Does the application of constraint-induced movement therapy during acute rehabilitation reduce arm impairment after ischemic stroke?

BACKGROUND AND PURPOSE: Motor dysfunction after unilateral deafferentation in primates can be overcome by restraining the unaffected limb. We asked whether a constraint-induced movement (CIM) program could be implemented within 2 weeks after stroke and whether CIM is more effective than traditional upper-extremity (UE) therapies during this period. METHODS: Twenty-three persons were enrolled in a pilot randomized, controlled trial that compared CIM with traditional therapies. A blinded observer rated the primary end point, the Action Research Arm Test (ARA). Inclusion criteria were the following: ischemic stroke within 14 days, persistent hemiparesis, evidence of preserved cognitive function, and presence of a protective motor response. Differences between the groups were compared by using Student's t tests, ANCOVA, and Mann-Whitney U: tests. RESULTS: Twenty subjects completed the 14-day treatment. Two adverse outcomes, a recurrent stroke and a death, occurred in the traditional group; 1 CIM subject met rehabilitation goals and was discharged before completing 14 inpatient days. The CIM treatment group had significantly higher scores on total ARA and pinch subscale scores (P:<0.05). Differences in the mean ARA grip, grasp, and gross movement subscale scores did not reach statistical significance. UE activities of daily living performance was not significantly different between groups, and no subject withdrew because of pain or frustration. CONCLUSIONS: A clinical trial of CIM therapy during acute rehabilitation is feasible. CIM was associated with less arm impairment at the end of treatment. Long-term studies are needed to determine whether CIM early after stroke is superior to traditional therapies.

Does modification of the Innsbruck and the Glasgow Coma Scales improve their ability to predict functional outcome?

BACKGROUND: The accurate prediction of functional outcome requires the development of multivariate models. To enhance their contribution to such models, the predictive power of each component must be optimized. OBJECTIVES: To improve the predictive power of coma scales as the first step in building more sophisticated multivariate models to predict specific levels of functional outcome. DESIGN: Prospective descriptive study. SETTING: Neurology and neurosurgery intensive care unit (NNICU) in a tertiary care academic center. PATIENTS: Eighty-four patients with acute traumatic brain injury, intracerebral hemorrhage, subarachnoid hemorrhage, or ischemic stroke. INTERVENTIONS: None. MAIN OUTCOME MEASURES: The Glasgow Coma Scale (GCS) and Innsbruck Coma Scale (ICS) were administered within 24 hours of admission to the NNICU and then at 48-hour intervals until discharge of the patient from the NNICU. The assessments were performed by 3 occupational therapy graduate students working under the supervision of the medical director of the NNICU. The functional outcome at 3 months after discharge from the hospital was assessed by telephone by the same nurse using the following categories: (1) dead, (2) receiving nursing home or custodial care, (3) home with help, or (4) independent. Cronbach's alpha estimates of reliability for each scale were computed using all scores obtained during the study. The analyses indicated that the verbal response item of the GCS and the oral automatisms item of the ICS were less reliable in this patient population. The scales were modified by deleting those items, and predictive validity for the original and modified scales was computed using a discriminant function of the admission scores. RESULTS: Before modification, both scales were best at predicting independence (GCS and ICS, 71% correct) and mortality (GCS, 60% correct; ICS, 56% correct). The modifications produced a modest improvement in the ability of both scales to better predict levels of outcome (modified GCS: home with help, 33% correct, independent, 71% correct; modified ICS: home with help, 0% correct, independent, 74% correct). CONCLUSIONS: By deleting items with low reliability from the ICS and the GCS we achieved improved reliability and predictive validity. The improvement in predictive power, however, was inadequate to accurately predict functional outcome. Combining clinical scales with other demographic, physiological, functional, and radiographic data will be needed to achieve useful predictions of functional outcome.

Artificial neural networks improve the prediction of mortality in intracerebral hemorrhage.

