Adjunctive hyperbaric oxygen therapy for spinal cord ischemia after complex aortic repair

OBJECTIVE

Spinal cord ischemia (SCI) with paraplegia or paraparesis is a devastating complication of complex aortic repair (CAR). Treatment includes cerebrospinal fluid drainage, maintenance of hemoglobin concentration (>10 g/L), and elevating mean arterial blood pressure. Animal and human case series have reported improvements in SCI outcomes with hyperbaric oxygen therapy (HBOT). We reviewed our center's experience with HBOT as a rescue treatment for spinal cord ischemia post-CAR in addition to standard treatment.

METHODS

A retrospective review of the University Health Network's Hyperbaric Medicine Unit treatment database identified HBOT sessions for patients with SCI post-CAR between January 2013 and June 2021. Mean estimates of overall motor function scores were determined for postoperative, pre-HBOT, post-HBOT (within 4 hours of the final HBOT session), and at the final assessment (last available in-hospital evaluation) using a linear mixed model. A subgroup analysis compared the mean estimates of overall motor function scores between improvement and non-improvement groups at given timepoints. Improvement of motor function was defined as either a ≥2 point increase in overall muscle function score in patients with paraparesis or an upward change in motor deficit categorization (para/monoplegia, paraparesis, and no deficit). Subgroup analysis was performed by stratifying by improvement or non-improvement of motor function from pre-HBOT to final evaluation.

RESULTS

Thirty patients were treated for SCI. Pre-HBOT, the motor deficit categorization was 10 paraplegia, three monoplegia, 16 paraparesis, and one unable to assess. At the final assessment, 14 patients demonstrated variable degrees of motor function improvement; eight patients demonstrated full motor function recovery. Seven of the 10 patients with paraplegia remained paraplegic despite HBOT. The estimated mean of overall muscle function score for pre-HBOT was 16.6 ± 2.9 (95% confidence interval [CI], 10.9-22.3) and for final assessment was 23.4 ± 2.9 (95% CI, 17.7-29.1). The estimated mean difference between pre-HBOT and final assessment overall muscle function score was 6.7 ± 3.1 (95% CI, 0.6-16.1). The estimated mean difference of the overall muscle function score between pre-HBOT and final assessment for the improved group was 16.6 ± 3.5 (95% CI, 7.5-25.7) vs -4.9 ± 4.2 (95% CI, -16.0 to 6.2) for the non-improved group.

CONCLUSIONS

HBOT, in addition to standard treatment, may potentially improve recovery in spinal cord function following SCI post-CAR. However, the potential benefits of HBOT are not equally distributed among subgroups.

Scalp acupuncture for post-stroke spastic hemiparesis: A systematic review and meta-analysis

BACKGROUND

Spastic paralysis is one of the most common sequelae of stroke, severely affecting patients' limb function and reducing their quality of life. Scalp acupuncture (SA) has been shown to significantly improve cerebral blood supply and reduce the severity of limb spasticity. This meta-analysis aims to systematically evaluate the clinical efficacy of SA in the treatment of post-stroke spastic paralysis, providing evidence-based medicine for clinical management of this condition.

METHODS

We comprehensively searched databases including China National Knowledge Infrastructure, Wanfang Data, VIP Chinese Science and Technology Periodical Database, China Biomedical Literature Database, PubMed, Embase, and Cochrane Library. Randomized controlled trials investigating the efficacy of SA in post-stroke spastic paralysis were identified until July 28, 2023. Meta-analysis was conducted using RevMan 5.4 and Stata17.0.

RESULTS

A total of 16 studies were included. Meta-analysis showed that the modified Ashworth spasticity assessment scale in the SA group was significantly higher than that in the rehabilitation group (mean difference [MD] = -0.56, 95% confidence interval [CI] [-0.75, -0.37], Z = 5.67, P < .00001). The simplified Fugl-Meyer motor function assessment scale in the SA group was significantly higher than that in the rehabilitation group (MD = 5.86, 95% CI [3.26, 8.46], Z = 4.41, P < .0001). The modified Barthel index assessment scale in the SA group was significantly higher than that in the rehabilitation group (MD = 5.79, 95% CI [4.73, 6.84], Z = 10.77, P < .00001). Additionally, the clinical effective rate in the SA group was significantly higher than that in the rehabilitation group (relative risk = 1.25, 95% CI [1.16, 1.36], Z = 5.42, P < .00001).

CONCLUSION

SA combined with rehabilitation therapy has certain advantages in reducing limb spasticity, improving limb function, and enhancing activities of daily living in patients with post-stroke spastic paralysis. This study provides reference and theoretical support for the promotion of SA in the treatment of this condition.

Lesion mapping and functional characterization of hemiplegic children with different patterns of hand manipulation

Brain damage in children with unilateral cerebral palsy (UCP) affects motor function, with varying severity, making it difficult the performance of daily actions. Recently, qualitative and semi-quantitative methods have been developed for lesion classification, but studies on mild to moderate hand impairment are lacking. The present study aimed to characterize lesion topography and preserved brain areas in UCP children with specific patterns of hand manipulation. A homogeneous sample of 16 UCP children, aged 9 to 14 years, was enrolled in the study. Motor assessment included the characterization of the specific pattern of hand manipulation, by means of unimanual and bimanual measures (Kinematic Hand Classification, KHC; Manual Ability Classification System, MACS; House Functional Classification System, HFCS; Melbourne Unilateral Upper Limb Assessment, MUUL; Assisting Hand Assessment, AHA). The MRI morphological study included multiple methods: (a) qualitative lesion classification, (b) semi-quantitative classification (sq-MRI), (c) voxel-based morphometry comparing UCP and typically developed children (VBM-DARTEL), and (d) quantitative brain tissue segmentation (q-BTS). In addition, functional MRI was used to assess spared functional activations and cluster lateralization in the ipsilesional and contralesional hemispheres of UCP children during the execution of simple movements and grasping actions with the more affected hand. Lesions most frequently involved the periventricular white matter, corpus callosum, posterior limb of the internal capsule, thalamus, basal ganglia and brainstem. VMB-DARTEL analysis allowed to detect mainly white matter lesions. Both sq-MRI classification and q-BTS identified lesions of thalamus, brainstem, and basal ganglia. In particular, UCP patients with synergic hand pattern showed larger involvement of subcortical structures, as compared to those with semi-functional hand. Furthermore, sparing of gray matter in basal ganglia and thalamus was positively correlated with MUUL and AHA scores. Concerning white matter, q-BTS revealed a larger damage of fronto-striatal connections in patients with synergic hand, as compared to those with semi-functional hand. The volume of these connections was correlated to unimanual function (MUUL score). The fMRI results showed that all patients, but one, including those with cortical lesions, had activation in ipsilesional areas, regardless of lesion timing. Children with synergic hand showed more lateralized activation in the ipsilesional hemisphere both during grasping and simple movements, while children with semi-functional hand exhibited more bilateral activation during grasping. The study demonstrates that lesion localization, rather than lesion type based on the timing of their occurrence, is more associated with the functional level of hand manipulation. Overall, the preservation of subcortical structures and white matter can predict a better functional outcome. Future studies integrating different techniques (structural and functional imaging, TMS) could provide further evidence on the relation between brain reorganization and specific pattern of manipulation in UCP children.

Thrombosis secondary to penetration of internal carotid artery due to soft palate impalement injury: A case report of hemiplegic syndrome and literature review

Intraoral injuries are frequently encountered in emergency departments due to children's desire and curiosity to put objects in their mouths. However, forward falls with objects in children's mouths can cause impalement injuries to soft palate, retropharyngeal-peritonsillar, and retromolar tissues, leading to serious morbidity and even mortality. These transoral (soft palate, pharynx-tonsil, retromolar region) penetration injuries can especially result in damage to major vascular structures like the Internal Carotid Artery (ICA) due to their close proximity. Dissection, thrombosis, and subsequent stroke can occur in the delicate ICA as a result. In the presented case, a 3-year-old male child experienced internal carotid artery dissection following penetrating injury with a pen, as demonstrated by imaging studies. A literature review is provided along with the case of this child, who developed a reduction in middle cerebral artery (MCA) flow due to thrombosis in the ICA. The study encompasses all penetrating oropharyngeal traumas reported in individuals aged 0-18 years from 1936 to 2023. A search in PubMed and Google Scholar using keywords such as 'internal carotid artery injury,' 'penetrating trauma,' and 'children' yielded 78 case reports from a pool of 36,000 studies. The analysis excludes injuries in areas like tongue, cheek, gums, lips, and floor of the mouth, post-tonsillectomy injuries, and those from sudden braking vehicles. This review encompasses the evaluation, diagnosis, and treatment of penetrating injuries to the soft palate, pharyngeal wall, tonsil, and retromolar regions.

