Anarchic hand syndrome following resection of a frontal lobe tumor.

Anarchic hand syndrome (AHS) is a rare disorder characterized by unwilled, but seemingly purposeful movements of the affected upper limb which are perceived by the patients not to be under their control. It often interferes with goal-directed movements and bimanual tasks. At present there is no effective method of treatment of AHS. We report here a case of AHS following resection of a frontal lobe tumor and describe its effects on the patient's functional activities. The patient used avoidance behavior and mental concentration to overcome the disabling effect of AHS. These strategies appear to be useful in the management of AHS.

Successful treatment of severe abulia with co-beneldopa.

Abulia is a disorder of the executive and frontal lobe function. It is characterised by severe psychomotor slowing that is not due to depressive illness or catatonic schizophrenia. Abulia is thought to be due to disruption of the meso-cortico-limbic dopaminergic system. Preliminary evidence suggests that patients with abulia may respond to treatment with dopaminergic drugs. We extend this evidence by reporting a significant and sustained functional improvement in a severely abulic patient after treatment with co-beneldopa (Madopar).

Remission of life-long stammering after posterior circulation stroke.

Developmental stammering is relatively common in the adult population. Stammering has a poor prognosis when it persists beyond adolescence and spontaneous or treatment-induced remission is very rare in adults. In this communication we report a case of life-long developmental stammering that resolved completely after the onset of a posterior circulation stroke and we speculate on the reason for this.

A prospective, randomized, parallel group, controlled study of the effect of intensity of speech and language therapy on early recovery from poststroke aphasia.

OBJECTIVE: To examine whether the amount of speech and language therapy influences the recovery from poststroke aphasia. SETTING: A hospital stroke unit and community. DESIGN: A prospective, randomized controlled trial. INTERVENTION: Aphasic stroke patients were randomly allocated to receive 5 hours (intensive therapy group, n=51) or 2 hours (standard therapy group) of speech and language therapy per week for 12 consecutive weeks starting as soon as practicable after the stroke. Another 19 patients were recruited for 2 hours per week of therapy and were treated by National Health Service (NHS) staff (NHS group). OUTCOME MEASURE AND ASSESSMENT: The Western Aphasia Battery. Assessments were made blind to randomization at baseline and 4, 8, 12 and 24 weeks after the start of therapy. Data were analysed by intention to treat. RESULTS: The mean (SD) Western Aphasia Battery score at week 12 for the intensive, standard and NHS groups was 70.3 (26.9), 66.2 (26.2) and 58.1 (33.7), respectively. There was no treatment effect of intensive therapy (P > 0.05), but there was a statistically significant difference between the standard study and the NHS groups (P = 0.002 at week 12 and 0.01 at week 24). CONCLUSIONS: Intensive speech and language therapy (as delivered in this study) did not improve the language impairment significantly more than the ;standard' therapy which averaged 1.6 hours/week. The improvement in aphasia was least in patients who were in the NHS group. These patients received 0.57 (0.49) hours of therapy per week.

The rate and extent of improvement with therapy from the different types of aphasia in the first year after stroke.

OBJECTIVE: To examine the rate and extent of improvement from the different types of aphasia in the first year after stroke. DESIGN: A prospective longitudinal study. SETTING: A specialist stroke unit. PARTICIPANTS: Seventy-five aphasic patients with first-ever stroke. INTERVENTION: The type of aphasia was classified according to the criteria of the Western Aphasia Battery. The Western Aphasia Battery aphasia quotient was used to measure the initial severity and the rate and extent of improvement from aphasia. Assessments were made at baseline and 4, 8, 12 and 24 weeks later. RESULTS: The median percentage increase in the Western Aphasia Battery aphasia quotient was statistically higher in patients with Broca's aphasia than in the other groups at all weeks. Patients with Wernicke's aphasia had a significantly greater median percentage increase in their aphasia quotient than those with conduction and anomic aphasia at weeks 12 and 24, but less than patients with global aphasia at week 24. CONCLUSIONS: Patients with Broca's aphasia appear to have the best prognosis for improvement of language function in the first year of stroke. The extent of improvement in patients with global aphasia is better than that of patients with Wernicke's aphasia.

