Passive standing as an adjunct rehabilitation intervention after stroke: a randomized controlled trial.

BACKGROUND: Early physical rehabilitation enhances functional recovery in stroke survivors. Supported standing is a common adjunctive therapeutic practice in subjects with several central nervous diseases who are unable to stand actively. Data on the effect of supported positioning on standing frames in individuals with recent stroke are scarce and contradictory. OBJECTIVES: To verify if the addition of supported standing practice (SSP), delivered by means of a standing frame in two durations, to conventional physical therapy (CPT), may improve motor function, autonomy, and mobility in individuals with disability due to recent stroke. METHODS: After baseline assessment, 75 participants with severe disability due to stroke, all receiving CPT, were randomly assigned to adjunctive 20 or 40 min of SSP, or CPT only (control). Motor function, autonomy, and mobility were assessed before and after training, and three months later. RESULTS: All participants assessed received the planned dose of intervention. No adverse events of SSP were detected. Most outcome measures improved from baseline through the end of treatment and in the follow-up in all groups; the extent of change was comparable across the three randomization groups. CONCLUSIONS: In this randomized trial, SSP was unable to provide any sizeable adjunctive benefit, above and beyond CPT, in subjects with recent stroke.

Urinary incontinence after ischemic stroke: clinical and urodynamic studies.

AIMS: To investigate the frequency, the prognostic effect on functional status and the urodynamic patterns of post-stroke urinary incontinence (UI) in a sample of in-patients affected by ischemic stroke. METHODS: One hundred six patients with recent ischemic stroke admitted to a neurorehabilitation unit were enrolled. Stroke localization was made according to the Oxfordshire Community Stroke Project (OCSP) stroke subtypes and assessment of stroke severity using the National Institute of Health Stroke Scale (NIHSS). The presence of UI was associated with functional status, measured with Barthel Index and Functional Independence Measure (FIM). At admission, urodynamic studies were performed on all the patients and repeated in 63 patients after 30 days. RESULTS: Eighty-four patients (79%) were incontinent. Incontinence was associated with age (P<0.05) and functional disability (P=0.01), but not with sex, side of stroke, or time from stroke to entry in the study. Urodynamic studies, performed on all 106 patients at admission, showed normal studies in 15%, detrusor overactivity (DO) in 56%, detrusor overactivity with impaired contractility (DOIC) in 14%, and detrusor underactivity (DU) in 15%. After 1 month urodynamic studies, repeated on 63 patients, showed normal studies in 30%, DO in 48%, DOIC in 6%, and DU in 16%. CONCLUSIONS: Incontinent patients showed a worse functional outcome compared to continent patients. Post-stroke incontinence may be associated with different urodynamic patterns, each of which may necessitate different treatment strategies. Urodynamic findings in patients with ischemic stroke vary depending upon timing of the study.

Prognostic value of motor evoked potentials in motor function recovery of upper limb after stroke.

OBJECTIVE: To determine the prognostic value of clinical assessment and motor evoked potentials for upper limb strength and functional recovery after acute stroke, and to establish the possible use of motor evoked potentials in rehabilitation. DESIGN: A prospective study. SUBJECTS: Fifty-two patients with hemiparesis were enrolled one month post-stroke; 38 patients concluded the study at 12 months. METHODS: Motor evoked potentials were recorded at baseline and after one month. Upper limb muscular strength (Medical Research Council Scale, MRC) and functional tests (Frenchay Arm Test, Barthel Index) were used as dependent outcome variables 12 months later. Motor evoked potentials were classified as present or absent. Predictive values of motor evoked potentials and MRC were evaluated. RESULTS: At 12 months, patients with baseline recordable motor evoked potentials showed a good functional recovery (positive predictive value 94%). The absence of motor evoked potentials did not exclude muscular strength recovery (negative predictive value 95%). Motor evoked potentials had a higher positive predictive value than MRC only in patients with MRC < 2. CONCLUSION: Motor evoked potentials could be a supportive tool to increase the prognostic accuracy of upper limb motor and functional outcome in hemiparetic patients, especially those with severe initial paresis (MRC < 2) and/or with motor evoked potentials absent in the post-stroke acute phase.

