Does the addition of virtual reality training to a standard program of inpatient rehabilitation improve sitting balance ability and function after stroke? Protocol for a single-blind randomized controlled trial.

BACKGROUND: Sitting ability and function are commonly impaired after stroke. Balance training has been shown to be helpful, but abundant repetitions are required for optimal recovery and patients must be motivated to perform rehabilitation exercises repeatedly to maximize treatment intensity. Virtual reality training (VRT), which allows patients to interact with a virtual environment using computer software and hardware, is enjoyable and may encourage greater repetition of therapeutic exercises. However, the potential for VRT to promote sitting balance has not yet been explored. The objective of this study is to determine if supplemental VRT-based sitting balance exercises improve sitting balance ability and function in stroke rehabilitation inpatients. METHODS/DESIGN: This is a single-site, single-blind, parallel-group randomized control trial. Seventy six stroke rehabilitation inpatients who cannot stand independently for greater than one minute but can sit for at least 20 minutes (including at least one minute without support) are being recruited from a tertiary-care dedicated stroke rehabilitation unit. Participants are randomly allocated to experimental or control groups. Both participate in 10-12 sessions of 30-45 minutes of VRT performed in sitting administered by a single physiotherapist, in addition to their traditional therapy. The experimental group plays five games which challenge sitting balance while the control group plays five games which minimize trunk lean. Outcome measures of sitting balance ability (Function in Sitting Test, Ottawa Sitting Scale, quantitative measures of postural sway) and function (Reaching Performance Scale, Wolf Motor Function Test, quantitative measures of the limits of stability) are administered prior to, immediately following, and one month following the intervention by a second physiotherapist blind to the participant's group allocation. DISCUSSION: The treatment of sitting balance post-stroke with VRT has not yet been explored. Results from the current study will provide important evidence for the use of low-cost, accessible VRT as an adjunct intervention to increase sitting balance in lower-functioning patients receiving inpatient rehabilitation. The motivating and enjoyable attributes of VRT may increase exercise dosage, leading to improved function and optimal results from rehabilitation. TRIAL REGISTRATION: https://clinicaltrials.gov/; Identifier: NCT02285933. Registered 06 November 2014. Funded by the Heart & Stroke Foundation of Canada and a generous donation from Tony & Elizabeth Graham.

Energy and protein intakes of acute stroke patients.

BACKGROUND: Although protein-energy malnutrition has been cited as a frequent complication following stroke, there is very little data describing nutritional intake among hospitalized patients. OBJECTIVE: To report: i) the level of protein and energy intake, ii) the adequacy of intake during the first 21 days of hospitalization and iii) to examine the differences in nutritional intake associated with diet type (regular texture, texture-modified and enteral feeding). DESIGN: Prospective observational study of an inception cohort. The energy and protein intakes of well-nourished patients with recent onset of first time stroke were assessed at admission to hospital and at days 7, 11, 14 and 21. Adequacy of energy intake at each of these intervals was expressed as a percentage (actual intake/energy requirement assessed by indirect calorimetry x 100). Adequacy of protein intake was assessed in a similar manner, with 1 g/kg of actual or adjusted body weight used to estimate requirement. The nutritional intakes of patients receiving regular diets, dysphagia diets and enteral tube feedings were compared using one-way ANOVA. RESULTS: The average energy intakes of the entire study group ranged from 19.4-22.3 Kcals/kg/day over five observation points, representing 80.3-90.9% of measured requirements; protein intake and ranged from 0.81-0.90 g/kg day yielding adequacy of intake of 81-90% of requirement. There were significant differences in energy intakes and/or adequacy of intake of patients receiving different diet types at days 11, 14 and 21 (p < 0.05) and differences in protein intake and/or adequacy of protein intake at all intervals except admission (p < 0.05). Patients receiving enteral tube feedings consumed more calories and protein compared to those patients on regular or dysphagia diets. CONCLUSIONS: On average, newly diagnosed, well-nourished, hospitalized patients consumed 80-91% of their both their energy and protein requirements, in the early post stroke period.

Benefits of activity and virtual reality based balance exercise programmes for adults with traumatic brain injury: perceptions of participants and their caregivers.

