Bodyweight-supported treadmill training for retraining gait among chronic stroke survivors: A randomized controlled study.

OBJECTIVE: To evaluate the role of bodyweight-supported treadmill training (BWSTT) for chronic stroke survivors. DESIGN: Prospective, randomized controlled study. METHODS: Patients with a first episode of supratentorial arterial stroke of more than 3months' duration were randomly allocated to 3 groups: overground gait training, treadmill training without bodyweight support, and BWSTT (20 sessions, 30min/day, 5days/week for 4weeks). The primary outcome was overground walking speed and endurance and secondary outcome was improvement by the Scandinavian Stroke Scale (SSS) and locomotion by the Functional Ambulation Category (FAC). We analyzed data within groups (pre-training vs post-training and pre-training vs 3-month follow-up) and between groups (at post-training and 3-month follow-up). RESULTS: We included 45 patients (36 males, mean post-stroke duration 16.51±15.14months); 40 (89.9%) completed training and 34 (75.5%) were followed up at 3months. All primary and secondary outcome measures showed significant improvement (P<0.05) in the 3 groups at the end of training, which was sustained at 3-month follow-up (other than walking endurance in group I). Outcomes were better with BWSTT but not significantly (P>0.05). CONCLUSION: BWSTT offers improvement in gait but has no significant advantage over conventional gait-training strategies for chronic stroke survivors.

Rehabilitation interventions to improve locomotor outcome in chronic stroke survivors: A prospective, repeated-measure study.

OBJECTIVE: To ascertain whether rehabilitation interventions improve locomotion beyond 6 months post stroke. Site: The Neurological Rehabilitation Department of a university tertiary research hospital. STUDY DESIGN: Prospective, repeated-measure study. PATIENTS: Patients with first episode of supra-tentorial stroke of more than 6 months duration. INTERVENTION: Twenty sessions of task-specific interventions consisting of lower limb resistive exercises and treadmill gait training to locomotor abilities (90 min/day, 5 days/week for 4 weeks). Evaluations were performed at the beginning and end of training and at a follow-up of 3 months. OUTCOME MEASURES: Stroke severity (Scandinavian Stroke Scale - SSS), balance (Berg Balance scale - BBS), ambulation (Functional Ambulation Category), walking ability (speed 10-m walk test - WS) and functional ability (Barthel Index - BI). RESULTS: Forty patients (32 men and eight women; age range: 22-65 years; mean post-stroke duration of 18.90 ± 12.76 months) were included in the study. Thirty-two (80.0%) patients completed their training and 28 (70.0%) patients reported at a follow up of 3-months. At the beginning, the end of training and at follow-up, the mean SSS scores were 41.71, 44.09, and 43.96; the BBS scores were 36.28, 46.75 and 46.82; the WS scores were 0.41, 0.53 and 0.51; and the BI scores were 77.34, 89.06 and 92.32, respectively. All outcome measures showed statistically significant improvement (P < 0.001) at the end of training and at follow-up. CONCLUSION: Rehabilitation interventions significantly improve locomotor outcome even in the chronic phase following a stroke.

Post-stroke depression: prevalence and relationship with disability in chronic stroke survivors.

