Assessment of motor function in studies of chronic disability

Transcutaneous Spinal Cord Stimulation Enhances Walking Performance and Reduces Spasticity in Individuals with Multiple Sclerosis

Gait dysfunction and spasticity are common debilitating consequences of multiple sclerosis (MS). Improvements of these motor impairments by lumbar transcutaneous spinal cord stimulation (tSCS) have been demonstrated in spinal cord injury. Here, we explored for the first time the motor effects of lumbar tSCS applied at 50 Hz for 30 min in 16 individuals with MS and investigated their temporal persistence post-intervention. We used a comprehensive protocol assessing walking ability, different presentations of spasticity, standing ability, manual dexterity, and trunk control. Walking ability, including walking speed and endurance, was significantly improved for two hours beyond the intervention and returned to baseline after 24 h. Muscle spasms, clonus duration, and exaggerated stretch reflexes were reduced for two hours, and clinically assessed lower-extremity muscle hypertonia remained at improved levels for 24 h post-intervention. Further, postural sway during normal standing with eyes open was decreased for two hours. No changes were detected in manual dexterity and trunk control. Our results suggest that transcutaneous lumbar SCS can serve as a clinically accessible method without known side effects that holds the potential for substantial clinical benefit across the disability spectrum of MS.

Vojta therapy improves postural control in very early stroke rehabilitation: a randomised controlled pilot trial

Background

It is still unclear, which physiotherapeutic approaches are most effective in stroke recovery. Vojta therapy is a type of physiotherapy that was originally developed for children and adolescents with cerebral palsy. Vojta therapy has been reported to improve automatic control of body posture. Because acute stroke patients are characterised by a disturbance in the ability to adapt to changes in body position, requiring automatic postural adjustment, we decided to investigate Vojta therapy in the early rehabilitation of stroke patients. Aim of the trial was to test the hypothesis that Vojta therapy - as a new physiotherapeutic approach in early stroke recovery - improves postural control and motor function in patients with acute ischaemic stroke (AIS) or intracerebral haemorrhage (ICH).

Methods

This prospective, randomised controlled trial included patients with imaging-confirmed AIS or ICH, severe hemiparesis and randomly assigned them to Vojta therapy or standard physiotherapy within 72 h after stroke onset. Main exclusion criterion was restricted ability to communicate. Primary endpoint was the improvement of postural control measured by the Trunk Control Test (TCT) on day 9 after admission. Secondary endpoint among others was improvement of arm function (measured with Motor Evaluation Scale for Upper Extremity in Stroke Patients [MESUPES]).

Results

Forty patients (20 per group) were randomised into the trial. Median age was 75 (66-80) years, 50% were women. The median improvement in TCT within 9 days was 25.5 points (=25.5%) (interquartile range [IQR] 12.5-42.5) in the Vojta group and 0 (IQR 0-13) in the control group (p = 0.001). Patients treated with Vojta therapy achieved a greater improvement in the MESUPES than patients in the control group (20% vs 10%, p = 0.006).

Conclusion

This first randomised controlled trial of Vojta therapy in acute stroke patients demonstrates improvement of postural control through Vojta therapy compared to standard physiotherapy. Although this trial has some methodical weaknesses, Vojta therapy might be a promising approach in early stroke rehabilitation and should be studied in larger trials.

Trial registration

ClinicalTrials.gov; Unique identifier: NCT03035968. Registered 30 January 2017 - Retrospectively registered; http://www.clinicaltrials.gov.

Post-stroke pathological crying: frequency and correlation to depression

While pathological crying has classically been described as a disturbance of the motor concomitants of emotional affect that is unrelated to mood, recent studies indicate that there may in fact be a correlation. We therefore undertook a study of post-stroke pathological crying in relation to mood score/depression and lesion site in an unselected stroke population the first year following stroke. The study population comprised 211 patients with first ever stroke (median age 69 years, range 25-80). The patients were included in the study within 7 days of the onset of stroke, and follow-up examinations were made at 1 month, 6 months and 1 year. Computerized tomography brain scans were obtained on Days 5-10. The frequency of pathological crying was 14% at 1 month, 10% at 6 months and 11% at 1 year. The overall 1 year incidence was 19%. Pathological crying correlated significantly to mood score and post-stroke depression (p < 0.005), as well as to lesion size (p < 0.05), Barthel Index (p < 0.05), Motricity Index (p < 0.005) and intellectual impairment (p < 0.05), but not to lesion location, sex, age, history of stroke or depression, predisposing disease or social distress before the stroke incident Post-stroke pathological crying was common and persistent in 11% of patients at 1 year and correlated strongly to mood score and post-stroke depression. The indication for treatment of pathological crying is therefore further strengthened.

