The cortical topography of human swallowing musculature in health and disease.

Because no detailed information exists regarding the topographic representation of swallowing musculature on the human cerebral cortex in health or disease, we used transcranial magnetic stimulation to study the cortical topography of human oral, pharyngeal and esophageal musculature in 20 healthy individuals and the topography of pharyngeal musculature in two stroke patients, one with and one without dysphagia. Our results demonstrate that swallowing musculature is discretely and somatotopically represented on the motor and premotor cortex of both hemispheres but displays interhemispheric asymmetry, independent of handedness. Following stroke, dysphagia appeared to be associated with smaller pharyngeal representation on the intact hemisphere, which increases in size with recovery of swallowing.

Development of a schedule of current physiotherapy treatment used to improve movement control and functional use of the lower limb after stroke: a precursor to a clinical trial.

OBJECTIVE: To develop a treatment schedule of physical therapy techniques used to improve movement control and functional use of the paretic lower limb after stroke in U.K. clinical centers to be involved in a subsequent clinical trial of experimental interventions given in addition to routine clinical practice. METHODS: Ten physiotherapists experienced in stroke rehabilitation who worked in or near the clinical centers to be involved in a subsequent clinical trial completed an individual semi-structured interview. The verbatim transcripts were condensed independently by 2 researchers into a draft list of interventions. The researchers then resolved disagreement through discussion and produced a preliminary list of interventions. At a focus group meeting, the participating physiotherapists discussed the preliminary list, refined it to produce a final list, and then transformed it into a draft treatment schedule. The draft treatment schedule was piloted in clinical practice. Refinements were made, and the final treatment schedule was produced. RESULTS: The treatment schedule consists of an A4 recording form with instructions and glossary of terms printed on the back. Each treatment record provides information including duration of treatment, treatment aims, and the 45 specific physical therapy interventions provided in the 11 sections (e.g., "splinting techniques" and "function - in sitting towards standing"). CONCLUSION: A treatment schedule was produced, which can now be used in a subsequent phase II evaluative trial.

The effect of body position on arterial oxygen saturation in acute stroke.

BACKGROUND: Evidence suggests that respiratory function is impaired poststroke. Body position is known to influence respiratory function in normal subjects and those with respiratory pathologies. Its effect on respiratory function after stroke has received little attention. However, one study suggests that some positions used in clinical practice may adversely influence respiratory function. This study therefore aimed to identify resting positions that maintain arterial oxygen saturation (SaO2) at optimal levels, changes in SaO2 during time spent in the test position, and differences in SaO2 among the positions investigated. METHOD: A within-subject, two-center clinical study was made. Patients in the first 72 hours following mild to moderately severe stroke were allocated a randomized sequence of four positions. One hour was spent in each position. SaO2 was recorded each minute by pulse oximetry with a finger probe. Mean values for the hour were calculated. RESULTS: Mean arterial oxygen saturation values for all patients were >90% for the hour spent in each test position for all patients. There were no changes in arterial oxygen saturation across the hour spent in the test positions (repeated-measures analysis of variance). No differences in arterial oxygen saturation were identified among positions (analysis of covariance). DISCUSSION: The saturation levels recorded corresponded to those observed in studies of normal elderly persons. The positions tested may be recommended for use in clinical practice to maintain arterial oxygen saturation in patients in the first 72 hours following mild to moderately severe stroke.

Muscle activity during gait initiation in normal elderly people.

The purpose of this study was to describe the patterns of phasic muscle during gait initiation in normal elderly people. Bilateral surface EMG recordings were made of tibialis anterior, medial gastrocnemius and gluteus medius activity throughout gait initiation in 21 subjects. A variable expression of the onset muscle pattern is shown, with a tendency for muscle activity to be more variable in the preparatory phase. These results provide a baseline of normal gait initiation muscle activity against which to compare that of patients with gait initiation and balance difficulties.

The use of patterned neuromuscular stimulation to improve hand function following surgery for ulnar neuropathy.

A 60-year-old man with wasting and weakness of the right hand following ulnar nerve entrapment at the elbow was referred for electrotherapy. An ulnar nerve transposition had been performed 2 years previously. This had produced some improvement in nerve conduction without significantly improving hand muscle function. The right first dorsal interosseous muscle (FDI) was stimulated for 4 hours per day over a 6-week period with a stimulus pattern replicating the discharge of a single motor unit from a healthy, fatigued FDI (patterned neuromuscular stimulation or PNMS). The response was assessed using a single case design. Significant improvements in the strength and fatigue resistance of the FDI were observed, associated with improvements in general hand function. PNMS may be useful in restoring hand function in patients with muscle atrophy following entrapment neuropathy.

Some recent advances in the clinical aspects of multiple sclerosis.