Precision therapy for a medically actionable ATP1A3 variant from a genomic medicine program in an underserved population

BACKGROUND

Genomic medicine is revolutionizing the diagnosis of rare diseases, but the implementation has not benefited underrepresented populations to the same degree. Here, we report the case of a 7-year-old boy with hypotonia, global developmental delay, strabismus, seizures, and previously suspected mitochondrial myopathy. This proband comes from an underrepresented minority and was denied exome sequencing by his public insurance.

METHODS

After informed consent was obtained, buccal cells from the proband were collected and whole exome sequencing was performed. Illumina Dragen and Emedgene software was used to analyze the data at Baylor Genetics. The variants were further intepreted according to ACMG guidelines and the patient's phenotype.

RESULTS

Through whole-exome sequencing (WES) under the Community Texome project, he was found to have a heterozygous de novo pathogenic variant in the ATP1A3 gene located on chromosome 19q13.

CONCLUSION

In retrospect, his symptomatology matches the known medical conditions associated with the ATP1A3 gene namely Alternating Hemiplegia of Childhood 2 (AHC), a rare autosomal dominant disorder with an incidence of 1 in one million. His single nucleotide variant, (c.2401G>A, p.D801N), is predicted to be damaging. The specific amino acid change p.D801N has been previously reported in ClinVar along with the allelic variant p.D801Y and both are considered pathogenic. The identification of this variant altered medical management for this patient as he was started on a calcium antagonist and has reported no further hemiplegic episodes. This case illustrates the value of implementing genomic medicine for precision therapy in underserved populations.

A Patient with a History of Right-Sided Stroke and Hemiplegia, in a Wheelchair, Presents with a Complaint of Upper Left Tooth Pain

Patients with a history of stroke often present with numerous neurologic deficits and varying degrees of disability. Ambulation problems requiring the use of a wheelchair can make accessing and receiving dental care difficult for these patients. Side effects from medications can compromise their oral health and complicate care. Possible dexterity limitations decrease their ability to maintain their oral health. Innovative care plans and adaptations may be needed to accommodate the needs of these patients but care generally can be provided safely and effectively in the outpatient dental setting.

Nonoperative Management of Humerus Fractures in Patients With Ispilateral Hemiparesis or Hemiplegia

BACKGROUND

Patients with upper limb dysfunction from a brain injury often have different goals of treatment and expectations following a fracture of the upper extremity. This study retrospectively reviewed outcomes of nonoperative management of acute humerus fractures in patients with severe ipsilateral hemiparesis or hemiplegia.

METHODS

Patients who had sustained an acute humerus fracture managed nonoperatively, greater than 1 year following an upper motor neuron (UMN) injury resulting in ipsilateral severe hemiparesis or hemiplegia at a single tertiary care center from 1988 to 2019, were reviewed. Fractures were classified using the AO-Müller/Orthopaedic Trauma Association and/or Neer classifications. Primary outcome measures included House classification level of function, pain, achievement of and time to radiographic union, and the need for subsequent surgical procedures.

RESULTS

Ten distinct nonoperatively managed humerus fractures-3 proximal (11A23), 5 mid-shaft (12A2b = 1, 12A2c = 2, 12A3a = 1, 12A2b = 1), and 2 distal (13A2 = 1, 13 C1 = 1)-were identified in 8 patients (6 women and 2 men) with ipsilateral hemiparesis or hemiplegia. The median radiographic follow-up was 20 months (range: 78 days to 12 years). The median clinical follow-up was 33.5 months (range: 100 days to 12 years). All patients presented with severe pain that was absent at final follow-up. Radiographic union was achieved in all patients with a mean time to union of 90.9 ± 39.3 days (range: 35-185 days). No patients required operative management.

CONCLUSIONS

Nonoperative management of humerus fractures in patients with an ipsilateral UMN injury might result in reliable pain relief and union without the need for further surgical intervention. Management of humerus fractures in this patient population should be individualized toward their goals of care.

Adult hemiconvulsive hemiatrophy syndrome: a novel clinicoradiologic disorder in adults

The association of focal motor seizures with cerebral hemiatrophy is a recognised rare paediatric syndrome known as 'hemiconvulsion, hemiatrophy and epilepsy' (HHE). To date, HHE has not been reported in adults. We present four adult patients with striking similarities to HHE, following alcohol withdrawal in chronic alcoholics. We document the imaging findings in the acute and subacute phases, discuss the underlying mechanisms and present a hypothesis regarding the pathophysiology.

Characterization of Atypical Corticospinal Tract Microstructure and Hand Impairments in Early-Onset Hemiplegic Cerebral Palsy: Preliminary Findings

Unilateral brain injuries occurring before at or shortly after full-term can result in hemiplegic cerebral palsy (HCP). HCP affects one side of the body and can be characterized in the hand with measures of weakness and a loss of independent hand control resulting in mirror movements. Hand impairment severity is extremely heterogeneous across individuals with HCP and the neural basis for this variability is unclear. We used diffusion MRI and tractography to investigate the relationship between structural morphology of the supraspinal corticospinal tract (CST) and the severity of two typical hand impairments experienced by individuals with HCP, grasp weakness and mirror movements. Results from nine children with HCP and eight children with typical development show that there is a significant hemispheric association between CST microstructure and hand impairment severity that may be explained by atypical development and fiber distribution of motor pathways. Further analysis in the non-lesioned (dominant) hemisphere shows significant differences for CST termination in the cortex between participants with HCP and those with typical development. These findings suggest that structural disparities at the cellular level in the seemingly unaffected hemisphere after early unilateral brain injury may be the cause of heterogeneous hand impairments seen in this population.Clinical Relevance- Quantitative measurement of the variability in hand function in individuals with HCP is necessary to represent the distinct impairments experienced by each person. Further understanding of the structural neural morphology underlying distal upper extremity motor deficits after early unilateral brain injury will help lead to the development of more specific targeted interventions that increase functional outcomes.

Hemiplegia resulting from acute carbon monoxide poisoning

Carbon monoxide (CO) poisoning can cause neurological complications such as movement disorders and cognitive impairment through hypoxic brain damage. Although peripheral neuropathy of the lower extremities is a known complication of CO poisoning, hemiplegia is very rare. In our case, a patient who developed left hemiplegia due to acute CO poisoning received early hyperbaric oxygen treatment (HBOT). The patient had left hemiplegia and anisocoria at the beginning of HBOT. Her Glasgow coma score was 8. A total of five sessions of HBOT at 243.2 kPa for 120 minutes were provided. At the end of the 5th session, the patient's hemiplegia and anisocoria were completely resolved. Her Glasgow coma score was 15. After nine months of follow-up, she continues to live independently with no sequelae, including delayed neurological sequelae. Clinicians should be aware that CO poisoning can (rarely) present with hemiplegia.

Early surgical treatment of closed reduction and internal fixation for a 30-day old intertrochanteric fracture with hemiplegia after acute stroke: A case report

RATIONALE

Currently, there are no clear guidelines to determine whether and when to perform surgical hip repair in patients with acute stroke and hip fracture.

PATIENT CONCERNS

In this case report, we report a case of 75-year-old woman admitted with left hip pain and limited mobility for 1 month.

DIAGNOSES

Patient had a history of acute cerebral infarction 42 days ago, and diagnosed with a left intertrochanteric fracture at another hospital 30 days ago.

INTERVENTION

Patient was treated with closed reduction and internal fixation with proximal femoral nail anti-rotation.

OUTCOMES

At 2-year follow-up, the patient's basic function was restored. The fracture healed well, and the Harris hip score was 75.

LESSONS

Without consistent guidelines, individualized treatment strategies including surgical methods and timing of surgery should be made to weigh the risks and benefits for patients with acute stroke and intertrochanteric fractures.

