Crying spells triggered by thumb-index rubbing after thalamic stroke: a case report.

BACKGROUND: Pathologic crying, devoid of any emotional counterpart, is known to occur as a consequence of various brain stem, cortical hemispheric and cerebellar lesions or, quite exceptionally, of "dacrystic" epilepsy. The case reported here suggests that thalamic lesions may also cause crying spells, under the special circumstances described below. CASE PRESENTATION: After a mild left thalamic stroke a caucasian 77 years old man presented with crying spells with no emotional counterpart, triggered by thumb-index rubbing of his right hand. Only a modest sensation loss on right infra-orbital and nose-labial areas and the first three right fingers could be detected at clinical examination. The circumstances and processes leading to the crying spells were investigated, together with their neural substrate. Brain computerized tomography (CT), magnetic resonance imaging (MRI) and functional magnetic resonance imaging (fMRI) were conducted. Neurophysiologic studies included Video-Electroencephalography, Electromyography, motor and sensory Evoked potentials. Active thumb-index rubbing, passive fingertips stimulation and interaction of sensory-motor stimulation with cognitive/speech activities were tested under different paradigms. A treatment with pregabalin (75 mg twice a day) was attempted. CT and MRI showed a small ischemic infarct in the left ventral postero-lateral thalamus, while fMRI led to the expected findings, i.e. a bilateral activation of the hand motor representation during the crying-triggering right-hand finger rubbing activity. Sensory potentials evoked from stimulation of the right upper limb were the only abnormal neurophysiologic test. Crying spells could be invariably evoked by both real and imagined active finger rubbing, in either the left of right hemi-space. Rubbing by an examiner was ineffective. Immersion in water (18 °C) but not oiling of the fingertips prevented the symptom. Administration and discontinuation of pregabalin 75 mg daily could be associated with suppression and reappearance of the symptom, respectively. CONCLUSIONS: In this patient loss of sensation seemed to generate crying spells rather than the more common allodynia. As a matter of speculation, both symptoms might represent responses to a sensory loss, but in this case the pathway might have been selectively affected providing inhibition from the lateral to the medial segment of the VPLT, which is linked to the anterior cingulate (limbic) cortex engaged in emotional behaviour.

Use of Rasch analysis to refine a patient-reported questionnaire on satisfaction with communication of the multiple sclerosis diagnosis.

BACKGROUND: The Comunicazione medico-paziente nella Sclerosi Multipla - Revised (COSM-R) is a patient self-assessed questionnaire probing the moment of multiple sclerosis (MS) diagnosis disclosure (section 1, five items) and following period (section 2, 15 items). OBJECTIVES: This study examined COSM-R dimensionality and measurement properties through Rasch analysis (partial-credit model) and proposed a revised questionnaire. METHODS: Cross-sectional COSM-R data were obtained from 1068 people with MS (PwMS, 1065 questionnaires) participating in four studies (102 centres). Mean age was 40 years (range 17-73); 70% were women; 53% were from Northern, 25% from Central, and 21% from Southern Italy. RESULTS: Unidimensionality was not confirmed for COSM-R section 1, but was for section 2 after removal of three items. The revised instrument (COSM-S, Shortened) consisted of the original five-item checklist (section 1), modified by removing the table grouping of three items, and 12 of the original 15 section 2 items, which could now be summed and transformed into an interval scale. Scores were higher for items assessing emotional satisfaction than for those assessing informational satisfaction. CONCLUSIONS: The proposed COSM-S is a composite measure of satisfaction with MS diagnosis communication with improved metric properties over the original COSM-R, and whose section 2 satisfies Rasch model expectations.

Observational case-control study of the prevalence of chronic cerebrospinal venous insufficiency in multiple sclerosis: results from the CoSMo study.

