Spasticity increases during pregabalin withdrawal.

PRIMARY OBJECTIVE: To determine whether pregabalin produces long-term spasticity reduction in subjects previously identified as responding in short-term trials. DESIGN, SUBJECTS AND SETTING: Prospective service evaluation of patients taking pregabalin for spasticity management for at least 1 year through a tertiary referral rehabilitation clinic. A graduated pregabalin withdrawal was undertaken as part of routine clinical management. METHOD: Twelve of 19 potential subjects agreed to participate. The primary outcome measures were visual analogue pain and spasticity scores at lowest dose of pregabalin compared to baseline and their choice to resume pregabalin therapy. RESULTS: Mean pre-withdrawal pregabalin dosage was 386 mg/day, decreasing to 70 mg/day at mean lowest dosage. Median subjective spasticity scores increased from 4 at baseline to 6 at lowest dose (p < 0.01) without a significant increase in median pain scores. Two patients with epilepsy, whose other anti-convulsants were not altered, had seizures. Following the evaluation, five subjects chose to return to the original dose, five recommenced pregabalin at a lower dose and two subjects no longer required the drug. CONCLUSION: Pregabalin withdrawal resulted in self-reports of increased spasticity without a concomitant increase in pain, with 91% choosing to continue pregabalin at the conclusion of the evaluation.

Head injury rehabilitation: the role of a neurotrauma clinic.

Survivors of head injury are often left with varying degrees of disability and complex and varied needs, necessitating prolonged periods of rehabilitation and continuing care. Advances have been made in the acute management of these patients, but continuing management in terms of rehabilitation remains deficient with lack of specialist resources and a fragmented service. For head-injured patients, lack of access to appropriate ongoing rehabilitation may have profound effects on outcome and social re-integration. There are also considerable economic implications for planning and provision of services. The aims of this paper are to describe, review and evaluate the role of a Neurotrauma clinic within the Head Injury Service at Addenbrooke's Hospital, Cambridge. The multidisciplinary Neurotrauma clinic commenced in June 2003 following an extensive collaborative research programme to assess current regional head injury service provision and address deficiencies and management issues. Patients of all ages with ongoing problems following varying severity of head injury are followed up at 2 months + post-injury for as long as appropriate. Patients complete an SF-36 and GOSE questionnaire at each clinic appointment and this self-reported data is complemented by neuropsychological assessments, and demographic data entered on a database. The clinic acts as a 'gateway' to access appropriate ongoing rehabilitation and a source of information and support. The routine collection of outcome data enables tracking of individual patient progress and outcome and provides an information resource for further research. The findings highlight deficiencies in rehabilitation both in general service provision and specific patient need. Evidence in support of demand, need and effectiveness of rehabilitation for head injury is particularly relevant within the limited resources of the NHS. Early indications show that a specialist clinic can assist in providing continuity of patient care, in improving coordination of services, and act as a resource for further research on epidemiology, outcome and impact of rehabilitation.

Pregabalin in the treatment of spasticity: a retrospective case series.

PURPOSE: To evaluate the therapeutic effects of the GABA analogue, pregabalin, on patients with conditions producing spasticity who had not responded to, or experienced problems with side-effects of the available anti-spasticity agents. METHOD: A retrospective case series review of 22 patients who were prescribed open label Pregabalin as monotherapy for spasticity, starting with 75 mg bd and increasing to 300 mg bd. Twenty one of these patients had previously tried gabapentin, 19 had tried baclofen, 7 had tried tizanidine and 3 had tried dantrolene. RESULTS: Twelve patients perceived a definite reduction in symptoms of spasticity with pregabalin, and 9 continued to take it. Eight patients experienced significant side-effects which limited its use, 5 experienced no beneficial or adverse effects. CONCLUSIONS: Pregabalin may be of value as a systemic agent in the treatment of spasticity, although properly controlled studies with clearly defined outcome measures are required to confirm this finding. This is relevant to the study of disability and rehabilitation because of the difficulties encountered in the management of spasticity and the impact that this can have on the rehabilitation of individuals with neurological conditions.