Mortality Patterns Associated with Central Sleep Apnea among Veterans: A Large, Retrospective, Longitudinal Report

Rationale: Central sleep apnea (CSA) is associated with high mortality. Current knowledge stems from studies with limited sample size (fewer than 100 subjects) and in homogeneous populations such as heart failure (HF). Objectives: To address this knowledge gap, we compared the mortality pattern and time to death between the CSA and obstructive sleep apnea (OSA) patients in the large Veterans Health Administration patient population using the big data analytic approach. Methods: This is a retrospective study using national Veterans Health Administration electronic medical records from October 1, 1999, through September 30, 2020. We grouped the patients with underlying sleep disorders into CSA and OSA, using the International Classification of Diseases, Ninth and Tenth Revision codes. We applied Cox regression analysis to compare the mortality rate and hazard ratio (HR) among the two groups and adjusted HR by gender, race, body mass index (BMI), age, and Charlson Comorbidity Index. In CSA groups, a machine-learning algorithm was used to determine the most important predictor of time to death. Further subgroup analysis was also performed in patients that had comorbid HF. Results: Evaluation of patients resulted in 2,961 grouped as CSA and 1,487,353 grouped as OSA. Patients with CSA were older (61.8 ± 15.6 yr) than those with OSA (56.7 ± 13.9 yr). A higher proportion of patients with CSA (25.1%) died during the study period compared with the OSA cohort (14.9%). The adjusted HR was 1.53 (95% confidence interval [CI], 1.43-4.65). Presence of HF history of cerebrovascular disease, hemiplegia, and having a BMI less than 18.5 were among the highest predictors of mortality in CSA. The subgroup analysis revealed that the presence of HF was associated with increased mortality both in CSA (HR, 7.4; 95% CI, 6.67-8.21) and OSA (HR, 4.3; 95% CI, 4.26-4.34) groups. Conclusions: Clinically diagnosed CSA was associated with a shorter time to death from the index diagnostic date. Almost one-fifth of patients with CSA died within 5 years of diagnosis. The presence of HF, history of cerebrovascular disease and hemiplegia, male sex, and being underweight were among the highest predictors of mortality in CSA. CSA was associated with higher mortality than OSA, independent of associated comorbidity.

Atypical symptom reporting after mild traumatic brain injury

OBJECTIVE

Early reporting of atypical symptoms following a mild traumatic brain injury (mTBI) may be an early indicator of poor prognosis. This study aimed to determine the percentage of people reporting atypical symptoms 1-month post-mTBI and explore links to recovery 12 months later in a community-dwelling mTBI sample.

METHODS

Adult participants (>16 years) who had experienced a mTBI were identified from a longitudinal incidence study (BIONIC). At 1-month post-injury, 260 participants completed the Rivermead Post-Concussion Symptoms Questionnaire (typical symptoms) plus four atypical symptom items (hemiplegia, difficulty swallowing, digestion problems and difficulties with fine motor tasks). At 12 months post-injury, 73.9% (n = 193) rated their overall recovery on a 100-point scale. An ordinal regression explored the association between atypical symptoms at 1 month and recovery at 12 months post-injury (low = 0-80, moderate = 81-99 and complete recovery = 100), whilst controlling for age, sex, rehabilitation received, ethnicity, mental and physical comorbidities and additional injuries sustained at the time of injury.

RESULTS

At 1-month post-injury <1% of participants reported hemiplegia, 5.4% difficulty swallowing, 10% digestion problems and 15.4% difficulties with fine motor tasks. The ordinal regression model revealed atypical symptoms were not significant predictors of self-rated recovery at 12 months. Older age at injury and higher typical symptoms at 1 month were independently associated with poorer recovery at 12 months, p < 0.01.

CONCLUSION

Atypical symptoms on initial presentation were not linked to global self-reported recovery at 12 months. Age at injury and typical symptoms are stronger early indicators of longer-term prognosis. Further research is needed to determine if atypical symptoms predict other outcomes following mTBI.

Hypoglycemic Hemiplegia Associated with Reversible Narrowing of the Contralateral Middle Cerebral Artery in a Patient with Adrenal Insufficiency

A 56-year-old man with a 2.5-month history of anorexia developed sweating, weakness, and left hemiplegia and hemispatial neglect. Brain magnetic resonance imaging detected no abnormalities, but magnetic resonance angiography revealed narrowing of the right middle cerebral artery (MCA). The focal neurological signs and narrowing of the MCA resolved after detection and correction of hypoglycemia. Endocrinological examinations indicated adrenal insufficiency. Hemiplegia is a rare but important neurological manifestation of hypoglycemia, although the mechanisms involved remain unknown. Combined hypoglycemia and decreased MCA blood flow associated with vasospasm probably induced regionally severe neuroglycopenia with ischemia, which presented as focal neurological symptoms.

Benign paroxysmal torticollis

Benign paroxysmal torticollis is a rare, usually benign, condition classified as an episodic syndrome. It is characterized by episodes of paroxysmal head tilt and associated symptoms, some of which are shared with migraine. It is likely to be the migraine equivalent with the earliest age of onset, starting in some cases in the neonatal period but resolving typically by the age of three or four. It may evolve into other episodic syndromes, migraine, or hemiplegic migraine, and an antecedent history or family history should be sought from migraineurs. Its prevalence and under-recognition has made it difficult to study. There are emerging associations with genes implicated in other paroxysmal syndromes, including hemiplegic migraine and episodic ataxia. Treatment currently centers on supportive care and environmental modification.

Case report of anosognosia for hemiplegia: A fMRI study

OBJECTIVE

The aim of this study is to verify the functional activation in a patient with anosognosia for hemiplegia following left brain lesions.

METHODS

We report a case of a 53-year-old right-handed female patient. She came to our rehabilitative unit with a diagnosis of an ischemic major stroke in the left internal carotid artery and important hemiplegia to the right side. She underwent functional magnetic resonance imaging (fMRI), during which she performed a motor imagery task.

RESULTS

The fMRI assessment showed an ischemic lesion in the frontotemporal and insular left areas. In the fMRI experiment, we revealed activation of the residual neural patterns of both hemispheres.

CONCLUSION

We underlined an interest in the compensation mechanism that involved neural networks near brain lesions and some areas of the contro-lesional hemisphere, suggesting that the synaptic plasticity permitted an intra and inter-hemispheric reorganization of the cerebral system.

The 'healthy side' of anosognosia for hemiplegia: Increased sense of agency for the unimpaired limb or motor compensation?

OBJECTIVES

Anosognosic patients show a lack of awareness for their hemiplegia coupled with a distorted sense of agency for the actions performed by the plegic limbs. Since anosognosia is often associated with right brain damage, this hemisphere seems to play a dominant role in monitoring awareness for motor actions. Therefore, we would expect that anosognosic patients show distorted awareness and sense of agency also for actions performed with the unimpaired limb.

METHOD

To test this hypothesis, we induced illusory actions that could be congruent or incongruent with a preceding verbal command. A group of 16 right brain-damaged patients performed this task and then rated i) their ability to anticipate the actions, ii) their sense of agency and iii) their sense of ownership for each limb. Measures of awareness, neglect and motor impairment were also considered for the patient group.

RESULTS

Following incongruent actions with the unimpaired limb, less aware patients showed a relatively mild distortion in all three aspects. In addition, we also found a crucial relationship between motor impairment (for the plegic limb) and sense of agency for both plegic and healthy limbs.

CONCLUSION

Although the distortion linked to both limbs supports the initial hypothesis that the right hemisphere is responsible for monitoring awareness for action for the whole body, our data also suggest that the observed distortion may be linked to a motor compensatory phenomenon, not necessarily related to awareness processes.

Distal Radius Fracture Treatment Outcomes in Patients With Ipsilateral Hemiplegia or Hemiparesis

BACKGROUND

Little information exists to guide decision-making with regard to distal radius fractures in the setting of ipsilateral hemiparesis or hemiplegia.

METHODS

Patients who sustained a distal radius fracture in the setting of ipsilateral hemiparesis or hemiplegia secondary to brain injury were evaluated. Investigated variables included perioperative pain, preinjury House functional classification score, length of immobilization, radiographic outcome measurements, and time to union.

RESULTS

There were 15 patients with distal radius fractures with a mean age of 65.9 years. The mean clinical and radiographic follow-up was 2.8 and 2.9 years, respectively. Wrists were placed into the nonoperative group (NOG, n = 10) and operative group (OG, n = 5). Pain significantly decreased at final follow-up for both groups. Baseline House functional classification scores averaged 1.3 and 1.6 for the NOG and OG, respectively, and were maintained at final follow-up. Length of immobilization for the NOG was 46 days and OG was 37 days, P = .15. Radiographic outcomes at final follow-up in the NOG and OG, respectively, were a mean radial height of 9.3 versus. 11.6 mm, radial inclination of 18.3° versus 22.3°, 4.2° dorsal tilt versus 5.3° volar tilt, and tear drop angle of 45.6° versus 44.5°. There were no significant differences in these measurements. Time to radiographic union averaged 58 days for the NOG and 67 days for the OG, P = .42. There were no revision surgeries.