BACKGROUND: Artificial neural network (ANN) analysis methods have led to more sensitive diagnosis of myocardial infarction and improved prediction of mortality in breast cancer, prostate cancer, and trauma patients. Prognostic studies have identified early clinical and radiographic predictors of mortality after intracerebral hemorrhage (ICH). To date, published models have not achieved the accuracy necessary for use in making decisions to limit medical interventions. We recently reported a logistic regression model that correctly classified 79% of patients who died and 90% of patients who survived. In an attempt to improve prediction of mortality we computed an ANN model with the same data. OBJECTIVE: To determine whether an ANN analysis would provide a more accurate prediction of mortality after ICH when compared with multiple logistic regression models computed using the same data. METHODS: Analyses were conducted on data collected prospectively on 81 patients with supratentorial ICH. Multiple logistic regression was used to predict hospital mortality, then an ANN analysis was applied to the same data set. Input variables were age, gender, race, hydrocephalus, mean arterial pressure, pulse pressure, Glasgow Coma Scale score, intraventricular hemorrhage, hydrocephalus, hematoma size, hematoma location (ganglionic, thalamic, or lobar), cisternal effacement, pineal shift, history of hypertension, history of diabetes, and age. RESULTS: The ANN model correctly classified all patients (100%) as alive or dead compared with 85% correct classification for the logistic regression model. A second ANN verification model was equally accurate. The ANN was superior to the logistic regression model on all objective measures of fit. CONCLUSIONS: ANN analysis more effectively uses information for prediction of mortality in this sample of patients with ICH. A well-validated ANN may have a role in the clinical management of ICH.

Familial immotile-cilia syndrome in English springer spaniel dogs.

A laboratory-maintained colony of English springer spaniel dogs heterozygous for a putative autosomal recessive immotile-cilia syndrome (ICS) has been studied. Matings between dogs thought to be heterozygous for ICS resulted in 22 pups, five (three males and two females) of which were homozygous for ICS. Four of the five ICS-affected dogs had chronic rhinitis and bronchopneumonia. The other dog had a serious nasal discharge and died at 10 days. Four dogs had situs inversus totalis (kartagener syndrome), and the two males of reproductive age were azoospermic. In the two ICS dogs studied for ciliary function, in vivo mucociliary clearance was absent, and in vitro ciliary beat was rarely observed and of low frequency. Scanning and transmission electron microscopy disclosed the same lesions in respiratory cilia from all dogs with ICS, including random orientation and partial outer dynein arm deficiency. Four of five dogs with ICS had dilated lateral ventricles. One female pup with neonatal rhinitis and bronchopneumonia, situs solitus, and dilated lateral ventricles was presumed to be homozygous for ICS, but died without functional or structural confirmation of defective respiratory cilia. An autosomal recessive mode of inheritance for the ciliary defects and respiratory signs of ICS in these dogs is proposed.

Longitudinal change in three brief assessments of SDAT.

Previous research has shown that there is considerable interest in the development of brief indices for use in the diagnosis and staging of senile dementia of the Alzheimer's type (SDAT). Examples of such measures include the Blessed Dementia Scale (BDS) and Pfeiffer's Short Portable Mental Status Questionnaire (SPMSQ). A third measure used in the assessment of organic cognitive impairment is the Face-Hand Test (FHT). This study, which was part of a large longitudinal investigation of SDAT, examined the performance of 43 subjects with SDAT and 57 healthy controls over 30 months. The subjects were assessed three times during this period. In addition to the brief measures (BDS, SPMSQ, and FHT) all subjects were rated on a Clinical Dementia Rating (CDR) Scale based on a lengthy clinical interview. The data were analyzed by means of a series of univariate, repeated measures ANOVAs, and discriminant analysis. Results indicate: control scores did not change over time on any of the measures; when classified according to severity of SDAT, different patterns of performance emerged over time for each measure; and it is difficult to accurately predict progression of SDAT from the three scores.

Identification and measurement of productive behaviors in senile dementia of the Alzheimer type.

Caregivers of 106 individuals with senile dementia of the Alzheimer type (SDAT) were administered the Functional Behavior Profile (FBP) as part of a caregiver assessment battery. Three factors--task performance, problem solving, and social interaction--accounted for 70.6% of the variance. Analysis yielded a reliable and valid assessment that documents the observable productive behaviors of a person with SDAT. Significant differences across the stages of the disease were observed. The FBP can serve as a guide for individualized caregiving strategies by helping the caregiver focus on the presence of productive behaviors useful in managing the impaired person.

Home-based multidisciplinary diagnosis and treatment of inner-city elders with dementia.

The Memory and Aging Project Satellite (MAPS) of the Washington University Alzheimer's Disease Research Center was developed to meet the medical, social, and housing needs of minority and medically underserved elders with cognitive impairments. MAPS is located in the offices of the St. Louis Area Agency on Aging (AAA). This program provides multidisciplinary outreach, as well as home-based diagnosis, treatment, and case management. It differs from most other satellite programs in that it seeks to provide service to individuals who do not voluntarily seek help for dementia. Cognitively impaired clients had numerous, unmanaged medical conditions and social problems. Few clients were adequately served by health and social service systems. Despite recent contact, only 10% of clients received a formal diagnosis of dementia from a physician. Treatment was hampered by the absence or limitations of caregivers. Despite the complexities of these cases, the MAPS staff have been generally successful in addressing client problems.