OBJECTIVES: To evaluate (1) the prevalence of operationally defined depressive disorder (ICD-10) in chronic stroke subjects and (2) the relationship of post-stroke depression (PSD) with disability. DESIGN: Cross-sectional, descriptive study. SETTING: Neurological rehabilitation unit of a tertiary care university research center. MATERIALS AND METHODS: Participants were those with first episode of supratentorial stroke of more than 3 months' duration with impaired balance and gait who had been referred for rehabilitation. Data were collected on demographic data, stroke data (side and type of lesion and post-stroke duration), cognition (mini mental state examination), depressive ideation (Hamilton Depression Rating Scale - HRDS), impairment (Scandinavian Stroke Scale), balance (Berg Balance Scale), ambulatory status (Functional Ambulation Category), walking ability (speed), and independence in activities of daily living (Barthel Index). Statistical analysis was done using SPSS 13.0. We carried out the chi-square test for ordinal variables and the independent t test for continuous variables. RESULTS: Fifty-one patients (M:F: 41:10) of mean age 46.06 +/- 11.19 years and mean post-stroke duration of 467.33 +/- 436.39 days) were included in the study. Eighteen of the 51 participants (35.29%) met the criteria for depression. Demographic variables like male gender, being married, living in a nuclear family, urban background, and higher HRDS score were significantly correlated with PSD (P < 0.05). Depression was related to functional disability after stroke but to a statistically insignificant level (P > 0.05) and was unrelated to lesion-related parameters. CONCLUSION: Depression occurs in one-third of chronic stroke survivors and is prevalent in subjects referred for rehabilitation. PSD is related primarily to demographic variables and only to a lesser extent to functional disability following stroke.

Guillain-Barre Syndrome – rehabilitation outcome, residual deficits and requirement of lower limb orthosis for locomotion at 1 year follow-up.

OBJECTIVE: To analyse long-term functional recovery, deficits and requirement of lower limb orthosis (LLO) for locomotion in patients with Guillain-Barre Syndrome (GBS). DESIGN: Prospective longitudinal follow-up study. SETTING: Neurological Rehabilitation unit of university hospital. PATIENTS AND METHOD: Sixty-nine patients of GBS admitted for inpatient rehabilitation. Thirty-five patients (M:F, 19:16) reporting after 1 year follow-up (50.72%) were included in study (between September 2005 and July 2009). Their residual deficits and requirement of LLO were recorded and analysed. RESULTS: Age ranged from 4 to 65 year (29.74 ± 15.75). Twenty-seven patients had typical GBS and eight patients had acute motor axonal neuropathy variant. Twenty-eight patients (80%) had neuropathic pain needing medication with 11 required more than one drug. Twenty-one patients (60%) had foot drop and advised ankle-foot orthosis-AFO (20 bilateral AFO). Thirty patients (85.71%) needed assistive devices also for locomotion at discharge. After 1 year, foot drop was still present in 12 patients (34.28%) using orthosis. Modified Barthel Index scores, Modified Rankin Scale and Hughes Disability Scale were used to assess functional disabilities. Significant recovery was observed at the time of discharge and after 1 year (p < 0.001 each). CONCLUSIONS: Patients with GBS continue to show significant functional recovery for long period. They have residual deficits even after 1 year with requirement of orthosis in large number of patients.

Catatonia and multiple pressure ulcers: A rare complication in psychiatric setting.

The incidence of pressure ulcers in patients with psychiatric illness, especially with catatonia might be more than what is reported in the literature. We report a case of catatonia secondary to severe depression presenting with multiple pressure ulcers. Single case report - description and management. An 18 yrs old boy reported with a continuous course illness characterized by features of catatonia secondary to severe depression with multiple pressure ulcers over sacrum and heels. Ulcers were effectively managed by a multidisciplinary team of physiatrist, psychiatrist, and rehabilitation nurses. Immobility, reduced nocturnal movements, increased skin fragility, and poor nutrition contribute to the development of the pressure ulcer in bed-bound psychiatric patients. Efforts should be directed toward the prevention of pressure ulcers in these patients to reduce additional morbidity.

Post-stroke balance training: role of force platform with visual feedback technique.

