Quantifying Neurological Examination in 21st Century: Yilmaz- Ilbay Plantar Flexion Test, A Novel and Reliable Test for Evaluation of Plantar Flexion in L5-S1 Disc Herniation.

Background: Current methods used to measure the muscle strength required to achieve plantar flexion may yield highly variable results depending on the perception of the physician conducting the examination because these tests involve subjective and qualitative evaluation. Objective: To describe and evaluate the efficacy of a novel examination technique that can quantitatively measure plantar flexion in L5-S1 disc herniation. Materials and Methods: A total of 32 patients (average age: 49.4 years, range: 23-78) with L5-S1 disc herniations were included. The patient to be tested stood next to a table on which they could lean with their hands. The leg closer to the table was fully flexed at the knee, and the other foot was brought to maximum plantar flexion on the toes. At this point, a stopwatch was started to measure the time that passed until the muscles fatigued and the heel fell. The differences between the right and left plantar flexion times were noted. In addition, three different physicians graded muscle strength by using the classical "The Medical Research Council of the United Kingdom" method. Results: The time until fatigue in right and left plantar flexion was measured using the proposed method, and each test underwent a video recording. The Yilmaz-Ilbay plantar flexion test yielded the correct classification for all cases. Conclusion: We suggest that the proposed method "Yilmaz-Ilbay plantar flexion test" can serve as a useful, practical, and effective test to detect quantitative evaluation of plantar flexion in L5-S1 herniation.

Development of stimulus-driven attention test for unilateral spatial neglect - Accuracy, reliability, and validity.

We developed a simple method to assess stimulus-evoked attention function in unilateral spatial neglect (USN), and examined its accuracy, reliability, and validity. Thirty-one patients with USN and sixteen patients with right hemisphere damage without USN were given a task of reading Japanese characters that suddenly appeared on a display, and a reading or touching task of red Japanese characters that are arranged on the display. The sensitivity and specificity were calculated from the measurement results, and the cutoff value was calculated using the receiver operating characteristic curve. Area under the curve was used to evaluate the discriminatory ability. Reliability was calculated by the intraclass correlation coefficient using the test-retest method. Validity was assessed by correlating the scores of the new method with the scores of the traditional assessment, the behavioral inattention test, and the Catherine Bergego Scale. This new method was able to detect left USN with the same level of accuracy as the conventional assessment and showed moderate or better reliability. In addition, a moderate correlation was found with the conventional assessment, and a higher correlation was observed with items related to perception and cognition in daily life.

State and trait of finger tapping performance in multiple sclerosis.

Finger tapping tests have been shown feasible to assess motor performance in multiple sclerosis (MS) and were observed to be strongly associated with the estimated clinical severity of the disease. Therefore, tapping tests could be an adequate tool to assess disease status in MS. In this study we examined potential influencing factors on a maximum tapping task with the whole upper-limb for 10 s in 40 MS patients using linear mixed effects modelling. Patients were tested in three sessions with two trials per body-side per session over the course of 4-27 days of inpatient rehabilitation. Tested factors were the expanded disability scale (EDSS) score, laterality of MS, age, sex, hand dominance, time of day, session, trial (first or second), time between sessions, and the reported day form. A second model used these factors to examine the self-reported day form of patients. Linear mixed effects modelling indicated the tapping test to have a good inter-trial (proportional variance < 0.01) and inter-session reliability (non-significant; when controlling for time between sessions), an influence of hand-dominance (proportional variance 0.08), to be strongly associated with the EDSS (eta2 = 0.22, interaction with laterality of MS eta2 = 0.12) and to be not associated with the reported day form. The model explained 87% (p < 0.01) of variance in tapping performance. Lastly, we were able to observe a positive effect of neurologic inpatient rehabilitation on task performance obvious from a significant effect of the time between sessions (eta2 = 0.007; longer time spans between sessions were associated with higher increments in performance). Day form was only impacted by EDSS and the time of the day (p < 0.01, R2 = 0.57, eta2TIME = 0.017, eta2EDSS = 01.19). We conclude that the tapping test is a reliable and valid assessment tool for MS.

