Dysphagia therapy in stroke: a survey of speech and language therapists.

BACKGROUND: Dysphagia is common after stroke, leading to adverse outcome. There is a paucity of high-quality evidence for dysphagia therapy, thus making it difficult to determine the best approaches to treatment. Clinical decisions are often based on usual practice, however no formal method of monitoring practice patterns exists. AIMS: To determine speech and language therapists' (SLTs) approaches to direct dysphagia therapy with stroke patients in the UK and Ireland. METHODS & PROCEDURES: A 24-item questionnaire was developed, piloted and delivered in a web-based cross-sectional survey targeting all SLTs working with stroke patients in the UK and Ireland. OUTCOMES & RESULTS: A total of 138 SLTs responded from a range of clinical settings and levels of experience. There was variation in the responses to all questions. Respondents reported treating patients a median of once a day, 3 days a week for 15 min. The most commonly recommended direct exercises were supervised swallow trials (recommended 'frequently or always' by 73%). Despite most respondents having access to an instrumental swallowing assessment, over half reported rarely or never conducting one before recommending exercises. Most (93%) did not use a protocol for systematically progressing patients' exercises and only 37% reported using standardized outcome measures. CONCLUSIONS & IMPLICATIONS: This survey gives valuable insight into the direct dysphagia therapy practices of SLTs based in the UK and Ireland working in stroke. It highlights discrepancies between reported approaches and recommendations from existing evidence and clinical guidelines. The variation in responses indicates a need to develop a consensus statement and further research to guide practice.

The use of minimally invasive techniques in multi-level surgery for children with cerebral palsy: preliminary results.

This study compares the initial outcomes of minimally invasive techniques for single-event multi-level surgery with conventional single-event multi-level surgery. The minimally invasive techniques included derotation osteotomies using closed corticotomy and fixation with titanium elastic nails and percutaneous lengthening of muscles where possible. A prospective cohort study of two matched groups was undertaken. Ten children with diplegic cerebral palsy with a mean age of ten years six months (7.11 to 13.9) had multi-level minimally invasive surgery and were matched for ambulatory level and compared with ten children with a mean age of 11 years four months (7.9 to 14.4) who had conventional single-event multi-level surgery. Gait kinematics, the Gillette Gait Index, isometric muscle strength and gross motor function were assessed before and 12 months after operation. The minimally invasive group had significantly reduced operation time and blood loss with a significantly improved time to mobilisation. There were no complications intra-operatively or during hospitalisation in either group. There was significant improvement in gait kinematics and the Gillette Gait Index in both groups with no difference between them. There was a trend to improved muscle strength in the multi-level group. There was no significant difference in gross motor function between the groups. We consider that minimally invasive single-event multi-level surgery can be achieved safely and effectively with significant advantages over conventional techniques in children with diplegic cerebral palsy.

FES cycling.

Spinal cord injury (SCI) leads to a partial or complete disruption of motor, sensory, and autonomic nerve pathways below the level of the lesion. In paraplegic patients, functional electrical stimulation (FES) was originally widely considered as a means to restore walking function but this was proved technically very difficult because of the numerous degrees of freedom involved in walking. FES cycling was developed for people with SCI and has the advantages that cycling can be maintained for reasonably long periods in trained muscles and the risk of falls is low. In the article, we review research findings relevant to the successful application of FES cycling including the effects on muscle size, strength and function, and the cardiovascular and bone changes. We also describe important practical considerations in FES cycling regarding the application of surface electrodes, training and setting up the stimulator limitations, implanted stimulators and FES cycling including FES cycling in groups and other FES exercises such as FES rowing.

Size and shape of the posterior neck muscles measured by ultrasound imaging: normal values in males and females of different ages.

