Differences in lateral ankle ligaments between affected and unaffected legs in children with spastic hemiplegic cerebral palsy

OBJECTIVES

To investigate the architectural alterations of the lateral ankle ligaments in spastic hemiplegic cerebral palsy.

METHODS

Eight children (5 male and 3 female; mean age ± SD, 5.2 ± 2.7 years) with spastic hemiplegic cerebral palsy were recruited. A modified Ashworth scale and passive ankle dorsiflexion angle were evaluated. Sonograms of the anterior talofibular ligament and calcaneofibular ligament were obtained to measure ligament thickness, and the anterior talofibular/calcaneofibular ligament thickness ratio was calculated. Two sonographic measurements were taken to check for intra-rater reliability.

RESULTS

The interclass correlation coefficients of the repeated anterior talofibular ligament and calcaneofibular ligament thickness measurements in the unaffected/affected legs were 0.960/0.945 and 0.922/0.933, respectively. The anterior talofibular ligament thickness in the affected legs was significantly greater than that in the unaffected legs (2.50 ± 0.35 versus 1.40 ± 0.28 mm; P = .011), but the calcaneofibular ligament thickness in the affected legs was significantly less than that in the unaffected legs (0.80 ± 0.18 versus 1.28 ± 0.31 mm; P = .021). The anterior talofibular/calcaneofibular ligament thickness ratio in the affected legs was significantly greater than that in unaffected legs (2.10 ± 0.81 versus 1.03 ± 0.13; P = .012). The ratio was positively correlated with the modified Ashworth scale and age but negatively correlated with the passive ankle dorsiflexion angle in the affected legs.

CONCLUSIONS

This study revealed an increased anterior talofibular ligament thickness and a decreased calcaneofibular ligament thickness in the affected legs compared with the unaffected legs. These architectural features of the lateral ankle ligaments may contribute to the equinovarus deformity of the ankle together with spastic leg muscles in children with spastic hemiplegic cerebral palsy.

[Spatial-temporal analysis and clinical findings of gait: comparison of two modalities of treatment in children with cerebral palsy-spastic hemiplegia. Preliminary report]

INTRODUCTION

Cerebral palsy is the most common cause of disability among children. Parent's main concerns are the acquisition and improvement of gait. The aim of this study was to compare long term results of the effect of two modalities of gait training.

METHODS

Quantitative measurement of gait and clinical assessment of the gross motor function classification system and Modified Ashworth Scale were perfomed in 14 patients with Cerebral palsy -spastic hemiplegia and randomizedly assigned into two groups of treatment: the first one using a driven gait orthosis (Lokomat(®)) and the second a gait training a long a rail inside a hydrotherapy tank. Measurements and assessments, above described, were performed immediately and one year after the treatment concluded.

RESULTS

Significant change was observed in the gross motor function classification system from II to I among children (p=0.042) and a positive correlation between the shape functional of the march and the gross motor function classification system (r = 0.54, p = 0.042). Patients on the Lokomat(®) training improved on gait symmetry over patients on the conventional therapy (p = 0.05). A year after, this intervention showed tendency to kept the gait patterns only on patients treated with the Lokomat(®)

CONCLUSION

Benefit obtained with either modality was evident for both groups. However, residual effects observed on the Lokomat group, either in clinical assessment or gait parameters, were more promising than in the conventional therapy. Due to the size of the sample used in this study the results are not conclusive and more research must be done on this subject in long term time horizon.

