The neurophysiology of deforming spastic paresis: A revised taxonomy.

This paper revisits the taxonomy of the neurophysiological consequences of a persistent impairment of motor command execution in the classic environment of sensorimotor restriction and muscle hypo-mobilization in short position. Around each joint, the syndrome involves 2 disorders, muscular and neurologic. The muscular disorder is promoted by muscle hypo-mobilization in short position in the context of paresis, in the hours and days after paresis onset: this genetically mediated, evolving myopathy, is called spastic myopathy. The clinician may suspect it by feeling extensibility loss in a resting muscle, although long after the actual onset of the disease. The neurologic disorder, promoted by sensorimotor restriction in the context of paresis and by the muscle disorder itself, comprises 4 main components, mostly affecting antagonists to desired movements: the first is spastic dystonia, an unwanted, involuntary muscle activation at rest, in the absence of stretch or voluntary effort; spastic dystonia superimposes on spastic myopathy to cause visible, gradually increasing body deformities; the second is spastic cocontraction, an unwanted, involuntary antagonist muscle activation during voluntary effort directed to the agonist, aggravated by antagonist stretch; it is primarily due to misdirection of the supraspinal descending drive and contributes to reducing movement amplitude; and the third is spasticity, one form of hyperreflexia, defined by an enhancement of the velocity-dependent responses to phasic stretch, detected and measured at rest (another form of hyperreflexia is "nociceptive spasms", following flexor reflex afferent stimulation, particularly after spinal cord lesions). The 3 main forms of overactivity, spastic dystonia, spastic cocontraction and spasticity, share the same motor neuron hyperexcitability as a contributing factor, all being predominant in the muscles that are more affected by spastic myopathy. The fourth component of the neurologic disorder affects the agonist: it is stretch-sensitive paresis, which is a decreased access of the central command to the agonist, aggravated by antagonist stretch. Improved understanding of the pathophysiology of deforming spastic paresis should help clinicians select meaningful assessments and refined treatments, including the utmost need to preserve muscle tissue integrity as soon as paresis sets in.

Functional recovery differences after stroke rehabilitation in patients with uni- or bilateral hemiparesis.

OBJECTIVE: To examine the functional recovery differences after stroke rehabilitation in patients with uni- or bilateral hemiparesis. METHODS: In this retrospective study, we included data from the medical record of all 383 patients with uni- or bilateral hemiparesis after stroke who were admitted to King Fahad Medical City-Rehabilitation Hospital between 2008 and 2014 in Riyadh, Kingdom of Saudi Arabia. According to the site of hemiparesis, we classified patients into 3 groups: right hemiparesis (n=208), left hemiparesis (n=157), and bilateral hemipareses (n=18). The patients (n=49) who did not have either site of hemiparesis were excluded. The Functional Independence Measures (FIM) instrument was used to assess the score at admission and discharge. A post hoc test was conducted to examine the functional recovery differences between groups. Multiple regression analyses were used to confirm the findings. RESULTS: Amongst the three groups, there were significant (p<0.05) differences in the total-FIM score as well as motor- and cognitive-FIM sub-scores between admission and discharge of stroke rehabilitation. The differences were significantly greater in the bilateral hemipareses group than in either unilateral hemiparesis group. Multiple regression analyses also confirmed that the site of hemiparesis significantly (p<0.05) differs in the total-FIM score as well as motor-FIM and cognitive-FIM sub-scores. CONCLUSION: Our results demonstrate that differences in functional recovery after stroke rehabilitation may be influenced by the site of hemiparesis after stroke.

Motor exam of patients with spinal cord injury: a terminological imbroglio.