CONCLUSIONS

Based on this small case series, patients with distal radius fracture and ipsilateral hemiparesis or hemiplegia may have similar clinical, functional, and radiographic outcomes, regardless of nonoperative or operative treatment.

Child Neurology: Hemiconvulsion-Hemiplegia-Epilepsy Syndrome in the Setting of COVID-19 Infection and Multisystem Inflammatory Syndrome

Hemiconvulsion-hemiplegia-epilepsy (HHE) syndrome is a rare pediatric epilepsy syndrome characterized by prolonged focal febrile convulsive status epilepticus with unilateral hemispheric cerebral edema, followed by the subsequent development of hemiplegia, global atrophy of the affected hemisphere, and epilepsy. The pathophysiology of HHE syndrome remains poorly understood though is clearly multifactorial. Factors thus far implicated are hyperthermia, proinflammatory state, and cytotoxic edema from prolonged ictal activity. Prognosis is variable, from the resolution of hemiplegia and seizures to permanent hemiparesis and refractory epilepsy. We describe a 2-year-old boy who presented with superrefractory focal status epilepticus in the setting of acute coronavirus infectious disease-2019 (COVID-19) and multisystem inflammatory syndrome in children (MIS-C). He had right-sided hemiplegia on neurologic examination, and an MRI examination of the brain showed left cerebral hemispheric edema consistent with HHE syndrome. Our case represents the first report in the literature on HHE syndrome in the setting of acute COVID-19 and MIS-C.

Effects of whole body vibration combined with extracorporeal shock wave therapy on spasticity and balance gait parameters in hemiplegic patients with stroke

OBJECTIVES

Stroke patients may have various sensory-motor disorders, such as spasticity, muscle weakness or sensory damage. Spasticity affects 20% to 40% of stroke patients. Patients with spasticity may have problems such as pain, motor function damage, and the decreased range of motion, which leads to decline of activity and quality of daily life. Extracorporeal shock wave therapy (ESWT) is a technique that can improve post-stroke spasticity. Whole body vibration (WBV), as a passive neuromuscular muscle stimulation technique, can improve the posture control, muscle strength, and muscle work of different people. At present, there are still few studies using WBV combined with ESWT for the treatment of hemiplegic patients with stroke. This study aims to explore the effects of WBV combined with ESWT on spasticity of the affected lower limb and gait function in stroke patients.

METHODS

From March 2020 to March 2021, 50 hemiplegic patients with stroke were treated in the Department of Rehabilitation Medicine of the First Hospital of Changsha and they were assigned into a control group and a combined group, 25 cases per group. Both groups carried out conventional treatment, while the control group undertook the ESWT and fake WBV based on conventional treatment, and the combined group undertook ESWT after WBV and conventional treatment. Modified Ashworth Scale (MAS), Lower Extremity portion of the Fugl-Meyer Motor Assessment (FMA-LE), Berg Balance Scale (BBS), and parameters of three-dimensional gait analysis including kinematic parameters (peak value of hip flexion and knee flexion) and spatiotemporal parameters (velocity, cadence and stride length) were assessed before and after 4-week treatment between the 2 groups.

RESULTS

After 4 weeks of treatment, MAS scores in 2 groups were lower than before (both P<0.05), and the combined group was lower than the control group (P<0.001); BBS and FMA-LE scores were higher than those before treatment (both P<0.05), and the combined group was higher than the control group (both P<0.001); in the control group, the walking speed, stride frequency, and stride length were higher than those before treatment (all P<0.05), and there was no significant difference between the peak value of flexion hip and peak value of flexion knee (both P<0.05); the peak value of hip flexion, peak value of knee flexion, step speed, step frequency, and stride length in the combined group were higher than those before treatment (all P<0.05), and were higher than those in control group (P<0.05 or P<0.001).

CONCLUSIONS

WBV combined with ESWT can improve the spasticity and motor function of the affected lower extremity, balance, and gait in hemiplegic patients with stroke.

Effects of Acupuncture and Rehabilitation Training on Limb Movement and Living Ability of Patients with Hemiplegia after Stroke

Stroke is a disease with a high disability rate, having a serious impact on that patient's working and daily survival quality and bringing economic burden to the family and society. Patients with stroke hemiplegia are mostly tetraplegic and have difficulty regulating their balance, and their long-term symmetry has been destroyed. The application in the rehabilitation process of acupuncture in patients with hemorrhagic stroke may produce unexpected effects. It is very effective to study the effect of acupuncture combined with rehabilitation training on limb movement and patient survival. It is very helpful in improving normal motor function and normal life, increasing joint mobility and muscle strength, and reducing muscle tension. In this paper, it is found that the observational group has a complication rate of 2.13%, in contrast to 17.02% as in the group of control, and the pin-prick combined with a rehabilitative training makes a significant improvement to the patients. This study provides suggestions for the study to investigate acupuncture combined with recovery exercise on limb movement and living capacities of people with stroke paraparesis.

Corticocortical paired associative stimulation for treating motor dysfunction after stroke: study protocol for a randomised sham-controlled double-blind clinical trial

INTRODUCTION

Stroke survivors can have a high disability rate with low quality of daily life, resulting in a heavy burden on family and society. Transcranial magnetic stimulation has been widely applied to brain injury repair, neurological disease treatment, cognition and emotion regulation and so on. However, there is still much to be desired in the theories of using these neuromodulation techniques to treat stroke-caused hemiplegia. It is generally recognised that synaptic plasticity is an important basis for functional repair after brain injury. This study protocol aims to examine the corticocortical paired associative stimulation (ccPAS) for inducing synaptic plasticity to rescue the paralysed after stroke.

METHODS AND ANALYSIS

The current study is designed as a 14-week double-blind randomised sham-controlled clinical trial, composed of 2-week intervention and 12-week follow-up. For the study, 42 patients who had a stroke aged 40-70 will be recruited, who are randomly assigned either to the ccPAS intervention group, or to the control group at a 1:1 ratio, hence an equal number each. In the intervention group, ccPAS is practised in conjunction with the conventional rehabilitation treatment, and in the control group, the conventional rehabilitation treatment is administered with sham stimulation. A total of 10 interventions will be made, 5 times a week for 2 weeks. The same assessors are supposed to evaluate the participants' motor function at four time points of the baseline (before 10 interventions), treatment ending (after 10 interventions), and two intervals of follow-up (1 and 3 months later, respectively). The Fugl-Meyer Assessment Upper Extremity is used for the primary outcomes. The secondary outcomes include changes in the assessment of Action Research Arm Test (ARAT), Modified Barthel Index (MBI), electroencephalogram (EEG) and functional MRI data. The adverse events are to be recorded throughout the study.

ETHICS AND DISSEMINATION

This study was approved by the Medical Ethics Committee of Yueyang Hospital. All ethical work was performed in accordance with the Helsinki declaration. Written informed consent was obtained from all individual participants included in the study. Study findings will be disseminated in the printed media.

TRIAL REGISTRATION NUMBER

Chinese Clinical Trial Registry: ChiCTR2000036685.

Alternating hemiplegia of childhood: An electroclinical study of sleep and hemiplegia

OBJECTIVE

Alternating Hemiplegia of Childhood (AHC) is characterised by paroxysmal hemiplegic episodes and seizures. Remission of hemiplegia upon sleep is a clinical diagnostic feature of AHC. We investigated whether: 1) Hemiplegic events are associated with spectral EEG changes 2) Sleep in AHC is associated with clinical or EEG spectral features that may explain its restorative effect.

METHODS

We retrospectively performed EEG spectral analysis in five adults with AHC and twelve age-/gender-matched epilepsy controls. Five-minute epochs of hemiplegic episodes and ten-minute epochs of four sleep stages were selected from video-EEGs. Arousals were counted per hour of sleep.

RESULTS

We found 1) hemispheric differences in pre-ictal and ictal spectral power (p = 0.034), during AHC hemiplegic episodes 2) 22% reduced beta power (p = 0.017) and 26% increased delta power (p = 0.025) during wakefulness in AHC versus controls. There were 98% more arousals in the AHC group versus controls (p = 0.0003).

CONCLUSIONS

There are hemispheric differences in spectral power preceding hemiplegic episodes in adults with AHC, and sleep is disrupted.

SIGNIFICANCE

Spectral EEG changes may be a potential predictive tool for AHC hemiplegic episodes. Significantly disrupted sleep is a feature of AHC.