Unilateral bullous pemphigoid without erythema and eosinophil infiltration in a hemiplegic patient

In this report, we describe an 88-year-old male stroke patient with unilateral bullous pemphigoid limited to the hemiplegic side. Physical examinations revealed multiple tense bullae with clear and/or bloody contents without apparent erythema on the right thigh and lower leg, accompanied by erosions on the right chest. Histopathologically, no eosinophils were infiltrated into and around the subepidermal bullae. Immunofluorescence revealed deposited and circulating immunoglobulin (Ig)G anti-basement membrane zone antibodies. Immunoblot assays using various antigen sources and enzyme-linked immunosorbent assay revealed that IgG antibodies in this case reacted with unique epitopes between NC16a and C-terminal domains on the 120-kDa LAD-1, the extracellular truncated form of BP180. Three observations were unique in our case. First, the distribution of bullae in our patient was limited to the hemiplegic side. Second, there was no apparent erythema clinically and no eosinophilic infiltration histopathologically. Third, the patient achieved remission without the use of oral corticosteroids. The unusual epitopes in this case may contribute to these phenomena.

Subjective outcome of reconstruction of the adult acquired neurological equinovarus foot

A retrospective study was done of the subjective outcome of surgical correction of a spastic equinovarus foot deformity in 27 adult patients with acquired spastic hemiplegia. The mean age of the patients was 49 years and the mean follow-up period was 29 months. The patients were submitted to individualized soft-tissue surgery intended to correct their deformities and rebalance the affected joints, and subsequently subjected to a standard rehabilitation protocol. The assessment was based on the clinical records and on a questionnaire sent to the patients about relevant aspects of their gait, lifestyle and untoward effects and complications. The results have shown that patients experience frank improvement in terms of gait, orthostatic posture, self-esteem and quality of life. Transient or permanent adverse effects occurred in 11 of the 27 patients. The changes induced by surgery to reduce the imbalance and deformity of the foot have a considerable impact on independence and quality of life of these patients despite the high rate of complications.

Patient-centered rehabilitation, three years of gait recovery in a child affected by hemiplegia:. case report

The aim of this report was to illustrate and to discuss a method capable of improving the person-oriented decision-making process during three years of gait rehabilitation based on the integration of: 1) the fundamental principles of motor learning and 2) the outcomes made available by both clinical standardized assessment tools (SAT) and measures made available by a gait analysis system (GA). The subject studied was a six-year-old child affected by hemiplegia after arterial ischemic stroke (AIS) who had limited upper and lower right-limb function but unaffected sensory and cognitive skills. Four different rehabilitative treatments were chosen when the child was inpatient or outpatient. Measurements of gait performance before and after selected treatments were evaluated using PEDI and GMFM (i.e., SAT) and kinematic and kinetic parameters (i.e., GA). Gait pattern and inter- and intralimb-joint coordination changed over time during the three examined years. However, after the first eight months of recovery, gait pattern modifications were detected by GA measures but not by SAT. The integration of SAT and GA findings, during the examined recovery evolution, resulted effective in the decision-making process for a person-oriented rehabilitative treatment.

Two patients with abducens nerve palsy and crossed hemiplegia (Raymond syndrome)

We report 2 patients of alternating hemiplegia with abducens nerve palsy. One patient was also complicated by contralateral supranuclear facial nerve palsy. MRI showed an infarct involving the paramedian and lateral area of the pontine basis in both patients. We considered that corticospinal tract and infraabducens nerve fibers were involved in both patients, and that the corticobulbar tract was involved in 1 patient with supranuclear facial nerve palsy. Although supranuclear facial nerve palsy was not found in the other patient, we speculated that supranucler facial nerve fibers might pass mainly through the aberrant pyramidal tract in this patient.

Self-injection of insulin using appropriate supportive devices in handicapped subjects with diabetes

BACKGROUND

To self-inject insulin, individuals with diabetes must be able to attach the needle to the injector, recognize the appropriate insulin dosage, detach the needle from the injector, and perform a series of operations necessary for the actual injection. These tasks require a grip strength that is strong enough to hold the necessary devices, eyesight, the use of both hands, and at least a minimum intellectual capacity. Subjects who are unable to grasp or handle the devices required for insulin injection often have difficulties with the self-injection of insulin.