The description of the motor deficit of patients with spinal cord injury (SCI) varies significantly, leading to confusion within the neurological terminology. This paper proposes a concise and easy to use terminology to describe the motor deficit of patients with SCI. A broad review of the origin of the nomenclature used to describe the motor deficit of patients with SCI was performed and discussed. The prefix: "hemi" should be used to describe paralysis of one half of the body; "mono" for one limb; "para" for lower limbs, di" for two symmetrical segments and/or parts in both sides of the body; "tri" for three limbs, or two limbs and one side of the face; and "tetra" for four limbs. The suffix: "plegia" should be used for total paralysis of a limb or part of the body, and "paresis" for partial paralysis. The term "brachial" refers to the upper limbs; and "podal" to the lower limbs. According to the spinal cord origin of the main key muscles for the limbs, patients with complete injury affecting spinal cord segments C1-5 usually presents with "tetraplegia"; C6-T1 presents with "paraplegia and brachial diparesis"; T2-L2 with "paraplegia"; and L3-S1 with "paraparesis".

Proposition of a Classification of Adult Patients with Hemiparesis in Chronic Phase.

BACKGROUND: Patients who have developed hemiparesis as a result of a central nervous system lesion, often experience reduced walking capacity and worse gait quality. Although clinically, similar gait patterns have been observed, presently, no clinically driven classification has been validated to group these patients' gait abnormalities at the level of the hip, knee and ankle joints. This study has thus intended to put forward a new gait classification for adult patients with hemiparesis in chronic phase, and to validate its discriminatory capacity. METHODS AND FINDINGS: Twenty-six patients with hemiparesis were included in this observational study. Following a clinical examination, a clinical gait analysis, complemented by a video analysis, was performed whereby participants were requested to walk spontaneously on a 10m walkway. A patient's classification was established from clinical examination data and video analysis. This classification was made up of three groups, including two sub-groups, defined with key abnormalities observed whilst walking. Statistical analysis was achieved on the basis of 25 parameters resulting from the clinical gait analysis in order to assess the discriminatory characteristic of the classification as displayed by the walking speed and kinematic parameters. Results revealed that the parameters related to the discriminant criteria of the proposed classification were all significantly different between groups and subgroups. More generally, nearly two thirds of the 25 parameters showed significant differences (p<0.05) between the groups and sub-groups. However, prior to being fully validated, this classification must still be tested on a larger number of patients, and the repeatability of inter-operator measures must be assessed. CONCLUSIONS: This classification enables patients to be grouped on the basis of key abnormalities observed whilst walking and has the advantage of being able to be used in clinical routines without necessitating complex apparatus. In the midterm, this classification may allow a decision-tree of therapies to be developed on the basis of the group in which the patient has been categorised.

Is the basic trunk control recovery different between stroke patients with right and left hemiparesis?

BACKGROUND: Basic trunk movement control is often impaired after stroke and its recovery is a "miliary stone" in rehabilitation. OBJECTIVE: In this prospective, observational, parallel-group study, we investigated whether there are differences in terms of post-stroke recovery of basic trunk control between patients with left or with right hemiparesis. METHODS: We recruited 94 patients with loss of postural trunk control due to stroke. Patients were divided into Group A (48 patients with left hemiparesis) and Group B (46 patients with right hemiparesis). We administered the Trunk Control Test (TCT) and the 13 motor items included on the Functional Independence Measure. Evaluation was performed at admission (To) and discharge (T1). RESULTS: TCT increased respectively from 46.7 ± 23.3 to 62.6 ± 19.5 (mean ± standard deviation-SD, p < 0.0001) in Group A and from 49.4 ± 23.2 to 79.1 ± 14.4 (mean ± SD, p < 0.0001) in Group B. TCT resulted significantly higher in Group B than in Group A, at T1 (p < 0.0001). No significant difference was found for motFIM at T1. CONCLUSION: Side of hemiparesis could affect the degree of recovery of basic trunk control after stroke. Patients with right hemiparesis benefit more than those with left hemiparesis. Improvement of basic trunk control was not responsible for an advantage on functional independence.

Inconsistent classification of pusher behaviour in stroke patients: a direct comparison of the Scale for Contraversive Pushing and the Burke Lateropulsion Scale.