Comparison of three definitions of the mid-stance and mid-swing events of the gait cycle in children.

PURPOSE: Different criteria are used to define the terms mid-stance (MST) and mid-swing (MSW) when describing the gait cycle. None of these definitions is universally accepted. This causes difficulties with the interpretation of gait analysis data and hinders the comparison between the different studies. The aim of the present study was to compare three definitions of MST and MSW by examining the gait of a group of healthy children. METHOD: A prospective comparison of three commonly used definitions of the MST and MSW events of the gait cycle. OUTCOME MEASURES: The timing of the temporal, kinematic and kinetic MST and MSW of the gait cycle. RESULTS: Thirty healthy 8 - 10-year-old children were studied. There was no consistent correlation between the timing of the chosen definitions of MST and MSW. However, there was a tendency for the timing of the temporal and kinetic MST and MSW to occur, respectively, at approximately 30 and 80% of the gait cycle. CONCLUSIONS: The temporal definition of MST and MSW as the midpoints in time of the respective phases of the gait cycle appears to be more appropriate than other definitions. The use of this definition may prevent misunderstanding and permit comparison of the results of the different gait analysis studies.

Recognition of acute illness in people with chronic neurological disability.

Coincidental acute illness is common in patients with chronic progressive or stable neurological disability. Although the presentation of acute illness in these patients is often similar to that in people without pre-existing disability, sometimes it may be atypical. In addition, an adequate medical history is often difficult to obtain in patients with advanced neurological disease, for example because of the presence of aphasia, severe dysarthria, or cognitive impairment. In these circumstances early and accurate diagnosis of acute medical and surgical emergencies requires both clinical acumen and a high index of suspicion. The aim of this article is to describe the main atypical manifestations of acute illness in patients with chronic disabling neurological disorders.

The effects of isotonic and isokinetic muscle stretch on the excitability of the spinal alpha motor neurones in patients with muscle spasticity.

To examine the effect of isotonic (with and without weight bearing) and isokinetic muscle stretch on the excitability of the spinal alpha motor neurones (alphaMN) in patients with spasticity and to establish whether this effect is maintained for at least 24 h after the intervention. A single 20-min session of isotonic muscle stretch (with or without weight bearing) or isokinetic stretch was delivered to the ankle plantar flexors in patients with post-stroke lower limb spasticity and healthy control subjects. The effect of these types of muscle stretch on the excitability of alphaMN was assessed by measuring the latency of the Hoffmann reflex (H-reflex) and the ratio of the amplitude of the maximum H-reflex (H(max)) to that of the maximum action motor potential of the soleus muscle (M(max)). Sixty-six hemiplegic stroke patients and 21 healthy control subjects were recruited and completed the trial. The H(max):M(max) ratio was significantly higher in patients with spasticity than in healthy control subjects. However, there were no statistically significant differences in the H-reflex latency or the change in H(max):M(max) ratio between the baseline values and those recorded immediately after the therapy intervention or 24 h later for each type of muscle stretch. Similarly, there were no significant differences in these variables between the interventions. In the present study neither isotonic muscle stretch (with or without weight bearing) or isokinetic stretch had a statistically significant effect on the excitability of the alphaMN in patients with muscle spasticity. This suggests that the previously reported reduction in spasticity after muscle stretch is because of mechanisms other than the direct effect on alphaMN. However, the lack of a demonstrable benefit of treatment may be due the fact that we examined the effects of a single, rather than repeated treatment cycles.

High scores on the Western Aphasia Battery correlate with good functional communication skills (as measured with the Communicative Effectiveness Index) in aphasic stroke patients.