METHODS

We treated four diabetes patients who had trouble grasping objects and using both hands. One patient had lost five fingers in an accident, two patients had suffered from ischemic cerebral infarction resulting in complete one-sided hemiplegia with no movement in one arm, and one patient had limited muscular power in an arm as a result of spinal cord disease. The plasma glucose control was poor, and the initiation of insulin therapy was necessary in each of these patients. In three cases, we used a commercially available self-injection device (HumaHelper; Eli Lilly Japan K.K., Kobe, Japan) to enable self-injection; in the fourth case, we used a newly manufactured device similar to HumaHelper.

RESULTS

All the patients were able to inject insulin by themselves using the appropriate supplementary devices. The blood glucose control of all the patients subsequently improved.

CONCLUSION

Existing or newly manufactured supportive devices can enable handicapped subjects to self-inject insulin.

Effects of an experiential learning program on the clinical reasoning and critical thinking skills of occupational therapy students

This study examined the effects of participation in a 1-week, experiential, hands-on learning program on the critical thinking and clinical reasoning skills of occupational therapy students. A quasi-experimental, nonrandomized pre- and post-test design was used with a sample of 25 students. The students had completed three semesters of didactic lecture coursework in a master's level OT educational program prior to participation in a hands-on therapy program for children with hemiplegic cerebral palsy. Changes in critical thinking and clinical reasoning skills were evaluated using the following dependent measures: Self-Assessment of Clinical Reflection and Reasoning (SACRR) and the California Critical Thinking Skills Test (CCTST). Changes in pretest and posttest scores on the SACRR and the CCTST were statistically significant (p>0.05) following completion of the experiential learning program. This study supports the use of hands-on learning to develop clinical reasoning and critical thinking skills in healthcare students, who face ever more diverse patient populations upon entry-level practice. Further qualitative and quantitative investigations are needed to support the results of this study and determine which components of experiential learning programs are essential for developing clinical reasoning and critical thinking skills in future allied health professionals.

[Sporadic hemiplegic migraine in a 14-year-old boy--a case report]

Hemiplegic migraine is a specific form of migraine with aura including hemiparesis. It is a rare condition of unclear aetiology. The authors present a case of a 14-year-old boy with persistent foramen ovale, suffering from sporadic hemiplegic migraine. The authors broadly describe the symptoms and types of hemiplegic migraine as well as underlining diagnostic and therapeutic difficulties of the attacks. The patient suffered from recurrent severe headaches, vomiting and co-existing focal neurological symptoms, including alternant hemiparesis. On the basis of the history, thorough clinical observation and numerous accessory investigations a diagnosis of sporadic hemiplegic migraine was established. However, the last attack, with prolonged neurological deficits, was treated as a complication of migraine and defined as persistent aura without infarction. The authors also broadly discuss a differential diagnosis, including other stroke-like incidents, vascular diseases, immunological and mitochondrial disorders that mimic the symptoms and clinical course of sporadic hemiplegic migraine.

Verbal intelligence in Neglect: the role of anosognosia for hemiplegia

AIM

General intelligence of patients with neglect has been poorly investigated and data at present are contrasting. Moreover it is not yet defined whether the presence of anosognosia for hemiplegia is associated with intellectual impairment in patients with neglect.

METHODS

In this prospective study the authors evaluated the verbal intelligence quotient in neglect patients. This study was carried out on 33 patients with left hemiparesis: 11 patients had neglect (group N), 11 had neglect + anosognosia (group N+A) and 11 had neither neglect nor anosognosia (control group).

RESULTS

Patients of group neglect + anosognosia had significantly lower verbal IQ (VIQ) and mini-mental state examination (MMSE) scores than those of neglect (respectively: P=0.004 and P=0.000) and control groups (respectively: P=0.041 and P=0.000). No significant differences were detected between neglect and control groups for VIQ and MMSE. In N+A group VIQ score was lower than 90 in 81.8% and MMSE score was lower than 24 in 100% of patients. Moreover, 18.2% of N+A patients had VIQ score lower than 80 and 45.4% had MMSE score lower than 18/30. Also 9.1% of neglect group had VIQ score lower than 90 and 36.4% MMSE scores less than 24/30, but none of these patients had VIQ and MMSE scores respectively lower than 80 and 18/30. Similar data were present in control group.