OBJECTIVE: To compare the classification of two clinical scales for assessing pusher behaviour in a cohort of stroke patients. DESIGN: Observational case-control study. SETTING: Inpatient stroke rehabilitation unit. SUBJECTS: A sample of 23 patients with hemiparesis due to a unilateral stroke (1.6 ± 0.7 months post stroke). METHODS: Immediately before and after three different interventions, the Scale for Contraversive Pushing and the Burke Lateropulsion Scale were applied in a standardized procedure. RESULTS: The diagnosis of pusher behaviour on the basis of the Scale for Contraversive Pushing and the Burke Lateropulsion Scale differed significantly (χ2 = 54.260, p < 0.001) resulting in inconsistent classifications in 31 of 138 cases. Changes immediately after the interventions were more often detected by the Burke Lateropulsion Scales than by the Scale for Contraversive Pushing (χ2 = 19.148, p < 0.001). All cases with inconsistent classifications showed no pusher behaviour on the Scale for Contraversive Pushing, but pusher behaviour on the Burke Lateropulsion Scale. 64.5% (20 of 31) of them scored on the Burke Lateropulsion Scale on the standing and walking items only. CONCLUSIONS: The Burke Lateropulsion Scale is an appropriate alternative to the widely used Scale for Contraversive Pushing to follow-up patients with pusher behaviour (PB); it might be more sensitive to detect mild pusher behaviour in standing and walking.

Short-term and long-term outcomes of serial robotic training for improving upper limb function in chronic stroke.

The aim of this study was to determine short-term and long-term changes in motor function in patients with chronic hemiparesis who underwent robot training and to evaluate its long-term benefit after 6 months. This was a longitudinal study with a 6-month follow-up. The 15 patients included in this study underwent the Fugl-Meyer test, the Ashworth Scale test, the Frenchay Arm test, and the Box and Block test according to the following schedule: immediately before (T1, T3) and after each treatment (T2, T4), and 6 months after T4 (T5). There were statistically significant improvements in Fugl-Meyer test between T1 and T2 and between T1 and T4; the score increased in the Ashworth Scale test for Shoulder between T1 and T3 and between T1 and T5; a statistically significant decrease was found between T1 and T2 and between T1 and T4, in the Box and Block test between T1 and T4, and also between T1 and T5. This original rehabilitation treatment may contribute toward increasing upper limb motor recovery in stable chronic stroke patients.

Two types of exercise-induced neuroplasticity in congenital hemiparesis: a transcranial magnetic stimulation, functional MRI, and magnetoencephalography study.

AIM: Early unilateral brain lesions can lead to a persistence of ipsilateral corticospinal projections from the contralesional hemisphere, which can enable the contralesional hemisphere to exert motor control over the paretic hand. In contrast to the primary motor representation (M1), the primary somatosensory representation (S1) of the paretic hand always remains in the lesioned hemisphere. Here, we report on differences in exercise-induced neuroplasticity between individuals with such ipsilateral motor projections (ipsi) and individuals with early unilateral lesions but 'healthy' contralateral motor projections (contra). METHOD: Sixteen children and young adults with congenital hemiparesis participated in the study (contralateral [Contra] group: n=7, four females, three males; age range 10-30y, median age 16y; ipsilateral [Ipsi] group: n=9, four females, five males; age range 11-31y, median age 12y; Manual Ability Classification System levels I to II in all individuals in both groups). The participants underwent a 12-day intervention of constraint-induced movement therapy (CIMT), consisting of individual training (2h/d) and group training (8h/d). Before and after CIMT, hand function was tested using the Wolf Motor Function Test (WMFT) and diverging neuroplastic effects were observed by transcranial magnetic stimulation (TMS), functional magnetic resonance imaging (fMRI), and magnetoencephalography (MEG). Statistical analysis of TMS data was performed using the non-parametric Wilcoxon signed-rank test for pair-wise comparison; for fMRI standard statistical parametric and non-parametric mapping (SPM5, SnPM3) procedures (first level/second level) were carried out. Statistical analyses of MEG data involved analyses of variance (ANOVA) and t-tests. RESULTS: While MEG demonstrated a significant increase in S1 activation in both groups (p=0.012), TMS showed a decrease in M1 excitability in the Ipsi group (p=0.036), but an increase in M1 excitability in the Contra group (p=0.043). Similarly, fMRI showed a decrease in M1 activation in the Ipsi group, but an increase in activation in the M1-S1 region in the Contra group (for both groups p<0.001 [SnPM3] within the search volume). INTERPRETATION: Different patterns of sensorimotor (re)organization in individuals with early unilateral lesions show, on a cortical level, different patterns of exercise-induced neuroplasticity. The findings help to improve the understanding of the general principles of sensorimotor learning and will help to develop more specific therapies for different pathologies in congenital hemiparesis.