A critical evaluation of the Incapacity Status Scale

The Incapacity State Scale (ISS) of the research version of the Minimal Record of Disability in Multiple Sclerosis has been tested in parallel with Assessment of the Activities of Daily Living (ADL) Index. Reliance of the ISS scoring on the use of aids and adaptive devices was found to be a major source of variation. It is suggested that the general scoring of the proposed ISS scale should be modified so that it employs that of the ADL method, i.e. measuring only independence (irrespective of the use of side and adaptive devices), partial and total dependence.

Impairment and recovery of left motor function in patients with right hemiplegia

OBJECTIVE

To assess the motor function of the left, supposedly unaffected, limbs of patients with an acute right vascular hemiplegia.

METHODS

Fifteen patients with an acute vascular right hemiplegia and 16 matched healthy controls were studied. Motor function of the left limbs of each patient was evaluated on days 20 and 90 after their stroke using four validated tools (hand dynamometer, isokinetic dynamometer, finger tapping, and nine hole peg test).

RESULTS

There was a significant impairment of motor function of the left limbs of patients at day 20 compared with controls. The impairment had recovered almost completely at day 90 after the stroke.

CONCLUSION

These results show the bilateral cerebral representation of the human motor system and suggest the participation of ipsilateral motor pathways in recovery after a stroke.

Dementia of depression or depression of dementia in stroke?

This study describes the correlation between changes in mood symptoms assessed by the Hamilton Depression Rating Scale (HDRS) and intellectual impairment assessed by the Brief Cognitive Rating Scale (BCRS) and Mattis Dementia Rating Scale (MDRS) in 166 unselected 1-year survivors after stroke, in whom post-stroke depression (PSD) has previously been described and validated. The course of intellectual impairment associated with PSD was compared with the course of intellectual impairment in non-PSD patients. In general, improvement in mood symptoms was correlated with an improvement in intellectual function. However, in 53 PSD patients improvement in intellectual performance was absent, despite the fact that the patients reported being significantly less distressed by dementia symptoms. Antidepressive medication did not lead to any improvement in MDRS score. No evidence was found to support the hypothesis of 'dementia of depression'. To the contrary, the findings indicate 'depression of dementia'.

Risk factors for post-stroke depression

An unselected cohort of 285 stroke patients, median age 69 years, were studied for correlation between potential risk factors and the 1-year incidence of post-stroke depression (PSD). The following factors correlated significantly with PSD: a history of previous stroke, a history of previous depression, female gender, living alone and social distress prestroke. Further, social inactivity, decrease in social activity, pathological crying and intellectual impairment at 1 month but not functional outcome correlated to PSD. A multivariate regression analysis showed that intellectual impairment explained 42% of variance of mood score. Major depression was unrelated to lesion location. We conclude that etiology to PSD is a complex mixture of prestroke personal and social factors, and stroke induced social, emotional and intellectual handicap.