Gait in hemiplegia: evaluation of clinical features with the Wisconsin Gait Scale.

OBJECTIVE: To assess the ability of the Wisconsin Gait Scale to evaluate qualitative features of changes in hemiplegic gait in post-stroke patients. DESIGN: A prospective observational study. SUBJECTS: Ten healthy subjects and 56 hemiplegic outpatients, more than 12 months post-stroke, consecutively admitted in a rehabilitation centre. METHODS: Patients were videotaped while walking at a comfortable speed. Quantitative and clinical gait parameters were derived from videotaped walking tasks at admission and at the end of a period of rehabilitation training. Qualitative features were assessed using the Wisconsin Gait Scale. Functional status was rated through the modified Barthel Index. RESULTS: After training, the median Wisconsin Gait Scale score improved significantly (28 vs 26.5; p = 0.003). In particular, "weight shift to paretic side" and patterns during the swing phase of the affected leg were improved. Gait velocity (0.3 vs 0.4 m/sec; p = 0.001) and stride length (77 vs 85 cm; p = 0.0002) increased significantly, whereas number of steps (25 vs 23; p = 0.004), stride period (2.5 vs 2.3 sec; p = 0.04), and stance period (2.1 vs 2 sec; p = 0.03) of the unaffected side were reduced. The Barthel Index score increased (71 vs 78; p = 0.005). CONCLUSION: The Wisconsin Gait Scale is a useful tool to rate qualitative gait alterations of post-stroke hemiplegic subjects and to assess changes over time during rehabilitation training. It may be used when a targeted and standardized characterization of hemiplegic gait is needed for tailoring rehabilitation and monitoring results.

Application of a volar static splint in poststroke spasticity of the upper limb.

OBJECTIVE: To evaluate clinical and neurophysiologic effects of 3-month reflex inhibitory splinting (RIS) for poststroke upper-limb spasticity. DESIGN: Pretest-posttest trial. SETTING: Outpatient rehabilitation center. PARTICIPANTS: Forty consecutive patients with hemiplegia and upper-limb spasticity after stroke that had occurred at least 4 months before. INTERVENTION: Patients wore an immobilizing hand splint custom-fitted in the functional position for at least 90 minutes daily for 3 months. MAIN OUTCOMES MEASURES: Patients underwent measurement of (1) spasticity at the elbow and wrist according to Modified Ashworth Scale; (2) passive range of motion (PROM) at the wrist and elbow; (3) pain at the shoulder, elbow, and wrist using a visual analog scale; (4) spasms; and (5) comfort and time of splint application. The instrumental measure of spasticity was the ratio between the maximum amplitude of the H-reflex and the maximum amplitude of the M response (Hmax/Mmax ratio). RESULTS: A significant improvement of wrist PROM (F=8.92, P=.001) with greater changes in extension than in flexion, and a reduction of elbow spasticity (F=5.39, P=.002), wrist pain (F=2.89, P=.04), and spasms (F=4.33, P=.008) were observed. The flexor carpi radialis Hmax/Mmax ratio decreased significantly (F=4.2, P=.007). RIS was well tolerated. CONCLUSIONS: RIS may be used as an integrative treatment of poststroke upper-limb spasticity. It can be used comfortably at home, in selected patients without functional hand movements, and in cases of poor response or tolerance to antispastic drugs.

Evaluation of upper-limb spasticity after stroke: A clinical and neurophysiologic study.

OBJECTIVES: To assess upper-limb spasticity after stroke by means of clinical and instrumental tools and to identify possible variables influencing the clinical pattern. DESIGN: Descriptive measurement study of a consecutive sample of patients with upper-limb spasticity after stroke. SETTING: Neurorehabilitation hospital. PARTICIPANTS: Sixty-five poststroke hemiplegic patients. INTERVENTIONS: Not applicable. Main outcome measures Upper-limb spasticity, as assessed clinically (Modified Ashworth Scale [MAS], articular goniometry) and neurophysiologically (maximum H-reflex [Hmax], maximum M response [Mmax], Hmax/Mmax ratio). RESULTS: Poorer MAS scores were associated with lower passive range of motion (PROM) values at the wrist ( P =.01) and elbow ( P =.002). The flexor carpi radialis Hmax/Mmax ratio correlated directly with MAS scores at the wrist ( P =.005) and correlated inversely with PROM. The presence of pain in the fingers, wrist, and elbow was significantly associated only with lower PROM values at the wrist. CONCLUSIONS: Upper-limb spasticity is involved in the development of articular PROM limitation after a stroke. Pain appears to be related to PROM reduction as well, but the exact causal relationship between these 2 factors is still unclear. The MAS and the Hmax/Mmax ratio correlated when evaluating poststroke spasticity; they characterize 2 different aspects of spasticity, clinical and neurophysiologic, respectively, and they could be used as an integrated approach to study and follow poststroke patients.