UNLABELLED: Recent work on the clinical aspects of multiple sclerosis is reviewed with particular regard to symptomatology: New approaches to clinical symptoms and the identification of more subtle impairments are illustrated by recent studies of visual function in M.S. patients; pathophysiology: It is now widely appreciated that the dysfunction observed in patients is not determined solely by histologically demonstrable demyelination. The function of the demyelinated neuron is highly variable, being dependent upon factors which may change from day to day. Recent ideas about 'neuro-electric blocking factors' and other factors that may influence demyelinated neurons and hence symptoms are discussed; diagnosis: tests on C.S.F., electro-physiological and psychophysiological tests and computer tomography as aids to diagnosis and the controversy over 'specific' blood tests are reviewed; course and prognosis: Long term follow-up studies confirm that, in a significant proportion of cases, the course of M.S. may be benign and have identified some early prognostic indices; TREATMENT: The results of trials of symptomatic (spinal cord stimulation) and would-be curative therapies (such as dietary supplementation with poly-unsaturated fatty acids and immunosuppression) are briefly discussed.

An unusual case of myasthenia gravis in an elderly patient with severe muscular atrophy.

Myasthenia gravis is an uncommon disease and severe muscular atrophy is a rare manifestation. We present the case of an 83-year-old woman who demonstrates this clinical feature to an extreme degree and who survived 40 years after presentation, for most of this time without therapy.

Reasons for variability in the reported rate of occurrence of unilateral spatial neglect after stroke.

BACKGROUND AND PURPOSE: We sought to determine the frequency of occurrence of contralesional unilateral spatial neglect (USN) after stroke and to investigate the effect of side of lesion, nature of assessment tool used, and timing of assessment relative to stroke onset. METHODS: We performed a systematic review of published reports, identified by a search of electronic databases (MEDLINE 1966-1997, PSYCHLIT 1974-1996, and CINAHL 1982-1997) and by searching reference lists of the reports selected. Excluded were unpublished, non-English language, and nonhuman studies. RESULTS: Thirty published reports met the selection criteria, 17 of which directly compared right brain damage (RBD) and left brain damage (LBD). Contralesional USN appeared to occur more frequently after RBD than LBD in 16 of these. Both the assessment tool used and the time of assessment relative to stroke onset affected the reported rate of occurrence, although recovery rate data were inadequate (4 reports). CONCLUSIONS: The clinical belief that USN occurs more frequently after RBD than LBD was apparently supported by a systematic review of published data. However, an accurate estimate of the rates of occurrence and recovery after stroke could not be derived. Four reasons for the variability among studies were discussed, including subject selection, lesion localization, and nature and timing of assessment. Different USN disorders may exist, which may require type-specific rehabilitation approaches. This may have implications for epidemiological studies and for the development of new treatments. Theoretically driven epidemiological studies are required before adequately powered randomized controlled trials of rehabilitation can be conducted.

Intermittent compression for the treatment of the oedematous hand in hemiplegic stroke: a randomized controlled trial.

OBJECTIVE: To evaluate the efficacy of intermittent pneumatic compression in treating oedema in the hemiplegic hand of stroke patients. DESIGN: Single-blind randomized control trial. SETTING: acute and rehabilitation elderly care wards in a teaching district. SUBJECTS: 37 Subjects with a first ever hemisphere stroke were randomized to treatment with standard physiotherapy either alone or combined with intermittent pneumatic compression. MAIN OUTCOME MEASURES: The effect of treatment on oedema was assessed using measures of the hand volume of the hemiplegic hand. The impact on function was assessed using the motricity index. RESULTS: The treated group showed no change in the mean stroke hand volume. In the control group the mean stroke hand volume decreased by 3.2 ml. There was no statistically significant difference between the groups. The median scores for the motricity index increased for both groups but there was no significant difference between the groups and any improvement in motor function was independent of any treatment effects. CONCLUSION: Intermittent pneumatic compression at the prescribed pressure and duration of this study is not an effective treatment for the oedematous stroke hand.

Antiepileptic drugs: coprescription of proconvulsant drugs and oral contraceptives: a national study of antiepileptic drug prescribing practice.

OBJECTIVES: To determine the frequency of coprescription of antiepileptic drugs (AEDs) and drugs with proconvulsant potential and of coprescription of AEDs and low dose oral contraceptives. METHODS: Using information from all 294 fully computerised general practices participating in the General Practice Research Database who entered complete data in 1995, persons were identified who had a prescription for an antiepileptic drug and who had a diagnosis of epilepsy or epileptic seizures in their medical records. Other medication was also recorded. RESULTS: Of women with epilepsy aged 15-45, 16.7% were on the oral contraceptive pill and of 200 on both an enzyme inducing AED and an oral contraceptive, 56% were on formulations with an estrogen content less than 50 microg. This will be associated with increased risk of contraceptive failure and unwanted pregnancy. Over 10% of all AED prescriptions in adults were associated with simultaneous prescription of at least one drug with a potential proconvulsant effect. CONCLUSIONS: Prescribers should be alert to the possibility of pharmacodynamic and pharmacokinetic interactions between AEDs and other medication. With the aging of the population of people with seizures, and the polypharmacy often associated with old age, the likelihood of adversely interacting drug combinations will increase.