Incidence of central post-stroke pain

Central post-stroke pain (CPSP) is a neuropathic pain syndrome characterized by constant or intermittent pain in a body part occurring after stroke and associated with sensory abnormalities in the painful body part. This study describes CPSP prospectively during the first year after stroke and characterizes the cerebrovascular lesions and neurological signs associated with the CPSP syndrome. Two hundred and sixty-seven consecutively admitted patients younger than 81 years were examined in the first week, at 1, 6 and 12 months after stroke. Sensibility to touch (cotton wool), temperature (20 degrees C and 40 degrees C), and pinprick was studied using the contralateral face and extremity as control. A CT scan was done 8 (median) days (range: 1-34 days) after stroke. Two hundred and seven (78%) patients surviving at least 6 months who were able to communicate reliably formed the basis of the study. Abnormal sensory signs were found at least once in 87 (42%) patients. CPSP was found in 16 (8%) patients of whom all but 1 patient also had evoked dysesthesia or allodynia. Further 1 patient had persistent evoked dysesthesia but denied pain. CPSP was not related to sex or age. In patients with single acute cerebral lesions there were no relation between size or location of the lesions and the presence of CPSP. The pain was light in 6 (3%) patients and moderate to severe in 10 (5%) patients. The pain quality was usually lacerating or aching. Fifteen (94%) patients had decreased temperature, touch and pain sensibility and 9 (56%) reported allodynia to cold stimulation and another 9 (56%) patients reported this to touch.(ABSTRACT TRUNCATED AT 250 WORDS)

Incidence of post-stroke depression during the first year in a large unselected stroke population determined using a valid standardized rating scale

This study describes the development of post-stroke depression (PSD) prospectively during the first year post-stroke in 285 unselected stroke patients. An appropriate unselected population-based control group without cerebral pathology is included for comparison. Psychiatric assessment with the Hamilton Depression Rating Scale (HDRS) was undertaken unmodified. PSD was defined as HDRS > or = 13. The one-year incidence of PSD among the 209 survivors able to communicate reliably at 1 month was 41%. Most cases develop within the first months following stroke (79%), the frequency of new cases of PSD at one year being 5%, a level comparable to that in the control group. Depressed and nondepressed stroke patients consistently scored 4 points greater on total HDRS than in the corresponding controls.

Effective treatment of poststroke depression with the selective serotonin reuptake inhibitor citalopram

BACKGROUND AND PURPOSE

The aim of the study was to investigate the efficacy and safety of the selective serotonin reuptake inhibitor citalopram in treating poststroke depression, since available treatments are usually poorly tolerated.

METHODS

A 6-week double-blind, placebo-controlled trial was undertaken. Diagnosis and outcome were determined using the Hamilton Depression Scale, and unwanted effects were measured using the UKU side effect rating scale. Sixty-six consecutive depressed patients from an unselected population of 285 stroke patients aged 25 to 80 years entered the trial 2 to 52 weeks after stroke. They were assigned to equally sized treatment and placebo groups. The initial level of depression was comparable in the two groups (mean baseline Hamilton Depression scores, 19.4 and 18.9, respectively). Demographic parameters were also comparable in the two groups.

RESULTS

Significantly greater improvement was seen in patients treated with citalopram (10 to 40 mg/d) for 3 and 6 weeks, both when including all patients (intention-to-treat analysis, P < .05) and excluding patients who dropped out during the first 3 weeks (efficacy analysis, P < .005). Half of the 28 patients who entered the trial 2 to 6 weeks after stroke recovered within 1 month, independent of the treatment given. This indicates a high degree of spontaneous recovery in the early phase after stroke. In contrast, recovery was infrequent in placebo group patients who became depressed 7 weeks or more after stroke. No serious side effects related to the treatment were detected; those present were mild and usually transient.

CONCLUSIONS

This trial demonstrates that the selective serotonin reuptake inhibitor citalopram offers an advantageous new treatment of poststroke depression that is both safe and effective.

Describing patterns of recovery as a basis for evaluating progress

Collecting descriptive data on patterns of recovery from a disabling condition could provide a baseline for assessing treatment methods and for monitoring the progress of individual patients. An illustrative study of patients recovering from stroke is presented and the strengths and weaknesses of such studies are discussed.

Assessing motor impairment after stroke: a pilot reliability study

Two short tests of motor function, the Motricity Index (MI) and the Trunk Control Test (TCT), were assessed at regular intervals after stroke and compared with a detailed physiotherapy test, the Rivermead Motor Assessment (RMA). The MI and TCT were valid and reliable tests which were usually quicker to perform than the RMA. The TCT was of predictive value when related to eventual walking ability. All three tests appeared to be of equal sensitivity in detecting change.