Split-hand index: A diagnostic and prognostic marker in amyotrophic lateral sclerosis across varying regions of onset.

OBJECTIVE: The split-hand index (SI), a reliable diagnostic marker of amyotrophic lateral sclerosis (ALS), was prospectively assessed for differences across ALS subtypes and between the onset side of clinical symptoms or the dominant and contralateral sides. In addition, the prognostic utility of the SI was longitudinally assessed. METHODS: Two hundred and forty-five ALS patients underwent measurement of SI on both sides compared with 126 neuromuscular mimic disorders (NMD). A subset of patients (N = 45) underwent longitudinal assessment of SI. RESULTS: The SI was significantly reduced (SI RIGHT ALS 5.47(4.2), SINMD 9.0 (5.0); P < 0.001; SILEFT ALS 5.5 (4.1), SI NMD 9.4 (5.0), P < 0.001) on both sides in all ALS patients with prominent reduction on the onset side in upper limb onset ALS (SI RIGHT P < 0.001; SI LEFT P < 0.05) and in Awaji definite/probable diagnostic category (SI RIGHT P < 0.05; SI LEFT P < 0.05). Longitudinal studies disclosed that the rate of SI decline correlated with the decline in ALSFRS-R (r = 0.21, P < 0.05). CONCLUSION: The SI is reduced in all ALS subtypes most prominently in upper limb onset disease, on the side of clinical onset, and in patients with Awaji definite/probable diagnostic category. SIGNIFICANCE: The split-hand index is a reliable diagnostic and outcome biomarker across ALS subtypes and may have potential utility in a clinical trial setting, although further multicenter studies are required to confirm this.

Automated Quantitative Pupillometry in the Critically Ill: A Systematic Review of the Literature.

OBJECTIVE: A systematic literature search has been performed to identify potential confounders for outcome prediction using pupillary light reflex in adult critically ill patients, as measured by handheld automated pupillometry devices. METHODS: Three digital databases (PubMed, EmBase, Cochrane) were systematically searched. Articles published between 1990 and 2019 in adult patients using monocular automated handheld devices were considered. Studies were classified according to the Oxford Centre for Evidence-Based Medicine classification (level 1 represents the highest and level 5 the lowest level of evidence). Case reports, original research, and systematic reviews were included and cross-referenced. RESULTS: With the use of 202 search terms, 58 eligible articles reporting the use of handheld pupillometry in the critically ill could be identified, considering 3,246 patients. The highest level of evidence came from 10 randomized trials and 19 prospective observational studies. The level of evidence was mostly 2 to 3 and highest with studies regarding the potential confounding effects of pain, the use of opioids, and increased intracranial pressure. Additional potential confounders found are selective serotonin reuptake inhibitors, α2-adregenic receptor agonists, and NMDA antagonists. CONCLUSIONS: The pupillary light reflex is susceptible to factors resulting from underlying comorbid conditions and effects of treatment regimens. Scenarios frequently encountered in critical care such as pain, use of opioids, and proof of increased intracranial pressure have potential confounding effects on outcome and pupillary reflexes. When treatment is guided by pupillary metrics, such confounders put patients at risk of overtreatment or undertreatment. Future research should validate and identify additional confounders, because our review suggests that even more unexplored confounders may exist.

Accurate prediction of clinical stroke scales and improved biomarkers of motor impairment from robotic measurements.

OBJECTIVE: One of the greatest challenges in clinical trial design is dealing with the subjectivity and variability introduced by human raters when measuring clinical end-points. We hypothesized that robotic measures that capture the kinematics of human movements collected longitudinally in patients after stroke would bear a significant relationship to the ordinal clinical scales and potentially lead to the development of more sensitive motor biomarkers that could improve the efficiency and cost of clinical trials. MATERIALS AND METHODS: We used clinical scales and a robotic assay to measure arm movement in 208 patients 7, 14, 21, 30 and 90 days after acute ischemic stroke at two separate clinical sites. The robots are low impedance and low friction interactive devices that precisely measure speed, position and force, so that even a hemiparetic patient can generate a complete measurement profile. These profiles were used to develop predictive models of the clinical assessments employing a combination of artificial ant colonies and neural network ensembles. RESULTS: The resulting models replicated commonly used clinical scales to a cross-validated R2 of 0.73, 0.75, 0.63 and 0.60 for the Fugl-Meyer, Motor Power, NIH stroke and modified Rankin scales, respectively. Moreover, when suitably scaled and combined, the robotic measures demonstrated a significant increase in effect size from day 7 to 90 over historical data (1.47 versus 0.67). DISCUSSION AND CONCLUSION: These results suggest that it is possible to derive surrogate biomarkers that can significantly reduce the sample size required to power future stroke clinical trials.