Spinal cord stimulation in multiple sclerosis: clinical results.

Clinical results of spinal cord stimulation by means of epidural electrodes are reported in 19 patients with multiple sclerosis. On temporary stimulation with percutaneous electrodes, significant improvement in mobility occurred in 27.7% of 18 patients and the same number showed improved sensory function. Only one of 13 patients with severe upper limb ataxia improved. The major response, both in terms of the percentage of patients responding and the extent of the responses seen was in bladder function: 75% of 16 patients with bladder symptoms improved and seven of the 11 patients with severe bladder disturbance (Kurtzke grade 3 or more) improved. Four of these seven patients had before and after cystometry and 3 showed reduced detrusor hyperreflexia. Altogether, 10 patients had a worthwhile clinical response in one or more aspects of the disease and of these, nine have so far gone on to permanent stimulation. Medium-term results (up to two years) show that, with one exception, improvement in bladder function has been maintained as long as stimulation has been continued and at least 50% of improvement in mobility has been maintained. A favourable response depends not upon the fact of stimulation but upon the type of stimulation received. This, along with other evidence, indicates that the response is not caused either by a placebo effect or by the natural fluctuation of the disease.

The quantitative assessment of the influence of spinal cord stimulation on motor function in patients with multiple sclerosis.

This paper gives the results of quantitative measurements of motor function made in a group of 23 patients receiving spinal cord stimulation (SCS) for multiple sclerosis. Although 14 out of the 23 patients reported subjective improvement in motor function and many felt these improvements were significant to them, only 4 patients showed an improvement in pyramidal function, only 1 in cerebellar function. There was no statistically significant improvement in walking speed. It is concluded that SCS does not have a major impact upon motor disability in multiple sclerosis and bladder dysfunction remains the main indication for SCS.

Freezing episodes in hemiparetic stroke: results of a pilot survey.

OBJECTIVE: To determine whether freezing episodes commonly occur in patients who have had a hemiparetic stroke. DESIGN: A postal questionnaire sent to 108 patients who had been admitted to our Stroke Unit with a hemiparesis due to an acute ischaemic stroke or a primary intracerebral haemorrhage. RESULTS: Ninety-three questionnaires were returned, of which 14 were unsuitable for analysis as the patients were unable to walk. The remaining 79 questionnaires were analysed (response rate 73%). Twenty-six (33%) patients reported freezing episodes while walking. CONCLUSIONS: Freezing episodes have been underappreciated in patients who have had a hemiparetic stroke. This is potentially important as these patients may benefit from some of the rehabilitation techniques currently being developed for patients with cerebral multi-infarct states who have similar gait problems. Future studies should be more widely based and designed to characterize the nature of the freezing episodes and their relationship to the location of the lesion.

Guillain-Barré syndrome in the elderly. A retrospective comparative study.

There have been no reported studies specifically devoted to the Guillain-Barré syndrome in elderly patients. The survey reported in this paper investigated the manifestations of the disease in older patients and compared them with those seen in younger patients. All adult patients with an established diagnosis of Guillain-Barré syndrome admitted over 9 years to a Regional Referral Centre providing services for a population of 543,213 were identified and studied. Fifteen patients were over the age of 60 years and 21 between 19 and 60 years of age. Antecedent illnesses and, in particular, gastro-intestinal symptoms were reported less frequently in older patients. Where there was an antecedent illness, this was of shorter duration in elderly subjects. Neurological symptoms related to peripheral nerve damage, such as paraesthesiae, myalgia, backache and an inability to stand, occurred with a similar frequency in both age groups. Double vision and facial weakness, however, occurred less often in older patients, and cerebellar features were not encountered in the older age group. The cerebrospinal fluid immunoglobulin abnormality was more marked in the elderly. The interval between onset and peak severity was shorter in elderly patients. The duration of hospital stay was significantly greater in the elderly, though the overall prognosis was similar in both age groups. There was only one death in each group. The incidence of the Guillain-Barré syndrome in the elderly was higher than in subjects aged 19-60 years, but this difference was not significant.(ABSTRACT TRUNCATED AT 250 WORDS)

Spinal cord stimulation in the United Kingdom.

All the medical, surgical and engineering personnel in the UK who have used spinal cord stimulation (SCS) in patients, attended a workshop to discuss their results. The major use of SCS has been for multiple sclerosis and intractable pain. It was concluded that the technique benefited up to two thirds of patients with bladder dysfunction, and that pain and possibly spasticity also responded to SCS, but other manifestations of multiple sclerosis did not. Further information on long term benefit is needed and the use of SCS in other conditions, such as spinal injury and peripheral vascular disease, is not yet established. SCS cannot be recommended for use outside large centres as x-ray screening, urodynamic and neurophysiological assessment facilities are required as well as biological engineering assistance.