Randomised double blind controlled trial of cyclosporin in multiple sclerosis

In a 2 year double blind controlled trial of cyclosporin against placebo in multiple sclerosis conducted at two centres there was a beneficial effect of the therapy upon the progression of the disease, relapse rate and relapse severity at one of the centres where the patients received a mean dose of 7.2 mg/kg/day. This beneficial effect was not seen in the other centre where a lower dose (mean 5 mg/kg/day) was given. Reduction in clinical progression was accompanied by decreased IgG synthesis in the central nervous system. Side effects included hypertension, renal insufficiency and anaemia and were of such severity to preclude the use of cyclosporin in a high enough dose to alter the course of the disease.

Recovery from physical disability after stroke: normal patterns as a basis for evaluation

In 368 patients with residual hemiplegia after stroke, monitoring of recovery over eight weeks showed a distinct time-related pattern. Patterns of this sort could provide useful baselines in various conditions entailing physical disability, allowing comparison of individual scores with the average for that phase of the illness, the setting of precise goals, and the examination of factors that influence recovery.

Recovery after stroke--the first 3 months

Ninety-nine patients had their function recorded regularly over the first 13 weeks after their stroke. Five functional areas were studied: urinary continence, mobility, the ability to dress, feeding, and the ability to transfer from bed to chair. Thirty-two patients died before 13 weeks. Forty-five of the 67 survivors had assessments twice weekly from within 4 days of their stroke. Recovery in these 45 patients occurred fastest in the first 2 weeks, by which time at least 50% of recovery had occurred, but it was still continuing at 13 weeks. Urinary incontinence present between 7 and 10 days after stroke was the most important adverse prognostic factor both for survival and for recovery of function. Age was the second most important factor. Hospital discharge seemed to occur once recovery had stopped, although four of the 49 patients discharged had been fully independent for at least 12 days prior to discharge. It is suggested that rehabilitative therapy should concentrate less on physical function and more on cognitive ability.

Musculoskeletal impairment among the non-institutionalized aged

This study examines musculoskeletal impairment among 711 community elders living in Massachusetts; all are over 70 years of age, most are Caucasian (99%) and female (65%). Impairment was assessed by having trained interviewers ask participants to perform 10 standardized range-of-motion patterns. Findings reveal a high degree of musculoskeletal ability in this very aged sample. In only 3 of 10 movement patterns do more than 25% of the sample display any sign of impairment.

Double-blind controlled trial of immunosuppression in the treatment of multiple sclerosis: final report

In a double-blind controlled trial 43 patients with relapsing-remitting multiple sclerosis were treated either with anti-lymphocyte globulin, prednisolone, and azathioprine, or with placebo preparations. Treatment began with a combination of the three medicaments but after 1 month was continued for another 14 months with azathioprine (3 mg/kg dialy) only. There was a marginally beneficial effect of immunosuppression on the overall relapse rate and clinical progression. However, there were significant effects on in-vitro lymphocyte function and in the visual evoked potentials in favour of the group receiving suppressive treatment. Placebo-treated patients of the HLA A3 tissue type had significantly more relapses than placebo-treated patients who were not of type HLA A3. Nevertheless, HLA-A3-positive patients treated with immunosuppression had significantly fewer relapses than A3-positive placebo-treated patients.

The rate of recovery from stroke - and its measurement

A battery of tests to measure improvement over time in physical recovery of stroke patients - and to compare this with varying levels of disability at onset, is described. Recovery in a series of 135 patients with fresh stroke treated by traditional methods of rehabilitation is principally in the first 3 months - but also continues in the second 3 months, except for muscle power. Recovery after 6 months is least in muscle power and is limited mainly to walking and mobility (e.g. getting out of the house) which in some cases may be due to altered environmental factors. At onset only 62 per cent showed moderate or severe impairment of muscle power compared to 88 per cent with similar impairment in mobility and dependency. By 1 year 30 per cent of survivors remained dependent.

Double-blind, controlled trial of immunosuppression in treatment of multiple sclerosis

30 multiple sclerosis patients in a double-blind, controlled trial were given immunosuppressive treatment consisting of antilymphocyte globulin, prednisolone, and azathioprine, or placebo. After 15 months of treatment the immunosuppressed group had a reduction in the number of relapses and some retardation of the clinical course of the disease (p < 0.06). The beneficial effect was seen only in females.