Predictive Value of A2HD Scoring for Transient Symptoms Associated with Infarction.

BACKGROUND Effective early management of cerebral infarction patients with transient ischemic attack (TIA) is undermined by an inability to predict who is at highest risk of stroke. MATERIAL AND METHODS A total of 577 TIA patients with symptoms lasting no more than 1 hour were prospectively investigated and divided into a TIA group and a transient symptoms associated with infarction (TSI) group based on diffusion-weighted magnetic resonance imaging findings after hospital admission. The baseline characteristics, symptoms of TIA, features of disease onset, and findings from clinical examinations were compared between the 2 groups. Factors related to TSI were further analyzed. RESULTS Of 577 TIA patients, 127 patients were in the TSI group and 450 were in the TIA group. Anterior circulation events, hemiplegia, aphasia, multiple seizures, maximal duration, atrial fibrillation, and hypointense plaques were included as risk factors for stroke in a model of multivariate analysis, and results showed that hemiplegia, aphasia, multiple seizures, and atrial fibrillation were independent risk factors for TSI. In the final mode, the area under the curve (AUC) was 0.766 (95% confidence interval: 0.729-0.800). According to the A2HD score and odds ratio, hemiplegia (score 2), aphasia (score 2), multiple seizures (score 2), and atrial fibrillation (score 1) were scored, and any increment in the score increased the risk for cerebral infarction by 1.893-fold (95% confidence interval: 1.643-2.181). CONCLUSIONS Risk of TSI seems to be highly predictable. The A2HD score can be used in clinical practice to identify high-risk cerebral infarction patients with TIA who need emergency diagnosis and treatment.

Mastery motivation as a predictor of occupational performance following upper limb intervention for school-aged children with congenital hemiplegia.

AIM: To determine the extent to which children's mastery motivation predicts occupational performance outcomes following upper limb intervention (ULI). METHOD: In this cohort study, participants received 45 hours of ULI, either in an intensive group-based or distributed individualized model. The Dimensions of Mastery Questionnaire (DMQ) measured mastery motivation at baseline. Occupational performance outcomes were assessed at baseline and 13 weeks' post-intervention using the Canadian Occupational Performance Measure (COPM). Multivariable models determined the contribution of mastery motivation to COPM outcome irrespective of group membership. RESULTS: Forty-two children with congenital hemiplegia (29 males, 13 females; mean age 7y 8mo [SD 2y 2mo]; range 5y 1mo-12y 8mo; Manual Ability Classification System [MACS] I=20 and II=22; predominant motor type unilateral spastic n=41) participated in the study. Significant gains were seen in COPM performance and satisfaction scores (p<0.001) post-intervention with no between group differences. Children who had greater persistence with object-oriented tasks (p=0.02) and better manual ability (p=0.03) achieved higher COPM performance scores at 13 weeks. Children's persistence on object-oriented tasks was the strongest predictor of COPM satisfaction (p=0.01). INTERPRETATION: Children's persistence with object-oriented tasks as well as manual abilities needs to be considered when undertaking ULI. Predetermining children's motivational predispositions can assist clinicians to tailor therapy sessions individually based on children's strengths, contributing to effective engagement in ULI.

Further evidence of validity of the Modified Melbourne Assessment for neurologically impaired children aged 2 to 4 years.

AIM: This paper reports the second phase of a study to extend the Melbourne Assessment for use with children with neurological impairment aged 2 to 4 years. The aim was to establish if (1) children's scores on the Modified Melbourne Assessment (MMA) and the Quality of Upper Extremity Skills Test (QUEST) showed a moderate to high, positive relation, (2) children had comparable behaviours for task and time demands on both tools, and (3) scores on the MMA could discriminate between children with mild, moderate, and severe levels of upper limb impairment. METHOD: An observational study of 30 children (19 males, 11 females) with neurological impairment aged 2 to 4 years. Twenty-four children had spasticity (20 with a unilateral and four with a bilateral impairment) and two children presented with athetosis, two with ataxia, and two with hypotonia. RESULTS: A high, positive relation was found between children's scores on the MMA and the QUEST (ρ=0.90; p=0.001). The clinical use of the MMA was comparable to the QUEST. MMA scores were able to discriminate between children's levels of upper limb impairment as determined by clinicians' ratings (F(2,27) =67.76, p=0.001). INTERPRETATION: These findings suggest the MMA can be clinically useful for children as young as 2.5 years and has the advantage of being valid for use with older children. Scores from the tool can also provide therapists with a quantitative means of consistently reporting level of upper limb impairment.