BACKGROUND: Chronic cerebrospinal venous insufficiency (CCSVI) has been proposed as a possible cause of multiple sclerosis (MS). OBJECTIVES: The CoSMo study evaluated the association between CCSVI and MS. METHODS: The primary end-point of this multicentric, case-control study was to compare the prevalence of CCSVI between patients with MS, patients with other neurodegenerative diseases (ONDs) and healthy controls (HCs). Color-coded duplex sonography was performed by a sonologist and the images were sent to one of three central sonologists for a second reading. Agreement between local and central sonologists or, in case of disagreement, the predominant judgment among the three central readers, was required for a diagnosis of CCSVI. All readings, data collection and analysis were blinded. RESULTS: The study involved 35 MS centers across Italy and included 1874 subjects aged 18-55. 1767 (94%) were evaluable: 1165 MS patients, 226 patients with ONDs and 376 HCs. CCSVI prevalence was 3.26%, 3.10% and 2.13% for the MS, OND and HC groups, respectively. No significant difference in CCSVI prevalence was found amongst the three cohorts (MS versus HC, OR = 1.55, 95%CI = 0.72-3.36, p = 0.30; OND versus HC, OR = 1.47, 95%CI = 0.53-4.11, p = 0.46; MS versus OND, OR = 1.05, 95%CI = 0.47-2.39, p = 0.99). High negative and low positive agreement was found between the local and centralized readers. CONCLUSIONS: CCSVI is not associated with MS.

A new grading for easy and concise description of functional status after spinal cord lesions.

BACKGROUND: Disability scales do not enable the transmission of concise, meaningful and daily function description for clinical purposes. STUDY DESIGN: Cross-sectional statistical analysis of 328 patients' Spinal Cord Independence Measure (SCIM) III item scores (SIS). OBJECTIVE: To develop a concise and clinically interpretable data-based characterization of daily task accomplishment for patients with spinal cord lesions (SCLs). SETTING: Multi-center study at 13 spinal units in 6 countries. METHODS: Patients were grouped into clusters characterized by smaller differences between the patients' SIS within the clusters than between their centers, using the k-medoides algorithm. The number of clusters (k) was chosen according to the percent of SIS variation they explained and the clinical distinction between them. RESULTS: Analysis showed that k=8 SIS clusters offer a good description of the patient population. The eight functional clusters were designated as A-H, each cluster (grade) representing a combination of task accomplishments. Higher grades were usually (but not always) associated with patients implementing more difficult tasks. Throughout rehabilitation, the patients' functional grade improved and the distribution of patients with similar functional grades within the total SCIM III score deciles remained stable. CONCLUSIONS: A new classification based on SIS clusters enables a concise description of overall functioning and task accomplishment distribution in patients with SCL. A software tool is used to identify the patients' functional grade. Findings support the stability and utility of the grades for characterizing the patients' functional status.

Functional assessment in rehabilitative medicine: principles and methods.

In rehabilitative medicine, functional assessment means a decision process that results from the interaction between classifications (for example, diagnostic) and measures, and that aims to recognize, anticipate or modify the interaction between the disabled person and his environment. In this context, the measure is the intersection of a person along the conceptual gradient and continuum ''from less to more'' attributed to variability in the ''total person,'' such as independence, pain, cognitive capacity, or fatigability. The principal instrument is the additive questionnaire (functional scale). This consists of various items believed to represent a common variable. These kinds of variables are observable only partially across various aspects of the whole person, and are not completely predictable. Their measure, consequently, can only be derived from an estimated statistic. The additive questionnaire is the principal measurement instrument. Several items all representing the same variable receive scores whose sum is assumed to be proportional to the quantity of the underlying variable. For various reasons the sum of the scores does not represent a true linear and continuous measure like those seen in chemistry and physics. Recently developed methods, in particular Rasch analysis, can extract true measures from raw scores. Thanks to better measurement of variability in persons within rehabilitative medicine, functional assessment can become increasingly more valid and informative.

Rehabilitation and outcome measurement: where is Rasch analysis-going?

Outcomes are clinical or functional changes at the whole-person level. Measures are based on questionnaires which summate scores assigned to a series of items representing a person's variable. The metric properties of raw scores are known to be of limited validity. Yet, such variables represent the main target of outcome assessment in Rehabilitation Medicine as far as they may cover performances, perceptions and knowledge. Rasch statistical models, first available in English to a large readesrship in late 70s, allow to transform the arbitary raw scores into true linear measures. Rehabilitation seemed a privileged field for the application of Rasch models, yet these are still far from becoming popular. A bibliometric study was conducted across ten leading digital libraries. A MEDLINE search showed a dramatic increment of published papers covering the intersection between the MESH terms ''Rehabilitation'' and ''Outcome assessment'', which rose in from 5 to 4 302 between the 1981-90 and 2001-07 time frames, respectively. ''Rasch'' paper also rose remarkably from 35 to 539. When the triple intersection was considered, articles only rose from 0 to 12. Results point towards a privileged application of Rasch analysis to build and refine questionnaires, rather than to actually measuring people. Commentaries and suggestions are invited.