Ultrasound guidance may have advantages over landmark-based guidance for some nerve conduction studies.

BACKGROUND: Precise placement of stimulating and recording electrodes is vital when performing nerve conduction studies (NCSs). In this study, we aimed to determine whether ultrasonography (US) was more precise in localizing the superficial radial nerve (SRN), dorsal ulnar cutaneous nerve (DUCN), ulnar nerve (UN) crossing the cubital tunnel, and radial nerve (RN) crossing the spiral groove (SG) compared to conventional techniques. METHODS: Thirty healthy young subjects (15 male) were recruited. Each subject underwent both landmark-based and US-guided NCS. Onset latencies and amplitudes of compound motor action potentials (CMAPs) and sensory nerve action potentials (SNAPs), and stimulation levels (ie, intensity × duration) required to obtain maximal CMAP amplitudes were compared between the two techniques. RESULTS: The mean CMAP amplitudes of the UN above the cubital tunnel (9.55 ± 1.96 vs 8.96 ± 1.94 mV, P = .030), UN below the cubital tunnel (10.11 ± 2.07 vs 9.37 ± 1.95 mV, P < .001), and RN below the SG (5.21 ± 1.56 vs 4.34 ± 1.03 mV, P < .001) were significantly greater using US-guided NCSs compared to landmark-based NCSs. The mean onset latency of the DUCN was significantly shorter using US-guided NCSs (1.49 ± 0.15 vs 1.57 ± 0.14 ms, P = .020). The required stimulation level in the UN and RN was significantly lower using US-guided NCSs. CONCLUSIONS: When performing NCSs, US guidance provides a more precise localization of the stimulator and electrodes for the DUCN, UN, and RN, while providing comparable localization for the SRN, compared to landmark-based techniques.

Assessing Physical Medicine and Rehabilitation Residency Education Using the Neurological Assessment Competency Evaluation System.

ABSTRACT: Competent neurologic examination and clinical skills are essential components in the care for patients in acute hospital and rehabilitation settings. To enhance the evaluation and education of Physical Medicine and Rehabilitation residents, the authors developed an educational objective structured clinical examination, the Neurological Exam Assessment Competency Evaluation System, and gathered 2 yrs of baseline data. The Neurological Exam Assessment Competency Evaluation System consisted of nine 9-min examination stations, seven with written clinical scenario with instructions for junior residents to complete the appropriate examination (stations: Altered Mental Status, Mild Traumatic Brain Injury, Dementia, Stroke, Falls, and the International Standards for Neurological Classification of Spinal Cord Injury Sensory and Motor Examinations). Examinees provided written responses to posed questions for the other two stations-Modified Ashworth Scale and brachial plexus. The assessment tools for this examination were designed for residency programs to evaluate the basic competencies as outlined by the Accreditation Council for Graduate Medical Education and Physical Medicine and Rehabilitation milestones. Based on the feedback received from the examinees and examiners, the Neurological Exam Assessment Competency Evaluation System can serve as an educational objective structured clinical examination for the improvement of trainee core competencies.

Development of Gross Motor Evaluation for Children Aged 18 to 42 Months.

PURPOSE: To test the reliability and validity of the gross motor items making up a new instrument, Hong Kong Comprehensive Assessment Scales for Toddlers (HKCAS-T) for quantifying gross motor development among children aged 18 to 42 months. METHODS: The 37 items were administered to 330 children, including 258 typically developing children and 72 children with gross motor delay. RESULTS: Rasch analyzes indicated that the fit statistics of the 37 items were within the acceptable range. The assessment was found able to differentiate between typically developing children and those with gross motor delay and among children of different ages. The raw score reliability (KR-20) was 0.94. CONCLUSION: The new instrument is a promising alternative for assessing young children's gross motor development.

