoulder imaging. As an alternative to direct MR arthrography, the less invasive indirect MR arthrography technique was proposed, offering logistic advantages because fluoroscopic or ultrasonographic guidance for joint injection is not required. PURPOSE: To assess the diagnostic performance of indirect MR arthrography in the diagnosis of full- and partial-thickness supraspinatus tears in a symptomatic population. MATERIAL AND METHODS: Two radiologists with different levels of experience independently and retrospectively interpreted indirect MR (1.5T) arthrograms of the shoulder obtained in 67 symptomatic patients who underwent subsequent arthroscopy. On MR, the supraspinatus tendon was evaluated for full- or partial-thickness tear. With arthroscopy as the standard of reference, sensitivity, specificity, and diagnostic accuracy of indirect MR arthrography in the detection of full- and partial-thickness tears of the supraspinatus tendon was calculated. Kappa (kappa) statistics were used for the assessment of the agreement between arthroscopic and imaging findings and for the assessment of interobserver agreement. RESULTS: For full-thickness tears of the supraspinatus tendon, sensitivities, specificities, and accuracies exceeded 90% for both observers, with excellent interobserver agreement (kappa = 0.910). For partial-thickness tears, sensitivities (38-50%) and accuracies (76-78%) were poor for both reviewers, and interobserver agreement was moderate (kappa = 0.491). Discrepancies between MR diagnosis and arthroscopy were predominantly observed with small partial-thickness tears. CONCLUSION: Indirect MR arthrography is highly accurate in the diagnosis of full-thickness rotator cuff tears. However, the diagnosis of partial-thickness tears with indirect MR arthrography remains faulty, because exact demarcation of degenerative change and partial rupture is difficult. On the basis of the above findings, we do not recommend indirect MR arthrography on patients for whom rotator cuff disease is suspected clinically.

Prediction of driving after stroke: a prospective study.

BACKGROUND: The process of determining whether patients with stroke should drive again often involves off-road evaluations and road tests that usually take about 2 to 3 h to complete. OBJECTIVES: This prospective study sought to identify the combination of tests that best predicts fitness to drive after stroke. The main aim was to develop a short and predictive predriving assessment battery. METHODS: Sixty-eight consecutive stroke patients were studied who performed a mandatory predriving assessment at the Belgian Road Safety Institute, Brussels, within 18 months. Performance in a predriving assessment included medical examination (when needed), visual and neuropsychological evaluations, and an on-road test. Based on these assessments, a physician, psychologist, and the driving safety expert who administered the tests decided if a subject was either "fit to drive,""temporarily unfit to drive," or "unfit to drive." RESULTS: Logistic regression analysis revealed a combination of visual neglect, figure of Rey, and on-road tests as the model that best predicted (R(2) = 0.73) fitness to drive after stroke. Using a discriminant function that included the 3 tests of the logistic model, the fitness to drive judgments of 59 (86.8%) subjects were correctly predicted. The sensitivity and specificity of the predictions were 79.4% and 94.1%, respectively. CONCLUSION: Fitness to drive after stroke can be predicted from performance on a few road-related tests with a high degree of accuracy. However, some individuals require extended assessments and further tests.

Discriminant ability of the Trunk Impairment Scale: A comparison between stroke patients and healthy individuals.

PURPOSE: The Trunk Impairment Scale (TIS) is a standardized scale to evaluate the trunk function in stroke patients. It was the aim of this study to determine the discriminant ability of the TIS by comparing stroke patients with healthy individuals. Further, the variables that had an influence on obtaining a high score on the TIS in healthy subjects were examined. METHOD: Forty stroke patients and 40 age- and sex-matched healthy individuals were included in the study. TIS scores from the stroke patients and healthy individuals were compared using the Wilcoxon ranked sum test. RESULTS: Sub-scale and total TIS scores showed significant differences between stroke patients and healthy individuals (P < 0.0001). Univariate analysis and logistic regression analysis further revealed that younger persons, women and people who are more active in daily life have a higher chance of obtaining a high score on the TIS. CONCLUSIONS: The TIS discriminates between stroke patients and healthy individuals. A submaximal score on the TIS was found in 45% of the healthy subjects suggesting that a lower score on the TIS still indicates normal trunk function and full participation in daily life.

Walking ability after implantation of a pallidal stimulator: analysis of plantar force distribution in patients with Parkinson's disease.