A multicenter international study on the Spinal Cord Independence Measure, version III: Rasch psychometric validation.

BACKGROUND: A third version of the Spinal Cord Independence Measure (SCIM III), made up of three subscales, was formulated following comments by experts from several countries and Rasch analysis performed on the previous version. OBJECTIVE: To examine the validity, reliability, and usefulness of SCIM III using Rasch analysis. DESIGN: Multicenter cohort study. SETTING: Thirteen spinal cord units in six countries from North America, Europe, and the Middle-East. SUBJECTS: 425 patients with spinal cord lesions (SCL). INTERVENTIONS: SCIM III assessments by professional staff members. Rasch analysis of admission scores. MAIN OUTCOME MEASURES: SCIM III subscale match between the distribution of item difficulty grades and the patient ability measurements; reliability of patient ability measures; fit of data to Rasch model requirements; unidimensionality of each subscale; hierarchical ordering of categories within items; differential item functioning across classes of patients and across countries. RESULTS: Results supported the compatibility of the SCIM subscales with the stringent Rasch requirements. Average infit mean-square indices were 0.79-1.06; statistically distinct strata of abilities were 3 to 4; most thresholds between adjacent categories were properly ordered; item hierarchy was stable across most of the clinical subgroups and across countries. In a few items, however, misfit or category threshold disordering were found. CONCLUSIONS: The scores of each SCIM III subscale appear as a reliable and useful quantitative representation of a specific construct of independence after SCL. This justifies the use of SCIM in clinical research, including cross-cultural trials. The results also suggest that there is merit in further refining the scale.

Depression is the main determinant of quality of life in multiple sclerosis: a classification-regression (CART) study.

PURPOSE: Quality of life in multiple sclerosis has been often measured through the SF-36 questionnaire. In this study, validation of the SF-36 summary scores, its 'physical' component, and its 'mental' component was attempted by exploring the joint predictive power of disability (EDSS score), of anxiety and depression (HADS-A and -D scores, respectively), and of disease duration, progression type, age, gender and marital status. METHOD: The sample consisted of 75 patients suffering from multiple sclerosis admitted to an inpatient rehabilitation unit. The interplay between potential predictors was assessed through a particular regression model (classification and regression tree, CART). Two main advantages of this technique are its robustness with respect to distributional assumptions (rarely met by scores coming in from questionnaires) and its sensitivity to high-order interactions, between independent variables, difficult to detect through conventional multiple regression. RESULTS: Predictive variables for physical component of the SF-36 were EDSS and HADS-D (36.8% variance explanation). The only predictive variable for mental component of SF-36 was HADS-D (39.1% variance explanation). CONCLUSION: Results confirm previous findings showing that in patients with multiple sclerosis quality of life is heavily determined by person's mood, whatever his/her neurological or functional severity. The usefulness and validity of the SF-36 as an index representative of quality of life is debatable, as long as depression explains much of its variance. Further refinement of quality of life definition and measurement is worth further psychometric and statistical research.

Cross-cultural validity of FIM in spinal cord injury.

OBJECTIVE: To analyse cross-culture validity of the Functional Independence Measure (FIM) in patients with a spinal cord injury using a modern psychometric approach. SETTINGS: A total of 19 rehabilitation facilities from four countries in Europe. PARTICIPANTS: A total of 647 patients at admission, median age 46 years, 69% male. METHODS: Data from the FIM, collected on inpatient admission, was fitted to the Rasch model. A detailed analysis of scoring functions of the seven categories of the FIM items was undertaken before to testing fit to the model. Categories were rescored where necessary. Fit to the model was assessed initially within country, and then in the pooled data. Analysis of differential item functioning (DIF) was undertaken in the pooled data for each of the FIM motor and social cognitive scales, respectively. Final fit to the model was tested for breach of local independence by principle components analysis (PCA). RESULTS: The present scoring system for the FIM motor and cognitive scales, that is a seven category scale, was found to be invalid, necessitating extensive rescoring. Following this, DIF was found in a number of items within the motor scale, requiring a complex solution of splitting items by country to allow for the valid pooling of data. Five country-specific items could not be retained within this solution. The FIM cognitive scale fitted the Rasch model after rescoring, but there was a substantial ceiling effect. CONCLUSIONS: Data from the FIM motor scale for patients with spinal cord injury should not be pooled in its raw form, or compared from country to country. Only after fit to the Rasch model and necessary adjustments could such a comparison be made, but with a loss of clinical important items. The FIM cognitive scale works well following rescoring, and data may be pooled, but many patients were at the maximum score.