Measurements of muscle strength or size are valuable indicators of muscle status in health and disease. When force cannot be measured directly, due to a particular muscle being one of a functional group or because of pain, size measurements may be the only option. For such data to be useful, normal values for age and gender are necessary. Procedures for scanning and measuring semispinalis capitis and the deep posterior neck muscles (semispinalis cervicis, multifidus and rotatores) using ultrasound imaging are described and normal data provided on size, shape and symmetry of these muscles from a sample of 99 healthy subjects (46 males aged 20-72 years and 53 females aged 18-70 years). Significant gender differences were found (P<0.001) but muscle size did not alter significantly with age. Between-side symmetry can be used to assess abnormality of the deep neck muscle group but not semispinalis capitis. A regression equation is provided for predicting the cross-sectional area (CSA) of the deep neck muscles from spinous process length in males. Clinically, linear measurements can be used to predict the neck muscle CSAs (r=0.66-0.84, P<0.001). The method described for assessing the neck muscles is a potentially valuable tool in clinical practice.

Ultrasound imaging of lumbar multifidus muscle: normal reference ranges for measurements and practical guidance on the technique.

This cross-sectional, prospective study aimed to produce normal reference data for measurements of the lumbar multifidus muscle. A total of 120 subjects, 68 females (aged 20-64 years) and 52 males (20-69 years) were studied. Bilateral transverse ultrasound images were made of multifidus at the fourth and fifth lumbar vertebrae (L4 & L5). Cross-sectional area (CSA, cm(2)) and linear dimensions (AP, anteroposterior; Lat, lateral) were measured and the latter expressed as a ratio (AP/Lat) to reflect shape. Relationships between CSA and anthropometric measures were examined. Multifidus CSA was larger in males (P<0.001) and age had no effect. The CSA was larger at L5 than L4 (P<0.001) and highly correlated between the two levels (males r=0.82, females 0.80). Differences in muscle shape were observed for gender, age and vertebral level. Between-side symmetry was high for size but not shape (CSA <10% difference). Linear measurements multiplied (APxLat) correlated highly with CSA (all groups r0.94, P<0.0001). The AP dimension was also acceptably predictive of CSA at L4 (r0.79). There were no clinically useful correlations between CSA and anthropometric measures. These findings provide normal references ranges for objective assessment of lumbar multifidus. This paper also addresses specific practical issues when scanning multifidus.

Effect of recommended positioning on stroke outcome at six months: a randomized controlled trial.

OBJECTIVE: To evaluate the effect on patient outcome of a teaching package for nurses designed to improve the positioning of stroke patients. DESIGN: Cluster randomized controlled trial with six-month follow-up. SETTING: Ten stroke rehabilitation hospital units located within one UK inner city region. These were randomized to control or intervention group. SUBJECTS: A sample of 120 patients admitted within four weeks of a first stroke and with a hemiplegia. No eligible patient refused to participate. Eighty-three (69%) completed the study. INTERVENTION: All nursing staff on the intervention units received a group teaching package to improve their clinical practice in patient positioning. MAIN OUTCOME MEASURE: Rivermead Mobility Index (RMI) at six months post stroke. Patient's position was recorded using an established observational tool. RESULTS: After the teaching there was some evidence of better positioning in the intervention than the control group (difference in percentage of correct positions per patient 4.9%, 95% confidence interval (Cl -0.1% to 9.9%, p = 0.055). There was no evidence of differences between the two groups in any of the outcome measures at six months although there was a trend towards increased elbow flexor tone in the control group. CONCLUSIONS: A teaching intervention to improve patient positioning made no significant impact on outcome at six months post stroke. However, following the teaching there was only a slightly higher incidence of recommended patient positioning within the intervention group. Thus, a teaching package may not be powerful enough to enable any effect on patient outcome to be measured.

The relationship between EMG and change in thickness of transversus abdominis.

OBJECTIVE: To investigate the relationship between changes in thickness and EMG activity in the transversus abdominis muscle of healthy subjects and the reliability of ultrasound measurements using different modes and transducers. DESIGN: Convenience sampling. BACKGROUND: Chronic low back pain is associated with transversus abdominis dysfunction but EMG studies of this muscle are restricted to invasive techniques. Since the thickness of transversus abdominis changes with activity, such changes measured from ultrasound images might provide insight into this muscle's function non-invasively. In addition, little is known about the comparability of ultrasound measurements from different modes and transducers, nor the reliability of transversus abdominis measurements. METHODS: In 9 healthy subjects (aged 29-52 years, four male) transversus abdominis was studied at rest and during activity (5-80% max) with simultaneous EMG and ultrasound (M mode, 5 MHz curvilinear transducer) measurements. Intra-rater reliability for thickness measurements was studied on 13 subjects using 7.5 MHz linear and 5 MHz curvilinear transducers in B and M modes. RESULTS: Muscle thickness changes correlated well with EMG activity (P < 0.001, R2 = 0.87) and there were no significant differences between subjects (P > 0.05). Using 7.5 MHz head, the ICC for B mode was 0.989 and for M mode was 0.981 for between days reliability. The ICC for between transducer reliability was 0.817. CONCLUSIONS: Changes in thickness of transversus abdominis can be used to indicate changes in the electrical activity in this muscle. RELEVANCE: Ultrasound scanning can be used in the clinical setting to provide objective information about transversus abdominis function.