OBJECTIVE: To explore multi-dimensional benefits of exercise participation perceived by adults with traumatic brain injury (TBI) and their caregivers. METHODS: Adults (n=27, aged 18-66) with moderate or severe TBI 6 months or more earlier participated in focus groups following 6 weeks of an activity-based (ABE) or a virtual reality (VR) delivered balance exercise programme. Family members and care providers participated in separate focus groups. Perceptions related to programme participation as well as balance confidence and lower extremity function were extracted from focus group verbatim and quantitative scales, respectively. OUTCOMES: Benefits in three domains, psychosocial, physical and programme, were identified from transcription and analyses of focus group verbatim. Improvements were noted in balance confidence and function in both groups. Substantially greater enthusiasm and knowledge was expressed by participants in the VR group and their caregivers. CONCLUSIONS: Both exercise programmes offered benefits in addition to improved balance. The VR participants had greater improvements on quantitative measures and provided more comments expressing enjoyment and improved confidence. Applications in terms of community reintegration and quality of life are discussed.

Outcomes of intervention programs using flatscreen virtual reality.

Virtual reality (VR) has the potential to offer experiences which are engaging and rewarding. In VR, the focus is shifted from the person's efforts in producing a movement or completing a task to that of interaction with the virtual environment. We have found that participants place value and meaning on and enjoy the activities programmed. Virtual reality interventions have been shown to improve cognitive function and concentration through an individual's interaction with a pleasant activity. Importantly, the enjoyment experienced while working with VR may increase the level of participation. In addition to generating realistic situations for testing, intervention and collection of data, the provision of immediate and positive feedback through VR has been shown to increase self esteem and empowerment. We will report outcomes from several intervention and feasibility trials using a flat screen virtual reality system with survivors of traumatic brain injury, community living older adults and children with spastic cerebral palsy. Gross motor movements were elicited through various game-like VR applications without the need for head-mounted displays or other peripherals. The impact of VR exercise participation ranged from improvements in clinical measures of functional balance and mobility, time on task, as well as participant and care provider perceptions of enjoyment, independence and confidence. Although still preliminary, our data suggest that simple applications of virtual reality have significant impacts on physical and psychosocial variables. Possibilities for and benefits of home and community-based access to virtual reality based programs will be explored.

Quantifying fluid intake in dysphagic stroke patients: a preliminary comparison of oral and nonoral strategies.

OBJECTIVE: To determine whether dysphagic stroke patients receiving oral (thickened-fluid dysphagia) diets or nonoral (enteral feedings supplemented with intravenous fluids) diets met their estimated fluid requirements. DESIGN: Cohort study. SETTING: University-affiliated hospital. PARTICIPANTS: Thirteen dysphagic patients with new strokes were studied for 21 days postadmission to hospital. INTERVENTIONS: Seven patients (group 1) were started on nonoral feeding and later progressed to oral diets and 6 patients (group 2) received oral dysphagia diets only. MAIN OUTCOME MEASURE: Fluid intake. RESULTS: Fluid intake of patients in group 1 significantly declined over the 21 days (mean +/- standard deviation, 3158 +/- 523mL/d vs 984 +/- 486mL/d; p < .0001), representing 134% +/- 26% and 43% +/- 20% of their fluid requirements, respectively. Mean fluid intake of patients in group 2 was 755 +/- 162mL/d, representing 33% +/- 5% of requirements. This volume was significantly lower than the fluid intake of patients who received nonoral feeding (p < .0001). CONCLUSIONS: Dysphagic stroke patients who received thickened-fluid dysphagia diets failed to meet their fluid requirements whereas patients on enteral feeding and intravenous fluid regimens received ample fluid.

Use of percutaneous gastrojejunostomy feeding tubes in the rehabilitation of stroke patients.