Combined transcranial direct current stimulation and robot-assisted arm training in subacute stroke patients: a pilot study.

BACKGROUND AND PURPOSE: Preliminary reports suggest that central stimulation may enhance the effect of conventional physical therapies after stroke. This pilot study examines the safety and methodology of using transcranial direct stimulation (tDCS) with robot-assisted arm training (AT), to inform planning a larger randomised controlled trial. SUBJECTS: Ten patients, after an ischaemic stroke 4-8 weeks before study onset, no history of epilepsy, participated. Eight had a cortical lesion and 2 had subcortical lesions: all had severe arm paresis and, co-incidentally, 5 had severe aphasia. METHODS: Over six weeks, they received thirty 20 min-sessions of AT. During the first 7 minutes, 1.5mA of tDCS was applied, with the anode over the lesioned hemisphere and the cathode above the contralateral orbit. Arm and language impairment were assessed with the Fugl-Meyer motor score (FM, full range 0-66) and the Aachener Aphasie Test. RESULTS: No major side effects occurred. Arm function of three patients (two with a subcortical lesion) improved significantly, with FM scores increasing from 6 to 28, 10 to 49 and 11 to 48. In the remaining seven patients, all with cortical lesions, arm function changed little, FM scores did not increase more than 5 points. Unexpectedly, aphasia improved in 4 patients. CONCLUSIONS: These procedures are safe, and easy to use in a clinical setting. In future studies, patients should be stratified by degree of arm weakness and lesion site, also the unexpected aphasia improvement warrants following-up.

The Papworth Early Rehabilitation Programme: vocational outcomes.

BACKGROUND: There are 2.7 million people in the UK receiving incapacity benefits, costing approximately pound 18 billion pa. Government has adopted a policy of helping claimants back into work, through structured vocational rehabilitation schemes. There are no published results of vocational rehabilitation services in the UK. We present the results of the Papworth Trust vocational rehabilitation programme. Depending on the severity of their disability, the 'Early Rehab Programme' aims to get people on incapacity benefits: (a) into employment, (b) fit for and seeking work, (c) involved in voluntary work, (d) education, or (e) able to live independently. METHODS: Retrospective chart survey and telephone follow up. SETTING: Cambridgeshire. RESULTS: Since 1995, 274 people attended for a preliminary interview, of which 107 subsequently started a full rehab programme. Eighty-seven were male and 20 female. Half had been unemployed for more than two years. Ninety-four completed the programme, of whom 53 had gained employment, 33 were 'work ready' and four were doing voluntary work. At long-term follow-up, 52 were employed, 12 were in voluntary work, and 7 had retired on medical grounds. CONCLUSIONS: This programme demonstrates that long-term Incapacity Benefit recipients can return to sustained employment, as shown in those who participated in the Papworth Trust's vocational rehabilitation programme.

Standards for head injury management in acute hospitals: evidence from the six million population of the Eastern region.

OBJECTIVES: To develop standards of care for head injury and thereby identify and prioritize areas of the service needing development; to report the findings from a survey of compliance with such standards in the Eastern region of UK. METHODS: The standards were collaboratively developed through an inclusive and iterative process of regional surveys, multidisciplinary conferences, and working groups, following a method similar to that used by the Society of British Neurological Surgeons. The standards cover seven topics relating to all aspects of service delivery, with standards within each objective. Each standard has been designated a priority level (A, B, or C). The standards were piloted using a self-assessment questionnaire, completed by all 20 hospitals of the Eastern region. RESULTS: Full compliance was 36% and a further 30% of standards were partially met across the region, with some areas of service delivery better than others. Seventy eight per cent of level A standards were either fully or partially met. Results were better in the north of the region compared with the south. CONCLUSION: A survey of compliance with the head injury standards indicate that, with their whole systems approach and subject to further refinement, they are a useful method for identifying deficiencies in service provision and monitoring for quality of care both within organisations and regionally.

Vitamin B12 metabolism in multiple sclerosis.

