Multiple Sclerosis/Chronic Fatigue Syndrome overlap: When two common disorders collide.

INTRODUCTION: Fatigue is a major cause of disability and handicap in Multiple Sclerosis (MS) patients. The management of this common problem is often difficult. Chronic Fatigue Syndrome (CFS/ME) is another common cause of fatigue which is prevalent in the same population of middle aged females commonly affected by MS. AIM: This report aims at examining the potential coexistence of MS and CFS/ME in the same patients. METHOD: This is a retrospective study examining a cohort of MS patients referred for rehabilitation. The subjects were screened for CFS/ME symptoms. RESULTS: Sixty-four MS patients (43 females) were screened for CFS/ME. Nine patients (14%) with a mean age 52 (SD 9.7) who were all females fulfilled the Fukuda criteria for diagnosis of CFS/ME. Their symptoms, including muscular and joint pain, malaise and recurrent headaches, were not explained by the pattern of their MS. DISCUSSION: MS and CFS/ME are two common conditions with increased prevalence in middle aged females. As the diagnosis of CFS/ME is clinical with no positive clinical signs or investigations; it can be made with difficulty in the presence of another clear explanation for the disabling fatigue. Our results suggest that the two conditions may co-exist. Considering CFS/ME as a potential co-morbidity may lead to more focused and appropriate management.

Outcomes of inpatient rehabilitation of patients with multiple sclerosis.

BACKGROUND: Several trials have demonstrated improved outcomes following inpatient rehabilitation for Multiple Sclerosis patients. Two populations were studied: patients in relapse and patients with no active medical problems recruited from the community. In every day practice, most admissions for MS inpatient rehabilitation aim to improve function following sudden deterioration. The outcomes of inpatient rehabilitation for this population were never studied. METHOD: Retrospective case note analysis of consecutive admissions of MS patients from 2005 to 2009 to a specialist neurological rehabilitation unit. RESULTS: Forty-one cases were identified. 26 were females. Age 25-71 (mean 52 ± 12). Disease duration 0-39 years (mean 13 ± 11). 20 patients were admitted from the community and 21 were transferred from acute hospital beds. Length of stay ranged between 11 to 152 days (mean 49 ± 36). Mean length of stay for wheelchair dependent patients was approximately double the length of stay for ambulatory patients. Improving mobility, transfer or posture were the primary cause of admissions in 37 cases. Sixteen out of 21 ambulatory patients (76%) attained 100% mobility goals. Only 4 out of 20 wheelchair bound patients (20%) achieved 100% mobility goals (P 0.002). Neither the type of MS nor the duration of it influenced the overall outcome. CONCLUSION: Our results suggest that MS patients admitted for rehabilitation following deterioration secondary to a medical or surgical cause show the same favourable outcome that was demonstrated with MS stable patients or in relapse. Baseline mobility, but not type and duration of MS, seems to have a significant impact on the rehabilitation outcome in terms of gaol achievement.

Validation of the language component of the Addenbrooke's Cognitive Examination--Revised (ACE-R) as a screening tool for aphasia in stroke patients.

AIM: Several tests are available for aphasia screening following stroke. However, some of them have shortcomings such as need of specialist knowledge, low sensitivity and/or specificity and lengthy administration time. Our study aims to evaluate the language component of the Addenbrooke's Cognitive Examination--Revised (ACE-R) as a screening tool for aphasia in stroke patients. METHODS: The language component of ACE-R was administered to consecutive patients admitted to a post-acute stroke unit. Patients who were medically unstable or had a significant history of sensory impairment or mental health issues were excluded. The test was administered by two junior doctors with basic training in ACE-R administration. Patients recruited were also assessed by an experienced speech and language therapist (SLT). The results of the two assessments were documented by a different member of the team and the SLT results were used as the benchmark to calculate the ACE-R language component sensitivity and specificity. RESULTS: Fifty-nine participants were recruited and 27 of them were women. The mean age was 72 (SD 11.9). Thirty-four participants had left and 11 right hemisphere stroke. Fourteen had bilateral affection. Six participants were left handed. A cut-off value of 22/26 of ACE-R language component showed 100% specificity and 83.1% sensitivity, while a cut-off value of 16/26 had 88.2% specificity and 100% sensitivity. CONCLUSION: Our results suggest that the language component of ACE-R has a satisfactory sensitivity and specificity compared with other screening tests used in strokes. It is easy to administer and free to use.

