Clinical characteristics and functional outcome after rehabilitation of middle cerebral artery stroke

To describe the clinical profile of MCA stroke. Also, to describe the functional outcome and to identify factors associated with functional changes after rehabilitation of MCA stroke. Sixty five hemiplegic patients due to MCA stroke were studied. Patients underwent complete neurological and functional evaluation on admission. Evaluation included stroke type, cardiovascular risk factors for stroke, associated neurological deficits, total motricity index [MI] of upper and lower extremities, motor function of the trunk assessed by Trunk Control Test [TCT], and Functional Independence Measure [FIM]. All patients were enrolled in an inpatient rehabilitation program. Patients were re-evaluated at discharge. Statistical analyses were carried out to determine factors associated with functional outcome after rehabilitation of MCA stroke. The total MI and TCT improved significantly after rehabilitation. In addition, discharge total FIM score was statistically higher than admission total FIM score. Patients with hemineglect, impaired cognition, dysphagia, hemihypoesthesia incontinence or multiple neurological deficits had significantly lower discharge total FIM score than patients without such variables. The discharge FIM score correlated strongly with admission total FIM score [r= 0.88, p<0.001] moderately with admission TCT score [r= 0.69, p<0.001], fairly with admission total MI [r=0.37, P=0.002] and negatively with age [r= -0.2, p=0.01]. On multiple linear regression analysis, admission total FiM and TCT scores score were the only significant predictors of discharge FIM scores. Rehabilitation improved the functional outcome of MCA stroke patients. The initial functional status was the most important factor associated with functional improvement

Aberrant co-contraction of agonist and antagonist muscles in post-stroke hemiparetic patients: relation to motor impairment

Impairment of upper limb function is a common problem following hemiplegic stroke. The aim of this study is to assess the extent of aberrant co-contraction of agonist/antagonist muscles during voluntary movement of the paretic upper extremity and its relation to motor abilities assessed by motor scales. Twenty post-stroke hemiparetic patients were evaluated. Modified Ashworth Scale was used as a measure of spasticity. Upper limb motor impairment was assessed with the Fugl-Meyer motor assessment scale [FMS]. Integrated electromyographic activities [IEMG] of wrist extensors and flexors were simultaneously recorded during isometric wrist extension [WE] and were simultaneously recorded during isometric wrist flexion [WF]. The degree of co-contraction and the strength of contraction were assessed. Co-contraction was calculated as ratio of antagonist to agonist IEMG. Strength of contraction was calculated as ratio of affected to non-affected IEMG. The affected and the non-affected side were compared. Significant differences were found between the affected and the unaffected sides regarding the measured parameters. The degree of co-contraction was significantly greater in the affected limb during WE [p<0.001] and WE [p<0.001] and was found to correlate significantly with FMS during WE [r=-0.847. p<0.001] and WF [r=-0.736, p<0.001]. The degree of co-contraction measured during WE and WF correlated with the degree of spasticity [r=0.841, p<00.01 and r=0.480, p<0.001 respectively]. It was also found to correlate with strength of contraction of wrist extensors [r=-0.654, p=0.002] and flexors [r=-0.737, p<0.001]. Co-contraction is a manifest phenomenon in pa relic upper extremity. Its degree correlates significantly with motor impairment. Antagonist co-contraction can contribute, in part, to weak agonist activity further contributing to impaired functional abilities of post-stroke hemiparetic patients

Functional capacity in patients with coronary artery bypass grafting surgery after cardiac rehabilitation program

To evaluate the effect of cardiac rehabilitation program on cardiac function and functional capacity in patients with coronary artery bypass grafting surgery. Forty patients with CABG were included. Thirty patients served as group I and ten patients as group II [control group]. Group I patients were enrolled in cardiac rehabilitation program for 12 weeks. All patients were subjected to: functional classification scaling, exercise stress test at the start and at 12 weeks [to detect the metabolic energy times and functional capacity of patients] and echocardiography at the start and at 12 weeks to evaluate the cardiac function. There was no significant difference between patients and controls at the start as regard exercise stress test, left ventricular ejection fraction and functional class. At 12 weeks: the exercise stress test results showed a significant increase in exercise duration, METs and VO2 max in group I in comparison to group II, and in group I at 12 weeks in comparison to its initial results. The echocardiography results showed a highly significant difference of LVEF between group I and group II at 12 weeks and in group I at 12 weeks in comparison to the start. Early return to work, at 12 weeks, was noticed in 14 out of 16 male patients [87%] in group I, and two out of five male patients [40%] in group II. Cardiac rehabilitation is an important component of the current interdisciplinary approach to the management of the patients with various presentations of coronary heart disease

Postural profile in patients with ankylosing spondylitis: correlation with clinical and electrophysiological findings