CONCLUSIONS

This study focuses on mental impairment in neglect + anosognosia patients and indicates that A for hemiplegia is a condition that more often occurs when severe mental impairment is present.

Neural network and fuzzy control in FES-assisted locomotion for the hemiplegic

This study is aimed at establishing a neural network and fuzzy feedback control FES system used for adjusting the optimum electrical stimulating current to control the motion of an ankle joint. The proposed method further improves the drop-foot problem existing in hemiplegia patients. The proposed system includes both hardware and software. The hardware system determines the patient's ankle joint angle using a position sensor located in the patient's affected side. This sensor stimulates the tibialis anterior with an electrical stimulator that induces the dorsiflexion action and achieves the ideal ankle joint trace motion. The software system estimates the stimulating current using a neural network. The fuzzy controller solves the nonlinear problem by compensating the motion trace errors between the neural network control and actual system. The control qualities of various controllers for four subjects were compared in the clinical test. It was found that both the root mean square error and the mean error were minimal when using the neural network and fuzzy controller. The drop-foot problem in hemiplegic's locomotion was effectively improved by incorporating the neural network and fuzzy controller with the functional electrical simulator.

Assessment of shoulder pain in hemiplegia: Sensitivity of the ShoulderQ

BACKGROUND

The ShoulderQ is a structured questionnaire designed to assess timing and severity of hemiplegic shoulder pain (HSP), in order to target pain relief effectively. It includes both verbal and visual graphic rating scale questions, simply presented for patients with language/visuo-spatial deficits following stroke.

OBJECTIVE

To assess the sensitivity of the ShoulderQ to clinical improvement in shoulder pain following multi-disciplinary intervention. Design and setting. Retrospective analysis of serial questionnaires collected in the course of clinical treatment in an in-patient neurological rehabilitation unit. Subjects and interventions. Thirty consecutive adults with cognitive and communicative deficits, presenting with hemiplegic shoulder pain following acquired brain injury. Multi-disciplinary treatment was delivered through an integrated care pathway, and ShoulderQs recorded fortnightly, including at baseline and end of treatment.

RESULTS

Changes on visual graphic rating scale (VGRS) were associated with verbal reports of improvement (rho 0.665, p < 0.001). Patients were divided retrospectively on the basis of their overall clinical response into responders (n = 18) and non-responders (n = 12). Responders showed significant change in both VGRS and verbal scores, whereas the non-responder group did not. A change in summed VGRS score of =3 showed 77% sensitivity and 91.3% specificity for identifying the responders, with a positive predictive value of 93.3%. Summed VGRS scores of =2 had a negative predictive value of 73.3%.

CONCLUSION

In this preliminary evaluation of clinical data, the ShoulderQ appears to provide a sensitive measure of shoulder pain which is responsive to change in pain experience for those able to complete the questionnaire, despite the difficulties that many of this group of patients may have in reporting their symptoms. Set alongside previously reported test-retest reliability, the results support the utility of the ShoulderQ as a simple and practical tool for evaluation of shoulder pain in patients with severe complex disabilities.

Long-term outcome of superficialis-to-profundus tendon transfer in patients with clenched fist due to spastic hemiplegia

BACKGROUND

Spastic hemiplegia is a common feature after stroke, which can result in a clenched fist deformity with secondary hygienic problems and pain. Operative treatment can improve these problems, although literature about its long-term effects is lacking.

PURPOSE

To determine whether Superficialis-to-Profundus tendon (StP-) transfer procedure leads to permanent improvement of hygiene and reduction of pain in patients with clenched fist due to spastic hemiplegia following stroke.

METHOD

Patients who underwent a StP-transfer in 2003-2005 were evaluated on skin condition, upper extremity joint mobility, resting position and muscle tone and with VAS scores on hygiene maintenance and pain in the hand.