OBJECTIVE: To determine the characteristics of and complications in the rehabilitation of stroke patients in whom percutaneous gastrojejunostomy (PGJ) feeding tubes have been placed. DESIGN: Retrospective cohort study. SETTING: A rehabilitation unit in a tertiary care hospital. PARTICIPANTS: Stroke patients (n = 563) admitted to a tertiary care hospital over a 10-year period. INTERVENTION: PGJ feeding tubes. MAIN OUTCOME MEASURES: Evidence of aspiration in all videofluoroscopic modified barium swallow (VMBS) studies was noted. For patients with a PGJ feeding tube, the following were recorded: stroke location; results of subsequent VMBS reports; length of time from stroke onset to PGJ feeding tube insertion; total time the PGJ feeding tube remained in situ; discharge disposition; and concurrent feeding status. Follow-up was at 1-year poststroke. Complications during the inpatient stay attributable to the PGJ feeding tube were recorded. RESULTS: Thirty-two of all 563 (5.7%) stroke patients admitted and 28 of the 115 (24.3%) proven aspirators, as shown on VMBS studies, had a PGJ feeding tube inserted. Twenty-one of the 563 (3.7%) stroke patients were discharged to the community with PGJ feeding tubes in place. The tubes were inserted on average 37 days after stroke onset. Seventeen of all 88 (19.3%) brainstem stroke patients and 15 of all 29 (51.7%) brainstem stroke patients with documented aspiration had feeding tubes inserted, whereas only 15 of 475 (3.2%) hemispheric stroke rehabilitation patients received a tube. Eleven of 32 (34.3%) patients with a feeding tube were able to resume oral feedings at discharge; within 1 year of discharge, 24 of 32 (75%) had done so. Although there were no serious complications resulting from tube insertions, minor complications were documented in more than 50% of the cases. The tubes were associated with prolonged institutionalization in only 1 case; most patients were discharged on a home tube-feeding program. CONCLUSIONS: PGJ feeding tubes were placed in approximately 1 of every 20 of our stroke rehabilitation patients. One third of the tubes were removed before the patients were discharged from rehabilitation and 75% were removed within 1 year. Insertion of the tubes was most common in patients with evidence of aspiration and in patients with brainstem strokes. Complications caused by the tube were minor and all patients but 1 who were discharged with feeding tubes were able to manage the home tube-feeding program.

Chronic pain and health care utilization in women with a history of childhood sexual abuse.

OBJECTIVE: This cross-sectional controlled study investigated the association between chronic pain, health care utilization and a history of childhood sexual abuse. SUBJECTS: Three groups, constituting 80 women in total, were studied (1) attendees at group therapy for individuals who had experienced childhood sexual abuse (n = 26); (2) Two control groups consisting of nonabused (a) psychiatric outpatients (n = 33); and (b) nurses (n = 21). SETTING: The setting was a university affiliated community and tertiary care hospital in London. Ontario. OUTCOME MEASURES: Each subject voluntarily completed questionnaires documenting history of childhood abuse, pain, psychological symptomatology and medical and surgical history. RESULTS: Sixty-nine percent of the women who had experienced childhood sexual abuse reported a chronic painful condition lasting more than three months, compared to 43% of the combined control groups (p = .026). Women who had experienced childhood sexual abuse reported a greater number of painful body areas (p = .003), more diffuse pain and more diagnoses of fibromyalgia (p = .013). They had more surgeries (p = .037), hospitalizations (p = .0004) and family physician visits (p = .046). CONCLUSIONS: Women with a history of childhood sexual abuse reported more chronic pain symptoms and utilized more health care resources compared to nonabused control subjects. Identification of such a history in the patient experiencing persisting pain may be the first step toward a successful combination of medical and psychosocial interventions.

Social issues in the rehabilitation of younger stroke patients.

OBJECTIVES: To study social factors and outcomes in stroke rehabilitation patients under the age of 50. STUDY DESIGN: Retrospective chart review examining (1) martial status and employment status on admission and at 3 months post discharge, (2) discharge destination, (3) the presence of absence of children under the age of 16, and (4) psychosocial difficulties as recorded by staff during hospitalization. SUBJECTS AND SETTING: Eighty-three consecutive stroke patients under the age of 50 admitted to a Canadian tertiary-care hospital rehabilitation unit. MAIN OUTCOME MEASURES: Discharge destination and primary caregiver at discharge, and return to work and marital separation 3 months after rehabilitation discharge. RESULTS: Of the 55 patients with spouses, 8 (14.5%) separated within 3 months of hospital discharge. Fifteen of the 83 patients (18.1%) were not able to return to their premorbid place of residence; 4 (4.8%) required institutionalization. Of the 64 patients employed outside the home or studying at the time of their stroke, only 13 (20.3%) were able to return to work within 3 months of their discharge to home. Only 9.4% of those working full-time were able to return to full-time employment. CONCLUSIONS: Rehabilitation of young stroke patients is associated with a variety of social problems, including marital breakup, child care responsibilities, and return to employment, which are uniquely important in this age group.

Hypofrontality and negative symptoms in patients with dementia of Alzheimer type.