The amplitude of the slow component of oxygen uptake is related to muscle contractile properties.

During constant-load exercise above the lactate threshold, oxygen-uptake kinetics deviate from the pattern seen below the threshold, with an additional, delayed component superimposed on the monoexponential pattern. It was hypothesised that this slow component is due to the progressive recruitment of type II muscle fibres. Oxygen uptake was measured for six male power athletes (group P) and six male endurance athletes (group E) during constant-load knee extension exercise tests in order to determine slow component amplitude. In addition, an electrical stimulation protocol was employed in order to assess the functional contractile profile and fatiguability of the knee extensors. The amplitude of the slow component during exercise was significantly ( P<0.05) greater in group P than in group E when expressed as an absolute value [mean (SEM)=77 (17) ml min(-1) and 24 (16) ml min(-1)] and when normalised to end-exercise oxygen uptake, VO(2) [8.2 (0.5)% and 2.6 (1.8)%]. Group differences were observed for percentage force loss during the electrical stimulation protocol [50.0 (3.4)% and 31.5 (3.7)% for groups P and E, respectively], increase in relaxation time from start to end of the fatigue test [87.9 (15.5)% and 31.1 (11.9)%], and relaxation time for fresh muscle [32.4 (1.0) ms and 40.6 (2.1) ms]. These contractile parameters may indicate a higher proportion of type II fibres in group P compared with group E. These experiments have shown evidence of a relationship between the amplitude of the slow component and muscle contractile properties, indicating that the origin of the slow component may lie in the pattern of different muscle fibre types.

Quadriceps voluntary activation at different joint angles measured by two stimulation techniques.

People are able to fully activate their quadriceps at mid-length during a brief isometric contraction but it is uncertain whether this is the case at other muscle lengths. With the twitch superimposition technique for determining levels of voluntary activation (VA), the muscle may be stimulated through the intramuscular branches of the nerve or via the nerve trunk itself. The former technique is easier to use, but different populations of motor units may be stimulated if the joint position is changed to alter muscle length. The purpose of this study was to investigate quadriceps VA at a range of knee joint angles using both magnetic stimulation of the motor nerve and percutaneous electrical stimulation over the muscle belly. Eight healthy subjects (six females, mean age 29 years) performed maximal voluntary contractions of the quadriceps at knee joint angles at 10-110 degrees of flexion. Surface electromyography (EMG) of quadriceps and hamstrings was recorded as an indication of the amount of muscle activity. Nearly all subjects showed >95% VA at all joint angles. VA did not vary with joint angle nor were there significant differences between the two stimulation techniques. Similarly, there was no significant effect of knee joint angle on the EMG activity of either muscle group. These findings indicate that VA of the quadriceps during a brief isometric contraction is not affected by muscle length and can be measured by either stimulation technique.

Effect of eccentric exercise on patients with chronic exertional compartment syndrome.