OBJECTIVE: To examine the correlation between an impairment-level and a functional-level assessment scale of aphasia. DESIGN: Prospective, longitudinal study. SETTING: A stroke rehabilitation unit. SUBJECTS: Sixty-seven aphasic acute stroke patients who were undergoing a multi-disciplinary rehabilitation programme, including conventional speech and language therapy (SLT). INTERVENTION: Patients were assessed on study entry and 4, 8, 12 and 24 weeks after the start of SLT. The language impairment was assessed with the Western Aphasia Battery (WAB) and the communicative functional limitation associated with aphasia was measured with the Communicative Effectiveness Index (CETI).Results. There was a statistically significant correlation between the two scales for all assessment periods (Pearson's r=0.71; P<0.01). CONCLUSION: The study suggests that in the acute and subacute stages of stroke the scores of WAB and CETI can be surmised from one another.

Comparison of the impact of a single session of isokinetic or isotonic muscle stretch on gait in patients with spastic hemiparesis.

OBJECTIVE: To establish if isokinetic and isotonic muscle stretch (with or without weight-bearing) of the ankle plantar flexors improves gait in hemiplegic patients. A further aim was to compare the effectiveness of these treatment methods. DESIGN: A randomized, parallel group prospective study. SETTING: A stroke rehabilitation unit. SUBJECTS: Ambulatory hemiparetic stroke patients with mild to moderately severe muscle hypertonia of the lower limb and a group of healthy control subjects. INTERVENTION: Subjects were randomized to receive a single 20-min session of isokinetic muscle stretch or isotonic muscle stretch with or without weight-bearing. OUTCOME MEASURES: Selected kinematic, kinetic and spatio-temporal gait parameters were measured at baseline, immediately after the muscle stretch and 24 h later. RESULTS: Sixty-six patients and 21 healthy control subjects were recruited and completed the study. There were statistically significant differences between the patient groups and the healthy subjects on most of the gait parameters studied. However, the differences between the patient groups or between the three measurements over time for each type of muscle stretch did not reach statistical significance. CONCLUSIONS: A single session of isokinetic or isotonic muscle stretch (with or without weight-bearing) of the ankle plantar flexors has no clinically observable effect on the gait of hemiplegic stroke patients.

Supernumerary phantom limb after stroke.

The perception of a phantom limb is commonly reported after amputations. However, only a few cases have been described after a stroke. This article presents a patient who reported a supernumerary phantom limb (pseudopolymelia) after spontaneous intracerebral haemorrhage and discusses the possible underlying mechanisms for this rare phenomenon.

The beneficial antispasticity effect of botulinum toxin type A is maintained after repeated treatment cycles.

OBJECTIVE: To study the efficacy, safety, and incidence of BtxA antibody formation with repeated treatments with BtxA in post-stroke upper limb muscle spasticity. METHODS: The study was a prospective open label trial. Patients with established post-stroke upper limb spasticity received 1000 units of BtxA (Dysport) into five muscles of the affected arm on study entry. Treatment was repeated every 12, 16, or 20 weeks as clinically indicated. Each patient received a total of three treatment cycles. Efficacy of treatment was assessed using the Modified Ashworth Scale. Patients were assessed on study entry and on week 4 and 12 of each treatment cycle for all safety and efficacy parameters. Blood samples for BtxA antibody assay were taken at baseline and on completion of the trial. RESULTS: Fifty one patients were recruited and 41 of them completed the study. Improvement from the cycle one baseline was observed in all the outcome measures. Mild to moderately severe treatment related adverse events were reported in 24% of cases. There were no serious adverse events. No BtxA antibodies were detected. CONCLUSION: BtxA at a dose of 1000 units Dysport was efficacious in the symptomatic treatment of post-stroke upper limb spasticity. The study suggests that this effect can be maintained with repeated injections for up to at least three treatment cycles, with duration of effect per cycle of between 12 and 20 weeks. BtxA was safe in the dose used in this study and did not induce the formation of detectable levels of neutralising BtxA antibodies.