OBJECTIVE: The purpose of the current study was to examine the relation between regional cerebral blood flow (rCBF) and negative symptoms (NS) in patients with dementia of Alzheimer type (DAT). BACKGROUND: Negative symptoms in neuropsychiatric disorders were associated with altered rCBF in frontal cortex. METHODS: Twenty-five subjects with a diagnosis of DAT were administered the Scale for the Assessment of Negative Symptoms (SANS), the Positive and Negative Symptom Scale, the Hamilton Rating Scale for Depression, and the Mini-Mental State Examination. The subjects were divided into two groups by means of a median split with regard to NS severity (high NS group, N = 12; low NS group, N = 13). Each patient underwent a single photon emission tomography scan using 99mTc-HMPAO at rest. Cortical and subcortical regions of interest were symmetrically defined in each hemisphere. Cortical-to-cerebellar perfusion ratios were established quantitatively using ADAC software. RESULTS: High NS group subjects had a significantly lower rCBF than low NS group subjects in the frontal cortex and cingulate gyrus (MANOVA: p = 0.022) as a result of differences in the dorsolateral prefrontal cortex bilaterally (right: F = 12.12, p = 0.002; left: F = 6.55, p = 0.02) and in the frontal cortex, mainly in the right hemisphere (right: F = 6.33, p = 0.02; left: F = 3.26, p = 0.08). For all the subjects (N = 25), there were negative correlations between the SANS total score and rCBF, most prominently in the dorsolateral prefrontal cortex bilaterally (right: r = -0.48, p <0.01; left: r = -0.49, p = 0.01). No significant correlation was found between rCBF in any of the regions of interest and either the Mini-Mental State Examination or the Hamilton Rating Scale for Depression scores. CONCLUSIONS: This study indicates that decreased perfusion in the frontal cortex is associated with NS severity but not with measures of cognitive impairment or depressive symptoms in DAT patients. These results support the hypothesis that the frontal lobes may be involved in the cause of NS in DAT, and they underscore the importance of NS evaluation in neuroimaging studies.

Frequency of videofluoroscopic modified barium swallow studies and pneumonia in stroke rehabilitation patients: a comparative study.

OBJECTIVE: To study the association between the frequency of videofluoroscopic modified barium swallow (VMBS) studies and the incidence of pneumonia in stroke rehabilitation patients. DESIGN: Retrospective comparative study. SUBJECTS AND SETTING: Five hundred sixty-three consecutive stroke patients admitted to one hospital rehabilitation unit in London, Ontario, Canada were compared with 461 consecutive stroke patients admitted to another hospital rehabilitation unit in the same city. INTERVENTIONS: The number of initial and total VMBS studies and the timing from stroke onset to initial VMBS studies. MAIN OUTCOME MEASURE: Incidence of pneumonia. RESULTS: At the first hospital, 146 patients (25.9%) had 232 total VMBS studies performed, whereas at the second hospital 57 patients (12.4%) had 73 total studies (p<.001). For the first 15 days there was no significant difference in the number of initial VMBS studies performed (8.2% vs. 9.2%). There was a marked difference in the number of initial VMBS studies performed after 15 days (17.2% vs. 2.0%, p<.0001). The difference between the hospitals in the number of VMBS studies in patients with brain stem strokes was not statistically significant, but for patients with hemispheric stroke, the difference was statistically significant. Pneumonia developed in 12 patients at the first hospital (2.1%) and 10 patients at the second hospital (2.2%), a difference that was not significant. CONCLUSIONS: The more frequent use of VMBS beyond 15 days after stroke was not associated with a change in the incidence of pneumonia among hemispheric stroke rehabilitation patients, assuming the two units were otherwise similar.

Sudden death in the dysphagic stroke patient--a case of airway obstruction caused by a food bolus: a brief report.

The clinical events leading up to the sudden death of a dysphagic stroke patient with dementia is described. A 63-yr-old man sustained right thalamic and mid-brain infarctions. On the inpatient stroke rehabilitation ward, he exhibited significant impulsivity and dementia, the latter felt to be premorbid. The patient frequently coughed, and modified barium swallow testing showed dysphagia, with aspiration occurring only when consuming greater than teaspoon amounts of liquid. He subsequently died at home while eating a meal. Autopsy showed an intact large cheese ball (bocconcini) occluding the airway. Sudden death in the impulsive stroke patient secondary to airway occlusion by a food bolus has not previously been reported, although such patients seem to be at greater risk. New eating-related interventions are warranted for dysphagic patients who exhibit impulsivity. It is proposed that food particle size be limited to 1 cm2 and that such patients be closely monitored while eating.

[Surgical treatment results in patients with severe forms of the carpal tunnel syndrome]. / Rezul'taty khirurgicheskogo lecheniia bol'nykh s tiazhelymi formami sindroma zapiastnogo kanala.

A retrospective and prospective study was undertaken to determine efficacy of carpal tunnel decompression in patients with advanced carpal tunnel syndrome (CTS). The criteria for inclusion in this study were clinical and nerve conduction studies (NCS). Between 1985-1991, 1511 NCSs performed were positive for CTS.