To assess postural profile in patients with AS and to determine the correlation between equilibrium score and clinical, functional, and electrophysiological findings. Twenty patients with definite AS and fifteen healthy controls were included. Bath Ankylosing Spondylitis Metrology Index, Bath Ankylosing Spondylitis Disease Activity index, and Bath Ankylosing Spondylitis Functional index were used for patients' evaluation. The postural profile was determined using the sensory organization test [SOT]. Electrophysiological studies for detection of central nerve system lesions were carried out. No significant differences could be detected between patients and controls as regards the equilibrium scores, sensory ratios, or strategy scores. All patients, except for two, had their composite equilibrium score well within tile normal limits. Three patients were abnormally more reliant on the hip strategy to regain balance under condition 6 of SOT. The center of gravity [COG] was excessively displaced anteriorly in patients with significant differences between them and controls. Electrophysiological abnormalities consistent with posterior column involvement were detected in six patients [30%]. In one of them, the pyramidal tract was also affected. The equilibrium score did not correlate with clinical, functional indices or electrophysiological findings. Most patients with AS were posturally stable. Their equilibrium scores were maintained well within normal values. The main abnormality was excessive forward displacement of the center of gravity. This was compensated for with no negative impact on balance abilities. The equilibrium score did not correlate with clinical, functional, or electrophysiological findings

Plasma polymorphonuclear neutrophil elastase in systemic sclerosis: clinical correlative study

To measure the plasma level, of polymorphonuclear neutrophil [PMN] elastase in patients with systemic sclerosis [SSc] and to study its relation to interstitial pulmonary fibrosis, extent of skin sclerosis, and other clinical manifestations of the disease. Seventeen patients with SSc [7 diffuse SSc [dSSc] and 10 limited SSc [lSSc]] and 13 controls were included. The degree of skin involvement was quantified by modified Rodnan skin thickness score [mRSS]. Pulmonary involvement was assessed in all patients by high resolution computerized tomography [HRCT] and pulmonary function tests [PET]. Plasma PMN elastase was measured in all patients and controls. There was a significant increase of plasma PMN elastase levels in SSc patients compared to controls. Elevated plasma PMN elastase levels were observed in 47.05% of all SSc patients especially in dSSc subtype and were significantly associated with the more frequent presence of arthritis [P=0.049]. Pulmonary fibrosis was detected in 82.35% of SSc patients by HRCT and restrictive lung disease, defined by FVC <80%, was detected in 70.58% of patients. Ground glass opacification [GGO] was detected more frequently in SSc patients with elevated PMN elastase levels compared to patients with normal levels. The presence elevated plasma PMN elastase in SSc patients had a positive predictive value PV] of 83.3% in detecting early interstitial lung fibrosis. Plasma PMN elastase correlated with CRP but not with the extent of skin involvement or PFT results. Elevated PMN elastase may be used as a simple screening test to predict early interstitial pulmonary fibrosis in patients with SSc

efficacy of bilateral arm training with rhythmic auditory cueing in stroke rehabilitation: clinical and electrophysiological study

To study the efficacy of repetitive bilateral arm training with rhythmic auditory cueing [BATRAC] on motor recovery in stroke patients clinically and electrophysiologically. Forty patients with chronic hemiplegia were included in the study. All patients participated in BATRAC [3 sessions/week] for six weeks. The upper extremity functional performance was evaluated by the Fugl-Meyer Upper Extremity Motor Performance [FMUEMP] and grip strength. Transcranial magnetic stimulation [TMS] was used to elicit MEP to the abductor digiti minimi. Functional performance and MEP were recorded before and after BATRAC. Following BATRAC there were improvement in functional performance [FMUEMP and grip strength], decrease in TMS threshold, decrease in the central motor conduction time and increase in MEP amplitude. These changes were significant [p<0.01]. Besides, there was a significant positive correlation between pre-rehabilitation MEP amplitudes and the improvement in FMUEMP. BATRAC for 6 consecutive weeks has been proven effective in improving both functional performance [of the paretic upper extremity] and MEP parameters in chronic stroke patients suggesting that functional improvement might has been secondary to central motor excitability changes