Drug treatment of poststroke aphasia.

Impairment of language function (aphasia) is one of the most common neurological symptoms after stroke. Approximately one in every three patients who have an acute stroke will suffer from aphasia. The estimated incidence and prevalence of stroke in Western Europe is 140 and 800 per 100,000 of the population. Aphasia often results in significant disability and handicap. It is a major obstacle for patients to live independently in the community. When recovery from aphasia occurs, it is usually incomplete and patients are rarely able to return to full employment and other social activities. Currently, the main treatment for aphasia is conventional speech and language therapy. However, the effectiveness of this intervention has not been conclusively demonstrated and empirical observations suggest that spontaneous biological recovery may explain most of the improvement in language function that occurs in aphasics. The generally poor prognosis of the severe forms of poststroke language impairment (Broca, Wernicke and global aphasia), coupled with the limited effectiveness of conventional speech and language therapy has stimulated the search for other treatments that may be used in conjunction with speech and language therapy, including the use of various drugs. Dopamine agonists, piracetam (Nootropil), amphetamines, and more recently donepezil (Aricept), have been used in the treatment of aphasia in both the acute and chronic phase. The justification for the use of drugs in the treatment of aphasia is based on two types of evidence. Some drugs, such as dextroamphetamine (Dexedrine), improve attention span and enhance learning and memory. Learning is an essential mechanism for the acquisition of new motor and cognitive skills, and hence, for recovery from aphasia. Second, laboratory and clinical data suggest that drug treatment may partially restore the metabolic function in the ischemic zone that surrounds the brain lesion and also has a neuroprotective effect following acute brain damage. An example of this is the nootropic agent piracetam. Extensive animal studies have demonstrated the beneficial effects of this and other drugs on neural plasticity, but data on humans are still sparse. This review provides a critical analysis of the current evidence of the effectiveness of these drugs in the treatment of acute and chronic aphasia.

Botulinum toxin in the management of childhood muscle spasticity: comparison of clinical practice of 17 treatment centres.

At least two randomized controlled trials (RCTs) have shown botulinum toxin type A (BtxA) to be efficacious and safe when used in the management of muscle spasticity in children. However, the need to use standard treatment protocols in these studies obscures some aspects of routine clinical practice that may have important effect on clinical outcomes. The purpose of this study was to seek additional information on the use of BtxA that is not usually captured by RCTs. This was performed by reviewing the clinical practice of practitioners in 17 treatment centres in Europe. The details of treatment with BtxA, including the dose, site and frequency of injections and the use of anaesthesia or sedation, were abstracted from the patient's records. Information was also obtained on the response to treatment and the occurrence and severity of adverse events. The data on 758 children who received a total of 1,594 treatments in 17 different clinics in Europe were analysed. Ninety-four per cent of patients had cerebral palsy. There was a general agreement on the indications for treatment but the average dose of BtxA used varied between centres. One treatment centre used general anaesthesia (GA) prior to injections in most patients. The reported efficacy and adverse events profile was similar for all centres. The evidence from routine clinical practice for the efficacy and safety of BtxA in the management of muscle spasticity in children, as described in this study, is in agreement with that of most of the open-label and RCTs published to date. The present study also demonstrates the disagreement between clinicians on the optimal dose of BtxA for individual muscles and confirms that the injections can be carried out without GA in almost all cases.

The relation between Ashworth scale scores and the excitability of the alpha motor neurones in patients with post-stroke muscle spasticity.

