Reliability of a new device used to measure shoulder subluxation

The purposes of the study were to determine the reliability of a new device used to quantify shoulder subluxation and to estimate its standard error of measurement. The device is an L-shaped thermoplastic jig with a metric tape measure embedded in it. A sliding beak-like marker, which can be anchored with a thumbscrew, is used to identify landmarks and to measure the amount of subluxation. Eight male and two female hemiplegic subjects, 40 to 80 years old, consented to be measured for subluxation. Three standardized subluxation measurements were taken by one investigator to determine the reliability with a single rater. One measurement was taken by a second investigator and compared with the first measurement obtained by the first investigator to determine the reliability using more than one rater. Both investigators were experienced physical therapists. Each measurement was read by the other investigator, who disassembled the jig and cleaned the marks from the patient between measurements. For both analyses, an analysis of variance for repeated measurements reflected no differences between measurements attributable to raters. The unbiased intraclass correlation coefficient for a single measurement by a single rater was .89 (p less than .01) and for more than one rater was .74 (p less than .01). The standard error of measurement was +/- 0.77 mm for a single rater and +/- 1.20 mm for more than one rater. We recommend the jig as a tool to measure shoulder subluxation in patients.

Prior neurologic illness and the syndrome of irreversible lithium-effectuated neurotoxicity (SILENT)

Prior neurologic illness or CNS insult of any kind is known to increase the vulnerability to neurotoxicity of lithium. In this event the occurrence of neurotoxicity does not correlate with serum lithium levels. The authors describe a patient with hemiparesis who developed the syndrome of irreversible lithium-effectuated neurotoxicity (SILENT) while being treated with lithium for a manic episode. The authors review the literature on this aspect and highlight the dangers of starting lithium treatment in patients with neurologic impairment.

Focal neurological signs in cerebral malaria accounted for by preceding neurological damage

In 1987 at Port Moresby General Hospital, Papua New Guinea, two out of 103 adults with a final diagnosis of cerebral malaria had focal neurological signs noted on admission. In both cases the focal signs could be explained by documented prior neurological disease with residual focal damage. Focal neurological signs in patients presenting with malaria should prompt careful investigation to exclude other active neurological disease. Where no additional diagnosis is evident a history of past neurological damage may become apparent to explain the focal nature of the malaria presentation.

Male sexual dysfunction after stroke

Male sexual functions namely libido and potency were evaluated in fourteen right handed stroke patients. Half of the studied patients had reduced libido while reduced potency was found in 86% patients. Right hemispheric stroke patients had significantly higher reduction in libido as compared to left hemispheric stroke patients. Libido may have some specific cortical or limbic representation in right cerebral hemisphere.

Motor learning in ideomotor apraxia

Using Luria's motor sequence test, we studied the learning ability of 34 right-handed patients with unilateral hemisphere lesions. Patients with ideomotor apraxia needed 4 to 6 trials in the test, while the remainder needed only 1 or 2. Ideomotor apraxics also required more time to complete the test. The lesions of patients who failed to master this test were not always found in the frontal lobes. These results suggest that the ability to learn motor sequences is impaired in apraxic patients and that the left hemisphere of the brain plays the major role in learning a new motor sequence. Patients with ideomotor apraxia are impaired not only when performing previously learned motor tasks but also when learning a new motor task.

Hemiplegia and amputation: rehabilitation in the dual disability

About 10% of all elderly dysvascular amputees have had cerebrovascular accidents at some time. This is an often overlooked but important fact which significantly impacts the outcomes of their rehabilitation, especially where prosthetic ambulation is attempted. This study reviews the rehabilitation outcomes of 46 patients with the dual disability of hemiplegia and amputation. The mean age of the patients was 63 years (range 49 to 84). Forty-one (89%) could participate in a trial of physical therapy, and 25 (54%) in a comprehensive rehabilitation program. Seventeen (37%) were fitted with a prosthesis, and 12 (26%) became independent ambulators. Eighteen (39%) achieved independence in their activities of daily living (ADL) and transfers. Patients were reviewed to establish those features predictive of a good outcome. The following factors were associated with regaining independent ambulation: the presence of a mild hemiparesis with residual hand function (p less than 0.001), a below-knee amputation (p less than 0.01), and a history of ambulation before the second disability (p = 0.05). The ADL independence was associated with a mild hemiparesis (p less than 0.001), and age less than 60 years (p less than 0.05). Incontinence of bowel or bladder was strongly predictive of failure to achieve independence in either ADL or ambulation (p less than 0.001). Of those patients who did achieve independent ambulation, 73% were still ambulating a mean of 16.5 months later. These findings should be considered when planning rehabilitation goals for patients with the dual disability of hemiplegia and amputation.