Rasch analysis staging methodology to classify upper extremity movement impairment after stroke.

OBJECTIVES: To define Fugl-Meyer Assessment of the Upper Extremity (FMA-UE) cutoff scores that demarcate 1 level of upper extremity (UE) impairment from another, and describe motor behaviors for each category in terms of expected FMA-UE item performance. DESIGN: Analysis of existing FMA-UE data. SETTING: University research laboratory. PARTICIPANTS: Persons (N=512) 0 to 145 days poststroke, 42 to 90 years of age. INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: An item response Rasch analysis staging method was used to calculate cutoff scores, which were defined as the Rasch-Andrich threshold values of 2 criterion FMA-UE items derived from an analysis of this sample. The analysis enabled conversion of cutoff scores, in logit units, to FMA-UE points assessed on 30 FMA-UE voluntary movement items (60 possible points). RESULTS: The boundary between severe and moderate impairment was defined as -1.59 ± .27 logits or 19 ± 2 points; and between moderate and mild impairment was defined as 2.44 ± .27 logits or 47 ± 2 points. A description of expected performance in each impairment level shows that patients with severe impairment exhibited some distal movements, and patients with mild impairment had difficulties with some proximal movements. CONCLUSIONS: The cutoff scores, which link to a description of specific movements a patient can, can partially, and cannot perform, may enable formation of heterogeneous patient groups, advance efforts to identify specific movement therapy targets, and define treatment response in terms of specific movement that changed or did not change with therapy.

Unilateral versus bilateral upper limb exercise therapy after stroke: a systematic review.

OBJECTIVE: To compare the effects of unilateral and bilateral training on upper limb function after stroke with regard to two key factors: severity of upper limb paresis and time of intervention post-stroke. DESIGN: Systematic review and meta-analysis of randomized controlled trials. METHODS: Two authors independently selected trials for inclusion, assessed the methodological quality and extracted data. Study outcomes were pooled by calculating the (standardized) mean difference ((S)MD). Sensitivity analyses for severity and time of intervention post-stroke were applied when possible. RESULTS: All 9 studies involving 452 patients showed homogeneity. In chronic patients with a mild upper limb paresis after stroke a marginally significant SMD for upper limb activity performance (SMD 0.34; 95% confidence interval): 0.04-0.63), and marginally significant MDs for perceived upper limb activity performance (amount of use: MD 0.42; 95% confidence interval: 0.09-0.76, and quality of movement: MD 0.45; 95% confidence interval: 0.12-0.78) were found in favour of unilateral training. All other MDs and SMDs were non-significant. CONCLUSION: Unilateral and bilateral training are similarly effective. However, intervention success may depend on severity of upper limb paresis and time of intervention post-stroke.

Guillain-Barre syndrome: a clinical study in King Chulalongkorn Memorial Hospital.