We have previously described 10 patients with multiple sclerosis (MS) and unusual vitamin B12 deficiency. We have therefore studied vitamin B12 metabolism in 29 consecutive cases of MS, 17 neurological controls, and 31 normal subjects. Patients with MS had significantly lower serum vitamin B12 levels and significantly higher unsaturated R-binder capacities than neurological and normal controls, and they were significantly macrocytic compared with normal controls. Nine patients with MS had serum vitamin B12 levels less than 147 pmol/L and, in the absence of anemia, this subgroup was significantly macrocytic and had significantly lower red blood cell folate levels than neurological and normal controls. Nine patients with MS had raised plasma unsaturated R-binder capacities, including three patients with very high values. There is a significant association between MS and disturbed vitamin B12 metabolism. Vitamin B12 deficiency should always be looked for in patients with MS. The cause of the vitamin B12 disorder and the nature of the overlap with MS deserve further investigation. Coexisting vitamin B12 deficiency might aggravate MS or impair recovery from MS.

Mapping rehabilitation resources for head injury.

Several reports have pointed to the unevenness in the UK of services for rehabilitation after head injury. A study was conducted in the Eastern Region of England to define the key stages in recovery and rehabilitation, by an iterative process of questionnaire, interview and consensus conference. Findings were translated into a draft set of maps showing current availability of services which were revised after feedback. Working groups then developed a set of definitions and classification codes for each stage of rehabilitation which were likewise disseminated for feedback. The maps were then redrafted to correspond with the definitions together with a flowchart of potential head injury rehabilitation services. The definitions were piloted at a regional neurosurgery unit and a rehabilitation hospital. Core services for neurorehabilitation region-wide were found to be variable and uncoordinated with fragmented and inequitable allocation of resources. The definitions and mapping system that emerged from this study should facilitate the design of care pathways for patients and identify gaps in the services.

Silicone roll-on suspension for upper limb prostheses: users' views.

OBJECTIVE: To determine the perceived benefit, pattern of use and problems of the ICEROSS socket for upper limb prostheses. DESIGN: Structured questionnaire sent to patients provided with ICEROSS systems. SETTING: NHS artificial limb clinic. SUBJECTS: All patients (20) who have used an upper limb prosthesis with an ICEROSS inner socket between 1995-1999. MAIN OUTCOME MEASURES: Purpose-designed questionnaire. RESULTS: Replies were obtained from 18 patients. Eight (8) amputees continue to use their ICEROSS limb regularly (44%) after a mean of 32 months. Ten (10) amputees stopped using the ICEROSS system. Six (6) developed persistent skin problems, 2 switched to myoelectric prostheses, 1 was unable to put the ICEROSS on independently and 1 amputee stopped using all kinds of prostheses because he did not find them useful. Fourteen (14) amputees complained of phantom pain, 4 of whom reported worsening of the pain with ICEROSS sockets. CONCLUSION: The ICEROSS socket provides good suspension for upper limb prostheses, but its use is limited by skin problems and incompatibility with myoelectric contacts.

Characterising phantom limb phenomena in upper limb amputees.

A systematic descriptive survey was carried out on a clinic population with acquired upper limb amputation in which clear distinctions were made between phantom experiences, pre-amputation pain and stump pain. It was found that of 76 participants 96% reported phantom experiences and 84% were currently experiencing phantom limb phenomena (PLP). Sixty-nine percent (69%) of those currently experiencing phantom phenomena stated that the phantoms were painful. Significant relationships were found between frequency of phantom experiences and side and level of amputation. In addition, the presence of 'trigger' points reported by a sub group of participants was found to be associated with the frequency of phantoms and painful phantoms. This finding could provide support for cortical reorganisation post amputation. It is suggested that detailed individual 'profiling' of phantom experiences is important and would have the following implications: it would contribute to existing knowledge and provide new insights into the central nervous system's reorganisation post-amputation; it would provide an accurate way of representing amputees' anomalous perceptions; it would alert health professionals to the presence, variety and extent of PLP following amputation.