Chest wall kinematics in patients with hemiplegia.

Owing to difficulties in measuring ventilation symmetry, good evidence of different right/left respiratory movements has not yet been provided. We investigated VT differences between paretic and healthy sides during quiet breathing, voluntary hyperventilation, and hypercapnic stimulation in patients with hemiparesis. We studied eight patients with hemiparesis and nine normal sex- and age-matched subjects. Right- and left-sided VT was reconstructed using optoelectronic plethysmography. In control subjects, no asymmetry was found in the study conditions. VTs of paretic and healthy sides were similar during quiet breathing, but paretic VT was lower during voluntary hyperventilation in six patients and higher during hypercapnic stimulation in eight patients (p = 0.02). The ventilatory response to hypercapnic stimulation was higher on the paretic than on the healthy side (p = 0.012). In conclusion, hemiparetic stroke produces asymmetric ventilation with an increase in carbon dioxide sensitivity and a decrease in voluntary ventilation on the paretic side.

Dissociation between respiratory effort and dyspnoea in a subset of patients with stroke.

Dyspnoea is not a prominent complaint of resting patients with recent hemispheric stroke (RHS). We hypothesized that, in patients with RHS presenting abnormalities in respiratory mechanics, increased respiratory motor output could translate into an increased perception of dyspnoea. We studied eight wheelchair-bound patients with RHS (mean age 62.4 years), previously evaluated by computerized tomography scanning, and a control group of normal subjects, matched for age and sex. We assessed routine spirometry, inspiratory and expiratory muscle pressures, breathing pattern and dyspnoea using a modified Borg scale. In six patients, we also measured oesophageal pressure during the maximal sniff manoeuvre and tidal inspiratory swing, and mechanical characteristics of the lung in terms of dynamic elastance during both quiet breathing and a hypercapnic/hyperoxic rebreathing test. During room air breathing, ventilation and tidal volume were similar in patients and controls, while tidal inspiratory swings of oesophageal pressure, an index of inspiratory motor output, were greater in patients ( P =0.005). Patients also exhibited a greater dynamic elastance ( P =0.013). During rebreathing, dynamic elastance remained higher ( P =0.01) and a greater than normal inspiratory motor output was found ( P =0.03). Responses of ventilation and tidal volume to carbon dioxide tension were normal, and in all patients but one a lower Borg score for the unit change in carbon dioxide tension and ventilation was found. In conclusion, a higher than normal inspiratory motor output was unexpectedly associated with a blunted perception of dyspnoea in this subset of RHS patients. This is likely to be due to the modulation of the integration process of respiratory sensation.

Familial amyloid polyneuropathy with genetic anticipation associated to a gly47glu transthyretin variant in an Italian kindred.

The most frequent localization of amyloid in transthyretin (TTR) mutations is in the peripheral nerve, causing familial amyloidpolyneuropathy (FAP). It is generally accompanied by involvement of other organs such as the myocardium and kidney. To date, over 70 TTR point mutations have been reported in literature, with different phenotypes depending on the location of the mutation in the TTR gene. This paper deals with a point mutation in exon 2 position 47 of the TTR gene, encoding the substitution of glycine with glutamate. The mutation was found in an Italian family with 5 patients over 3 generations. The phenotype was characterised by peripheral neuropathy and autonomic dysfunction, associated in some patients with cardiomyopathy and renal involvement. The symptoms were very severe and the patients did not survive long, thus suggesting the aggressive nature of the pathological process. Moreover, in the succeeding generations of this family, there was genetic anticipation in the age of onset of the disease.