BACKGROUND: Guillain-Barre Syndrome (GBS) is an acute,fatal, but treatable polyradiculopathy. Clinical data concerning this entity is scarce in Thailand The purpose of the present study was to describe clinical profiles and management of GBS as well as to determine prognostic factors in GBS. MATERIAL AND METHOD: Clinical data of GBS in King Chulalongkorn Memorial Hospital during 2002-2007 were searched by using in-patients hospital database. Asbury and Cornblath's criteria were applied for the diagnosis of GBS. Clinical data, electrophysiological data, management, and clinical prognostic factors were collected and analyzed by SPSS version 16. RESULTS: Fifty-five patients with GBS were recruited, 26 wire male and 29 were female. Mean age was 43 +/- 17 years. History of antecedent infection included: respiratory tract 29%, gastrointestinal tract 7%, ear 2%, and non-specific infection 14%. Initial presentations were limb weakness 87%, limb numbness 78%, bulbar weakness 31%, and facial weakness 18%. Electrodiagnostic study revealed demyelinating process in 54% and axonopathy in 46%. Twenty-nine patients received intravenous immunoglobulin while 13 patients underwent plasmapheresis. Clinical outcomes were satisfactory in most of the patients and only two patients died from sepsis and pneumonia. On discharge, the status of the patients were Hughes grade 1-4 in 73%, 14%, 5%, and 4% respectively. Bulbar paresis as the presenting symptom was the only clinical prognostic factor that significantly determined airway compromised and subsequently respiratory failure. CONCLUSION: Clinical features of GBS in the present series were characterized by generalized muscle weakness with mild numbness in combination with facial and bulbar paresis in nearly half of patients. Respiratory failure was encountered in 9% of cases. Clinical outcomes were satisfactory in most of the patients with or without specific treatment. The most significant predictor for adverse clinical course was the bulbar paresis as a presenting symptom and patients who presented with less disability score had a better recovery.

Presumed perinatal ischemic stroke: vascular classification predicts outcomes.

OBJECTIVE: Perinatal stroke commonly causes childhood neurological morbidity. Presumed perinatal ischemic stroke (PPIS) defines children presenting outside a normal perinatal period with chronic, focal infarction on neuroimaging. Infarcts are assumed to represent arterial strokes, but recent evidence suggests the periventricular venous infarction (PVI) of infants born preterm may also occur in utero and present as PPIS. Using the largest published cohort, we aimed to define arterial and PVI PPIS syndromes and their outcomes. METHODS: A PPIS consecutive cohort was identified (SickKids Children's Stroke Program, 1992-2006). Systematic neuroradiological scoring executed by blinded investigators included previously defined arterial stroke syndromes. PVI criteria included unilateral injury with at least four of the following conditions: (1) focal periventricular encephalomalacia, (2) internal capsule T2 prolongation, (3) cortical and (4) relative basal ganglia sparing, and (5) remote hemorrhage. Arterial and PVI classifications were validated and correlated with neurological outcomes (Pediatric Stroke Outcome Measure). RESULTS: In 59 PPISs (64% male), 94% of lesions fell within potential middle cerebral artery territories. Although arterial proximal M1 infarction was most common (n = 19; 35%), venous PVI was second (n = 12; 22%) and accounted for 75% of subcortical injuries. Motor outcomes (mean follow-up, 5.3 years) were predicted by basal ganglia involvement including leg hemiparesis, spasticity, and need for assistive devices (p < 0.01). Nonmotor outcomes were associated with cortical involvement, including cognitive/behavioral outcomes, visual deficits, and epilepsy (p < 0.01). Classification interrater reliability was excellent (correlation coefficients > 0.975). INTERPRETATION: Recognizable PPIS patterns predict long-term morbidity and may guide surveillance, therapy, and counseling. PVI is an underrecognized cause of PPIS and congenital hemiplegia.

Factors associated with life satisfaction in Japanese stroke outpatients.