Electrophysiological procedures in diagnosis of carpal tunnel syndrome

To evaluate some electrophysiological procedures adopted for the diagnosis of carpal tunnel syndrome [CTS] in Egyptian patients. The study was conducted on forty-one patients diagnosed as primary CTS according to the criteria proposed by the American Academy of Electrodiagnostic Medicine [AAEM, 1993]. The control group included thirty apparently healthy volunteers, of matching age and sex to the patients group. All patients and controls were subjected to: history taking, thorough clinical examination and electrophysiological studies that included: 1] Median and ulnar motor study, F-wave and axilllary F central latency, 2] Median and ulnar sensory study, 3] Median and ulnar mixed study and 4] Median lumbrical and ulnar interosseous study. Median motor conduction study revealed delayed distal latency, reduced CMAP amplitude and slowing in the forearm conduction velocity. Median sensory conduction studies revealed delayed sensory peak latency, slowed sensory conduction velocity of the median nerve in the distal segment and reduced SNAP amplitude. Motor and sensory nerve conduction studies of the ulnar nerve were all normal thus excluding the presence of peripheral neuropathy. Median nerve latency to the second lumbrical was prolonged and CMAP amplitude was reduced, also the difference between the median lumbrical and ulnar interosseous distal motor latency was prolonged whereas the ulnar to first palmar interosseous distal latency and CMAP amplitude were within normal The median mixed palm to wrist peak latency was prolonged and the difference between the median and ulnar mixed peak latencies was prolonged, the ulnar mixed palm to wrist peak latency and CMAP amplitude were within normal limits. The sensitivity and specificity for some tests were calculated and the results revealed that the highest sensitivity was for the median sensory peak latency to digit II versus the ulnar peak sensory latency to digit V 91.43%, followed by the median versus ulnar mixed palm to wrist peak latency 87.5%, the median lumbrical versus the ulnar interosseous distal latency 86.11%, median sensory peak latency to digit II 84.29% and lastly the median motor distal latency to the APB muscle 80.65%. The highest specificity was for the median versus ulnar mixed palm to wrist peak latency 100%, that is to say there were no false positive cases. So this test is highly specific, followed by the median sensory peak latency to digit II 95.0%, the median lumbrical versus the ulnar interosseous distal latency 92.5%, the median distal motor latency to the APB 92.5% and lastly the median sensory peak latency to digit II versus the ulnar peak sensory latency to digit V87.5%. The conventional motor and sensory conduction studies of the median nerve are sensitive and that calculating the difference between the median peak latency to digit II and the ulnar peak latency to digit V increases the diagnostic yield of the sensory study and increases the sensitivity of digit II sensory study. The median versus ulnar mixed palm to wrist peak latency is a very specific test that can be used as a screening test in cases of unilateral CTS. The median lumbrical versus ulnar interosseous distal latency is of high sensitivity and specificity

Subcortical and cervical somato-sensory evoked potentials in cervical spondylotic myelopathy

To determine whether the diagnostic yield of SEPs in cervical spondylotic myelopathy can be improved by assessing separately dorsal column and dorsal horn responses to stimulation of the median nerve in patients with cervical spondylotic myelopathy. The study was carried out on 20 patients with cervical spondylotic myelopathy and 20 healthy controls. Somatosensory evoked potentials to median nerve stimulation were studied. The following montages were used: Erb's point ipsilateral to stimulation, Erb's point contralateral to stimulation [N9], spinous process of 5[th] cervical vertebra, anterior cervical [N13], parietal scalp contralateral to stimulation, parietal scalp ipsilateral to stimulation [N20], parietal scalp contralateral to stimulation and shoulder contralateral to stimulation [P9, P14]. Abnormal N13 potential, P14 and N20 was found in 17 [85%], 10 [50%] and 6 [30%] of cases respectively. Thus normal N20 coexist with a abnormal P14 in four patients .Abnormalities of scalp and cervical SEPs, defined respectively as abnormal N20 or P14 on the one hand and abnormal N13 on the other were combined in three different patterns, and distributed as follows: 9 patients [45%] had normal scalp SEPs with abnormal cervical responses; 8 patients [40%] showed abnormalities of both scalp and cervical SEPs; in two patients [10%] normal cervical responses were associated with abnormal scalp SEPs on both sides. Thus, about half of the patients with an isolated abnormality of the cervical N13 response would have been considered as having normal upper limb SEPs if recorded with a conventional frontal montage, which does not allow a selective assessment of this variable. In nine patients there was an increased signal on T2-weighted MRI scans of the cord at the cervical level. The cervical potential N13 and the subcortical potential P14 are reliable in diagnosing cervical spondylotic myelopathy. They are more frequently abnormal than the cortical N20 potential

Painful neck movement: an additional differentiating sign between cervical spondylosis and myofascial pain syndrome

To find any specific pattern of pain severity during various neck movements in cervical spondylosis versus the myofascial pain syndrome. The study was carried out on 50 myofascial pain syndrome patients and 60 cervical spondylosis patients. Neck pain during neck flexion, extension, rotation and lateral flexion was measured using a numerical rating scale. Pain score during neck flexion was more in myofascial pain syndrome than in cervical spondylosis patients. On the other hand, neck pain during neck extension was more in cervical spondylosis patients than in myofascial pain syndrome patients. There was no statistical significant difference between both groups as regard rotation and lateral flexion. Moreover, neck extension was more painful than neck flexion in 90% of patients with cervical spondylosis. On the other hand, neck flexion was more painful than extension in myofascial pain syndrome patients. This study suggested that comparing pain severity during neck flexion to that during neck extension could be of help not only in differentiating pain of cervical spondylosis from that of MPS, but also in identifying the main cause of neck pain in patients with clinical signs suggestive of MPS and who have concomitant radiological evidence of cervical spondylosis. This could be of therapeutic value