There are a number of similarities between chronic exertional compartment syndrome (CECS) and the effects of high force eccentric contractions in healthy controls. We hypothesised that CECS patients would be particularly susceptible to pain, fatigue and swelling after eccentric exercise. Ten CECS patients [aged 30.3 (8.0) years, mean (SD)], 7 males) and 14 healthy controls [aged 32.3 (9.0) years, 7 males] performed 40 maximal eccentric contractions of the anterior tibial muscles at an angular velocity of 90(o) s(-1). Maximal voluntary isometric contractions (MVC), force generated by electrical stimulation at 10 Hz and 50 Hz and muscle thickness (measured by real-time ultrasound scanning) were measured before exercise and for 10 min afterwards. Ratings of pain and tenderness were made before exercise, then 24 h and 48 h later. The two groups were comparable for initial isometric strength and muscle size. MVC force immediately after exercise fell to 90 (2.5)% [mean (SEM)] in patients and 86.5 (2.4)% in controls (P<0.0005 for both groups) and had not recovered after 10 min. Preferential loss of force at the low stimulation frequency occurred in both groups to a similar extent (20%, P<0.0005) and continued to decline over 10 min of recovery. There was no significant change in muscle thickness in either group. Only mild pain and tenderness were reported by the controls. The patients showed great individual variation but their mean pain scores were significantly higher during dorsiflexion and palpation (P<0.05) 24 h after exercise. After 48 h the patients reported more pain during dorsiflexion (P=0.005), plantarflexion (P<0.05) and palpation (P<0.05). These results suggest that some, but not all, CECS patients may be more susceptible to the pain associated with eccentric contractions that is thought to be the cause of damage and inflammation of connective tissue.

The human force:velocity relationship; activity in the knee flexor and extensor muscles before and after eccentric practice.

The human voluntary force:velocity relationship frequently fails to demonstrate the expected high eccentric forces. Possible explanations include unique activation strategies which might be affected by neural learning mechanisms. We investigated the effect of practicing eccentric contractions on (1) the force:velocity relationship of the human knee extensor muscles and (2) the extent of agonist and antagonist muscle activity. Eight healthy adults [seven women, group mean age 31 (SEM 5) years +/-] practiced twice a week for 4 weeks using their non-dominant legs. Each session comprised three isokinetic concentric and eccentric maximal voluntary contractions (MVC) at randomised angular velocities of 100, 200 and 300 degrees.s-1. Before and after, the force:velocity relationship was determined bilaterally (angular velocities 0-300 degrees.s-1). There were no significant differences in the forces generated or relative electromyogram (EMG) activity after practice, although there was a trend for dynamic forces to increase. Beforehand, the bilateral eccentric MVC forces were lower than isometric (P < 0.0025); afterwards they were broadly similar. The agonist EMG was similar during isometric and eccentric contractions, but lower during concentric (P < 0.03). Antagonist EMG activity showed considerable individual variation, was similar during all contraction types and tended to be greater during dynamic contractions. These data indicate that neither central learning mechanisms nor total muscle activation strategies underlie the human failure to produce the expected high eccentric voluntary forces in humans.

Knee muscle isometric strength, voluntary activation and antagonist co-contraction in the first six months after stroke.

PURPOSE: Muscle weakness may contribute to functional problems after stroke, but is rarely addressed during rehabilitation. Functional problems are commonly thought to be caused by abnormal movement patterns or possibly disuse atrophy. We investigated voluntary isometric strength, activation and the extent of co-contraction in the knee muscles during the first six months during stroke. METHODS: Twelve stroke patients (58 +/- 3 years, mean+/- SEM, 7 female) were studied bilaterally on admission for rehabilitation (21 +/- 1 days after stroke) and then at 1, 2, 3, and 6 months. Twenty healthy controls (61 +/- 5 years, 17 female) were tested once on their preferred leg. Subjects performed maximal voluntary contractions of the quadriceps and hamstring muscles. Simultaneous measurements were made of agonist force and surface EMG from agonist and antagonist muscles. Voluntary activation was estimated using the twitch superimposition technique. RESULTS: Both paretic muscles showed lower (p = 0.01-0.0005) voluntary strength than both non-paretic and control muscles until three months after stroke. Co-contraction of antagonists was similar in all groups and greater during knee extension than flexion. Stroke patients showed considerable bilateral voluntary activation failure (25-40%, p = 0.01-0.001) throughout the study while most control subjects did not (group mean 7%). CONCLUSIONS: The muscle weakness and bilateral activation failure in the stroke patients was not explained by either excessive antagonist activity or disuse atrophy. They had potential for increased voluntary strength and if this were addressed during rehabilitation, then the rate and extent of functional recovery might be enhanced.

Influence of muscle temperature during fatiguing work with the first dorsal interosseous muscle in man: a 31P-NMR spectroscopy study.