PURPOSE: To measure life satisfaction in Japanese stroke outpatients and randomly-sampled community residents and to investigate variables influencing their life satisfaction. METHOD: Data on the demographic and clinical profiles, Satisfaction in Daily Life (SDL), other measurements, were obtained from 869 stroke outpatients (552 males, 317 females) and 748 community-dwelling elderly (360 males, 388 females), aged 55 years and older. Differences in categorical variables and continuous variables were tested by chi-square test and ANCOVA with age as the covariate, respectively. RESULTS: The 11 SDL items were subjected to a factor analysis, which extracted two factors. Factor 1 (F1), labeled as 'satisfaction with one's own abilities', included satisfaction with housework, self-care, gait, physical health, hobby and leisure, social intercourse and mental health. Factor 2 (F2), 'satisfaction with external factors', included satisfaction with partner/ family relationship, economic state and social security, and house facilities. Both F1 and F2 scores were significantly lower for stroke outpatients (M = 19.7 and 10.9, respectively) than for community-dwelling elderly (M = 28.2 and 12.0, respectively) (p < 0.001). Living conditions were significantly associated with F2, but not with F1. Males living alone scored lowest on F2 than the others for both groups. Among stroke outpatients, both F1 and F2 scores differed significantly by the type of hemiparesis and the severity of aphasia. CONCLUSIONS: SDL of stroke outpatients, which was lower than community-dwelling elderly, differed by the type of hemiparesis, the severity of aphasia, and living conditions. The effects of living conditions might vary with gender.

Cognitive-behavioural stimulation protocol for severely brain-damaged patients in the post-acute stage in developmental age.

PURPOSE: To present a cognitive-behavioural stimulation (CBS) protocol designed to help severely damaged patients in the early post-acute stage by describing the underlying methodology and assessing its efficacy compared to traditional rehabilitation methods. This protocol combines multisensory stimulation and cognitive-behavioural techniques to elicit and intensify the occurrence of adaptive responses and reduce maladaptive behavioural patterns. METHODS: A control group and an experimental group--both evaluated with the Levels of Cognitive Functioning Assessment Scale (LOCFAS)--were compared at the beginning of the rehabilitation programme and at the end of it. The control group consisting of patients assessed and treated before receiving the CBS protocol was enrolled in a traditional rehabilitation programme (only physical therapy and speech therapy). Besides the traditional therapy, the experimental group also received the CBS protocol. RESULTS: Patients on the CBS protocol show a greater improvement and are therefore more responsive than the control group after the 16-week remediation programme. The mean LOCFAS improvement of the experimental group is more marked during the first month of rehabilitation and is associated to the entry LOCFAS level, while in the control group the improvement on LOCFAS is considered to be 'spontaneous' and is associated to the aetiology of the brain damage. CONCLUSIONS: Our results show a better initial outcome for patients receiving the CBS protocol.

Paretic upper-limb strength best explains arm activity in people with stroke.

BACKGROUND AND PURPOSE: The purpose of this study was to determine the relationship among variables of upper-limb impairment, upper-limb performance in activities of daily living (activity), and engagement in life events and roles (participation) in people with chronic stroke. SUBJECTS: The subjects were 93 community-dwelling individuals with stroke (> or =1 year). METHODS: This study, which was conducted in a tertiary rehabilitation center, used a cross-sectional design. The main measures of impairment were the Modified Ashworth Scale, handheld dynamometry, sensory testing (monofilaments), and the Brief Pain Inventory. The main measures of activity were the Chedoke Arm and Hand Activity Inventory (CAHAI) and the Motor Activity Log (MAL). The main measure of participation was the Reintegration to Normal Living (RNL) Index. RESULTS: Paretic upper-limb strength (force-generating capacity) (r=.89, P<.01), grip strength (r=.69, P<.01), and tone (resistance to passive movement) (r=-.80, P<.01) were the impairment variables that were most strongly related to activity. Tone (r=-.23, P<.05) and CAHAI scores (r=.22, P<.05) had a significant, but weak, relationship to participation. Upper-limb strength accounted for 87% of the variance of the CAHAI scores and 78% of the variance of the MAL scores. In the participation models, tone and CAHAI scores accounted for 5% of the variance of the RNL Index scores. DISCUSSION AND CONCLUSION: Paretic upper-limb strength had the strongest relationship with variables of activity and best explained upper-limb performance in activities of daily living. Grip strength, tone, and sensation also were factors of upper-limb performance in activities of daily living. Increased tone and upper-limb performance in activities of daily living had a weak relationship with participation.