This preliminary study aimed to analyse the roll-off of the foot during gait before and after implantation of a unilateral pallidal electrode in severely affected patients with Parkinson's disease (PD). Five subjects were tested in a gait laboratory during the "on" phase of the medication cycle. Spatiotemporal variables demonstrated a pronounced increase of stride length and gait speed in three patients. Plantar force distribution and roll-off was considerably improved in one patient, which was not replicated in others. Gait analysis highlighted the variable effects found after surgery with a pallidal stimulator and might contribute to future studies into the effect of surgical procedures in PD.

Effect of the serotonin agonist 8-OH-DPAT on the sensorimotor system of the rat.

8-Hydroxy-2-(di-n-propylamino)-tetralin hydrobromide (8-OH-DPAT, 2 mg/kg) is used to induce perseverative behavior in rats in a T-maze as a model for obsessive-compulsive disorder (OCD). Using the open-field test, radiant heat test, and the test with von Frey filaments, we examined whether alterations in sensorimotor functioning could contribute to the perseverative tendencies in this model by measuring differences in left versus right hind paw reactions after 8-OH-DPAT administration (2 mg/kg, sc). Also, the effect of repeated 8-OH-DPAT administration on sensorimotor functioning was tested every third day. 8-OH-DPAT administration induced a significantly decreased sensorimotor performance in the open-field test, an increased threshold for noxious thermal stimulation (increased withdrawal latency, WL, and decreased elevation time, ET) in the radiant heat test, and a decreased nociceptive threshold for mechanical stimulation in the test with von Frey filaments. All changes in sensorimotor functioning were similar for left and right hind paws suggesting that, these changes as measured with the tests in the present study, are not likely to contribute to the perseverative behavior of rats in a T-maze. Further, repeated administration of 8-OH-DPAT had no effect in the radiant heat test and the test with the Frey filaments, but produced a tolerance effect in the open-field test.

Development of an activity scale for individuals with advanced Parkinson disease: reliability and "on-off" variability.

BACKGROUND AND PURPOSE: Functional mobility in people with advanced Parkinson disease, some of whom have a variable response to drug treatment, is often difficult to evaluate. The objectives of this study were to investigate the interrater reliability of measurements obtained with a scale designed to measure mobility and to determine the impact of self-rated dyskinesias and fluctuations on the measure. SSUBJECTS: Twenty-nine people with Parkinson disease and with disability and considerable disease duration (mean=11.7 years, SD=4.9, range=6-22) took part in the study. METHODS: The subjects' performance on a 10-item scale was videotaped. The videotapes were then scored by 2 independent raters, and the scores were used to determine interrater reliability. The stability of 6 repeated measurements was examined in the home situation, taking into account self-rated fluctuations of motor performance. RESULTS: Weighted Kappa values of agreement (.86-.98) confirmed the reliability between testers. Measurement during the "on" phase (when medication was working optimally) and the "off" phase (when the action of medication was strongly decreased or absent) led to different measurements. Measuring frequently within "on" and "off" phases gave relatively stable measurements for total function, bed transfers, and gait akinesia, the latter during the "off" phase only (intraclass correlation coefficients [ICCs]=.70-.93). However, more modest repeatability applied to transfers from a chair (ICC=.65-.67). CONCLUSION AND DISCUSSION: To ensure valid results in future effect studies, clinical differentiation between "on" and "off" phase measurements is proposed on the basis of patients' own perception of their medication status.

Aspects of the validity of the Movement Assessment Battery for Children.

Does the Movement Assessment Battery for Children (M-ABC) measures what it claims to measure? The concurrent validity of the total impairment score and some of the item scores of the second and third age band of the M-ABC test were investigated. One hundred thirty three children, between 7- and 9-year-old, were assessed with the M-ABC test, a ball catching test and two tasks measuring dynamic balance. Ninety of these children were identified as children with a poor ball catching skill and 43 children were typically developing children. One hundred and seven children were assessed with the second age band of the M-ABC (the 7- and 8-year-old children) and 26 with the third age band (the 9-year-old children). The results of the correlation analysis between the ball catching test, the two dynamic balance tasks and the corresponding items of the M-ABC, varied from non-significant to a highly significant correlation coefficient of -0.74. For some items concurrent validity was established but other items seemed less valid, probably due to a lack of discriminative power. The concurrent validity of the total impairment score of the M-ABC was confirmed for the second age band. Correlation coefficients between the ball catching test, the dynamic balance skills and the M-ABC varied between -0.72 and -0.76. The results for the third age band have to be interpreted with prudence because they were based on only 26 children.

Torque variations during repeated passive isokinetic knee movements in persons with multiple sclerosis.