Six healthy subjects rapidly lifted and lowered a small (250 g) weight with the first dorsal interosseous muscle (FDI) of one hand while the work performed was recorded continuously until fatigue (defined as losing the ability to continue lifting). Work was recorded in units of chart recorder trace displacement from baseline (centimeters) as an isotonic transducer followed the movement of the weight. In all experiments, the temperature of the hand was first adjusted by immersion in a controlled-temperature water bath. In the warmest condition, the skin surface temperature over the FDI was 30.5(0.30) degrees C [mean (SE)]. After moderate cooling, this surface temperature was 21.5(0.16) degrees C. Cooling significantly reduced the time taken to reach fatigue and more than halved the work capacity. An intermediate degree of cooling was also used in four subjects, showing that most of the effects seen were changing incrementally. Before work, and at fatigue, intracellular metabolic conditions in the FDI were studied by phosphorus nuclear magnetic resonance (31P-NMR) spectroscopy, with occlusion of the blood flow maintained during measurements. The mean intracellular pH of the FDI was also calculated. The changes observed were all consistent with the fact that intense work requires energy which must be derived largely from intracellular stores of phosphocreatine and glycogen. Less work made less demand upon reserves, and created lower concentrations of waste products and by-products. The observations did not, however, allow us to explain why fatigue occurred at a particular point or why work capacity was reduced by cooling.

Inter-rater reliability of postural observation after stroke.

OBJECTIVE: To explore the inter-observer reliability of bedside observations of stroke patients' posture using two versions of a pictorial tool. DESIGN: Three projects were conducted. The initial version of the tool was used in project 1. The modified version was used in projects 2 and 3. In each project a pair of observers (comprising the main observer and one of five co-observers with varying degrees of experience in observing posture) used the tool to make simultaneous observations of 19 aspects of the posture of a sample of stroke patients. Each patient was observed in one or more of four positions (seated, supine and lying on the affected and unaffected side). The degree of inter-observer agreement was sought by calculating kappa values and percentage agreement. SETTING: Medical wards, care of the elderly wards and a stroke unit. SUBJECTS: A convenience sample of 57 stroke patients. RESULTS: Four hundred and forty paired sets of observations were made (200 in project 1, 140 in project 2 and 100 in project 3). The main observer was in every pair. The co-observers made between 50 and 135 sets of observations each. When the results from all three projects were amassed, acceptable percentage agreement (i.e. > or =70%) was obtained for 67% (n = 78) and 73% (n = 55) of the results collected on aspects of the posture of the affected upper and lower limbs respectively. In contrast, acceptable percentage agreement for observations relating to the head, neck and trunk was obtained for only 34% (n = 50) of the results collected. Uneven distributions in the data made kappa values difficult to interpret. Inter-observer agreement was not noticeably higher for pairs in which both observers had prior experience of observing posture after stroke than for pairs in which one observer was relatively inexperienced. CONCLUSIONS: The tool has potential as a quick and simple means of collecting information at the bedside about stroke patients' posture. Refinements, additional training in using the tool for observers and further testing are suggested before its wider use is advocated.

Positioning of stroke patients: evaluation of a teaching intervention with nurses.

BACKGROUND AND PURPOSE: There is agreement, although little evidence, that consistently positioning stroke patients in allegedly reflex-inhibiting positions is therapeutic and will enhance functional recovery. The nursing staff, therefore, needs to know and implement these postures and understand their potential underlying value. We examined nurses' knowledge of and practice in positioning stroke patients before and after a formal teaching intervention. METHODS: In a quasi-experimental study, 38 stroke patients and 59 nursing staff members (44 trained nurses and 15 healthcare assistants) from 6 wards were studied. The wards were randomly allocated to experimental or control status. Patients were assessed on entry into the study by use of a range of measures to establish group equivalence. Nineteen aspects of their position were documented at intervals throughout their stay with a previously developed observational tool. One thousand sets of observations of patient position were made. Using 2 questionnaires, the nurses' knowledge of the terminology used to denote posture and of issues relating to the moving and positioning of stroke patients was assessed before, immediately after, and 3 months after a package of formal teaching was implemented on the experimental wards. Nurse knowledge and patient position were used as the main outcome measures. RESULTS: Immediately after teaching, nurses in the experimental group scored significantly higher than those in the control group on the terminology questionnaire (P < 0.05) and the moving and positioning questionnaire (P < 0.001). Three months later, the experimental group scored higher on the latter questionnaire only (P < 0.005). The positioning of patients in the experimental group was improved overall after the teaching (P < 0.0005), and improvements to specific parts of the body were noted. CONCLUSIONS: It was possible to effect a degree of change in the nurses' knowledge of and practice in the positioning of stroke patients. However, the quality of patient positioning remained variable. More effective ways of improving positioning need to be developed. Only then can the effects of recommended positioning be evaluated.