Hypofrontality and negative symptoms in major depressive disorder.

UNLABELLED: The purpose of the current study was to compare regional cerebral blood flow (rCBF) in patients with major depressive disorder (MDD) to that of healthy subjects and to examine the relationship between rCBF, depressive symptoms (DS) and negative symptoms (NS) in these patients. METHODS: Eleven psychiatric inpatients with diagnosed (MDD) and 15 normal control subjects were administered the scale for the assessment of negative symptoms (SANS) and the modified Hamilton rating scale for depression with items descriptive of NS excluded (HRSD-DS). Each patient underwent a SPECT scan using 99mTc-HMPAO at rest. Cortical and subcortical regions of interest (ROIs) were symmetrically defined in each hemisphere. Cortical-to-cerebellar perfusion ratios were established quantitatively using ADAC software. RESULTS: Subjects in the MDD group had significantly lower rCBF in the frontal cortex and cinglulate gyrus (MANOVA, p = 0.038) due to differences in dorsolateral prefrontal cortex bilaterally (right F = 7.69, p = 0.01; left F = 8.41, p = 0.01) in the right orbitofrontal cortex (F = 6.79, p = 0.02) and in the cingulate gyrus (F = 5.34, p = 0.03). The MDD group also had lower rCBF in the posterior cortical structures (MANOVA, p = 0.072), which was due to decreased perfusion in the right parietal cortex (F = 7.54, p = 0.01). There were negative correlations between the SANS total score and rCBF in both the left dorsolateral prefrontal cortex (Pearson's correlation coefficient r = .-67, p < 0.05) and the left anterior temporal cortex (r = -0.71, p < 0.01) in MDD patients. Additionally, there were positive correlations between HRSD scores and rCBF in the left anterior temporal (r = 0.71, p < 0.01), left dorsolateral prefrontal (r = 0.70, p < 0.01), right frontal (r = 0.82, p < 0.01) and right posterior temporal (r = 0.74, p < 0.01) cortices. Cerebral blood flow was not correlated with either mini-mental state examination scores or age. CONCLUSION: This preliminary study replicates the finding of hypofrontality in MDD and indicates that decreased perfusion is associated specifically with negative symptom severity. These results support the hypothesis that, in MDD, negative symptoms and symptoms of depression are distinct phenomena and underscore the importance of negative symptom evaluation in neuroimaging studies of MDD and other disorders.

Gallium scanning in the 'new' tuberculosis.

PURPOSE: To evaluate the findings and usefulness of Ga-67 scanning in recent cases of tuberculosis (TB). MATERIALS AND METHODS: The authors reviewed chest x-ray films and Ga-67 citrate scans of 52 patients with culture-confirmed infection caused by Mycobacterium tuberculosis treated after 1988. RESULTS: Ga-67 scans were positive in every case, delineating upper lobe lung lesions in 6 patients, diffuse involvement or lower lobe disease in 34 patients, and intrathoracic adenopathy in 15 patients. Pulmonary parenchymal lesions were not detected on x-ray films in 3 patients, and nodal lesions were not apparent in 3 patients. In addition, in 6 patients cervical adenopathy was detected by Ga-67 scintigraphy; 4 underwent biopsy with culture confirmation. CONCLUSIONS: Ga-67 scanning is more sensitive than routine chest radiography for detection of both TB parenchymal lung involvement and adenopathy. Ga-67 imaging facilitates the choice of biopsy sites by identifying accessible peripheral nodes. Typical patterns in recent cases of TB differ significantly from the upper lobe predilection of classical TB.

ECT treatment and cerebral perfusion in Catatonia.

A 40-yr-old woman with a diagnosis of schizoaffective disorder developed catatonia in the context of a depressive episode. A dramatic decrease in perfusion of the inferior frontal, posterior temporal and parietal lobes bilaterally and in posterior frontal lobes corresponding to the motor cortices was noted on the 99mTc-HMPAO SPECT scan obtained in the acute phase. The most dramatic decreases compared to normal control subjects were observed in the left parietal and left motor cortices. The patient was treated with a five-treatment course of electroconvulsive therapy (ECT), which resulted in a complete resolution of catatonia and some resolution of her symptoms of depression. The repeat HMPAO-SPECT scan showed improved perfusion in all areas. The most dramatic increases occurred in the left parietal and left motor cortices. Decreased perfusion in motor and parietal cortices could be state-specific to catatonia. Thus, SPECT imaging may be a useful method for monitoring catatonia treatment response.