Secondary prevention of arteriosclerosis in lower limb vascular amputees: a missed opportunity.

OBJECTIVES: To determine the numbers of patients with peripheral vascular disease prescribed secondary prevention agents following a lower limb amputation. DESIGN: A retrospective cross sectional study. METHODS: The clinical documentation of 107 vascular amputees (mean age 69.5, 2:1 male:female ratio) referred for prosthesis provision in 2004 and 2005 were analysed to determine levels of prescribing of anti-platelet agents, anti-coagulants and cholesterol lowering drugs. RESULTS: Analysis of vascular amputees referred in 2004 and 2005 reveals that 41% were prescribed a statin and 39% were prescribed a statin and 60% an anti-platelet agent. While 39% of these patients were on both drugs, 32% had been prescribed neither. CONCLUSIONS: The medical management of patients with severe peripheral vascular disease, even where their disease has led to an amputation, is sub-optimal.

A decade of change in regional head injury care: a retrospective review.

This paper reviews local and national changes and progress in the care of head injuries over the past decade in the Eastern Region.

Inappropriate acute neurosurgical bed occupancy and short falls in rehabilitation: implications for the National Service Framework.

Patients undergoing neurosurgical intervention may require different types of organized rehabilitation. A prospective study was performed of the care needs of neurosurgical inpatients between the ages of 16 and 70 years who were in acute wards for more than 2 weeks. Only 58% of bed occupancy days were devoted to essential acute neurosurgical ward management. This figure was even lower for patients admitted with subarachnoid haemorrhage (36%) or traumatic brain injury (38%). Overall, 21% of bed days would have more appropriately spent in 'rapid access'/acute rehabilitation beds, 13% in 'active participation' rehabilitation beds and 5% in cognitive/behavioural rehabilitation units. Addressing this unmet need would increase the availability of acute neurosurgery beds, without needing to build and staff more neurosurgery wards.

Lateral balance organisation in human stance in response to a random or predictable perturbation.

The effect of the predictability of perturbation to standing balance was evaluated in terms of the muscle activity and response dynamics of five subjects exposed to horizontal forces at the pelvis producing sideways or forward sway. Rapid (EMG onset latencies of 70-80 ms recorded from the left gluteus medius and gastrocnemius) and qualitatively different patterns of response were produced by forward pushes and pushes to either side. However, the EMG response to left push was constant in pattern and timing, whether the push direction was constant and, therefore, predictable over a block of trials or whether the left push trials were interleaved randomly with right push or forward push trials. Moreover, there were no systematic effects of perturbation direction uncertainty on the latency and rate of increase of ground reaction forces. We conclude that prior information does not speed postural responses that differ quantitatively according to the direction of perturbation to balance.

Ground reaction force after a sideways push as a measure of balance in recovery from stroke.

OBJECTIVE: To investigate if measuring ground reaction force after a sideways push at the hips gives a measure of standing balance in stroke subjects. METHODS: Fifteen control subjects and 13 right hemiparetic subjects who were able to stand independently stood with their feet on a single forceplate. Horizontal sideways pushes of 3% body weight were delivered to each side of the pelvis with the subjects held firmly in a semi-rigid belt. Measurements were made of lateral pelvic displacement (sway) and the lateral sheer component of ground reaction force (GRF). RESULTS: Right hemiparetic subjects showed significantly greater sway after a sideways push (p < 0.01) and later onset of GRF (p < 0.01) when pushed to their weak side compared with control subjects. There was also a positive correlation between sway after a sideways push and the onset latency of GRF in both strokes (0.41) and controls (0.61). The hemiparetic subjects swayed more (p < 0.01) when pushed to their weak side compared with their stronger side and their GRF latency was longer, but this latter measurement failed to reach statistical significance. No difference was seen between sides in sway or GRF latency in controls. CONCLUSIONS: The latency of GRF onset after a push at the hips in controls and in stroke subjects is related to sway and both measurements increase after a stroke. This test offers a method of measuring balance after a stroke, and serial testing of an individual after a stroke may prove a useful measure of an individual's recovery of balance.