Can the ARAT Be Used to Measure Arm Function in People With Cerebellar Ataxia?

OBJECTIVE: For people with ataxia, there are validated outcome measures to address body function and structure (BFS) impairments and participation; however, no outcome measure exists for upper extremity (UE) activity level in this population. The purpose of this study was to determine whether the action research arm test (ARAT), a measure of UE activity validated for other neurological conditions, might be a useful outcome measure for capturing UE activity limitations in ataxia. METHODS: A total of 22 participants with ataxia were evaluated to assess construct validity of the ARAT; 19 of the participants were included in the interrater reliability assessment. Participants received a neurologic examination and completed a battery of outcome measures, including the ARAT. ARAT performance was video recorded and scored by 4 additional raters. RESULTS: For construct validity, Spearman rho showed a significant moderate relationship between the ARAT and BSF outcome measures. A small, nonsignificant relationship was noted for the ARAT and the participation measure. For interrater reliability, Spearman rho showed a large, significant relationship among all raters for the ARAT (range = .87-.94). High reliability was demonstrated using the intraclass correlation coefficient ([2,1] = .97). CONCLUSION: The ARAT is moderately correlated with ataxia BFS outcome measures, but not with participation scores. The ARAT is a measure of UE activity, which is different from BFS and participation outcome measures. The ARAT was identified to have strong interrater reliability among raters with varying amounts of experience administering the ARAT. Thus, for the ataxic population, the ARAT may be useful for assessing UE activity limitations. IMPACT: Ataxia can negatively affect reaching tasks; therefore, it is important to assess UE activity level in people with ataxia. Until this study, no outcome measure had been identified for this purpose. LAY SUMMARY: People with ataxia may have difficulty with daily tasks that require reaching. The ARAT is an outcome measure that clinicians can use to assess UE activity limitations to help design a treatment program.

Concurrent and predictive validity of the Motor Functional Development Scale for Young Children in preterm infants.

BACKGROUND: The Motor Functional Development Scale for Young Children (DF-mot) is a developmental tool assessing both gross and fine motor skills in term infants. AIMS: To examine the concurrent validity of the DF-mot with the Alberta Infants Motor Scale (AIMS) in preterm infants and compare their ability in predicting scores on the Bayley Scales of Infant-Toddler Development (Bayley-III) at 12 months. STUDY DESIGN: Retrospective cohort study. SUBJECTS AND OUTCOME MEASURES: Hundred and eleven infants born at less than 32 weeks' gestation or with a birthweight less than 1500 g were assessed simultaneously on the DF-mot and the AIMS at age 3-5 months. Correlation analysis was used to determine the strength of association between the DF-mot and the AIMS. Among these, 62 were reassessed on the Bayley-III at age 9-12 months. Clinimetric properties were calculated to evaluate their ability to predict motor delay on the Bayley-III. RESULTS: The concurrent validity study found a good level of correlation between the two scales (r = 0.79). The predictive validity study showed good sensitivity and negative predictive value for the AIMS 25th centile and the DF-mot -1 standard deviation to predict motor delay at 12 months (respectively Se = 100% and 84%; NPV = 100% and 77.8%). CONCLUSIONS: The DF-mot is a valid instrument with good predictive validity in preterm infants, suggesting it can be used as a clinical useful tool to assess motor development.

A new child-friendly 3D bimanual protocol to assess upper limb movement in children with unilateral cerebral palsy: Development and validation.