Evaluation of the bilateral function in para-athletes with spastic hemiplegia: A model-based clustering approach.

OBJECTIVES: Spastic hemiplegia is one of the most common forms of cerebral palsy, in which one side of the body is affected to a greater extent than the other one. Hemiplegia severity (i.e. moderate vs mild forms) is currently used in some Para sports for classification purposes. This study evaluates the sensitivity of several tests of stability (e.g. one-legged stance test), dynamic balance (side-step test), coordination (rapid heel-toe placements), range of movement (backward stepping lunge), and lower limb power (the triple hop distance and the isometric peak force of the knee extensors) to discriminate between the impaired and unimpaired lower extremities' function in para-athletes with spastic hemiplegia. METHODS: A sample of 87 international para-athletes with cerebral palsy took part in the study, and their bilateral performance was measured for the abovementioned tests. The tests' sensitivity to discriminate between impaired vs unimpaired legs was assessed using Boruta's method. RESULTS: The triple hop distance, the magnitude of the mean velocity in the one-legged stance test and the time to perform the rapid heel-toe placement test are the most sensitive variables when performing random forest classifiers. In addition, the study confirms two optimal clusters by Gaussian finite mixture models to represent the athletes' performance. CONCLUSIONS: Reference scores for the clusters are provided, demonstrating that coordination, balance, and power of the lower limbs are relevant variables for classifying para-athletes with spastic hemiplegia.

The interrater and intrarater reliability of the Modified Ashworth Scale in the assessment of muscle spasticity: limb and muscle group effect.

The Modified Ashworth Scale (MAS) is a clinical scale used to assess muscle spasticity. While the evidence indicates that the reliability of the MAS is better in the upper limb and in certain distal muscle groups, no investigation has compared the effect of limbs and muscle groups on the MAS reliability. This study aimed to evaluate the effect of limb and muscle group on the reliability of the MAS in patients with spastic hemiplegia. Thirty subjects with upper and lower limb muscle spasticity were recruited for this trial. Two female experienced physiotherapists participated in this examination of reliability, and rated each patient in a randomized order in a single session. For the intrarater reliability, the second rater repeated the test 1 week later. Shoulder adductor, elbow flexor, wrist flexor, hip adductor, knee extensor, and ankle plantar flexor were tested on the hemiplegic side. Results demonstrated moderate inter (kappa=0.514, SE=0.046, p < 0.001) and intrarater (kappa=0.590, SE=0.051, p<0.001) reliability. For the inter and intrarater reliability, the agreement obtained for the upper and lower limb was similar. In the upper limb, the agreement between raters on the distal wrist flexor was significantly higher than the agreement on the proximal shoulder adductor. In the lower limb, there was a similar agreement between raters on the distal ankle plantar flexor and proximal hip adductor. For within rater, the agreement on the proximal and distal muscles of both limbs was not statistically significant. The Modified Ashworth Scale had moderate reliability. The limbs had no effect on the reliability. The agreement on distal wrist flexor in the upper limb was significantly higher between rater than in the proximal shoulder adductor. The agreement obtained with the MAS was not good, which questions the validity of the measurements.

Effects of ideomotor apraxia on functional outcomes in patients with right hemiplegia.

The aim of this study was to investigate the effect of ideomotor apraxia on activities of daily living and to determine if the presence of apraxia interferes with rehabilitation. This study was conducted on 47 patients with right hemiplegia. All the patients were assessed at their admission and discharge, respectively, for apraxia by Ideomotor Apraxia Test, for daily living activities by Functional Independence Measure (FIM, Santa Clara Valley Medical Center, San Jose, California, USA), for cognitive functions by Mini Mental State Examination (MMSE), and for language components by Gulhane Aphasia Test (GAT). The effects of apraxia presence and time course on FIM, MMSE, and GAT scores were investigated. Presence of apraxia was found to have significant effect on all test scores (P<0.05). Time course had the main significant effect on FIM, MMSE, and GAT scores (P<0.05). Interaction effect of both presence of apraxia and time course on the test scores was not significant either. In other words, apraxic and nonapraxic patients seemed to gain benefits from the neurological rehabilitation. However, mean FIM scores of apraxic patients during discharge have failed to reach the mean FIM scores of nonapraxic patients during admission. Apraxia is considered as an important determinant in the dependence of patients with stroke in their activities of daily living. For this reason, during the initial assessment of patients with right hemiplegia, apraxia should be tested, and the presence of apraxia as well as its severity should be determined.