BACKGROUND: The modified Ashworth scale (MAS) is the most widely used method for assessing muscle spasticity in clinical practice and research. However, the validity of this scale has been challenged. OBJECTIVES: To compare the MAS with objective neurophysiological tests of spasticity. METHODS: The MAS was recorded in patients with post-stroke lower limb muscle spasticity and correlated with the excitability of the alpha motor neurones. The latter was evaluated by measuring the latency of the Hoffmann reflex (H reflex) and the ratio of the amplitude of the maximum H reflex (H(max)) to that of the compound action motor potential of the soleus muscle (M(max)). RESULTS: Data on 24 randomly recruited patients were analysed. Patients were divided into two groups according to their MAS score: 14 had a MAS score of 1 (group A) and 10 scored 2 (group B). The two groups were comparable with respect to age and sex, but in group A there was a longer period since the stroke. The H reflex latency was reduced and the H(max):M(max) ratio was increased in both groups. The H(max):M(max) ratio values were higher for group B but the differences were not statistically significant. CONCLUSIONS: There is a relation between the MAS scores and alpha motor neurone excitability, although it is not linear. This suggests that the MAS measures muscle hypertonia rather than spasticity.

Intra-rater and inter-rater reliability of gait measurements with CODA mpx30 motion analysis system.

Variations between measurements of clinical outcomes sometimes result from observer errors and are not due to the therapeutic intervention. For the correct interpretation of clinical data it is, therefore, important to ascertain the reliability of the measurement methods used. In the present study we evaluated the test-retest and between observer reliability of gait measurements with the Cartesian Optoelectronic Dynamic Anthropometer (CODA mpx30) motion analysis system. Our findings suggest a better intra-rater and inter-rater reliability of kinetic than kinematic data. Disagreements between the investigators were most marked for the kinematic data, especially the hip angle, and disagreements were least for the spatio-temporal gait parameters. The poor reproducibility of kinematic variables may be due to problems with the accurate placement of markers on the surface anatomical landmarks.

The effects of botulinum toxin treatment on associated reactions of the upper limb on hemiplegic gait--a pilot study.

PURPOSE: The involuntary movements of the paretic arm during ambulation and other motor activities are known as associated upper limb reactions (ARs). ARs occur in 80% of stroke patients with spastic hemiplegia and often interfere with balance and safe mobilization. It is hypothesized that the treatment of localized muscle spasticity with botulinum toxin type A (BtxA) would abolish the ARs and improve balance and mobility. METHOD: This hypothesis will need to be tested in a randomized controlled trial (RCT). The aim of the present pilot study is to obtain preliminary data to inform the design of a future RCT. Eight patients received a single injection of 500 units of BtxA (Dysport((R)) Ipsen, Ltd) into the biceps brachii of the paretic arm. The patients' balance and mobility were assessed before and 2, 4 and 6 weeks after treatment using observational gait analysis and other subjective assessment scales. RESULTS: There was a significant reduction of the ARs after treatment but this did not appear to improve the patients' balance or mobility as assessed by the clinicians. Interestingly, seven out of the eight patients reported improvement in their walking. CONCLUSION: The discrepancy between the observed and reported effects of treatment could be due to the poor sensitivity of the outcome measures used in this study.

A study of the gait characteristics of patients with chronic osteoarthritis of the knee.

PURPOSE: There is scant information at present on the effects of severe osteoarthritis (OA) of the knee joint on gait. In the present study the kinematic and kinetic parameters of gait and the pattern of activation of four lower limb muscles were examined during walking at a self-selected pace on level ground. The spatiotemporal parameters of gait were also computed. METHODS: Measurements were made using a three-dimensional optico-electronic motion analysis system integrated with a force plate and telemetered electromyography. RESULTS: Fifty-eight patients with severe OA of the knee and 25 age-matched healthy control subjects were examined. Patients demonstrated a significantly reduced walking speed, shorter stride length and a more prolonged stance phase of the gait cycle compared with the control subjects. They also had less range of motion at the hip, knee and ankle, joints and generated less moments and powers at the ankle and more moments at the knee than the control group. The differences were statistically significant for all parameters except the degree of ankle plantar flexion in stance. Activation of the rectus femoris muscle was prolonged in the patients group. CONCLUSIONS: It is concluded that the observed gait abnormalities were due to instability of the knee joint in stance. This may have important clinical implications for the rehabilitation of patients with severe OA of the knee.