Wrist-hand extension function recovery in spastic hemiplegia patient by botulinum toxin injection plus surface electromyography biofeedback therapy: A case report

RATIONALE

Wrist-hand extension function rehabilitation is a vital and difficult part of hand function recovery in spastic stroke patients. Although botulinum toxin type A (BoNTA) injection plus post injection therapy was applied to the wrist-hand rehabilitation in previous reports, conclusion was inconsistent in promoting function. For this phenomenon, proper selection of patients for BoNTA injection and correct choice of post-injection intervention could be the crucial factors for the function recovery.

PATIENT CONCERNS

We reported a 46-year-old male suffered a spastic hemiplegia with wrist- hand extension deficit.

DIAGNOSES

Computed tomography showed cerebral hemorrhage in the left basal ganglia region.

INTERVENTIONS

Four hundred units of BoNTA were injected into the spasticity flexors, and four-week post injection surface electromyography (sEMG) biofeedback therapy was applied to the patient.

OUTCOMES

The patient exhibited post-intervention improvement in wrist-hand extensors performance (strength, range of motion, sEMG signals), the flexors spasticity, and upper extremity function.

LESSONS

The present case showed that 4-week of BoNTA injection plus sEMG biofeedback exercise improved the performance and function of wrist-hand extensors in the patient for short- and long-term. Proper selection of patients for BoNTA injection and correct choice of post injection exercise could play a vital role in the hand rehabilitation for patient with spastic hemiplegia.

Fitting the task to a person with disabilities: A case of return-to-work support for a patient due to left-sided poststroke hemiplegia using tailor-made jigs-and-tools

BACKGROUND

A 45-year-old Japanese male pharmacist developed a stroke in December 2018; hence, he had left-sided hemiplegia due to the after-effects of cerebral stroke. This paper reports the return-to-work (RTW) and after RTW support for poststroke patients from a combined ergonomic and rehabilitation perspective.

METHODS

From April 2019 to July 2020, we visited hospitals and workplaces multiple times, making various preparations for workplace accommodation and exchanging information as follows: allowing staggered working hours; securing the flow routes in the back room; equipping a cane holder on his working desk; and adjusting the position of the work tablet. In August 2020, after RTW, we conducted a brief evaluation of residual motor function and an on-site task analysis, and we subsequently made a support tool.

RESULTS

In July 2020, his RTW was eventually realized. Moreover, as a result of introducing the tailor-made support tool, the duration of certain tasks that he had been claiming to be difficult was reduced when compared to that before support-tool use, and the average task duration before and after support-tool use was 32.8 s and 10 s, respectively (reduced by approximately 69.5%).

CONCLUSION

To augment our efforts, hospital staff, support staff in his workplace, and his employer collaborated to make various workplace accommodations for the smooth realization of RTW before and after RTW. In the present case, the ergonomic and rehabilitation approach after RTW might have contributed to ease of task, work efficiency, and the potential for future job retention.

Comprehensive Exonic Sequencing of Hemiplegic Migraine-Related Genes in a Cohort of Suspected Probands Identifies Known and Potential Pathogenic Variants

Hemiplegic migraine (HM) is a rare migraine disorder with aura subtype including temporary weakness and visual, sensory, and/or speech symptoms. To date, three main genes—CACNA1A, ATP1A2, and SCN1A—have been found to cause HM. These encode ion channels or transporters, important for regulating neuronal ion balance and synaptic transmission, leading to HM being described as a channelopathy. However, <20% of HM cases referred for genetic testing have mutations in these genes and other genes with roles in ion and solute transport, and neurotransmission has also been implicated in some HM cases. In this study, we performed whole exome sequencing for 187 suspected HM probands referred for genetic testing, but found to be negative for CACNA1A, ATP1A2, and SCN1A mutations, and applied targeted analysis of whole exome sequencing data for rare missense or potential protein-altering variants in the PRRT2, PNKD, SLC1A3, SLC2A1, SLC4A4, ATP1A3, and ATP1A4 genes. We identified known mutations and some potentially pathogenic variants in each of these genes in specific cases, suggesting that their screening improves molecular diagnosis for the disorder. However, the majority of HM patients were found not to have candidate mutations in any of the previously reported HM genes, suggesting that additional genetic factors contributing to the disorder are yet to be identified.

Characteristics and risk factors of deep vein thrombosis in hemiplegic, healthy and bilateral limbs of hemiplegic patients: a 10-year retrospective study

Deep vein thrombosis (DVT) in hemiplegic patients mainly affects hemiplegic limbs, DVT can also occur only in healthy limbs, and some hemiplegic patients have DVT in both limbs. Characteristics and risk factors of DVT in hemiplegic, healthy, and bilateral limbs are unknown. To describe the proportion, risk factors, extent, and timing of DVT in hemiplegic, healthy and bilateral limbs. A 10-year retrospective review of consecutive patients was performed. DVT affected hemiplegic limbs in 34 (62%), healthy limbs in 11 (20%), and was bilateral in 10 (18%). DVT was more likely to develop in healthy limbs of hemiplegic patients without surgery (odds ratio (OR) 0.022; 95% confidence interval (CI) 0.001-0.922), and without diabetes (OR 0.023, 95% CI 0.001-0.853). Among the veins at the level of which DVT occurred, intermuscular veins represented 20 (45%) in hemiplegic, 5 (37%) in healthy, and 6 (74%) in bilateral limbs. The median time that DVT occurred after hemiplegia onset was 18 days (interquartile range [IQR] 9-79) in hemiplegic, 17 days (IQR 10-56) in healthy, and 21 days (IQR 8-27) in bilateral limbs. Early and effective prevention of DVT after surgery and optimal management of diabetes may reduce the risk of DVT in bilateral limbs. It's important to prevent proximal extension of calf vein DVT. DVT prophylaxis should be started early and continued for at least 3 weeks after hemiplegia onset.

Clinical effectiveness of ultrasound guided subacromial-subdeltoid bursa injection of botulinum toxin type A in hemiplegic shoulder pain: A retrospective cohort study

Hemiplegic shoulder pain (HSP), which occurs in most patients with hemiplegia, causes considerable distress and worsens outcomes in rehabilitation. Although they have received the treatments such as anti-inflammatory drugs or physical therapy, many of the individuals remain suffering from shoulder pain 6 months after acute stroke event. In this retrospective study, we evaluated the effectiveness of ultrasound guided subacromial-subdeltoid (SASD) bursa injections with botulinum toxin type A (BoNT/A) compared to steroids for refractory HSP.The data were collected retrospectively by reviewing the patient's medical records and pain questionnaires in our rehabilitation center. In total, 38 patients who received ultrasound guided SASD bursa injection (BoNT/A group, n = 18; corticosteroid group, n = 20) were included. The pain visual analog scale (VAS) score at rest and during arm passive abduction, Fugl-Meyer score of upper limbs (F-M score) were evaluated before, 2, 4, 8, and 12 weeks after injection.Both 2 groups obtained a significant improvement of VAS score at rest or during arms passive abduction compared to baseline score (within group compare, P < .05). There were no significant differences of pain score improvement between two groups at week 2, 4, 8, and 12 after injection either at rest or during passive arm abduction (between 2 groups compare, P > .05). There were also no differences in results of the post treatment F-M score between 2 groups (between 2 groups compare, P > .05). Similarly, during the follow-up period no collateral effects were reported after BoNT/A injection.SASD bursa BoNT/A injection can substantially reduce the pain as corticosteroid in patients with HSP. BoNT/A injection could be a useful strategy for replacing steroids as a treatment for refractory HSP especially in the patients who cannot tolerate the steroids injection.

CONSORT-Assistive technology-180° rotating eating spoon improves the ability of eating of self-care patients with upper extremity dyskinesia: Rotating eating spoon improves eating ability

OBJECTIVE

This study aims to develop an assistive technology-180° rotating feeding spoon that could improve the ability of eating of self-care patients with upper extremity dyskinesia.

METHODS

The Brunnstrom 6-stage rating of hemiplegia was adopted. During the different recovery stages of the upper limbs, the patients orally ate using a feeding spoon with a non-rotatory head and a 180° rotating feeding spoon. The ability of these patients to eat by themselves was observed, and the basic activity of daily living (BADL) was assessed using the Barthel index (BI).

RESULTS

The Brunnstrom assessment scale was used to analyze the results of the patient's upper limb function examination, and the results revealed that the 180° rotating feeding spoon could assist patients with different degrees of upper limb dysfunction when eating independently.

CONCLUSIONS

The 180° rotating feeding spoon can assist patients with upper limb dysfunction when eating independently. For patients with different degrees of upper limb dysfunction, the spoon can provide different degrees of aid.