[A group therapy assessment tool (GrETha-Q)]. / Uno strumento per la valutazione dell'attività terapeutica di gruppo (GrEThA-Q).

This paper presents a questionnaire designed to assess the aspecific treatment efficacy and subjective perceived efficacy of group therapy. A preliminary version of the instrument was administered to a sample of 151 subjects undergoing group therapy. The psychometric properties of the instrument were evaluated by means of the Rasch model, and showed a good score range, good reproducibility and adequate coherence. The hierarchy of difficulty of the items remained stable among the respective categories of sex, age and professional level.

The ABILHAND questionnaire as a measure of manual ability in chronic stroke patients: Rasch-based validation and relationship to upper limb impairment.

BACKGROUND AND PURPOSE: Chronic hemiparetic patients often retain the ability to manage activities requiring both hands, either through the use of the affected arm or compensation with the unaffected limb. A measure of this overall ability was developed by adapting and validating the ABILHAND questionnaire through the Rasch measurement model. ABILHAND measures the patient's perceived difficulty in performing everyday manual activities. METHODS: One hundred three chronic (>6 months) stroke outpatients (62% men; mean age, 63 years) were assessed (74 in Belgium, 29 in Italy). They lived at home and walked independently and were screened for the absence of major cognitive deficits (dementia, aphasia, hemineglect). The patients were administered the ABILHAND questionnaire, the Brunnström upper limb motricity test, the box-and-block manual dexterity test, the Semmes-Weinstein tactile sensation test, and the Geriatric Depression Scale. The brain lesion type and site were recorded. ABILHAND results were analyzed with the use of Winsteps Rasch software. RESULTS: The Rasch refinement of ABILHAND led to a change from the original unimanual and bimanual 56-item, 4-level scale to a bimanual 23-item, 3-level scale. The resulting ability scale had sufficient sensitivity to be clinically useful. Rasch reliability was 0.90, and the item-difficulty hierarchy was stable across demographic and clinical subgroups. Grip strength, motricity, dexterity, and depression were significantly correlated with the ABILHAND measures. CONCLUSIONS: The ABILHAND questionnaire results in a valid person-centered measure of manual ability in everyday activities. The stability of the item-difficulty hierarchy across different patient classes further supports the clinical application of the scale.

Falls in the elderly: the development of a risk questionnaire and posturographic findings.

In elderly people, owing to a perturbation at several levels, including the motor, sensory and cognitive levels, a condition of dizziness and unsteadiness complicated by frequent falls often appears. In this article, we review the most recent information about clinical and instrumental tools available for preventing mobility-related accidents and report the results of a comparative study of postural control, carried out through tetraataxiometry (by Tetrax, Tel Aviv, Israel), in two samples of elderly women belonging to two different populations: 24 Italian women (11 reporting falls and 13 without falls) having a mean age of 73.1 years, and 37 Israeli women (12 with falls and 25 without falls) having a mean age of 72.5 years. The posturographic findings show that the falling subjects, to maintain postural control, are highly dependent on somatosensory inputs and have a weaker "systeme postural fin" (fine postural system), according to Gagey. They also show that an elderly subpopulation exists that, for unknown reasons, is immune to destabilization and falls.

The use of outcome measures in physical medicine and rehabilitation within Europe.