Hip displacement in cerebral palsy.

BACKGROUND: Hip displacement is considered to be common in children with cerebral palsy but the reported incidence and the proposed risk factors vary widely. Knowledge regarding its overall incidence and associated risk factors can facilitate treatment of these children. METHODS: An inception cohort was generated from the Victorian Cerebral Palsy Register for the birth years 1990 through 1992, inclusive, and multiple data sources pertaining to the cohort were reviewed during 2004. Gross motor function was assessed for each child and was graded according to the Gross Motor Function Classification System (GMFCS), which is a valid, reliable, five-level ordinal grading system. Hip displacement, defined as a migration percentage of >30%, was measured on an anteroposterior radiograph of the pelvis with use of a reliable technique. RESULTS: A full data set was obtained for 323 (86%) of 374 children in the Register for the birth years 1990 through 1992. The mean duration of follow-up was eleven years and eight months. The incidence of hip displacement for the entire birth cohort was 35%, and it showed a linear relationship with the level of gross motor function. The incidence of hip displacement was 0% for children with GMFCS level I and 90% for those with GMFCS level V. Compared with children with GMFCS level II, those with levels III, IV, and V had significantly higher relative risks of hip displacement (2.7, 4.6, and 5.9, respectively). CONCLUSIONS: Hip displacement is common in children with cerebral palsy, with an overall incidence of 35% found in this study. The risk of hip displacement is directly related to gross motor function as graded with the Gross Motor Function Classification System. This information may be important when assessing the risk of hip displacement for an individual child who has cerebral palsy, for counseling parents, and in the design of screening programs and resource allocation.

Multiple gait patterns within the same Winters class in children with hemiplegic cerebral palsy.

BACKGROUND: Previous literature hypothesized that Winters type I are mainly characterized by a hypo-activation of dorsiflexors and type II by hyperactivation of plantarflexors around initial contact. However, it is currently not known if hemiplegic children belonging to the same Winters class really share the same muscle activation patterns, although this information might have relevant clinical implications in the patient management. METHODS: Gait data of 38 hemiplegic cerebral palsy children (16 Winters type I, 22 Winters type II) were analyzed, focusing on the foot and shank. A 2.5-minute walk test was considered, corresponding to more than 100 gait cycles for each child, analyzing the muscle activation patterns of tibialis anterior and gastrocnemius lateralis. The large stride-to-stride variability of gait data was handled in an innovative way, processing separately: 1) distinct foot-floor contact patterns, and for each specific foot-floor contact pattern 2) distinct muscle "activation modalities", averaging only across gait cycles with the same number of activations, and obtaining, in both cases, the pattern frequency-of-occurrence. FINDINGS: At least 2 representative foot-floor contact patterns within each Winters group, and up to 4-5 distinct muscle activation patterns were documented. INTERPRETATION: It cannot be defined a predominant muscle activation pattern specific for a Winters group. For a correct clinical assessment of a hemiplegic child, it is advisable to record and properly analyze gait signals during a longer period of time (2-3 min), rather than (subjectively) selecting a few "clean" gait cycles, since these cycles may not be representative of the patient's gait.

The Brown-Séquard syndrome. True or false?

In recent years the name of Brown-Séquard has been assigned to syndromes caused by spinal cord damage differing widely in extension. On the basis of a review of more than 600 published cases, we propose that Brown-Séquard-plus syndromes be distinguished from the pure Brown-Séquard syndrome. This distinction is shown to be justified on clinical, anatomic, and historical grounds. Two case histories are reported herein to illustrate the essential differences between these syndromes.

Quantitative analysis and classification of gait patterns in cerebral palsy using a three-dimensional motion analyzer.