The purposes of this study were to investigate the effect of movement repetitions on resistive torque during passive isokinetic dynamometry of the knee and to determine the role of electromyographic activity in the stretched muscles on the torque measurements. Ten persons with multiple sclerosis and hypertonia of the knee muscles were compared with 10 healthy age- and gender-matched control subjects. During series of 10 flexion and extension movements of the knee at 60, 180 and 300 degrees/s, torque and electromyographic activity in the stretched muscles were registered. The persons with hypertonia presented a significantly larger torque reduction (p < 0.05) than the control subjects in all test conditions except for repeated knee flexion at 300 degrees/s. Electromyographic activity in the stretched muscles was not identified as the only explanatory mechanism for the reduction in hypertonia during the movement repetitions, suggesting that other factors were also involved.

The effect of a home physiotherapy program for persons with Parkinson's disease.

The purpose of this study was to evaluate the effect of a home physiotherapy program for persons with Parkinson's disease. Thirty-three patients took part in the study using a within-subject controlled design. Functional activities including walking and carrying out transfers were measured at home and in the hospital before and after a 6-week baseline period, after 6 weeks home physiotherapy and after 3 months follow-up. Spatiotemporal and plantar force variables of gait were determined with video and pododynography. Treatment provided by community physiotherapists consisted of teaching cueing and conscious movement control 3 times a week. The study revealed that patients had significantly higher scores on a functional activity scale after treatment in the home setting and to a lesser degree in hospital, a result, which was partly sustained at follow-up. However, duration of the transfer movements, spatiotemporal and plantar force variables were not significantly improved except for stride length. The results support application and development of the treatment concept and highlight that physiotherapy aimed at improving function in Parkinson's disease is best provided in the home situation.

Problem list of stroke patients as identified in the problem orientated medical record.

In a retrospective study problem orientated physiotherapy records were examined on 156 consecutive stroke patients admitted to medical wards and referred to the physiotherapy department. The purpose of the study was to identify from the problem lists those problems physiotherapists are dealing with in stroke care. There were 1338 problems recorded, and these were divided into 16 clinically meaningful subgroups. Three of the sixteen subgroups accounted for 60.2 percent of all the problems recorded, namely lack of voluntary movement and mobility in general (25.7%), imbalance in muscle tone (19.5%), and problems in maintaining balance (15.0%). On discharge only 34.1 per cent of all problems were reported to be resolved. There was wide variation in the success rate claimed with different problems.

Group physiotherapy improves time use by patients with stroke in rehabilitation.

Does feedback about the time use of patients with stroke influence the organisation of services in rehabilitation? An observation was made of the time use by 22 patients with stroke in a specialised rehabilitation unit, feedback was given to the staff, and another observation on 16 patients was made one year later. As a result of the first observation, the physiotherapy staff were urged to organise group sessions for patients with similar levels of disability, allowing practice with a higher patient to staff ratio. During the second observation, patients spent significantly more time on therapy (8%) and with their peers (25%). These results indicate that feedback about patients' time use can substantially influence management and consequently patients' behaviour in rehabilitation.

A frequency and correlation analysis of motor deficits in Parkinson patients.

PURPOSE: The present study explored the frequency and pattern of functional motor problems of a group of Parkinson patients, as a first step towards developing a rational approach to rehabilitation intervention addressing the primary symptoms of the disease. METHOD: Sixty patients, consisting of 40% women and 60% men with a mean age of 63.5 years and of which 88% were taking L-dopa, underwent a number of standardized clinical tests including part III of the UPDRS. They were also interviewed about the frequency of motor problems occurring at home. RESULTS: Loss of trunk rotation as expressed in rolling in supine and reduced arm swing were the most frequently registered motor disorders (73%, 75%). Freezing at the start of, or during, walking was not observed during clinical testing but was frequently claimed to occur at home (48%, 23%). A broad spectrum of deficits regarding gait, posture, transfers and distal motor problems formed a cluster, which was strongly correlated with bradykinesia (p < 0.001). Principal component analysis identified four distinct problem areas: (1) axial motor performance; (2) akinetic gait problems; (3) rigidity; and (4) tremor. CONCLUSIONS: Parkinson patients, particularly in the later stages of the disease, presented with significant levels of functional disability which was mainly linked with the underlying impairment of bradykinesia.

Disability in an urban black community in Zimbabwe.