OBJECTIVE: To evaluate the role of balance training on Force Platform with Visual Feedback technique (FPVF) in improving balance and functional outcome in chronic stroke survivors. DESIGN: Prospective, repeated measure study. SETTINGS: Neurological rehabilitation department of a tertiary research center. PARTICIPANTS: First episode of supra-tentorial stroke with more than 3 months duration, ability to follow 3 step commands, and impaired balance and gait with ability to walk independently or with one person support (Functional Ambulation Category II-IV). INTERVENTIONS: Training on "Balance Master" for 20 sessions (20 min/day, 5 days/week for 4 weeks). OUTCOME MEASURES: Balance on Berg Balance Scale, Balance Index and Limits of Stability scores, walking ability on over ground walking speed, and functional ability on Barthel Index. Evaluation was done pre- and post-training and at 3 months follow-up. Statistical analysis was done by Paired t test on SPSS 13.0. RESULTS: Forty five patients (M:W: 36:9, age range: 22-65 years, mean post-stroke duration of 16.51+/-15.14 months) were included. Forty (89.9%) subjects completed training and all primary and secondary outcome measures showed statistically significant improvement (p<0.000) at the end of training. Thirty-four (75.6%) subjects were followed up and statistically significant improvement (p<0.000) was maintained for all outcome measures. CONCLUSION: Balance training by FPVF technique significantly improves balance and functional outcome even in chronic phase after stroke. Large scale, controlled studies are recommended.

Surgical management of pressure ulcers during inpatient neurologic rehabilitation: outcomes for patients with spinal cord disease.

BACKGROUND/OBJECTIVE: To study efficacy of surgery in the management of pressure ulcers and evaluate the effect of simultaneous comprehensive rehabilitation in improving outcome. METHOD: Prospective, follow-up study. SETTING: Neurologic rehabilitation unit of a tertiary care center. PARTICIPANTS: Patients with spinal cord diseases who had stage III/IV pressure ulcers underwent surgical reconstruction and inpatient rehabilitation in 2005 with a minimum follow-up duration of 1 year. OUTCOME MEASURES: Ulcer healing rate, postoperative complications, ulcers recurrence rate, and neurologic (ASIA grade), and functional recovery (Barthel Index). STATISTICAL ANALYSIS: Frequency analysis and paired t test on SPSS 13.0. RESULTS: Surgical intervention was carried out in 25 participants (19 men, 6 women), having a total of 39 ulcers (13 Stage III, 23 Stage IV, 3 unstaged). Surgeries performed were debridement (3), split skin grafting (13), and flap mobilization and closure (23). Only 4 participants (16.6%) had initial complications: wound dehiscence (2) and delayed graft healing (2). Follow-up rate was 92.0% (23/25 patients), with a duration of 12 to 21 months (mean, 15.4 +/- 7.45 months), and only 4 participants (17.3%) had ulcer recurrence. The majority of participants (13 of 25; 56.5%) improved neurologically on ASIA grade and functional evaluation on Barthel Index, suggesting statistically significant improvement (P < 0.005). CONCLUSIONS: All outcome variables showed significant improvement at follow-up with good ulcer healing rate (87.0%), low initial complication (16.6%) and recurrence rates (17.3%), and good neurologic (56.5%) and functional (P < 0.005) recovery. Timely surgical interventions are necessary for Stage III to IV pressure ulcers, and simultaneous inpatient rehabilitation significantly improves outcome of patients with spinal cord disease.

Stroke with supernumerary phantom limb: case study, review of literature and pathogenesis.

OBJECTIVE: Constitute hypothesis for origin of supernumerary phantom limb (SPL) after stroke. METHOD: Single case description, review of literature and formulation of hypothesis. RESULTS: A 59-year-old lady was evaluated for complaints of left-sided hemiparesis and extra limbs attached to her left shoulder for the past 7 months. Neuropsychological assessment revealed left hemineglect with SPL, and profile suggested bilateral frontal, right parietotemporal and basal ganglia involvement. Magnetic resonance imaging brain scan showed gliotic cavity secondary to the old haematoma in right putamen with white matter changes in the right frontoparietotemporal lobes. CONCLUSIONS: The conceptual framework of body schema can be used to classify many of the neurological disorders of body representation. Generation of SPL comes under the subtype of pathology of updating among the disorders of body schema. The continuous updating allows the body schema to modulate perceptual processing of objects according to their position in space. Brain areas classified as parts of motor system can, under pathological conditions (haemorrhage), influence body perception. So, when she used to move her arm, the representation of the estimated position was not updated by the motor commands. Sensory and motor information therefore becomes discrepant, and failure to integrate these two sources of information leads to loss of normal coherence, and the perceived shape of the body was altered by adding a SPL to accommodate the discrepancy.