Gait disorders in cerebral palsy can be accurately analyzed using the CODA-3 system presenting quantitative data representing movement of the hip, knee, and ankle in the sagittal plane. We describe a technique that classifies abnormal gait automatically on the basis of sagittal kinematic data. Fifty-five hemiplegic and 91 diplegic patients were analyzed using an opto-electronic scanner (CODA-3). The sagittal kinematics of the affected limb in hemiplegics correlated with those of both affected limbs in diplegics. We introduce the concept of the "plegic limb." Sagittal kinematics of 237 affected limbs were studied using cluster statistical analysis. Eight clear groups emerged. The predominant clinical features, typical of each group, were identified and described (eg, stiff leg gait, genu recurvatum, or crouch gait). We propose this classification system as a new technique to use gait analysis data to automatically classify abnormal movements of the lower limb in cerebral palsy.

Acute hemiplegia syndrome in childhood.

Three types of clinical features at the onset are well known to be characteristic of acute hemiplegia syndrome (AHS). Type 1 comprises status epilepticus of hemiconvulsions with fever. Representative diseases of this type are the infectious diseases of the central nervous system, acute encephalopathy and cerebral vascular diseases. Type 2 comprises status epilepticus of hemiconvulsions without fever. Cerebral vascular diseases and epilepsy are the major ones of this type. Type 3 comprises hemiplegia or hemiparesis of sudden onset without fever or convulsions. Most patients with this type had cerebral vascular diseases, about half of which were moyamoya disease in Japan. Recent progress in neuroimaging studies has allowed considerable elucidation of the etiology of AHS. Gadolinium-enhanced MRI showed minimal lesions such as capsular infarction more clearly than plain MRI. Acetazolamide test 99mTc-HMPAO SPECT imaging is one of the useful assisted diagnostic techniques for moyamoya disease, because it reveals the reserve capacity of the collaterals. [123I]IMP SPECT is useful for the diagnosis and follow-up of acute disseminated encephalomyelitis (ADEM), as the images of the lesions coincide well with the MRI ones. 99mTc-HMPAO SPECT in a case with alternating hemiplegia revealed normoperfusion in the ictal periods. Four cases of AHS are reported here.

Motor cortex excitability changes within 8 hours after ischaemic stroke may predict the functional outcome.

Motor evoked potentials after magnetic transcranial stimulation and the excitability of the motor cortex to increasing magnetic stimulus intensities were evaluated in six patients with hemiparesis after ischaemic stroke within 8 hours after stroke. The latencies of motor evoked potentials were normal in all patients. After stimulation of the ischaemic hemisphere we obtained responses comparable with the contralateral ones in two patients (mean NIH score 2 (SD 0)) and this group was completely asymptomatic after 15 days (NIH score 0). In four patients the excitability of the motor cortex involved by the ischaemia was reduced and magnetic motor threshold was higher than that of the spared motor cortex. This finding was associated with a poor motor recovery and the NIH score after 15 days was unchanged (NIH score 1.75 (SD 1.5)). The present data suggest that the evaluation of the excitability of motor cortex may offer a mean of predicting functional outcome following stroke.

Electrical stimulation in the management of spastic deformity.

This article outlines a nonsurgical approach that includes neuromuscular electrical stimulation and dynamic bracing for the management of spastic deformity in cerebral palsy. Neuromuscular electrical stimulation is used commonly for lower extremity spasticity. Its clinical application in upper extremity spasticity, together with dynamic bracing, is a new entity providing predictable and quick short-term results with significant improvement in quality of life.

The correlation of the short latency somatosensory evoked potentials and the strokes disability.

Median and tibial short latency somatosensory evoked potentials (SSEPs) were studied in 54 stroke patients, 27 males and 27 females. Thirty-two patients had cerebral infarction and 22 had cerebral hemorrhage. Median SSEPs abnormalities correlated with the Barthel score (p = 0.005) as well as tibial SSEPs (p = 0.01). Both median and tibial SSEPs were very sensitive (sensitivity = 79.41% and 85.71%) and high positive predictive value (77.14% and 75%) in the assessment of neurological disability. However, normal median and tibial SSEPs did not exclude severe neurological deficits (positive predictive value = 63.16%, 64.29% and sensitivity = 60%, 47.37%).

Hyperventilation-precipitated cerebrovascular accident in a patient with sickle cell anaemia.

Hyperventilation exercise during electroencephalography precipitated a recurrence of right hemiplegia and aphasia in a patient with Hb SS disease. Although recovery of function started within hours of the event, full recovery has not occurred six months after. Hyperventilation provocative test during electroencephalography should be discouraged in patients with sickle cell anaemia.