Treadmill training with partial body weight support and physiotherapy in stroke patients: a preliminary comparison.

Treadmill training with partial body weight support can restore the gait ability of chronic non-ambulatory hemiparetic subjects. A combination of physiotherapy and treadmill training may accelerate the rate of recovery. Therefore a randomized study was planned. Twenty-eight non-ambulatory hemiparetic patients were randomly assigned to group A or B. A 3-week baseline of conventional therapy was followed by 15 sessions of physiotherapy and treadmill training in patients of group A and by 15 sessions of treadmill training in patients of group B over a period of 3 weeks. Follow-up was 4 months later. The major outcome variables were gait ability and ground level walking velocity. Gait ability and velocity did not change during the baseline. In group B, five patients became independent walkers after the specific intervention, whereas 10 patients of group A regained independent walking ability in the same period (P < 0.05). Four months later group differences had waned. Three weeks of treadmill training plus physiotherapy accelerated the restoration of gait ability in hemiparetic subjects, however, the double amount of therapy in group A does not exclude a simple dose-response phenomenon.

Stepping before standing: hip muscle function in stepping and standing balance after stroke.

OBJECTIVE: To compare the pattern of pelvic girdle muscle activation in normal subjects and hemiparetic patients while stepping and maintaining standing balance. DESIGN: Group comparison. METHOD: Seventeen patients who had regained the ability to walk after a single hemiparetic stroke were studied together with 16 normal controls. Median interval between stroke and testing was 17 months. Amplitude and onset latency of surface EMG activity in hip abductors and adductors were recorded in response to sideways pushes in either direction while standing. Similar recordings were made in the same subjects during gait initiation and a single stride. RESULTS: In the standing balance task, normal subjects resisted a sideways push to the left with the left gluteus medius (74 ms) and with the right adductor (111 ms), and vice versa. In hemiparetic patients, the amplitude of activity was reduced in the hemiparetic muscles, the onset latencies of which were delayed (gluteus medius 96 ms, adductor 144 ms). Contralateral, non-paretic, adductor activity was increased after a push towards the hemiparetic side of patients with stroke and the latency was normal (110 ms). During self initiated sideways weight shifts at gait initiation, hemiplegic muscle activation was impaired. By contrast, the pattern and peak amplitude of hip muscle activation in stepping was normal in both hemiparetic and non-hemiparetic muscles of the subjects with stroke. CONCLUSIONS: In ambulant patients with stroke, a normal pattern of activation of hemiparetic muscles is seen in stepping whereas the response of these muscles to a perturbation while standing remains grossly impaired and is compensated by increased activity of the contralateral muscles. This suggests that hemiparetic patients should be able to step before regaining standing balance.

Current practice of prophylactic anticoagulation in Guillain-Barré syndrome.

OBJECTIVE: To document the incidence of venous thromboembolism in Guillain-Barré syndrome and current practice of anticoagulating these patients. DESIGN: Retrospective study. SETTING: Acute neurology and rehabilitation wards in a teaching hospital. SUBJECTS: Seventy-three patients with Guillain-Barré syndrome admitted to Addenbrooke's Hospital from 1995 to 1999. RESULTS: Out of 73 patients, 50 were anticoagulated (68%) for 5-490 days with mean of 72 days. Anticoagulation was discontinued in 28 patients when they could walk independently and in six who were still wheelchair dependent. Five patients developed clinical deep venous thrombosis (DVT) (7%), three of them had pulmonary emboli. Venous thrombosis occurred in the first two months after onset in four patients. Two patients were not anticoagulated when they developed their DVT and the other three were on enoxaparin; one of these three had a pulmonary embolism and died. CONCLUSION: Despite prophylactic anticoagulants being used in the majority of patients admitted with major problems of mobility, 6% (3 out of 50) still developed clinically detected DVT and two developed pulmonary embolism. While this incidence is considerably lower than data reported before routine anticoagulation became a standard practice, these data reinforce the need for anticoagulation and suggest that full anticoagulation might be needed to reduce the incidence of thromboembolic complications further.