Probable vitamin K--deficient bleeding in two cats with malabsorption syndrome secondary to lymphocytic-plasmacytic enteritis.

Two cats with intestinal malabsorption developed a hemorrhagic diathesis. Although unsubstantiated, the probable cause of bleeding was a chronic malabsorption of fat and the fat-soluble vitamin K. When treated with vitamin K1 per os, one cat's clotting times were only partially corrected. Since vitamin K1 is actively absorbed in the proximal small intestine, the incomplete response of this case to orally administered vitamin K1 was predictable. The infrequent occurrence of bleeding in animals with malabsorption is, in part, attributable to the ileal and colonic absorption of bacterially derived vitamin K2. For this reason, nonspecific use of antibiotics in these animals is contraindicated. Since long-chain, polyunsaturated fats impair vitamin K absorption, dietary fat given to animals with malabsorption should be restricted to medium- and short-chain, saturated fats. Vitamin K should be administered subcutaneously to these animals if prolonged clotting times or active bleeding is present, and routinely prior to surgery. Oral supplementation with vitamin K3, which is absorbed in the colon and less lipid soluble than vitamin K1, should be given to animals with malabsorption that are maintained as outpatients. Adequate dosage levels of vitamin K3, however, are yet to be established for the cat, and dose-dependent hemolytic anemia is a probable toxic manifestation.

Thoracic, abdominal, and vertebral actinomycosis. Diagnosis and long-term therapy in three dogs.

The clinical, laboratory, radiographic, and histologic features and the response to therapy in three dogs with actinomycosis are reported. One dog (dog 1) had a 12-cm nonresectable mass extending from the ventrolateral chest wall into the left ventricular myocardium. Another dog (dog 2) had a diffuse peritonitis with "sulfur granules" and two large masses. One of these masses was nonresectable involving adjacent abdominal structures. A third dog (dog 3) had a subvertebral mass at T1-3 producing quadraplegia. Two dogs had periosteal reactions involving adjacent sternebrae (dog 1) or ribs and vertebral bodies (dog 3) that are characteristic of Actinomyces spp infections. In dogs 1 and 2 the diagnosis was based on the morphologic and tinctorial properties of free sulfur granules and/or tissue granules. Culture results were variable. Tissue from dog 1 yielded no growth, while polymicrobial infections, which included Actinomyces spp, were identified in dogs 2 and 3. Actinomyces odontolyticus was isolated from dog 3. Although the actinomycotic granulomas were either not excised or only partially excised from dogs 1 and 2, both animals were cured by the oral administration of high doses of penicillin G for 19 and 6 months, respectively. Dog 3 responded dramatically to the same antibiotic therapy given for 5 months. However, within 4 months of discontinuing treatment an abscess and draining fistulous tracts developed in the left axillary region. Two surgical fistulectomies and additional penicillin therapy were required to cure this animal. These cases and the current veterinary and human literature on actinomycosis are used to propose a rational approach to the treatment of actinomycosis in the dog.

Plasma cell myeloma in the horse. A case report and literature review.

Plasma cell myelomas in horses have been reported infrequently. Data from 10 cases, 9 from the literature and 1 new case, are used to characterize the disease in the horse. Hot-blooded horses (7/10), specifically Quarter Horses (4/10), were most often affected. Median age at diagnosis was 11 years (range, 3 mo-22 yr) and both male (5) and female horses (5) were represented equally. Clinical findings included weight loss (6/8), anorexia (4/8), fever (4/8), limb edema (4/8), pneumonia (3/8), rear leg paresis/ataxia (3/8), epistaxis (3/8), palpable lymphadenopathy (2/8), and bone pain (2/8). Anemia (8/8) was present routinely, and in three horses, RBCs were macrocytic. Leukopenia (2/8), thrombocytopenia (2/8), and circulating plasma cells (3/8) were variable findings. Except for abnormal protein concentrations and hyponatremia (3), abnormal results from serum biochemical analysis including hypocholesterolemia (1), hypercalcemia (1), and azotemia (1) were reported infrequently. Hyperproteinemia (8/9), hypoalbuminemia (7/9), and hyperglobulinemia (8/9) were characteristic but not invariable findings. Monoclonal proteins (7/7) were detected in the alpha 2, beta, or gamma region by serum electrophoresis. The paraprotein's heavy chain, determined in four horses, was a subclass of IgG. Three horses had decreased concentrations of normal immunoglobulins. Variable proteinuria (trace to 4+) was detected by routine urinalysis in four of six horses. Bence Jones proteinuria was detected in one of five horses (heat precipitation) and monoclonal proteins were detected in two of three electrophoresed urine samples. Three of the horses had lytic bone lesions detected radiographically. Bone marrow aspirates were diagnostic in two of five horses.(ABSTRACT TRUNCATED AT 250 WORDS)

Treatment of canine blastomycosis with amphotericin B and ketoconazole.