Altered White Matter Connectivity Associated with Intergyral Brain Disorganization in Hemiplegic Cerebral Palsy

Despite extensive literature showing damages in the sensorimotor projection fibers of children with hemiplegic cerebral palsy (HCP), little is known about how these damages affect the global brain network. In this study, we assess the relationship between the structural integrity of sensorimotor projection fibers and the integrity of intergyral association white matter connections in children with HCP. Diffusion tensor imaging was performed in 10 children with HCP and 16 typically developing children. We estimated the regional and global white-matter connectivity using a region-of-interest (ROI)-based approach and a whole-brain gyrus-based parcellation method. Using the ROI-based approach, we tracked the spinothalamic (STh), thalamocortical (ThC), corticospinal (CST), and sensorimotor U- (SMU) fibers. Using the whole-brain parcellation method, we tracked the short-, middle-, and long-range association fibers. We observed for the more affected hemisphere of children with HCP: (i) an increase in axial diffusivity (AD), mean diffusivity (MD), and radial diffusivity (RD) for the STh and ThC fibers; (ii) a decrease in fractional anisotropy (FA) and an increase in MD and RD for the CST and SMU fibers; in (iii) a decrease in FA and an increase in AD, MD, and RD for the middle- and long-range association fibers; and (iv) an association between the integrity of sensorimotor projection and intergyral association fibers. Our findings indicate that altered structural integrity of the sensorimotor projection fibers disorganizes the intergyral association white matter connections among local and distant regions in children with HCP.

The long-term effects of hyaluronic acid on hemiplegic shoulder pain and injury in stroke patients: A randomized controlled study

BACKGROUND

Hemiplegic shoulder pain (HSP) is one common complication after stroke. The interferes with the functionality of the affected shoulder in patients with stroke during rehabilitation. Hyaluronic acid (HA) could have positive effects on pain relief and shoulder motion in stroke patients with hemiplegic shoulders. We investigated long-term benefits of HA injection in stroke patients with HSP and rotator cuff injury.

METHODS

A randomized, double-blinded controlled trial was conducted in one medical center. The stroke patients with HSP and rotator cuff injury were randomized and allocated to the control (n = 9) and experimental (n = 18) groups. The control and the experimental groups received ultrasound-guided subacromial 0.9% sodium chloride and HA injections, respectively. All injections were performed once per week for 3 weeks. The associated upper extremity functional assessments, shoulder pain scale, and sonography findings on affected shoulders were measured before interventions and at the 4th and 12th week after local injections.

RESULTS

The visual analog scale (VAS) scores of HSP were significantly reduced in the control and experimental groups at the 4th week following intervention. Additionally, the VAS score at the 12th week was also significantly reduced in the experimental group. Significant differences were found in the hyperemia occurrence in the subscapularis tendon at the 12th week after intervention (P = .018) and in the severity of hyperemia in the long head of the biceps tendon (P = .042) and the subscapularis tendon after intervention (P = .014).

CONCLUSION

Subacromial HA injections might provide longer HSP reduction and decrease in hyperemia reactions at the long head of biceps tendon and subscapularis tendon in stroke patients with HSP and tendon injury.

Usefulness of F-18 FP-CIT PET to predict dopamine-responsive hand tremor in patients other than Parkinson's disease: Two case reports

RATIONALE

Treating the patients with hand tremors is clinically difficult, because a wide range of disorders can result in hand tremors. Therefore, when treatment for hand tremors begins, various pharmacological options have to be considered. In clinical practice, a practical approach is to initially check hand tremor patients for signs of Parkinson's disease (PD), because patients with PD can benefit from dopamine treatment. However, only part of patients with PD tends to show a meaningful improvement in hand tremors for dopamine treatment. On the other hand, dopamine treatment may help with hand tremors of patients with other disorders, but dopamine responsiveness can't be predicted by clinical assessment alone.

PATIENTS CONCERNS

Hand tremors.

DIAGNOSES

Hemiplegic patients (A 78-year-old man with cerebral infarction and a 65-year-old woman with traumatic brain injury) with hemi-sided hand tremor.

INTERVENTIONS

Fluorinated N-3-fluoropropyl-2β-carbomethoxy-3β-(4-iodophenyl) nortropane (F-18 FP-CIT) positron emission tomography (PET) and dopamine agonist.

OUTCOMES

After the medication, hemi-side hand tremor dramatically improved.

LESSONS

Collectively, a dysfunction of the dopaminergic nigro-striatal pathway may lead to abnormal findings of F-18 FP-CIT PET, and these abnormal findings in brain-lesion patients with hand tremor may help predict dopamine responsiveness of hand tremor. We believe that our report may be helpful in the diagnosis and treatment of hand tremor in patients with brain-lesion.

Ocular Dipping in a Patient With Hemiplegic Migraine

A 5-year-old girl presented with acute, rapidly progressive encephalopathy following minor head trauma and was found to have ocular dipping. Her encephalopathy was secondary to a channelopathy caused by a CACNA1A mutation. This is the first reported case of ocular dipping in an encephalopathic child with CACNA1A-confirmed hemiplegic migraine. [J Pediatr Ophthalmol Strabismus. 2018;55:e4-e6.].

Efficacy of early rehabilitation therapy on movement ability of hemiplegic lower extremity in patients with acute cerebrovascular accident

This study aims to investigate the efficacy of early rehabilitation therapy on the movement ability of hemiplegic lower extremity in patients with acute cerebrovascular accident (CVA).A total of 86 patients who suffered from acute CVA were selected and divided into 2 groups, according to random number tables: control group, and research group. Patients in the control group received routine primary therapy, while patients in the research group received rehabilitation based on the basic therapy. The recovery of hemiplegic limb movement ability and the improvement of daily living ability before and after treatment were evaluated using the simplified Fugl-Meyer assessment (FMA), neurologic deficit scale (NDS), and Barthel index (BI). After treatment, the clinical efficacy and satisfaction degree for treatment were compared.The FMA, NDS, and BI of patients in these 2 groups were distinctly ameliorated after treatment (P <.05). After treatment, the ameliorated degrees of FMA, NDS, and BI in the research group were obviously superior to those in the control group, and the differences were statistically significant (P <.05). The total efficacy and satisfaction degree in the research group were evidently higher than those in the control group after early rehabilitation therapy, and the differences were statistically significant (P <.05).Early rehabilitation therapy can significantly ameliorate the movement ability of hemiplegic lower extremity in patients with acute CVA. Its therapeutic effect is remarkable. Hence, it is worthy of popularizing in clinical practice.

[Dyke Davidoff Masson Syndrome Presenting with Intellectual Disability with Behavioral Problems and Substance Use Disorder: A Case Report]

Dyke Davidoff Masson Syndrome (DDMS) is a rare condition with varied presentation. Characteristic features are cerebral hemiatrophy, enlargement of ipsilateral ventricle, enlargement of ipsilateral air sinuses and clinical finding of contralateral hemiparesis or hemiplegia and seizures. DDMS may have comorbid intellectual disability or speech disorder but presentation with psychiatric disorders is rare. We present a case of DDMS who first came to attention with behavioral problems associated with aggression, social disinhibition and with alcohol and cannabis use disorder.

The effects of hyaluronic acid on hemiplegic shoulder injury and pain in patients with subacute stroke: A randomized controlled pilot study

BACKGROUND

Hemiplegic shoulder pain (HSP) is one of the most common comorbidities in stroke patients with flaccid shoulders. The pain limits functional motor recovery and affects the activities of daily living after acute stroke. This study investigated the effects of hyaluronic acid (HA) injection on pain reduction and motor function in subacute stroke patients with HSP and injury.

METHODS

A randomized, double-blinded controlled trial was conducted in a medical center. Twenty-six subacute stroke patients were enrolled and randomly divided into 2 groups: the experimental group (n = 16) received ultrasound-guided, subacromial HA injections once per week for 3 weeks and conventional rehabilitation, whereas the control group (n = 10) received 0.9% sodium chloride injections once per week for 3 weeks and conventional rehabilitation. Shoulder pain and motor function were evaluated before and after the intervention using the visual analog scale (VAS) and the Fugl-Meyer assessment for the upper extremity (FMA-UE), respectively.

RESULTS

In the experimental group, significant differences were found in VAS (P = 0.003), shoulder flexion (P = 0.03) and abduction (P = 0.02), and FMA-UE (P = 0.003) after treatment. In the control group, there were significant differences in VAS (P = 0.007), shoulder flexion (P = 0.035), and FMA-UE (P = 0.042) after treatment. The comparison of the changes in the parameters between the experimental and control groups, after each intervention, revealed a significant difference in VAS (P = 0.001).

CONCLUSION

Subacromial HA injection could result in positive effects on shoulder pain and shoulder abduction in subacute stroke patients with HSP and injury.

