[Recovery from locked-in syndrome: rule rather than exception]. / Herstel na locked-insyndroom.

The prognosis for locked-in syndrome after acquired brainstem injury is unfavourable. However, partial recovery of motor function occurs in many patients and benefits from intensive rehabilitation. Here we evaluate two patient cases and results of a questionnaire among medical doctors specialised in rehabilitation. We define bottlenecks in the treatment of acute locked-in syndrome in the ICU. Locked-in patients have a years-long life expectancy once they have survived the acute phase. There is no validated prognostic instrument to predict recovery, but even small neurological recovery can have large functional benefits. Recovery may take place over an extended period of time, up to years after onset. To unlock the potential to recover we recommend to start with early rehabilitation while the patient is still in the ICU on life sustaining treatment This may set the patient off along the road from locked-in to unlocked.

Self-regulation as rehabilitation outcome: what is important according to former patients?

PURPOSE: Self-regulation refers to self-management and self-control, with or without disability. Outcomes of rehabilitation with respect to self-regulation are unclear. This study aims to identify elements of self-regulation that former patients consider important in the context of medical rehabilitation. MATERIALS AND METHODS: Qualitative exploration based on focus group discussions (FGDs). Transcripts were analysed using thematic analysis as well as open coding. Forty individuals participated in seven diagnosis-related FGDs. RESULTS: Six subthemes were raised in the FGDs which could be merged into three main themes. Two main themes are conditional for regaining self-regulation: 1) having insight into one's condition and abilities (i.e., insight into impairments. consequences of impairments. abilities); 2) to know how to cope with the consequences of the condition (be able to communicate limitations; have to trust in body and functioning). The subject of the last theme 3) is how to apply self-regulation in one's own life (to make use of abilities and optimize functioning). CONCLUSIONS: Three main themes of self-regulation in the context of medical rehabilitation were identified by former patients, partly relating to the ability to self-regulate and partly to the execution of self-regulation. This knowledge can be used to define specific rehabilitation goals and further develop rehabilitation outcome measurement.IMPLICATIONS FOR REHABILITATIONAwareness of the fundamental subthemes of self-regulation in rehabilitation will positively contribute to theory building and improve clinical practice (e.g., goal setting).Paying explicit attention to the six subthemes as standard elements of rehabilitation will help to provide a comprehensive view concerning self-regulation.The conceptual model of self-regulation, based on patient perspectives, can contribute to the measurement of rehabilitation outcomes.

Muscle fiber conduction abnormalities in early diabetic polyneuropathy.

OBJECTIVE: Diabetic polyneuropathy (PNP) has been proposed to be a primary disorder of sensory nerves. At an early stage motor nerve conduction velocity (MNCV) and muscle strength remain preserved due to compensatory mechanisms (axonal sprouting, reinnervation). We evaluated the use of invasive muscle fiber conduction velocity (MFCV) measurements as a method to detect muscle fiber denervation atrophy, as an early sign of motor axonal loss in diabetes mellitus (DM). METHODS: Twelve selected male patients (8 type 1, 4 type 2; mean age 35.8 years, SD 10.6), without any sign of micro- or macroangiopathy, were studied by systematic clinical and neurophysiological testing including MFCV estimation. RESULTS: Hand-held dynamometry was normal in all subjects. There were no signs of recent denervation by concentric needle EMG in any of the patients. Sensory nerve conduction velocity (SNCV) was abnormal in 6 subjects, MFCV in 6 subjects (5 had also low SNCV). The ratio of fastest/slowest muscle fibers in MFCV was correlated to SNCV of sural nerve (-.59, p < .05), but not to MNCV. CONCLUSIONS: Half of the clinically asymptomatic DM subjects showed sensory involvement together with MFCV abnormalities, despite normal needle EMG and force. SIGNIFICANCE: MFCV estimation offers a sensitive method in detecting early signs of motor axonal dysfunction in DM.

Long-term outcome of superficialis-to-profundus tendon transfer in patients with clenched fist due to spastic hemiplegia.

BACKGROUND: Spastic hemiplegia is a common feature after stroke, which can result in a clenched fist deformity with secondary hygienic problems and pain. Operative treatment can improve these problems, although literature about its long-term effects is lacking. PURPOSE: To determine whether Superficialis-to-Profundus tendon (StP-) transfer procedure leads to permanent improvement of hygiene and reduction of pain in patients with clenched fist due to spastic hemiplegia following stroke. METHOD: Patients who underwent a StP-transfer in 2003-2005 were evaluated on skin condition, upper extremity joint mobility, resting position and muscle tone and with VAS scores on hygiene maintenance and pain in the hand. RESULTS: Six patients (mean age 54 years; duration after stroke 10 years) were included. Indications to operate were hygienic problems only (3) or combined with pain (3). The average follow-up period was 19 months. After 6 weeks of post-operative splinting, no standard follow-up was applied. Serious post-operative complications were not reported. At follow-up no hygienic problems were present and pain was decreased in all except one patient. All hands could passively be fully opened. In resting position, flexion was seen in the MCP-joints (60-90 degrees). Muscle tone was raised in flexors of the wrist and fingers and m. adductor pollicis (Ashworth 1-2). Given the same pre- and post-operative circumstances, all patients would agree to have the surgery over again. CONCLUSION: Even 19 months after the StP-transfer for clenched fist, all operated hands could still be fully opened and there was a permanent improvement of hygiene and pain reduction.

Symptom scoring systems to diagnose distal polyneuropathy in diabetes: the Diabetic Neuropathy Symptom score.

AIMS: To provide one of the diagnostic categories for distal diabetic polyneuropathy,several symptom scoring systems are available, which are often extensive and lack in validation. We validated a new four-item Diabetic Neuropathy Symptom (DNS) score for diagnosing distal diabetic polyneuropathy. METHODS: We compared score characteristics of the generally accepted Neuropathy Symptom Score (NSS) with the DNS score, and tested construct validity,predictive value and reproducibility with the Diabetic Neuropathy Examination score, Semmes-Weinstein monofilaments and Vibration Perception Threshold(clinical standards) in 73 patients with diabetes (24 Type 1, 49 Type 2;43 male/30 female; mean age 57 years (19-90);mean diabetes duration 15 years (1-43)). RESULTS: Correlation between NSS and DNS score was high (Spearman r= 0.88). Patient scores were more differentiated on the DNS score. The relation of the NSS and DNS scores, respectively, with clinical standards was good (Spearman r= 0.21-0.60). Reproducibility of the DNS score was high (Cohen weighted kappa 0.78-0.95). The DNS score was easier to perform in clinical practice. CONCLUSIONS: The DNS is validated, fast and easy to perform, with a high predictive value when screening for diabetic polyneuropathy.