Botulinum Toxin in the management of hitchhiker's toe.

INTRODUCTION: Hyperextension of the extensor hallucis longus (EHL) muscle is a well recognised disabling sequel of either pyramidal or extrapyramidal lesions causing what is known as striated or hitchhiker's toe. Surgery was the only effective strategy to manage EHL hyperextension before botulinum toxin's use to manage muscular dystonia and spasticity became widely popular. METHODS: A multicentre retrospective study. A standard proforma was sent to specialists in neurological rehabilitation dealing routinely with this problem. The data was analysed using descriptive statistics. RESULTS: Four consultants and two trainees representing five separate neurological rehabilitation services agreed to participate in the study. Full data was available from the 29 proformas completed. The subjects were 15 females with an age range between 20 and 78 years (mean 58.7). Stroke was the primary diagnosis in 18 subjects. Four subjects had bilateral involvement. 16 subjects had either an associated foot drop or equino varus deformity. Dysport® was used in 15 subjects with an average dose of 170 units per injection and Botox® in the other 14 with an average dose of 65 units. The treatment was effective in 24 subjects (83%). All patients receiving Dysport® responded to the treatment. Whilst 5 Botox® treated patients failed to respond to it (35% failure rate). Most of the non respondents seemed to receive insufficient doses of Botox® (below 60 units). Surgical management was successful in 3 out of the 5 non respondent cases. CONCLUSION: Botilinum Toxin is an effective and safe method to manage hitchhicker's toe. In our study the conversion ratio between Dysport® and Botox® was 2.5:1. Third of the patients receiving Botox® failed to respond to the treatment most probably due to insufficient doses used.

Rehabilitation of cortical blindness secondary to stroke.

BACKGROUND: Cortical blindness is a rare complication of posterior circulation stroke. However, its complex presentation with sensory, physical, cognitive and behavioural impairments makes it one of the most challenging. Appropriate approach from a rehabilitation standpoint was never reported. AIM: Our study aims to discuss the rehabilitation methods and outcomes of a cohort of patients with cortical blindness. METHOD: The notes of all patients with cortical blindness referred to a local NHS rehabilitation service in the last 6~years were examined. Patients' demographics, presenting symptoms, scan findings, rehabilitation programmes and outcomes were documented. RESULTS: Seven patients presented to our service, six of them were males. The mean age was 63. Patients 1, 2 and 3 had total blindness with severe cognitive and behavioural impairments, wandering and akathisia. All of them failed to respond to any rehabilitation effort and the focus was on damage limitation. Pharmacological interventions had a modest impact on behaviour and sleep pattern. The 3 patients were discharged to a nursing facility. Patients 4, 5, 6 and 7 had partial blindness with variable severity. All of them suffered from significant memory impairment. However, none suffered from any behavioural, physical or other cognitive impairment. Rehabilitation efforts on 3 patients were carried out collaboratively between brain injury occupational therapists and sensory disability officers. All patients experienced significant improvement in handicap and they all maintained community placements. CONCLUSION: This small cohort of patients suggests that the rehabilitation philosophy and outcomes of these 2 distinct groups of either total or partial cortical blindness differ significantly.

Complete immobility as a potential biomechanical complication of Achilles tendon lengthening.

Proximal muscle weakness is a common association of muscular dystrophies. Knees and hip extensor weakness limit the patients' ability to counteract flexor knee joints' moments. Therefore, patients try to toe walk to move the ground reaction force (GRF) anteriorly to help to stabilise the knee. We report a case of a patient with Becker's muscular dystrophy who lost his ability to walk completely following a bilateral Achilles tendons operation. The patient's ability to heel-strike moved his GRF posteriorly resulting in creation of excessive knees flexion moments. Three years following the operation and following a lengthy rehabilitation programme, the patient managed to mobilise using an orthosis.

Evaluation of the Addenbrooke's Cognitive Examination's validity in a brain injury rehabilitation setting.