Efficacy of two injection-site localisation techniques for botulinum toxin injections: a single-blind, crossover, randomised trial protocol among adults with hemiplegia due to stroke

INTRODUCTION

Botulinum toxin injections are an effective treatment for limb spasticity following stroke. Different tracking techniques are used for this purpose: palpation, electrostimulation, electromyography and ultrasound. Yet very few studies have compared these different techniques, and none has successfully proved the superior efficacy of ultrasound-guided injections compared to another tracking method. The primary objective of our study was therefore to compare the efficacy of botulinum toxin injections depending on the tracking technique used: ultrasound versus electrostimulation.

METHODS AND ANALYSIS

This is a clinical, single-centre, prospective, interventional, single-blind, crossover, randomised trial. In total, 30 patients aged between 18 and 80 years presenting with triceps surae spasticity (evaluated >1 on the modified Ashworth scale) associated with hemiplegia sequelae due to stroke will be included. The patients will be selected among those who attend for consultation the Physical Medicine and Rehabilitation Department of the Clermont-Ferrand University Hospital. One group will receive the abobotulinumtoxinA (BoNT-A) injection guided by electrostimulation then ultrasound, and the second group's botulinum toxin injections will be guided by ultrasound then electrostimulation. For each patient, the duration of study participation is 5 months. The primary end point is variation in passive ankle dorsiflexion range of motion at slow and high speeds (Tardieu scale) with the knee straight.

ETHICS AND DISSEMINATION

This study received ethics approval form the CPP of Rhônes-Alpes region. Results will be published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT01935544; pre-results.

Does hemiplegic shoulder pain share clinical and sensory characteristics with central neuropathic pain? A comparative study

BACKGROUND

Hemiplegic shoulder pain (HSP) is a common poststroke complication and is considered to be a chronic pain syndrome. It is negatively correlated with the functional recovery of the affected arm and the quality of life of the individual. It also leads to a longer length of stay in rehabilitation. Today, there is no consensus as to the underlying mechanism causing HSP, making the syndrome difficult to treat.

AIM

The aim of this study was to compare the clinical and sensory profile of individuals with HSP to that of individuals with established central neuropathic pain (CNP) in order to identify common features and the presence of neuropathic components in HSP.

DESIGN

Cross sectional controlled study.

SETTINGS

Outpatient rehabilitation clinics.

POPULATION

Sixteen chronic HSP patients and 18 chronic CNP patients with spinal cord injury (SCI-CNP).

METHODS

The chronic pain characteristics, thresholds of thermal and tactile sensations and presence of pathological sensations were compared between groups, and between painful and pain free body regions within groups. Correlations were calculated between HSP intensity and sensory and musculoskeletal characteristics.

RESULTS

Patients with HSP and patients with SCI-CNP had similar decrease of thermal sensibility in the painful compared to intact body regions and both groups presented similar rates of pathological sensations in painful regions. HSP and SCI-CNP differed however, in the quality of pain and aggravating factors. Significant correlations were found between HSP intensity and heat-pain threshold, presence of subluxation and spasticity.

CONCLUSIONS

The similarities between HSP and SCI-CNP and the altered spinothalamic function and sensitization suggest that HSP has neuropathic components in its mechanism. Nevertheless, the unique features of HSP point towards additional possible mechanisms.

CLINICAL REHABILITATION IMPACT

The use of specific therapy options for neuropathic pain should be considered when treating patients with HSP.

Contracture preventive positioning of the hemiplegic arm in subacute stroke patients: a pilot randomized controlled trial

Objective: To investigate the effectiveness of a contracture preventive positioning procedure for the hemiplegic arm in subacute stroke patients in addition to conventional physio and occupational therapy.

Design: A single-blind pilot randomized controlled trial.

Setting: Inpatient neurological units from three rehabilitation centres in the Netherlands.

Subjects: Nineteen subacute stroke patients (minus two drop-outs) with a severe motor deficit of the arm.

Interventions: All subjects underwent conventional rehabilitation care. Nine subjects additionally received a positioning procedure for two 30-min sessions a day, five days a week, for five weeks.

Main measures: Passive range of motion of five arm movements using a hydrogoniometer and resistance to passive movement at the elbow using the Ashworth Scale. Secondary outcome measures were pain at the end range of passive motions, the arm section of the Fugl-Meyer Assessment and Barthel Index scores for ADL-independence. Outcome measures were taken after five weeks and additional measurements after 10 weeks by two assessors blinded to group allocation.

Results: Comparison of the experimental ( n = 9) with the control subjects ( n = 8) after five weeks showed that additional positioning significantly slowed down development of shoulder abduction contracture ( P = 0.042, −5.3 degrees versus −23 degrees). No other differences were found between the groups.

Conclusions: Applying a contracture preventive positioning procedure for the hemiplegic arm slowed down the development of shoulder abduction contracture. Positioning did not show significant additional value on other outcome measures. Since the sample size was small, results of this study need future verification.

Percutaneous neuromuscular electrical stimulation (P-NMES) for treating shoulder pain in chronic hemiplegia. Effects on shoulder pain and quality of life

Objective: To evaluate the effect of percutaneous neuromuscular electrical stimulation (P-NMES) of the shoulder muscles on shoulder pain intensity and health-related quality of life in chronic hemiplegia.

Design: Prospective, open label design.

Setting: The outpatient services of a large teaching rehabilitation hospital in the Netherlands.

Subjects: Fifteen stroke survivors with chronic (> six months) hemiplegia and a therapy-resistant painful shoulder with subluxation. All patients suffered from clinically relevant shoulder pain, as assessed by a score of at least 4 out of 10 on a numerical rating scale. Shoulder subluxation was indicated by at least 1/2 fingerbreadth of glenohumeral separation on palpation.

Intervention: Six hours of P-NMES per day for a total of six weeks.

Main outcome measures: Shoulder pain (Brief Pain Inventory), shoulder subluxation (clinical and radiographic), shoulder pain-free external rotation (hand-held goniometer), motor impairment (Fugl-Meyer Motor test) and quality of life (SF-36) were assessed before treatment, after six weeks of intramuscular stimulation, at three months and six months follow-up.

Results: A significant reduction in pain was found on the Brief Pain Inventory. Pain reduction was still present at six months follow-up. All domains, in particular bodily pain, of the SF-36 showed improvement in the short term. After six months of follow-up, bodily pain was still strongly and significantly reduced, whereas social functioning and role physical demonstrated a nonsignificant improvement of more than 10% compared with baseline.

Conclusion: This pilot suggests that P-NMES potentially reduces shoulder pain in chronic hemiplegia. To establish the clinical value of P-NMES in treating hemiplegic shoulder pain a randomized controlled trial is needed.

Upper Extremity Functional Evaluation by Fugl-Meyer Assessment Scoring Using Depth-Sensing Camera in Hemiplegic Stroke Patients

Virtual home-based rehabilitation is an emerging area in stroke rehabilitation. Functional assessment tools are essential to monitor recovery and provide current function-based rehabilitation. We developed the Fugl-Meyer Assessment (FMA) tool using Kinect (Microsoft, USA) and validated it for hemiplegic stroke patients. Forty-one patients with hemiplegic stroke were enrolled. Thirteen of 33 items were selected for upper extremity motor FMA. One occupational therapist assessed the motor FMA while recording upper extremity motion with Kinect. FMA score was calculated using principal component analysis and artificial neural network learning from the saved motion data. The degree of jerky motion was also transformed to jerky scores. Prediction accuracy for each of the 13 items and correlations between real FMA scores and scores using Kinect were analyzed. Prediction accuracies ranged from 65% to 87% in each item and exceeded 70% for 9 items. Correlations were high for the summed score for the 13 items between real FMA scores and scores obtained using Kinect (Pearson’s correlation coefficient = 0.873, P<0.0001) and those between total upper extremity scores (66 in full score) and scores using Kinect (26 in full score) (Pearson’s correlation coefficient = 0.799, P<0.0001). Log transformed jerky scores were significantly higher in the hemiplegic side (1.81 ± 0.76) compared to non-hemiplegic side (1.21 ± 0.43) and showed significant negative correlations with Brunnstrom stage (3 to 6; Spearman correlation coefficient = -0.387, P = 0.046). FMA using Kinect is a valid way to assess upper extremity function and can provide additional results for movement quality in stroke patients. This may be useful in the setting of unsupervised home-based rehabilitation.

A randomized controlled study of botulinum toxin A in the treatment of hemiplegic shoulder pain associated with spasticity

Objectives: To assess the effects of botulinum toxin A (BT-A) on hemiplegic shoulder pain associated with spasticity.