Single-stage multilevel soft-tissue surgery in the lower limbs with spastic cerebral palsy: Experience from a rehabilitation unit.

BACKGROUND: To assess the effect of single-stage multilevel soft-tissue surgery (Single Event Multiple Level Resections, SEMLR) on deformities and locomotion in patients with cerebral palsy (CP) with static contracture(s) in lower limbs. PATIENTS AND METHODS: Study included 34 patients (M:F, 23:11) with mean age of 9.53 +/- 3.92 years (4-16 years). Among them 22 had diplegia and four each had quadriplegia and right and left hemiplegia. Fourteen patients (41.2%) had their intelligence quotient (IQ) in the normal range (IQ >/= 80), while others had mental retardation (MR) of varying severity: borderline MR (IQ = 70-79) in 12, mild MR (IQ = 50-69) in 5, and moderate MR (IQ = 35-49) in patients 3. All patients underwent surgery (total number of procedures 153, average 4.5 procedures/patient) over a period of 30 months (April 2005 to September 2007). Improvement in functional abilities and locomotion was assessed using Gross Motor Functional Classification Scale (GMFCS) scores and by physical examination. RESULTS: Significant improvement in function was observed (P = 0.000) after surgery when comparing the preoperative and postoperative GMFCS scores. All patients were maintaining ambulation at a mean follow-up duration of 13.12 +/- 6.07 months (3-24 months), with five patients using knee-ankle-foot orthoses (KAFO), 22 using ankle-foot orthoses (AFO), and six patients using knee gaiters. Sixteen patients were using walker, and two were using crutches as assistive devices. CONCLUSION: This study suggests that CP patients with good trunk control and static contractures at multiple joints in the lower limbs can be made ambulant with single-stage multilevel soft-tissue surgery. It has to be a team effort of the surgeon and the rehabilitation team in the postoperative period for the attainment of satisfactory goal.

Efficacy of multiwavelength light therapy in the treatment of pressure ulcers in subjects with disorders of the spinal cord: A randomized double-blind controlled trial.

OBJECTIVE: To study the efficacy of multiwavelength light therapy in the treatment of pressure ulcers in subjects with spinal cord disorders. DESIGN: Randomized controlled trial. SETTING: Neurologic rehabilitation ward of a referral center in India. PARTICIPANTS: Thirty-five subjects with spinal cord injury, with 64 pressure ulcers (stage 2, n=55; stage 3, n=8; stage 4, n=1), were randomized into treatment and control groups. One subject refused consent. Mean duration of ulcers in the treatment group was 34.2+/-45.5 days and in the control group, 57.1+/-43.5 days. INTERVENTIONS: Treatment group received 14 sessions of multiwavelength light therapy, with 46 probes of different wavelengths from a gallium-aluminum-arsenide laser source, 3 times a week. Energy used was 4.5 J/cm(2). Ulcers in the control group received sham treatment. MAIN OUTCOME MEASURES: Healing of the ulcer, defined as the complete closure of the wound with healthy scar tissue, time taken for the ulcer to heal, and stage of the ulcer and Pressure Sore Status Tool score 14 days after last treatment. RESULTS: There was no significant difference in healing between the treatment and control groups. Eighteen ulcers in treatment group and 14 in control group healed completely ( P =.802). Mean time taken by the ulcers to heal was 2.45+/-2.06 weeks in the treatment group and 1.78+/-2.13 weeks in the control group ( P =.330). Time taken for stage 3 and 4 ulcers to reach stage 2 was 2.25+/-0.5 weeks in treatment group and 4.33+/-1.53 weeks in control group ( P =.047). CONCLUSIONS: Multiwavelength light therapy from a gallium-aluminum-arsenide laser source did not influence overall healing pressure ulcers. Limited evidence suggested that it improved healing of stage 3 and 4 pressure ulcers.