The treatment of 62 dogs with blastomycosis was reviewed to identify prognostic factors and response to various treatment regimens. Severity of lung involvement, as determined by radiography, and the number of nonsegmented neutrophils were useful prognostic factors. Females survived treatment better than did males, but females were more prone to relapse. Ketoconazole treatment at a dose of 10 mg/kg daily for 60 days was not as effective as amphotericin B. The most notable adverse effect of amphotericin B treatment was nephrotoxicosis . Treatment with amphotericin B followed by ketoconazole was as effective as amphotericin B alone and resulted in less nephrotoxicosis . Most dogs that had relapses were retreated effectively with amphotericin B and/or ketoconazole. Canine blastomycosis was shown to be a treatable disease, with a cure rate of approximately 75%.

Hypoglycemia and chronic renal failure in a cat.

Spontaneous hypoglycemia developed in a 9-year-old cat with chronic renal failure. Resulting seizures stopped after intravenous administration of glucose, but the cat died within 10 hours. This case and reports in human beings suggest that hypoglycemia should be considered in any cat with chronic renal failure that experiences sudden deterioration in mental status or begins having seizures.

Portal hypertension secondary to a right atrial tumor in a dog.

A German Shepherd Dog was examined because of ascites and hepatomegaly. The finding of proteinaceous ascitic fluid and hepatic histologic features of centrizonal sinusoidal congestion suggested hepatic venous outflow obstruction. Diagnostic tests eliminated heart failure from the differential diagnosis and thus indicated an obstruction between the right atrium and hepatic sinusoids. Vascular manometry and angiography established the site of the lesion in the right atrium and confirmed portal vein hypertension. Surgical exploration revealed an unresectable right atrial tumor occluding the caudal vena cava.

Letter: Electrical method of detecting optimum time to inseminate.

PIP: Recently translated studies of the electrical resistance of cervical mucus as a test for the optimum time of insemination of agricultural animals are reviewed. The technique involves the measurement of the electrical conductivity of the surface of the mucosa in the vaginal vestibule. Experiments with cows and sows have shown that pregnancy or fertilization rates are considerably higher when mucosal electrical resistance is low at the time of insemination than when resistance is high. It has also been demonstrated in sows that mucosal resistance is higher in pregnant than in nonpregnant animals. Further research into these results is recommended.^ieng

Documenting productive behaviors. Using the functional behavior profile to plan discharge following stroke.

The Functional Behavior Profile (FBP) is presented as a clinically useful measurement tool to guide placement decisions following stroke. The measure provides the practitioner with a tool to identify the nature and extent of the behavioral capabilities and problems caregivers will face if they choose to manage their loved ones at home. The FBP yields information for planning treatment. Individuals with scores of 84 or lower were five times more likely to need supervision after discharge than those with scores of 85 or higher. The FBP was able to correctly classify 69% of the 45 patients in this study. Additionally, the FBP identified key behaviors that discriminated between patients who go home compared to those who require supervised care.

Cognitive performance in senile dementia of the Alzheimer's type: the Kitchen Task Assessment.

The Kitchen Task Assessment (KTA) is a functional measure that records the level of cognitive support required by a person with Senile Dementia of the Alzheimer's Type (SDAT) to complete a cooking task successfully. The results allow the clinician to help caregivers understand the level of support the impaired person needs to perform daily living tasks. This paper presents the validity and internal consistency of the KTA. Data were collected from 106 persons diagnosed with SDAT. Construct validity was established by examining the relationship between subjects' performance on the KTA and standard neuropsychological measures.

Initiating occupational therapy clinical research.

The purpose of research is to give us indications of what the effectiveness of particular treatments are on groups of people. The similarities between what we accept as a standard of education and practice and what we conceive to be research are striking. In both cases, these are disciplined methods of collecting and analyzing data, and acting upon the results of it. Those of us with clinical populations have unanswered questions and thus, good reasons for conducting research. The professional who wants answers must be willing to work for them knowing that the rewards and personal satisfaction will be great. Hopefully, the membership will recognize the importance of providing support to research and will be generous in their contribution to the American Occupational Therapy Foundation. The AOTF provides the necessary seed money to answer the questions that we are all facing.