RESULTS

Six patients (mean age 54 years; duration after stroke 10 years) were included. Indications to operate were hygienic problems only (3) or combined with pain (3). The average follow-up period was 19 months. After 6 weeks of post-operative splinting, no standard follow-up was applied. Serious post-operative complications were not reported. At follow-up no hygienic problems were present and pain was decreased in all except one patient. All hands could passively be fully opened. In resting position, flexion was seen in the MCP-joints (60-90 degrees). Muscle tone was raised in flexors of the wrist and fingers and m. adductor pollicis (Ashworth 1-2). Given the same pre- and post-operative circumstances, all patients would agree to have the surgery over again.

CONCLUSION

Even 19 months after the StP-transfer for clenched fist, all operated hands could still be fully opened and there was a permanent improvement of hygiene and pain reduction.

Assessment of oedema in stroke patients: comparison of visual inspection by therapists and volumetric assessment

PURPOSE

To examine the agreement of assessment of hand oedema in stroke patients by clinical judgement and by use of a hand volumeter.

METHOD

A total of 88 rehabilitation patients with stroke received both assessments. Experienced physical therapists classified oedema as 'none', 'minor' or 'severe'. Swelling was independently measured with a hand volumeter. Population data were used to adjust volumeter reading differences for handedness and side of paresis, and to define a cut-off point for oedema of 2 SD of the population distribution.

RESULTS

Based on volumetric assessment, 33% of patients had oedema. Physical therapists classified 50% of patients as having minor or severe oedema. Results of both methods were clearly related, but agreement between the assessments was not more than 'fair' (67% agreement; Kappa 0.34). The level of agreement was not substantially affected by the cut-off point used for the volumeter score, the time between both assessments or by the side of paresis.

CONCLUSION

Agreement between clinical and volumetric assessment of hand oedema in stroke patients is less than desirable. Volumetric assessment of oedema is recommended for research purposes.

Acute spinal cord injury in pregnancy: an illustrative case and literature review

Acute trauma is not all that uncommon in pregnancy. It accounts for 15% of non-obstetric maternal deaths. Moreover, about 15% of acute spinal cord injuries involve young women of childbearing age (Gilson et al., 1995). Most of the existing literature on spinal cord injury in pregnancy is concerned with the management of patients with pre-existing lesions; very few articles deal with acute injuries. We report the management of a case of acute spinal cord injury in the third trimester of pregnancy and review the major clinical issues associated with such cases.

[Total hip arthroplasty after femoral neck fracture in patients with acquired neurological deficit]

PURPOSE OF THE STUDY

To evaluate the outcome of total hip arthroplasty (THA) performed for femoral neck fracture in patients with a paralytic hip.

MATERIAL AND METHODS

Between 1997 and 2004, total hip arthroplasty was performed in 301 patients with a medio-cervical or sub-capital fracture of the femoral neck. In 17 of them there was also neurological deficit due to a stroke in 11, multiple sclerosis in four, and conditions following cranial injury in two. The degree of neurological deficit was assessed pre-operatively and its effect on the outcome was evaluated, in particular that on the overall results of THA, implant stability and post-operative complications.

RESULTS

At an average follow-up of 61 months, 15 out of the 17 patients were examined, because one died and one failed to turn up. Four patients had a dislocation and two had a post-operative infection and para-articular ossification. Seven patients could walk with the use of walking aids, eight had serious difficulties or were in a wheelchair.

DISCUSSION

The incidence of post-operative complications is much more frequent in patients with neurological deficit than in the other THA patients. Some possibilities to improve the prospects of neurologically affected patients are discussed, such as fall prevention, rational drug therapy, etc. Options for operative techniques and implant use are also dealt with as well as post-operative care to prevent complications.

CONCLUSIONS

In patients with medio-cervical or sub-capital fracture of the femoral neck and co-existent neurological deficit, operative considerations should also involve further surgical techniques, such as osteosynthesis or Girdlestone arthroplasty. To achieve a good outcome it is necessary to choose a correct operative procedure with an optimal combination of acetabular and femoral components, to perform additional periarticular surgery and to indicate post-operative comprehensive rehabilitation.