Structural and functional changes in skeletal muscle in anorexia nervosa.

Protein-energy malnutrition in anorexia nervosa is an under-recognised cause of muscle dysfunction. To characterise the skeletal myopathy that occurs in patients with severe anorexia nervosa, muscle function and structure were comprehensively examined in eight young adult female patients with severe (40%) self-induced weight loss. All of the patients showed impaired muscle function on strength and exercise measurement. The maximum voluntary contraction force for the patient group was significantly less than predicted values. Electromyography revealed myopathy in five of the patients, four of whom also had electro-physiological evidence of neuropathy. However, muscle biopsy specimens consistently showed myopathic changes with severe type 2 fibre atrophy but with no evidence of neuropathic changes. Ultrastructurally, there was separation and segmental loss of myofibrils and most biopsy samples contained abundant glycogen granules; we have previously reported that one of the most consistent biochemical abnormalities in these patients is impaired ischaemic lactate responses to forearm exercise. The result of severe protein-energy malnutrition on the musculo-skeletal system is a metabolic myopathy. Although the patients admitted to a variety of abnormal dieting behaviours, such as over-exercising and self-induced vomiting, no association was found between any of these and quantitative histological changes in the muscle biopsy samples. It is recommended that myopathy in anorexia nervosa be treated by instituting an appropriate refeeding programme.

Quadriceps function, proprioceptive acuity and functional performance in healthy young, middle-aged and elderly subjects.

BACKGROUND: Muscle functions to generate force-producing movement and also has a role in proprioception. If ageing compromises these sensorimotor functions of muscle, the ability of older subjects to detect and correct postural sway may be impeded, resulting in impairment of functional performance. METHOD: To see if age-related changes occurred and, if so, what their effects might be. Quadriceps strength, proprioception, postural stability and functional performance were assessed in young (n = 20, mean age 23 years), middle-aged (n = 10, mean age 56 years) and elderly (n = 15, mean age 72 years) subjects. RESULTS: With increasing age there were decreases in quadriceps strength (r = -0.511; P < 0.001), acuity of joint position sense (r = -0.603; P < 0.001) and postural stability (ANOVA < 0.002) during stance conditions which placed a greater reliance on muscle proprioceptors. These changes may decrease postural stability confidence, resulting in impaired performance of common activities of daily living (r = 0.635; P < 0.001). CONCLUSIONS: The age-related deterioration in sensorimotor function of muscle may contribute to the increased fear and frequency of falls in elderly subjects, thereby decreasing independence.

Effect of manual therapy techniques on the stretch reflex in normal human quadriceps.

The effect of four manual therapy techniques on the quadriceps stretch reflex amplitude (elicited by mechanical vibration) was studied in a randomized, controlled trial in 120 (20 in each of six groups) healthy human subjects aged 18-64 years. Passive and active techniques were studied; each under static and dynamic conditions. The passive procedures were massage (static) and knee oscillation (dynamic) for 5 min. Active techniques involved eight repetitions of isometric quadriceps contractions (static) and leg extension (dynamic). The two static techniques had no effect on the stretch reflex amplitude. Both dynamic techniques caused a reduction (active by 25%, p < 0.00001 and passive 12%, p < 0.05). Only the active, dynamic technique caused a greater change than in the control group (p < 0.005). The effect lasted for less than 1 min. These data question the ability of such techniques to make clinically valid changes in motoneuron excitability. Further studies are required on those with neuromuscular pathology, who may respond differently to normal subjects.