Unilateral cerebral palsy (uCP) causes upper limb movement disorders that impact on daily activities, especially in bimanual condition. However, a few studies have proposed bimanual tasks for 3D motion analysis. The aim of this study was to validate the new version of a child-friendly, 3D, bimanual protocol for the measurement of joint angles and movement quality variables. Twenty children with uCP and 20 typically developing children (TDC) performed the five-task protocol integrated into a game scenario. Each task specifically targeted one or two upper limb degrees of freedom. Joint angles, smoothness and trajectory straightness were calculated. Elbow extension, supination, wrist extension and adduction amplitudes were reduced; hand trajectories were less smooth and straight in children with uCP compared to TDC. Correlations between the performance-based score and kinematic variables were strong. High within and between-session reliability was found for most joint angle variables and lower reliability was found for smoothness and straightness in most tasks. The results therefore demonstrated the validity and reliability of the new protocol for the objective assessment of bimanual function in children with uCP. The evaluation of both joint angles and movement quality variables should increase understanding of pathological movement patterns and help clinicians to optimize treatment. ClinicalTrials.gov identifier: NCT03888443.

Alberta Infant Motor Scale: Cross-cultural analysis of gross motor development in Dutch and Canadian infants and introduction of Dutch norms.

BACKGROUND: The Alberta Infant Motor Scale (AIMS) has been developed in Canada in the 90ies. The AIMS and its Canadian norms are frequently used across the world to monitor infants' gross motor development. Currently, it is disputed whether the Canadian norms are valid for non-Canadian infants. AIMS: To compare scores on the AIMS of Dutch infants with that of the Canadian norms, to compare the sequence of motor milestones in Dutch and Canadian infants, and to establish Dutch AIMS norms. STUDY DESIGN: Cross-sectional study. SUBJECTS: 1697 infants, aged 2-18 months, representative of the Dutch population (gestational age 39.7 weeks (27-42)). OUTCOME MEASURE: AIMS assessments, based on standardized video. Perinatal and social information was obtained by questionnaire and medical records. To create Dutch reference values quantile regression with polynomial splines was used. RESULTS: 1236 Dutch infants (73%) scored below the 50th (P50) percentile of the Canadian norms, 653 (38%) below the P10 and 469 (28%) below the P5. In infants aged 6 to 12 months these values were: 567 infants (81%) < P50, 288 infants (41%) < P10, 201 infants (29%) < P5. The sequence of achievement of motor milestones of Dutch and Canadian infants was similar. Dutch norm-reference values of the AIMS were calculated. CONCLUSIONS AND IMPLICATIONS: Gross motor development of Dutch infants is considerably slower than that of the Canadian AIMS norms sample. To prevent overdiagnosis of developmental delay and overreferral to paediatric physiotherapy Dutch AIMS norms are required. The paper introduces these norms, including percentile ranks.

Test Utilization and Value in the Evaluation of Peripheral Neuropathies.

Peripheral neuropathies can be classified as typical or atypical. Patients with atypical neuropathy have one or more of the following features: acute/subacute onset, non-length dependence, motor predominance, or asymmetry. This classification is important because it informs the appropriate diagnostic evaluation of this highly prevalent condition. The evaluation of a typical peripheral neuropathy, also known as distal symmetric polyneuropathy, requires a thorough history, neurologic examination, and focused laboratory testing. Electrodiagnostic testing and MRI account for the majority of costs but rarely lead to changes in diagnosis or management. These costs are increasingly being passed on to patients, especially those with high-deductible health plans. In contrast, patients with atypical neuropathy require more extensive testing, including electrodiagnostic tests. These tests are much more likely to lead to the use of disease-modifying therapies in these patients compared to in those with typical peripheral neuropathy. This article describes two cases to illustrate the appropriate diagnostic workup of those with typical or atypical neuropathy.

Self-Reported Versus Objectively Assessed Olfaction and Parkinson's Disease Risk.