Dynamic postural control in patients with hemiparesis.

OBJECTIVE: Decreased postural stability is a common problem associated with hemiparesis secondary to stroke. The purpose of this study was to evaluate dynamic postural control in patients with hemiparesis and in normal subjects matched for age. DESIGN: Quantitative posturography (EquiTest System) was performed to assess the response of subjects to sudden perturbations. A total of 59 patients with hemiparesis and 98 healthy volunteers were evaluated. All the patients were able to walk inside their house without lower limb orthoses. Both the patients and the healthy volunteers were subjected to forward and backward perturbations while standing on a movable force platform. Balance responses were analyzed in terms of weight symmetry, latency, amplitude (relative response strength), and strength symmetry. They were also subjected to toes-up and toes-down perturbations to evaluate their response to a disruptive balance force. RESULTS: The response latency to perturbations was longer and the response strength was weaker on the paretic side of patients with hemiparesis. The dynamic postural control was impaired in patients with hemiparesis as compared with healthy subjects. CONCLUSION: The results suggest that patients with hemiparesis tend to fall easily and that the risk of falls toward the paretic side is high.

Does preoperative paresis influence intraoperative monitoring of the motor cortex?

Intraoperative monitoring of motor function by means of motor evoked potentials (MEPs) is a new method. The current study examines the influence of preoperative paresis on the feasibility and reliability of this method. Intraoperative monitoring of MEPs was performed in 58 patients during surgery in the central region. The patients were divided into three groups according to their preoperative strength (group I, muscle strength less than or equal to grade 4 according to the British Medical Research Council grading system [n = 17]; group II, normal strength (n = 36); and group III, muscle strength less than grade 5 but not worse than grade 4 [n = 5]). The motor cortex was stimulated directly with a high-frequency monopolar anodal train. In groups II and III, MEPs were elicited in all patients on cortical stimulation, whereas in group I a response was obtained in only 88% of patients. The MEP parameters in all groups had a broad interindividual range of variation. A correlation between individual intraoperative potential changes and surgical maneuvers was observed in seven patients in group II and in four patients in group I. No MEP changes were recorded in group III. Irreversible MEP changes (groups I and II) resulted in postoperative clinical deterioration. No postoperative deterioration of motor function was observed in patients with reversible MEP changes. Preoperative paresis reduces the feasibility of the method; however, it has no influence on the intraoperative pattern and reaction of the MEPs.

Neurobehavioral aspects of recovery: assessment of the learned nonuse phenomenon in hemiparetic adolescents.

OBJECTIVE: To test the learned nonuse assumption of constraint-induced movement therapy (CIMT), through behavioral assessment, that residual movement abilities are not used to their fullest extent in persons with chronic hemiparesis. DESIGN: Repeated-measures cohort design. SETTING: Rehabilitation clinic in southwest Germany. PARTICIPANTS: Twenty-one persons with upper-limb hemiparesis after brain injury and 21 age-matched healthy controls. Participants were hospitalized when tested. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Spontaneous affected hand use for the items of the Motor Activity Log and the Actual Amount of Use Test were compared with the subjects' actual ability to perform these items with the affected hand. RESULTS: A significant difference between the residual movement capability and the spontaneous use was found in both tests. Most movements could be performed with moderate to good movement quality with the affected hand, but were still performed with the unaffected "good" hand in the spontaneous-use condition. This effect was equally strong in right- and left-side affected persons. CONCLUSION: Hemiparetic persons do not use their residual movement capabilities to the fullest extent. According to the learned nonuse model, this behavior reflects a learned suppression of affected arm movements, which may be overcome by CIMT.

Dejerine's syndrome or Spiller's syndrome?

We report the difference existing between two clinical syndromes: Spiller's syndrome is caused by a complete involvement of the medial hemimedulla, while Déjérine's syndrome is determined by lesions restricted to the anterior portion of the medial hemimedulla and is characterized by hypoglossal nerve palsy and contralateral hemiparesis.