BACKGROUND: Several reports have warned of the Mini Mental State Examination's (MMSE) inability to detect gross memory and high executive impairments. Addenbrooke's Cognitive Examination-Revised (ACE-R) has gained enormous popularity in dementia screening as it addresses the main shortcomings of MMSE. AIM: This study aimed at evaluating the use of ACE-R and to establish its sensitivity compared to MMSE in a cohort of brain injury patients. METHOD: ACE-R was administered to a cohort of chronic brain injury patients. All patients had a cognitive impairment which was severe enough to prevent them working or studying. Patients with significant mental health, sensory, communication or physical impairments were excluded. RESULTS: Thirty-six patients were recruited, 31 males with a mean age of 37 years. For an upper cut-off value of 27/30 for MMSE and 88/100 for ACE-R, their sensitivities were 36% and 72%, respectively. For a lower cut-off value of 24/30 and 82/100 the tests sensitivities were 11% and 56%, respectively. Analysis of the ACE-R sub-tests indicated that memory and verbal fluency sub-tests showed the most dramatic impairment. CONCLUSION: MMSE is insensitive as a screening test in brain injury patients. The results show ACE-R to be a sensitive, easily administered test.

Guidelines for prevention of venous thromboembolism in immobile patients secondary to neurological impairment.

BACKGROUND: Venous thromboembolism (VTE) is a major cause of morbidity and mortality in hospitalized patients and 7% of these cases are due to immobility secondary to a neurological impairment. Many guidelines are available to guide clinicians dealing with medical or surgical patients. However, and with the exception of spinal injuries, no guidelines are available to deal with other neurologically impaired patients at risk of VTE. AIM: Our study aimed at gathering evidence from the literature to enable us to deal with the main controversial issues of VTE prevention. Guidelines will be formulated. METHOD: A Clinical Standards Group is responsible for the development of clinical guidelines for the Greater Manchester Neurorehabilitation network with services covering a population of around 3 million. The development of VTE prevention guidelines started with the formulation of the main questions, then gathering evidence from the literature to address these questions. Wide consultation then took place. The guidelines were then put before the group for endorsement. RESULTS: Answers for the main questions such as duration of thromboprophylaxis, TEDS and antiplatelets drugs use were suggested. The resulting document was summarized as a flow chart for use. CONCLUSION: We feel that the proposed guidelines are a useful tool for clinicians as they reflect the evidence available from the literature at the moment.

Medico-legal and ethical aspects in the management of wandering patients following brain injury: questionnaire survey.

BACKGROUND: Different methods are often used to deter head injury patients, who have a tendency to wander, from leaving the rehabilitation wards. The extent to which these patients could be restrained is controversial. Despite the fact that the majority of these patients lack mental capacity, Mental Health Act sections are rarely invoked. Under common law, informal patients should have the right to refuse treatment and to leave the hospital whenever they like. OBJECTIVE: To examine the current practice in the management of wandering patients following brain injury in rehabilitation units in the UK and to formulate practical guidelines based on this common practice. METHODS: A postal survey in the form of a structured questionnaire was sent to 58 consultants in Rehabilitation Medicine and Neuropsychologists based at different neurological rehabilitation units in the UK. RESULTS: A total of 30 clinicians (52%) completed the questionnaire. One-to-one supervision was the method most commonly used to manage wandering patients (83%) followed by implementation of a structured daily routine (73%) and the use of different medications (70%). Only 17% would lock the door without giving the patient lock combination/key and another 17% would physically restrain the patient without invoking mental health act (MHA) section; 60% would consider MHA section with great variability in the mental health team response time and the place where patient is managed once under MHA section. CONCLUSIONS: The questionnaire showed great variations in the methods and the medico-legal framework used in the management of wandering patients. There was, however, a tendency to avoid physical restraint which may reflect the recognition of the unlawfulness of detaining informal patients.

Significant reduction of the risk of venous thromboembolism in all long-term immobile patients a few months after the onset of immobility.

Prophylactic anticoagulation is a standard practice in patients with sudden lower limbs paralysis. Thromboprophylaxis is usually continued until the patient regains independent mobility. The duration of anticoagulation in long-term immobile patients is unknown. Spinal cord injury patients are the only population that was comprehensively studied and prophylactic anticoagulation is discontinued after 4 months as the risk of venous thromboembolism drops dramatically after 3-4 months. Development of muscle spasticity has been traditionally considered to be the reason for this low risk as lower limbs spasticity/spasms might be able to improve the calf muscle pump action. We are presenting the evidence from physiological studies of the lower limbs vascular system that cast doubt over this explanation and present an alternative hypothesis backed by several clinical circumstantial evidence suggesting that the vascular changes following long term lower limbs inactivity which are universal to all immobile patients is probably the main protecting factor. We suggest that prophylactic anticoagulation is necessary only on the first 4 months following the acute onset of immobility in all neurologically impaired immobile patients regardless of their muscle tone state.