PURPOSE: This study was undertaken to establish which health conditions are primarily responsible for disability and morbidity in a high-density area in Harare, Zimbabwe. METHOD: House-to-house screening visits were followed up by medical examination and interview of those identified as having a functional limitation. RESULTS: Information was obtained during screening on 10,839 residents. Of these, 608 were examined by medical professionals. The rate of disability/morbidity was 5.6% for the whole sample. Headaches and migraine were the most common problem. These were followed by back pain, hypertension and osteoarthritis. HIV/AIDS was the fifth most common condition. Depression, based on responses to a screening tool, was evident in one-third of the subjects. Common activity limitations included difficulty with the performance of housework activities and with walking. HIV/AIDS resulted in the most severe activity limitation, in that cognitive functions were also affected. CONCLUSION: The middle-aged and elderly with osteoarthritis and young women with depression constitute vulnerable groups who are not in a position to demand services. The older women particularly need assistance as they are bearing the double burden of their own degenerative conditions and the results of the HIV/AIDS pandemic.

Time use of stroke patients in an intensive rehabilitation unit: a comparison between a Belgian and a Swiss setting.

PURPOSE: Functional improvement after stroke has been related to the intensity of treatment. The present study was set up to observe how stroke patients spend their time in a rehabilitation unit. METHOD: Behavioural mapping was performed throughout a full working day in a Belgian and Swiss stroke unit. RESULTS: Patients were most frequently involved in therapeutic activities, 28% of the day in Belgium and 45% in Switzerland. Physiotherapy accounted for the majority of the therapy time. The Belgian patients spent 27% of the day in their own room and Swiss patients 49% of the day. The most striking finding was that the Swiss patients spent nearly 1.5 hours per day more in therapy. CONCLUSIONS: Differences between the two settings could only partially be explained by more favourable patient-staff ratios in the Swiss setting. Autonomous practice, group therapy sessions and family involvement have to also be considered.

Treatment of vertigo based on habituation. 2. Technique and results of habituation training.

In this paper we have tried to explain and to substantiate the physiopathological basis of a new method of treatment for vertigo. In accordance with experimental and clinical evidence, we have based it upon the principle of habituation, which favours the development of what is well-known in Otoneurology as 'central vestibular compensation'. The habituation effect, with pattern building and rebuilding, when applied to the functional sequelase of a labyrinthine lesions, can explain how a new, central regulation of balance can be rebuilt in spite of the persistence of peripheral dysfunction. Habituation is developed by repeating a specific mode of stimulation, but only for the effect of this particular stimulation. Our treatment, based upon the principle of habituation, consists in repeating those movements (or components of movements) which provoke dizziness. Habituation will be stimulated and the information pattern elicited during these movements evolves from 'unadapted' and 'unknown' to 'normal'.

The reliability of the Shona version of the EQ-5D.

BACKGROUND: There is an increasing need to have locally applicable health related quality of life outcome measures that are both reliable and valid. The aim of this paper was to present the Shona version of a Health Related Quality of Life Measure, the EQ-5D (Euro Quality of Life--5 Dimensions) and to examine the reliability and validity of the translated instrument. METHOD: Thirty eight test-retest responses from randomly selected members of a high density suburb in Harare were analysed. The measures of agreement (Kappa statistic) between the two sets of scores were very high and ranged from 0.78 to 1.00 for different domains of activity. The correlation between the two sets of scores in the section of the instrument that calls for valuation of health state on a visual analogue scale (VAS) was high (Spearman's rho = 0.793). It is suggested that, based on this small sample, the EQ-5D is a reliable measure of HRQoL and can be utilised in studies in a high density Shona speaking population.

Predicting motor recovery of the upper limb after stroke rehabilitation: value of a clinical examination.

BACKGROUND AND PURPOSE: Only a few studies have been conducted to predict motor recovery of the arm after stroke. The aims of this study were to identify which clinical variables, assessed at different points in time, were predictive of motor recovery, and to construct useful regression equations. METHOD: One hundred consecutive stroke patients who had an obvious motor deficit of the upper limb were evaluated on entry to the study (two to five weeks post-stroke) and at two, six and 12 months after stroke. The Brunnström-Fugl-Meyer test was used as the outcome measure. Predictors included demographic data, overall disability, clinical neurological features, neuropsychological factors and secondary shoulder complications. RESULTS: In multiple regression analyses, motor performance was invariably retained as the predictive factor with the highest R-square. Other significant predictive variables were overall disability, muscle tone, proprioception and hemi-inattention. Between 53% and 89% of the total amount of variance was accounted for in all selected models. The accuracy of prediction from clinical measurement in the acute phase diminished as the time span of measurement of outcome increased. Similarly, assessment of the variables at two and six months, rather than in the acute stage, resulted in a considerable improvement in the percentage variance explained at 12 months. The highest accuracy was obtained when predictions were made step-by-step in time. CONCLUSIONS: It is possible to predict motor recovery of the upper limb accurately through the use of a few clinical measures. Predictive equations are proposed, the use of which are practicable in both clinical practice and research.