Erectile dysfunction in older male stroke patients: correlation between side of hemiplegia and erectile function

This study was conducted to determine the effects of hemiplegia on erectile function in stroke patients. One hundred and five stroke patients grouped into left (61.78 +/- 7.79 years) and 55 right hemiplegic (62.11 +/- 9.32 years) and 40 age-matched controls (64.00 +/- 8.53 years). The International Index of Erectile Function questionnaire was used for data collection. One way analysis of variance and Spearman correlation tests were used in data analysis. Erectile function was significantly decreased in the both right (IIEF-5, 7.55 +/- 4.07) and left hemiplegic groups (IIEF-5, 10.40 +/- 5.70) compared with the control group (IIEF-5, 20.50 +/- 4.2 7) p < 0.05. Side of hemiplegia significantly correlated with erectile dysfunction at p < 0.01. Conclusively, stroke mostly affects erectile function of right hemiplegia.

[Case of sporadic hemiplegic migraine with cerebellar ataxia]

A 34-year-old man was admitted with his unsteady gait, difficulty in speech and a paroxysmal severe headache accompanied with sensori-motor disturbance of the right extremities and aphasic symptom. His family history was unremarkable. His unsteadiness has progressed very slowly from childhood. He noted to be inarticulate at the age of 18 years. At the age of 33 years, he suddenly had an attack of severe throbbing headache, which was mainly left parietal, with nausea and photophobia. During the headache, his right extremities were paralyzed and he became aphasic. He had lost a partial memory of the event All these symptoms had gone within 24 hours. Thereafter, the same headache occurred about once a month. Neurological examination revealed a mild truncal ataxia and ataxic dysarthria. Electroencephalography (EEG) showed intermittent delta waves restricted over the left fronto-temporal region. Brain MRI showed a moderate atrophy of superior cerebellar vermis and anterior cerebellar lobe. The diagnosis of sporadic hemiplegic migraine (SHM) with cerebellar ataxia was made. Our case was very similar to familial hemiplegic migraine (FHM) 1, of which some families are accompanied with transient amnesia, cerebellar ataxia and EEG abnormality. Although we did not detect any mutations in CACNA1A gene previously reported in FHM1, our case might share same pathogenesis with FHM1.

Joint-position sense and kinesthesia in cerebral palsy

OBJECTIVES

To examine joint-position sense and kinesthesia in all extremities in participants with diplegic or hemiplegic cerebral palsy (CP).

DESIGN

Survey of joint-position sense and kinesthesia differences between aged-matched controls and 2 groups with CP.

SETTING

University movement assessment laboratory.

PARTICIPANTS

Population-based sample of participants with CP, diplegia (n=21), hemiplegia (n=17), and age-matched volunteers (n=21) without neurologic disease.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Joint-position sense and kinesthesia were measured in the transverse plane (forearm pronation/supination and hip internal/external rotation) using a custom-built device. For joint-position sense, participants actively rotated the tested limb to align the distal end with 10 target positions first with the limb and targets visible to assess their ability to perform the task motorically. The task was then repeated with vision of the limb occluded, with targets remaining visible. Joint-position sense error was determined by the magnitude and direction of the rotation errors for each limb in the vision and no vision conditions. Kinesthesia was evaluated by the ability to detect passive limb rotation without vision.

RESULTS

No group differences were detected in the vision condition. Indicative of joint-position sense deficits, a significant increase in errors was found in the no vision condition in all limbs except the dominant upper limb for both groups with CP. Joint-position sense errors were systematically biased toward the direction of internal rotation. Kinesthesia deficits were evident on the nondominant upper limb in diplegia and hemiplegia, and bilaterally in the lower limbs in hemiplegia. In hemiplegia, joint-position sense and kinesthesia deficits were noted on the dominant limbs, but were significantly worse on the nondominant limbs.

CONCLUSIONS

These results indicate that people with CP have proprioception deficits in all limbs.