[Value of the MSH classification in the hemiplegic stroke patient]. / Valor de la clasificación MSH en el paciente hemipléjico tras un ictus.

INTRODUCTION: The functional prognosis of patients should be known when planning their rehabilitation treatment. OBJECTIVE: To find the prognostic value of the MSH classification for hemiplegic patients, which is based on the clinical deficits seen after the stroke, and to distinguish between the M group (motor deficit), MS group (motor and sensory deficits) and the MSH group (motor, sensory and homonymous deficits). PATIENTS AND METHODS: A prospective analytical study was made of the hemiplegic patients admitted consecutively to the Rehabilitation Department after strokes. The initial examination was made 17 days (CI: 15-19) after the stroke. Satisfactory functional results were considered to be obtaining a Barthel index of > 90 together with the ability to walk unaided on level ground six months after the stroke. RESULTS: Of the 55 patients finally included in the study, 23 were in group M (41.8%) 21 in group MS (38.1%) and 11 patients in group MSH (20.1%). Walking ability and function in the different cohorts showed a statistically significant difference. Whilst 96% of the patients with pure hemiparesia (group M) attained a satisfactory degree of independence in walking, only 54% of the patients with three associated deficits (MSH) achieved this. Even more difference was found with acquired functional independence, since whilst 82% of group M attained a good degree of autonomy in carrying out everyday activities, only 18% of the MSH group achieved this. The remaining patients (MS group) had intermediate results. CONCLUSION: The MSH classification is, soon after having a stroke, a useful means of determining the functional prognosis of hemiplegic patients.

MRI-based radiologic scoring system for extent of brain injury in children with hemiplegia.

BACKGROUND AND PURPOSE: Brain MR imaging is recommended in children with cerebral palsy. Descriptions of MR imaging findings lack uniformity, due to the absence of a validated quantitative approach. We developed a quantitative scoring method for brain injury based on anatomic MR imaging and examined the reliability and validity in correlation to motor function in children with hemiplegia. MATERIALS AND METHODS: Twenty-seven children with hemiplegia underwent MR imaging (T1, T2-weighted sequences, DTI) and motor assessment (Manual Ability Classification System, Gross Motor Functional Classification System, Assisting Hand Assessment, Jebsen Taylor Test of Hand Function, and Children's Hand Experience Questionnaire). A scoring system devised in our center was applied to all scans. Radiologic score covered 4 domains: number of affected lobes, volume and type of white matter injury, extent of gray matter damage, and major white matter tract injury. Inter- and intrarater reliability was evaluated and the relationship between radiologic score and motor assessments determined. RESULTS: Mean total radiologic score was 11.3 ± 4.5 (range 4-18). Good inter- (ρ = 0.909, P < .001) and intrarater (ρ = 0.926, P = < .001) reliability was demonstrated. Radiologic score correlated significantly with manual ability classification systems (ρ = 0.708, P < .001), and with motor assessments (assisting hand assessment [ρ = -0.753, P < .001]; Jebsen Taylor test of hand function [ρ = 0. 766, P < .001]; children's hand experience questionnaire [ρ = -0. 716, P < .001]), as well as with DTI parameters. CONCLUSIONS: We present a novel MR imaging-based scoring system that demonstrated high inter- and intrarater reliability and significant associations with manual ability classification systems and motor evaluations. This score provides a standardized radiologic assessment of brain injury extent in hemiplegic patients with predominantly unilateral injury, allowing comparison between groups, and providing an additional tool for counseling families.

A new Multiple ANFIS model for classification of hemiplegic gait.

Neuro-fuzzy system is a combination of neural network and fuzzy system in such a way that neural network learning algorithms, is used to determine parameters of the fuzzy system. This paper describes the application of multiple adaptive neuro-fuzzy inference system (MANFIS) model which has hybrid learning algorithm for classification of hemiplegic gait acceleration (HGA) signals. Decision making was performed in two stages: feature extraction using the wavelet transforms (WT) and the ANFIS trained with the backpropagation gradient descent method in combination with the least squares method. The performance of the ANFIS model was evaluated in terms of training performance and classification accuracies and the results confirmed that the proposed ANFIS model has potential in classifying the HGA signals.