The aim of the study was to survey the use of outcome measures in rehabilitation within Europe. It was envisaged that this would provide the basis for further studies on the cross-cultural validity of outcome measures. A postal questionnaire was distributed in November 1998 to 866 units providing rehabilitation. In total, 418 questionnaires were returned, corresponding to a response rate of 48%. These 418 centres treated an estimated 113,000 patients annually, undertaking 360,000 assessments. The survey focused on nine diagnostic groups: hip and knee replacement, low back pain, lower limb amputees, multiple sclerosis, neuromuscular disorders, rheumatoid arthritis, spinal cord lesions, stroke and traumatic brain injury. It identified a relatively small number of dominant outcome assessments for each diagnostic group and some variation in the preference for measures across regions. A large number of measures, however, are being used in one or a small number of locations and with relatively few patients. For rehabilitation of orthopaedic patients the majority of assessments undertaken are at the impairment level. For patients with neurological disorders the emphasis is mostly upon measures of disability.

Life Satisfaction Index: Italian version and validation of a short form.

The Life Satisfaction Index-version A (LSIA) is a 20-item questionnaire providing a cumulative score acknowledged as a valid index of quality of life. In the present study, an Italian version was produced through validated procedures of repeated back-translations. The final Italian version (LSIA.it) was administered to 90 healthy subjects (55 women; aged 40-65 yr, median 51). Cronbach alpha was 0.74, in agreement with previous studies on English, Greek, and Spanish versions, suggesting satisfactory internal consistency of the scale. Also in agreement with previous studies, factor analysis identified three factors (mood tone, zest for life, and congruence between desired and achieved goals), with eigenvalues of 2.80, 1.72, and 1.34, respectively. Nine of the original 20 items were dropped because of inconsistency with the overall scale and/or because of ambiguous loading onto the extracted factors. The resulting 11-item short form (LSI-11) had alpha = 0.69 and Kaiser-Meyer-Olkin measure of sample adequacy = 0.65. In our sample, the mean score of LSIA.it was almost the same as that previously reported in the literature for LSIA, and the correlation between LSIA and LSI-11 was very high (r = 0.91). In a test-retest trial, the cumulative score of LSI-11 showed a percentage of agreement ranging from 73.9 to 100 and Cohen's k statistic for reliability ranging from 0.51 to 1. The individual items of the LSI-11 presented substantial (k > 0.6) to excellent (k > 0.8) levels of agreement. The responsiveness of LSIA and LSI-11 during a hospital stay for 30 consecutive inpatients for medical rehabilitation programs, as measured by effect size, was 0.57 and 0.63, respectively. The results suggest that (1) the LSIA it has cultural equivalence with the English LSIA and that (2) the 11-item short form of LSIA is not only simpler but also more valid from a psychometric standpoint.

Vasoactive hormones induce nitric oxide synthase mRNA expression and nitric oxide production in human endothelial cells and monocytes.

Isoform-2 nitric oxide synthase (NOS-2) mRNA expression and nitric oxide (NO) production are induced in endothelial cells and monocytes by cytokines such as gammaIFN and LPS. We evaluated NOS-2 and isoform-3 NOS (NOS-3) mRNA expression and NO production in human monocytes and human umbilical vein endothelial cells (HUVEC), under basal conditions and after incubation with physiologic concentrations of vasoactive hormones. NOS mRNA expression was detected by reverse transcription polymerase chain reaction (RT-PCR) and NO production by electronic paramagnetic resonance spectroscopy (EPR). We showed that NOS-2 mRNA expression and NO production were induced by stimulation with epinephrine, dopamine, endothelin-1, and angiotensin II, both in monocytes and HUVEC. NOS-3 mRNA expression and NO production were detected under basal conditions in monocytes and HUVEC and were not modified by the presence of vasoactive hormones. Human endothelial cells and monocytes express the NOS-2 and NOS-3 mRNA and the inducible NOS-2 mRNA expression increases after vasoactive hormone stimulation.

Short form of the Dizziness Handicap Inventory: construction and validation through Rasch analysis.