Design: Randomized, double-blind, placebo-controlled study.

Setting: Outpatient clinic of a rehabilitation department. Participants: Patients, more than three months post stroke, with hemiplegic shoulder pain associated with shoulder adductor and elbow flexor spasticity, randomly assigned to BT-A or placebo.

Intervention: One-time injection of BT-A (500 units) into the pectoralis major and biceps brachii on the hemiplegic side.

Main measures: Visual analogue scale of shoulder pain (0 –10), shoulder adductor and elbow flexor tone using the Ashworth Scale and passive range of shoulder abduction. These were assessed at baseline, four weeks, eight weeks and 12 weeks post injection.

Results: Seventeen patients were enrolled, eight in the BT-A group and nine in the placebo group. At baseline, the median visual analogue scale score for shoulder pain was 6, the median Ashworth Scale shoulder adductor and elbow flexor spasticity score was 2 and the median range of shoulder abduction 76 degrees. Subjects who received BT-A showed significantly greater improvements in median shoulder adductor and elbow flexor Ashworth Scale scores than placebo at week 4 (P B / 0.01) but not at week 8 and 12. For shoulder pain and passive shoulder abduction range, all subjects showed postinjection improvements and no difference could be demonstrated between the two groups.

Discussion: Possible reasons for the negative finding in this study include the small sample size and the presence of causes of shoulder pain not related to spasticity which could have confounded outcome.

Mentalizing the body: spatial and social cognition in anosognosia for hemiplegia

Following right-hemisphere damage, a specific disorder of motor awareness can occur called anosognosia for hemiplegia, i.e. the denial of motor deficits contralateral to a brain lesion. The study of anosognosia can offer unique insights into the neurocognitive basis of awareness. Typically, however, awareness is assessed as a first person judgement and the ability of patients to think about their bodies in more 'objective' (third person) terms is not directly assessed. This may be important as right-hemisphere spatial abilities may underlie our ability to take third person perspectives. This possibility was assessed for the first time in the present study. We investigated third person perspective taking using both visuospatial and verbal tasks in right-hemisphere stroke patients with anosognosia (n = 15) and without anosognosia (n = 15), as well as neurologically healthy control subjects (n = 15). The anosognosic group performed worse than both control groups when having to perform the tasks from a third versus a first person perspective. Individual analysis further revealed a classical dissociation between most anosognosic patients and control subjects in mental (but not visuospatial) third person perspective taking abilities. Finally, the severity of unawareness in anosognosia patients was correlated to greater impairments in such third person, mental perspective taking abilities (but not visuospatial perspective taking). In voxel-based lesion mapping we also identified the lesion sites linked with such deficits, including some brain areas previously associated with inhibition, perspective taking and mentalizing, such as the inferior and middle frontal gyri, as well as the supramarginal and superior temporal gyri. These results suggest that neurocognitive deficits in mental perspective taking may contribute to anosognosia and provide novel insights regarding the relation between self-awareness and social cognition.

Arthroscopic tibiotalocalcaneal arthrodesis in neurological pathologies: outcomes after at least one year of follow up

The main complications of open tibiotalocalcaneal arthrodesis are wound healing disorders and nonunion. Our hypothesis was that arthroscopy and interlocking intramedullary nailing decrease these complications. We retrospectively reviewed six patients (mean age: 58 years; mean preoperative Kitaoka score: 51/100) having undergone arthroscopic tibiotalocalcaneal arthrodesis with retrograde intramedullary nailing between January and November 2011 for equinus deformity of the hindfoot and subtalar instability of neurological origin. Postoperative pain disappeared completely in four cases, one patient presented some pain associated with projection of the proximal locking screw head under the skin and the remaining patient presented fibular tendinitis that resolved after infiltration of anti-inflammatory drugs. The mean postoperative Kitaoka score was 64/100. None of the patients presented any wound healing complications or nonunion. The observed incidence of wound complications and bone consolidation disorders after tibiotalocalcaneal arthrodesis was lower than the ones reported for open tibiotalocalcaneal arthrodesis. Level of clinical evidence IV: retrospective case series.

Pamidronate effect compared with a steroid on complex regional pain syndrome type I: Pilot randomised trial

OBJECTIVES

This study aims to compare the effectiveness of a bisphosphonate (pamidronate) and a steroid (prednisolone) in complex regional pain syndrome (CRPS) type I during four weeks of follow-up in hemiplegic stroke patients.

METHODS

Twenty-one hemiplegic stroke patients with CRPS type I were enrolled in the study. Patients were randomly assigned to receive either intravenous pamidronate (n = 11; total cumulative dose of 180 mg) or oral prednisolone (n = 10). Subjective pain and hand oedema (circumference of the middle finger, CMF, and the wrist, CW) were measured at baseline and at one, two and four weeks after the end of treatment.

RESULTS

Both groups showed significant improvement in subjective pain VAS scores at 1-week follow-up and this effect was maintained until 4-week follow-up. Time-by-group interactions were not significant at 4-week follow-up. The reduction of the CMF observed at 1-week follow-up in both groups was maintained until 4-week follow-up in the steroid group, but until 2-week follow-up in the pamidronate group. A significant change in CW was observed at 4-week follow-up in the pamidronate group. There were no significant adverse effects in either treatment group during the follow-up period.

CONCLUSIONS

Intravenous pamidronate therapy was safe, well tolerated and appeared as effective as a steroid for pain control for post-stroke CRPS. However, this result should be interpreted with caution, since it included a relatively small number of patients. Further larger controlled studies followed over a longer period are needed to validate these findings and to determine clinical treatment standards.

Accelerated bone turnover identifies hemiplegic patients at higher risk of demineralization

Immobilization osteoporosis represents a severe complication in hemiplegic patients (HPs), causing fragility fractures, which may occur during rehabilitation reducing functional recovery and survival. The aim of the study was to investigate determinants of bone loss, independent from length of immobilization, which may be useful in early identification of HPs at higher risk of demineralization. Forty-eight HPs of both sexes underwent anthropometric measurements, evaluation of scores of spasticity and of lower limb motory capacity. Laboratory tests were performed. On serum: calcium; phosphorus; creatinine; ALP; iPTH; 25(OH) vitamin-D; sex hormones; Δ4-androstenedione; DHEA-S; insulin; IGF-1; FT3; FT4; TSH; c-AMP. On urine: c-AMP and calcium/creatinine ratio. Two bone turnover markers were measured: serum osteocalcin (BGP) and urinary deoxypyridinoline (DPD). Bone mineral density was determined at both femoral necks, defining a percentage difference in bone loss between paretic and non-paretic limb, thus controlling for the complex cofactors involved. Only bone turnover markers significantly and directly correlated with the entity of demineralization, controlling for age, sex and length of immobilization in the multivariate analysis (BGP coefficient estimate=0.008; SE=0.003; p=0.020; DPD coefficient estimate=0.005; SE=0.002; p=0.036). BGP and DPD are not dependent on anthropometric and endocrine-metabolic parameters, disability patterns and duration of immobilization, thus represent independent determinants of the degree of demineralization. A cutoff was defined for BGP and DPD above which subjects show significantly greater risk of demineralization. The immobilization event generates more severe bone loss when it occurs in subjects with higher bone turnover. BGP and DPD measurements may be of primary importance for early identification of HPs at risk, with relevant preventive implications.

A new classification of hemiplegia gait patterns based on bicluster analysis of joint moments

PURPOSE

Hemiplegia is a paralysis on one side of the body resulting from disease or injury to the motor centers of the brain that may lead to difficulty in walking and problems in balance. A new methodology for hemiplegia gait patterns classification based on bicluster analysis, which aims to identify a group of patients with similar gait patterns, and verify if spatial-temporal gait parameters are correlated with the Barthel Index, has been proposed.

METHODS

Eighteen hemiplegia patients were recruited. Measurements included spatialtemporal gait parameters and joint moments. Gait data were measured using a motion tracking system and two force platforms. Bicluster analysis was used to classify the subjects' gait patterns. The relation between Barthel Index and spatial-temporal gait parameters was determined based on the Spearman correlation.

RESULTS

A high correlation between spatial-temporal gait parameters and Barthel Index (r>0.5, p <0.05) was observed. Well-separated biclusters presenting similarity among the lower limb joints during the gait cycles were obtained from the data.

CONCLUSIONS

Bicluster analysis can be useful for identifying patients with similar gait patterns. The relation between the gait patterns and the underlying impairments would allow clinicians to target rehabilitation strategies at the patient's individual needs.