Forced use of hemiplegic upper extremities to reverse the effect of learned nonuse among chronic stroke and head-injured patients

To test the clinical counterpart of the learned nonuse theory, 25 chronic hemiplegic stroke and head-injured patients with minimal to moderate upper extremity extensor muscle function were required to keep their uninvolved upper extremities within a hand-enclosed sling during waking hours over a 2-week interval. During this forced use period and for 1 year thereafter, changes in force or time-based measures among 21 functional tasks were compared to values at the sixth baseline session, a preintervention time when relearning had plateaued. Significant (P less than 0.05, Friedman's repeated measures followed by Tukey multiple comparison tests) changes were seen in 19 of the 21 tasks with most persisting at the 1-year follow-up. There were no apparent differences between right- and left-sided involvement or between stroke versus head injury clients (Mann-Whitney procedure). Ratings for quality of movement scored from videotapes presented in random order showed no change over time. These data suggest that learned nonuse does occur in select neurological patients and that this behavior can be reversed through application of a forced use paradigm.

Late-onset post-hemiplegic hemidystonia: CT and angiographic findings

A 27-year-old woman is described who suffered an acute left hemiplegia at the age of three years and 20 years later she noted the onset of unilateral left limb dystonic movements. Her cranial CT scan showed an area of low density, consistent with longstanding infarction, in the right lentiform nucleus. Cerebral angiography demonstrated aneurysmal dilatation of the terminal portion of the right internal carotid artery, minor irregularity of the lenticulostriate branches of the right middle cerebral artery (suggestive of Moya Moya disease) and occlusion of the right anterior cerebral artery. The dystonic movements improved with levodopa therapy. Clinico-radiological correlation in this case supports recent evidence for a disruption of pathways between the caudate nucleus, lentiform nucleus and thalamus in the pathophysiology of hemidystonia.

[A case of crossed aphasia in a right-handed person]

A 17-year-old boy, right-handed, and without a family history of left-handedness is described. Occlusion of the right internal carotid artery caused in him left-sided hemiparesis with aphasia. The cross-aphasia of right-handed individuals is discussed in the light of literature reports.

Hemispherectomy for seizures

Hemispherectomy, or hemidecorticectomy as it is more accurately described, has been highly effective in reducing or eliminating medically intractable seizures associated with hemiplegia. Because of late onset postoperative superficial cerebral hemosiderosis and its associated neurologic deterioration, this procedure was all but abandoned for years. With improved surgical techniques and diagnostic testing, some medical centers with a special interest in epilepsy are again using hemispherectomy as a treatment for uncontrolled seizures associated with Rasmussen's encephalitis, as well as other etiologies. Specialized nursing care throughout the hospital course is essential to a positive outcome for the patient and family.

Hemodynamic alterations in hemiplegic patients as a cause of edema in lower extremities

The purpose of the study is to investigate the relationship between the hemodynamic change and the production of edema in the hemiplegic leg. This study was designed to compare the hemodynamics in the involved edematous leg with that in the unaffected non-edematous leg in hemiplegic patient using straingauge plethysmography and photo-plethysmography. Examinations were undertaken in 20 patients with hemiplegia. Arterial Inflow Ratio [healthy side; hemiplegic side (100/ml ml/min)]: 19.2 +/- 16.2; 27.6 +/- 23.4. Venous Distensitivity: 1.5 +/- 0.8; 1.9 +/- 1.0. Maximum Venous Outflow: 90.8 +/- 43.1; 120.0 +/- 52.9. Tissue Flow Ratio: 1.1 +/- 0.5; 1.6 +/- 0.6. The values for hemiplegic side were significantly higher than those for healthy side in all patients. It was confirmed by using photo-plethysmography that none of the patients had arterial obliterative disease. It was suggested that one of the causes of the production of edema in a hemiplegic limb was due to the dilated capillary vessels and congested lower extremity.

Kluver-Bucy syndrome in systemic lupus erythematosus

The Kluver-Bucy syndrome has not been previously reported as a complication of systemic lupus erythematosus (SLE). A 48-year-old female is described who sustained several cerebral infarcts, some of which were bitemporal, due to SLE vasculopathy. She developed a complex behavioural picture consisting of global aphasia, left-side neglect, hyperorality, hypermetamorphosis and hypersexuality. She displayed appropriate emotional reaction to visually presented objects, indicating that her Kluver-Bucy syndrome could not be explained by lack of visual recognition.