A new item response scale is presented, which measures the severity of self-reported balance deficits. The scale, DHIsf, is a short form of the Dizziness Handicap Inventory. The scale was constructed and validated by Rasch analysis. Rasch analysis was applied to rescore or remove any items misfitting, redundant, or off-target, until an optimal instrument was obtained. The 25-item, 3-level Dizziness Handicap Inventory was, thus, reduced to the 13-item, 2-level DHIsf. The retained items explore the domains of eye/head movements, full body activities, and mood alterations. Data were collected from 55 outpatients (63 +/- 13 yr; 43 females) attending otoneurological rehabilitation referral at a general hospital because of complaints of dizziness or imbalance. They were fully independent in ambulation and showed no evidence of major neurological or orthopedic diseases. Objective tests included brain computed tomography, sovraaorctic Doppler sonography, craniocorpography, static posturography, and nystagmography. The findings were categorized as pathologic, borderline, or normal. At least one examination was borderline or abnormal in 42 patients. The DHIsf was well targeted on this sample, with a mean score of 5.7/13 (standard deviation, 2.8; median, 5; range, 1-13). The Rasch statistics showed that the 13 items evenly fitted a hierarchy of difficulty within a homogeneous construct. A moderate but significant variance explanation of DHIsf measures was provided by a two-way analysis of variance model, with craniocorpography and nystagmography as independent categorical variables (r2 = 0.15; P = 0.018). When the clinical tests were individually taken into account, their outcome (dichotomized as abnormal v borderline or normal) could not be predicted by either of the DHIsf measures or raw scores (logistic regression). The DHIsf compares favorably with the original Dizziness Handicap Inventory, shows some consistency with the instrumental findings, and provides original information on the severity of imbalance syndromes, as it is seen from the patient's perspective.

ABILHAND: a Rasch-built measure of manual ability.

OBJECTIVE: To apply the Rasch measurement model to the development of a clinical tool for measuring manual (dis)ability (ABILHAND). DESIGN: Manual ability was evaluated in terms of the difficulty perceived by a hand-impaired patient on 57 representative unimanual or bimanual activities. SETTING: A clinical laboratory. PATIENTS: Eighteen rheumatoid arthritis patients (14 women, 4 men) were interviewed after wrist arthrodesis (10 right, 4 left, and 4 both wrists). Their ages ranged from 38 to 77 years, time since diagnosis ranged from 7 to 41 years, and time since surgery ranged from 0.5 to 17 years. MAIN OUTCOME MEASURE: ABILHAND, administered at a mean duration of 7 years after arthrodesis. RESULTS: Forty-six of the 57 items define a common, single manual ability continuum with widespread measurement range and regular item distribution. Items relating to feeding, grooming, and dressing upper body worked consistently with their counterparts in other disability scales. More difficult items extend the measurement range beyond that of most existing manual ability scales. CONCLUSION: Even in a small sample of patients, using the Rasch methodology enabled the investigators to produce a useful scale of manual (dis)ability and to define manual ability as a unique construct, at least in patients with rheumatoid arthritis.

The functional assessment measure (FAM) in closed traumatic brain injury outpatients: a Rasch-based psychometric study.

The Functional Assessment Measure (FAM) has been proposed as a measure of disability in post-acute Traumatic Brain Injury (TBI) outpatients. It is comprised of the 18 items of The Functional Independence Measure (FIMSM), scored in terms of dependence, and of 12 newly designed items, scored in terms of dependence (7 items) or performance (5 items). The FIMSM covers the domains of self-care, sphincter management, mobility, locomotion, communication and social cognition. The 12 new items explore the domains of community integration, emotional status, orientation, attention, reading/writing skills, swallowing and speech intelligibility. By addressing a set of problems quite specific for TBI outpatients the FAM was intended to raise the ceiling of the FIMSM and to allow a more precise estimate of their disability. These claims, however, were never supported in previous studies. We administered the FAM to 60 TBI outpatient, 2-88 months (median 16) from trauma. Rasch analysis (rating scale model) was adopted to test the psychometric properties of the scale. The FAM was reliable (Rasch item and person reliability 0.91 and 0.93, respectively). Two of the 12 FAM-specific items were severely misfitting with the general construct, and were deleted. Within the 28-item refined FAM scale, 4 new items and 2 FIMSM items still retained signs of misfit. The FAM was on average too easy. The most difficult item (a new one, Employability) did not attain the average ability of the subjects. Also, it was only slightly more difficult than than the most difficult FIMSM item (Memory). The FAM does not seem to improve the FIMSM as a far as TBI outpatients are to be assessed.