BACKGROUND: Poor olfaction is a prodromal symptom of Parkinson's disease (PD); however, self-reported sense of smell is often dismissed as unreliable. OBJECTIVE: To assess self-reported and objectively assessed sense of smell, independently and jointly, in relation to future risk for PD. METHODS: We conducted a prospective analysis using data from 2,424 participants, ages 71-82 at baseline, from the Health, Aging, and Body Composition study. Exposures were self-reported poor sense of smell or taste and the objectively measured 12-item Brief Smell Identification Test score. The outcome was incident PD, analyzed using Cox proportional hazard models adjusted for age, sex, race, and cognitive function. RESULTS: After approximately 10 years of follow-up, both self-reported and objectively tested poor sense of smell were independently associated with a higher risk of developing PD: the hazard ratios (95% confidence interval) were 2.8 (1.3, 5.9) and 4.0 (2.1, 7.5), respectively. When analyzed jointly, compared with participants who reported and tested normal, the hazard ratio was 2.2 (1.0, 4.6) for those reported poor sense of smell but tested normal, 3.6 (1.9, 6.9) for reported normal but tested poor, and 7.8 (3.2, 19.4) for both reported and tested poor. We did not find significant interactions between self-reported and objectively tested sense of smell in predicting PD risk. CONCLUSION: This study provides preliminary evidence that self-reported poor sense of smell or taste should not be simply dismissed as useless in predicting risk of PD. Future studies should confirm our finding and evaluate whether structured questionnaires may further improve the predictability.

Typical general movements at 2 to 4 months: Movement complexity, fidgety movements, and their associations with risk factors and SINDA scores.

BACKGROUND: Movement complexity and the presence of fidgety movements (FMs) during general movements (GMs) both reflect aspects of neurological integrity in early infancy. AIM: To assess interrelations between the degree of movement complexity and characteristics of FMs during typical GMs and to investigate associations between mildly impaired GMs and risk factors and neurodevelopmental condition. STUDY DESIGN: Observational cohort study. SUBJECTS: 283 infants (25 born preterm) at 2-4 months corrected age, representative of the general Dutch population. OUTCOME MEASURES: GMs were classified in terms of GM-complexity (normal or mildly abnormal (MA)) and FMs (clearly present, sporadic, or exaggerated). Concurrent neurological, developmental and socio-emotional status were measured with the Standardized Infant NeuroDevelopmental Assessment (SINDA). RESULTS: Infants with MA GM-complexity had a higher risk of having sporadic FMs and exaggerated FMs. Perinatal complications were not associated with mildly impaired GMs. MA GM-complexity was associated with advanced maternal age (adjusted OR = 2.29 [1.11, 4.76]) and having a non-native Dutch mother (adjusted OR = 2.93 [1.29, 6.64]). It was also associated with atypical neurological (OR = 7.62 [3.51, 16.54]) and developmental scores (OR = 2.38 [1.16, 4.88]). Sporadic and exaggerated FMs were associated with low-to-middle maternal education (adjusted OR = 2.88, [1.45, 5.72]) and having a non-native Dutch father (adjusted OR = 7.16 [1.41, 36.32]), respectively. However, neither sporadic nor exaggerated FMs were associated with the SINDA outcomes. CONCLUSIONS: GM-complexity and FMs are two interrelated but different aspects of GMs. Mild impairments in GM-complexity and FMs share a non-optimal socio-economic background as risk factor, but only MA GM-complexity is associated with a concurrent non-optimal neurodevelopmental condition.

Test-retest reliability of the Friedreich's ataxia rating scale.

The modified Friedreich Ataxia Rating Scale (mFARS) is a disease specific, exam-based neurological rating scale commonly used as a outcome measure in clinical trials. While extensive clinimetric testing indicates it's validity in measuring disease progression, formal test-retest reliability was lacking. To fill this gap, we acquired results from screening and baseline visits of several large clinical trials and calculated intraclass correlation coefficients, coefficients of variance, standard error, and the minimally detectable changes. This study demonstrated excellent test-retest reliability of the mFARS, and it's upright stability subscore.

Video consultations in ordinary and extraordinary times.

Tele-neurology is a neurological consultation at a distance, or not in person, using various technologies to achieve connectivity, including the telephone and the internet. The telephone is ubiquitous and is a standard part of how we manage patients. Video consulting has been used for a long time in some centres, particularly in those where the geography means that patients have to travel long distances. Various technologies can be used, and with the development of various internet-based video-calling platforms, real-time video consulting has become much more accessible. We have provided a tele-neurology service in the North East of Scotland since 2006 using video conferencing with far-end camera control. More recently, we have complemented this using an internet-based platform (NHS Near Me). Here we outline the practicalities of video consulting in 'ordinary' times and comment on its use in the 'extraordinary' times of the coronavirus pandemic.