[Pathomechanogenesis of contractures and deformities of the upper extremities in children with cerebral palsy]

The authors carried out dynamic observation of 180 children aged 3-14 with infantile cerebral paralysis (ICP) who were treated for pronation flexion contractures of the forearm and of the hand, studied up to 45 values connected with the age of the patients, terms of appearance of the symptoms of the disease, subsequently processed the results of their investigations employing methods of analysis of variance, non-linear correlation and regression analysis and constructed analytical models of development of the pathologic process, which allowed to draw the following conclusions. Pathomechanogenesis of disturbances of the upper extremity in ICP includes primary muscular disbalance, successive formation of faulty postures, pathologic locomotor stereotype, vegetotrophic disturbances, contractures of the joint and anatomical changes of the skeleton. These changes are closely correlated with the age of the patients and according to the degree of the disturbances may be regarded as stages of the disease.

Stretch reflex dynamics in spastic elbow flexor muscles

Previous studies of stretch reflexes in patients with spastic hypertonia have emphasized the dynamic character of stretch reflex output. In contrast, our own studies of stretch reflex dynamics in spastic elbow flexor muscles of 14 hemiparetic human subjects have shown that stretch-evoked torque displays a relatively weak dependence on stretch velocity, and there is generally no preferential enhancement of dynamic as compared with static reflex output. Moreover, stretch reflex dynamics are broadly similar in voluntarily activated spastic and normal elbow flexor muscles. These findings support our hypothesis that spastic hypertonia results primarily from a decrease in stretch reflex threshold. The strong velocity dependence of stretch-evoked electromyographic activity in initially inactive spastic muscles could be due to a decrease in reflex threshold with increasing stretch velocity, rather than an abnormal velocity-dependent increase in stretch reflex responsiveness.

The 'herald hemiparesis' of basilar artery occlusion

In thrombosis of the basilar artery, not infrequently a hemiparesis is present at an early stage, when brain-stem signs may be absent or few, slight or equivocal. It is natural to suspect that such a hemiparesis signifies localization in a cerebral hemisphere, but unexpectedly in a few hours bilateral hemiplegia appears associated with coma or a locked-in syndrome, indicating basilar artery occlusion. I would term this disarming hemiparesis the "herald hemiparesis" of basilar artery occlusion. If the true nature of the condition is recognized early, the use of heparin and other measures may forestall disaster.

Neurologic fragments. I. Clinical observations in demented patients

Some 28 clinical observations of behavior, mainly in demented patients, have been singled out for brief description and comment. Most are familiar, and the aim of the presentation is to identify and codify them, complementing formal psychological tests. Several have been given names--eg, insistence, balking, dread of being alone, the obligatory alibi, lability of temper, amphigory, reaching out, etc. Others draw attention to and characterize fragments of behavior--eg, ambient echolalia, periodic repetition of questions and comments, failure to recognize the spouse, turning the back, etc. Finally, a few clinical phenomena are commented upon.

Ataxic hemiparesis syndrome: sensory disturbances and somatosensory evoked potentials

26 patients with ataxic hemiparesis syndrome (AHS), due to acute ischemic cerebrovascular disease, have been submitted to clinical and electrophysiological evaluation, in order to assess the frequency of sensory disturbances in this condition. Sensory impairment were present in 78% and SEP abnormalities in 54% of the patients, while they were entirely absent in 23% of them. Lesions responsible for AHS, detected by CT scan, were mainly located in the thalamus, capsula interna, subcortical white matter, centro parietal cortex; sensory and SEP changes were more frequent in gross infarct involving the cortex and in smaller infarcts involving the thalamus, less frequent in the lacunar infarcts of the capsula interna and subcortical white matter, relatively rare in patients with CT scan without hypodense lesions. Although a statokinesthesic defect and/or major SEP abnormalities were often present (38% of patients), our findings do not support the view that they are involved in the pathogenesis of the ataxia, which may rather be attributed to a derangement of cerebro-cerebellar and cerebello-cerebral connections.

Effect of hemiparesis on polymyalgia rheumatica

Central nervous system insults with secondary hemiparesis appears to influence the symptom complex of polymyalgia rheumatica. Symptoms are reported here not to develop in established hemiparesis.